Shastry Shashank, Rajesh Ramyasri, Sangamesh Samarth, Siddharth Gosavi
Department of General Medicine, JJM Medical College, Davanagere, Karnataka, India.
J Family Med Prim Care. 2020 Jul 30;9(7):3749-3752. doi: 10.4103/jfmpc.jfmpc_549_20. eCollection 2020 Jul.
Hepatitis A virus is a common cause of acute viral hepatitis in India, due to lack of clean water and sanitation. Usual presentations include gastroenteritis or a viral respiratory infection. Hepatitis A has a variety of extra-hepatic manifestations which, if failed to be recognized, evades diagnosis. A 28-year-old lady presented with pain abdomen for 1 week, fever with rashes for 1 day. Patient was febrile at the time of examination. Rash was maculopapular with irregular edges, tender. On examining abdomen, tenderness noted in right hypochondrium and epigastrium with hepatomegaly. Patient was then admitted. Working diagnosis was Viral hepatitis for evaluation. Hepatitis A serology was sent which came positive for Ig M. Patient was treated with IV fluids, bile acid sequestrants, IV PPI, IV and oral antibiotics, antihistamines and 3 doses of injection Vit K. Calamine lotion was also given for skin care. Patient improved symptomatically in 2 days and was discharged after 3 days of hospital stay. In our case, the maculopapular rash spreading to the whole body was the major presenting symptom. The presentation of Hepatitis A with rashes maybe seen in around 10% of patients with extrahepatic manifestations along with arthralgia. Differential diagnosis in this case should be erythema multiforme which is the most common maculopapular eruptive rash. Other viral hepatitis causing agents (Hepatitis B&E) have been documented to present with rashes. SLE and Kawasaki disease rarely present with fever with rash with nonspecific multisystemic involvement. Borrelia, Leptospira also have icterus in their presentations. Early diagnosis and management in this case prevented complication such as autoimmune hepatitis, pleural effusion, ascites acute kidney injury. This case presentation urges the need to consider Hepatitis A to be an important differential diagnosis of fever with rash especially in tropical/sub-tropical countries with poor sanitation.
由于缺乏清洁水和卫生设施，甲型肝炎病毒是印度急性病毒性肝炎的常见病因。常见表现包括肠胃炎或病毒性呼吸道感染。甲型肝炎有多种肝外表现，如果未能识别，会导致漏诊。一名28岁女性因腹痛1周、发热伴皮疹1天前来就诊。检查时患者发热。皮疹为边缘不规则的斑丘疹，有压痛。检查腹部时，右季肋部和上腹部有压痛，肝脏肿大。患者随后入院。初步诊断为病毒性肝炎以便进行评估。送检甲型肝炎血清学检查，结果IgM呈阳性。患者接受了静脉输液、胆汁酸螯合剂、静脉注射质子泵抑制剂、静脉和口服抗生素、抗组胺药以及3剂维生素K注射治疗。还给予炉甘石洗剂用于皮肤护理。患者症状在2天内有所改善，住院3天后出院。在我们的病例中，蔓延至全身的斑丘疹是主要的表现症状。约10%有肝外表现且伴有关节痛的甲型肝炎患者可能会出现皮疹。该病例的鉴别诊断应考虑多形红斑，这是最常见的斑丘疹性皮疹。其他引起病毒性肝炎的病原体（乙型和戊型肝炎）也有出现皮疹的记录。系统性红斑狼疮和川崎病很少出现发热伴皮疹以及非特异性多系统受累的情况。疏螺旋体、钩端螺旋体感染的表现中也有黄疸。该病例的早期诊断和治疗预防了自身免疫性肝炎、胸腔积液、腹水、急性肾损伤等并发症。该病例报告促使我们在热带/亚热带卫生条件差的国家，对于发热伴皮疹的情况，需要将甲型肝炎视为重要的鉴别诊断疾病。
