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1 Med J Chin PLA, Vol. 39, No. 9, September 1, [ ] / 335 (HA n=100) (HE n=235) (APRI ) HBV / logistic HE ( ) HA ( P<0.001) HE HA (P<0.001) 2 4 HE (Tbil) (P 0.05) (P 0.001) HA HE Tbil PTA ALB ALT Tbil (P 0.05) HAV HEV (P 0.05) HBV HE HA HE HA HE HBV HA HE [ ] [ ] R R [ ] A [ ] (2014) [DOI] /j.issn Clinical analysis of clinical feature of sporadic acute icteric hepatitis A and hepatitis E: A report of 335 cases ZHU Peng 1, ZHU Ji-xiang 2, HE Deng-ming 1, XU Cheng 1, GUO Shi-min 1, LI Mao-shi 1, WANG Yu-ming 1* 1 Institute of Infectious Diseases, Southwest Hospital, Third Military Medical University, Chongqing , China 2 Department of Gastroenterology, Suining First People s Hospital, Suining, Sichuan , China * Corresponding author, wym417@163.com This work was supported by the State Key Project Specialized for HBV-Related Severe Hepatitis of China (2012ZX ) and the National Natural Science Foundation of China ( ) [Abstract] Objective To investigate the clinical feature and outcome of patients with pre-existing chronic liver disease were co-infected with acute icteric hepatitis A or E. Methods 335 patients diagnosed with acute icteric hepatitis in Southwest Hospital were divided into hepatitis A (HA) group (n=100) and hepatitis E (HE) group (n=235). The clinical features (age, gender, season distribution, prodromal symptom) and laboratory data were analyzed retrospectively. The stratification analysis was performed in the two groups according to the degree of hepatic fibrosis (APRI ratio index), HBV infection and cirrhosis status. The risk factors affecting the outcome were analyzed by logistic regression analysis. Results The mean age of patients of HE group ( ) was older than that of HA group ( , P= ). Male patients were predominant in the two groups, and male/female ratio was higher in HE group (P= ). High prevalence was found within the period of February to April. Except for a higher total bilirubin (Tbil) level (P<0.05) and lower incidence of fever, nausea and vomiting (P<0.05) in HE group, there was no difference in other clinical manifestations between the two groups. Compared with those without cirrhotic, cirrhosis patients co-infected with HA or HE showed an increased Tbil, decreased PTA and Alb, prolonged ALT and Tbil recovery time, higher incidence of hepatic decompensation and related complications, and higher mortality (P<0.05). Liver injury was more marked in patients with chronic liver disease who were infected with HAV or HEV with exacerbation of previous liver fibrosis. [ ] (2012ZX ) ( ) [ ] [ ] () ( ) [ ] wym417@163.com

2 726 军杂 Alcohol consumption, age and chronic HBV infection were risk factors for liver decompensation in patients with cirrhosis associated with HE. Conclusion Sporadic acute icteric HA and HE showed similar clinical features, but different in age distribution and jaundice index. Its coexistence with HA or HE can cause severe liver decompensation, the degree of which is associated with basal liver fibrosis status. [Key words] hepatitis A; hepatitis E; jaundice; liver cirrhosis; risk factors (hepatitis A HA) (hepatitis E HE) (hepatitis A virus HAV) (hepatitis E virus HEV) [1-2] HBV HAV HEV [3-5] HA HE HBV HA HE HA HE (3~80) ALT 2 (2 ULN) Tbil 37 mol/l HA HAV IgM HAV IgG 3 ( 2 1 ) HE HEV IgM HEV IgG 3 ( 2 1 ) IgM IgG ELISA HAV HEV HBV / [6] (acute-chronic liver failure ACLF) [7] 1.2 Excel ALT AST Tbil ALB PTA PLT ( 3 7d 1 ) ALT Tbil 2 ULN APRI [8] (AST/PLT 100%) HA (3~75) HE (11 80) HBV ( APRI ~0.5 ) 3 (HA 1 HE 2 ) 1.4 SPSS 18.0 GraphPad Prism 5.0 x±s t χ 2 Fisher logistic HE HA (P< ) 79.0% HA % HE 30 ( 1) HA 2.1:1 HE 6.3:1 (P<0.01) 40 HA group HE group Ratio (%) < >60 Age(year) 1 Fig.1 Age distribution of acute icteric hepatitis A or E patients ( ) M % 49.4%( 2) 2.3

3 Med J Chin PLA, Vol. 39, No. 9, September 1, Clinical characteristics 1 Tab.1 Comparison of baseline profile, laboratory data and clinical symptoms of hospitalized patients HA group (n=100) HE group (n=235) Demographic data Age(years) t= <0.001 Gender(Male/Female) 68/32 203/32 χ 2 = <0.001 Basal liver fibrosis status(cirrhosis/non-cirrhosis) 26/73 59/174 χ 2 = Chronic HBV infection 26(26.0) 89(37.9) χ 2 = Drinking history( 40g/d, 5 years) 22(22.0) 49(20.9) χ 2 = Laboratory data ALT( ULN) t= AST( ULN) t= Tbil( ULN) a t= APRI(AST/PLT 100) t= PTA (%) t= Clinical symptoms Fatigue 89(89.0) 194(82.6) χ 2 = Poor appetite 84(84.0) 185(78.7) χ 2 = Fever 86(86.0) 28(11.9) χ 2 = <0.001 Nausea and vomiting 53(53.0) 71(30.2) χ 2 = <0.001 Abdominal pain or diarrhoea 35(35.0) 80(34.0) χ 2 = Icterica Mild( 5 ULN) 64(64.0) 122(51.9) χ 2 = Moderate[(5-10) ULN] 28(28.0) 61(26.0) χ 2 = Severe( 10 ULN) 8(8.0) 52(22.1) χ 2 = Incidence of complications during the course (percentage of intragroup cirrhosis patients) Ascites 7(26.9) 21(35.6) Spontaneous peritonitis 3(11.5) 13(20.3 b ) Upper gastrointestinal hemorrhage 5(19.2) 10(16.9) Hepatic encephalopathy 5(19.2) 6(8.5 b ) Acute kidney injury 3(11.5) 9(11.9 c ) Acute on chronic (acute) liver failure 7(26.9) 17(27.1 b ) a. Peak value of Tbil level during the course; b. One non-cirrhosis patient was excluded; c. Two non-cirrhosis patients were excluded;. The comparison among groups were not performed (in the case of small samples, direct description outperforms Fisher's exact test) t/χ 2 P value Ratio (%) HA group HE group 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Months of the year 2 AHA AHE Fig.2 Each month morbidity situation of acute icteric hepatitis A or E HA HE (P<0.001) HE ACLF ( 1) 2.4 HA HE HA HE ( 3 ) 1 : 1 26 HA-HE 13 HA-HE 3 HA-HE t HA ALT 44.3 ULN HE 62.8 ULN(P<0.001) HA AST 24.8 ULN HE 48.3 ULN(P<0.001) HA APRI 0.29 HE 0.48(P<0.001) HA ALT 19.5 ULN

4 728 军杂 HE 45.3 ULN(P=0.096) HA AST 17.8 ULN HE 41.6 ULN(P=0.021) 2.5 HA HE Tbil PTA ALB ALT Tbil 2 ULN (P ) HA HE (7.7% vs 8.5%) 8 (5/8) (3/8) HA AST Tbil PTA HE (P ) HBV ACLF ( ACLF 1 ACLF 0) logistic ( 40g/d 5 ) HA ACLF ( OR= %CI P =0.02) ( 40g/d 5 OR= %CI P=0.001) HBV (OR= %CI P=0.013) (OR= %CI P=0.028) HE ACLF (APRI ) HAV HEV (ALT AST PTA) (P 0.05) HA HE 3 (P 0.05) HA HE (APRI 0.2) HE AST HA (P=0.001) (0.2 APRI 0.5) HE Tbil HA (P= ) 2 HA HE Tab.2 Differences of HA and HE severity between patients with or without pre-existing liver cirrhosis Item HA group(n=99 a ) HE group(n=233 b ) Non-cirrhosis (n=73) Cirrhosis (n=26) Non-cirrhosis (n=174) Cirrhosis (n=59) Age(year) (1) (1)(2) ALT( ULN) AST( ULN) (1) Tbil( ULN) (1) (2) (2) PTA (%) (1) (2) (2) ALB(g/L) (2) (2) APRI(AST/PLT 100) HBsAg (Negative/Positive) 59/14 13/13 134/40 10/49 Time of ALT drop to 2 ULN(d) (2) (2) Time of Tbil drop to 2 ULN(d) (2) (2) Death 0 2(7.7) 1(0.6) 5(8.5) Incidence of severe hepatitis (%) 1.4% 14.8% (2) 2.1% 18.7% (2) (1)P 0.05 compared with HE group; (2)P 0.01 compared with non-cirrhosis; a. One pregnant woman was excluded; b. Two pregnant women were excluded 3 HA HE Tab.3 Clinical characteristics of HA or HE patients with different basal liver fibrosis status Clinical characteristics HA(n=73) HE(n=174) APRI 0.2(n=34) 0.2 APRI 0.5(n=27) APRI 0.5(n=12) APRI 0.2(n=72) 0.2 APRI 0.5(n=68) APRI 0.5(n=34) Age(year) ALT( ULN) AST( ULN) Tbil( ULN) a APRI(AST/PLT 100) ALB(g/L) PTA (%) a. Peak level of Tbil

5 Med J Chin PLA, Vol. 39, No. 9, September 1, HA HE HA HE [1-2] 10 HA HE HA HE HE HA HA HE 2 4 HA [9-10] HA HE HA HE AST ALT [11] HA HE [12] IL-1 IL-6 IL-10 [13] HAV [14] IL-1 IL-6 3~4 [15] HEV [16] HAV HBV HAV HEV [2-4,17] HA HE Tbil ACLF 7.7% 8.5% Yellapu [18] HAV HEV ACLF % Kumar [4] HEV HEV HAV HEV HAV HEV HAV HEV [12,19-20] HE HBV HA ACLF HBV HAV HEV HE 60 [21-22] HE 18.7% 32.4% 8.5% HA HA HA HBV [23-25] APRI [26-27] APRI HA HE APRI ( ~0.5 ) HA HE HA HE HEV HA HE

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