MORBIDITY AND MORTALITY ASSESSMENT IN ACUTE HEPATITIS-E
AbstractBackground: Hepatitis-E is an enterically transmitted virus causing acute hepatitis. Mostly it is a self-limiting clinical course, but can be life threatening in certain high risk groups. Pakistan is endemic for Hepatitis-E with limited published literature. The aim of this study is to evaluate the predictors of mortality in patients with acute Hepatitis-E. Methods: We analyzed the medical records of 369 adult patients with Hepatitis-E infection admitted at Aga khan University Hospital, from January 1996 to December 2010. Details of their laboratory investigations, clinical course and complications such as FHF and mortality were noted. The outcome was compared, and determinants of mortality were evaluated in important patient subgroups. Results: Out of 369 patients with Hepatitis-E, 326 (88.3%) were discharged after full recovery. Out of these 22 (6%) patients had chronic liver disease CLD in this study, of whom 10 (2.7%) expired (p-value <0.001). There were about 67 (18%) pregnant patients, with a mean gestational age of 29.19±7.68 weeks and 5 (1.4%) pregnant patients died (p-value=0.23). A total of 58 (15.7%) patients were co-infected with other hepatotropic virus, and a comparison did not find an increased risk of mortality in this group. Conclusion: This study showed that Hepatitis-E is significantly associated with mortality in patients suffering from pre-existing chronic liver disease. Pregnancy was not a determinant of mortality in Hepatitis-E patients in this study, and neither was co-infection with other Hepatotropic viruses.Keywords: Acute Hepatitis, Hepatitis-E, Hepatitis.
Gupta DN, Smetana HF. The histopathology of viral hepatitis as seen in the Delhi epidemic (1955-56) Indian J Med Res 1957;45:101–13.
Emerson SU, Purcell RH. Running like water-the omnipresence of Hepatitis-E. N Engl J Med 2004;351(23):2367–8.
World Health Organization. Viral hepatitis. October 28, 2010, date last accessed. Available from: http://apps.who.int/gb/ebwha/pdf_files/A62/A62_22-en.pdf.
Sheikh A, Sugitani M, Kinukawa N, Moriyama M, Arakawa Y, Komiyama K, et al. Hepatitis-E virus infection in fulminant hepatitis patients and an apparently healthy population in Bangladesh. Am J Trop Med Hyg 2002;66(6):721–4.
Bansal J, He J, Yarbough PO, Sen S, Constantine NT, Sen D. Hepatitis-E virus infection in eastern India. Am J Trop Med Hyg 1998;59(2):258–60.
John R, Abraham P, Kurien G, Chandy G, Sridharan G. Sporadic Hepatitis-E in southern India. Trans R Soc Trop Med Hyg 1997;91(4):392.
Clayson ET, Myint KS, Snitbhan R, Vaughn DW, Innis BL, Chan L, et al. Viremia, fecal shedding, and IgM and IgG responses in patients with Hepatitis-E. J Infect Dis 1995;172(4):927–33.
Khuroo MS, Rustgi VK, Dawson GJ, Mushahwar IK, Yattoo GN, Kamili S, et al. Spectrum of Hepatitis-E virus infection in India. J Med Virol 1994;43(3):281–6.
Acharya SK, Panda SK, Saxena A, Gupta SD. Acute hepatic failure in India: a perspective from the East. J Gastroenterol Hepatol 2000;15(5):473–9.
Shrestha SM. Enteric Non-A, Non-B Hepatitis in Nepal: Clinical and Epidemiological Observations. Amsterdam, the Netherlands: Elsevier Science Publishers BV; 1991. pp. 265–75.
Khuroo MS, Khuroo MS. Hepatitis-E virus. Curr Opin Infect Dis. 2008;21:539–43.
Pavio N, Meng XJ, Renou C. Zoonotic Hepatitis-E: animal reservoirs and emerging risks. Vet Res 2010;41(6):46.
Dalton HR, Bendall R, Ijaz S et al. Hepatitis-E: an emerging infection in developed countries. Lancet Infect Dis 2008;8(11):698–709.
Meng XJ. From barnyard to food table: The omnipresence of Hepatitis-E virus and risk for zoonotic infection and food safety. Virus Res 2011;161(1):23–30.
Lu L, Li C, Hagedorn CH. Phylogenetic analysis of global Hepatitis-E virus sequences: genetic diversity, subtypes and zoonosis. Rev Med Virol 2006;16(1):5–36.
Gust ID, Purcell RH. Report of a workshop: waterborne non-A, non-B hepatitis. J Infect Dis 1987;156(4):630–5.
Mathur P, Arora NK, Panda SK, Kapoor SK, Jaikhani BL, Irshad M. Sero-epidemiology of Hepatitis-E virus (HEV) in urban and rural children of north India. Indian Pediatr 2001;38(5):461–75.
Das K, Agarwal A, Andrew R, Frosner GG, Kar P. Role of Hepatitis-E and other hepatotropic virus in aetiology of sporadic acute viral hepatitis: A hospital based study from urban Delhi. Eur J Epidemiol 2000;16(10):937–40.
Daniel HD, Warier A, Abraham P, Sridharan G. Age-wise exposure rates to Hepatitis-E virus in a southern Indian patient population without liver disease. Am J Trop Med Hyg 2004;71(5): 675–8.
Centers for Disease Control and Prevention (CDC) Hepatitis-E among U.S. travelers, 1989-1992. MMWR Morb Mortal Wkly Rep 1993;42(1):1–4
Rao VC and Melnick JL, Environmental Virology. Wokingham: Van Nostran Reinhold (UK) Co Ltd. 1986; pp. 10–17.
Pusch D, Oh DY, Wolf S, Dumke R, Schröter-Bobsinm U, Höhne M, et al. Detection of enteric viruses and bacterial indicators in German environmental waters. Arch Virol 2005;150(5):929–47.
Ippagunta SK, Naik S, Sharma B, Aggarwal R. Presence of Hepatitis-E Virus in Sewage in Northern India: Frequency and Seasonal Pattern. J Med Virol 2007;79(12):1827–31.
Vaidya SR, Tilekar BN, Walimbe AM, Arankalle VA. Increased risk of HEV in sewage workers from India. J Occup Environ Med 2003;45(11)1167–70.
Ahmad T, Waheed Y, Tahir S, Safi SZ, Fatima K, Afzal MS, et al. Frequency of HEV contamination in sewerage waters in Pakistan. J Infect Dev Ctries. 2010;4(12):842–5.
Kumar A, Beniwal M, Kar P, Sharma JB, Murthy NS. Hepatitis-E in pregnancy. Int J Gynaecol Obstet 2004;85:240–4.
Khuroo MS, Kamili S. Aetiology, clinical course and outcome of sporadic acute viral hepatitis in pregnancy. J Viral Hepat 2003;10:61–9.
Beniwal M, Kumar A, Kar P, Jilani N, Sharma JB. Prevalence and severity of acute viral hepatitis and fulminant hepatitis during pregnancy: a prospective study from north India. Indian J Med Microbiol 2003;21(3):184–5.
Medhat A, el-Sharkawy MM, Shaaban MM, Makhlouf MM, Ghaneima SE. Acute viral hepatitis in pregnancy. Int J Gynaecol Obstet 1993;40(1):25–31.
Tsega E, Krawczynski K, Hansson BG, Nordenfelt E. Hepatitis-E virus infection in pregnancy in Ethiopia. Ethiop Med J 1993;31(3):173–81.
Hussaini SH, Skidmore SJ, Richardson P, Sherratt LM, Cooper BT, O’Grady JG. Severe Hepatitis-E infection during pregnancy. J Viral Hepat 1997;4(1):51–4.
Khuroo MS, Teli MR, Skidmore S, Sofia MA, Khuroo MI. Incidence and severity of viral hepatitis in pregnancy. Am J Med 1981;70(2):252–5.
Khuroo MS, Kamili S, Khuroo MS. Clinical course and duration of viremia in vertically transmitted Hepatitis-E virus (HEV) infection in babies born to HEV-infected mothers. J Viral Hepat 2009;16(7):519–23.
Stoszek SK, Engle RE, Abdel-Hamid M, Mikhail N, Abdel-Aziz F, Medhat A, et al. Hepatitis-E antibody seroconversion without disease in highly endemic rural Egyptian communities. Trans R Soc Trop Med Hyg 2006;100(2):89–94.
Monga R, Garg S, Tyagi P, Kumar N. Superimposed acute Hepatitis-E infection in patients with chronic liver disease. Indian J Gastroenterol 2004;23(2):50–2.
Kc S, Sharma D, Basnet BK, Mishra AK. Effect of acute Hepatitis-E infection in patients with liver cirrhosis. J Nepal Med Assoc 2009;48(175):226–9.
Kumar Acharya S, Kumar Sharma P, Singh R. Hepatitis-E virus (HEV) infection in patients with cirrhosis is associated with rapid decompensation and death. J Hepatol 2007;46(3):387–94.
Mahtab MA, Rahman S, Khan M, Karim MF. Hepatitis-E virus is a leading cause of acute-on-chronic liver disease: experience from a tertiary centre in Bangladesh. Hepatobiliary Pancreat Dis Int 2009;8(1):50–2.
Kamar N, Selves J, Mansuy JM, Ouezzani L, Péron JM, Guitard J, et al. Hepatitis-E Virus and Chronic Hepatitis in Organ-Transplant Recipients. N Engl J Med 2008;358(8):811–7.
Kamar N, Mansuy JM, Cointault O, Selves J, Abravanel F, Danjoux M, et al. Hepatitis-E virus-related cirrhosis in kidney- and kidney-pancreas-transplant recipients. Am J Transplant 2008;8(8):1744–8.
Haagsma EB, Niesters HG, van den Berg AP, Riezebos-Brilman A, Porte RJ, Vennema H, et al. Prevalence of Hepatitis-E virus infection in liver transplant recipients. Liver Transpl 2009;15(10):1225–8.
Kamar N, Garrouste C, Haagsma EB, Garrigue V, Pischke S, Chauvet C. Factors associated with chronic hepatitis in patients with Hepatitis-E virus infection who have received solid organ transplants. Gastroenterology 2011;140(5):1481–9.
Qureshi H, Shahid A, Mujeeb SA. Exposer rate of Hepatitis-E (IgG) in a selected population of children and adults in Karachi. J Pak Med Assoc 2000;50(10):352–4.
Saeedi MI, Mahmood K, Amanullah, Ziauddin M, Ilyas N, Zarif M. Frequency and clinical course of Hepatitis-E in tertiary care hospitals. J Coll Physicians Surg Pak 2004;14(9):527–9.
Iqbal M, Ahmed A, Qamar A, Dixon K, Duncan JF, Islam NU, et al. An outbreak of entericallv transmitted non-A non-B hepatitis in Pakistan, Am. J Trop Med Hyg 1989:40(4):438–43.
van Cuyck-Gandré H, Zhang HY, Tsarev SA, Warren RL, Caudill JD, Snellings NJ, et al. Short report: Phylogenitically distinct Hepatitis-E viruses in Pakistan. Am J Trop Med Hyg 2000;62(2):187–9.
Bryan JP, Iqbal M, Tsarev S, Malik IA, Duncan JF, Ahmed A, et al. Epidemic of Hepatitis-E in a military unit in Abbottabad, Pakistan. Am J Trop Med Hyg 2002;67(6):662–8.
Rab MA, Bile MK, Mubarik MM, Asghar H, Sami Z, Siddiqi S, et al. Water-brone Hepatitis-E virus epidemic in Islamabad, Pakistan: A common source of outbreak traced to the malfunction of a modern water treatment plant. Am J Trop Med Etyg 1997;57(2):151–7.
Shams R, Khero RB, Ahmed T, Hafiz A. Prevalence of Hepatitis-E virus (HEV) antibody in pregnant women of Karachi. J Ayub Med Coll Abbottabad 2001;13(3):31–5.
Hamid SS, Jafri SM, Khan H, Shah H, Abbas Z, Fields H. Fulminant hepatic failure in pregnant women: acute fatty liver or acute viral hepatitis? J Hepatol 1996;25(1):20–7.
Kumar A, Yachha SK, Poddar U, Singh U, Aggarwal R. Does co-infection with multiple viruses adversely influence the course and outcome of sporadic acute viral hepatitis in children? J Gastroenterol Hepatol 2006;21(10):1533–7.
Arora NK, Nanda SK, Gulati S, Ansari IH, Chawla MK, Gupta SD, et al. Acute viral hepatitis types E, A, and B singly and in combination in acute liver failure in children in north India. J Med Virol 1996;48(3):215–21.
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