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August 1994, Volume 44, Issue 8

Original Article

Sero-Diagnosis for Viral Hepatitis in 93 Patients Admitted with Acute Hepatitis in Three Different Teaching Hospitals in Lahore

Zulfiqar Haider  ( Institute of Experimental Medicine, Shaikh Zayed Hospital, Lahore. )
Anwaar A. Khan  ( Department of Gastroenterology, Shaikh Zayed Hospital, Lahore. )
Khalilur Rehman  ( Department of Medicine, Services Hospital, Lahore. )
M. Islam Janjua  ( Institute of Experimental Medicine, Shaikh Zayed Hospital, Lahore. )
Jamila Iqbal  ( Department of Microbiology, Shaikh Zayed Hospital, Lahore. )
Mukhtar Ahmad Chishti  ( Department of Medicine, Mayo Hospital, Lahore. )
Arif Qayyum  ( Department of Medicine, Mayo Hospital, Lahore. )
Sibtal Hasnain Syed  ( Department of Medicine, Services Hospital, Lahore. )
Aamir Shahzad,  ( Department of Medicine, Services Hospital, Lahore. )

Abstract

Serodiagnosis was done in 93 patients admitted with acute viral hepatitis (AVH) to three teaching hospitals in Lahore. Five (5.4%) had hepatitis A, 39(41.9%) hepatitis B (2 of these were anti delta positive), 44 (47.3%) probable hepatitis E and 3(3.2%) had HAVIHBV co-infection. Antibody to hepatitis C (anti HCV) was detected in 6 patients (6.4%); 2 with HBV and 4 with probable HEY infection. Excluding 39 patients with hepatitis B and 3 with HBV as part of co-infection, there was evidence of previous HBV infection in 39 out of the remaining 51 patients. In the subset of 6 children, 3 had hepatitis A and 3 hepatitis E Of these, Shad evidence of previous exposure to HBV and one was also positive for anti HCV. Our results are suggestive of a strong background of HBV infection raising concern about its chronic sequelae in the community (JPMA 44:182, 1994).

Viral hepatitis is a worldwide problem, but is particu­larly rampant in the developing countries including Pakistan. In these countries viral hepatitis is endemic and is punctuated by periodic outbreaks1. Apart from the widespread morbidity caused by acute phase of infection there is a predilection to chronicity by HBV, I{DV and HCV in a certain proportion of patients. There are 300 million carriers of HBVin the World2. The pattern of infection by hepatitis vimses differs in various countries and geographical areas3-8. In Pakistan sporadic studies have been undertaken on seroepidemiology of AVH in hospitalized patients by workers in Rawalpindi9 and Karachi10, which showed differences in frequencies of NANB and B hepatitis adult in cases of AVH. These studies used acute phase serological markers for hepatitis A and B to categorize their patients. In this study of serodiagnosis of AVH, we used a range of seromarkers for HAY, HBV, HDV as well as a second generation seromarker for HCV In addition, our patients were drawn from three different hospitals in the metropolitan city of Lahore sewing localities of relatively different socioeco­nomic background.

Patients and Methods

This was a collaborative hospital based study carried out by the Liver Study Group in Lahore, between May, 1991 to December, 1991 after approval by the ethical committee of the group based on the criteria laid down in the declaration of Helsinki. The Group comprised of senior investigators from three teaching hospitals and Institute of Experimental Medi­cine, Lahore. The three hospitals i.e. Mayo, Services and Shaikh Zayed are located in the different areas of the city serving patients of relatively different socioeconomic strata; for instance, Mayo Hospital near the old walled city serves the lower class area, while Shaikh Zayed is located in a relatively upper class suburb. The Services Hospital is located between these two and the patients sewed are of a mixed type. Ninety-three unselected hospitalized patients with clini­cal diagnosis of AVH were investigated after obtaining informed consent from the patients or their guardians in those below 18. Thirty-five patients were from Mayo, 39 from Services and 19 from Shaikh Zayed Hospital. The diagnosis was based on history, clinical findings and raised alanine amino transferase (ALT) levels of more than 2.5 times the maximum limit. Relevant information regarding their socio­economic background, history of drug intake, injections, transfusion, vaccination and contact with a case of hepatitis was recorded. Monthly family income was used to determine the socioeconomic class. Besides seromarkers for hepatitis, laboratory investigations in all patients included CBC, uri­nalysis, serum bilirubin, transaniinases and alkaline phos­phatase. Other causes of jaundice were excluded by careful history and physical examination. Screening tests for infec­tious mononucleosis (I.M Quick, Human) and IgM antibody to cytomegalovirus (Abbott CMY-M-EIA) were also done. Blood samples were collected in vacutainers for sero­markers, sera separated by centrifugation and stored at -70°C until analyzed. The in-vitro, qualitative enzyme immunoassay serodiagnostic tests were performed in duplicate by ELISA test system of Abbott Laboratories, Chicago (USA) according to the procedure recommended by the manufacture. The serodiagnostic criteria for AVH due to hepatitis viruses were: i)acute HAy: positive for IgM anti HAY, ii)HBV: positive for IgM anti HBc; iii) HEV (NANB): negative for IgM anti HAY and IgM anti HBc; iv)HDY: positive for anti HDY in}{Bs Ag positive patients and v) co-infection: when two acute phase semmarkers were present Since acute phase tests for HCV are not available, anti HCVpositivity was considered as denoting past HCY infection.

Results

There were 70 males and 23 females and except for 6 children (age <12 years), all were adults. The mean age of adult patients was 32 years and that of children 7 years. The age distribution showed 18 patients (13 males and 5 females) between 0-19 years, 49 (40 males and 9 females) between 20-39 years and 26 patients (17 males and 9 females) of 40 years or above. Sixty-eight of 93 patients (73%) were drawn from u than or semi-u than areas and 25 (27%) from rural setting. The number of patients was almost equally distributed between lower and middle class i.e., 46 and 44 subjects respectively with only 3 patients from the upper class. History of contact with a case of hepatitis during the preceding 6 months was present in 20(21.5%) and of injections during the similar period in 29(30.2%) patients. There was a past history of jaundice in 10 and blood transfusions in 3 patients. History of vaccinations against hepatitis B was negative in all. The serum bilirubin ranged between 2.5-21 mg/dl. In 44 patients, serum bilirubin was more than 10 mg/dl and in 49 patients less than 10 mg/dl. The ALT levels ranged between 95-2865 I.U./L with levels of more than 10 times of up perlimit in 38 patients. The screening tests for infectious mononucleosis and 1gM anti-CMV were negative in all patients. The results of serodiagnosis for hepatitis viruses in 93 patients of AVH are shown in Table I.

In 3 patients in this group, positivity of other seromark­ers included HBsAg(n=3), IgGanti-HBc(n=3), HBeAg(n=1), and anti- }{Be(n=1). Serodiagnostic and other features in the group of 6 children are shown in Table II.

Ages of 6 children ranged between 4-9 years. The socioeconomic status was equally distributed between lower and middle class. Four cases were from  urban and 2 from rural areas. History of contact with a hepatitis patient during the preceding 5 months in 1, while past history  of jaundice was negative in all. A history of injections and dental treatment during the past 6 months was present in 2 while  none had history of recent drug intake or vaccination against HBV. Of 6 children AVH was caused by HAV in 3, and  HEV(NANB) in 3, one of whom was also positive for anti-HCV. Five out of 6 children had evidence of antecedent HBV exposure   which included positivity for HBsAg in 4, HBeAg in 1 and anti-HBc in 3.

Discussion

Over the past few years attempts have been made to characterize the seroepidemiology of AVH in our country. A study in  adult patients from a military hospital in Rawalpindi during 1984-869 showed NANB as the predominant type (77%) whereas,  the next major type was HBV (23%). Another report by the same investigators10, revealed that in children HAV (59.3%) was  the most frequent type followed by NANB (29.7%), HEV (6.6%) with dual infection of HAV and HBV in (4.4%) of these  patients. Report from Karachi showed NANB in 53% HBV in 45% and HAV in 2% of the adult patients11. Our study showed  that 5 patients had acute HAV of whom 4(3 of whom children), also had antecedent HBV infection; the remaining one patientum  a foreign student, was positive only for IgM anti HAV. There were 3 other patients, all adults, with HAV was associated with  HBV co-infection, meaning there by that HAV could still be a diagnostic consideration in adults. Acute HBV was diagnosed in  42 patients negative test for HBsAg in 8 patients supports the observation that the presence of IgM anti-HBc provides cretical  diagnostic information for the acute phase of HBV infection12. NANB or probable HEV was another major group comprising of  44 patients, 11 of whom were negative for all sero-markers, whereas 33 had evidence of antecedent HBV infection. These  cases were of hepatitis E which is common in the developing countries13. In countries like USA, however, HCV account for a  vast majority of community acquired NANB hepatitis5. Anti HCV was positive in 6 patients; 4 with hepatitis E and past HBV  exposure and 2 with acute HBV. It is difficult to differentiate between acute and chronic HCV on the basis of currently available  assays, as it has been observed that HCV anti-bodies may take longer to appear following infection14. For the same reason,  some clinically suspected cases may remain undetected without follow-up. The prevalence of delta super infection was low  (2.2%) amongst HBsAg positive patients. A similar relatively low prevalence i.e., 3.1% was reported from Rawalpindi15. In  conclusion, the study group showed HEV (NANB) and HBV as the major causative agents for AVH. However, there was  evidence of past HBV infection in a sizeable number of patients including children. A part from HBV, HCV can pose a threat as  it can last for indefinite period even after the resolution of hepatitis and has a high tendency to choronicity16. A recent study in  patients on choronc haemodialysis in a Lahore hospital showed that the prevalence of anti HCV was 62%17. The  predominance of antecedent and acute HBV infection raises concern for chronic liver disease and calls for extensive  epidemiological studies and preventive measures.

Acknowledgements

We wish to thank the medical staff of Shaikh Zayed, Services and Mayo Hospitals, the senior technicians MR. M. Siddique,  Institue of Experimental Medicine and Mr. M. Siddique, Microbiology Lab., Shaikh Zayed Hospital for their valuable assistance  throughout the study. Thanks are also due to Mr. Asghar Ali Anjum of Saikh Zayed Hospital and Mr. Zahid Kaleem, Services  Hospital for their efficient secretarial help in the preparation of the manuscript. Mr. Farooq of Abbots DIagnostic Division  extended his valuable support and cooperation on many occasions which is gratefully acknowledged. We also deeply appreciate the valuable help of Dr. Akmal Bhatti fin editing the manuscript.

References

1. Tandon, B.N., Joshi, Y.K., Jain, S.K et al. An epidemic of non-A, non-B hepatitis in North India. Indian J.Med.Res.,  1982;75:739-44.
2. World Health Organization, Progress in the control of viral hepatitis, memorandum, from a WHO meeting. Bull. W.H.O.,  1988;66:443-55.
3. Grossman, R.A., Benenson, M.W., Scott, R.M. et al. An epidemiologic study of hepatitis B virus in Bangkok, Thailand.  Am.J.Epidemiol., 1975;101:144-59.
4. Beasley, R.P., Hwang, L.Y., Lin, C.C. et al . Incidence of hepatitits B virus infections in preschool children in Taiwan.  J.Infec. Dis., 1982;146:198-202.
5. Alter, M.J., Hadler, S.C., Judson, F.N. et al., Risk factors for acute non-A, non-B hepatitis in the United States and  association with hepatitis C virus antibody. JAMA., 1990;264:2231-35.
6. Kelen, G.D., Green, G.B., Purcell, R.H. et al. Hepatitis B and hepatitis C in emergency department patients N.Engl.J.Med.,  1992;326:1399-404.
7. Wong, D.C., Purcell, R.H., Sreenivasart, M.A. et al. Epidemic and endemic hepatitis in India, evidence for a non-A, non-B  hepatitis virus aetiology. Lancet, 1980;ii:876-78.
8. khuroo, M.S. Study of an epidemic of non- A, non- B hepatitis possibility of another hepatitis virus distinct from  post-transfusion non-A, non-B type, Am.J.Med., 1980;68:818-24.
9. Malik, I,A, Luqman, M., Ahmad, A. et al. Sporadic non-A, non-B hepatits; a sero- epidemiological study in urban population:  J.Pak.Med.Assoc., 1987;37:190-92.
10. Malik, I.A., Anwar, C.M., Luqman, M. et al. The pattern of acute viral hepatitis in children: a study based on  sero-epidermiology and biochemical profile J.Pak.Med.Assoc., 1987;37:314-17.
11. Zuberi, S.J., Lodi, T.Z., Alam, S.E. Spectrum of viral hepatitis. J.Pak.Med.Assoc., 41:288.
12. Hoofnagle, J.H. Serodiagnosis of acute viral hepatitis. Hepatology, 1983;3:267-68.
13. Zuckerman, A.J. Hepatitis E virus; the main cause of enterically transmitted non-A, non-B hepatitis: Br.Med.J.,  1990;300:1947-76.
14. Alter, H.J., Purcell, R.H., Shih, J.W. et al. Detection of antibody to hepatitis C virus in prospectively followed transfusion  recipients with acute and chronic non-A, non-B hepatitis N.Engl.J.Med., 1989;321:1494-1500.
15. Malik, I.A., Ahmad, A., Iqbal, M. et al. Infection with delta agents in Pakistan introduction of a new hepatitis agent.  J.Pak.Med.Assoc., 38:126-28.
16. Alters, M.J., Margolis, H.S., Krawczynski, K. et al. The natural history of community acquired hepatitis C in the United  States. N. Engl.J.Med., 1992;327:1899-1905.
17. Shafi, T., Iqbal, J. and Ahmad, S. Prevalence of anti-Hcv i hemodialysis patients. Pak.J.Med.Res., 1992;32:42-45.

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