Hepatitis A and B discrimination according to aminotransferases/ Aminotransferazlara gore hepatit A ve B enfeksiyonu ayrimi.
Aminotransferases (Physiological aspects)
Hepatitis A (Complications and side effects)
Hepatitis A (Comparative analysis)
Hepatitis A (Care and treatment)
Hepatitis B (Complications and side effects)
Hepatitis B (Comparative analysis)
Hepatitis B (Care and treatment)
Children (Comparative analysis)
Children (Care and treatment)
Parlakay, Aslinur Ozkaya
Cengiz, Ali Bulent
|Publication:||Name: Journal of Pediatric Infection Publisher: Aves Yayincilik Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Aves Yayincilik ISSN: 1307-1068|
|Issue:||Date: March, 2011 Source Volume: 5 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
Objective: Acute infection of hepatitis A and B viruses is
accompanied by biochemical evidence of liver injury. In acute
symptomatic hepatitis, transaminase tests are markedly elevated,
especially, in hepatitis A. This study was carried out to examine the
feasibility of discrimination between hepatitis A and B in acute phase
using serum transaminase concentrations so as to take isolation
precautions and to plan supportive therapy in early phase.
Methods: Between January 1996 and December 1998, 444 patients, [239 (53.8%) males and 205 (46.2%) females] are tested for hepatitis B surface antigen (HBsAg), hepatitis B core IgM antigen (anti-HBc IgM), and hepatitis A immunglobuline M (anti-HAV IgM), alanine aminotransferase (ALT), aspartat aminotransferase (AST) and bilirubin concentrations and comparison of transaminase concentrations between patients infected with hepatitis A and hepatitis B has been made.
Results: ALT concentrations of HAV-infected patients had a median of 879 (minimum: 4, maximum: 7201), whereas HBV-infected patients had a median of 66 (minimum: 16, maximum: 3118). AST concentrations of HAV-infected patients had a median of 492 (minimum: 8, maximum: 5718), whereas HBV-infected patients had a median of 59,5 (minimum: 13, maximum: 2040). Transaminase concentrations of patients infected with hepatitis A are higher than patients infected with hepatitis B (for ALT and AST p<0,001). Also there was difference in transaminase concentration in acute hepatitis with age. Concentrations of serum transaminases in acute hepatitis increased with age and peaked at 7-8 years, having a median of 1565 (minimum: 9 and maximum: 4014) for AST and 1942 (minimum: 22 and maximum: 3950) for ALT.
Conclusion: Discrimination between hepatitis A and B in acute phase using serum transaminase concentrations could be helpful to get isolation precautions and to plan supportive therapy in early phase.
Anahtar kelimeler: Hepatitis, aminotransferases, child
Aminotransferazlara Goe Hepatit A ve B Enfeksiyonu Ayrimi
Amac: Hepatit A ve B viruslerinin neden oldugu akut hepatit tablosuna, biyokimyasal karaciger hasari eslik eder. Akut semptomatik hepatit enfeksiyonunda, ozelikle Hepatit A enfeksiyonunda, transaminaz duzeyleri belirgin olarak artar. Bu calisma akut donemde serum transaminaz duzeylerinin olcumuyle hepatit A ve B enfeksiyonu ayrmi yapilarak, erken donemde izolasyon onlemlerinin alinmasi ve destekleyici tedavinin verilmesinin onemini arastirmak amaciyla planlanmistir.
Yontemler: Ocak 1996 ve Aralik 1998 yillari arasinda (Hepatit B asisinin asi takvimine dahil edilmesinden once) akut hepatit suphesiyle basvuran 239 erkek (%53.8), 205 kiz (%46.2) toplam 444 hastanin hepatit B yuzey antijeni (HBsAg), hepatit B kor Ig M antikoru (anti-HBc Ig M), hepatit A Ig M antikoru (anti-HAV Ig M), alanin aminotransferaz (ALT), aspartat aminotransferaz (AST) ve bilirubin duzeyleri olculerek akut hepatit tablosunun nedeninin hepatit A veya B enfeksiyonu olmasina gore karsilastirilmasi yapilmistir.
Bulgular: Hepatit A enfeksiyonu saptanan vakalarin ALT duzeylerinin medyan? 879 (minimum: 4, maksimum: 7201) iken, HBV enfeksiyonu olan vakalarin ALT duzeylerinin medyani 66 (minimum: 16, maksimum: 3118) olarak saptanmistir. Hepatit A enfeksiyonu olan vakalarin AST duzeylerinin medyani (minimum: 8, maksimum: 5718)iken, HBV enfeksiyonu olan vakalarin medyani 59,5 (minimum: 13, maksimum: 2040) olarak belirlenmistir. Hepatit A enfeksiyonu geciren hastalarin transaminaz duzeylerinin hepatit B enfeksiyonu geciren hastalara kiyasla daha yuksek oldugu saptanmistir (ALT ve, AST icin p<0,001). Sadece iki hepatit B enfeksiyonu vakasinin ortalama ALT ve AST degerlerinin hepatit A enfeksiyonu ortalama transaminaz degerlerinden yuksek oldugu gozlenmistir. Ayrica transaminaz duzeylerinin yala arttigi, 7-8 yas civarinda pik yaparak medyan AST duzeyinin 1565 (minimum: 9 ve maksimum: 4014)'e, medyan ALT duzeyinin ise 1942 (minimum: 22 ve maksimum: 3950)'ye yukseldigi saptanmistir.
Sonuc: Akut donemde serum transaminaz duzeylerinin olcumuyle hepatit A ve B enfeksiyonu ayrimi yapilarak, erken donemde izolasyon onlemlerinin alinabilmekte ve destekleyici tedavi verilebilmektedir.
Key words: Hepatit, aminotransferazlar, cocuk
Hepatitis A, a naked RNA virus, is a member of Picornaviridae family Hepatovirus genus, transmitted via the fecal-oral route. Prevalance is generally parallel to age and socioeconomic level. Hepatitis A is more commonly encountered in childhood in developing countries. According to WHO data and seroprevalence studies, hepatitis A infection has an intermediate seropositivity in Turkey, regarding HAV seroprevalance (1).
Hepatitis B, a member of the Hepadnaviridae family, is a small DNA virus with unusual features similar to those of retroviruses. HBV replicates through an RNA intermediate and can integrate into the host genome. The unique features of the HBV replication cycle confer a distinct ability of the virus to persist in infected cells. HBV infection has an insidious course, with an incubation period of 60-80 days, and is usually asymptomatic in 80% of cases. However it may also lead to a wide spectrum of liver disease ranging from acute (including fulminant hepatic failure) to chronic hepatitis, cirrhosis, and hepatocellular carcinoma (2).
Clinical and routine laboratory evaluation is not helpful for differentiating symptomatic hepatitis etiology. Clinical presentation of hepatitis includes jaundice, fatigue, anorexia, tiredness, muscular pain, and,rarely, rash.
After the neonatal period, differential diagnosis of jaundice is a challenging situation for the clinician. Routine tests, especially ALT and AST could be very helpful to predict the etiology. We retrospectively collected data to analyse the concentration of transaminases in acute symptomatic hepatitis A and B cases to evaluate the predictive value of concentration of transaminases to discriminate between hepatitis A and B.
Material and Methods
From January 1996 through December 1998 (before the incorporation of hepatitis B vaccine in the vaccination schedule), 445 patients, who were suspected of having acute hepatitis and tested for HBsAg, anti-HBc IgM, and anti-HAV Ig M bilirubin, ALT, and AST were included and data were collected retrospectively. As the number of patients with hepatitis, especially hepatitis B, has decreased significantly after 1997, with the implementation of hepatitis B vaccine in routine immunisation schedule, the study was conducted in 1996-1998. In order to analyse hepatitis B cases, we would prefer to observe at least 3 cases per year.However, after 1999, there was either only one case or no acute hepatitis B cases. Therefore, we enrolled no hepatitis cases after December 1998. Mann-Whitney u test was used for biostatistics. As descriptive statistics mean, minimum and maximum values are used.
Of the 444 patients, 239 (53.8%) were males and 205 (%46.2) were females, whose age varied between 1-25 years, with a mean of 9.12 [+ or -] 3.85 (Distribution of Hepatitis and ALT, AST concentrations is summarized in Figure 1).
Acute viral hepatitis was serologically diagnosed in 440 patients, of which 416 (94.5%), 24 (5.5%) had HAV and HBV infections, respectively. Four patients had hepatitis not caused by HAV or HBV. Of the patients infected with HAV, 222 were male and 194 were female. There were 13 males and 11 females with HBV infection.
ALT concentrations of HAV-infected patients had a median of 879 IU/ml (minimum: 4 IU/ml, maximum: 7201 IU/ml), whereas HBV-infected patients had a median of 66 IU/ml (minimum: 16 Ill/ml, maximum: 3118 IU/ml). AST concentrations of HAV-infected patients had a median of 492 IU/ml (minimum: 8 IU/ml, maximum: 5718 IU/ml), whereas HBV-infected patients had a median of 59,5 IU/ml (minimum: 13 IU/ml, maximum: 2040 IU/ml). Concentrations of serum transaminases, increasing with age and peaking at 7-8 years, had a mean of 1565 (minimum: 9 and maximum: 4014) for AST and 1942 (minimum: 22 and maximum: 3950) for ALT (Distribution of hepatitis A and B according to age groups and distribution of ALT and AST in hepatitis A and B due to age groups is summarized in Table 1 and 2 respectively).
[FIGURE 1 OMITTED]
In our study serum transaminases were higher in hepatitis A infection (for ALT and AST p<0.001).
Acute infection caused by HAV and HBV is accompanied by biochemical evidence of liver injury. In acute symptomatic hepatitis, trasnaminase tests are markedly elevated (3,4). The concentrations of other enzymes such as lactic dehydrogenase (LD) and alkaline phosphatase (ALP) are usually only mildly increased. In one patient suspected of acute hepatitis, tests for serological markers of acute viral infection were ordered for confirmation and categorisation of viral etiology. Marked abnormalities of serum transaminases occur with HAV, but HBV may not be associated with elevated serum concentrations of transaminases (5).
Elevation of serum transaminases is a biochemical hallmark of hepatocellular injury. In acute symptomatic hepatitis, the rise in transaminase activity begins in the prodromal phase, preceding the onset of jaundice (6). ALT is found in cell cytoplasm and has a half life of 47 [+ or -] 10 hours. AST is found both in cytoplasm and mitochondria and has a half life of 17 [+ or -] 5 hours. Serum AST and ALT can be as high as 100 times the upper limit of normal (2). Serum ALT is usually slightly higher than the AST (7).
In our study serum transaminases were higher in hepatitis A infection compared to hepatitis B infection. Results also showed that transaminases increased with age, having a maximum peak around 7-8 years, and a slight fall was observed after these ages.
The results of our study show that serum transaminase concentrations were more elevated in HAV infection compared to hepatitis B infection. Only two of the acute HBV-infected patients have higher ALT and AST concentrations compared to the mean concentration of HAVinfected patients (ALT: 1063.4, AST: 855.1).
This study showed that serum transaminases could be used as a biochemical screen to discriminate between hepatitis A and B infections, to suggest post-exposure and to take infection control precautions.
Conflict of Interest
No conflict of interest is declared by the author.
Gelis Tarihi: 18.05.2010
Kabul Tarihi: 14.12.2010
(1.) Available in World Health Organisation webpage. http://www.emro.who.int/emhj/1305/13_5_2007_1108_1113.pdf (accessed on May 6th, 2010).
(2.) Liang TJ. Hepatitis B: the virus and disease. Hepatology 2009; 49: 13-21.
(3.) Hoofnagle JH. Serodiagnosisof acute viral hepatitis. Hepatology 1983; 3: 267-8.
(4.) Kamath PS. Clinical approach to the patient with abnormal liver test results. Mayo Clin Proc 1996; 71: 1089-94.
(5.) Chitkara YK, Fontes MD. Guidelines for serological testing in the diagnosis of acute hepatitis A and B. Diagn Microbiol Infect Dis 1999; 33: 241-5.
(6.) Spearman CW. The laboratory diagnosis of acute viral hepatitis. SAfr Med J 1994; 84: 556-9.
(7.) Spearman CW. Clinical and biochemical features of acute viral hepatitis. S Afr Med J 1994; 84: 524-5.
Aminotransferazlara Gore Hepatit Ave B Enfeksiyonu Ayrimi
Aslinur Ozkaya Parlakay , Ates Kara , Ilker Devrim , Ali Bulent Cengiz , Sevilay Karahan , Mehmet Ceyhan 
 Department of Pediatric Infectious Diseases, Medical Faculty, Hacettepe University, Sihhiye, Ankara, Turkey
 Department of Pediatric Infectious Diseases, Behcet Uz Research Hospital, Izmir, Turkey
 Department of Biostatistics, Medical Faculty, Hacettepe University, S?hhiye, Ankara, Turkey
Correspondence Address: Yazisma Adresi: Dr. Aslinur Ozkaya Parlakay Department of Pediatric Infectious Diseases, Medical Faculty, Hacettepe University, Sihhiye, 06100 Ankara, Turkey Phone: +90 312 305 11 66 Fax: +90 312 212 10 49 E-mail: email@example.com
Table 1. Distribution of hepatitis A and B according to age groups AGE GROUPS HEPATITIS A HEPATITIS B 1y-2y 8 2 3y-4y 41 1 5y-6y 61 6 7y-8y 84 5 9y-10y 77 3 11y-12y 67 1 13y-16y 80 6 17y-25y 10 -- Table 2. Distribution of ALT and AST in hepatitis A and B due to age groups HEPATITIS A HEPATITIS B AGE MEAN MEAN MEAN MEAN GROUPS ALT AST ALT AST 1-2 1661 845 47 80 3-4 996 900 173 187 5-6 1069 853 326 415 7-8 1251 1064 708 373 9-10 1000 847 838 740 11-12 1142 912 496 243 13-16 861 595 118 112 17-25 869 817 -- --
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