CASE PRESENTATION

HEPATITIS A

Presentant
Hanifia Zahra Rahmawati
Mentor
dr. Ulynar M, Sp.A

Faculty of Medicine UIN Syarif Hidayatullah Jakarta

Pediatric Department
Bhayangkara Tk. I R. Said Sukanto Hospital
CASE ILLUSTRATION
 IDENTITIY
Name : Child MA
Birth Date : February 16th, 2005
Age : 12 years 8 months
Gender : Female
Address : Swadaya I street, number II
Religion : Islam
MR No. : 858954
Date of admission : October 24th, 2017
Date of examination : October 24th, 2017
IDENTITIY

Father Mother

Name Mr.M Mrs.S

Age 35 years old 32 years old

Job Police Housewife

Nationality Indonesian Indonesian

Religion Islam Islam

Education S1 S1

Address Swadaya I street, number II, RT/RW 01/09, Jakarta

 ANAMNESIS
• The anamnesis was taken on October 24th, 2017, using autoanamnesis
and alloanamnesis method (from the patient's mother)
• It was taken at room No.208 Hardja 2A Ward, Bhayangkara tk.I R. Said
Sukanto Hospital, Jakarta.

Chief Complaint

Jaundice since 1 day before admission to the

hospital.

Additional Complaint

Vomitus, nuause, fever

 History of Present Illness
5 days 3 days 1 days
before the before the before the
admission admission admission

 Taken to
 Fever, suddenly Jatipadang Primary  Jaundice, in both
rises, the the Public Health eyes. Initially
temperature is Center not too yellow
unknown but for long the
 The patient yellow more clear
 Nausea and consumed
Vomitus, 2 times Paracetamol and  Urine looks more
containing food antibiotic  darker
symptoms
 Malaise and decreased, not  Pale Stool as
anorexia completely putty
recovered
 History of Past Illness

History of Past Illness History of Past Illness

Pharyngitis/Tonsilitis - Diarrhea -

Bronchitis - Thypoid -

Pneumonia - Worms -

Morbilli - Surgery -

Varicella At 2 years of age Brain Concussion -

Diphteria -
Fracture -
Enteritis -
Drug Reaction -
Bacillary Dysentry - Febril seizure -

Amoeba Dysentry -
Allergic History

The patient has no allergy to medicine and food

Birth History
(Mother’s pregnancy history)
 Antenatal care : Mother checks up her pregnancy to
midwife mothnly
 Pregnancy illness : no history of problem and diseases
during pregnancy
 Drug consumed : Mother get vitamis every antenatal care
Child’s Birth History

• Labor : Hospital
• Birth attendants : Doctor
• Mode of delivery : Pervaginam
• Gestation : 39 weeks
• Infant state : Healthy
• Birth weight : 2800 grams
• Body length : 50 cm
• According to the mother, the baby started to
cry, the baby’s skin was red, and no
congenital defects were reported.
Development History
• First dentition: 8 months
• Psychomotor development
– Head Up : 1 month old
– Smile : 4 month old
– Laughing : 1- 2 month old
– Slant : 4 months old
– Speech Initation : 6 months old
– Prone Position : 6 months old
– Food Self : 5 – 6 months old
– Sitting : 6 months old
– Crawling : 7 months old
– Standing : 13 months old
– Walking : 15 months old
– Jumping : 24 months old
• Mental Status: Normal
• Conclusion: Growth and development status is still in the
normal limits and was appropriate according to the
patient’s age
History of Eating
Breast milk : Exclusively
Formula milk : SGM
Baby biscuit : Milna
Fruit and vegetables : Banana

History Immunization

Immunization Frequency Time

BCG 1 time 1 month old

Hepatitis B 3 times 0, 1, 6 months old
DPT 3 times 2, 4, 6 months old
Polio 4 times 0, 2, 4, 6 months old
Hib 3 times 2, 4, 6 months old
 Family History
No history of allergy, renal disease, DM, and
any congenital diseases. No history of jaundice

History of Sibling
• The patient is the first child of the family
• The patient has no sibling
• Born died : (-)
• Child dies : (-)
• Miscarriage : (-)
 Physical Examination

Was done at October 24th, 2017 (1st day of hospitalization, 5th day of illness)
 GENERAL STATUS
General condition Mild ill
Awareness Compos Mentis GCS 15 (E4 M6 V5)

VITAL SIGNS
b. Pulse 71x/ min, regular, full strong
c. Breathing rate 21x / min
d. Temperature 37 0C

ANTROPOMETRY STATUS

Weight 40 Kg
Height 154 cm
Nutritional Status based on NCHS
(National Center for Health
Statistics) year 2000 :

• WFA (Weight for Age) :

40/43 x 100 % = 93% (good nutrition)
• HFA (Height for Age) :
154/152 x 100 % = 101% (good
noutrition)
• WFH (Weight for Height):
40/44 x 100 % = 90,9% (good
noutrition)

Conclusion : The patient has good

nutritional status.
 Head to Toe Examination
BODY PART RESULT
Head Normocephaly, hair : black, normal distribution, not
easily removed), sign of trauma (-)

Eyes Scleral icteric +/+, pale conjunctiva -/-, pupil

isochor +/+ 3mm/3mm,

Ears Normotia +/+, wound (-), bleeding (-), serumen (-)

Nose Normal shape, midline septum normal, secretion -/-

Mouth Wet lips, lips edema (-), moist mucous, dirty tongue
(-), caries (-)

Throat Tonsil T1/T1, pharynx hyperemia (-),

BODY PART RESULT
Neck Lymph node enlargement (-), scrofuloderma (-).
Thorax I : symmetric at statis and dynamic, retraction (-)
(Pulmo) P : Fremitus tactile +/+ symmetric
P : sonor on both lungs
A : vesicular +/+, rhonchi -/-, wheezing -/-
Cor I : ictus cordis is not visible
P : ictus cordis is palpable
P : normal cor border
A : S1-S2 regular, murmus (-), gallop (-)
Abdomen I : Distended (+), spider nevi (-)
P: Hepatomegaly (+) 2 cm from arcus costae,
tenderness (+) and splenomegaly (-)
P : Tympany
A : Normal bowel sound, bruit (-)
Genitalia Erythema (-),

Extremity Warm, capillary refill time <2 second, edema -/-

Documentation

Picture 1.2
Hepatomegaly

Picture 3
Icterus
 Neurogical Examination
Meningeal Sign
Nuchal rigidity (-) Defecation Normal (frequency 1 times

Kernig sign daily)

(-)
Lasegue sign Urination Normal (4-5 times daily)
(-)
Sweating Normal
Brudzinski I (-)
Brudzinski II (-)

Motoric Examination
Power Pathologic Reflex
-Hand 5 5 5 5 / 5 5 5 5 Upper
-Feet 5 5 5 5 / 5 5 5 5 extremities - / -
Tonus -Hoffman - / -
-Hand Normotonus/ Normotonus -Trommer
-Feet Normotonus / Normotonus Lower extremities - / -
-Babinsky - / -
Troph -Chaddock - / -
y Normotrophy / Normotrophy -Oppenheim - / -
-Hand Normotrophy / Normotrophy -Gordon - / -
-Feet -Schaeffer
 Motoric Examination

Physiologic Reflex Clonus

Upper extremity -Patella - / -
-Biceps +2 / +2 -Achilles - / -
-Triceps +2 / +2
Lower extremities
-Patella +2 / +2
-Achilles +2 / +2
 Laboratory Investigation
Results Normal Value
HEMATOLOGIC
Hemoglobin 14.3 13 – 16 g/dl
White blood cells 5.100 5.000 – 10.000 u/l
Hematocrit 41 40 – 48 %

Platelet count 408.000 150.000 –390.000 /ul

Erythrocyte 5.29 4.5 – 5.5 million/ul

CLINICAL BIOCHEMISTRY
SGOT/AST 1716 <37 U/L
SGPT/ALT 2070 <40 U/L
Ureum 26 10 – 50 mg/dl
Creatinine 0.6 0.5 – 1.5 mg/dl
ELECTROLITE
Natrium 141 135 – 145 mmol/l
Kalium 4.2 3.5 – 5.0 mmol/l
Chloride 108 98 – 108 mmol/l
 Working Diagnosis

1. Hepatitis A
2. Normal Growth Status
3. Good Nutritional Status
4. Complete Basic Immunization Status
 MANAGEMENT

NON-PHARMACOLOGY PHARMACOLOGY

 Hospitalized • IVFD Kaen 3B

 Bed rest 2000cc/24jam, 20
 Nutritional drip/minutes, makro
support • Domperidon 3x10 mg po
• Asam Ursodeoksikolat
3x250 mg po
PROGNOSIS

Quo ad vitam
ad bonam

Quo ad fungsionam
ad bonam

Quo ad sanactionam
ad malam
 FOLLOW UP
The patient was hospitalized for 5 days
 Oct 25th 2107 (Hospitalize H.2)
S Fever (-), jaundice in the eye (+) vomitus 5 times . Urine like a tea . Stool like putty . Epigastric pain. nausea

O KU: moderate ill

compos mentis
TD: 100/70 mmHg,
HR: 63x/menit,
RR: 20x/menit,
T: 36,5°C
Eye: konjungtiva anemis -/-, sklera ikterik +/+
Pulmo: vesikuler, ronkhi -/-, wheezing -/-
Jantung : BJ I-II regular, murmur -, gallop –
Abdomen :, supel, bowel sound + normal, epigastrium tenderness (+), Hepatomegaly (+) 2 cm from arcus costae,
tenderness (+)
Ekstremitas : akral hangat +/+, CRT < 2 detik, edema -/-
A Hepatitis A
P - IVFD Kaen 3B 2000cc/24jam, 20 tetes/menit, makro
- Ranitidin 2x50mg iv
- Domperidon 3x10 mg po
- Asam Ursodeoksikolat 3x250 mg po
 Oct 26th 2107 (Hospitalize H.3)
S Fever (-), jaundice in the eye (+) vomitus 2 times . Urine like a tea . Stool like putty . Epigastric pain. nausea

O KU: moderate ill

compos mentis
TD: 100/70 mmHg,
HR: 63x/menit,
RR: 20x/menit,
T: 36,5°C
Eye: konjungtiva anemis -/-, sklera ikterik +/+
Pulmo: vesikuler, ronkhi -/-, wheezing -/-
Jantung : BJ I-II regular, murmur -, gallop –
Abdomen :, supel, bowel sound + normal, epigastrium tenderness (+), Hepatomegaly (+) 2 cm from arcus costae,
tenderness (+)
Ekstremitas : akral hangat +/+, CRT < 2 detik, edema -/-
A Hepatitis A
P - IVFD Kaen 3B 2000cc/24jam, 20 tetes/menit, makro
- Ranitidin 2x50mg iv
- Domperidon 3x10 mg po
- Asam Ursodeoksikolat 3x250 mg po
 Laboratorium finding

SeroImmunology

HbsAg Non reaktif

HCV RNA kuantitatif Non reaktif

Anti HAV IgM reaktif

 Oct 27th 2107 (Hospitalize H.4)
S Fever (-), jaundice in the eye (+) vomitus 2 times . Urine like a tea . Stool like putty . Epigastric pain. nausea

O KU: moderate ill

compos mentis
TD: 100/70 mmHg,
HR: 63x/menit,
RR: 20x/menit,
T: 36,5°C
Eye: konjungtiva anemis -/-, sklera ikterik +/+
Pulmo: vesikuler, ronkhi -/-, wheezing -/-
Jantung : BJ I-II regular, murmur -, gallop –
Abdomen :, supel, bowel sound + normal, epigastrium tenderness (+), Hepatomegaly (+) 2 cm from arcus costae,
tenderness (+)
Ekstremitas : akral hangat +/+, CRT < 2 detik, edema -/-
A Hepatitis A
P - IVFD Kaen 3B 2000cc/24jam, 20 tetes/menit, makro
- Ranitidin 2x50mg iv
- Domperidon 3x10 mg po
- Asam Ursodeoksikolat 3x250 mg po
USG

•Slightly hepatomegali ec
acute parenkimal liver
disease
•Other organs are normal
 Results Normal Value
HEMATOLOGIC
Hemoglobin 13 13 – 16 g/dl
White blood 5.200 5.000 – 10.000 u/l
cells
Hematocrit 38 40 – 48 %
Platelet count 408.000 150.000 –390.000 /ul

Erythrocyte 5.29 4.5 – 5.5 million/ul

CLINICAL BIOCHEMISTRY
SGOT/AST 150 <37 U/L
SGPT/ALT 748 <40 U/L
Bilirubin 5,3
direct
Bilirubin 1,1
Indirect
Ureum 26 10 – 50 mg/dl
Creatinine 0.6 0.5 – 1.5 mg/dl
Urinalisa
Natrium 141 135 – 145 mmol/l
Kalium 4.2 3.5 – 5.0 mmol/l
 Oct 28th 2107 (Hospitalize H.5)
S Fever (-), jaundice in the eye (+) vomitus (-) . Urine like a tea . Stool like putty . Epigastric pain. nausea

O KU: moderate ill

compos mentis
TD: 100/70 mmHg,
HR: 63x/menit,
RR: 20x/menit,
T: 36,5°C
Eye: konjungtiva anemis -/-, sklera ikterik +/+
Pulmo: vesikuler, ronkhi -/-, wheezing -/-
Jantung : BJ I-II regular, murmur -, gallop –
Abdomen :, supel, bowel sound + normal, epigastrium tenderness (+), Hepatomegaly (+) 2 cm from arcus costae,
tenderness (+)
Ekstremitas : akral hangat +/+, CRT < 2 detik, edema -/-
A Hepatitis A
P - IVFD Kaen 3B 2000cc/24jam, 20 tetes/menit, makro
- Ranitidin 2x50mg iv
- Domperidon 3x10 mg po
- Asam Ursodeoksikolat 3x250 mg po
- Besok rencana USG Abdomen
CLINICAL BIOCHEMISTRY
SGOT/AST 56 <37 U/L
SGPT/ALT 316 <40 U/L
Bilirubin direct 4.0

Bilirubin Indirect 1.0

LITERATURE OF REVIEW
 Hepatitis Virus
• Hepatitis  inflammation procces
and/or necrosis of liver tissue.
• Causeinfection, drugs, toxin,
metabolic disturbans, or auto-immune.
• Hepatitis in Indonesia: 0,6%  1,6%.
 Indonesia
Hepatitis A Hepatitis B Hepatitis C Lain-lain

19%

56% 22%

3%
DEFINITION

• Hepatitis means inflammation of the liver

Hepat (liver) + itis (inflammation)  hepatitis
• Hepatitis A  inflammation and necrotic
causes by hepatitis A virus
 ETIOLOGY
 HAV: non-enveloped, belongs to Hepatovirus
genus, famili Picornavirus
 Host: human and primates.
 Incubation: 18-50 days (average: 28 days)

Hepatitis A virus as viewed through electron

microscopy.
 Transmission
 Transmission  fecal-oral: contact or
ingestion something, food or water that has
been contaminated with human infected’s
feces.
 No transmission: urine, nasopharynx secret,
or droplet.
 Epidemiology
• Distribution area:
• High viral invection distribution area: 90% children
had been infected before 10 y.o  poor hygiene and
sanitation.
• Moderate viral invection distribution area: various
sanitation  children usually not infected  no
immunity  high prevalence in adult.
• Low viral invection distribution area: good hygiene
and sanitation  low transmission rate.
 STAGE OF HEPATITIS A
Started with yellow urine.
18-50 days feces such as putty.
(Average: 28 days) Jaundice eyes.
Symptoms are getting worse.
Incubation Jaundice
Phase Phase

Prodromal Recovery
Phase Phase
(4 days – 1 week)
Fatigue, malaise, anorexia, nausea, Jaundice disappears
vomitting, discomfort in the upper after 4 weeks
right, fever, headache.
 Clinical Manifestation
Classic hepatitis A Relaps Hepatitis A
Sudden onset, preceded prodormal Occurs 6-10 weeks after previously
symptoms about 1 week before infection is healed. Lighter than
jaundice. the first episode

Cholestatis Protracted
Prologned symptoms of hepatitis Virus clearance going slowly 
within months with fever, itching, recovery hepatocytes more slowly
and jaundice. 120 days

Fulminant
Severe jaundice, encephalopathy, and
prolongation of prothrombin time.
Occurs in the 1st week at the onset of
symptoms
 Pathogenesis
Food contaminated 
fecal-oral transmission
ingestion Through stomach barrier

transport through
Viral replication in the
portal vein  flow to GI tract
cripta of intestines.
the liver

Immunopathologic
virus replicates in response to antigens Lymphocyte T cells vs
hepatocytes expressed by infected HAV antigen
hepatocyte cells

Damage of hepatocyte with

necrosis, lymphocyte cell
infiltration, and
macrophages.
 Hepatitis A: Natural history,
immunopathogenesis, and outcome

Clinical Liver Disease

Volume 2, Issue 6, pages 231-234, 20 DEC 2013 DOI: 10.1002/cld.253
http://onlinelibrary.wiley.com/doi/10.1002/cld.253/full#cld253-fig-0002
 Hepatitis A: Natural history,
immunopathogenesis, and outcome

Clinical Liver Disease

Volume 2, Issue 6, pages 231-234, 20 DEC 2013 DOI: 10.1002/cld.253
http://onlinelibrary.wiley.com/doi/10.1002/cld.253/full#cld253-fig-0001
Interpretation of Diagnostic Test
Results for Hepatitis A Virus
 Treatment

Symptomatic and Bed rest till

supportive. jaundice relieve.

- Hospitalization:
- Severe vomiting.
- Dehydration and poor intake.
- SGOT SGPT > 10 x
- Coagulopathy
- Ensephalopathy.
 Prevention

General Specific
Prevention Prevention
 General Prevention
• Improve hygiene: wash hand, heat
food, avoid raw foods.
• Improve of environmental and
personal sanitation.
• Isolation of the patient.
Specific Prevention

Pasive Active
immunitation immunitation
 Passive Immunitation
Indication
1. All person who contact with patient.
2. Employees and visitors of daycare when a sufferer or his
family has hep. A
3. Catering staff where one is known to have hepatitis A
4. Someone from low endemic countries who travel to
countries wih moderate to high endemicity within 4
weeks.
 Active Immunitation
1. Someone who will work to other countries with moderate to high HAV
prevalence.
2. Children > 2 y.o in aereas with high endemicity of periodic
outbreak.
3. Drug users.
4. Homosexual.
3. HAV researcher.
4. Patient with chronic liver disease, and patient before and after
liver transplant, as the likelihood of developing fulminant
hepatitis increases.
5. Patient with blood clotting disorders (deficiency factor VIII and
IX).
 PROGNOSIS
• Patient with classic symtomp have
good prognosis
• Clinical Indicator for fulminant
hepatitis
1. Prolong Protrombine time >30 sec
2. <10 y.o or >40 y.o
3. Bilirubin serum > 17 mg/dl