Hepatita Virala A
Transcript of Hepatita Virala A
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Dr. Eva-Anna Kenez Coordonator: Dr.??
PREZENTARE DE CAZ
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Nume pacient: V.L.
Varsta: 20
Sex: M
Perioada internarii : 13.11.13- 27.11.13
MI:• greata, epigastralgii, meteorism abdominal postprandial,
tensiune dureroasa la nivelul hipochondrului drept, inapetenta, astenie
• icter sclerotegumentar, urini colurice de “bere bruna”, scaune hipocolice
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AHC:• nesemnificative pentru boala actuala;
APP:• Dermatita atopica
CVM:• mediu urban• casa 4 persoane (adulti) /4 camere • tamplar (afacere de familie)
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Ancheta epidemiologica:
•sursa de apa – din sistemul de apa oraseneasca;•animale de companie- o caine;•calatorii in strainetate (in ultimele 2 luni)- neaga;•transfuzii de sange/alte preparate- neaga;•consum de alimente neprelucrate termic- neaga;•vaccinare antihepatitica A, B – neaga;•folosirea drogurilor iv- neaga;•contact cu cimpanzei- neaga;•nu frecventeaza colectivitati aglomerate; •contact cu caz similar in urma cu o luna – mama (caz confirmat de hepatita A, internat in SCBI Cluj);•focare infectioase de hepatita A in oras;
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ISTORICUL BOLII
- debut insidos in data de 10.11.13 prin alterarea starii generale, greata, inapetenta, astenie, epigastralgii, meteorism postprandial, apoi tenesme dureroasa in hipochondrul drept
- in 13.11.13 se prezinta la UPU, de unde este indrumat catre serviciul nostru
- in 13.11.13 internare in spital
- in data de 16.11.13 apar urini colurice, scaune hipocolice, incter slero-tegumentar, febra moderata
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EXAMEN OBIECTIV (16.11.13)- stare generala usor alterata- constient, orientat temporo-spatial- buze carminate, paloare perioronazala- sclere icterice- tegumente icterice, uscate, rugoase, prezinta multiple echimoze post venopunctie
pe antebrate, leziuni petesiale pe toracele anterior (la locul electrozilor de EKG), fara sindrom hemoragipar manifest
- mucoase uscate, fara gingivoragii- limba saburala, abdomen suplu-elastic, cu sensibilitate usoara spontana si
palpatorie in etajul abdominal superior drept- ficat cu 3 cm sub rebord, cu consistenta nemodificata, usor sensibil la palpare- splina cu 3 cm sub rebord- T=37.8° C, AV=96 b/min, TA=100/60 mmHg, SO=98%, FR=12-14 r/min, urini
hipercrome, scaune hipocolice;
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INTERPRETARE CLINICA
•sdr. dispeptic•sdr. asteno-adinamic•sdr. dureros abdominal
•sdr. icteric•sdr febril•sdr. hemoragipar usor•hepato-splenomegalie usoara
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Biochimie Serică
14.11.13 18.11.13 21.11.13 26.11.13 17.12.13 07.01.14 unit. măs.
BD 2.34 1 0.8 mg/dl
BT 3.36 1.67 1.79 mg/dl
Fbg mg/dl
FA 211 114 99 u/l
GGT 241 37 28 u/l
Glicemie 110 mg/dl
GOT 1881 598 194 122 61 51 u/l
GPT 2022 1914 801 298 147 131 u/l
K 4.6 mEq/l
Na 130 mEq/l
Uree 23.4 mg/dl
Cr 0.74 mg/dl
CRP 0.6 mg/dl
PT 7.9 7.2 g/dl
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Sumar de urina
14.11.13 21.11.13 unit. măs.
BIL 1 3 mg/dl
UBG normal
KET negativ mg/dl
ASC negativ
GLU normal mg/dl
PRO 30
ERY negativ
PH 5
NIT negativ
LEU negativ
SG 1.025
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Hemoleucograma
Data 14.11.13 unit. măs.
Leucocite 5.0
Limph# 0.94
Mid# 0.54
Gran# 3.9
Limph% 18.6 %
Mid% 11.2 %
Mon% 10.8 %
Hemoglobina 13.9 g/dl
Eritrocite 4.43
Hematocrit 42.1 %
MCV 86.9 fL
MCH 29.3 pg
MCHC 33.7 g/dl
RDW 13.1 %
VSH 17 mm/h
Trombocite 151 x10³/µl
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Grup sangvin si RH
Grup + RH 0 I pozitiv
Coagulograma
Data 14.11.13 18.11.13
21.11.13 17.12.13 07.01.14 unit. măs.
INR 1.56 1.31 1.41 1.07 1.13
PT(sec) 18.7 16.2 17.2 13.7 14.3 sec
PT% 42.4 57.3 49.4 86.1 77.5 %
APTT 30.4 25.7 27.6 25.8 27 /sec.
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Serologie
Ecografia abdominala (13.11.13 UPU): - colecist transonic, hepatosplenomegalie usoara, fara
ascita.
Serologie
Marker Rezultat Data
IgM HAV pozitiv
Ag HBs negativ
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INTERPRETARE PARACLINICA
• sdr de hepatocitoliza marcata (GPT>GOT)
• sdr de colestaza
• sdr hepatopriv
• serologie pozitiva – IgM HAV
• hepato-splenomegalie usoara
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ALTE INVESTIGATII COMPLEMENTARE (neefectuate)
• Colinesteraza • Amilaza• Proteinograma• Fibrinogen• Amoniemie• Profil glicemic• Ag HVA (RIA, ELISA, IES)• Test toxicologic• Ac HCV• HIV, VDRL• IgM CMV, EBV, Toxoplasma
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anamneza
ancheta epidemiologica
examen clinic
examen paraclinic
DIAGNOSTIC POZITIV
HEPATITA ACUTA VIRALA TIP A, IN PERIOADA DE STARE- ICTERICA, FORMA MODERATA
TULBURARI SPONTANE DE COAGULARE
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DIAGNOSTIC DIFERENTIAL
I) Perioada preicterica:
• viroze respiratorii• suferinte digestive• tulburari nevrotice• alergii• RAA
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II)Perioada icterica:
a) ictere hemolitice: deficit de glucozo 6 fosfat-dehidrogenaza, sdr Rotor, Criegler-Najar, Dubin-Johnson, hematoame masive;
b) ictere parenchimatose: hepatita B, C, D, E, F, CMV, MNI, toxoplazma, enterovirusuri, leptospira, salmonella, malaria, leichmania
c) ictere mecanice: colestaza in sarcina, steatoze hepatice acute, litiaze biliare, neoplasme biliare, hepatice, pancreatice
d) inctoxicatii: ciuperci, tetraclorura de carbon, metale grele, alcool, medicamentos (sulfasalazina, acetaminophen, ecstazy)
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PARTICULARITATEA CAZULUI
• sursa de infectie neelucidata;• absenta febrei in perioada icterica;• focar infectios intrafamilial ( 2 adulti cu boala
manifesta clinic, 2 adulti clinic sanatosi- nevaccinati, cu IgM HAV negativ, probabil cu imunitate postinfectioasa)
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MANAGEMENTUL CAZULUI
Internare/ Izolare – anuleaza riscul de transmisie
Raportarea cazului la DSP (grupa A, declarare nominala obligatorie) !
Cautare activa de cazuri noi in randul contactilor !
Controlul mediului (DSP):•rezervele de apa potabila (persista luni in apa contaminata)
•canalizare (persista luni in apa contaminata si materii fecale contaminate)
•alimente - origine/servicii
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TRATAMENT
• IGIENO-DIETETIC:- internare in SCBI, izolare in salon salon
separat / cuplare cu caz similar- repaus absolutla pat in perioada
preicteriac/icterica- ( regim hidro-lacto- zaharat in perioda febrila)- alimentatie in functie de toleranta digestiva
(evitarea alimentelor colecistokinetice, fara condimente iuti, grasimi)
- abstinenta de la alcool, tutun – corelat cu reaparitia icterului
- evitarea medicamentelor hepatotoxice
• ETIOLOGIC:- nu exista!!!
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• PATOGENETIC: HHC
Dexametazona
• SUPORTIV:
Trofice hepatice - Aspatofort iv 2 fiole în 300 ml soluție glucozată izotonă in primele zile
Extracte vegetale - Liv 52, Essentiale, Lagosa po 2x 150 mg/zi- pana la normalizarea TRZ
Vitamine- vit B1, B2, B6, vit C
Detoxifiant hepatic- Arginina sorbitol 250 ml iv – pana la normalizarea proteinelor totale si scaderea amoniemiei
RHE si acido-bazica
Plasma izogrup/RH iv 2UI- pana la normalizarea coagulogramei
Chelatori de saruri biliare -(Ursofalk po 2 tb/zi)- pana la reducerea colestazei
Evitarea constipatiei (preparate pe baza de plante, Lactuloza)
Reducerea amoniemiei cu ATB (Ampicilina, Normix)
• SIMPTOMATIC:
Antialgic/antipiretic - Paracetamol (500mg/6-8h)
Antiemetic - Metoclopramid ( 3x 1 tb/zi)Antispastic- Nospa iv (1-2f/zi)
- in formele fulminante si colestatice- reduce colestaza- cure scurte
in perioada preicterica
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CONSILIERE
EDUCAREA PACIENTULUI:- natura infectiei si modalitati de transmitere (transmitere fecal-orala, rar prin transfuzie)
- respectarea masurilor de igiena personala si alimentara (rezistent la solventi organici, acizi, persista la temperturi scazute -20 gr, sensibil la clorinare intensa 2mg/l, fierbere la 100 gr, autoclavare, ultraviolete, persista in materii fecale contamiante, pe suprafete la temperatura camerei)
- in timpul perioadei de infectie a se evita: donarea de sange, prelucrarea alimentelor ce vor fi consumate de alti oameni, contact sexual, prezenta la serviciu
- in timpul calatoriilor in zone endemice sa se evita consumul de apa din surse nesigure, consumul de fructe de mare, cruditati, fructe/legume nespalate;
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MANAGEMENTUL CONTACTILOR:- imunizare activa - vaccin cu virus inactivat: Havrix, Twinrix
(HAV+HBV) 0-1-6 luni- exista un singur serotip, un singur determinant antigenic, 7
genotipuri virale
- imunizare pasiva- varste extreme si imunodeprimati – pana la 14 zile postexpunere: gamma globuline nespecifice (Gammagard), Ig umane specifice anti VHA 0.02-0.06 ml/kg IM- este recoamandat vaccinarea pacientilor cu boala hepatica
cronica, personal de bucatarie;
Educarea contactilor:
- riscul infectiei
- simptomatologie (12-45 de zile de la expunere) => prezentarea la medic
- igiena personala si alimentara riguroasa
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EVOLUTIA CAZULUI
FAVORABILA/ AUTOLIMITANTA
ameliorarea graduala a starii generale in 6 zile reacastigarea apetitului si tolerantei digestiva dupa 9
zile disparitia urinii colurice si a scaunelor hipocolice, apoi
diparitia treptata a icterului sclero-tegumentar in 14 zile tendinta de normalizare a coagulogramei dupa
administrare de plasma, normalizarea transaminazelor (100 UI/ spt), si a bilirubinei in 6 (intre 5-20) spt
vindecare completa in 2-4 luni, fara recadere, fara sechele, fara suprainfectii
hepatita A nu se cronicizeaza!
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COMPLICATII POSILE- Colestaza prelungita - febra, prurit, icter prelungit (2-6
luni), scadere ponderala (GPT < 500 IU/L)
- Recadere (3-20%) dupa o initiala evolutie tipica - Hepatita fulminanta (1-2% dintre adulti)- Insuficienta renala acuta/ nefrita interstitiala- Pancreatita acuta- Agranulocitoza, aplazie de maduva- Artrita acuta- Sdr Guillain-Barre- Hepatita autoimuna (predizpozitie genetica+ mimicrie
moleculara)- Suprainfectii (colangita, colecistita, pancreatita)
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CONDITII DE EXTERNARE
CLINIC:afebrilizarerecastigarea tolerantei digestiva cu tranzit intestinal normal ameliorarea icterului/pruritului tegumentarabsenta sangerarilorabsenta complicatiilor
PARACLINIC: reducerea transaminazelor pana la 200 U/lreducerea colestazeinormalizarea coagulogramei si proteinogramei
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RECOMANDARI
- continuarea tratamentului cu Lagosa 150mg 2x1tb/zi, pana la control
- CM 21 de zile- regim alimentar echilibrat, in functie de toleranta
digestiva, consum adecvat de lichide, evitarea consumului de alcool/ tutun, evitarea medicamentelor hepatotoxice (acetamonofen, fluconazol, antibiotice, etc)
- evitarea constipatiei- respectarea masurilor de igiena personala si alimentara- repaus relativ, evitarea efortului fizic intens si sustinut,
evitarea traumatismelor in zona abdominala- control clinic si paraclinic saptamanal (coagulograma,
transaminaze)