Cholestatic viral hepatitis A with refractory pruritus successfully treated with combination of MARS and corticosteroids – a case report
Abstract
Introduction. Hepatitis A virus is a major cause of acute viral hepatitis worldwide with approximately 1.5 million cases annually. The clinical manifestations of hepatitis A virus infection range from asymptomatic to acute liver failure. The cholestatic viral hepatitis A is a rare clinical manifestation characterized by a prolonged course, refractory pruritus, imminent acute liver failure and generally good prognosis. Treatment of pruritus in cholestatic viral hepatitis A is challenging because response to conventional therapy is limited.
Case report. In this case report we present the effectiveness of applying a combination of pulse doses of prednisolone and two cycles of the Molecular Adsorbents Recirculating System in the treatment of a young female patient with cholestatic viral hepatitis A. With this therapeutic option, the duration of the disease was significantly shortened, the intensity of pruritus was reduced and a full recovery was achieved with the normalization of laboratory parameters of cholestasis.
Conclusion. This therapeutic combination showed significant efficiency with lasting effect and no relapse of pruritus. Shorter administration of small doses of corticosteroid therapy reduces their possible side effects. Also, we want to emphasize the importance of vaccination especially passengers in international traffic.
References
Acevedo Ribó M et al. Therapy of intractable pruritus with MARS. Transplant Proc. 2005 Apr;37(3):1480-1. Available at: https://doi.org/10.1016/j.transproceed.2005.02.002
Coppola N et al. Acute hepatitis with severe cholestasis and prolonged clinical course due to hepatitis A virus Ia and Ib coinfection. Clin Infect Dis. 2007 May 1;44(9):e73-7. Available at: https://doi.org/10.1086/513430
Daghman D, Rez MS, Soltany A, Alsaleh A. Two case reports of corticosteroid administration-prolonged and pulsed therapy-in treatment of pruritus in cholestatic hepatitis A patients. Oxf Med Case Reports. 2019 Aug 26;2019(8):omz080. Available at: https://doi.org/10.1093/omcr/omz080
Gavrilovic J, Velickovic J, Mijailovic Z, Lazarevic T, Gavrilovic A, Tomovic M. Applying the Molecular Adsorbent Recirculating System (MARS) in the Treatment of Acute Liver Failure (ALF) Case Report. Serbian Journal of Experimental and Clinical Research. 2018; 9(2) 189-194. Available at: https://doi.org/10.1515/sjecr-2017-0074
Jacobsen KH, Wiersma ST. Hepatitis A virus seroprevalence by age and world region, 1990 and 2005. Vaccine. 2010 Sep 24;28(41):6653-7. Available at: https://doi.org/10.1016/j.vaccine.2010.08.037
Jeong SH, Lee HS. Hepatitis A: clinical manifestations and management. Intervirology. 2010;53(1):15-9. Available at: https://doi.org/10.1159/000252779
Lisboa LF et al. Blood cytokine, chemokine and gene expression in cholestasis patients with intractable pruritis treated with a molecular adsorbent recirculating system: a case series. Can J Gastroenterol. 2012 Nov;26(11):799-805. Available at: https://doi.org/10.1155/2012/623862
Mathiesen LR. The hepatitis A virus infection. Liver. 1981 Jun;1(2):81-109. Available at: https://doi.org/10.1111/j.1600-0676.1981.tb00027.x
Miller WC, Shao JF, Weaver DJ, Shimokura GH, Paul DA, Lallinger GJ. Seroprevalence of viral hepatitis in Tanzanian adults. Trop Med Int Health. 1998 Sep;3(9):757-63. Available at: https://doi.org/10.1046/j.1365-3156.1998.00289.x
Petrović D. Albuminska dijaliza: osnovni principi i klinički značaj. In: Petrović D. Bolesti jetre i oštećenje bubrega u kliničkoj praksi. Kragujevac: Fakultet medicinskih nauka Univeziteta u Kragujevcu; 2018. p. 295-99.
Piscitani L, Di Vito R, Tunno M, Bonomini M. Successful use of single-pass albumin dialysis in the correction of severe hyperbilirubinemia in a case of acute hepatitis E. Ther Apher Dial. 2022 Jul 15. Available at: https://doi.org/10.1111/1744-9987.13909
Pullukçu H. Use of steroids for prolonged cholestasis secondary to acute hepatitis A infection. Journal of Microbiology and Infectious Diseases. 2014;4. 162-164. Available at: https://doi.org/10.5799/ahinjs.02.2014.04.0161
Sciot R, Van Damme B, Desmet VJ. Cholestatic features in hepatitis A. J Hepatol. 1986;3(2):172-81. Available at: https://doi.org/10.1016/S0168-8278(86)80023-X
Sponholz C et al. Molecular adsorbent recirculating system and single-pass albumin dialysis in liver failure--a prospective, randomised crossover study. Crit Care. 2016 Jan 4;20:2. Available at: https://doi.org/10.1186/s13054-015-1159-3
Trauner M, Fickert P, Stauber RE. Inflammation-induced cholestasis. J Gastroenterol Hepatol. 1999 Oct;14(10):946-59. Available at: https://doi.org/10.1046/j.1440-1746.1999.01982.x
Vuković B, Rončević N, Borota R. Antitela protiv hepatitis A virusa u populaciji SAP Vojvodine. Vojnosanitetski pregled. 1980;37: 85-8. PMID: 6249042