A 27 years old pregnant lady comes with severe jaundice and altered sensorium. On examination, the patient is deeply icteric, not responding to commands and pelvic sonogram reveals intrauterine fetal death. Serum bilirubin levels are 28.8 mg/dL (direct = 18.6 mg/dL), AST levels are 1063 and ALT levels are 1191. The viral markers are as follows. What is the likely diagnosis?Anti-HAV IgGReactiveAnti-HAV IgMNonreactiveHbSAgNon reactiveAnti-HbSAgNonreactiveAnti-HBc IgMNonreactiveAnti-HBc IgGReactiveAnti-HCV IgGNonreactiveAnti-HEV IgMReactiveAnti-HEV IgGNon reactive
(A) Acute hepatitis E superimposed on chronic liver failure due to hepatitis B (B) Fulminant hepatitis due to hepatitis B infection (C) Acute hepatitis E with chronic hepatitis A (D) Fulminant hepatitis due to hepatitis E infection
(D) Ans: D. Fulminant hepatitis due to hepatitis E infection(Ref: Harrison 191e p2018, 18/e p2546)In the question, anti-HBc IgG is reactive but HbsAg is negative, the case is a recovered case from hepatitis B.Hepatitis A is rarely chronic, can he ruled out from the given options.Anti-HAV IgG suggests recovered case from HAV infections.Anti-HEV 1gM is an indicator of acute hepatitis E infection.History of pregnancy and high serum bilirubin with raised AST and ALT is suggestive of fulminant hepatitis E.Commonly Encountered Serologic Patterns of Hepatitis B InfectionHBsAgAnti-HBsAnti-HBcHBeAgAnti-HBeInterpretation+-IgM+-* Acute hepatitis B, high infectivity+-IgG+-* Chronic hepatitis B, high infectivitydeg+ IgG-+* Late acute or chronic hepatitis B, low infectivitydeg* HBeAg-negative (`precore-mutant) hepatitis B (chronic or rarely acute)