Infections Hepatitis - Study of 100 Cases

Deshpande, R.S., M.B.,B.S., D.P.H. (Bom.), Medical Superintendent In-charge, Kasturba City Fever Hospital, Bombay
Shantilal C. Sheth, M.D., F.R.C.P. (Lond.), Hon. F.A.A.P. (U.S.A.), (U.S.A.), F.A.Sc., F.C.P.S., D.C.H. (Lond.) Honorary Paediatrician, Kasturba City Fever Hospital and Emeritus Director Professor of Paediatrics, Topiwala National Medical College and Nair Hospital, Bombay and Joykutty, M.D., M.B.,B.S., D.C.H. (Bom.), Research Scholar, Bombay, India.

The well-recognised credo of students of human illness introduced by the founders of present day medicine is that a disease process can only be fully understood and interpreted if the functional derangement can be clearly associated with the morphological changes observed during life or at the autopsy. Despite efforts of the clinicians and pathologists, the task of correlating the clinical manifestations of liver diseases, the functional derangement as recognised in the laboratory and the morphological alteration remains unfinished. The basic functions of the liver are not fully understood so far and there are various tests to estimate them. The evaluation of hepatic function is of major importance in diagnosis and management of diseases of an organ system with such diverse functional activities. Functional diagnosis in hepatic disease is of limited value and this has created a demand for supplementation for the study of structural alterations. Liver is the main organ affected in infectious hepatitis and each case presents a new problem in correlating between clinical manifestations and disturbed liver functions. Diseases of the liver throw the entire system out of gear and many systemic diseases are responsible for affections of the liver.

HISTORICAL

The first report of contagious or infectious type of jaundice came from Germany in 751 A.D. in a personal communication from a letter by Pope Zacharias to St. Boniface, Archbishop of Mainz. Rokitansky in 1842 described jaundice due to massive necrosis of liver and named it acute yellow atrophy. Virchow in 1865 suggested that benign transient form of jaundice usually seen in young persons was due to catarrhal inflammation which included papilla of vater with a mucous plug. He proposed the name “Icterus Catarrhalis”. In 1890 Flindt suggested that the essential lesion was degeneration of hepatic parenchyma and in 1912 cockayne independently reached the same conclusion. Abundant confirmation followed particularly from Scandinavians Lindstedt, Ehrstron, Wallgren, Eppinger and later Stilzer in 1876, Frolich in 1879 showed that the first evidence of hepatocellular degeneration in early stages of disease. They conclusively demonstrated that catarrhal jaundice and epidemic hepatitis and some cases of acute yellow atorphy were manifestations of the same disease.

In 18th and 19th century infectious hepatitis was a disease of military importance. The French designated at “Jeunisee descamps” and the Germans ad “Kriegsikoruror Soldatengelbsucht”. Yeogt in Germany was the first to demonstrate infectivity of the disease in volunteers. Roholm and Iversen in 1939 developed a technique of liver biopsy and Dible, McMichael, Sherlock in England and Axenfeld and Brass in Germany utilised the knowledge with great success. In U.S.A., there were 72,000 cases in 1961, the highest incidence for any year since the disease was reported in 1952.

This study was conducted on one hundred cases of viral hepatitis admitted at the Kasturba City Fever Hospital. The clinical feature course, prognosis and therapeutic response to the indigenous drug Liv.52 are studied and presented.

Detailed history was taken through clinical examination was made and the degree of jaundice and state of consciousness were noted. Laboratory studies included routine blood and urine examination, urine urobilinogen, blood bilirubin content—total and direct, serum protein estimation including serum albumin, serum globulin levels, serum alkaline phosphatase level. Serum transaminase activity was studied only in a few cases.

Table 1: Duration of jaundice
Period	No. of cases
1 - 6 weeks	88
6 - 12 weeks	9
12 - 25 weeks	1
Duration could not be determined in dead cases	2

The patients ranged in age from 2 to 12 years, the majority of cases being in the age of 6-12 years (65%). Cases below one year are also reported. There were 59 males and 41 females.

The patients were mostly drawn from poor socio-economic group 80%, 15% belonged to lower middle class and 5% middle and upper middle class. Sixty percent of children did not receive adequate caloric intake and there were signs of various nutritional deficiencies. Thirty six percent children showed signs of multiple vitamin deficiencies and 17% children showed various manifestations of protein deficiency. Mild anaemia was noted in 11 cases, moderate in 9 and severe in 4 cases. Twelve children came from localities from which cases of viral hepatitis were reported.

The following table shows the duration of jaundice. The intensity and degree of jaundice varied from case to case. Two patients died of hepatic coma of which one had jaundice for six weeks and the other, two days after admission to the hospital. One case was discharged against medical advice when the bilirubin level was 10 mgms.

Table 2: The age incidence
	1-3 years	3-6 years	6-9 years	8-10 years	10-12 years	Total
No. of cases	2	33	21	30	14	100

The signs and symptoms as observed were as follows:

Table 3
Signs and symptoms	No. of cases
Anorexia	77
Yellow discolouration of urine	69
Vomiting	64
Fever	58
Nausea	42
Pruritus	39
Malaise	31
Epigastric discomfort	28
Clay coloured stools	12
Diarrhoea	11
Headache	6
Bleeding tendency	Nil

The above table shows that anorexia, yellow discolouration of urine, vomiting, fever, nausea and pruritus were the ‘important’ symptoms.

The size of the liver and its tenderness associated with other findings were noted and are presented in table 4. Enlarged liver was the most outstanding finding in 95 cases being tender in 76 cases.

Table 4: Clinical findings
Findings	No. of cases
Tender liver	76
Palpable liver	95
Liver enlarged and palpable	40
Liver moderately enlarged	36
Liver markedly enlarged	7
Liver massively enlarged	2
Oedema of legs	15
Ascites	11
Spleen palpable	2
Palmer erythema	Nil

Study of the degree of jaundice as judged clinically showed the following:

Table 5
Jaundice	No. of cases
Mild	65
Moderate	20
Severe	15

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