Snapshot A 28-year-old man presents to his primary care physician for fatigue, malaise, and abdominal pain. He reports his symptoms began a few days ago and have progressively worsened. His symptoms are associated with nausea, 2 episodes of emesis, and generalized pruritus. Social history is significant for recent travel to India. He is currently sexually active with multiple men and does not use condoms. Physical examination is notable for scleral icterus, generalized jaundice, and hepatomegaly. Serologic testing is remarkable for anti-HAV IgM antibodies. Introduction Classification a Hepatovirus in the Picornaviridae family single-stranded positive-sense RNA virus with an icosahedral capsid Epidemiology risk factors sexual contact working in a daycare serving in the military eating raw or undercooked shellfish and vegetables Transmission via the fecal-oral route Pathogenesis within the cytoplasm of a hepatocyte, the virus replicates CD8+ T-cells and natural killer cells destroy the infected hepatocytes, leading to hepatocellular damage when the immune response to the infected hepatocytes is severe, it can result in severe hepatitis Prognosis typically a self-limited illness does not become a chronic condition Presentation Symptoms nausea and vomiting anorexia abdominal pain dark urine pale stools Physical exam hepatomegaly jaundice and scleral icterus Studies Serologic testing anti-HAV IgM active infection is present anti-HAV IgG a previous infection was present no active disease the patient is protected against infection elevated aminotransferases Differential Hepatitis B infection differentiating factors presence of anti-hepatitis B antibodies in serological testing Hepatitis C infection differentiating factor presence of anti-hepatitis C antibodies in serological testing Treatment Medical hepatitis A virus (HAV) vaccine indication all children at 1 year of age all children between ages 2 and 18 who live in an area with a high disease incidence people who travel or work in countries with a high disease incidence men who have sex with men illicit drug users patients with chronic liver disease comments used to protect against exposure to the HAV immune globulin indication in infants < 6 months of age in travelers who have a contraindication to the vaccine (e.g., allergy) comments this provides passive immunization against the HAV hepatitis A virus vaccine and immune globulin indication patients with chronic liver disease immunocompromised patients who are not able to mount an adequate immune response to the hepatitis A vaccine Complications Cholestatic hepatitis Fulminant hepatitis (< 1% of cases)