Relapsing/Slow to Recover Hepatitis A ~or~ Autoimmune Hepatitis?

I had acute hepatitis A in mid-Feb. Approximately 4 weeks after recovery (including triathlete training of 15 hrs/wk), I experienced a relapse. ALT jumped to 1100, minor inflammation returned, and total Bili went to 1.4. I was given a Doppler (clean) and liver biopsy (negative ANA, slight positive SMA.) I was told "could be autoimmune hepatitis" but I asked to forgo steroid treatment because I felt great and my enzyme levels started to drop again. Each week since April 19 my enzymes have dropped from 170 to 220 points. This week the drop is smaller, however still trending down (I also worked out relatively hard within 12 hours of testing.) I am now at ALT 429, AST 329, total bili at .6 and INR of 1.0. I have little to no inflammation of my liver and no other clinical symptoms. I do not want to start steroids unless an autoimmune diagnosis is more certain, however the slow to recover ALT numbers concern me. I understand some Hepatitis A patients can encounter a waxing and waning recovery, or can be slow to recover. Should I seek a second opinion from a hepatologist or should I trust my general gastro doc with his desire to treat this like autoimmune hepatitis? As a female athlete, taking steroids is not appealing and I dread the side effects. Any perspective or advice is welcome.  I am a 37-year old female, excellent health with no previous medical history of any kind and no genetic markers for other autoimmune diseases in my family.

[Kevin Pho, MD]

Obtaining a second opinion if the treatment course is in question is always recommended.

You are right that there are some patients that may experience a slower recovery time, and there is no way to predict how fast recovery can be made.

It is encouraging however to see the liver enzymes decreasing.  A negative liver biopsy would make autoimmune hepatitis less likely.  Repeating the SMA can be considered.  Anti-actin antibodies are more investigational, and can be considered if the diagnosis is in question.

The data shows that 80 percent have recovery from hepatitis A within 3 months, and nearly all have recover after 6 months.  

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
kevinmd_

[mplssrg]

Thank you.  I am seeing a hepatologist at the University hospital on Tuesday to go over my case and gain a second opinion.  My case of Hep A was quite severe.  Is it possible that the slow to recover enzymes are merely a result of residual liver damage and that it has been slow to recover / unable to keep up with the demands I keep tossing at it?  Is it possible to "tax" your system through activity?  I do admit that I returned to normal activity (45 hours of work, workout schedule, etc.) almost immediately after beginning to feel well again, and I hope that I didn't cause this.  The other thing I am puzzled about... is how could autoimmune hepatitis be caused by Hep A?  I couldn't find anything in the medical writings online.  Finally, what are the potential health risks of elevated enzyme levels if I say "I want to wait this out to see if these numbers return to normal levels before starting a steroid treatment"?