How do you differentiate and manage dengue hepatitis versus acute viral hepatitis?

Differentiating Dengue Hepatitis from Acute Viral Hepatitis

The key to differentiating dengue hepatitis from acute viral hepatitis lies in the clinical context: dengue presents with fever, thrombocytopenia, bleeding manifestations, and plasma leak syndrome, while acute viral hepatitis typically presents with isolated hepatic symptoms without these systemic features. 1, 2

Clinical Presentation Differences

Dengue Hepatitis Features

• Fever with thrombocytopenia is the hallmark distinguishing feature—this combination is rare in isolated viral hepatitis 3, 1
• Bleeding manifestations (epistaxis, hematemesis, petechiae) occur commonly due to thrombocytopenia and coagulopathy 3, 4
• Plasma leak syndrome with hemoconcentration, pleural effusions, and ascites 1
• Acute lung injury occurs in 23% of dengue hepatitis cases 1
• Acute kidney injury develops in 16% of cases 1
• Painful hepatomegaly is characteristic 4
• AST typically exceeds ALT (median AST 174 IU/L vs ALT 88.5 IU/L), which is opposite to most viral hepatitides 3

Acute Viral Hepatitis Features

• Jaundice is prominent in >70% of adults with hepatitis A, B, or E, whereas dengue hepatitis may have minimal jaundice 5, 6
• Platelet counts remain normal or only mildly decreased 5
• No plasma leak syndrome or hemorrhagic manifestations 5
• ALT typically exceeds AST in hepatitis A, B, and C 5
• Acute hepatitis E should be suspected with ALT >7 times upper limit of normal 5

Diagnostic Algorithm

Initial Laboratory Testing (Perform Simultaneously)

• Complete blood count with platelet count—thrombocytopenia (<100,000/μL) strongly suggests dengue 3, 1
• Hepatic panel (ALT, AST, bilirubin, INR)—AST/ALT ratio >1 favors dengue 3
• Dengue serology (IgM/IgG) or NS1 antigen—positive confirms dengue 4, 1
• Viral hepatitis serologies: IgM anti-HAV, HBsAg, IgM anti-HBc, anti-HCV with HCV RNA 5
• Hepatitis E testing (anti-HEV IgM and HEV RNA)—now recommended as first-line for all acute hepatitis 5

Critical Pitfall to Avoid

Do not wait for viral hepatitis serology results to be negative before testing for dengue—test for both simultaneously, as dengue hepatitis can be severe and requires immediate supportive care 5, 1

Severity Assessment

Dengue Hepatitis Severity Stratification

• Mild/moderate hepatitis: ALT 23-300 IU/L (71% of cases) 3
• Severe hepatitis: ALT >300 IU/L (15% of cases)—associated with 4.91-fold increased mortality risk 3
• Acute liver failure: occurs in 4% of dengue hepatitis cases, with 38% mortality 1
• Severe dengue (50% of dengue hepatitis cases) includes shock, severe bleeding, or organ impairment 1
• Dengue shock syndrome (16% of cases) has 47% mortality rate 1

Acute Viral Hepatitis Severity

• Hepatitis A: 10-15% have relapsing illness; some progress to acute liver failure 6, 7
• Acute hepatitis B: >95% of adults recover spontaneously; treatment only for severe cases with coagulopathy or acute liver failure 6
• Acute hepatitis C: 15-50% spontaneously resolve within 6 months 5
• Hepatitis E: can cause acute liver failure, especially in pregnant women 5

Management Approach

Dengue Hepatitis Management

• Supportive care is the cornerstone—no specific antiviral therapy exists 1, 2
• Fluid management is critical to prevent shock while avoiding fluid overload from plasma leak 1
• Avoid hepatotoxic medications, particularly NSAIDs and aspirin (use acetaminophen cautiously) 2
• Monitor for complications: bleeding (requires platelet transfusion if active bleeding with severe thrombocytopenia), acute kidney injury, acute lung injury, and multi-organ failure 3, 1
• ICU transfer immediately if shock develops (independent predictor of mortality with OR 6.4) 1
• Expect longer hospital stay with severe hepatitis (mean 4.3 days vs 3.6 days for mild/moderate) 3

Acute Viral Hepatitis Management

Hepatitis A

• Entirely supportive management—no specific antiviral therapy needed 6, 7
• Avoid hepatotoxic drugs and medications metabolized by liver 7
• Post-exposure prophylaxis for contacts within 2 weeks of exposure 7

Acute Hepatitis B

• No treatment for uncomplicated cases (>95% spontaneous recovery in adults) 6
• Treat only severe acute hepatitis B (coagulopathy, protracted course, or acute liver failure) with entecavir or tenofovir 6
• Supportive care with rest, hydration, and symptomatic relief 5

Acute Hepatitis C

• Initiate DAA therapy immediately upon diagnosis without awaiting spontaneous clearance 5
• Use same regimens as chronic hepatitis C (12-week courses with >90% SVR rates) 5
• Counsel to reduce transmission risk and refer to addiction medicine if injection drug use involved 5

Hepatitis E

• Supportive care for immunocompetent patients 5
• Consider ribavirin for chronic HEV in immunosuppressed patients 5

Acute Liver Failure Management (Any Etiology)

• Transfer to ICU immediately upon diagnosis 8
• Administer N-acetylcysteine systematically regardless of etiology 8
• Contact liver transplant center early for all patients 8
• Monitor for encephalopathy and maintain sodium 140-145 mmol/L 8
• Avoid benzodiazepines and nephrotoxic agents 8
• Urgent transplantation when prognostic indicators suggest high mortality risk (80-90% post-transplant survival) 8

Key Differentiating Points Summary

Dengue hepatitis is distinguished by the triad of fever, thrombocytopenia, and hepatitis, with AST>ALT, whereas acute viral hepatitis presents with isolated hepatic dysfunction, normal platelets, and typically ALT>AST. 3, 1 Test for both simultaneously rather than sequentially, as dengue hepatitis carries 17% mortality in hospitalized patients and requires immediate supportive care to prevent multi-organ failure. 1