What is the appropriate diagnosis and treatment for a patient presenting with fever, itchy purpura, and hepatitis?

Diagnosis and Management of Fever, Itchy Purpura, and Hepatitis

The clinical triad of fever, itchy purpura, and hepatitis most strongly suggests Henoch-Schönlein purpura (HSP) triggered by hepatitis A virus infection, and management should focus on confirming viral hepatitis etiology, excluding other causes, and providing supportive care while monitoring for renal complications.

Diagnostic Approach

Immediate Laboratory Evaluation

The diagnostic workup must prioritize identifying the underlying hepatitis etiology and confirming HSP:

• Obtain hepatitis A IgM antibody, which becomes positive 5-10 days before symptom onset and remains positive for 6-12 months 1
• Complete viral hepatitis panel including hepatitis B surface antigen, hepatitis B core IgM, hepatitis C antibody, and hepatitis E IgM 1
• Measure serum aminotransferases (AST/ALT) and bilirubin to grade hepatitis severity, as AST/ALT typically rise rapidly during the prodromal period and reach peak levels before declining 2
• Check complete blood count looking for thrombocytopenia, which is present in 70-79% of infectious hepatitis cases 3
• Obtain renal function tests and urinalysis to detect proteinuria and hematuria, as HSP commonly causes glomerulonephritis 1, 4

Critical Differential Diagnoses to Exclude

The combination of fever persisting into the icteric phase requires excluding concurrent infections:

• Blood cultures (two sets) must be obtained to rule out typhoid fever, which can present with fever during the icteric phase of viral hepatitis and may be diagnosed by Widal test even with negative cultures 5
• Malaria blood films (thick and thin) should be performed immediately if there is any travel history to endemic areas, as three films over 72 hours are necessary to exclude malaria with confidence 3
• Abdominal ultrasound to evaluate the hepatobiliary tree and exclude biliary obstruction or hepatic metastases 1

Confirming Henoch-Schönlein Purpura

HSP is an exceptional extra-hepatic manifestation of hepatitis A infection that meets American College of Rheumatology criteria 6:

• Palpable purpura on dependent regions (lower extremities, buttocks) with pruritus
• Arthralgia or arthritis affecting large joints
• Abdominal pain from gastrointestinal vasculitis
• Renal involvement with proteinuria or hematuria 6, 4

Management Algorithm

Grade 1 Hepatitis (AST/ALT 1-3× ULN or Bilirubin 1-1.5× ULN)

• Monitor liver chemistries once or twice weekly without treatment delay 1
• Provide supportive care as hepatitis A is self-limiting with complete clinical recovery by 6 months in nearly all adult patients 2
• Monitor for HSP complications, particularly renal involvement with serial urinalysis 6

Grade 2 Hepatitis (AST/ALT >3-5× ULN or Bilirubin >1.5-3× ULN)

• Hold all potentially hepatotoxic medications and discontinue non-essential drugs 7, 8
• Consult gastroenterology or hepatology for patients with grade 2 or higher disease 1
• Consider prednisone 0.5-1.0 mg/kg/day only if clinical symptoms of severe liver toxicity are present 1
• Repeat liver function tests within 7-10 days to confirm pattern and assess trend 7

Grade 3-4 Hepatitis (AST/ALT >5× ULN or Signs of Hepatic Decompensation)

• Hospitalize immediately and urgently consult gastroenterology/hepatology 1
• Initiate methylprednisolone 1-2 mg/kg/day for grade 3 or 2 mg/kg/day for grade 4 hepatitis with planned 4-6 week taper 1, 7
• Consider liver biopsy before starting glucocorticoids to maximize diagnostic utility and exclude autoimmune hepatitis 1, 9
• Monitor for hepatic decompensation including ascites and encephalopathy 1

Critical Management Pitfalls

Common Errors to Avoid

• Do not assume mild fever in icteric hepatitis is residual viral symptoms—concurrent typhoid or other bacterial infections must be excluded, particularly in endemic areas 5
• Do not delay malaria testing if any travel history exists, as falciparum malaria can progress rapidly to cerebral involvement and death 3
• Do not overlook renal monitoring in HSP—glomerulonephritis is a major complication requiring serial urinalysis and renal function tests 1, 6, 4
• Do not use infliximab if considering immunosuppression, as it carries risk of idiosyncratic liver toxicity 1

Special Considerations

The association between hepatitis A and HSP is rare but well-documented 6, 4:

• HSP typically appears 3-7 days after hepatitis onset and represents an immune-mediated vasculitis triggered by viral infection 6, 4
• Evolution is usually favorable with no long-term renal involvement in most cases, though 3-year follow-up is recommended 6
• Autoantibody testing (ANA, rheumatoid factor, cryoglobulins) may be positive and represents immune dysregulation from viral hepatitis 4

Monitoring Requirements

• Weekly liver function tests until normalization for grade 1-2 hepatitis 1, 7
• Daily monitoring for hospitalized patients with grade 3-4 hepatitis 1
• Serial urinalysis every 1-2 weeks for 3 months to monitor for HSP-related glomerulonephritis 6
• Document hepatotoxic drug reactions in medical records to prevent re-exposure 8