{"version":"1.0.0","segments":[{"startTime":0.214,"endTime":3.19,"body":"[upbeat intro music]"},{"startTime":3.19,"endTime":5.58,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.19,"endTime":5.58,"body":"to Harrison's Podclass"},{"startTime":5.58,"endTime":8.72,"body":"where we discuss important"},{"startTime":5.58,"endTime":8.72,"body":"concepts in internal medicine."},{"startTime":8.72,"endTime":9.87,"body":"I'm Cathy Handy."},{"startTime":9.87,"endTime":11.518,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.87,"endTime":11.518,"body":"Wiener and we're coming to you"},{"startTime":11.518,"endTime":14.002,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.9,"endTime":18.02,"body":"Welcome to Harrison's Podclass."},{"speaker":"This is episode 50","startTime":18.02,"endTime":22.12,"body":"A"},{"speaker":"This is episode 50","startTime":18.02,"endTime":22.12,"body":"34-Year-Old with Yellow Eyes."},{"speaker":"This is episode 50","startTime":22.12,"endTime":25.24,"body":"The question starts, a"},{"speaker":"This is episode 50","startTime":22.12,"endTime":25.24,"body":"34-year-old man presents"},{"speaker":"This is episode 50","startTime":25.24,"endTime":27.69,"body":"to the physician"},{"speaker":"This is episode 50","startTime":25.24,"endTime":27.69,"body":"complaining of yellow eyes."},{"speaker":"This is episode 50","startTime":27.69,"endTime":29.66,"body":"For the past week, he has felt ill"},{"speaker":"This is episode 50","startTime":29.66,"endTime":31.31,"body":"with decreased oral intake,"},{"speaker":"This is episode 50","startTime":31.31,"endTime":34.968,"body":"low grade fevers that he"},{"speaker":"This is episode 50","startTime":31.31,"endTime":34.968,"body":"measured about a 100 Fahrenheit,"},{"speaker":"This is episode 50","startTime":34.968,"endTime":38.07,"body":"fatigue, nausea, and occasional vomiting."},{"speaker":"This is episode 50","startTime":38.07,"endTime":41.95,"body":"He noticed that his eyes became"},{"speaker":"This is episode 50","startTime":38.07,"endTime":41.95,"body":"yellow about four days ago."},{"speaker":"This is episode 50","startTime":41.95,"endTime":43.8,"body":"And since that time he's noticed pain"},{"speaker":"This is episode 50","startTime":43.8,"endTime":45.41,"body":"in his right upper quadrant."},{"speaker":"This is episode 50","startTime":45.41,"endTime":48.74,"body":"He currently uses marijuana"},{"speaker":"This is episode 50","startTime":45.41,"endTime":48.74,"body":"and ecstasy recreationally"},{"speaker":"This is episode 50","startTime":48.74,"endTime":52.24,"body":"and has a prior history of"},{"speaker":"This is episode 50","startTime":48.74,"endTime":52.24,"body":"injection drug use with cocaine."},{"speaker":"This is episode 50","startTime":52.24,"endTime":55.9,"body":"He has not injected drugs"},{"speaker":"This is episode 50","startTime":52.24,"endTime":55.9,"body":"in at least one year."},{"speaker":"This is episode 50","startTime":55.9,"endTime":57.82,"body":"He has no other past medical history"},{"speaker":"This is episode 50","startTime":57.82,"endTime":59.28,"body":"but he was unable to donate blood"},{"speaker":"This is episode 50","startTime":59.28,"endTime":63.45,"body":"for reasons that he cannot"},{"speaker":"This is episode 50","startTime":59.28,"endTime":63.45,"body":"recall within the past year."},{"speaker":"This is episode 50","startTime":63.45,"endTime":65.13,"body":"His social history is remarkable"},{"speaker":"This is episode 50","startTime":65.13,"endTime":67.29,"body":"for working as a veterinary assistant."},{"speaker":"This is episode 50","startTime":67.29,"endTime":68.36,"body":"His only medication"},{"speaker":"This is episode 50","startTime":68.36,"endTime":71.08,"body":"is over the counter ibuprofen on occasion."},{"speaker":"This is episode 50","startTime":71.08,"endTime":74.66,"body":"On sexual history, he reports"},{"speaker":"This is episode 50","startTime":71.08,"endTime":74.66,"body":"five male sexual partners"},{"speaker":"This is episode 50","startTime":74.66,"endTime":76.0,"body":"over the past six months"},{"speaker":"This is episode 50","startTime":76.0,"endTime":78.92,"body":"and he does not consistently use condoms."},{"speaker":"This is episode 50","startTime":78.92,"endTime":79.95,"body":"[Dr. Handy] Let's stop for a minute"},{"speaker":"This is episode 50","startTime":79.95,"endTime":83.123,"body":"and unpack that history because"},{"speaker":"This is episode 50","startTime":79.95,"endTime":83.123,"body":"there's really a lot there."},{"speaker":"This is episode 50","startTime":83.123,"endTime":85.76,"body":"So from the beginning, it"},{"speaker":"This is episode 50","startTime":83.123,"endTime":85.76,"body":"sounds like he's jaundiced."},{"speaker":"This is episode 50","startTime":85.76,"endTime":87.55,"body":"What you describe is scleral icterus"},{"speaker":"This is episode 50","startTime":87.55,"endTime":89.38,"body":"which you start to see with a bilirubin"},{"speaker":"This is episode 50","startTime":89.38,"endTime":91.93,"body":"of about three milligrams per deciliter."},{"speaker":"This is episode 50","startTime":91.93,"endTime":93.63,"body":"So I'm immediately starting to think,"},{"speaker":"This is episode 50","startTime":93.63,"endTime":95.42,"body":"why does he have an elevated bilirubin?"},{"speaker":"This is episode 50","startTime":95.42,"endTime":96.63,"body":"[Dr. Wiener] So what are you thinking?"},{"speaker":"This is episode 50","startTime":96.63,"endTime":98.188,"body":"[Dr. Handy] Well, there"},{"speaker":"This is episode 50","startTime":96.63,"endTime":98.188,"body":"are a lot of things"},{"speaker":"This is episode 50","startTime":98.188,"endTime":99.405,"body":"that can cause that."},{"speaker":"This is episode 50","startTime":99.405,"endTime":101.34,"body":"His social history suggests a lot"},{"speaker":"This is episode 50","startTime":101.34,"endTime":103.41,"body":"of possible exposures that could be toxic"},{"speaker":"This is episode 50","startTime":103.41,"endTime":106.54,"body":"to the liver or could be"},{"speaker":"This is episode 50","startTime":103.41,"endTime":106.54,"body":"associated with something else."},{"speaker":"This is episode 50","startTime":106.54,"endTime":108.3,"body":"You mentioned he has illicit drug use"},{"speaker":"This is episode 50","startTime":108.3,"endTime":111.75,"body":"which exposes him to"},{"speaker":"This is episode 50","startTime":108.3,"endTime":111.75,"body":"infections like hepatitis, HIV,"},{"speaker":"This is episode 50","startTime":111.75,"endTime":115.22,"body":"although the IV drug use that"},{"speaker":"This is episode 50","startTime":111.75,"endTime":115.22,"body":"you mentioned is not recent."},{"speaker":"This is episode 50","startTime":115.22,"endTime":116.73,"body":"There was something"},{"speaker":"This is episode 50","startTime":115.22,"endTime":116.73,"body":"else that prevented him"},{"speaker":"This is episode 50","startTime":116.73,"endTime":118.11,"body":"from donating blood."},{"speaker":"This is episode 50","startTime":118.11,"endTime":119.27,"body":"Who knows what that is?"},{"speaker":"This is episode 50","startTime":119.27,"endTime":121.91,"body":"Maybe infection, tattoos possibly,"},{"speaker":"This is episode 50","startTime":121.91,"endTime":125.25,"body":"possibly travel though presumably"},{"speaker":"This is episode 50","startTime":121.91,"endTime":125.25,"body":"he would remember that."},{"speaker":"This is episode 50","startTime":125.25,"endTime":127.84,"body":"Maybe it's anemia from some other cause."},{"speaker":"This is episode 50","startTime":127.84,"endTime":129.32,"body":"And of course he also has to work"},{"speaker":"This is episode 50","startTime":129.32,"endTime":130.79,"body":"as a veterinary assistant."},{"speaker":"This is episode 50","startTime":130.79,"endTime":133.637,"body":"Who knows what zoonotic"},{"speaker":"This is episode 50","startTime":130.79,"endTime":133.637,"body":"infections he might be at risk of"},{"speaker":"This is episode 50","startTime":133.637,"endTime":137.11,"body":"and that would really depend"},{"speaker":"This is episode 50","startTime":133.637,"endTime":137.11,"body":"on any recent animal exposures."},{"speaker":"This is episode 50","startTime":137.11,"endTime":139.76,"body":"And he's also at risk of"},{"speaker":"This is episode 50","startTime":137.11,"endTime":139.76,"body":"sexually transmitted infections"},{"speaker":"This is episode 50","startTime":139.76,"endTime":142.18,"body":"given the unprotected"},{"speaker":"This is episode 50","startTime":139.76,"endTime":142.18,"body":"sex that you mentioned."},{"speaker":"This is episode 50","startTime":142.18,"endTime":143.74,"body":"[Dr. Wiener] Okay, well, I'm"},{"speaker":"This is episode 50","startTime":142.18,"endTime":143.74,"body":"going to give you some help."},{"speaker":"This is episode 50","startTime":143.74,"endTime":146.55,"body":"So here's a physical exam"},{"speaker":"This is episode 50","startTime":143.74,"endTime":146.55,"body":"and laboratory values."},{"speaker":"This is episode 50","startTime":146.55,"endTime":148.89,"body":"On physical examination, he appears ill"},{"speaker":"This is episode 50","startTime":148.89,"endTime":151.73,"body":"and has obvious jaundice"},{"speaker":"This is episode 50","startTime":148.89,"endTime":151.73,"body":"with scleral icterus."},{"speaker":"This is episode 50","startTime":151.73,"endTime":154.38,"body":"His temperature is a 100.4 Fahrenheit."},{"speaker":"This is episode 50","startTime":154.38,"endTime":156.34,"body":"His blood pressure is 110 over 70,"},{"speaker":"This is episode 50","startTime":156.34,"endTime":158.32,"body":"heart rate is 105 per minute."},{"speaker":"This is episode 50","startTime":158.32,"endTime":159.75,"body":"And his respiratory rate is 16"},{"speaker":"This is episode 50","startTime":159.75,"endTime":162.59,"body":"with a room air saturation of 99%."},{"speaker":"This is episode 50","startTime":162.59,"endTime":165.5,"body":"His lung and his heart are"},{"speaker":"This is episode 50","startTime":162.59,"endTime":165.5,"body":"normal other than tachycardia."},{"speaker":"This is episode 50","startTime":165.5,"endTime":168.1,"body":"His liver is 15 centimeters to percussion"},{"speaker":"This is episode 50","startTime":168.1,"endTime":171.56,"body":"and palpable six centimeters"},{"speaker":"This is episode 50","startTime":168.1,"endTime":171.56,"body":"below the right costal margin."},{"speaker":"This is episode 50","startTime":171.56,"endTime":174.42,"body":"The liver edge is smooth"},{"speaker":"This is episode 50","startTime":171.56,"endTime":174.42,"body":"and tender to palpation."},{"speaker":"This is episode 50","startTime":174.42,"endTime":177.22,"body":"His spleen is not enlarged"},{"speaker":"This is episode 50","startTime":174.42,"endTime":177.22,"body":"and there are no stigmata"},{"speaker":"This is episode 50","startTime":177.22,"endTime":180.56,"body":"of chronic liver disease"},{"speaker":"This is episode 50","startTime":177.22,"endTime":180.56,"body":"and no peripheral edema."},{"speaker":"This is episode 50","startTime":180.56,"endTime":181.814,"body":"[Dr. Handy] Well, it"},{"speaker":"This is episode 50","startTime":180.56,"endTime":181.814,"body":"sounds like he could have"},{"speaker":"This is episode 50","startTime":181.814,"endTime":185.02,"body":"acute hepatitis, I would"},{"speaker":"This is episode 50","startTime":181.814,"endTime":185.02,"body":"definitely want more lab studies"},{"speaker":"This is episode 50","startTime":185.02,"endTime":187.58,"body":"to include electrolytes,"},{"speaker":"This is episode 50","startTime":185.02,"endTime":187.58,"body":"liver function tests,"},{"speaker":"This is episode 50","startTime":187.58,"endTime":190.67,"body":"and given the high likelihood,"},{"speaker":"This is episode 50","startTime":187.58,"endTime":190.67,"body":"viral hepatitis testing."},{"speaker":"This is episode 50","startTime":190.67,"endTime":194.866,"body":"[Dr. Wiener] Okay. His AST is 1,232."},{"speaker":"This is episode 50","startTime":194.866,"endTime":197.934,"body":"His ALT is 1,560."},{"speaker":"This is episode 50","startTime":197.934,"endTime":200.91,"body":"His alkaline phosphatase is 394."},{"speaker":"This is episode 50","startTime":200.91,"endTime":203.65,"body":"His total bilirubin is 13.4."},{"speaker":"This is episode 50","startTime":203.65,"endTime":206.902,"body":"And his direct portion of that is 12.2."},{"speaker":"This is episode 50","startTime":206.902,"endTime":211.902,"body":"His INR is 2.3 and his APTT is 52 seconds."},{"speaker":"This is episode 50","startTime":211.902,"endTime":213.9,"body":"[Dr. Handy] Well, he clearly"},{"speaker":"This is episode 50","startTime":211.902,"endTime":213.9,"body":"has an acute hepatitis"},{"speaker":"This is episode 50","startTime":213.9,"endTime":215.26,"body":"with notable liver injury"},{"speaker":"This is episode 50","startTime":215.26,"endTime":217.38,"body":"and disruption of synthetic function."},{"speaker":"This is episode 50","startTime":217.38,"endTime":220.12,"body":"Acute hepatitis can have"},{"speaker":"This is episode 50","startTime":217.38,"endTime":220.12,"body":"numerous etiologies."},{"speaker":"This is episode 50","startTime":220.12,"endTime":224.13,"body":"These include viruses, toxins,"},{"speaker":"This is episode 50","startTime":220.12,"endTime":224.13,"body":"drug-induced hepatitis,"},{"speaker":"This is episode 50","startTime":224.13,"endTime":226.76,"body":"auto-immune diseases, metabolic diseases,"},{"speaker":"This is episode 50","startTime":226.76,"endTime":229.9,"body":"exposures like alcohol,"},{"speaker":"This is episode 50","startTime":226.76,"endTime":229.9,"body":"ischemia can cause this."},{"speaker":"This is episode 50","startTime":229.9,"endTime":232.51,"body":"If this were a pregnant woman,"},{"speaker":"This is episode 50","startTime":229.9,"endTime":232.51,"body":"you sometimes see it as well."},{"speaker":"This is episode 50","startTime":232.51,"endTime":234.659,"body":"And there are other infectious etiologies"},{"speaker":"This is episode 50","startTime":234.659,"endTime":235.992,"body":"like rickettsial diseases"},{"speaker":"This is episode 50","startTime":235.992,"endTime":238.2,"body":"and leptospirosis that can cause it too."},{"speaker":"This is episode 50","startTime":238.2,"endTime":239.37,"body":"In this clinical scenario,"},{"speaker":"This is episode 50","startTime":239.37,"endTime":242.21,"body":"the patient has risk factors"},{"speaker":"This is episode 50","startTime":239.37,"endTime":242.21,"body":"for hepatitis A, B, and C"},{"speaker":"This is episode 50","startTime":242.21,"endTime":244.77,"body":"infection including being"},{"speaker":"This is episode 50","startTime":242.21,"endTime":244.77,"body":"a man who has sex with men"},{"speaker":"This is episode 50","startTime":244.77,"endTime":246.8,"body":"and a prior history of injection drug use."},{"speaker":"This is episode 50","startTime":246.8,"endTime":248.867,"body":"So I would definitely want viral studies."},{"speaker":"This is episode 50","startTime":248.867,"endTime":250.97,"body":"[Dr. Wiener] Okay, you"},{"speaker":"This is episode 50","startTime":248.867,"endTime":250.97,"body":"got it. Here it goes."},{"speaker":"This is episode 50","startTime":250.97,"endTime":253.907,"body":"Hepatitis serologies reveal the following."},{"speaker":"This is episode 50","startTime":253.907,"endTime":257.225,"body":"His hepatitis A IgM is negative."},{"speaker":"This is episode 50","startTime":257.225,"endTime":260.544,"body":"Hepatitis A IgG is negative."},{"speaker":"This is episode 50","startTime":260.544,"endTime":264.5,"body":"Hepatitis B core IgM is positive."},{"speaker":"This is episode 50","startTime":264.5,"endTime":268.1,"body":"Hepatitis B core IgG is negative."},{"speaker":"This is episode 50","startTime":268.1,"endTime":271.5,"body":"His hepatitis B surface"},{"speaker":"This is episode 50","startTime":268.1,"endTime":271.5,"body":"antigen is positive."},{"speaker":"This is episode 50","startTime":271.5,"endTime":275.46,"body":"His hepatitis B surface"},{"speaker":"This is episode 50","startTime":271.5,"endTime":275.46,"body":"antibody is negative."},{"speaker":"This is episode 50","startTime":275.46,"endTime":279.15,"body":"His hepatitis B e-antigen is positive."},{"speaker":"This is episode 50","startTime":279.15,"endTime":282.88,"body":"His hepatitis B e-antibody is negative,"},{"speaker":"This is episode 50","startTime":282.88,"endTime":286.74,"body":"and is hepatitis C antibody is positive."},{"speaker":"This is episode 50","startTime":286.74,"endTime":287.79,"body":"[Dr. Handy] That's very helpful."},{"speaker":"This is episode 50","startTime":287.79,"endTime":289.49,"body":"What does the question ask?"},{"speaker":"This is episode 50","startTime":289.49,"endTime":291.57,"body":"[Dr. Wiener] The question"},{"speaker":"This is episode 50","startTime":289.49,"endTime":291.57,"body":"asks what is the cause"},{"speaker":"This is episode 50","startTime":291.57,"endTime":294.41,"body":"of the patient's current"},{"speaker":"This is episode 50","startTime":291.57,"endTime":294.41,"body":"clinical presentation?"},{"speaker":"A","startTime":294.41,"endTime":297.073,"body":"acute hepatitis A;"},{"speaker":"B","startTime":297.073,"endTime":299.66,"body":"acute hepatitis B;"},{"speaker":"C","startTime":299.66,"endTime":302.65,"body":"acute hepatitis C;"},{"speaker":"D","startTime":302.65,"endTime":305.77,"body":"chronic hepatitis B;"},{"speaker":"or E","startTime":305.77,"endTime":308.763,"body":"drug-induced hepatitis."},{"speaker":"or E","startTime":308.763,"endTime":310.64,"body":"[Dr. Handy] All right, let's"},{"speaker":"or E","startTime":308.763,"endTime":310.64,"body":"take this systematically."},{"speaker":"or E","startTime":310.64,"endTime":313.04,"body":"We think the patient has"},{"speaker":"or E","startTime":310.64,"endTime":313.04,"body":"acute viral hepatitis"},{"speaker":"or E","startTime":313.04,"endTime":316.78,"body":"and not drug-induced so we"},{"speaker":"or E","startTime":313.04,"endTime":316.78,"body":"can rule out E off the bat."},{"speaker":"or E","startTime":316.78,"endTime":318.68,"body":"The presentation that"},{"speaker":"or E","startTime":316.78,"endTime":318.68,"body":"you initially described"},{"speaker":"or E","startTime":318.68,"endTime":320.19,"body":"does not really help distinguish"},{"speaker":"or E","startTime":320.19,"endTime":322.74,"body":"because all present with a"},{"speaker":"or E","startTime":320.19,"endTime":322.74,"body":"similar clinical pattern,"},{"speaker":"or E","startTime":322.74,"endTime":325.97,"body":"although incubation periods"},{"speaker":"or E","startTime":322.74,"endTime":325.97,"body":"vary after the exposure."},{"speaker":"or E","startTime":325.97,"endTime":328.37,"body":"The most common initial"},{"speaker":"or E","startTime":325.97,"endTime":328.37,"body":"symptoms are fatigue,"},{"speaker":"or E","startTime":328.37,"endTime":331.7,"body":"anorexia, nausea, vomiting,"},{"speaker":"or E","startTime":328.37,"endTime":331.7,"body":"myalgias, and headache."},{"speaker":"or E","startTime":331.7,"endTime":333.21,"body":"And he had a lot of those."},{"speaker":"or E","startTime":333.21,"endTime":334.86,"body":"These symptoms precede the onset"},{"speaker":"or E","startTime":334.86,"endTime":337.47,"body":"of jaundice by about one to two weeks."},{"speaker":"or E","startTime":337.47,"endTime":341.2,"body":"Once jaundice develops, the"},{"speaker":"or E","startTime":337.47,"endTime":341.2,"body":"prodromal symptoms regress."},{"speaker":"or E","startTime":341.2,"endTime":343.93,"body":"On physical examination,"},{"speaker":"or E","startTime":341.2,"endTime":343.93,"body":"as we saw in this patient,"},{"speaker":"or E","startTime":343.93,"endTime":345.55,"body":"there's usually obvious icterus"},{"speaker":"or E","startTime":345.55,"endTime":348.16,"body":"with an enlarged and tender liver."},{"speaker":"or E","startTime":348.16,"endTime":350.29,"body":"Splenomegaly can also occur."},{"speaker":"or E","startTime":350.29,"endTime":353.41,"body":"On labs, we would see AST"},{"speaker":"or E","startTime":350.29,"endTime":353.41,"body":"and ALT that are elevated"},{"speaker":"or E","startTime":353.41,"endTime":355.28,"body":"with peak levels that are quite variable"},{"speaker":"or E","startTime":355.28,"endTime":358.89,"body":"and can be between 400 and"},{"speaker":"or E","startTime":355.28,"endTime":358.89,"body":"4,000 international units"},{"speaker":"or E","startTime":358.89,"endTime":361.92,"body":"per liter and alkaline"},{"speaker":"or E","startTime":358.89,"endTime":361.92,"body":"phosphatase levels are increased"},{"speaker":"or E","startTime":361.92,"endTime":363.975,"body":"to a much lesser degree."},{"speaker":"or E","startTime":363.975,"endTime":367.44,"body":"Hyperbilirubinemia with"},{"speaker":"or E","startTime":363.975,"endTime":367.44,"body":"levels between about 5 to 20"},{"speaker":"or E","startTime":367.44,"endTime":370.01,"body":"can occur also with primarily an increase"},{"speaker":"or E","startTime":370.01,"endTime":372.16,"body":"in levels of conjugated bilirubin."},{"speaker":"or E","startTime":372.16,"endTime":374.69,"body":"And in this case, we heard"},{"speaker":"or E","startTime":372.16,"endTime":374.69,"body":"that he had a total bilirubin"},{"speaker":"or E","startTime":374.69,"endTime":377.39,"body":"of 13 that was mostly conjugated."},{"speaker":"or E","startTime":377.39,"endTime":379.54,"body":"[Dr. Wiener] Okay. So you"},{"speaker":"or E","startTime":377.39,"endTime":379.54,"body":"mentioned he's at risk"},{"speaker":"or E","startTime":379.54,"endTime":381.926,"body":"of hepatitis A, B and C."},{"speaker":"or E","startTime":381.926,"endTime":384.5,"body":"Which do you think he has? Tell me more."},{"speaker":"or E","startTime":384.5,"endTime":387.36,"body":"[Dr. Handy] Hepatitis A is"},{"speaker":"or E","startTime":384.5,"endTime":387.36,"body":"an RNA virus that presents"},{"speaker":"or E","startTime":387.36,"endTime":389.34,"body":"with acute hepatitis and is transmitted"},{"speaker":"or E","startTime":389.34,"endTime":390.96,"body":"by the fecal oral route."},{"speaker":"or E","startTime":390.96,"endTime":395.5,"body":"In the acute state, the"},{"speaker":"or E","startTime":390.96,"endTime":395.5,"body":"immunoglobulin or IgM is elevated,"},{"speaker":"or E","startTime":395.5,"endTime":397.92,"body":"and we do not see that in this scenario,"},{"speaker":"or E","startTime":397.92,"endTime":400.76,"body":"so we can rule out answer A."},{"speaker":"or E","startTime":400.76,"endTime":403.045,"body":"[Dr. Wiener] Okay. He does"},{"speaker":"or E","startTime":400.76,"endTime":403.045,"body":"not have acute hepatitis A"},{"speaker":"or E","startTime":403.045,"endTime":404.6,"body":"because his IgM is negative."},{"speaker":"or E","startTime":404.6,"endTime":406.32,"body":"And his IgG being negative,"},{"speaker":"or E","startTime":406.32,"endTime":408.54,"body":"does that suggest he was not vaccinated?"},{"speaker":"or E","startTime":408.54,"endTime":410.31,"body":"[Dr. Handy] Yeah. So based"},{"speaker":"or E","startTime":408.54,"endTime":410.31,"body":"on that, he has not been"},{"speaker":"or E","startTime":410.31,"endTime":413.16,"body":"vaccinated for hepatitis A"},{"speaker":"or E","startTime":410.31,"endTime":413.16,"body":"and has not had a history"},{"speaker":"or E","startTime":413.16,"endTime":414.49,"body":"of hepatitis A."},{"speaker":"or E","startTime":414.49,"endTime":415.97,"body":"Based on the values you presented,"},{"speaker":"or E","startTime":415.97,"endTime":417.71,"body":"he has acute hepatitis B."},{"speaker":"or E","startTime":417.71,"endTime":418.63,"body":"[Dr. Wiener] Why do you say that?"},{"speaker":"or E","startTime":418.63,"endTime":419.56,"body":"And you're going to have to explain"},{"speaker":"or E","startTime":419.56,"endTime":422.49,"body":"to me why he's not been"},{"speaker":"or E","startTime":419.56,"endTime":422.49,"body":"vaccinated against hepatitis B,"},{"speaker":"or E","startTime":422.49,"endTime":424.8,"body":"also, as you come through"},{"speaker":"or E","startTime":422.49,"endTime":424.8,"body":"with this explanation."},{"speaker":"or E","startTime":424.8,"endTime":427.04,"body":"[Dr. Handy] Hepatitis"},{"speaker":"or E","startTime":424.8,"endTime":427.04,"body":"B virus is a DNA virus"},{"speaker":"or E","startTime":427.04,"endTime":429.87,"body":"with three common antigens"},{"speaker":"or E","startTime":427.04,"endTime":429.87,"body":"that are tested serologically"},{"speaker":"or E","startTime":429.87,"endTime":432.37,"body":"to determine the time"},{"speaker":"or E","startTime":429.87,"endTime":432.37,"body":"course of the illness."},{"speaker":"or E","startTime":432.37,"endTime":434.64,"body":"These antigens are the surface antigen,"},{"speaker":"or E","startTime":434.64,"endTime":437.28,"body":"the core antigen, and the e-antigen"},{"speaker":"or E","startTime":437.28,"endTime":439.03,"body":"which is a nuclear capsid protein"},{"speaker":"or E","startTime":439.03,"endTime":441.42,"body":"produced from the same"},{"speaker":"or E","startTime":439.03,"endTime":441.42,"body":"gene as the core antigen"},{"speaker":"or E","startTime":441.42,"endTime":443.7,"body":"but immunologically distinct."},{"speaker":"or E","startTime":443.7,"endTime":445.96,"body":"Several distinct patterns can be observed."},{"speaker":"or E","startTime":445.96,"endTime":448.98,"body":"And that helps us figure out"},{"speaker":"or E","startTime":445.96,"endTime":448.98,"body":"what we're dealing with here."},{"speaker":"or E","startTime":448.98,"endTime":453.975,"body":"So in acute hepatitis B, the"},{"speaker":"or E","startTime":448.98,"endTime":453.975,"body":"core IgM, the surface antigen,"},{"speaker":"or E","startTime":453.975,"endTime":456.91,"body":"and the e-antigen are all positive,"},{"speaker":"or E","startTime":456.91,"endTime":459.01,"body":"and that's what we see in this case."},{"speaker":"or E","startTime":459.01,"endTime":461.27,"body":"At this point, the patient"},{"speaker":"or E","startTime":459.01,"endTime":461.27,"body":"is highly infectious"},{"speaker":"or E","startTime":461.27,"endTime":463.37,"body":"and there's viral"},{"speaker":"or E","startTime":461.27,"endTime":463.37,"body":"shedding in bodily fluids,"},{"speaker":"or E","startTime":463.37,"endTime":465.4,"body":"including saliva usually."},{"speaker":"or E","startTime":465.4,"endTime":466.86,"body":"In the late acute infection,"},{"speaker":"or E","startTime":466.86,"endTime":469.79,"body":"core IgG may be positive at the same time"},{"speaker":"or E","startTime":469.79,"endTime":472.81,"body":"as surface and e-antigen positivity."},{"speaker":"or E","startTime":472.81,"endTime":474.49,"body":"In chronic hepatitis B,"},{"speaker":"or E","startTime":474.49,"endTime":477.05,"body":"the same pattern of serologies is seen."},{"speaker":"or E","startTime":477.05,"endTime":478.99,"body":"If a patient has a prior infection"},{"speaker":"or E","startTime":478.99,"endTime":481.35,"body":"without development of chronic hepatitis,"},{"speaker":"or E","startTime":481.35,"endTime":484.83,"body":"the core IgG and surface"},{"speaker":"or E","startTime":481.35,"endTime":484.83,"body":"antibody are positive."},{"speaker":"or E","startTime":484.83,"endTime":487.83,"body":"However, when immunity is"},{"speaker":"or E","startTime":484.83,"endTime":487.83,"body":"obtained via vaccination,"},{"speaker":"or E","startTime":487.83,"endTime":490.1,"body":"only the surface antibody is positive."},{"speaker":"or E","startTime":490.1,"endTime":492.62,"body":"The e-antigen and surface"},{"speaker":"or E","startTime":490.1,"endTime":492.62,"body":"antigen will be negative"},{"speaker":"or E","startTime":492.62,"endTime":494.71,"body":"since the patient was never infected."},{"speaker":"or E","startTime":494.71,"endTime":496.151,"body":"[Dr. Wiener] Okay. So I'm convinced he has"},{"speaker":"or E","startTime":496.151,"endTime":497.409,"body":"acute hepatitis B."},{"speaker":"or E","startTime":497.409,"endTime":499.41,"body":"You made a very compelling case there."},{"speaker":"or E","startTime":499.41,"endTime":501.96,"body":"But why does he not"},{"speaker":"or E","startTime":499.41,"endTime":501.96,"body":"have acute hepatitis C?"},{"speaker":"or E","startTime":501.96,"endTime":503.9,"body":"[Dr. Handy] Hepatitis C is an RNA virus"},{"speaker":"or E","startTime":503.9,"endTime":506.96,"body":"with at least six different"},{"speaker":"or E","startTime":503.9,"endTime":506.96,"body":"genotypes causing the disease."},{"speaker":"or E","startTime":506.96,"endTime":509.89,"body":"The RNA virus can be"},{"speaker":"or E","startTime":506.96,"endTime":509.89,"body":"detected in the serum."},{"speaker":"or E","startTime":509.89,"endTime":512.05,"body":"We did not report that"},{"speaker":"or E","startTime":509.89,"endTime":512.05,"body":"result in this patient"},{"speaker":"or E","startTime":512.05,"endTime":515.05,"body":"but he does have a positive"},{"speaker":"or E","startTime":512.05,"endTime":515.05,"body":"hepatitis C antibody."},{"speaker":"or E","startTime":515.05,"endTime":517.04,"body":"He could have acute hepatitis C however,"},{"speaker":"or E","startTime":517.04,"endTime":518.18,"body":"given his clinical history"},{"speaker":"or E","startTime":518.18,"endTime":522.14,"body":"of prior injection drug use"},{"speaker":"or E","startTime":518.18,"endTime":522.14,"body":"and inability to donate blood,"},{"speaker":"or E","startTime":522.14,"endTime":524.94,"body":"this likely indicates a"},{"speaker":"or E","startTime":522.14,"endTime":524.94,"body":"chronic hepatitis C infection"},{"speaker":"or E","startTime":524.94,"endTime":528.36,"body":"and may have excluded him"},{"speaker":"or E","startTime":524.94,"endTime":528.36,"body":"from previous blood donation."},{"speaker":"or E","startTime":528.36,"endTime":530.87,"body":"In some instances,"},{"speaker":"or E","startTime":528.36,"endTime":530.87,"body":"ecstasy has been reported"},{"speaker":"or E","startTime":530.87,"endTime":532.53,"body":"to cause drug-induced hepatitis"},{"speaker":"or E","startTime":532.53,"endTime":534.59,"body":"but given the viral"},{"speaker":"or E","startTime":532.53,"endTime":534.59,"body":"serologies in this patient,"},{"speaker":"or E","startTime":534.59,"endTime":535.91,"body":"I think that that's more likely"},{"speaker":"or E","startTime":535.91,"endTime":538.88,"body":"than ecstasy causing his presentation."},{"speaker":"or E","startTime":538.88,"endTime":541.03,"body":"[Dr. Wiener] How do you think"},{"speaker":"or E","startTime":538.88,"endTime":541.03,"body":"he got the acute hepatitis B?"},{"speaker":"or E","startTime":541.03,"endTime":543.196,"body":"[Dr. Handy] Probably"},{"speaker":"or E","startTime":541.03,"endTime":543.196,"body":"from the sexual activity"},{"speaker":"or E","startTime":543.196,"endTime":544.63,"body":"that you reported."},{"speaker":"or E","startTime":544.63,"endTime":546.64,"body":"[Dr. Wiener] Okay. So"},{"speaker":"or E","startTime":544.63,"endTime":546.64,"body":"there's a follow-up question."},{"speaker":"or E","startTime":546.64,"endTime":549.46,"body":"And that reads, in the"},{"speaker":"or E","startTime":546.64,"endTime":549.46,"body":"patient described above,"},{"speaker":"or E","startTime":549.46,"endTime":551.88,"body":"what would be the best approach"},{"speaker":"or E","startTime":549.46,"endTime":551.88,"body":"to prevent the development"},{"speaker":"or E","startTime":551.88,"endTime":553.69,"body":"of chronic hepatitis?"},{"speaker":"And the options are A","startTime":553.69,"endTime":557.73,"body":"administration of anti-hepatitis A"},{"speaker":"And the options are A","startTime":557.73,"endTime":560.45,"body":"virus immunoglobulin, or IgG;"},{"speaker":"B","startTime":560.45,"endTime":564.188,"body":"administration of lamivudine;"},{"speaker":"C","startTime":564.188,"endTime":567.822,"body":"administration of"},{"speaker":"C","startTime":564.188,"endTime":567.822,"body":"pegylated interferon alpha"},{"speaker":"C","startTime":567.822,"endTime":569.52,"body":"plus Ribavirin;"},{"speaker":"D","startTime":569.52,"endTime":573.04,"body":"administration of prednisone"},{"speaker":"D","startTime":569.52,"endTime":573.04,"body":"beginning at one dose"},{"speaker":"D","startTime":573.04,"endTime":575.46,"body":"of one milligram per kilogram, daily;"},{"speaker":"or E","startTime":575.46,"endTime":577.702,"body":"do nothing and observe"},{"speaker":"or E","startTime":577.702,"endTime":581.35,"body":"as 99% of individuals"},{"speaker":"or E","startTime":577.702,"endTime":581.35,"body":"with this disease recover."},{"speaker":"or E","startTime":581.35,"endTime":583.22,"body":"[Dr. Handy] The answer in this case is E."},{"speaker":"or E","startTime":583.22,"endTime":586.027,"body":"No treatment is recommended"},{"speaker":"or E","startTime":583.22,"endTime":586.027,"body":"for acute hepatitis B"},{"speaker":"or E","startTime":586.027,"endTime":589.68,"body":"in most individuals because"},{"speaker":"or E","startTime":586.027,"endTime":589.68,"body":"99% of infected individuals"},{"speaker":"or E","startTime":589.68,"endTime":591.89,"body":"will recover without any assistance."},{"speaker":"or E","startTime":591.89,"endTime":593.36,"body":"Therefore it would not be expected"},{"speaker":"or E","startTime":593.36,"endTime":596.047,"body":"that an individual would"},{"speaker":"or E","startTime":593.36,"endTime":596.047,"body":"derive any particular benefit"},{"speaker":"or E","startTime":596.047,"endTime":597.91,"body":"from additional treatment."},{"speaker":"or E","startTime":597.91,"endTime":601.3,"body":"In severe acute hepatitis"},{"speaker":"or E","startTime":597.91,"endTime":601.3,"body":"B nucleoside analogues"},{"speaker":"or E","startTime":601.3,"endTime":604.06,"body":"including lamivudine have"},{"speaker":"or E","startTime":601.3,"endTime":604.06,"body":"been used successfully,"},{"speaker":"or E","startTime":604.06,"endTime":605.98,"body":"although there are no clinical trial data"},{"speaker":"or E","startTime":605.98,"endTime":607.87,"body":"to support such an approach."},{"speaker":"or E","startTime":607.87,"endTime":609.36,"body":"I would suggest following the patient"},{"speaker":"or E","startTime":609.36,"endTime":611.83,"body":"for resolution of the acute infection."},{"speaker":"or E","startTime":611.83,"endTime":614.43,"body":"Now, this is in contrast to hepatitis C."},{"speaker":"or E","startTime":614.43,"endTime":617.2,"body":"So in typical cases of acute hepatitis C,"},{"speaker":"or E","startTime":617.2,"endTime":621.571,"body":"recovery is not common,"},{"speaker":"or E","startTime":617.2,"endTime":621.571,"body":"maybe about 15 to 20%."},{"speaker":"or E","startTime":621.571,"endTime":624.8,"body":"So progression to chronic"},{"speaker":"or E","startTime":621.571,"endTime":624.8,"body":"hepatitis is generally the rule."},{"speaker":"or E","startTime":624.8,"endTime":627.975,"body":"[Dr. Wiener] So if he"},{"speaker":"or E","startTime":624.8,"endTime":627.975,"body":"had acute hepatitis C,"},{"speaker":"or E","startTime":627.975,"endTime":630.099,"body":"would you recommend treatment?"},{"speaker":"or E","startTime":630.099,"endTime":631.81,"body":"[Dr. Handy] Not usually"},{"speaker":"or E","startTime":630.099,"endTime":631.81,"body":"in the acute setting"},{"speaker":"or E","startTime":631.81,"endTime":634.83,"body":"but we do have a lot of"},{"speaker":"or E","startTime":631.81,"endTime":634.83,"body":"treatments for chronic hepatitis C"},{"speaker":"or E","startTime":634.83,"endTime":637.35,"body":"and there about a half"},{"speaker":"or E","startTime":634.83,"endTime":637.35,"body":"a dozen different oral,"},{"speaker":"or E","startTime":637.35,"endTime":640.46,"body":"generally brief duration,"},{"speaker":"or E","startTime":637.35,"endTime":640.46,"body":"usually about 12 weeks."},{"speaker":"or E","startTime":640.46,"endTime":641.8,"body":"They're very well tolerated"},{"speaker":"or E","startTime":641.8,"endTime":644.162,"body":"and they're highly"},{"speaker":"or E","startTime":641.8,"endTime":644.162,"body":"effective with sustained"},{"speaker":"or E","startTime":644.162,"endTime":647.95,"body":"virologic response rates"},{"speaker":"or E","startTime":644.162,"endTime":647.95,"body":"that exceed 90 to 95%."},{"speaker":"or E","startTime":647.95,"endTime":649.39,"body":"And there are generally a combination"},{"speaker":"or E","startTime":649.39,"endTime":651.68,"body":"of regimens which include"},{"speaker":"or E","startTime":649.39,"endTime":651.68,"body":"polymerase inhibitors,"},{"speaker":"or E","startTime":651.68,"endTime":654.96,"body":"protease inhibitors, and NS5A inhibitors."},{"speaker":"or E","startTime":654.96,"endTime":657.26,"body":"And they're available"},{"speaker":"or E","startTime":654.96,"endTime":657.26,"body":"again to treat patients"},{"speaker":"or E","startTime":657.26,"endTime":658.98,"body":"with chronic hepatitis C."},{"speaker":"or E","startTime":658.98,"endTime":659.84,"body":"And just to note,"},{"speaker":"or E","startTime":659.84,"endTime":662.83,"body":"this patient should"},{"speaker":"or E","startTime":659.84,"endTime":662.83,"body":"also be tested for HIV."},{"speaker":"or E","startTime":662.83,"endTime":665.05,"body":"[Dr. Wiener] Okay, so the"},{"speaker":"or E","startTime":662.83,"endTime":665.05,"body":"teaching points in this case"},{"speaker":"or E","startTime":665.05,"endTime":667.15,"body":"are that acute hepatitis may be caused"},{"speaker":"or E","startTime":667.15,"endTime":669.68,"body":"by a variety of viral and non-viral causes"},{"speaker":"or E","startTime":669.68,"endTime":672.44,"body":"that typically can not be"},{"speaker":"or E","startTime":669.68,"endTime":672.44,"body":"distinguished clinically."},{"speaker":"or E","startTime":672.44,"endTime":675.23,"body":"Understanding the time course"},{"speaker":"or E","startTime":672.44,"endTime":675.23,"body":"and the immunologic response"},{"speaker":"or E","startTime":675.23,"endTime":677.02,"body":"to viral infections can help determine"},{"speaker":"or E","startTime":677.02,"endTime":679.386,"body":"whether a patient is acutely infected,"},{"speaker":"or E","startTime":679.386,"endTime":682.15,"body":"chronically infected, or vaccinated."},{"speaker":"or E","startTime":682.15,"endTime":684.37,"body":"Most patients with acute hepatitis B"},{"speaker":"or E","startTime":684.37,"endTime":686.23,"body":"recover without treatment."},{"speaker":"or E","startTime":686.23,"endTime":687.44,"body":"[Dr. Handy] And if you want"},{"speaker":"or E","startTime":686.23,"endTime":687.44,"body":"to read more about this,"},{"speaker":"or E","startTime":687.44,"endTime":689.26,"body":"you can check out the Harrison's chapter"},{"speaker":"or E","startTime":689.26,"endTime":691.549,"body":"on acute viral hepatitis."},{"speaker":"or E","startTime":691.549,"endTime":694.132,"body":"[outro music]"},{"speaker":"or E","startTime":695.11,"endTime":696.535,"body":"[Mr. Shanahan] This is Jim Shanahan,"},{"speaker":"or E","startTime":696.535,"endTime":697.976,"body":"publisher at McGraw Hill."},{"speaker":"or E","startTime":697.976,"endTime":699.59,"body":"Harrison's Podclass is brought to you"},{"speaker":"or E","startTime":699.59,"endTime":701.58,"body":"by McGraw Hill's Access Medicine,"},{"speaker":"or E","startTime":701.58,"endTime":704.19,"body":"the online medical resource"},{"speaker":"or E","startTime":701.58,"endTime":704.19,"body":"that delivers the latest"},{"speaker":"or E","startTime":704.19,"endTime":706.91,"body":"trusted content from the"},{"speaker":"or E","startTime":704.19,"endTime":706.91,"body":"best minds in medicine."},{"speaker":"or E","startTime":706.91,"endTime":709.483,"body":"Go to accessmedicine.com to learn more."}]}