3 Case Reports of Fulminant Hepatitis A after Karballa Pilgrimage

Introduction: Fulminant hepatitis is a very rare disease that occurs as an acute liver failure within eight weeks of the onset of symptoms following hepatitis A in adults or in patients with a history of chronic hepatitis B or C [1]. Case presentation: There were three cases in this research. The first case was a self-employed male patient aged 26 years from Gaz Borkhar, admitted to Al-Zahral Hospital on January 1, 2016 for fever, chills and vomiting. The second patient was a 20-year-old male athlete from Lenjan and was hospitalized on May 3, 2016 for fever, chills, anorexia, yellowing of the skin, and low consciousness. The third case was a 20-year-old male employee from Isfahan who visited Al-Zahra Hospital for developing nausea, vomiting, and discolored urine, followed by icterus. Conclusion: all patients were young without any underlying disease. Although the disease had a very progressive course leading to coma, all cases fortunately survived through supportive measures and returned to their normal lives.


Introduction
Fulminant hepatitis is a partially known, yet complex, clinical disease that continues to remain a serious clinical challenge [2]. It is an infectious disease often caused by hepatitis B virus [3]. Hepatitis A is known as a mild liver disease, which rarely causes fulminant hepatitis [4] [5]. Therefore, fulminant hepatitis is rarely seen in hepatitis A, and most often occurs in those with an underlying disease. Patients with chronic liver diseases are prone to fulminant hepatitis failure, and thus immunization is necessary [6].
The mortality rate from this disease is slightly higher than 80% in case of getting into deep coma [1]. It is worth noting that fulminant hepatitis A is a rare problem in young individuals without any underlying disease. Hepatitis A is a self-limited disease in children, but symptomatic in adults. Reports indicate high rate of fulminant hepatitis in patients with an underlying chronic liver disease without cirrhosis in Italy [7] [8] [9] whereas it is unusual among children and rare in adults [10] [11] [12] [13] and [14].
In patients introduced to us, young individuals with acute hepatitis A have got into a state of deep coma and completely recovered. Our patients have not positive family history of hepatitis or liver failure. Our patients did not mention any history of acute hepatitis B or C.

Case Presentation
First case: Second case: The second patient was a 20-year-old male athlete and student from Lenjan. The patient did not mention any history of having a specific disease but he had a contact to Karbala travelers.
At admission, he experienced loss of consciousness and had icterus, but no organomegaly was observed; in addition, his BP and T levels were 120/90 and 39 respectively.
We observed in lab data HAV IgM  Third case: The case was a 20-year-old male employee from Isfahan who visited Al-Zahra Hospital for developing nausea, vomiting, and discolored urine, followed by ic-  (Table 3). Although, the ultrasound examination of the patient showed a mild increase in hepatic echogenicity, the liver size  was normal. Ultrasound results of the patient were normal during the hospitalization period. After the administration of the maintenance treatment with lactulose and a high-carbohydrate diet, the symptoms were eliminated and test results became normal.

Discussion and Conclusions
In this study, two patients had travelled to Karbala (Iraq) and one patient had travelled to Khuzestan (Iran) before the admission but he had contacted with Their diets were high carbohydrate and also lactulose syrup was prescribed.
The authors report a cluster of 5 serologically-confirmed cases of acute Hepatitis A Virus (HAV), all serum IgM positive for HAV Genotype 1A. This is on a background of only 2 other cases notified to HSE-South in 2016 to date, both travel related. There was a considerable delay in notification in two out of 5 cases. This case report highlights the importance of prompt notification of Hepatitis A, as timely notification would have facilitated prompt contact vaccination and might well have prevented illness in two subsequent household contacts [15].
Fulminant case is rare but needs to be managed appropriately and may require transplantation in extremely ill patients [15].
Poor hygienic and sanitary condition allow HAV to spread therefore availability of effective vaccine against hepatitis has markedly affected the epidemiology of hepatitis [16].
Paradoxically average age of reported cases is higher than in highly endemic area, perhaps high level virus circulates in a population.
The most serious complication of hepatitis A is fulminant hepatic failure.
Danger signs include excitability, confusion, insomnia, sever vomiting, liver test abnormal and prolonged PT. Laboratory diagnose is helpful .We detected HAVIgM in three cases.
We warn the Karbala traveler about the foodborne and waterborne transmission.
Travelers who acquire hepatitis during trip may transmit to others [16].
HAV can remain infectious for long periods of time [16].
Susceptible persons who travel to endemic area should be vaccinated to prevent infection.