A 28-year-old man from rural India presents with jaundice, dark urine, and abdominal pain for 5 days. He has no history of intravenous drug use, tattoos, or sexual contact with known hepatitis B carriers. Liver function tests show ALT 2800 IU/L, AST 2200 IU/L, bilirubin 8.2 mg/dL, and INR 1.1. HBsAg is negative. Anti-HAV IgM is positive. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis **Key Point:** Anti-HAV IgM positivity confirms acute hepatitis A infection. The negative HBsAg and absence of risk factors for blood-borne transmission rule out hepatitis B, C, or D. ## Management of Acute Hepatitis A ### Pathophysiology & Natural History Hepatitis A is a self-limited RNA virus infection that causes acute hepatitis but does NOT progress to chronic disease. Even in fulminant cases, the prognosis depends on supportive care and monitoring for complications, not antiviral therapy. **High-Yield:** Hepatitis A has NO specific antiviral therapy. The mainstay of management is supportive care. ### Appropriate Management Steps 1. **Supportive care** — fluid balance, nutritional support, rest 2. **Monitor for fulminance** — INR, bilirubin, encephalopathy, renal function 3. **Infection control** — counsel on fecal-oral transmission; strict hygiene; avoid food preparation for others 4. **Prognosis** — >99% of adults recover completely; mortality <1% except in those with underlying cirrhosis ### Why INR is Normal Here INR 1.1 indicates preserved synthetic function, suggesting this is acute hepatitis without fulminant failure. Continued monitoring is essential. **Clinical Pearl:** Fulminant hepatic failure (INR >1.5, encephalopathy) in acute HAV warrants ICU admission and consideration of transplantation, but antiviral therapy does not alter outcome. ## Why Other Options Are Incorrect | Option | Why Wrong | |--------|----------| | Sofosbuvir | Hepatitis A is RNA virus but self-limited; antivirals do not shorten course or prevent fulminance; not indicated | | Hepatitis B vaccine | No indication; patient is HBsAg-negative; vaccination can be given after recovery if non-immune | | Liver biopsy | Unnecessary in acute HAV with clear diagnosis; biopsy is for staging chronic disease, not acute self-limited infection | [cite:Harrison 21e Ch 297]