Detecting Hepatitis Infection in the Emergency Department

Abstract

Objectives & BackgroundHepatitis (HBV&HCV) testing in the UK is currently targeted at groups perceived to be at high risk. Late diagnosis is common. Initial infection may only be accompanied by a mild illness or be completely asymptomatic. Chronic infection can occur and may progress to liver fibrosis, cirrhosis, decompensated liver disease or hepatocellular carcinoma if untreated.1Early diagnosis and treatment are effective in reducing disease progression (HBV) or elimination of the virus (HCV).Our aim was to determine the potential for blood borne virus testing within the ED and to evaluate the burden of HBV/HCV in our local population.MethodsPatients over the age of 16 were offered Hepatitis B (Surface antigen) and Hepatitis C (IgG antibodies) testing, if they required venepuncture during their ED attendance, in a 6 week period from 15th February 2016–27th March 2016. Tests were ordered using a pre-configured order-set including a pre-selected Hep BsAg and HepC IgGAbs. Patients were informed of the intention to test all attendances and were able to opt out if desired. Positive test results were followed up at a rapid access one-stop clinic.ResultsOver a 6 week period, 3073 (49%) and 2982 (47%) accepted testing for Hepatitis B and Hepatitis C respectively. 1.1% (n=35) tested positive for Hepatitis B surface antigen, indicating acute or chronic infection. 2.2% (n=66) tested positive for Hepatitis C antibodies, indicating current or previous HCV infection. Hepatitis C antigen testing was positive in 1.2% (n=35) indicating current HCV infection.The median age of all patients tested was 45 years (16–100 years) female 51%.HBVantibody positive: median age 42 years (24–82 years), Gender: Male 70% Ethnicity: 40% Black or Black British.HCVantigen positive: Median age 41 years (22–77 years) Gender: Male 72%, 40% White British. Two newly diagnosed patients were eligible to be commenced on direct acting anti-virals. One patient had evidence of cirrhosis on initial fibroscan.ConclusionConsider the ED for opportunistic blood borne virus testing in areas of high prevalence. We achieved testing rates of approximately 50% by use of a pre-configured blood order set and an opt-out policy, resulting in identification of new diagnoses and lost to follow-up patients. Use of a one-stop clinic provides rapid entry to care for positive patients and reduces burden of follow-up for the ED.

Seroprevalence of HCV, HBV and HIV in two inner-city London emergency departments

“…During that week, 27% of eligible patients accepted testing, with 0.8%, 0.7% and 1.8% diagnosed HIV, HBV and HCV, respectively, with the corresponding proportion newly diagnosed 0.3%, 0.5% and 0.7%, respectively [23]. Finally, among attendees at St Thomas’ ED, London 2016, half of persons accepted a test for either HBV or HCV, with a positivity of 1.1% and 2.2%, respectively [24].…”

Blood‐borne virus testing in emergency departments – a systematic review of seroprevalence, feasibility, acceptability and linkage to care

“…We identified 14 seroprevalence studies in populations attending and testing in EDs [12–25] (Figure 2); most were on HIV testing in the USA (see Appendix S2 for further details of the studies), and test positivity in 54 studies within the USA, Canada and Europe, most focused on HIV (see Appendix S2 for further details of the studies) [21, 25–77].…”

False-negative qualitative human chorionic gonadotropin (hCG) test result (‘hook effect’) with classical ultrasound findings of complete molar pregnancy: an uncommon case

“…Molar pregnancy can be highly suspected if transabdominal ultrasound shows a snowstorm sign, an endometrial mass with multiple anechoic spaces, no foetus, and no amniotic fluid. This abnormal scan is unlikely to be missed [ 4 , 6 ], but these features should not be relied on for diagnosis when evaluating molar pregnancies in first-trimester pregnancies [ 7 ].…”

“…Thus, a hallmark of diagnosing molar pregnancy is a positive β-hCG-assay urinary pregnancy test (UPT), in addition to a complete physical and pelvic examination, complete blood count, blood chemistry, and pelvic ultrasound. Interestingly, UPTs can produce false-negative results in the presence of high antigen concentrations (known as ‘hook effect’) [ 4 ]. We report a case of molar pregnancy presenting as abdominal pain and vaginal spotting with multiple false-negative UPTs.…”