An Evaluation of Two Screening Tests for

the Detection of Early and Sub-icteric

Viral Hepatitis* WILLIAM E. SWIFT, JR., M.D., WADE N. MILLER, M.D.,

New Haven, Connecticut Upton, New York

FRANKLIN H. STREITFELD, M.D. and MARJORIE KNOWLTON, H.S.

New York, New York

T

HE lack of a specific immunologic test for viral hepatitis makes it necessary to rely on clinical and

epidemiologic evidence in addition to cer- tain tests of hepatic function for diagnosis. When jaundice occurs the problem is usually not difficult, particularly in younger patients. However, when jaundice is absent the diagnosis of viral hepatitis is frequently not suspected. It is not known how often non-icteric hepatitis occurs’ and estimates of its frequency have ranged from one to eight persons for every patient with jaun- dice.2 Actually, it is entirely possible that mild forms of disease without icterus may occur far more frequently than is expressed by such ratios. There is good evidence to suggest that at least one form of the disease, infectious hepatitis, is, widely distributed. The fact that normal human gamma globu- lin, administered parenterally, will prevent this disease when given during the incuba- tion preiod suggests that the virus is dif- fusely spread and that infection in man, with resultant production of immune sub- stances, occurs frequently.3.4

Although no specific serologic test is available, certain tests of hepatic function become positive early in the pre-icteric phase of disease. Thus it has been shown that bilirubin and increased amounts of urobilinogen often appear in the urine as the first demonstrable evidences of viral

Munich, Germany

hepatitis.5 Since the tests for these two substances are easy to perform, an attempt was made to evaluate their usefulness in detecting early or non-icteric cases of viral hepatitis in persons suspected of having the disease or in groups in which cases with jaundice had occurred. It is the purpose of this paper to report the results of such tests in three groups of American troops in Germany. This study was undertaken by the Hepatitis Research Team in co-opera- tion with the 4th General Medical Labora- tory and the Branch of Preventive Medi- cine, Office of the Chief Surgeon, European Command, U. S. Army.

METHODS AND MATERIALS

Subjects. Three groups of men were selected for study. Group I was comprised of men in two Engineer Companies in Hanau, Germany, who had been having a greater than expected inci- dence of viral hepatitis for several months. Specimens of urine from 388 men present for duty were tested for bilirubin and urobilinogen at the beginning of the study, specimens from 399 men two weeks later and from 380 men six weeks later. Group II was comprised of twenty- two men in an Air Force Squadron in Hof, Germany, who had sustained a small outbreak of food-poisoning. They were tested three weeks after the outbreak because one man developed viral hepatitis at this time. One month later, specimens of urine from these men were tested again. Group III was comprised of fifteen men

* From the Section of Preventive Medicine, Yale University School of Medicine, and the 120th Station Hospital (Hepatitis Research Team), European Command, U. S. Army of Occupation in Germany. Representing work done under the auspices of the Commission on Virus and Rickettsial Diseases, Armed Forces Epidemiological Board, Office of The Surgeon General, U. S. Army, Washington, D. C.

MA,‘, 1950 581

582 Screening Tests for Viral Hepatitis-&@ et al.

in an Infantry Regiment in Bamberg, Germany, who reported to their dispensary with com- plaints suspicious of early viral hepatitis. These men were admitted to the hospital for study and treatment.

TABLE I

RELATIONSHIP OF BILIRUBINURIA, INCREASED UROBILINO-

GENURIA AND THE DEVELOPMENT OF VIRAL HEPATITIS

IN MEN EXPOSED TO THE DISEASE

GlYXip Time of ‘rest

I Initial 388 2 wk. later 399 4 wk. later 380

II Initial 4 wk. later

III Initial

* Equivocally positive.

-

! No. of Men

._

._

-

Tested

22 22

15 8 1 15 ) 8

With ,,E;;;ed Developed

ruE:iria Urobilino- Viral

genuria Hepatitis

-I-I- 1 10 1 1 8 1 0 9 0

0 4* 0 0 5* 0

In Groups I and II specimens of urine were collected early in the morning and in Group III

specimens were collected in the early afternoon. A qualitative test for urobilinogen was done on each specimen from subjects in Group I by add- ing 2.0 ml. Ehrlich’s reagent to 2.0 ml. urine in a Wassermann type test tube. This was mixed, allowed to stand for one minute, and 4.0 ml. of saturated sodium acetate solution were added. The presence of more than a faint pink color to the eye was graded as positive from 1 to 4 plus. The same method was used for the tests on the subjects in Group II except that the reading was done in a Coleman Junior Photometer, accord- ing to the method of Schwartz et a1.6 The tests for urobilinogenuria performed on patients in Group III were read in a comparator block.* The presence of bilirubin in the urine was deter- mined according to a modification of Harrison’s test.’

Each person whose urine contained bilirubin or increased amounts of urobilinogen had the following tests of hepatic function performed during the ensuing week: the one-minute and total serum bilirubin,* cephalin-cholesterol floc- culation,g thymol turbidity,‘O and bromsulfalein retention tests.”

RESULTS

The relationship of the results of the tests for bilirubinuria and urobilinogenuria to

* Will Corp., Rochester, N. Y., No. 17185, Uro- bilinogen Comparator Set.

the development of viral hepatitis in the three groups of men is recorded in Table I.

Group I. Specimens from twenty-seven men had increased amounts of urobilinogen and two of them contained bilirubin. The other tests of hepatic function which were made in these twenty-seven men from one to six days later were normal in twenty-one men. Six men had an increase above nor- mal in one or more tests. Two of these men who were asymptomatic at the time when they had bilirubinuria and increased uro- bilinogenuria developed viral hepatitis. One of them had jaundice; the other man remained asymptomatic but still had in- creased retention of bromsulfalein one month later. A third man had increased retention of bromsulfalein (9.25 per cent) but unfortunately a second determination was not made so that no definite conclusion can be made about him. Three others had transitory, slight increases in serum bili- rubin (two) and retention of bromsulfalein (one) about which it is impossible to draw conclusions although it is not likely that the alterations were of any significance.

Group II. None of the twenty-two sub- jects in this group had positive tests for bilirubin at the first examination; four of them had equivocal increases in urobilino- genuria. When these tests were repeated in the same persons one month later, the tests for bilirubinuria were again negative. Of the four who previously had equivocal increases in urobilinogenuria, three were normal and one remained equivocal. Four others previously normal had equivocally positive tests for urobilinogenuria on the second examination. Other tests of hepatic function in these five persons who showed equivocally positive tests for urobilinogen- uria at the time of the second examination were all normal except for one obese subject whose retention of bromsulfalein was 6.4 per cent or greater on three occasions.* None of the persons in Group II developed clinical evidence of hepatitis during the

* Five per cent retention (45 minutes after the intra- venous injection of 5 mg. dye/kg. body weight) is regarded as the upper limit of normal as the test is performed in this laboratory.

AMERICAN JOURNAL OF MEDICINE

Screening Tests for Viral Hepatitis-&+ et al.

month between tests nor for several months following the period of observation.

Group ZZZ. Eight of the fifteen men in this group developed viral hepatitis. Six of them had bilirubinuria and all had in- creased urobilinogenuria. Of the remaining seven men who failed to develop any addi- tional evidence of hepatitis, bilirubinuria was present in two, and all had an increased amount of urobilinogen in the urine. It is possible that some or allof these persons may have had transitory non-icteric hepatitis.

COMMENT

The data presented here indicate that the demonstration of bilirubinuria and increased urobilinogenuria in ten patients exposed to viral hepatitis was of value in the early diagnosis of hepatitis which subse- quently developed with jaundice in nine and as the non-icteric disease in the tenth person. It is possible that certain other persons with transitory, mild alterations in various tests of hepatic function represented cases of non-icteric viral hepatitis. The test for bilirubinuria is applicable for use in large numbers of persons due to its ease of performance, In addition, in the studies reported here bilirubinuria was a far more reliable sign of hepatitis than increase in urobilinogenuria although in three patients the latter test was positive before bilirubi- nuria occurred. This is in accord with the results of others and suggests that both tests be employed for detection of early or non-icteric cases. Since there is no specific serologic test available, the use of these tests, particularly in localities where viral hepatitis occurs in epidemics or is of frequent sporadic occurrence, may yield information of epidemiologic value.

SUMMARY

1. Tests for bilirubin and urobilinogen were performed on 1,226 specimens of urine from American soldiers who had been exposed to viral hepatitis.

2. These tests were of value in making an early diagnosis in the pre-icteric phase of nine patients who subsequently became jaundiced and in one patient with non- ‘icteric hepatitis. Eight of these patients had

MAY, 1950

symptoms suggestive of early viral hepatitis when the tests were made.

3. The apparent reliability and ease of performance of these tests suggest their possible value in epidemiologic surveys of groups exposed to viral hepatitis.

Acknowledgment is made herewith of the assistance from the following individuals: Lt. Col. Hartwin A. Schulze, Preventive Medicine Branch, Chief Surgeon’s Office, EUCOM, and Capt. Emil W. Johnson, T/Sgt. Clyde F. O’Brien, S/Sgt. Arnold A. Waldschmidt and Dr. H. Seeliger, all from the 4th General Medi- cal Laboratory, EUCOM.

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