patients may also present with extrahepatic signs and symptoms such as arthralgia, arthritis, or papular acrodermatitis (on face, buttocks, and extensor surfaces of arms and legs) The rash may be associated with lymphadenopathy and fever (Gianotti–Crosti syndrome), and has been reported with several viruses although HBV is the most common Onset of the icteric phase of acute hepatitis most commonly is temporarily associated with improvement in the constitutional symptoms In up to 15% of cases, severe fatigue, anorexia, nausea, and vomiting persist The icteric period usually lasts to weeks Occasionally, the jaundice is prolonged for to weeks, with increasing pruritus at to weeks A number of infectious agents may mimic a viral hepatitis-like illness The most common are EBV (infectious mononucleosis) and CMV Both agents rarely produce clinical jaundice, and high fever and diffuse adenopathy are more characteristic Less common agents include herpes, adenovirus, coxsackievirus, rheovirus, echovirus, rubella, arbovirus, leptospirosis, toxoplasmosis, and tuberculosis Management/Diagnostic Testing Most causes of hepatocellular injury are associated with an AST elevation that is lower than that of ALT An AST to ALT ratio of 2:1 or greater is suggestive of alcoholic liver disease, particularly in the setting of an elevated GGT, although much more common in the adult population The following laboratory tests should be performed in all cases of suspected viral hepatitis: serum transaminases (AST and ALT), alkaline phosphatase, serum GGT, total and direct bilirubin, CBC, PT, electrolytes, BUN, glucose, total protein, albumin, and globulin AST and ALT are the best indicators of ongoing hepatocellular injury, although it is important to note that in those with chronic and advanced disease, ALT and AST may be normal or only mildly elevated despite significant damage and fibrosis Alkaline phosphatase levels are usually less than two times the upper limit of normal for age Levels greater than three times normal should raise suspicions of EBV or CMV hepatitis or biliary tract disease Hepatitis classically produces direct fractions of serum bilirubin in excess of 30% of total, indicating definite liver disease Hyperbilirubinemia may be present in the absence of scleral icterus or jaundice because these signs usually cannot be appreciated until levels of total bilirubin exceed to mg/dL Serum bilirubin levels peak to days after the onset of jaundice