13. Viral Hepatitis Flashcards
1
Q
Acute viral hepatitis in the US is most commonly due to
A
HepB (51%)
2
Q
What is the most common cause of chronic viral hepatitis in the US?
A
HepC
**B is the second MCC
3
Q
What kind of genome does HAV have? Transmission?
A
RNA virus
Fecal-oral
**single serotype, only infects humans
4
Q
Incubation period of HAV
A
Mean 4 wk
2-6 wk range
5
Q
Who gets symptomatic HAV infection?
A
Adults 70-80%
Only 10% children with infectious are symptomatic
6
Q
Fatality with HAV infection
A
Overall 0.3%
1.8% over 50 yo
7
Q
Chronicity with HAV and HEV?
A
NO
8
Q
Where is there a high prevalence of HAV infectious?
A
South America
Africa
Southeast asia
9
Q
What body fluid have the highest concenrtation of HAV?
A
Feces **
Serum
Saliva
10
Q
What is the most common method of transmission of HAV?
A
Personal contact **
Day care centers
Foreign travel
Food outbreaks not very common
11
Q
Who is more at risk for HAV infection?
A
Children
Though adults are at lower risk for infection, they have higher mortality
12
Q
What rises first following HAV, aside from fecal HAV?
A
ALT level spikes
13
Q
What are the two components of the anti HAV antibody and what is their trajectory?
A
IgM anti-HAV: rises and falls, marks acute infection
IgG anti-HAV: rises and persists, resistance
14
Q
Transmission of HEV
A
Fecal oral
Contaminated drinking water
Minimal person to person contact
15
Q
What is the incubation period for HEV?
A
40 days
16
Q
What is the general fatality for HEV? Who has a higher fatality rate?
A
1-3%
Pregnant women 15-45%
17
Q
Where is HEV most common?
A
Northern Africa
SE asia
18
Q
What does the IgM increase in HEV infectious coorespond to?
A
Acute bout of hepatitis
19
Q
What kind of genome does HBV have? What does it infect?
A
DNA virus
Humans, some primates
20
Q
What is the incubation period of HBV?
A
60-90 days
21
Q
Acute case fatality for HBV
A
0.5-1%
22
Q
What determines the chronicity of HBV infection?
A
Age of exposure
23
Q
What is HBV infection the leading cause of worldwide?
A
Hepatocellular carcinoma
24
Q
What is the distribution of HBV
A
Africa
SE Asia
Alaska
25
What is the difference between children and adults being exposed to HBV?
Children: VERY HIGH chance of chronicity
Adults: Low risk of developing chronicity, but more likely to have a symptomatic infection
26
What body fluids have a high concentration of HBV? Moderate? Low?
High: blood, serum, wound exudates
Moderate: semen, vaginal fluid, saliva
Low: urine, feces, sweat, tears, breastmilk
27
What is the #1 risk factor for transmission of HepB?
Heterosexual transmission
28
What two levels rise and then fall with acute HBV infection with recovery? Which one does not fall in a chronic infection?
HBsAg **doesn't fall in chronic infection
| IgM anti-HBc
29
What increases 8 weeks after HBsAg levels disappear?
anti-HBs
| **window period between
30
The presence of ___ indicates immunity to HBV
Anti-HBs
31
What defines chronicity of HBV infection?
Presence of HBsAg for over 6 months
32
In HBV infection, what indicates infectivity?
HBeAg
33
What is the term for development of anti-HBe in HBV infection without immunity?
Seroconversion
34
What two components remain high in a chronic HBV infection?
Total anti-HBc (high in recovery too)
| HBsAg
35
What is a key difference between the development of cancer from HBV vs HCV?
HBV: Cancer can develop from cirrhosis or directly from chronic infection
HCV: Chronic infection must progress through cirrhosis to cause cancer
36
Risk for children vs adults to develop chronic from acute HBV infection
Children >90%
| Adules <5%
37
What % of people with chronic infection develop cirrhosis? Liver cancer directly?
30%
| 5-10%
38
What are two potential consequences of cirrhosis from HBV infection?
Liver failure 23% in 5 yr
Liver cancer
**both make patients candidates for transplant
39
When is the only time you can get HDV
In conjugation with HBV infection
40
What are the two ways that HDV infection can occur?
Coinfection: more severe, but less likely to become chronic
Superinfection: greater risk of chronic disease
41
What happens to IgG in HDV infection
Typically cleared from the bloodstream
42
HCV has both ___ and ___ genes
Structural
| Non-structural
43
What type of genome does HCV have? half life? daily virion production
RNA
2.7 hr
10^12 virions (very rapid replication)
44
What is the most common genotype of HCV in the US?
Type 1A: 37% **
Type 1B: 30% **
Type 2: 10%
Type 3: 6%
45
Why are different HCV genotypes important?
Respond differently to therapy
46
What is the most common type of HCV transmission?
IV drug abuse
47
When does the ALT spike in HCV infection?
203 months
48
What confirms the dx of HCV infection?
HCV RNA
49
What affects rate of progression to fibrosis in HCV infection?
Factors like alcohol, obesity, etc
50
After the acute phase of HCV infection, what % is resolved and what % is chronic?
Resolved: 15%
Chronic: 85%
51
What % of chronic HCV infection progresses to cirrhosis?
20%
52
What are two possible progressions from cirrhosis in HCV infection?
1. ESLD (6%/yr)
| 2. HCC (4%/yr)
53
What is the #1 indication for transplant in the US?
ESLD or HCC due to HCV
54
Does HepC have a fulminant hepatitis stage?
No--damage takes time
55
What are the clinical manifestations of acute viral hepatitis?
```
Fever
Malaise
Anorexia
Nausea/vomiting
Jaundice
Abdominal/RUQ pain
Hepatomegaly
```
56
What does it mean if a person is + for HepA antibody by negative for IgM?
Person had pervious exposure and is immune
57
How can HepA be prevented?
Hygiene
Sanitation
Immune globulin (pre and post exposure)
Hepatitis A vaccine (pre exposure)
58
What 4 types of people should get the HepA vaccine?
1. Infants
2. People traveling to endemic areas
3. People with chronic liver disease
4. People working with HAV
59
Who should get pre-exposure immune globulin for HAV?
Travelers going to endemic areas who are leaving within two weeks, making the vaccine ineffective
60
Who should get post-exposure immune globulin?
People with household or intimate contacts
Outbreaks in institutions
Common source exposure (Taco Bell)
61
What does it mean if a patient is IgM + for HEV?
Acute HepE infection
62
What is consistant with acute disease in HBV infection?
IgM anti-HBc
63
What must be used for dx of HBV infection in the window period?
IgM anti-HBc
64
What does HBsAg + indicate?
Current HepB infection, acute or chronic
65
What does anti-HBs + indicate?
Immunity
| **cant tell if this is from vaccine or natural infection
66
How do you tell if anti-HBs is from vaccine or a natural infection?
Presence of core antibody--will only be present with natural infection
IgM--recent exposure
IgG--old exposure (>6mo)
67
What is the most important indication for HBV vaccine?
People occupationally exposed to blood or body fluids
68
What makes the HBV vaccine less effective?
Old age and debilitation
69
What are two options for hepatitis B exposure in unvaccinated patients?
1. Giving hepatitis B immune globulin within 24 hr, up to a week after-->second dose 1 mo after the first
2. HepB vaccine within 24 hr, up to a week after -->second dose 1 mo after and third dose 6 mo after
70
What should be done in the case of a HBsAg + mother giving birth?
Newborn should get boths HBIG and vaccine
| **90% risk of vertical transmission without treatment
71
What are the goals of HepB therapy?
1. Repress HBV replication
2. Prevent cirrhosis and HCC
3. ALT normalizaiton
4. Histologic improvement
5. Loss of HBeAg and seroconversion to anti-HBe
6. Loss of HbsAg ******
72
What are the two modes of tx of chronic HBV infection?
Interferon:cytokines released by host cells, activate the immune system
Antiviral therapy: block reverse transcriptase which is needed for HBV replication
73
What is the main drawback of interferon tx?
Flu like sx: headaches, fevers, and muscle aches
74
What are the two first line tx for HBV therapy?
Entecavir and Tenofovir: associated with low levels of resistance (anti virals)
75
What treatment can be used along with entecavir and tenofovir in a very specific population of people with HBV infection (low viral load, high ALT/AST)
Peg-IFN
76
What are the SEs of Peg-IFN?
Flu-like sx
Neuropsychiatric sx and depression
Bone marrow depression
77
When is HepD IgG more likely to persist
With superinfection
78
What indicates acute HepD infection? Previous exposure?
IgM
| IgG **NOT PROTECTIVE
79
What will be the HCV antibody level and viral RNA level if the infection is cleared? Uncleared?
Cleared: anti-HCV + and viral RNA negative
Uncleared: anti-HCV + and viral RNA positive
80
In the case of HCV, ___ is present with all exposures while ___ is present only in those that are viremia
HepC antibody
| HepC RNA
81
What is the standard of care for HCV therapy?
Interferon-based therapy (immune activation)
82
Eradication rate for genotype 1? Genotype 2/3?
50-60%
| 80-90%
83
Eradiation rates for HCV are based on:
Undetectable virus 6 months after completion of therapy
84
What is the next step for a patient with high transferrin saturation?
HEF testing
85
What antibody will most likely be high in a woman with dry eyes and elevated liver enzymes with VERY HIGH ALP?
Anti-mitochondrial antibody
86
What tx is appropriate for a patient with AIH?
Prednisone
| Azothioprine
87
How do you determine the long term prognosis of a patient with liver disease?
INR
