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trop med > Hepatitides > Flashcards

Hepatitides Flashcards

1
Q

Presentation of Hep C?

A

Acute: Typically anicteric - only <25% are apparent
Chronic: persistent HCV RNA at 6 months - fatigue, weight loss, muscle and joint pain, RUQ discomfort

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2
Q

What Is immunoreactive disease?

A

Inflammation kicks in again, ALT rises, become symptomatic again.
This stage risks fibrosis

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3
Q

Loss of Hep B e antigen - what does this mean?

A

Partial host immune response
Not enough to clear the virus entirely

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4
Q

Transmission of hep E?

A

Water or food borne faecal oral

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5
Q

When do you stop Rx in someone with Hep B on Rx?

A

Cirrhosis - lifelong Rx
No cirrhosis - see chart

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6
Q

Cure for Hep D - how do you diagnose?

A
  • Clearance of HDV (suppression of HDV RNA 24 weeks after completion)
  • Clearance of HBV
  • Normalization of ALT levels
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7
Q

Which antigens are implicated in active viral replication in the liver in Hep B?

A

Hep E antigen
Hep S antigen

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8
Q

Classic leptospirosis and pattern of liver involvement?

A
  • Jaundice and fever +/- liver involvement
  • Bilirubin very high
  • Impairment of secretion of conjugated bilirubin as opposed to hepatocellular damage - therefore ALT usually <3 x ULN
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9
Q

Which diseases causes a much higher bilirubin than transaminases?

A

Leptospirosis
Malaria (haemolysis -> shock later)

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10
Q

Clinical presentation of Hep E?

A

Acute icteric hepatitis:
* Occurs in 5-30% of cases (more frequently HEV-1 and HEV-2).
* Lasts 2-6 weeks.
* Prodromal phase (~7d) followed by icteric phase.

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11
Q

Incubation period hep E?

A

2-6 weeks

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12
Q

What Rx should you initiate in Hep B cirrhosis?

A

Tenofavir or entecavir
Entecavir - children!

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13
Q

Risk of Hep D and Hep B together?

A

Fulminant hepatitis in 3-4% of coinfected patients.
Highest risk to patient if they already have Hep B for a long time (better prognosis if contract both at the same time)

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14
Q

Extra hepatic manifestations?

A
  • Neurological: Guillain-Barre syndrome, neuralgic amyotrophy, encephalitis, myelitis.
  • Renal: IgA nephropathy, membranoproliferative glomerulonephritis with or without cryoglobulinaemia, membranous glomerulonephritis.
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15
Q

How is Hep C transmitted?

A

Mainly transmitted trough percutaneous exposure to blood - needles, IVDU, medical devices in developing countries

Also: sexual, MTC

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16
Q

How long until DNA/surface antigen detectable in blood for hep B?

A

4–7 weeks before HBV DNA and HBsAg
become detectable

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17
Q

How do you treat Hep E?

A

Ribavarin for 3 months in immunocompromised patients if persistent RNA Hep E at 12weeks

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18
Q

What will tests show in a resolved Hep B infection?

A

Anti HBs
Anti HBc

Not antigens or DNA

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19
Q

Why is it rare for adults to get Hep A?

A

Previous infection

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20
Q

Extra hepatic manifestations of hep B?

A

*Renal
* Membranous glomerulonephritis
* Membranoproliferative glomerulonephritis

Rheumatologic
* Polyarteritis nodosa

Aplastic anemia

Vasculitis

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21
Q

Diagnosis of leptospirosis?

A
  • Within first week - PCR of blood
  • Urine PCR - better as it stays positive for longer
  • Serology - IgM ELISA or MAT agglutination test after 1st week
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22
Q

What constitutes chronic Hep E?

A

detection of HEV RNA in serum > 6 months

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23
Q

Pathogens causing haemolysis?

A
  • Viruses: CMV, EBV, Hep B and C, parvovirus
  • Bacteria: Leptospirosis, shigella, campylobacter
  • Fungus: Aspergillus
  • Parasites: malaria***
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24
Q

Which hepatitis has the highest rate of HCC and cirrhosis?

A

Hep B

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25
Q

Cure in Hep B?

A

Functional cure:
HBsAg loss
Undetectable levels of HBV DNA in peripheral blood
Could be reactivated if immunosuppressed

Virological cure not currently available but goal is:
Eradication of HBV DNA from blood and liver
Continued positive anti-HBc with or without anti-HBs

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26
Q

What would you advise for a Hep B positive mother re: Rx?

A

If HBV DNA >200,000 -> Rx with TDF
If not, TDF starting 30-32 weeks until 3 months post partum.
C-section not indicated.

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27
Q

When will you see IgG Anti HAV and how long for?

A

7 days following symptom onset

Last for years

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28
Q

What is the Hep A vaccine?

A
  • Inactivated HAV vaccine (age >1y)
  • 2-dose vaccination has 94% efficacy
  • HAV vaccine or immunoglobulin within 2 weeks of exposure.
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29
Q

39 yr old male with fever, jaundice, and bleeding, been in the jungle. Decreased GCS and bleeding. ∆∆?

A

Yellow fever
Dengue
Leptospirosis
Malaria
Hepatitis A/E

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30
Q

What is risk of HCC in patient with Hep C?

A

1-4% a year

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31
Q

Difference between acquiring Hep B infection as adult or neonate?

A

Immunotolerant disease - neonates
Immunoactive disease - adults

Difference is ALT rise (immunoactive)

Very high HBV DNA as very high e antigen (virus is replicating)

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32
Q

What is the difference between Hep E in developed vs developing countries?

A
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33
Q

∆ for entamoeba histolytica in context of liver abscess?

A

Drain abscess, antigen testing of fluid
ELISA against galactose-lectin antigen

Fluid culture - usually negative for trophozoites as they are in the wall of the abscess

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34
Q

Why do HIV drugs also work for Hep B?

A

DNA virus but becomes RNA and back to DNA again - reverse transcriptase responsible for the RNA part, HIV drugs can work here!

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35
Q

What is the Rx for Hep C?

A

Interferon free DAA (direct-acting antiviral) regimens

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36
Q

∆∆ hepatocellular injury causing jaundice?

A
  • YF - renal failure usually involves **proteinuria! Transaminases much higher than the bili
  • Dengue - no proteinuria
  • Acute fulminant hepatitis
  • Rift Valley fever - depends on epidemiology
  • Shock e.g. sepsis, cholera
  • Leptospirosis - do not get hepatocellular injury
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37
Q

Complications of Hep A?

A

hepatic failure, relapsing hepatitis, prolonged cholestasis, autoimmune hepatitis

Extra hepatic? Rash, arthritis, vasculitis

38
Q

What is the family and genus of hepatitis E?

A

*Family: Herpeviridae
*Genus: Orthohepevirus

4 genotypes HEV 1-4

39
Q

How long are patients contagious with Hep A?

A

Incubation period and 1 week after onset of jaundice

40
Q

What test can you do in resource poor settings to differentiate between fibrosis and cirrhosis? What about resource rich?

A

AST to platelet ratio index (>2 = cirrhosis)

Fibroscan

41
Q

How many patients with chronic Hep B will develop cirrhosis?

A

25%

42
Q

How do you monitor for Hep B related HCC?

A

Ultrasound every 6 months

43
Q

What happens when immune response kicks in for hep B?

A

Lose the Hep e Antigen
low viral load
No to mild inflammation of liver, asymptomatic

44
Q

Transmission of Hep D?

A

IVDU and other parenteral exposure
Sexual
Interfamilial
Perinatal

45
Q

Causes of conjugated/direct bilirubin rise?

A

Post hepatic
Some causes of hepatocellular damage

46
Q

Transmission of Hep A?

A

Faecal oral (contaminated food/water)

47
Q

Pattern of liver dysfunction in hep A?

A

ALT > AST
Liver enzymes >1000
Bilirubin not that high (<100)
Mildly raised ALP
Transaminases rise before bili

  • Alcohol and YF cause AST>ALT
  • Lepto - very high bili
  • Peak of bilirubin 7-10 days after onset of jaundice, ALT peaks at 1 month
48
Q

Antigens for hepatitis B?

A

Core antigen
Surface antigen
Envelope (E) antigen

49
Q

∆∆ of jaundice causing Intrahepatic cholestasis

A

Lepto **
Brucella - ** - transaminase rise
Typhoid - *** - transaminase rise
TB miliar disseminated
Pyogenic abscess
Ameobic abscess
Hep A with cholestasis
Non infectious/drugs

50
Q

When do you stop Rx in someone with Hep B on Rx?

A

Cirrhosis - lifelong Rx
No cirrhosis - see chart

51
Q

How do you diagnose chronic Hep B?

A

Defined as detection of HBsAg
on 2 occasions measured 6 months apart

52
Q

Single biggest risk factor for hep A?

A

Lack of access to clean water/sanitation

53
Q

What type of virus is Hep C?

A

*Family: Flaviridae
*Genus: Hepacivirus

54
Q

What do you see on liver biopsy in yellow fever?

A

Condensed chromatin in nucleus known as councilman bodies, with little inflammatory cells surrounding

55
Q

What do you need for infection with Hep D?

A

Hep B infection

56
Q

What type of virus is Hep A?

A

*Family: Picornaviridae
*Genus: Hepatovirus

57
Q

Partial cure in Hep B?

A

Continued detection of Hep B surface antigen (last one to go) but Hep B DNA <2000iu/ml

58
Q

Goal of Rx of Hep B?

A

Lose the Hep B s antigen
Undetectable Hep B DNA

59
Q

What are the WHO guidelines for Rx of Hep C?

A
60
Q

What does surface antigen in blood mean?

A

Hep B infection (screening test)
Does not tell you acute vs chronic

61
Q

How do you test for Hep E?

A

detection of anti-HEV IgM
HEV RNA detectable

62
Q

Prevention of Hep E and Hep A?

A

Boiling and chlorination of water
Heating food
Screening blood banks

63
Q

Diagnosis of Hep D?

A

HDV RNA (HDAg - very short-lived)

Anti-HDV IgM* Positive in acute infection
Anti-HDV IgG

HBsAg must also be present

64
Q

Hepatic complications of Hep E?

A

0.5-4% fulminant hepatic failure

Chronic infection: HEV-3 & HEV-4 - immunocompromised

Pregnant patients - higher risk of fulminant liver failure with high mortality risk

65
Q

Drug options for Hep C?

A
66
Q

Is there vaccine for Hep E?

A

Vaccine: recombinant vaccine. 3-dose series has >99% efficacy.

Licensed only in China for people >16y.

67
Q

Who are most at risk of chronic hep B infection?

A

Children!
90% of infants <1 year
30% of children aged 1-5 y
5-10% of adults

68
Q

Who should get treated for Hep C?

A

Anti HCV antibodies and HCV RNA at 6 months

Recommended for all people (adults and children) with acute or chronic HCV infection.

69
Q

How many people develop acute hep B infection? Symptoms?

A

1/3
Fever, fatigue, malaise, jaundice, abdo pain

70
Q

Which helminths cause cholangiocarcinoma?

A

Chlonorchis sinensis and Opistorchis viverrini

71
Q

29 year old female, onset of jaundice and fever 7 days ago. Febrile, heptaosplenomegaly, low Hb, low WCC, retics 12%, bili raised (indirect), LDH, ALT 2x ULN. ∆∆?

A

Babesia
Dengue
Malaria*** - strain depends, usually falciparum can be vivax (rare but can happen)
Bartonella bacilliformis causing Oroya fever
Snake and spider bites

72
Q

Incubation period for Hep A?

A

14-28 days

73
Q

Which test for Hep A and when?

A

IgM anti-HAV

If patient is symptomatic -> IgM probably effective

74
Q

Causes of unconjugated/indirect bilirubin rise?

A

pre hepatic/hepatic

75
Q

What is the window period in Hep B and how do you diagnosis Hep B in this period?

A

HBsAg coming down - too low to detect
Anti HBs not yet high enough

Must test anti Hep core IgM in this period

76
Q

What should you do if a patient is IgM positive?

A

Test for HEV RNA
If immunocompromised, always test HEV RNA if clinical suspicion even if IgM negative (do not mount response)

77
Q

What do you see under an electron microscope for hep B?

A

Dane particle (main virus)
Subviral particles shed nearby (contain surface antigen)

78
Q

Rx consideration for Hep D?

A

PEG-Interferon alpha for 1 year

Consider adding on nucleotide analogies (TDF)

79
Q

Anti HBc only (not surface)?

A

Previously infected, dormant infection, risk of reactivation

80
Q

Transmission of Hep B

A

Mother to child transmission
Transfusions
Intrafamilial transmissions
Sex
Percutaneous inoculations

81
Q

∆∆ of obstructive jaundice in the tropics?

A

Fasciola hepatica (CBD preferentially)
Chlonorchis sinensis and Opistorchis viverrini (intrahepatic ducts)
Ascaris lumbricoides
Echinococcus granulises (atypically)
Cryptosporidium parvum (rarely)
Non infectious causes

82
Q

If no cirrhosis but Hep B positive, how do you determine who needs Rx? (Resource limiting settings)

A

Age, ALT and HBV DNA

83
Q

What are the phases of Hep A?

A

Prodromal <7 days: fever, malaise, anorexia, abdo pain, N&V
Icteric >7days: jaundice, dark urine, pale stools, HM

84
Q

Extra hepatic disease manifestations of Hep E?

A
  • Mixed cryoglobulinaemia
  • Vasculitis
  • Atherosclerotic cardiovascular disease
  • Type 1 membranoproliferative glomerulonephritis
  • Focal segmental glomerulosclerosis
  • Interstitial nephritis
  • Type 2 diabetes
  • Lymphoproliferative disease
  • Non-Hodgkin lymphoma and hepatosplenic T-cell lymphoma
  • Porphyria cutanea tarda and lichen planus
  • Hashimoto’s thyroiditis and Graves’ disease
  • Mooren’sulcers and Sjogren’s syndrome
85
Q

Pattern of disease in yellow fever?

A

Period of infection 3-6 days - headache, fever, myalgia,leukopenia, bradycardia (pagets), conjunctival injection

1 day symptoms abate

Period of intoxication 3-6 days - jaundice, hypotension, haemorrhage, convulsions, liver failure

86
Q

What is the classic picture of deranged LFTs in yellow fever? Key differential?

A

Deranged transaminases - very high
AST > ALT

∆∆ - Alc hep

87
Q

What would you expect in immunity to Hep B?

A

Anti HBs

88
Q

73 yr old male with RUQ pain for 2 and half weeks, fever, chills, jaundice, vomiting. 4 months previously had bloody diarrhoea. WCC raised, normal plts, ALT 50, ALP 395. ∆∆?

A

Entamoeba Histolytica
Pyogenic abscess
Typhoid/Paratyphoid (but timing not quite right)

89
Q

How do you test for HCV?

A

*Anti-HCV antibodies (at 12 weeks)
*HCV RNA - confirm and monitor
*HCV core antigen can be used as a surrogate of HCV RNA testing
*HCV genotype and subtype determination

90
Q

What is the Hep A vaccine?

A
  • Inactivated HAV vaccine (age >1y)
  • 2-dose vaccination has 94% efficacy
  • HAV vaccine or immunoglobulin within 2 weeks of exposure.
91
Q

What are the Rx of all the hepatitides?

A

A - nil
B - TDF (or entecavir children)
C - Interferon Alpha DAA
D - interferon alpha
E - Ribavarin

92
Q

What does it mean if
1) HBsAb positive only?
2) HBsAb positive and HBcAb positive?
3) HBcAb positive and HBsAg positive?

A

1) immunity from vaccination
2) Immunity from previous infection
3) Chronic infection

trop med (49 decks)

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