Hepatitis Flashcards
Complications of HAV
- Usually improves w/o sequelae w/in 2mos
- relapsing hepatitis - 1 in 7
- during 6mos after acute infection
- prolonged cholestatic hepatitis >12wks
- <5%, resolves spontaneously
hepatitis in pregnancy a/w guillain-barre
HEV
Most effective therapies for tx cHBV
tenofovir (esp HIV)
entecavir
lamivudine - used in HIV, but has high rate of R development (30%)
Important complication of tx of HCV
HBV reactivation w/ flares of hepatitis, occasionally severe enough to require liver transplant or result in death
Who to screen for HCC in chronic HBV infection
- all pts w/ cirrhosis
- Asian M >40yo; Asian F >50yo
- African >20yo
- FH of HCC
Frequent extrahepatic manifestations of HCV
- AI thyroiditis
- B-cell NHL
- lichen planus
- porphyria cutanea tarda
- cryoglobulinemia: vasculitis, glomerulonephritis
Genotypes of HEV
- Genotype 1,2 - Asia, N Africa
- no animal reservoir
- Genotype - endemic in swine - butchers and farmers
Endemic in most of the developing world
Infectious related causes of hepatic parenchymal disease
- ART toxicity: ABC, nevirapine (classically). Can be seen with almost all ART
- Malignancy: KS, HCC
- Biliary disease: AIDS cholangiopathy
Common cause of hepatitis in children
worsened liver failure w/ chronic HBV/HCV
think parvovirus B19
exposure: contaminated water
jaundice, abd pn, + fever/HA/myalgias
consider lepto
Travel to SA or Africa
range from mild febrile illness to fulminant liver failure
consider yellow fever
Persons w/ isolated HBcAb+ in high-risk groups (BMT, SOT, ritux, HDS)
represents occult HBV most commonly
- need vaccination
- (note: if HBsAg+ –> need ppx always)
Tx HBV if…
- GFR 30-60
- GFR 10-30
- GFR <10 (no RRT)
- RRT
- GFR 30-60: TAF
- GFR 10-30: TAF or entecavir
- GFR <10 (no RRT): entecavir
- RRT: TDF or TAF or entecavir (anything)
When to tx pregnant women with HBV
*rec all pregnant women have HBV DNA
Tx if DNA >200k
The 4 preferred tx for chronic HBV
- Entevacir
- TAF
- TDF
- Peg-IFN
When to tx HBV
when high replication plus disease (ie liver damage) - phases 2 and 4 of natural history
- w/ HBeAg positive disease: limits are ALT >2xULN and DNA >20k
- w/ HBeAg negative disease: limits are ALT>2xULN and DNA >2k
HBV Disease Phase:
HBsAg negative
HBeAg-
HBV DNA <10
ALT normal
Liver disease none
resolved HBV infection (HBsAg-/anti-HBc Ab+)
(Phase 5)
HBV Disease Phase:
HBsAg - intermediate
HBeAg -
HBV DNA >2k
ALT elevated
Liver disease mod/sev
HBeAg- chronic HBV
(Phase 4)
*req tx
HBV Disease Phase:
HBsAg low
HBeAg -
HBV DNA <2k
ALT normal
Liver disease none
chronic HBC infection - inactive carrier
(Phase 3)
*latent/nonreplicative phase
HBV Disease Phase:
HBsAg high/intermediate
HBeAg +
HBV DNA 10^4-10^7
ALT elevated
Liver disease mod/sev
chronic HBV - immune reactive (Phase 2)
*req tx
HBV Disease Phase:
HBsAg high
HBeAg +
HBV DNA >10^7
ALT normal
Liver disease none/minimal
Chronic HBV infection - immune tolerant
(Phase 1)
Essential evaluation with chronic HBV
eAg, HBV DNA, HDV, genotype
HIV
stage (LFT, elastrography or bx)
renal status
u/s to r/o HCC (Asian, M>40yo, F>50yo, AA>25-30yo)
Which HCV regimen to avoid in pts with HIV on PI
grazoprevir (an HCV PI)
PIs interact (similarly, boosters will effect levels)
Which HCV regimens have concern with tenofovir?
sofosbuvir (TDF can increase sofosbuvir)
Which HCV regimens are safe with ESRD?
all are
Which HCV regimens are pangenotypic?
- glecaprevir/pibrentasvir
- sofosbuvir/velpatasvir
Usual answers for tx-naive HCV 1a
- *sofosbuvir/velpatasivir x12 weeks
- glecaprevir/pibrentasivir x8wk
Equation that could be helpful in determining likelihood of cirrhosis in HCV
FIB 4
= age (yrs) x AST (U/L) / plt count x ALT^1/2
(FIB4>fibrosure - though fibrosure still tends to be used for insurance purposes)
Accepted staging methods for HCV
liver bx
blood markers
elastography
or any combo of the above
HBsAg+
anti-HCV negative
polyarteritis nodosa
HCV
palpable purpura (often on LEs)
cryoglobulin vasculitis
HCV
pruritic rash
lichen planus
HCV
blister in sun-exposed areas
porphyria cutanea tarda
Hepatitis in pregnancy
- Rule out viral hepatitis (including HSV, as, though 50% will have MC lesions, hepatitis can occasionally be only presenting symptom)
- R/o meds
- HELLP
- AFLP - severe + low glucose, low fibrinogen
Hepatitis with Travel to Developing Country
Bacterial causes of hepatitis
Cholestatic
- coxiella burnetti
- spirochetes (syphilis, lepto)
bacterial sepsis, liver abscess
Brucellosis
TB
Typhus
low platelets, leukopenia
often hepatitis
exposure
Rickettsia/Ehrlicia
- acute hepatitis (bili>LFTs - cholestatic)
- multiorgan: kidney, eyes, skin, muscle, lungs
- exposure to fresh water (rafting in Hawaii or Costa Rica) OR rats (homeless or cabins)
leptospirosis
IDU, HIV + MSM
with acute elevated LFTs
think HCV
(most likely cause of acute hepatitis in these populations)
fulminant hepatitis in someone with either acute or chronic HBV
HDV
HAV post-exp ppx
- vaccinate and possibly IG
- unless >40yo or immunocompromised - then maybe just IG)
- all close exposures (not casual exposures)
MCC of acute hepatitis in the US
HAV
extrahepatic complications of HEV
GBS and other neuro manifestations
pancreatitis
Outbreaks - contaminated water Asia/Africa
Sporadic - undercooked meat (BOAR, deer)
**Overseas travel typical
Hep E
