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Hepatitis Viruses Flashcards

1
Q

Early lab changes in acute hepatitis infection? [3]

A
  1. Leukopenia
  2. Lymphocytosis
  3. AST/ALT elevation
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2
Q

Ddx of acute hepatitis? [7]

A
  1. HSV
  2. CMV
  3. EBV
  4. Leptospirosis
  5. Dengue Fever
  6. Yellow Fever
  7. Toxic exposures [tylenol, mushrooms]
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3
Q

Ddx of chronic hepatitis? [4]

A
  1. Wilson’s
  2. Autoimmune hepatitis
  3. NASH
  4. Drugs
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4
Q

How long are those with acute hepatitis A infective?

A

3-4 weeks before and 1 week after symptoms development.

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5
Q

Diagnosis of acute hepatitis A? [2]

A
  1. Hepatitis A IgM

2. Hepatitis A RNA [blood and stool]

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6
Q

Acute hepatitis A treatment?

A

Supportive.

Fulminant in <1%, may need liver transplant

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7
Q

Complications of Hep A?

A

Prolonged cholestatic hepatitis
–> Lasts >12 weeks
–> Occurs in <5%
Resolves spontaneously.

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8
Q

Phases of lab positivity with Hep A? [5]

A
  1. Viremia [0-6 wks]
  2. HAV in stool [1-5 wks]
  3. IgM starts being made wk 1
  4. AST elevation [2-10 wks]
  5. IgG starts around week 2-3
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9
Q

How many hep b genotypes are there?

A

10 [A-J]

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10
Q

How long can Hep B live outside the body?

A

1 week.

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11
Q

Presentation of acute hepatitis B

A

70% subclinical
Rarely fulminant hepatitis
Jaundice in 30%, fulminant in 0.1%

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12
Q

Treatment of acute hepatitis B

A

Supportive unless fulminant or HIV co-infection.

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13
Q

Likelihood acute Hep B will become chronic?

A
  1. > 90% of infected neonates
  2. 25% of 1-5 year olds
  3. <5% of adults
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14
Q

Extrahepatic manifestations of chronic hep B [2]

A
  1. Polyarteritis nodosa

2. Renal disease

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15
Q

What is precore and core promoter mutations?

A

Causes HBeAg production to be reduced or prevented

Infectious virions are still produced

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16
Q

What is the immune tolerant phase of chronic hep B

A
  • High levels of HBV replication
  • NO evidence of active liver damage
  • Lasts 10-30 years
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17
Q

What is the immune clearance [immune active] phase of chronic hep B

A
  • Increased rate of spontaneous HBeAG clearance with HBeAb seroconversion
  • Exacerbations of active hepatitis with raised ALT
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18
Q

What is the inactive carrier state of chronic hep B?

A
  • HBV DNA undetectable
  • No liver disease
  • May reactivate with immune compromise.
  • Consider HBV cAb if immune compromising medications are needed
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19
Q

What is reactiviation HBeAg negative chronic hep B?

A
  • Active HBV replication with active liver disease
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20
Q

What does Anti-HBc IgM represent?

A

Recent infection [<6 months]

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21
Q

Interpretation of +surface antigen, +core IgG, +envelope antigen, +/- envelope antibody, HBV DNA high, ALT low or normal.

A

Chronic infection, immune tolerant

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22
Q

Interpretation of +surface antigen, +core IgG, +/-eAg, +/- eAb, HBV DNA variable, HIGH ALT

A

Chronic infection, immune active [consider treatment]

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23
Q

Interpretation of +surface antigen, +core IgG, +eAg, +eAb, low HBV DNA, HIGH ALT.

A

Chronic infection - seroconverting.

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24
Q

Interpretation of +surface antigen, +core IgG, +eAb, low HBV DNA, LOW ALT.

A

Chronic infection, inactive carrier.

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25
Interpretation of +surface antigen, +core IgG, +eAb, variable HBV DNA, HIGH ALT.
Chronic infection reactivating. [consider treatment].
26
Interpretation of +Core IgG, all else negative. HBV negative, ALT normal.
Resolved infection, at risk for reactivation.
27
When should hepatitis B be treated?
If ALT is increased.
28
What is the most effective therapies?
Entecavir, tenofovir
29
What might result in fulminant HBV reactivation in an HIV patient?
Discontinuation of tenofovir.
30
What HBV treatment has high resistance rates?
Lamivudine [30%]
31
How does HCV treatment effect chronic HBV infection?
Treating HCV might cause HBV reactivation and flares of hepatitis. May result in death or transplant. Reactivation usually occurs at week 8 of HCV treatment.
32
How long should chronic HBV be treated?
Life long. 75% with get control of their disease if HBeAg +, about 90% get control of HBeAg negative
33
Incidence of cirrhosis in chronic HBV
300 per 100,000 person years.
34
What HBV genotype is most likely to cause cirrhosis?
Genotype C
35
Who with HBV should be screened for HCC?
1. ALL with cirrhosis 2. Asian males 40 and older 3. Asian females 50 and older 4. Sub-Saharan Africans 20 and older 5. Those with HCC history.
36
How often should HCC screening be done?
Every 6 months with US +/- AFP.
37
Highest risk for HCV?
- IVDU - MSM [receptive] - Receipt of blood products before 1990
38
How many genotypes of HCV?
6
39
Which HCV genotype is most common in US?
1
40
Presentation of acute HCV
- Most are asymptomatic - Rarely causes fulminant hepatitis Jaundice in 20-30%
41
Treatment of acute HCV?
- Supportive - Monitor for recovery - More likely to clear if symptomatic OR acquired at birth.
42
Rate of development of chronic hepatitis C in an adult?
50-80%
43
Risk of cirrhosis in chronic hepatitis C
15-30% within 20 year
44
What are extrahepatic manifestations of chronic hepatitis c? [6]
1. Autoimmune thyroiditis 2. B-cell non-Hodgkin lymphoma 3. Lichen planus 4. Porphyria cutanea tarda 5. Cryoglobulinemia [vasculitis] 6. Glomerulonephritis
45
Work up in chronic hep C prior to treatment [3]
1. HCV RNA to confirm active infection. 2. Genotype 3. Fibrosis staging.
46
Methods to fibrosis stage [3]
1. Liver biopsy 2. FibroScan [US based] 3. FibroSURE [blood test]
47
What are the classes of Hep C drugs? [4]
1. Protease inhibitors 2. NS5A inhibitors 3. NS5B polymerase inhibitors - nucleoside polymerase inhibitors 4. NS5B polymerase inhibitors - non-nucleoside polymerase inhibitors
48
Name the HCV protease inhibitors [5]
1. Telaprevir 2. Boceprevir 3. Asunaprevir 4. Simeprevir 5. Grazoprevir --> Ends in previr
49
Name the HCV NS5A inhibitors [3]
1. Daclatasvir 2. Ledipasvir 3. Elbasvir --> Ends in asvir
50
Name the HCV NS5B polymerase inhibitors nucleoside polymerase inhibitors [2]
1. Sofosbuvir | 2. Mercitabine
51
Name the HCV NS5B polymerase inhibitors non-nucleoside polymerase inhibitors [3]
1. Deleobuvir 2. Filibuvir 3. Tegobuvir --> Ends in buvir
52
How long should HCV be treated?
12 weeks. | Up to 24 weeks for cirrhotics or prior treatment failures.
53
Success rate of HCV treatment?
>95%.
54
What defines cure of HCV?
Sustained virologic response [SVR] with no detectable virus after 12 weeks.
55
Does cured HCV still need HCC monitoring?
If cirrhosis - yes.
56
How is HDV transmitted
IVDU Transfusion Prbly not sexually or perinatal.
57
Describe HDV/HBV coinfection
- More severe acute infection syndrome | - Clears with HBV clearance
58
Describe HDV/HBV superinfection.
- Can cause flares of hepatitis in chronically HBV-infected persons - Can accelerate disease due to HBV.
59
Treatment of HDV?
- Interferon. | - HBV antivirals have NO EFFECT.
60
Most common cause of acute viral hepatitis worldwide?
HEV.
61
Who will get severe fulminant hepatitis E?
Pregnant women, those with underlying liver disease.
62
Extrahepatic manifestations of HEV? Who gets them? [3]
OCCURS ONLY IN CHRONIC CARRIERS. 1. Cryoglobulinemia 2. Glomerulonephritis 3. Guillain-Barre.
63
Animal reservoir for HEV?
Pigs/Swine [only Genotypes 3-4]. --> Eating undercooked boar, deer meat in places like Germany, Spain etc a/w catching HEV.
64
What is Hepatitis G and Transfusion-Transmitted Virus?
Causes post-transfusion hepatitis | - Self limited.
65
Diagnosis of HDV?
HDV IgM, RNA
66
Diagnosis of HEV?
HEV IgM
67
Diagnosis of HCV?
HCV Ab | HCV RNA if HIV or acute disease
68
If a patient is exposed to Hep A what is the treatment? [2]
1. Vaccinate if exposure within 2 weeks 2. IVIG if immunocompromised --> IVIG preferred if over age 40
69
Who gets chronic HEV?
1. People with transplants [may get chronic hepatitis or cirrhosis, tacrolimus associated] 2. HIV [only 1 case]
70
High risk conditions for chronic HBV reactivation? [3]
1. Transplant 2. Steroids 3. Immunosuppression
71
Management of patient who is HBsAg + who is going to get immunosuppression.
Empiric treatment with Entecavir OR tenofovir
72
Management of isolated HBV +Core IgG who is going to get immunosuppression.
Watchful waiting; monitor HBV DNA and LFTs
73
How does HDV present?
Someone with known HBV who develops fulminant hepatitis with new exposure.
74
Ddx of hepatitis in pregnancy? [4]
1. HSV 2. HELLP 3. Acute Fatty Liver of Pregnancy 4. HEV
75
Evaluation of HSV hepatitis in pregnancy?
May not have skin lesions Check serum PCR If negative HSV is excluded
76
Presentation and labs of acute fatty liver of pregnancy?
Severe, fulminant disease looks like sepsis | Low glucose, low fibrinogen, HIGH INR
77
What is necrolytic acral erythema?
Rare HCV rash. pruritic, psoriasis-like skin disease characterized by sharply marginated, erythematous to hyperpigmented plaques with variable scale and erosion on the lower extremities Treated with zinc
78
In what circumstance should a treatment naive patient have HCV resistance testing? [2]
1. Genotype 1a and insurance is making you use elbasvir/grazoprevir 2. Genotype 3 with cirrhosis and using sofosbuvir/velpatasvir
79
In what circumstance should a treatment experienced patient have HCV resistance testing? [2]
1. Genotype 1a and ledipasvir/sofosbuvir considered | 2. Genotype 3 using sofosbuvir/velpatasvir
80
What is FIB4?
[Age x AST] / [Platelet Count x √ALT] Used in chronic hep c to estimate cirrhosis Low = less cirrhosis and scaring High = more cirrhosis and scaring --> Often combined with transient elastography in cirrhosis staging.
81
What is APRI?
AST to Platelet Ratio Index [(AST measured/AST ULN)/(Platelet Count)] Another way to predict cirrhosis in hep C
82
Most specific test for predicting cirrhosis for HCV?
APRI and elastography [91%]
83
Most sensitive test for predicting cirrhosis for HCV?
Elastography [89%]
84
Outpatient mgmt of HCV
1. Rule out cirrhosis [fibro, biopsy, elastography] 2. If cirrhosis rule out HCC and varicies 3. Rule out decompensated cirrhosis [MELD or CTP scores]
85
Mgmt of patient with HBV and HCV who is about to undergo treatment for HCV
Monitor for HBV reactivation and treat if ALT goes up.
86
Two HCV regimens can be used for any genotype.
1. Sofosbuvir + velpatasvir | 2. Glecaprevir + pibrentasvir
87
Two HCV regimens that can be used for CKD and ESRD?
1. Glecaprevir + pibrentasvir | 2. Elbasvir + Grazoprevir
88
Describe HIV integrase inhibitor interaction with HCV drugs.
None
89
Describe HIV protease inhibitor interaction with HCV drugs.
AVOID HIV PI with HCV PI. | --> Basically HIV protease inhibitors cannot be used when treating HCV.
90
What HCV medications have reduced absorption with PPIs?
NS5A inhibitors 1. Daclatasvir 2. Ledipasvir 3. Elbasvir 4. velpatasvir
91
NOTE:
Avoid cobicistat boosting with hepatitis C type protease inhibitors.
92
What is the only HCV treatment which can be used with efavirenz at the same time?
Ledipasvir + Sofosbuvir
93
Should HCV be treated in pregnancy?
No.
94
What is the definition of chronic HBV?
Surface antigen + 2x separated by 6 months.
95
When should chronic HBV be treated when HBeAg is positive?
1. ALT 2x ULN + HBV DNA >20,000
96
How often should HBV with +HBeAg and no ALT elevations be monitored and with what? [2]
1. ALT + HBV DNA levels q 3-6 months | 2. HBeAg q 6-12 months
97
When should chronic HBV be treated when HBeAg is negative?
1. ALT 2x ULN + HBV DNA >2000
98
How often should HBV with (-)HBeAg and no ALT elevations be monitored and with what?
1. ALT + HBV DNA levels q 3-6 months | 2. HBsAg yearly
99
Management of chronic hepatitis B with +HBeAg and a HBV DNA level between 2000-20,000
- -> May be seroconverting to HBeAg negative - -> Monitor every 1-3 months - -> TREAT IF PERSISTS FOR >6 months.
100
What type of HIV resistance does entecavir select for?
M184V in HIV.
101
Who should be screened for HDV?
ALL with chronic HBV 1x
102
How is HDV screened?
1. Start with anti-HDV | 2. HDV RNA if positive
103
Mgmt of IgG Core positive HBV with ALL OTHER negative
Vaccinate Likely is an old clear infection or false + Check titers after
104
Treatment of chronic HEV?
Ribavirin
105
Who with HCV should be screened for HCC?
1. Cirrhosis patients 2. Stage F3 fibrosis --> Screen them even if cured of hepatitis C

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