Liver Path 2 Flashcards
Clinicopathologic Syndromes of Viral Hepatitis
Acute asymptomatic infection with recovery (serologic evidence only)
Acute symptomatic hepatitis with recovery
Chronic hepatitis, with or without progression to cirrhosis
Acute liver failure with massive to submassive hepatic necrosis
Tests for Hepatitis Viruses
Antibody to viral proteins (often coat proteins) take day-weeks to develop (delay)
* IgM - initial response to acute infection
* IgG - long term response
ongoing chronic infection
past infection
Viral proteins
- rarely measurable
- exception: Hepatitis B
Viral nucleic acid
- Polymerase chain reaction assays available
- most infections will be diagnosed by detection of organism nucleic acid in the future
alk phos is a marker of
cholestasis
Typical Case History of Acute Viral Hepatitis
30 year old woman with a 1 week history of: increasing fatigue nausea loss of taste for meat, oily foods 1-2 days of darkening urine, yellow eyes
PE: jaundice and moderately tender liver
AST, ALT, Alk phos elevated
Jaundice detected clinically once the serum bilirubin level rises above
3 mg per dL
ratio of amino transferases to alk phosphatases
transferases up? hepatocellular
alk phosphatases? cholestasis
symptoms of obstructive jaundice
classic constellation of tea-colored urine and clay-colored stool
Histology Acute Hepatitis
Lobular disarray
– Ballooned hepatocytes and acidophilic bodies
– Individual or confluent hepatocyte dropout
– Zonal, bridging, or panlobular necrosis
– Sinusoidal inflammatory cells
– Prominent Kupffer cells
- Mild portal inflammation
- No fibrosis
Hepatitis A Virus
Hepatitis A virus (ssRNA) is usually * self-limited disease, incubation period of 2 to 6 wks
Does not cause chronic hepatitis or a carrier state in the * immunocompetent patient
Generally transmitted via the * oral-fecal route, person to person/contaminated water and foods
Blood-borne transmission of HAV occurs only rarely*
Risk factors for Hep A infection
mostly unknown
sexual or houshold contact men sex w/ men int'l travel day care injection drug use food or water outbreak
Hep A pathobiology
- Receptor for HAV (* Picornavirus) is an integral membrane glycoprotein receptor
Genome serves as a messenger RNA that encodes both structural and nonstructural *viral proteins
In the cytoplasm * RNA translation into a polyprotein that is later processed to mature viral proteins
- Replication membrane-bound complex generates new viral genomes that are * exported out of cell into bile and to a lesser extent into blood
Hepatitis Viruses that ONLY Cause Acute Self-limited Disease
Hepatitis A
RNA virus (picornavirus)
Good vaccine available
Hepatitis E RNA virus (Hepeviridae)
Hepatitis E Virus
Hepatitis E virus (HEV) is an * enterically transmitted, water-borne infection
Feature of HEV infection is the * high mortality rate among pregnant women, approaching 20%.
Typically acute, self-limited icteric disease *without a chronic/carrier state, much like Hepatitis A
Hep E lab tests
Laboratory Tests
IgM antibody to hepatitis E for acute disease
IgG antibody to hepatitis E for past disease or immunity
Vaccine under development
Histopathology of Hepatitis E Infection
- Not much information on detailed histological appearances in hepatitis E.
Focal hepatocyte necrosis including frequent acidophil bodies, swollen (or ballooned) hepatocytes, and lymphocytic parenchymal and portal infiltrates
Canalicular cholestasis and gland-like transformation of hepatocytes.
Hepatitis Viruses that may Cause both Acute and Chronic Disease
Hepatitis B
Hepatitis B + D
Hepatitis C
Hepatitis B Virus
DNA virus (Hepadnaviridae)
Replicates through RNA intermediate (like HIV)
Blood borne
Many serologic tests have been developed
prognosis with Hep B
Spontaneous recovery in patients infected at birth is less than 5%
Adult infections * spontaneously resolve in
95-99%
5-10% of infected individuals develop * chronic disease
Low prevalence areas (USA) unprotected sex and IV drug abuse are the * chief modes of spread.
Clinical Signs and Symptoms of Hepatitis B Infection
Fatigue Anorexia Nausea Jaundice/Scleral icterus Abdominal pain Arthralgia
The rate of new HBV infections in the US
has declined by approximately 82% since 1991, when a national strategy to eliminate HBV infection was implemented in the United States. The decline has been greatest among children born since 1991, when routine vaccination of children was first recommended
Hepatitis B Virion =
Dane particle
sphere with outer envelope, icosahedral core (nucleocapsid)
double stranded HBV DNA and viral DNA polymerase
Hep B Serological Testing:
Virus components: viral DNA DNA polymerase (research test) s antigen (surface coat protein) e antigen (clipped portion of core protein)
Serum antibodies:
Antibody to s (surface)
Antibody to c (core)
Antibody to e
Sequence of serologic markers for hepatitis B viral hepatitis
early: Total anti-HBc
later: Anti-HBs (immune and no longer contagious)
With recovery, the anti-HBc and HBs antibodies rise and stay high, while HBeAg, HBV-DNA and HBsAg go down.
with progression to chronic, the serum markers go down but HBeAg, HBV-DNA and HBsAg stay up
Serologic Markers for Acute Self-Limited Hepatitis B Viral Infection
In Acute Self-limited Infection:
In patients with acute hepatitis B, there is almost always an antibody response to HBcAg and usually an antibody response to HBsAg
With the appearance of * HBsAb, the patient becomes immune to a new HBV infection
Serologic Markers for Chronic Hepatitis B Viral Infection
HBsAg appears in the serum in a similar time course, but does not abate, and antibody to * HBsAg fails to develop.
- HBsAg in the blood is thus the hallmark of active current HBV infection, whether acute or chronic
Interpretation of Serological Markers for HBV Infection
- HBsAg HBV infection (acute or chronic)
- HBeAg High viral load/infectivity
- HBV DNA High viral load/infectivity
Anti-HBs Immunity
Anti-HBc IgM Acute infection
Anti-HBc IgG Past or chronic infection
Anti-HBe Past or low infectivity chronic infection
Anti-HBc IgG and HBsAg Chronic infection
Anti-HBc IgG and anti-HBs Resolved (past) infection
Histopathology of Hepatitis B Infection
Acute and chronic hepatitis B infection appear essentially similar to other forms of acute and chronic hepatitis
Chronic HBV distinctive histological feature is the ‘ground-glass hepatocyte’ containing abundant HBsAg
Hepatitis Viruses that may Cause both Acute and Chronic Disease
Hepatitis B
Hepatitis B + D
Hepatitis C
Hepatitis D (delta) Virus (HDV)
Defective RNA virus that * requires coinfection with Hepatitis B virus
HBV surface antigen surrounds HDV
Spread of HDV follows that of HBV, primarily through parenteral exposure
It can either be acquired at the same time as a primary HBV infection or later, superimposed on a pre-existent chronic hepatitis B.
HDV is rare in the USA and in other countries with a relatively low HBV incidence
Hepatitis B surface antigen
constitutes the HDV coat protein
most severe hepatitis
Delta hepatitis is considered to be the most severe viral hepatitis. In acute forms it produces more fatalities. In chronic forms it produces more cirrhosis
Most (50-70%) cases of superinfection develop a severe form of acute hepatitis and 90% of them become chronic carriers.
Histopathology of Hepatitis D Infection
Acute and chronic hepatitis D infections look like any other acute or chronic hepatitis.
Single distinguishing feature is the sanded nucleus due to HDAg accumulating in the nucleus of infected cells (looks like HBcAg in nucleus)
Hepatitis C prevalence
Most common cause of chronic hepatitis world-wide, including USA
In 85% of individuals, the clinical course of the * acute infection is asymptomatic and typically missed
Chronic infection can lead to cirrhosis and Hepatocellular carcnoma in up to 25%
Hepatitis C (HCV) clinical features
Clinical feature that is quite characteristic of chronic HCV infection is persistent elevations in serum aminotransferases
In symptomatic acute HCV infection, anti-HCV antibodies are initially detected in only 50% to 70% of patients
In the remaining patients, the anti-HCV antibodies emerge after 3 to 6 weeks.
the Hep C virus itself
Small single-stranded RNA virus (described in 1989) which has an inherently * unstable genome (mutates)
Rate of transmission by blood transfusion* is now close to zero
Chronic disease occurs in the majority of HCV-infected individuals (80% to 90%)*
Risk Factors for HCV Infection
Intravenous drug abuse (54%)
Multiple sex partners (36%)
Having had surgery within the last 6 month (16%)
Needle stick injury (10%)
Hepatitis C Serology
Hepatitis C IgG antibody:
Appears weeks after onset of new infection
Signifies past resolved or chronic hepatitis C
Occasional false positive
Hepatitis C RNA (by PCR):
Signifies the virus is present in liver/blood
Found in acute or chronic hepatitis C
Histopathology of Hepatitis C Infection
Acute and chronic hepatitis C infection appear essentially similar to other forms of acute and chronic hepatitis
Steatosis and bile duct damage may also be found.
Asymptomatic patients, even those without serum aminotransferase elevations, may have significantly abnormal histology
Hepatitis C Treatment
New direct-acting oral agents capable of curing hepatitis C virus (HCV) infection have been approved for use in the United States.
Effective hepatitis C medications cost $1,000 a pill and more than$100,000for a full course of treatment
Summary of Clinicopathologic Features of Viral Hepatitis
Acute asymptomatic:
All of the hepatotropic viruses
Acute symptomatic:
All of the hepatotropic viruses
Acute liver failure:
Viral hepatitis is responsible for about 10% of cases of acute liver failure
HAV, HEV and HBV, HDV
Chronic and carrier states
Chronic hepatitis
HCV >80%
HBV less than 10% in adults (perinatal >90%)
Carrier state
Small number of HBV
No HCV
HIV and Chronic Viral Hepatitis
10% of HIV-infected individuals are co-infected with HBV and 25% with HCV (USA)
In patients with acquired immunodeficiency syndrome (AIDS), liver disease is the second most common cause of death
Hepatitis C and Hepatitis A
In the presence of chronic hepatitis C * hepatitis A can become life-threatening.
If there is no prior evidence of infection with hepatitis A in people with hepatitis C, Hepatitis A immunization is strongly recommended.
Hepatitis B and Hepatitis A
In the presence of chronic hepatitis B * hepatitis A can become life-threatening.
If there is no prior evidence of infection with hepatitis A in people with hepatitis B, Hepatitis A immunization is strongly recommended.
vowels and consonants
The vowels (hepatitis A and E) never cause chronic hepatitis, onlyAcutEhepatitis, except HEV in immunocompromised hosts and pregnant females.
Only the consonants (hepatitis B, C, D) have the potential to cause chronic disease (C for consonant and for chronic).
Hepatitis B can be transmitted byblood,birthing, and sexual intercourse.
Mnemonics for C, D and E
Hepatitis C is the single virus that is more oftenchronic than not (almost never detected acutely; 80% or more of patients develop chronic hepatitis, 20% of whom will developcirrhosis).
Hepatitis D, the delta agent, is adefective virus, requiring hepatitis B co-infection for its own capacity to infect and replicate.
Hepatitis E isendemic inequatorial regions and frequentlyepidemic.
grading, staging, and carcinoma
The inflammatory cells in both acute and chronic viral hepatitis are mainly T cells; it is the pattern of injury that is different between the two time courses, not the nature of the infiltrate.
Biopsy assessment in chronic viral hepatitis is most important for grading and staging of disease, which are used to decide whether a patient undergoes often arduous antiviral treatments.
Patients with long-standing HBV or HCV related cirrhosis are at increased risk for the development of hepatocellular carcinoma.
hypervitaminosis A
–> hepatic stellate cell lipidosis
virus that happens to people who travel
Hep E
common in the rest of the world (Mexico, India) even though it’s not common here
