MI: Viral Hepatitis Flashcards by P P

How is hepatitis A spread?

Faecal-oral

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What is the incubation period for hepatitis A?

2-6 weeks

usually 4w

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Describe the natural history of hepatitis A infection.

2-6 weeks after the infection you will develop hepatitis (transaminitis)
This will be accompanied by a rise in IgM
A more gradual rise in IgG will follow
isolate for 7 days after onset

NOTE: hepatitis A infection is often subclinical

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How long are you infectious with HAV

2w pre symptom onset to 1w after jaundice

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What is the diagnostic test for hepatitis A?

Anti-hepatitis A IgM
HAV RNA PCR (lab)

if ALT>500u/L, may be negative in first few weeks

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Which antibodies will be present if someone has received a hepatitis A vaccine?

High IgM and high IgG but NO transaminitis

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Vaccine for Hep A?

yes 2 doses

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How is hepatitis B transmitted?

Sexually transmitted
Blood products (parenteral)
Mother-to-baby (e antigen is the biggest predictor)

the only DNA virus of the hepatitides

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What is the incubation period of hepatitis B?

2-6 months

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What is the risk of chronic infection in adults and babies?

5-10% in adults
95% in babies

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risk of chronic HBV in <5

90% progress to chronic HBV, only 10% progress to this in adults

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how to define chronic HBV

HBsAg reactivity >6 months

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complications of chronic HBV

cirrhosis
hepatocellular carcinomas
extra-hepatic complications

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Describe the molecular organisation of hepatitis B virus.

DNA virus with four overlapping reading frames (core, X, polymerase and surface antigen)

NOTE: as they overlap, a mutation in one reading frame could affect others

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Why do some antiretrovirals work on hepatitis B?

HBV uses reverse transcriptase to replicate

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Where is the hepatitis e antigen found?

Pre-core part of the core reading frame

It’s a marker of active replication

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What serological feature is suggestive of recent HBV infection?

Anti-HBV IgM antibodies

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What serological feature is suggestive of chronic HBV infection?

Prolonged presence of HBsAg (more than 6 months)

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What are some possible consequences of HBV infection?

Hepatocellular carcinoma
Cirrhosis

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List the HBV disease stages.

Immune tolerant
Immune reactive
Inactive HBV carrier state
HBeAg negative chronic HBV

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Symptoms of hepatitis

non specific
- fever
- malaise
- fatigue
- loss of appetite
- abdominal pain

high bili
- jaundice
- dark urine
- pale, gray, white stool
- pruritis

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how is cirrhosis staged

child-pugh score

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radiological findings of cirrhosis

coarse echotexture, nodularity, portal HTN- splenomegaly

what imaging can be used for cirrhosis

transient elastography >12.5kPa
histopath GOLD standard

how to check for hepatocellular carcinoma

alpha-fetoprotein imaging

What is a strong indicator of risk of cirrhosis in people with hepatitis B infection?

HBV DNA level (copies/mL)

List some treatment options for chronic HBV.

* Interferon alpha nucleos/tide analogues * Tenofovir * Entecavir * Adefovir * Lamivudine

how does IFN-a work in hbv

induces long term immune control: eAg, sAg loss | SC injection 48 weeks

Which of these treatments should not be used in liver transplant patients?

Interferon alpha

When do you NOT give Hep B immunoglobulin to babies born to mothers with Hep B

If the mother has anti-HBe (this confers protection to the baby, but you still give the accelerated vaccine)

Which patient populations are particularly at risk of hepatitis C virus infection?

* MSM * IVDU

Which phylogenetic family is HCV a part of?

Flaviviridae

What components constitute the viral RNA genome of hepatitis C?

* Core * Envelope * Non-structural components

What class of drugs are most antivirals used for hepatitis C?

* Protease inhibitors * Inhibitors of non-structural components

What is the incubation period of HCV?

6-8 weeks

Outline the serological changes that take place following HCV infection.

Anti-HCV antibodies develop after the acute infection has resolved (i.e. ALT has returned to normal)

How is HCV treated?

Early treatment with peginterferon alfa NOTE: peginterferon alfa 2b is interferon alpha with polyethelene glycol attached which improved its pharmacokinetics and turns it into a depot preparation

How is the response to treatment with peginterferon-alfa assessed in HCV infection?

Sustained viral response (SVR12) - no HCV RNA 12 weeks after stopping treatment

What is the main difference in the treatment of genotype 1 and non-genotype 1 HCV?

* **Genotype 1** - high-dose long-lasting ribavirin is required for high cure rates * **Non-genotype 1** - ribavirin does NOT increase cure rates

What is a key feature about hepatitis D virus?

Requires the presence of hepatitis B to replicate within the host

What is the difference between hepatitis D co-infection and superinfection?

**Co-infection:** * This happens when you are inoculated with HBV and HDV at the same time (e.g. sharing a needle with someone infected by both viruses) * Anti-HDV IgM will rise after inoculation causing hepatitis **Superinfection:** * This happens when someone with chronic hepatitis B infection is inoculated by HDV * This is more severe than coinfection * Patients can develop cirrhosis within 2-3 years

Which phylogenetic family is heaptitis E a part of?

Herpeviridae

How is hepatitis E transmitted?

Faecal-oral

What are the genotypes of hepatitis E?

* 1 + 2 = human * 3 + 4 = animals (mainly pigs) NOTE: there is very little person-to-person transmission

Which patient group has a high mortality if infected by hepatitis E?

Pregnant women NOTE: mainly associated with genotype 1

What is the incubation period of hepatitis E?

3 - 8 weeks

List some rare complications of hepatitis E.

* CNS disease (e.g. Bell's palsy) * Chronic infection

Outline the treatment of hepatitis E.

* Supportive * Ribavirin

Outline the serological changes that take place in hepatitis E infection.

* Acute infection is accompanied by a rise in IgM anti-HEV antibody * Rarely you can get persistently high levels of HEV RNA NOTE: it generally responds well to ribavirin

What is hepatitis G?

* Pegivirus * Simian virus * May cause higher CD4 counts in HIV-positive patients

incubation period of hepatitis C

2-6weeks

acute vs chronic infection HCV- % which progress

20-40% spontaneously clear 40-60% progress to chronicity

chronic infection risks of HCV

incidental finding CLD/ cirrhosis hepatocellular carcinoma

how long does it take for anti-HCV Ab to become reactive

4 weeks after infection so request HCV RNA

treatment of HCV

direct acting antivirals: 12w treatment with daily pill -previr (boceprevir) -asvir (velpasvir) - buvir (sofosbuvir)

HBV screening in pregnancy

HBsAg positive, eAg negative: vaccine at birth + routine schedule HBsAg positive, eAg positive: vaccine at birth, PLUS HBIg within 48 hours