Patient with jaundice: Viral hepatitis Flashcards
Hepatitis scenario
Why jaundice?
Why swollen?
Why bruise easily?
1) ^ bilirubin, haemolysis, decreased conjugation in liver, decreased excretion from liver
2) less albumin/protein made in liver, oncotic pressure in vasculature low so fluid leaks out
3) clotting proteins less
Types of viruses that cause hepatitis
Intra hepatic: liver main site of replication
others: EBV, CMV, HIV, mumps, yellow fever
Hepatitis A B and C features
type, route, acute/chronic?, asymptomatic?, vaccine
D?
HAV: RNA, faecal oral, acute hepatitis, higher in children, lowers, yes
HBV: DNA, blood borne, acute, chronic, cirrhosis, cancer, more likely to be asymptomatic, yes,
HCV: RNA, blood borne, acute, chronic, cirrhosis, cancer, curative treatment
D: only with hep B
HAV, HBV, HCV
HAV: Asymptomatic illness: <5yrs ___ 5-10yrs ____, adults ___. Not chronic
HBV: Very likely to be _____. Chronic illness <1 yr ___, 1-5 yr ____, adult __
HCV: asymp in >80% of adults. Chronic in 5-85% of adults
HAV: Asymptomatic illness: <5yrs 90%, 5-10yrs 60%, adults 30%. Not chronic
HBV: Very likely to be asymptomatic. Chronic illness <1 yr 90%, 1-5 yr 10-25%, adult <5%
HCV: asymp in >80% of adults. Chronic in 5-85% of adults
Hep B viral features and diagnosis
- partially ____ stranded ___ virus. _____ DNA VIRus
- Diagnosis through measuring hepatitis B surface antigen in the blood. Vaccine is based on this
- Some of DNA has _______ _____, so some drugs to treat same as HIV
- _ gene involved in hijacking hepatocyte division, so _____ eventually
- partially double stranded DNA virus. HEPAtotrophic DNA VIRus
- Diagnosis through measuring hepatitis B surface antigen in the blood. Vaccine is based on this
- Some of DNA has reverse trascriptase, so some drugs to treat same as HIV
- X gene involved in hijacking hepatocyte division, so carcinoma eventually
HBV life cycle
- Binds to receptor (unsure what)
- DNA ____ and moved into nucleus, and ____ DNA made.
- ____ transcribed into ___ and ___ portions.
- ___ portions go to ____ and make viral proteins, ____ ____ and core antigen. So much made of S.A that it spills out
- ___ strand floats in cytoplasm, and some proteins translated ____.
- Infected for up to __ months, no damage to liver cell until immune system and cytotoxic T cells start
- Can incorporate ___ into our ___, slight increased risk of ____ or reactivation in ____
- Binds to receptor (unsure what)
- DNA unpackaged and moved into nucleus, and complementary DNA made.
- mRNA transcribed into large and small portions.
- Small portions go to ribosomes and make viral proteins, surface antigen and core antigen. So much made of S.A that it spills out
- Long strand floats in cytoplasm, and some proteins translated inefficiently.
- Infected for up to 3 months, no damage to liver cell until immune system and cytotoxic T cells start
- Can incorporate DNA into our genome, slight increased risk of carcinoma or reactivation in immunosuppression
Main risk factors and incubations for HAV, HBV and HCV
HAV: 4 weeks, travel is highest risk
HBV: 3-4 months, transfusion, MSM, vertical (pregnancy)
HCV: 6-7 weeks, and IVDU
Diagnosis of HAV
HAv RNA PCR, usually not needed due to HAV antibody! IgG+, disease something else, happen to be immune, used to be infected. IgM+, current
HBV diagnosis Antigens -1st, \_\_\_\_\_ if +ve, \_\_\_ \_\_\_\_ -\_\_\_\_\_: surrogate for \_\_\_\_/infectivity. High means lots around. Eag + \_\_\_\_ \_\_\_\_ -Core Ag/CAg: never found in serum A -anti-\_\_\_, only found in \_\_\_\_ or \_\_\_\_ people -anti \_\_\_: not usually measured -anti \_\_\_\_: \_\_\_ or \_\_\_ infection- Ig_
Antigens
-1st, HBsag, surface ag, if +ve, current infection
-HBeag, Early/E ag: surrogate for replication/infectivity. High means lots around. Eag + highly infectious
-Core Ag/CAg HBCag: never found in serum
A
-anti-HBS, only found in cured or vaccinated people
-anti HBE: not usually measured
-anti HBC: cured or acute infection- IgM
Acute and chronic HBV graphically
Acute: Post infection, ____ rises, with and overlap of_____. Peak illness at peak ____. ______ after resolution
Chronic: __ ____ ____ rises and falls, total _____ ___ ___ and ____ ____ plateau at high. SO if ____ _____ maybe chronic infection
Acute: Post infection, HBsag rises, with and overlap of IgM anti HBc. Peak illness at peak HBsag. anti HBs after resolution
Chronic: IgM anti HBc rises and falls, total anti Hbc IgG and HBsag plateau at high. SO if anti HBc IgM-, maybe chronic infection
HCV diagnosis
Antibody for HCV+ then PCRHCV RNA + genotype
Chronic hepatitis diagnosis
HBsag 6+ months
most often diagnosed because ALT is elevated
examples
1) HBSag +, anti-HBS -, anti- HBC+, anti HBC IgM-, HBeag +
2HBSag +, anti-HBS -, anti- HBC+, anti HBC IgM-, HBeag -
1) potentially chronic, unsure as not over 6 months
2) chronic carrier
Chronic HBV
____ cleared in 20-30 year olds. Can result in flareof active hepatitis
_____ clearance uncommon
Adult after 5 years:-
-__-__% with chronic hepatitis will develop ____, 85% alive after 5 years
-__-__% with ____ will decompensate, 15-35% alive at 5 years
-6-15% with cirrhosis will develop _____ _____, seldom alive at 5 years
HBEAg cleared in 20-30 year olds. Can result in flareof active hepatitis
HBSAg clearance uncommon
Adult after 5 years:-
-12-20% with chronic hepatitis will develop cirrhosis, 85% alive after 5 years
-20-25% with cirrhosis will decompensate, 15-35% alive at 5 years
-6-15% with cirrhosis will develop hepatocellular carcinoma, seldom alive at 5 years
Chronic HCV
after 20 years of chornic HCV, 10% cirrhosis and of that 2-3% decompensate or get HCC
Acute viral hepatitis treatment
Not required,
supportive care
if fulminant transplant
Chronic hepatitis treatment
to prevent cirrhosis and cancer, reduce transmission. HBV suppress and cure HCV
HBV and HCV treatments
HBV :those with complications, high ALT with reverse transcriptase ____- entecavir, ____
HCV: depends on virus ____ (2&3> 1&4) + host immunity (gene for IL28B better with interferon).
Use non specific anti virals- ribavirin or interferon.
Now use sofoshuvir
HBV :those with complications, high ALT with reverse transcriptase inhibitors- entecavir, tenofovir
HCV: depends on virus genotype (2&3> 1&4) + host immunity (gene for IL28B better with interferon).
Use non specific anti virals- ribavirin or interferon.
Now use sofoshuvir
HBV prevention
- ____ at ___ + ___ _ weeks, _months, _ months
- prevent ____ transmission
- Screen ____ _____
- If +ve, ___ Ig at birth, start ____ at birth (4 doses)
- test after last vaccine to check _____ is >100IU/mL
- Vaccinate at risk + infants 6 weeks, 3months, 5 months
- prevent vertical transmission
- Screen pregnant women
- If +ve, HBV Ig at birth, start vaccination at birth (4 doses)
- test after last vaccine to check anti-HBS is >100IU/mL
