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Applied Pathophysiology > Viral Hepatitis > Flashcards

Viral Hepatitis Flashcards

1
Q

Hepatitis:

A

inflammation of the liver tissue

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2
Q

What are the major causes of hepatitis?

A

● INFECTIOUS (bacteria, parasites, viruses)

● METABOLIC (alcohol, toxins, drug-induced, herbal or
dietary supplements)

● AUTOIMMUNE (genetic predisposition, association with HLA antigens, auto-antibodies)

● GENETIC (α-1 antitrypsin deficiency, hemochromatosis, Wilson’s disease)

● ISCHEMIC (shock, heart failure, or vascular insufficiency)

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3
Q

What are the three types of hepatitis (based on clinical pattern)?

A

● ACUTE HEPATITIS: infection then recovery (eg HVA)

● FULMINANT HEPATITIS: massive hepatic cell death, rare, life-threatening (eg HBV)

● CHRONIC HEPATITIS: after acute phase, >6 months

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4
Q

Acute hepatitis:

A

infection then recovery (eg HVA)

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5
Q

Fulminant hepatitis:

A

massive hepatic cell death, rare, life-threatening (eg HBV)

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6
Q

Chronic hepatitis:

A

after acute phase, >6 months

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7
Q

What are the different types of viral hepatitis?

A

Viral Hepatitis
A B C D E

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8
Q

What is the prevalence of viral hepatitis worldwide?

A

Hep A & B - widespread

Hep C - broad prevalence everywhere in world

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9
Q

ADD slide 6

A

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10
Q

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11
Q

What is Viral Hepatitis A?

A

A small NON-ENVELOPED RNA- containing virus

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12
Q

Where family does the Viral Hepatitis A belong to?

A

belongs to PICORNAVIRUS family

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13
Q

What does Viral Hepatitis A contain?

A

It contains a positive-sense, single-strand of RNA packaged in a protein shell

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14
Q

What is the stability of a Viral Hepatitis A?

A

● STABLE in environment for at least ONE MONTH

● Inactivation: heat foods (≥85°C (185°F); 1 min) or disinfect with bleach (1:100 dilution in water)

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15
Q

What is Hepatitis A infection? & what can it cause?

A

usually a benign, SELF-LIMITING disease

It can cause fulminant hepatitis and hepatic failure leading
to death (not common)

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16
Q

What is the Hepatitis A infection typically by?

A

● FECAL-ORAL route
● direct: person-to-person
● indirect:
- water/food ingestion, contaminated with fecal
material of infected person (even microscopic amount)
- drinking contaminated milk, water, shellfish from infected waters

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17
Q

What is the population that is at high risk for HAV infection?

A

● Anyone who has NOT been VACCINATED or previously INFECTED can get infected with HAV.
● In areas where the virus is widespread (HIGH ENDEMICITY), most HAV infections occur during EARLY CHILDHOOD.

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18
Q

What are the risk factors for HAV infection?

A

● Travelling to areas of high endemicity without being immunized (44-55% cases in Canada linked to travel)
● Poor sanitation; lack of safe water supply
● Living in a household with an infected person
● Use of recreational drugs
● sexual partner of someone with acute hepatitis A;
oral/anal sexual contact
● Inmates in prisons or jails

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19
Q

What is the clinical presentation of acute hepatitis A?

A

● may be ASYMPTOMATIC (age <5 YEARS)
● non-specific flu-like symptoms (fever, fatigue,
malaise, anorexia)
● nausea, vomiting, diarrhea
● dark urine, pale stool (b/c of elevated bilirubin levels)
● pruritus, abdominal pain
● jaundice: skin, eyes (scleral icterus)
● fulminant hepatitis (rare)
● full recovery <2 MONTHS (up to 9 months)

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20
Q

What are the signs & symptoms of hepatitis A (at each phase)?

A

● PRE-ICTERIC PHASE
NONSPECIFIC FLU-LIKE symptoms consisting of anorexia,
nausea, fatigue, and malaise

● ACUTE ILLNESS (virus is actively replicating)
ABRUPT ONSET of anorexia, nausea, vomiting, malaise, fever, headache, and right upper quadrant abdominal pain with acute illness

● ICTERIC HEPATITIS
GENERALLY ACCOMPANIED by dark urine, acholic (light-
colored) stools, worsening of systemic symptoms, PRURITIS is often a major complaint of icteric patients

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21
Q

What is the diagnosis of acute hepatitis A?

A

● Physical examination
● icteric sclera, skin, and secretions
● mild weight loss (2-5 kg)
● hepatomegaly

Laboratory tests (NON-specific)
● positive serum anti-HAV (IgM, IgG)
● ↑ serum bilirubin (mild)
● ↑ liver enzymes
– alanine transaminase (ALT); aspartate transaminase (AST)
– alkaline phosphatase (ALP); γ-glutamyl transferase (GTT)
● total bilirubin in patients with cholestatic illness

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22
Q

What are the precautions in place to prevent hepatitis A?

A

● Washing hands before eating and drinking
● Avoid contaminated food and water (& swim/bath in water)
● Avoid uncooked foods, shellfish and salads
● Avoid unpasteurized dairy products
● Avoid food from street vendors
● Avoid swimming, wading, bathing or washing cloths in polluted or contaminated water

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23
Q

What are recommendations for HAV vaccination?

A

● All children at 1 year of age
● Consider older children (2–18 years) in AREAS WITHOUT
existing HAV vaccination programs
● TRAVELING/working in countries that have high/intermediate
endemicity of HAV infection
● Men who have SEX with men
● Illegal-DRUG users
● Persons with OCCUPATIONAL risk for infection (eg work with
HAV-infected primates, HAV research laboratory)
● Patients with CLOTTING factor DISORDERS or CHRONIC LIVER disease

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24
Q

ADD slide 17

A

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25
Q

What is the treatment of hepatitis A?

A

● Typically, NO SPECIFIC treatment is needed

● Symptoms are usually RESOLVED within 2 MONTHS

● ALMOST ALL patients RECOVER within 6 months (up to 9 months in some patients)

26
Q

What are the rate complications with hepatitis A?

A

● relapsing hepatitis
● cholestatic hepatitis
● fulminant hepatitis

27
Q

What does the Hepatitis B virus (HBV) look like?

A

● HBV has a CIRCULAR, PARTIALLY DOUBLE- STRANDED DNA

● Along with DNA POLYMERASE contained in an inner NUCLEOCAPSID surrounded by an outer ENVELOPE

28
Q

What family does the hep B (HBV) virus fall in?

A

● It is a prototype virus of the Hepadnaviridae family

● A small DNA virus with unusual features SIMILAR to RETROVIRUSES

29
Q

What does the HBV infect?

A

● Infects MAINLY HEPATOCYTES but it is also found in kidney, pancreas and mononuclear cells

● IMMUNE response to the virus is CYTOTOXIC to HEPATOCYTES (elevated ALT due to destruction of hepatocytes)

● Antigen NON-specific inflammatory responses are triggered by T CELLS

● Includes MHC class I CD8 cytotoxic T cells and class II CD4 T-helper cells

● CYTOTOXIC T-cell response is IMPORTANT for viral CLEARANCE

● WEAK immune response: MORE likely to develop CHRONIC infection

30
Q

What is the epidemiology & prevalence of HBV?

A

● >350 million people worldwide are infected with HBV
● Higher rate in ASIA and WESTERN PACIFIC rim
● About 257 million people have CHRONIC HBV globally
● It is the cause of about 887,000 deaths per year
● Rate has declined since 1980s because of vaccination
● WHO recommends routine hepatitis B SCREENING for
HIGH-RISK populations
● Incubation period: 90 days (60-150 days)
● HBV can cause both ACUTE and CHRONIC infection
*● It is a LEADING cause of CHRONIC hepatitis, liver CIRRHOSIS,
and CANCER worldwide
● Risk of development of CHRONIC HBV is HIGHER in CHILDREN
● About 90% of children infected during or shortly after BIRTH develop CHRONIC HBV
● Risk of CHRONIC HBV if infected at age of ≥5 years is <10%
● MOST patients with CHRONIC HBV have NO symptoms
● About 25% of patients with CHRONIC HBV eventually develop CIRRHOSIS and liver CANCER

31
Q

What is the incubation period of HBV?

A

90 days (60-150 days)

32
Q

What is the HBV transmission?

A

HBV is transmitted MAINLY by contact with contaminated BLOOD, blood PRODUCTS, and other BODY FLUIDS (eg semen)

33
Q

What are the HBV different ways of transmission?

A

● Percutaneous or mucosal contact with infected body fluids
- high concentration in blood and serum
- moderate in semen/vaginal fluid
- saliva (kiss: unlikely; damaged skin)

● Percutaneous insertion
- IV drug use, tattoos, acupuncture, body piercing
- health care workers (accidental needlestick)

● Perinatal infection
- HBV+ mother to newborn during delivery; 10-85%
- infected infants: 90% risk of being chronic careers

● Sexual contacts (most common source reported in MB)

34
Q

What does the clinical presentation of HBV infection depend on?

A
  • AGE at which the FIRST infection occurs (for child/adult)
  • IMMUNE system response to the virus
35
Q

What does the HBV present as in children?

A
  • Children <5 years and newly infected IMMUNOSUPPRESSED
    adults are usually ASYMPTOMATIC
  • About 30-50% of infected patients >5 years have signs/symptoms
36
Q

What are the signs & symptoms of HBV infection?

A
  • fever
  • fatigue
  • loss of appetite
  • joint pain
  • nausea, vomiting
  • abdominal pain
  • jaundice
  • dark urine
    *clay-colored stool

**only difference from HAV is: NO DIARRHEA b/c this is a blood contaminated inf. so not present

37
Q

What would it be if someone had:
HBsAg Negative
Anti-HBs Negative
Anti-HBc Negative

A

Susceptible

38
Q

What would it be if someone had:
HBsAg Negative
Anti-HBs Positive
Anti-HBc Positive

A

Immune due to natural infection

39
Q

What would it be if someone had:
HBsAg Negative
Anti-HBs Positive
Anti-HBc Negative

A

Immune due to Hepatitis B vaccination

40
Q

What would it be if someone had:
HBsAg Positive
Anti-HBs Negative
Anti-HBc Positive
IgM anti-HBc Positive

A

Acutely infected

41
Q

What would it be if someone had:
HBsAg Positive
Anti-HBs Negative
Anti-HBc Positive
IgM anti-HBc Negative

A

Chronically infected

42
Q

What would it be if someone had:
HBsAg Negative
Anti-HBs Negative
Anti-HBc Positive

A

Interpretation unclear; four possibilities:
1. Resolved infection (most common)
2. False positive anti-HBc, repeat test
3. Passive transfer to infant born to HBsAg-positive mother
4. Occult HBV infection: immunosuppressed, antivirus

43
Q

Describe the prevention of Hep B?

A

HBV vaccination
* Provides LONG-TERM protection

44
Q

Who is the CDC HBV recommended for?

A
  • ALL children <19 years
  • HIGH RISK individuals (HIV, injection drug users, etc)
  • HOUSEHOLD contacts and SEX PARTNERS of persons with chronic HBV infection
  • HEALTHCARE/public safety workers (exposure to blood)
  • international TRAVELERS who plan to spend >6 months in countries with ↑HBV rate (close contact with local)
  • recipients of CLOT-FACTOR concentrates, DIALYSIS patients
45
Q

What are the HBV vaccines?

A
  • Several HBV vaccines exist:
  • Recombivax HB (Merck)
  • Engerix-B (GSK)
  • Genevac B (Serum Institute)
  • Shanvac B (Sanofi)
  • Twinrix (against HAV and HBV)
  • These vaccines are given by intramuscular route

*** Three doses at different time intervals based on age

46
Q

What are the treatment goals for HBV infection?

A
  • MINIMIZE further LIVER DAMAGE and prevent progression of liver disease (cirrhosis, cancer)
  • Prevent TRANSMISSION to others
  • Achieve sustained SUPPRESSION of HBV REPLICATION and increase chances for seroclearance
  • NO CURE because virus INTEGRATES into the cell GENOME
  • Treatments do NOT CURE HBV but CONTROL the virus to prevent further damage to liver
47
Q

What are the treatment strategies for HBV infection?

A

Exposure to HBV <7 days:
Injection of hepatitis B IMMUNE GLOBULIN may prevent development of HBV

Acute hepatitis B:
* NO SPECIFIC treatment (rest, proper nutrition, fluid, monitor)
* In SEVERE cases, ANTIVIRAL DRUGS or hospital stay is needed to prevent complications

Chronic hepatitis B:
* INTERFERON injection
* oral ANTI-VIRAL drugs: lamivudine, adefovir, telbivudine,
tenofovir, entecavir

48
Q

What is the Viral hepatitis C?

A
  • HBC is a single stranded RNA virus with various genotypes
49
Q

What is the incubation period for hep C?

A

50 days (14-160 days)

50
Q

What are people like when they have hep C?

A
  • INITIAL infection MILD or NO symptoms

** MOST people with CHRONIC HBC are ASYMPTOMATIC (BAD)

  • About 80% of those exposed to HCV develop CHRONIC infection
  • MOST common cause of CHRONIC hepatitis, CIRRHOSIS, hepatocellular CARCINOMA
  • Currently *NO VACCINE against HCV
51
Q

What is the transmission for HCV?

A
  • blood-to-blood contact
  • injection drug use!! (MAJOR)
  • blood transfusion
  • poorly sterilized medical equipment
  • needlestick injuries in healthcare
  • tattooing, acupuncture, body piercing
  • infected mother to baby during birth
  • sexual contact
52
Q

What is the clinical presentation of HCV?

A
  • NO CLINICAL symptoms
  • May have fatigue, lethargy, nausea, reduced appetite,
    abdominal pain, jaundice
  • In about 25% of HCV INFECTED patients, VIRUS DISAPPEARS on its own (no longer infected)
  • In about 75% of HCV INFECTED patients, virus remains >6 months (CHRONIC HCV)
53
Q

What is the clinical presentation of CHRONIC HCV?

A
  • 75% of patients: MILD/MODERATE liver damage over time
  • 25% of patients: may lead to serious problems over time (25-30 yrs) such as CIRRHOSIS, LIVER FAILURE, CANCER
54
Q

What are the lab tests for HCV?

A

Hepatitis C antibody

Hepatitis C RNA test (if antibody is positive)

HCV genotyping

55
Q

Hepatitis C antibody lab test

A
  • Negative: not infected with HCV
  • Positive: infected with HCV in past but does not tell you:
  • if infection is new
  • how long patient has had infection
  • if infection is still present
56
Q

Hepatitis C RNA test (if antibody is positive) lab test

A
  • Negative: infected with HCV but virus has been cleared from body (no current infection)
  • Positive: has HCV infection
57
Q

HCV genotyping lab test

A
  • Identify HCV genotype (1-6; 1 most common in Canada)
58
Q

What is the treatment of HCV infection?

A
  • The primary goal of therapy: ERADICATE (get rid) HCV infection
  • PREVENT development of CHRONIC HCV infection
  • Since 2010, new therapies called direct acting antivirals (DAAs)
59
Q

What is the new therapies called direct acting antivirals (DAAs) for HCV?

A
  • act on virus to eradicate it from body
  • reported success rate is >90%
  • require SHORTER treatment period (8-24 weeks)
  • appear to be effective at *ALL STAGES of disease
  • LESS side effects than older drugs
  • expensive

Applied Pathophysiology (34 decks)

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