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Robbins Liver & Biliary > Viral hepatitis > Flashcards

Viral hepatitis Flashcards

1
Q

What are some viruses that cause hepatitis?

A

Hep A, B, C, D, and E

Epstein-Barr virus (EBV; infectious mononucleosis; acute phase)

Cytomegalovirus (CMV; in newborn or immunocompromised)

Yellow fever virus (tropical areas

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2
Q

What are the potential outcomes of hepatitis virus infection?

A

Acute asymptomatic infection with recovery

Acute symptomatic hepatitis with recovery, anicteric or icteric

Chronic hepatitis, with or without progression to cirrhosis

Fulminant hepatitis with massive to submassive hepatic necrosis

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3
Q

Do HAV or HEV cause chronic hepatitis?

A

No, they are acute only (but do not have to be symptomatic)

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4
Q

Does HCV cause acute hepatitis?

A

Mainly chronic

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5
Q

Which hepatotropic virus is most associated with fulminant hepatitis?

A

HBV

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6
Q

How are asymptomatic hepatotropic virus infected individuals diagnosed?

A

Incidental findings in serology

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7
Q

What hepatotropic viral infections are most commonly associated with asymptomatic infections?

A

HAV and HBV when infection occurs in childhood (only diagnosed in adulthood by antibodies)

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8
Q

What are the four phases of an acute hepatotropic viral infection?

A

Incubation

Symptomatic preicteric phase

Symptomatic icteric phase

Convalescence

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9
Q

When are hepatitis viruses most infectious during the infection?

A

The last part of the asymptomatic phase, and the first few days of symptoms

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10
Q

What is the definition of chronic hepatitis virus infection?

A

Symptomatic, biochemical or serological evidence of an ongoing or relapsing hepatitis infection over more than 6 months

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11
Q

Do the clinical features of chronic hepatotropic viral infection predict the prognosis?

A

No, unless they are bad signs such as cirrhosis or hepatocellular carcinoma

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12
Q

What are common symptoms of chronic hepatitis virus infection?

A

Fatigue (most common)

Malaise

Loss of appetite

Mild jaundice

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13
Q

What are common signs of chronic hepatitis virus infection?

A

Spider erythemas

Mild hepatosplenomegaly and tenderness

palmar erythema

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14
Q

What are some common laboratory findings in chronic hepatitis virus infection?

A

^ prothrombin time

Hyperglobulinaemia

Hyperbilirubinaemia

^ Alkaline phosphatase

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15
Q

What is an occasional complication of antibodies circulating in chronic hepatitis virus infection?

A

Immune complex disease secondary to the presence of circulating antibody-antigen complexes

Includes vasculitis and glomerulonephritis

Cryoglobulinaemia (35% of HCV infected)

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16
Q

HBV can be chronic – what predicts how chronic it will be?

A

Age at time of infection (much more chronic earlier in life)

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17
Q

What is a problem with reducing chronic HBV in endemic areas?

A

More chronic when infected earlier, but perinatal transmission is high

Difficult to cure as well

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18
Q

What are the treatment goals with chronic HBV?

A

Slow disease progression

Reduce liver damage

Prevent liver cirrhosis or cancer

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19
Q

What are the major problems with current HBV treatment regimens?

A

Viral resistance and side effects

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20
Q

How would you classify a patient who is infected with a hepatitis virus, but has either no liver damage or the liver damage is not progressing?

A

They are a carrier

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21
Q

How common is the carrier state with HBV?

A

<1% of cases in non-endemic areas

~90% of cases in endemic areas (because infected early in life)

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22
Q

Is there any evidence that HIV and HBV/HCV coinfect?

A

Yes – of HIV patients, 10% have HBV and 30% have HCV

Chronic HBV and HCV infection is now a leading cause of morbidity and mortality for HIV patients

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23
Q

What are the main consequences of liver cirrhosis?

A

Liver failure

Hepatic encephalopathy

Massive haematemesis from varices

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24
Q

What is the definition of fulminant hepatic failure?

A

Hepatic insufficiency that progresses from the onset of symptoms to hepatic encephalopathy within 2-3 weeks

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25
Q

What is the mortality of fulminant hepatic failure?

A

80% without transplantation

35% with transplantation

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26
Q

Which hepatitis viruses are transmitted through the faecal-oral route?

A

HAV and HEV

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27
Q

Which hepatitis virus has an incubation period of 1-6 months?

A

HBV

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28
Q

What fatality rate is associated with HAV?

A

0.1%

Only rarely progresses to serious disease

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29
Q

What are the symptoms of acute hepatitis virus infection?

A

Malaise/nausea

Fever

Jaundice

Hepatosplenomegaly in some cases

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30
Q

T/F HAV replicates in both intestinal epithelia and hepatocytes

A

True

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31
Q

What treatments are available for HAV infection?

A

Supportive (rehydration and nutrition)

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32
Q

Describe the HAV vaccine

A

Inactivated virions pre-expose

Requires more than one vaccination

Expensive process (diploid cells required)

Requires good testing to ensure virions are inactivated

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33
Q

When is an HAV infected individual excreting virions?

A

2 weeks before and 1 week after onset of jaundice (symptoms)

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34
Q

What does serum IgM anti-HAV in a patient tell you?

A

IgM correlates with loss of faecal shedding of virus

Reliable indicator of current active infection

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35
Q

IgM anti-HAV reduces after a few months – what is it replaced by?

A

Probably IgG, but there are no specific tests for IgG anti-HAV

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36
Q

What are the 5 possible outcomes of HBV infection? (percentages in low prevalence areas)

A

Acute hepatitis with clearance (90%)

Fulminant hepatitis with massive hepatic necrosis (30% of chronic)

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37
Q

How many people in the world have been infected with HBV?

A

2 billion

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38
Q

How many people in the world have chronic HBV infection?

A

400 million

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39
Q

How is HBV transmitted in high prevalence areas?

A

Perinatally (90% of cases)

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40
Q

How is HBV transmitted in moderate prevalence areas?

A

Horizontally (via wounds etc)

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41
Q

How is HBV transmitted in low prevalence areas?

A

Unprotected intercourse

IV drug use

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42
Q

Which hepatitis virus has an incubation period of 2-6 weeks?

A

HAV

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43
Q

What percentage of HBV acute infections show no symptoms?

A

~70%

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44
Q

How many HBV serotypes are there?

A

8

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45
Q

Describe the structure of HBV

A

Spherical double layered ‘Dane particle’

Partially dsDNA genome

46
Q

What does the HBV genome code for

A

HBcAg (hepatitis B core protein)

HBeAG (precore)

BHsAg (surface antigen)

Pol (DNA polymerase)

HBx

47
Q

What is the distribution of HBeAg and HBcAg?

A

HBeAg is secreted into the blood

HBcAg remains in hepatocytes for virion assembly

48
Q

What are the three types of HBsAg

A

Large HBsAg (containing Pre-S1, Pre-S2 and S transcripts)

Middle HBsAg (Pre-S2 and S)

Small HBsAg (S only)

49
Q

What is special about HBV polymerase?

A

Can act as both a DNA polymerase and a reverse transcriptase

50
Q

What is the function of HBxAg?

A

Transcriptional activator

Implicated in the progression to hepatocellular carcinoma

51
Q

Which antigens are present shortly after the incubation period?

A

HBeAg

HBV-DNA

HBsAg

52
Q

What is the best indicator of active HBV replication?

A

HBeAg

53
Q

What is the serological consequence of hepatocyte destruction?

A

Presence of HBcAg

Rising anti-HBcAg

54
Q

How do you know that an infection is a new infection, and not the result of a vaccination or past infection?

A

IgM titre

Rising IgG titre

55
Q

Does Anti-HBcAg or Anti-HBeAg rise earlier in disease progression?

A

Anti-HBcAg

56
Q

What does the presence of Anti-HBsAg in serology alone mean?

A

Vaccinated

57
Q

What does the presence of Anti-HBsAg and Anti-HBcAg in serology mean?

A

Previous infection with HBV

58
Q

Is Anti-HBsAg present during a HBV infection?

A

No

59
Q

Is HBsAg present during HBV infection?

A

Yes – rises before onset of symptoms and peaks during acute symptoms

60
Q

Does the HBV virus cause hepatocyte damage?

A

No – CD8+ T cells cause the damage

61
Q

How is HBV vaccinated against?

A

Purified HBsAg

Produces protective Anti-HBsAg in 95%

62
Q

What are the risk groups for HBV infection?

A

IV drug users

Health workers

Sexually promiscuous

63
Q

What are the symptoms of HBV infection?

A

Like HAV but arthralgia, urticaria as well

64
Q

What are some complications of HBV infection?

A

Fulminant hepatic failure

Relapse

Cholestasis

Cirrhosis

Hepatocellular carcinoma (more likely if HBsAg and HBeAg +ve)

Glomerulonephritis

Cryoglobulinaemia

65
Q

Is HVC a chronic or an acute infection?

A

Almost always chronic

66
Q

How often does HCV progress to cirrhosis?

A

20-30% of cases

67
Q

What are the common risk factors for HCV? (descending order)

A

IV drug use (80% of cases)

Promiscuity

Surgery within past 6 months

Needle stick injury

Health worker

68
Q

What is the most common paediatric route of transmission for HCV?

A

Perinatal

But much lower perinatal transmission than HBV

69
Q

Describe the structure of HCV

A

Enveloped

ssRNA

70
Q

Describe the genome of HCV

A

RNA that codes a single polyprotein

Nucleocapsid core protein

Envelope proteins E1 and E2

E2 has two hypervariable regions (HVR1 and 2)

NS2, NS3, NS4A and B, NS5A and B (NS = non-structural)

NS5B is the RNA dependant RNA polymerase

71
Q

How would you describe the NS5B (RNA polymerase) protein of HCV?

A

Poor fidelity

Leads to transcriptional errors, leading to multiple ‘quasispecies’ within one infected individual

72
Q

What is the most variable part of the HCV genome?

A

E2

Because of the two HVR (hypervariable) regions

73
Q

T/F E2 of the HCV genome is a target for anti-HCV antibodies

A

True

74
Q

HCV being highly variable presents which problems?

A

Anti-HCV antibodies do not always confer any protection

This means that HCV becomes chronic because it mutates and evades the immune system’s current response leading to renewed hepatic damage

75
Q

What is the incubation period of HCV?

A

6-12 weeks

76
Q

Is the percentage of acute phase HCV infection that are asymptomatic, 75% or 85%?

A

85%

77
Q

When is HCV-RNA detectable in the blood in a HCV infection?

A

After the incubation period (only in 50-70% of patients though, the rest of which have it later)

When symptoms are present

And when serum transaminases are present

78
Q

How do serum transaminase levels fluctuate in chronic HCV infection?

A

Rise and fall with the cyclical presentation of symptoms

79
Q

What are some methods by which HCV is able to evade the immune system in chronic infection?

A

NS5A is an IFN resistance factor which prevents IFN mediated cellular anti-viral responses

Inhibits TLR signalling in responset o viral RNA recognition

80
Q

What tests should you do in suspected HCV infection?

A

LFT (AST:ALT <1:1 until cirrhosis)

Anti-HCV antibodies

Liver biopsy to determine extent of damage and need for treatment/transplant

Screening tests for substance abuse and/or depression

Complete blood cell count (CBC) (thrombocytopaenia in 10% of patients)

81
Q

What are the limitations of using enzyme immunoassay (EIA) in HCV infection?

A

Cannot distinguish acute from chronic infection

Does have 97% specificity though

82
Q

How do you approach a health professional who has suffered a needlestick injury in the context of possible HCV infection?

A

Immediate PCR for HCV

Repeat every 2 months until 6 months since infection

83
Q

What is the standard HCV treatment?

A

PED-IFN, ribavirin and protease inhibitors (simprevir)

84
Q

Why are interferons given in HCV treatment?

A

Immunomodulatory cytokine that enhances phagocytic activity of macrophages and cytotoxic activity of lymphocytes

85
Q

Can HDV exist without HBV?

A

No

Needs HBV surface antigen

86
Q

What are the three types of HDV infection?

A

Acute coinfection

Superinfection

Helper-independant latent infection

87
Q

Describe acute coinfection of HDV

A

Follows exposure to serum containing HDV and HBV

HBV must become established to provide the HBsAg necessary for HDV assembly

Clinically presents as Hepatitis B+D

88
Q

Describe HDV superinfection

A

Occurs when a chronic HBV carrier is exposed to a new inoculate of HDV

Presents as clinical HDV symptoms with no HBV symptoms

Results in disease 30-50 days later

89
Q

Describe helper-independent latent HCV infection

A

Observed in liver transplant settings

HDV detectable in hepatocytes

Can be reactivated

90
Q

In the case of HDV, is co-infection or superinfection worse for prognosis?

A

Superinfection

Leads to chronic liver disease in 70-80% of patients

91
Q

What are the symptoms of HDV infection?

A

Jaundice

Abdominal pain

Nausea and vomiting

Dark urine

Anorexia

92
Q

How many HDV patients are asymptomatic?

A

90% (medscape)

93
Q

What lab tests can be performed to diagnose HDV infection?

A

HDV-RNA (90% specific)

Anti-HBcore IgM are positive only in co-infection

LFT (INR>1.5, Prothrombin time > 15s)

94
Q

How does HDV infection complicate HBV diagnosis?

A

Active HDV replication almost completely removes HBsAg from serum

95
Q

How do you treat a HDV/HBV co-infection?

A

Treating the HBV will limit HDV effectiveness

IFN-alpha-2a has shown effectiveness at directly treating the HDV

96
Q

How is HEV transmitted?

A

Faecal-oral route

Contaminated water (water-borne virus)

97
Q

Is HEV infection in children common?

A

Very rarely

Occurs mostly in young to middle-aged adults

98
Q

Does HEV have animal reservoirs?

A

Yes – commonly found and spread through animals

Monjeys, cats, pigs and dogs

99
Q

What is the mortality rate of HEV in pregnant women?

A

20%

Mortality increases in second and third trimesters

100
Q

How does HEV cause death in pregnant women?

A

Encephalopathy

DIC (disseminated intravascular coagulation)

Fulminant hepatic failure rates high

101
Q

What is the most common route of transmission of HEV in non-epidemic areas?

A

Contaminated food (eg undercooked pork)

Results from HEV making reservoirs in animals, such as pork

102
Q

What is the fatality rate of HEV infections?

A

4%

Though much higher in pregnant women and liver transplant patients

103
Q

How is HEV infection diagnosed?

A

The presence of anti-HEV IgM

HEV-RNA can be detected before onset of symptoms but not long after

104
Q

What is the incubation period of HEV?

A

15-60 days

105
Q

With what history will HEV patients present?

A

Anorexia

Nausea/vomiting

Right upper quadrant pain that increases with activity

Jaundice

Dark urine

Pale stools

Pruritus

106
Q

How is HEV infection treated?

A

Self-limiting, hence supportive therapy including rehydration

In severe cases, or in immunocompromised, may consider ribavirin

107
Q

How long do symptoms last in HEV?

A

2-4 weeks

108
Q

Is Hepatitis G virus (HGV; GB virus C) hepatotropic?

A

No

Causes no increase in aminotransferase levels

109
Q

Where does HGV (GBV-C) replicate?

A

Bone marrow

Spleen

110
Q

What are the symptoms of HGV (GBV-C) infection?

A

GBV-C does not cause human disease

111
Q

What is the relationship between HGV (GBV-C) and HIV?

A

Co-infection occurs in 35% of HIV cases

Co-infection is thought to be protective

112
Q

How often does cholestasis occur in HEV infection?

A

50%

Robbins Liver & Biliary (6 decks)

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