Viral Hepatitis Flashcards by Christopher Hauglid

Three main clinical presentations of Hepatitis

1) Acute
2) Chronic
3) Fulminant

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Acute Viral Hepatitis Symptoms

1) Jaundice
2) Dark Urine
3) Acholic stool (light or clay-colored due to reduced bile production)
4) Prodrome (1-2 weeks prior to jaundice; Headache, myalgias, arthralgias, fatigue, nausea, vomiting, pharyngitis, mild fever)

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Acute Viral Hepatitis Biochemistry

1) Bilirubin Levels
>3 mg/dL Jaundice
Commonly 5-20 mg/dL
Bilirubin in urine = liver disease

2) Liver Enzymes
- Alanine aminotransferase (ALT)
- Aspartate aminotransferase (AST)
- Elevation apparent as early as PRODROME PHASE
- Usually higher than that of other hepatitis causes
- May be up to 1000 U/L-ALT

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Chronic Viral Hepatitis

Hepatitis which DOES NOT resolve within 6 months

- Predisposes to hepatocellular carcinoma and cirrhosis

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Fulminant Viral Hepatitis

RAPID, SEVERE hepatitis
Massive hepatic NECROSIS
Encephalopathy (CNS EFFECTS): confusion, disorientation, coma
Edema
Complications: cerebral edema, brainstem compression, GI bleeding, sepsis, organ failure
LIVER TRANSPLANT can be lifesaving

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Hepatitis A (Virus Family, Transmission, Chronic Infection)

Picornavirus, Fecal-Oral, No

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Hepatitis B (Virus Family, Transmission, Chronic Infection)

Hepadnavirus, Body Fluids, Yes

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Hepatitis C (Virus Family, Transmission, Chronic Infection)

Flavivirus, Body Fluids, Yes

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Hepatitis D (Virus Family, Transmission, Chronic Infection)

Deltavirus, Body Fluids, Yes

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Hepatitis E (Virus Family, Transmission, Chronic Infection)

Hepevirus, Fecal-Oral, No

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Hepatitis A

Picornavirus Family
\+ssRNA
Fecal oral transmission
Seroprevalence 30%
All age groups susceptible, children usually ASYMPTOMATIC
Incubation period ~28 days
Resolution usually within 2 months
***DOES NOT cause chronic hepatitis***
Very rarely causes fulminant hepatitis

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Hepatitis A (Diagnosis)

Acute Infection = IgM antibodies against HAV

Anti-HAV IgG antibodies protective immunity (will be present in patients who were PREVIOUSLY exposed)

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Hepatitis A (Prevention)

HAVRIX and VAQTA
IM injection (2 dose schedule)
Since 2005, ACIP recommends universal vaccination for all infants (12-23 months), as well as high risk adult groups
Post-exposure Prophylaxis* (Vaccine or anti-HAV IgG antibodies)

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Hepatitis B (Appearance)

Tubes and Spheres: Incomplete, Noninfectious particles (Hepatitis B Surface Antigen - HBsAg)

Dane Particles: Complete Virions (HBsAg, Hepatitis B Core Antigen - HBcAg, and HBeAg)

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Hepatitis B (Characteristics)

Hepadnavirus Family
Partially dsDNA genome
REVERSE TRANSCRIPTION (via reverse transcriptase) is part of life cycle

NOT a Retrovirus

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Hepatitis B (Acute vs Chronic)

Acute:

HBsAg is cleared PRIOR TO 6 months
After this will see Anti-HBs
Early–> will see IgM
Late–> will see IgG

Chronic:

HBsAg is maintained for a long period of time
**DO NOT have Anti-HBs in this type because it is seen in RECOVERY and you are not having recovery in chronic infections

Hepatitis B (Diagnosis)

Viral antigens and anti-HBV antibodies used for diagnosis

- Presence of HBsAg within the blood is a marker of ACTIVE INFECTION

Hepatitis B (Acute vs Chronic Lab Tests)

Acute: Anti-HBc Total and IgM are POSITIVE

Chronic: Anti-HBc Total is POSITIVE and IgM is NEGATIVE

How do you know if a patient is susceptible to HBV?

They will have a NEGATIVE Anti-HBc Total test

How do you know if a patient has been previously infected with HBV?

Positive Anti-HBsAg and Positive Anti-HBc Total test

How do you know if a patient has been vaccinated against HBV?

Will have Positive Anti-HBsAg

Hepatitis B (Characteristics)

Incubation period median 90 days
Transmission route = Bodily Fluids (e.g. sexual transmission, percutaneous needle stick (6-30%), perinatal transmission at birth (10-90%)
Half of infected adults are ASYMPTOMATIC
Acute symptoms are often MILDER than HAV

Younger you are, the more likely you are to develop a chronic HBV infection
Birth = 90% ; Over 5 years old = 10%

Hepatitis B (Treatment)

None for acute infections
Chronic infections
a) Lamivudine —> REVERSE TRANSCRIPTION INHIBITOR
b) Famcyclovir/Adefovir dipivoxil: NUCLEOSIDE INHIBITOR
c) Interferon alpha

Usually a combo of either A and C or B and C

Hepatitis B (Vaccine)

IM injection - 3 dose schedule
Currently use Recombinant HBV vaccine produce in YEAST CELLS (Recombinvax HB and Engerix B)
-Recommended for all infants (1st dose soon after delivery)

Hepatitis B (Post-Exposure Prophylaxis)

- Premature infants born to mothers of unknown or HBsAg positive receive VACCINE and HEPATITIS B IMMUNOGLOBIN (HBIG) within 12 hours of birth - Full term infants born of HBsAg positive receive VACCINE and HBIG within 12 hours of birth - Percutaneous exposure of healthcare workers

Hepatitis C (Characteristics)

Flavivirus Family ***ENVELOPED*** +ssRNA genome

Hepatitis C (Transmission)

- ***INJECTION DRUG USE*** - Tattoos - Accidental needle stick (1.8%) - Perinatal (4%) - Sexual (VERY UNCOMMON)

Hepatitis C (Diagnosis)

***Chronic infection suspected*** Two-Step Test: 1) Screening test--> antibody-based test for anti-HCV antibodies 2) Confirmatory test--> Nucleic acid based tests for detection of the viral genome

Hepatitis C (Symptoms)

***MILDER acute symptoms than HAV or HBV*** Disease outcomes (across all age groups): - 15% acute only - 15% rapid progression to CIRRHOSIS - 70% CHRONIC INFECTION

Hepatitis C (Treatment)

* **Only treat CHRONIC infections*** - All treatments include ***SOFOSBUVIR (an RNA-Dependent RNA Polymerase Inhibitor)*** - Very expensive; newest way to treat Hep C

Hepatitis C (Prevention)

NO VACCINE AVAILABLE - Reduce high risk behaviors (e.g. IV drug use or unprotected sex) - Screening of bloody supply

Hepatitis D (Characteristics)

- Small circular ssRNA genome * **Encodes TWO PROTEINS (Delta-Short and Delta-Long long) that cover antigen*** * **Unique helper-dependent virus*** (e.g. RELIES ON ANOTHER VIRUS (Hepatitis B)) - Hepatitis B surface antigen forms the external surface of virion * **Replication REQUIRES HBV proteins*** ***KNOW: only infects cells that have been previously or concurrently infected with HBV***

Hepatitis D (Disease)

***FULMINANT HEPATITIS is a more likely outcome of HBV and HDV double infection than any other single hepatitis virus infection*** ***Hepatitis D virus is the ONLY hepatitis virus that DIRECTLY INJURES HEPATOCYTES*** Chronic infection can occur = carriers

Hepatitis D (Diagnosis, Treatment, Prevention)

Diagnosis: -ELISA to detect anti-HDV antibodies or the delta antigens Treatment: ***NO SPECIFIC ANTIVIRAL TREATMENTS*** Preventions: ***Since HBV infection is ABSOLUTELY required for HDV to infect and cause disease, vaccination against HBV prevents HDV disease***

Hepatitis E (Characteristics)

-Hepevirus family +ssRNA genome -Fecal oral transmission ***DOES NOT cause chronic infection*** -Most cases in US are travel-related -Epidemics: India, Pakistan, Nepal, Burma, North Africa, and Mexico -High risk of death due to infection in PREGNANT WOMEN (~20% mortality rate)

Hepatitis E (Treatment and Prevention)

Treatment: -Alleviate symptoms Prevention: -Prevent spread by providing clean water and proper food handling