VIRAL HEPATITIS Flashcards
How many hepatitis viruses are known?
6
Hep A, B, C, D, E, and G (where is F??)
Other than the hepatitis viruses, what viruses can cause damage to the liver?
Cytomegalovirus
EBV
Yellow fever
Herpes viruses
What is the most common type of hepatitis virus worldwide?
Hepatitis A
What age group is most commonly affected by hepatitis A?
Young
What is the method of transmission of hepatitis A?
Faecal-oral route
Contaminated water or shellfish
What does the icteric phase refer to, with regard to hepatitis?
The time when the patient is jaundiced.
What are the symptoms of the prodromal phase (early stages) of hepatitis A infection?
Nausea Vomiting Diarrhoea Headache Mild fever Malaise Abdominal discomfort
How does hepatitis A affect smokers?
They have a sudden distaste for cigarettes.
How long after infection does the icteric (jaundiced) phase of hepatitis A occur?
10-14 days
How long does the icteric (jaundiced) phase in hepatitis A infection last for?
2-3 weeks
Other than jaundice, what are the symptoms of the icteric phase of hepatitis A infection?
Malaise and fatigue (which may persists for months)
Hepatomegaly
Splenomegaly in 10%
What would give you a definitive diagnosis of on going hepatitis A infection?
Rising titre of anti-hep A IgM
Demonstration of viral particles in stools by electron microscopy
What in the blood might reflect previous exposure to hepatitis A infection?
Anti-hep A IgG
What would LFTs show in someone with an on going hepatitis infection?
Moderately raised AST and ALT (500-1000 IU/L) which normalise rapidly
With reference to the icteric (jaundiced) phase of hepatitis A infection, when is the disease most infectious?
Just before the onset of jaundice
What are the complications of hepatitis A and how frequent are they?
They are actually quite rare
Myocarditis Arthritis Vasculitis Fulminant hepatic failure (very rare) Can precipitate autoimmune hepatitis
Does hepatitis A infection ever become chronic?
No and infact previous sufferers have lifelong immunity
How are patients with on going hepatitis A infection managed?
Treatment is supportive and hospital admission is not necessary in most cases.
Antiemetics for nausea
IV fluids in vulnerable patients (elderly)
Analgesia for headaches
Maintain calorie intake
Avoid alcohol
What is the incidence of symptomless hepatitis B infected individuals in the UK and USA?
0.1%
What is the method of transmission of hepatitis B?
Bodily fluid, mostly blood
Contaminated blood products IV drug user Sexual transmission Vertical transmission (at birth) - most common worldwide (Mosquitoes are possible)
Is hepatitis B transmitted by breast feeding?
No
What is the basic structure of the hepatitis B virus?
An inner nucleocapsid surrounded by an outer envelope of surface protein.
Is hepatitis B infection acute or chronic?
It can be either or it can be symptomless (carrier)
What is the incubation time of hepatitis B?
60-160 days
What are the symptoms of the prodromal phase (early stages) of acute hepatitis B infection?
Very non-specific
Arthralgia
Anorexia
Abdominal discomfort
Other than jaundice, what are the features of the icteric (jaundiced) phase of acute hepatitis B infection?
Fever
Hepatomegaly
Urticarial or maculopapular rash
Polyarthritis
What are the clinical features of chronic hepatitis B infection?
Most chronic carriers are asymptomatic
May present with features of chronic liver disease or cirrhosis: jaundice, ascites, portal hypertension, hepatic failure
What would LFTs of someone with acute hepatitis B infection show?
Very high AST and ALT (1000-5000 IU/L) for the first week but falling rapidly after this
What are the first markers to appear in serology of someone with hepatitis B infection and when do they appear?
Surface antigens (HBsAg) - 6 week to 3 months after infection
What is the serological marker which indicates increased virus replication and high infectivity of hepatitis B?
The e antigen (HBeAg)
What will the serology of someone who has never been exposed to hepatitis B or had the vaccination show in terms of HBsAg, anti-HBc and anti-HBs?
HBsAg - negative
Anti-HBc - negative
Anti-HBs - negative
What will the serology of someone who has had the vaccination against hepatitis B show in terms of HBsAg, anti-HBc and anti-HBs?
HBsAg - negative
Anti-HBc - negative
Anti-HBs - positive
What will the serology of someone who has recovered from a hepatitis B infection show in terms of HBsAg, anti-HBc and anti-HBs?
HBsAg - negative
Anti-HBc - positive
Anti-HBs - positive
What will the serology of someone who is acutely infected with hepatitis B infection show in terms of HBsAg, anti-HBc, IgM anti-HBc and anti-HBs?
HBsAg - positive
Anti-HBc - positive
IgM anti-HBc - positive
Anti-HBs - negative
What will the serology of someone who is chronically infected with hepatitis B infection show in terms of HBsAg, anti-HBc, IgM anti-HBc and anti-HBs?
HBsAg - positive
Anti-HBc - positive
IgM anti-HBc - negative
Anti-HBs - negative
What does the following serological picture show about the patient in terms of hepatitis B?
HBsAg - positive
Anti-HBc - positive
IgM anti-HBc - positive
Anti-HBs - negative
The person is acutely infected with hepatitis B
What does the following serological picture show about the patient in terms of hepatitis B?
HBsAg - negative
Anti-HBc - positive
Anti-HBs - positive
The person has recovered from a natural infection of hepatitis B and is now immune.
What does the following serological picture show about the patient in terms of hepatitis B?
HBsAg - positive
Anti-HBc - positive
IgM anti-HBc - negative
Anti-HBs - negative
The person is chronically infected with hepatitis B.
What does the following serological picture show about the patient in terms of hepatitis B?
HBsAg - negative
Anti-HBc - negative
Anti-HBs - positive
The person has been successfully vaccinated against hepatitis B.
What is the serological marker which indicates low infectivity of hepatitis B?
Anti-HBe antibodies
What method might you use to quantify viral load in someone with hepatitis B?
Polymerase chain reaction (PCR)
What are the complications of hepatitis B?
Fulminant (sudden and severe) hepatitis and death occur in 1%
Arteritis
Glomerulonephritis
Cryoglobulinaemia
Also predisposes patient to hepatocellular carcinoma
How are patients with acute hepatitis B managed?
Symptomatic relief is all that is required, with extra care taken handling bodily fluids
Fulminant (sudden and severe) hepatitis carries a grave prognosis and may require liver transplant.
What are the anti-viral medications used in the treatment of chronic hepatitis B?
Lamivudine
Adefovir
Entecavir
Apart from anti-virals, what other medications are used in the treatment of chronic hepatitis B?
Alpha-interferon SC
How is hepatitis C transmitted?
Contaminated blood
IV drug users
Sexual transmission (rare)
Vertical transmission (rare)
Breast milk transmission (rare)
What are the clinical features of hepatitis C?
Jaundice only occurs in about 20% of patients
Fatigue or malaise are common
Cirrhosis
Extra-hepatic manifestations are rare
What do LFTs of someone with hepatitis C show?
Slightly elevated AST and ALT (50-150 IU/L)
Normal bilirubin
Raised ferritin
What do you look for in the blood in order to make a diagnosis of hepatitis C?
IgM anti-hepatitis C
Hepatitis C RNA (using PCR)
What are the complications of hepatitis C infection?
70% develop chronic indolent hepatitis of varying severity
20% progress to cirrhosis
What are the co-factors that might increase the likelihood of developing cirrhosis as a result of hepatitis C?
Advanced age
Male gender
HIV
Hepatitis B
Alcohol excess
Obesity
How are patients with hepatitic C medically managed?
Pegylated interferon
Ribavirin
Treatment is only really offered to those with mild hepatitis C infection as they will have a better response.
What are the three genotypes of hepatitis C and how well does each one respond to medical treatment?
Genotype 1 - 45% successful seroconversion
Genotype 2 - 90-100% successful seroconversion
Genotype 3 - 60-70% successful seroconversion
How long is each genotype of hepatitis C treated for with pegylated interferon and ribavirin?
Genotype 2 and 3 - 24 weeks
Genotype 1 - 48 weeks
What is the major side effect of pegylated interferon, used in the treatment of hepatitis C?
Depression
What is the major side effect of ribavirin, used in the treatment of hepatitis C?
Anaemia through suppressed haemoglobin synthesis
In someone with a liver transplant following hepatitis C infection, what are the chances of recurrence of the hepatitis C?
Almost 100%
In what patients might you see a hepatitis D infection?
Hepatitis D occurs as a co-infection with hepatitis B virus and is particularly seen in IV drug users.
What are the complications hepatitis D infection?
Increases chances of the hepatitis co-infection causing fulminant hepatitis and cirrhosis.
What might indicate that someone has an EBV infection if they are treated for a bacterial infection?
EBV can cause a rash if treated with ampicillin. This does mean patient is allergic to ampicillin in the future.
What is the prognosis of someone with hepatitis due to EBV?
Excellent prognosis with majority maintaining normal liver function.
Which group are particularly susceptible to hepatitis caused by cytomegalovirus?
Immunosuppressed
How is diagnosis of cytomegalovirus made?
May be detected in the urine
Most sensitive test is to detect antigen in buffy coat of EDTA treated blood
Rising IgM titre to CMV can also aid diagnosis of acute infection
What does the liver biopsy of someone with cytomegalovirus show?
Intracytoplasmic inclusion bodies and giant cells
