Viral Hepatitis

Question 1

What are the differentials for viral hepatitis?

Answer 1

Hepatitis A-E viruses
CMV
EBV
Paravirus B19
Adenovirus
Enterovirus
Yellow fever 
Dengue

Question 2

What are the signs and symptoms of viral hepatitis?

Answer 2

Non-specific symptoms
- malaise, fever, headache
- anorexia, nausea, vomiting 
RUQ abdominal pain
Dark urine
Clay coloured faeces
Jaundice

Question 3

Name some complications of fulminant acute hepatitis.

Answer 3

Encephalopathy
- decline in brain function and liver can’t remove toxins from the blood stream
Coagulopathy
- lack of coagultion factors being produced
Multi-organ failure

Question 4

What are the routes of transmission of the hepatitis viruses?

Answer 4

A&E - faecal-oral
Parenteral
- contact with body fluids

Question 5

How can faecal-oral transmissible viruses spread?

Answer 5

Lack of hand-washing
Lack of clean water
Food-bourne
- e.g. oysters and shellfish in the UK a common cause of HAV

Question 6

Through which ways do HBV and HCV spread?

Answer 6

HBV
- mostly sexual
- some parenteral and perinatal spread
HCV
- mostly parental
- only perinatal in HIV
- small amount sexually

Question 7

How can viral hepatitis be diagnosed with lab tests?

Answer 7

IgM - high in acute hepatitis
IgG - high in chronic hepatitis
Viral nucleic acid detection
- RNA or DNA

Question 8

What kind of virus is hepatitis A, and what is the incubation period?

Answer 8

ssRNA unenveloped hepatovirus

3-5 weeks

Question 9

What are the clinical features of hepatitis A?

Answer 9

Acute
- risk of jaundice increases with age
Rare complications
- fulminant hepatitis
- relapsing hepatitis

Question 10

What is the difference between chronic and acute hepatitis A?

Answer 10

Hep A is self-limting, so there is no chronic hepatitis

Question 11

How is hepatitis A diagnosed?

Answer 11

HAV IgM in the blood

HAV RNA in the blood/stool

Question 12

Name and describe the two methods of prevention in hepatitis A.

Answer 12

Passive (normal human Ig)
- immediate protection if there isn’t enough time to immunise
- household contacts
Active (inactivated vaccine e.g. Havrix)
- at risk groups: travellers, MSM, contacts or these
- occupational: sewage workers, foodhandlers

Question 13

What kind of virus is hepatitis B, and what is the incubation period?

Answer 13

Partially dsDNA hepadnavirus

6 weeks to 6 months (average 2.5 months)

Question 14

What are the clinical features of Hep B?

Answer 14

Acute hepatitis
- 10% adults jaundice
- children asymptomatic 
Fulminant hepatitis (1%)
Chronic hepatitis
- sAg positive 
- mostly found in babies
Complications
- cirrhosis
- hepatocellular carcinoma

Question 15

How is acute Hep B diagnosed?

Answer 15

Following markers are present in the blood
sAg
cIgM
eAg
sAb becomes present after the infection (also present in people with vaccines)

Question 16

How is chronic Hep B diagnosed?

Answer 16

The following three makers are present
sAg
cIgG
eAg/eAb

Question 17

When is chronic hepatitis B treated?

Answer 17

Evidence of active infection (HBV DNA>2000iu/ml)
AND
Evidence of inflammation
- fibrosis scan
- persistently raised LFTs
- biopsy
- cirrhosis

Question 18

What is the treatment for chronic hepatitis B?

Answer 18

1st line
- four weeks of pegylated IFN
2nd line
- tenofovir or entecavir (antireteroviral)

Question 19

Name and describe the two types of Hep B prevention.

Answer 19

Passive
- Hepatitis B immunoglobulin (needle-stick injury to susceptible, newborn babies of high infectivity carriers)
Active
- recombinant vaccine
- at risk groups (MSM, babies of HBV, IVDU)
- most countries immunise all babies

Question 20

Describe the hepatitis D virus.

Answer 20

ssRNA virus enveloped by HBsAg
A defective virus - occurs only where HBV has occured
- co-infection with HBV

Question 21

How is Hep D diagnosed?

Answer 21

Delta Abs and RNA in the blood

Question 22

What kind of virus is hepatitis C, and what is the incubation period?

Answer 22

ssRNA enveloped flavivirus

6-12 weeks

Question 23

What are the importance of Hep C genotypes?

Answer 23

7 different types

• worldwide distribution of genotypes
• mostly have genotype 1 and 3 in the UK
• treatment is different depending on the genotype

Question 24

What are the main causes of Hep C?

Answer 24

IVDU
MSM
Vertical
Pre-1991 blood transfusion recipients

Question 25

What are the clinical features of the Hep C virus?

Answer 25

Acute hepatitis
- mostly asymptomatic
- <1% fulminant 
Chronic infection
- 20% cirrhosis 
- 3-7% hepatocellular carcinoma
HCV accounts for 30% of liver transplants

Question 26

Hoe is Hep C diagnosed?

Answer 26

HCV antibody testing
- negative (no infection)
- positive (reative - needs more testing)
If positive, a PCR/HCV antigen from the original sample is done
- non-reactive HCV Ag or negative PCR means there was a past infection
- RNA detected or HCV Ag reactive means there is an ongoing infection

Question 27

How are genotypes 1 and 3 of Hep C treated?

Answer 27

• 1: Sofosbuvir (HCV NS5B polymerase inhibitor to suppress replication), Ledipasvir (also suppresses replication) and Ribavirin (an anti-viral)
• 3: the same but without Ledipasvir

Question 28

What kind of virus is hepatitis E, and what is the incubation period?

Answer 28

ssRNA unenveloped virus

6 weeks

Question 29

Describe the 4 genotypes associated with Hep E.

Answer 29

1 and 2 are found in Africa, Asia and South America, only in humans
- large, water borne outbreaks
3 and 4 are found worldwide in all kinds of animals (including humans)
- sporadic cases in the developed and developing world

Question 30

What are the clinical features of Hep E?

Answer 30

Acute hepatitis
- seen in young adults (developing countries)
- elderly men (developed countries)
Death (15-25% in pregnant women with G1)
Complications
- fulminant 
- haematological
- neurological
Chronic hepatitis
- only in immunocompromised

Question 31

How is Hep E diagnosed?

Answer 31

HEV IgM and IgG and RNA

Question 32

Name and describe the ways in which Hep E can be prevented.

Answer 32

General
- avoid drink water and shellfish when travelling
- cook pork and venison products well
Passive immunisation
- nothing
Acitve immunisation
- vaccine not available in UK