Viral hepatitis Flashcards
lifestyle indications for hepatitis A vaccination
men who have sex with men
illicit drug use
travel to endemic area
lab work with hepatitis A
close contact to a international adoptee
medical indications for hepatitis A vaccination
chronic liver dx,
clotting factor deficiency,
exposure during outbreak (childcare worker)
close contact with index case
hepatitis A incubation
fecal oral transmission with incubation of 30 days.
PEP options for post exposure outbreak is
single dose of inactivated HAV vaccine
OR
immune globulin IG. give within 14 days of HAV exposure
when is immune globulin for Hep A protection preferred
in children <12 yrs
in immune compromised pts (advanced HIV, chronic liver dx and those on immunosupressive medications)
as they will not respond to hepatitis A vaccine
Acute hepatitis B infection presentation
mild flu symptoms
fulminant liver failure
or serum sickness like reaction (fever, rash, symmetric polyarthralgias and arthritis then jaundice)
what causes acute hepatitis B serum sickness like reaction?
see accumulation of antigen antibody complexes leading to vascular or cellular inflammation.
Rash is pruritic and urticarial without mucosal involvement.
See symmetrical polyarthralgias and arthritis in the small joints and some morning stiffness.
This lasts for 2-3 weeks before start to see jaundice.
Treatment is supportive
extra hepatic manifestations of chronic hepatitis B include:
polyarteritis nodosa
membranous nephropathy (seen in 10-20% of cases)
can have palpable purpura too.
can see cryoglobulinemia too.
hepatitis C infection can cause clinical picture similar to
RA and from immune complex deposition from mixed cryoglobulinemia with arthritis, glomerulonephritis and vasculitis
Acute hep B infection presents
polyarthritis, skin involvement of lower extremities but usually has eruptive urticaria or maculopapular rash.
Joint disease is symmetrical, involves hands, knees, wrists, ankles, elbows or shoulders.
polyarteritis nodosa
medium vessel vasculitis without any signs of glomerulonephritis see abdominal pain, testicular pain, and weight loss and fevers and chills treat with steroids seen with hepatitis B
acute infection of hepatitis B includes:
asymptomatic transaminase elevation and 30% have nausea, fatigue, jaundice and abdominal pain fulminant hepatic failure can occur in <1%
95% of pts improve
who gets antiviral therapy for acute hepatitis B infectioN?
tenofovir and entecavir
are only considered in pts who have:
INR>1.5 and >4 weeks of symptoms with significant jaundice (bilirubin >10) or acute liver failure.
chronic hepatitis B develops in
5% of pts see persistent HBsAg for >6 months and can be active or inactive.
Chronic inactive HBV is seen with negative HBeAg and normal AST see <2000 HBV DNA and doesn’t require treatment
who gets treatment for chronic hepatitis B?
elevated HBV DNA ALT>2x normal HBeAg positive or
can be a part of pts who have chronic HBV infection (negative HBeAG but elevated HBV DNA)
treatment of chronic Hep C infection
sofosbuvir and velpatasvir
not used for HBV and can worsen HBV infection when pts have both HCV and HBV co infection who are not on HBV medication
do we ever biopsy liver in someone who has acute hepatitis B infection?
no can be done to think about treatment decisions
Treatment of acute hepatitis B infection:
supportive treatment and most don’t require antiviral therapy.
most will clear the infection but a small amount will develop a chronic infection with a persistence of HBsAg >6 months
Relapsing remitting varient of Hep A infection:
this is an Hep A infection characterized by multiple clinical or biochemical relapses within spontaneous improvement within months to 1 year without intervention.
Can see icteric illness 3 months after initial Hep A infection. Can have mulitple relapses which are milder and see cholestasis. Can have hepatitis, arthralgia, vasculitis and cryoglobulinemia.
Rarely HAV infection can trigger autoimmune hepatitis. But testing does not show ANA and antinuclear antibodies or elevated IgG
Chronic hep B and C infections should get this screening?
HCC u/s abd q 6 months
chronic hep B infection treatment is:
tenofovir or entecavir
not all patients with chronic Hep B go through each phase.
Active or re-activated phase Hep B infection, see elevated HBV DNA level
Immune active phase >20K in Hep B e antigen positive dx or in >2000 in HBeAg negative disease
Re-activated Hep B see HBeAg positive phase with ALT and ASPT exceeding upper limit of normal by 2x.
Treatment is necessary to decrease hepatic inflamation and risk for progression to fibrosis and eventual cirrhosis that will occur without treatment.
What is active Hep B defined as?
What is reactivated Hep B defined as?
Active or re-activated phase Hep B infection, see elevated HBV DNA level
Immune active phase:
>20K in Hep B e antigen positive dx
>2000 in HBeAg negative disease
Re-activated Hep B
see HBeAg positive above baseline with ALT and ASPT exceeding upper limit of normal by 2x.
Treatment is necessary to decrease hepatic inflamation and risk for progression to fibrosis and eventual cirrhosis that will occur without treatment.
presentation of hepatitis B?
RUQ pain,
nausea, vomiting
fatigue
anorexia and weight loss
seen with high risk sexual practices
suspect this when there’s a history of high risk behavior and when the duration of symptoms is >4 weeks. PT had symptoms for 4 months.
Hep B - rarely has chronic symptoms most people clear acute infection.
Duration of Hep E infection
transmitted through fecal oral and contaminated water
presents like Hep A wiht a flu-like prodrome, an icteric phase, and pts symptoms last <1 month.
when do we need to NOT do post exposure management for hepatitis B?
when there’s documentation of 3 dose hepatitis B vaccine series with subsequently documented anti-HBs >10 mIU/ML regardeless of pt’s source of HBsAG status.
if healthcare profession with needle stick doesn’t show adequate documentation of immunity and source pts has positive HBsAG or unknown HBsAg status, healthcare provider should get 1 dose of Hep B immunoglobulin and revaccinated as soon as possible.
post needle exposure for hepatitis B
do they need treatment?
get 1 dose of Hep B immunoglobulin and revaccinated as soon as possible.
if healthcare profession with needle stick doesn’t show adequate documentation of immunity and source pts has positive HBsAg or unknown HBsAg status
what are adequate titers against hep B?
>10 mIU/ml against hep B
classic hepatitis C involvement of kidneys
membranoproliferative glomerulonephritis - see elevated Cr, hematuria, subnephrotic proteinuria
see MPGN pattern on kidney biopsy and bifurication on immunofluorescence microscopy.
see immune complex deposition with presence of both immunoglobulin IgG, IgM and or IgA and complement C1q and C3 on immunoflorescence.
hepatitis B virus infection is associated with what renal pathology?
membranous glomerulopathy with hepatitis B infection
see nephrotic syndrome
