Viral hepatitis

Question 1

lifestyle indications for hepatitis A vaccination

Answer 1

men who have sex with men

illicit drug use

travel to endemic area

lab work with hepatitis A

close contact to a international adoptee

Question 2

medical indications for hepatitis A vaccination

Answer 2

chronic liver dx,

clotting factor deficiency,

exposure during outbreak (childcare worker)

close contact with index case

Question 3

hepatitis A incubation

Answer 3

fecal oral transmission with incubation of 30 days.

Question 4

PEP options for post exposure outbreak is

Answer 4

single dose of inactivated HAV vaccine

OR

immune globulin IG. give within 14 days of HAV exposure

Question 5

when is immune globulin for Hep A protection preferred

Answer 5

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

Question 6

Acute hepatitis B infection presentation

Answer 6

mild flu symptoms

fulminant liver failure

or serum sickness like reaction (fever, rash, symmetric polyarthralgias and arthritis then jaundice)

Question 7

what causes acute hepatitis B serum sickness like reaction?

Answer 7

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

Question 8

extra hepatic manifestations of chronic hepatitis B include:

Answer 8

polyarteritis nodosa

membranous nephropathy (seen in 10-20% of cases)

can have palpable purpura too.

can see cryoglobulinemia too.

Question 9

hepatitis C infection can cause clinical picture similar to

Answer 9

RA and from immune complex deposition from mixed cryoglobulinemia with arthritis, glomerulonephritis and vasculitis

Question 10

Acute hep B infection presents

Answer 10

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.

Question 11

polyarteritis nodosa

Answer 11

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

Question 12

acute infection of hepatitis B includes:

Answer 12

asymptomatic transaminase elevation and 30% have nausea, fatigue, jaundice and abdominal pain fulminant hepatic failure can occur in <1%

95% of pts improve

Question 13

who gets antiviral therapy for acute hepatitis B infectioN?

Answer 13

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.

Question 14

chronic hepatitis B develops in

Answer 14

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

Question 15

who gets treatment for chronic hepatitis B?

Answer 15

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)

Question 16

treatment of chronic Hep C infection

Answer 16

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

Question 17

do we ever biopsy liver in someone who has acute hepatitis B infection?

Answer 17

no can be done to think about treatment decisions

Question 18

Treatment of acute hepatitis B infection:

Answer 18

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

Question 19

Relapsing remitting varient of Hep A infection:

Answer 19

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

Question 20

Chronic hep B and C infections should get this screening?

Answer 20

HCC u/s abd q 6 months

Question 21

chronic hep B infection treatment is:

Answer 21

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.

Question 22

What is active Hep B defined as?

What is reactivated Hep B defined as?

Answer 22

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.

Question 23

presentation of hepatitis B?

Answer 23

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.

Question 24

Duration of Hep E infection

Answer 24

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.

Question 25

when do we need to NOT do post exposure management for hepatitis B?

Answer 25

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.

Question 26

post needle exposure for hepatitis B

do they need treatment?

Answer 26

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

Question 27

what are adequate titers against hep B?

Answer 27

>10 mIU/ml against hep B

Question 28

classic hepatitis C involvement of kidneys

Answer 28

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.

Question 29

hepatitis B virus infection is associated with what renal pathology?

Answer 29

membranous glomerulopathy with hepatitis B infection

see nephrotic syndrome