Viral Hepatitis

Question 1

What type of virus is hepatitis A?

Answer 1

An RNA virus

Question 2

Explain the spread of Hep A.

Answer 2

Faecal to oral or via shellfish.

It is an endemic in Africa and South America, this means that a Travel history is important.

Most infections are in childhood

Question 3

Incubation of Hep A.

Answer 3

2-6 weeks

Question 4

Symptoms of Hep A.

Answer 4

Fever, anorexia, malaise, nausea, arthralgia

And then jaundice.

Hepatomegaly

Adenopathy

Question 5

Test findings in Hep A.

Answer 5

ASt and ALT rise 22-40d after exposure.

ALT might be as high as >1000 IU/L.

It will then return to normal over 5-20 weeks.

IGM rises from day 25 and this indicates a recent infection.

IgG is detectable for life.

Question 6

Treatment of Hep A.

Answer 6

Supportive

Avoid alcohol

Rarely interferon alfa for fulminant hepatitis.

Question 7

Explain immunisation of hep A.

Answer 7

With inactivated viral protein.

1 intramuscular dose gives immunity for 1 year and then 20 years if further booster is given at 6-12 months.

Question 8

Prognosis of hep A.

Answer 8

Usually self-limiting

Fulminant hepatitis is rare and chronicity does not occur.

Question 9

What type of virus is Hep B?

Answer 9

HBV a DNA virus

Question 10

Explain the spread of Hep B.

Answer 10

Blood products

IV drug users

Sexual contact

Direct contact.

It is an endemic in Far east, Africa and Mediterranean.

Question 11

Incubation period of hep B.

Answer 11

1-6 months

(Hep A is 2-6 weeks)

Question 12

Risk groups of hep B.

Answer 12

IV drug users and their sexual partners or carers.

Health workers

Haemophiliacs

Men who have sex with men

Haemodialysis

Sexually promiscuous

Foster carers

Close familiy members of a carrier or case

Staff or residents of institutions/prisons

Babies of HBsAg +ve mothers

Adopted child from an endemic area

Question 13

Clinical features of hep B.

Answer 13

Similar to Hep A with Fever, malaise, anorexia, nausea arthralgia then jaundice, hepatosplenomegaly and adenopathy.

However the arthralgia and also urticaria are more common in hep B.

Question 14

Test findings in hep B.

Answer 14

HBsAg surface antigen is present 1-6 months after exposure.

HBeAg e-antigen is present for 1.5 to 3 months after acute illness. E-antigen implies high infectivity.

Antibodies to HBcAg (anti-HBc) imply past infection.

Antibodies to HBsAg (anti-HBs) alone implies past vaccination

HBV PCR allows monitoring of response to therapy.

Question 15

What does HBsAg persisting for over 6 months tell you?

Answer 15

This is a defining feature of carrier status.

It occurs in 5-10% of infections.

A biopsy may be indicated unless ALT is normal and HBV DNA is <2000iu/mL

Question 16

Explain vaccination of hep B.

Answer 16

Passive immunisation may be given to non-immune contacts after high-risk exposure

Question 17

Indications of hep B vaccination.

Answer 17

In the UK only at-risk groups are targetted.

Some other countries will vaccinate their whole population, regardless of endemicity.

Question 18

Complications of hep B.

Answer 18

Fulminant hepatic failure

Cirrhosis

HCC

Cholangiocarcinoma

Cryoglobulinaemia

Membranous nephropathy

Polyarteritis nodosa

Question 19

Treatment of hep B.

Answer 19

Avoid alcohol

Immunise sexual contacts

Refer all with chronic liver inflammaiton, cirrhosis or HBV DNA > 2000IU/mL for antivirals

The ai is to clear HBsAg and prevent cirrhosis and HCC.

However there is no definitive cure for Hep B, only vaccination.

Question 20

What type of virus is Hep C?

Answer 20

RNA flavivirus

Question 21

Explain the spread of Hep C.

Answer 21

Blood - transfusion, IV drug users, sexual contact

The UK prevalence is > 200000.

Question 22

Clinical features of hep C.

Answer 22

Early infection is often mild/asymptomatic

Around 85% will develop silent chronic infection

Around 25% will get cirrhosis in 20 years

Of these around 4% will develop HCC/yr

Question 23

Risk factors of progression of hep C.

Answer 23

Male

Older

Higher viral load

Use of alcohol

HIV

HBV

Question 24

Test findings in Hep C.

Answer 24

AST:ALT ratio will be <1:1 until cirrhosis develops.

Anti-HCV antibodies confirms exposure.

HCV-PCR confirms ongoing infection/chronicity.

Liver biopsy or non-invasive elastography if HCV-PCR +ve to assess the liver damage and need for treatment.

Question 25

Treatment of Hep C.

Answer 25

Sofosbuvir alone

Or

Ledipasvir

Also quit alcohol

Question 26

What type of virus is hep D?

Answer 26

Incomplete RNA virus.

Question 27

Immunisation of hep D.

Answer 27

Hep B vaccine causes immunity to hep D as well.

Question 28

Test findings in hep D.

Answer 28

Anti-HDV antibody

Question 29

Treatment of hep D.

Answer 29

Interferon alfa has limited success, this means that liver transplantation might be needed

Question 30

Complications of hep D.

Answer 30

Can cause acute liver failure and also cirrhosis.

Question 31

Complications of hep C.

Answer 31

Glomerulonephritis

Cryoglobulinaemia

Thyroiditis

Autoimmune hepatitis

PAN

Polymyositis

Prophyria cutanea tarda

And of course liver cirrhosis

Question 32

What type of virus is Hep E?

Answer 32

RNA virus similar to Hep A

Question 33

Where is hep E common?

Answer 33

Indochina

The mortality is high in pregnancy

It is associated with pigs.

Epidemics occur in Africa e.g.

Question 34

Vaccination of Hep E.

Answer 34

Available in China but not readily used in Europe.

Question 35

Diagnosis of hep E.

Answer 35

Via serology

Question 36

Treatment of hep E.

Answer 36

There no specific treatment of hep E.

Question 37

Give other infective causes of hepatitis.

Answer 37

EBV

CMV

Leptospirosis

Malaria

Q-fever

Syphilis

Yellow fever