Viral Hepatitis

Question 1

How do we define acute and chronic hepatitis?

Answer 1

Acute <6months

Chronic >6months

Question 2

Name some infectious & non-infectious causes of acute hepatitis?

Answer 2

Infectious
Viral
- Hepatitis A, B+D, C, E
- HHV, HSV, ZVZ (chicken pox, shingles), CMV, EBV

Non-viral infectious
- Spirochaetes (syphillis, leptospirosis)
- Mycobacteria (M. tuberculosis)
- Bacteria (barteonella)
Parasites (toxoplasma)

Non-infectious

• Drugs
• Alcohol
• NAFLD
• Pregnancy
• Autoimmune hepatitis
• Hereditary metabolic causes

Question 3

What are finger clubbing, palmar erythema, dupuytrens contracture and spider naevi a sign of? Acute or chronic hepatitis?

Answer 3

Chronic

Question 4

Infectious and non-infectious causes of chronic hepatitis?

Answer 4

Infectious

• B+D, C (E)

Non-infectious

• Alcohol
• NAFLD
• Autoimmune hepatitis
• Herditary metabolic causes
• Toxins or poisons

Question 5

Hepatitis A

• spread/transmission route
• epidemiology
• symptoms
• diagnosis
• treatment

Answer 5

RNA virus - short incubation period (2-6 weeks)

100% immunity following infection

• *Spread**
• Faeco-oral transmission or ingesting contaminated shellfish/water
• Link to access to safe water and socioeconomic indicators
• *Epidemiology**
• Most infections are in childhood
• More common in developing (South America, South Africa)> developed countries - poses a problem for travellers.
• Risk in MSM and IV drug users
• *Self-limiting infection**
• doesn’t cause a chronic disease but rarely, can progress to fulminant hepatitis
• *Symptoms**
• Usually asymptomatic in adults
• Preicteric phase - constituional symptoms (fever, malaise, anorexia, nausea, arthralgia
• Icteric phase - few days after preicteric phase and causes dark urine, jaundice, hepatosplenomegaly, adenopathy.
• *Diagnosis**
• Serology (anti-Hepatitis A IgM antibody)
• IgM levels rise 25 days following exposure to Hep A
• IgG levels are detectable for life
• *Treatment**
• No specific treatment - supportive management
• Monitor liver function (INR, albumin, bilirubin)
• Acute liver failure can occur in about 1% - liase with liver transplant centre
• Avoid alcohol
• Management of close contacts - human normal immunoglobulin (HNIG) for high risk post-exposure prophylaxis within 14 days to close contacts; notifiable to public health
• Primary prevention: vaccination (travellers, MSM, PWID)

Question 6

Hepatitis E
Epidemiology
Transmission
Symptoms
Diagnosis
Managment and prevention

Answer 6

RNA virus

• *Epidemiology**
• More common than Hep A in UK
• More common in older men

4 genotypes pathogenic to humans, with varying distribution worldwide (including the UK)

• GT1: Africa and Asia (contaminated food and water)
• GT2: Mexico and West Africa (contaminated food and water)
• GT3: Worldwide (high income countries) (Zoonotic reservoir in pigs and undercooked pork products)
• GT4: China and SE Asia (Zoonotic reservoir in pigs and undercooked pork products)
• *Transmission**
• Predominantly faeco-oral transmission (genotypes 1 and 2)
• Also zoonotic (pig reservoir)
• Vertical transmission and parental (blood-borne) transmission
• *Symptoms**
• Often asymptomatic (95%)
• Usually self-limiting
• Can lead to chronic infection in immunosuppressed patients (HIV) (GT3/4 only)
• Can progress to fulminant hepatitis, especially in pregnant females with high mortality (GT1/2)
• Patients at higher risk such as those who are pregnant are asked to cook meat thoroughly
• *Diagnosis**
• Serology (anti-hepatitis E IgM/IgG antibodies) and viral PCR (HEV RNA)
• *Management and prevention**
• No specific treatment in acute setting (supportive management)
• Monitor for fulminant hepatitis or acute on chronic liver failure
• Consider ribavirin
  
  • Ribavirin has been used to treat chronic hepatitis E in immunocompromised patients
• Prevention: avoid eating undercooked meats
• Vaccines in development but not commercially used yet.

Question 7

Which type of viral hepatitis is the most common worldwide?
How is it transmitted?
Who is at most risk?

Answer 7

Hepatitis B - 257 million people living with chronic Hep B
Blood borne virus spread through bodily fluids and bloods.

High risk

• Drug users
• Healthcare workers
• Haemophiliacs
• MSM
• Sexually promiscuous individuals
• Prisons
• Babies of infected mothers
• House hold contacts of infected individuals

Question 8

How is hepatitis B diagnosed?

Answer 8

HbsAg (surface antigen) present 1-6 months after exposure
HbeAg implies high infectivity
HbsAg persisting >6m = carrier status occuring in 5-10%

Abnormal LFTs - eleated AST, ALT, bilirubin, alk phosp, low albumin
AntiHBC -IgM
AntiHBC-IgG

Question 9

What do Anti Hbs and Anti Hbc imply?

Answer 9

Anti Hbs - vaccination against Hep B

Anti Hbc - immply previous infection

Question 10

Treatment options for Hep b?

Side effects of treatment?

Answer 10

• Supportive treatment - avoid alcohol
• Monitor liver function (INR, albumin, bilirubin)
• Patients who have successfully cleared HBV infection are at risk of re-activation of infection in context of future immunosuppression
• Treatment option 1 = pegylated interferon a 2a (stimulates the immune response, weekly subcutaneous injection for 48 weeks, offers the best chance of treatment-free control)
• Side effects: myalgia, flu like symptoms, mental health problems such as depression, thyroid problems.
• Treatment option 2 = oral nucleotide analogues (inhibits viral replication, take tablet once a day, minimal side effects, required renal monitoring and may. be required life long)
• These treatments are not cures, they are there to manage the symptoms

Question 11

Prevention of hep b?

Answer 11

• Antenatal screening (HBsAg testing) of pregnant mothers
• HBV vaccine administered at birth, 1,2,3,4,12 months
• HBIG given to baby if mother is e-antigen positive or has high HBV DNA levels or baby birth weight <1.5kg
• Screening and immunisation of sexual and household contacts
• Universal childhood immunisation since 2017 - hexavalent vaccine at 8,12,16 weeks
• Sterile equipment and universal precautions in healthcare
• Immunisation of all healthcare workers and other risk groups (MSM, PWID)

Question 12

Which type of hepatitis is an incomplete RNA virus so it required Hep B to replicate?
How is it transmitted & what is the prevention?
Treatment?

Answer 12

Hep D - required HBsAg to replicate.
Transmitted via bodily fluids
HBV vaccine. prevents HDV co-infection.
Treat with pegylated interferon

Question 13

How many genotypes are there of hep c? which are the most dominant in the uk?
How is it spread, what is the most common cause in the uk?
How is it diagnosed?
Treatment/prevention?

Answer 13

6 genotypes
1-3 most dominant in the uk
Bloodborne - blood transfusion, IV drug users (90% of UK transmission), needle stick injuries, sexual contact.

Diagnosis

• anti-HCV antibody confirms exposure
• if pos, viral PCR used to confirm current infection
• genotype is determined

Treatment

• Aim of treatment is cure; finite course of treatment offered (8, 12 or 16 weeks)
• Directly acting antivirals drugs (DAAs), which have specific targets to the hepatitis C virus have been developed and have replaced pegylated-interferon-α + ribavirin in treatment of HCV
• DAAs offer significantly shorter treatment duration, have significantly less (if any) side effects and are more efficacious, with cure rates exceeding 95% for some patients in specific patient groups
• No HCV vaccine
• Prevention through avoiding sharing of needles and drug-injecting equipment
• Provision of sterile needles and safe needle disposal and the screening of blood products