Viral Hepatitis: B and D

Question 1

Define Viral Hepatitis?

Answer 1

Hepatitis caused by infection with HBV, which may follow an acute or chronic course

Question 2

What is Chronic Viral Hepatitis?

Answer 2

Defined as viraemia and hepatic inflammation continuing for > 6 months

Question 3

What is HDV?

Answer 3

It is a defective virus, that may only co-infect with HBV or superinfect people who are already carriers of HBV

Question 4

What is HBV?

Answer 4

It is an enveloped, partially double-stranded DNA virus

Question 5

What is the transmission of HBV?

Answer 5

Sexual contact
Blood
Vertical transmission (from mother to baby)

Question 6

What viral proteins are produced in HBV?

Answer 6

Core antigen (HBcAg)
Surface antigen (HBsAg)
e antigen (HBeAg)

Question 7

What is the significance of the e antigen (HBeAg)?

Answer 7

It is a marker of high infectivity

Question 8

What is HDV?

Answer 8

It is a single-stranded RNA virus coated with HBsAg

Question 9

What is the aetiology of HDV?

Answer 9

Antibody and cell-mediated immune response to viral replication leads to liver inflammation and hepatocyte necrosis
Histology can show mild to severe inflammation and changes to cirrhosis

Question 10

What are the risk factors of HDV?

Answer 10

IV drug use
Unscreened blood and blood products
Infants of HBeAg-positive mothers
Sexual contact with HBV carriers
Younger individuals (particularly babies) are more likely to become chronic carriers
Genetic factors are associated with varying rates of viral clearance

Question 11

What is the epidemiology of HBV and HDV?

Answer 11

Common
1-2 million deaths annually
Common in SE Asia, Africa and Mediterrean countries
HDV is also found worldwide

Question 12

What is the incubation period for HBV and HDV?

Answer 12

3-6 months

Question 13

What are the presenting symptoms in the 1-2 week prodrome for HBV and HDV?

Answer 13

Malaise 
Headache 
Anorexia 
Nausea and vomiting 
Diarrhoea 
RUQ pain 
Serum-sickness type illness

Question 14

What are some of the symptoms associated with Serum-sickness type illness?

Answer 14

Fever
Arthralgia 
Polyarthritis 
Urticaria 
Maculopapular rash

Question 15

What is another symptom of HBV and HDV?

Answer 15

Jaundice develops with dark urine

Question 16

How long does it take to recover from HBV and HDV?

Answer 16

4-8 weeks

Question 17

What percentage of patients with HBV and HDV develop fulminant liver failure?

Answer 17

1%

Question 18

What are the Acute signs of HBV and HDV?

Answer 18

Jaundice
Pyrexia
Tender hepatomegaly
Splenomegaly
Cervical lymphadneopathy (in 10-20% of patients)
Occsaionally: urticaria and maculopapular rash

Question 19

What are the chronic signs of HBV and HDV?

Answer 19

May be no findings

May have signs of chronic liver disease or decompensation

Question 20

What investigations do you do for HBV and HDV?

Answer 20

Viral Serology
LFTs
Clotting
Liver Biopsy

Question 21

What Viral Serology tests do we see for Acute HBV?

Answer 21

HBsAg positive

IgM anti-HBcAg

Question 22

What Viral Serology tests do we see for Chronic HBV?

Answer 22

HBsAg positive
IgG anti-HBcAg
HBeAg positive or negative

Question 23

What viral serology tests do we do for HBV cleared or vaccinated against HBV patients?

Answer 23

Anti-HBsAg antibody positive

IgG anti-HBcAg

Question 24

What viral serology tests do we see for an HDV infection?

Answer 24

Detected by IgM or IgG against HDV

PCR is used for detection of HDV

Question 25

What do we look for on the LFTs for HBV and HDV?

Answer 25

``` HIGH: AST ALT ALP Bilirubin ```

Question 26

What clotting test do we do for HBV and HDV?

Answer 26

High PT (in severe disease)

Question 27

What prevention do we do for HBV and HDV?

Answer 27

Blood screening Safe sex Instrument sterilisation

Question 28

What is the Passive Immunisation for HBV and HDV?

Answer 28

Hepatitis B Immunoglobulin following acute exposure and to neonates born to HBeAg-positive mothers (in addition to active immunisation)

Question 29

What is the Active Immunisation for HBV and HDV?

Answer 29

Recombinant HBsAg vaccine for individuals at risk and neonates born to HB

Question 30

What is the mananagement plan for Acute HBV Hepatitis?

Answer 30

``` Symptomatic treament (antipyretics, antiemetics and cholestyramine) and bed rest Notifiable disease ```

Question 31

What is the management plan for Chronic HBV?

Answer 31

``` Interferon alpha (standard or pegylated) Nucleoside/nucleotide analogues (adefovir, entercavir, telbivudine, tenofovir) ```

Question 32

What are the side effects of Interferon alpha in the treatment of Chronic HBV?

Answer 32

Flu-like symptoms such as fever, chills, myalgia, headaches, bone marrow suppression and depression

Question 33

What are the possible complications of HBV and HDV?

Answer 33

1% get fulminant hepatic failure Chronic HBV infection (10% of adults, much higher in neonates) Cirrhosis HCC Extrahepatic immune complex disorders (e.g. glomerulonephritis, polyarteritis nodosa) Superinfection with HDV may lead to acute liver failure or more rapidly progressive disease

Question 34

What is the prognosis of patients with HBV and HDV?

Answer 34

Adults: 10% of infections become chronic | Of the chronic infections, 20-30% will develop cirrhosis