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viral hepatitis

Etiology: 1) hepatitis A a) oral-fecal transmission b) endemic in underdeveloped countries c) outbreaks in day care centers & nursing homes 2) hepatitis B a) parenteral, sexual or perinatal transmission b) 90% of patients recover c) > 1% develop fulminant hepatitis d) 10% develop chronic hepatitis e) incubation 4-6 weeks 3) hepatitis C a) accounts for 85% of transfusion-associated hepatitis b) parenteral transmission, especially IVDA c) sexual transmission < 5% in monogomous relationships d) > 50% progress to chronic hepatitis; 20% of these progress to cirrhosis e) incubation 5-10 weeks, but may be as short as 2 weeks 4) hepatitis D a) requires hepatitis B virus for replication 1] coinfects with hepatitis B virus 2] superinfects hepatitis B carrier b) parenteral & permucosal transmission c) incubation period 4-6 months d) may accelerate development of cirrhosis e) occasionally causes fulminant acute hepatitis 5) hepatitis E a) epidemic form of non-A, non-B hepatitis - India, Southeast Asia, North Africa, Soviet Union, Mexico b) self-limited illness c) 20% mortality in pregnant women d) incubation 2-9 weeks e) all reported cases in US have been in immigrants or visitors to endemic areas f) fecal-oral transmission 6) Cytomegalovirus 7) Epstein-Barr virus Epidemiology: - number of years lived with hepatitis-related disability increased from 1990-2013, from 653,000 to 874,000. - hepatitis B & hepatitis C account for 96% of hepatitis mortality (2013), most hepatitis deaths occur in East Asia - hepatitis is the 7th leading cause of death & disability (2013) [4] - 5 cases of adenovirus type 41 infection identified in Alabama Nov 2021 Laboratory: 1) anti hepatitis A virus - hepatitis A IgM: indicates current or recent infection - hepatitis A IgG: indicates immunity to hepatitis A 2) Hepatitis B markers a) hepatitis B surface antigen (HBsAg) - positive in both acute & chronic hepatitis B b) hepatitis B e antigen (HBeAg) - positive in acute hepatitis B & during active replication in chronic hepatitis B - reflects infectivity c) IgM antibody to hepatitis B core antigen (anti-HBc IgM) - marker of acute hepatitis B infection d) IgG antibody to hepatitis B core antigen (anti-HBc IgG) - marker of chronic hepatitis B & carrier state e) antibody to hepatitis B e antigen (anti-HBe) - transiently positive in convalescence & in some cases of chronic hepatitis B - not protective f) antibody to hepatitis B surface antigen (anti-HBs) - positive late in acute hepatitis B - protective 3) hepatitis C markers a) antibody to hepatitis C (anti-HCV) - 2nd generation ELISA 78-80% accuracy - 2nd generation recombinant immunoblot assay (RIBA) is used as a confirmatory test, 90% accurate - ELISA & RIBA may take 6 weeks - 12 months after infection with hepatitis C virus to become positive - antibody is not protective b) polymerase chain reaction (PCR) - useful in equivocal cases - positive 2 weeks after infection 4) hepatitis D antibody (anti-HDV) - hepatitis B e antigen negative for acute hepatitis D [6] - becomes positive 15 weeks after signs/symptoms - not protective 5) increased liver function tests a) increased serum transaminases (acute: 3+, chronic +) [2] b) increased serum bilirubin, serum conjugated bilirubin - variable, acute: normal to 3+, chronic: normal to + c) serum alkaline phosphatase (acute or chronic: normal to +) 6) see ARUP consult [3] Management: 1) hepatitis A a) after exposure - immune globulin (0.02 mL/kg) IM within 2 weeks - hepatitis A vaccine (Havrix) 1 mL IM (separate site) b) travel to endemic areas - hepatitis A vaccine (Havrix) 1 mL IM 15 days before travel; booster 1 mL IM in 6 months - immune globulin 0.02 mL/kg IM for travel < 3 months, 0.06 mL/kg for travel longer than 3 months repeatedevery 4-6 months if hepatitis A vaccine not available 2) hepatitis B a) after exposure - hepatitis B immune globulin (HBIG) plus immunization with HBV vaccine (Recombivax HB) - needle stick - within 14 days after sexual exposure to a partner with acute hepatitis B infection - at birth in infants born to HBsAg-positive mothers b) prophylaxis - HBV vaccine (Recombivax HB) - health workers - homosexual men - household & sexual contacts of HBsAg carriers - all neonates c) liver biopsy d) hepatocellular carcinoma may develop with chronic hepatitis B e) interferon-alpha - immune-mediated necro-inflammatory activity in the liver (ALT > 100 U/L) - low circulation HBV DNA levels (< 200 pg/mL) - may be transient rise in ALT after initiation of therapy - response indicated by loss of HBeAg from serum - contraindicated with decompensated cirrhosis (i.e.encephalopathy, variceal hemorrhage, ascites) unless liver transplant is available 3) hepatitis C a) alpha interferon for chronic infection - 3 million units SC or IM 3 times/week - prolonged therapy for 12-18 months results in improved sustained responses compared with 6 months of therapy - 30-50% remission - serial serum transaminases - liver biopsy b) hepatocellular carcinoma may develop with chronic hepatitis C 4) hepatitis D - no treatment - hepatitis B vaccine is preventative 5) hepatitis E - no treatment

Interactions

disease interactions

Related

hepatitis A virus (HAV) hepatitis B virus (HBV) hepatitis C virus

Specific

acute viral hepatitis chronic active hepatitis (CAH) chronic persistent hepatitis (CPH) chronic viral hepatitis hepatitis A infection hepatitis B infection hepatitis C infection hepatitis D infection viral hepatitis carrier

General

hepatitis hepatobiliary infection viral infection

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 369-70
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018
  3. ARUP Consult Hepatitis Virus Screening https://arupconsult.com/algorithm/hepatitis-virus-screening-algorithm
  4. Orciari Herman A, Sadoughi S Global Burden of Viral Hepatitis Rose Sharply Over Past Two Decades. Physician's First Watch, July 7, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Stanaway JD, Flaxman AD, Naghavi M et al The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013. Lancet July 2016 PMID: 27394647 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30579-7/abstract
  5. Centers for Disease Control & Prevention (CDC) Recommendations for Adenovirus Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology. CDC Health Alert Network. April 21, 2022 https://emergency.cdc.gov/han/2022/han00462.asp
  6. NEJM Knowledge+ Gastroenterology
  7. NIDDK: Viral Hepatitis https://www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis