viral hepatitis
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Etiology
- hepatitis A
- oral-fecal transmission
- endemic in underdeveloped countries
- outbreaks in day care centers & nursing homes
- hepatitis B
- parenteral, sexual or perinatal transmission
- 90% of patients recover
- > 1% develop fulminant hepatitis
- 10% develop chronic hepatitis
- incubation 4-6 weeks
- hepatitis C
- accounts for 85% of transfusion-associated hepatitis
- parenteral transmission, especially IVDA
- sexual transmission < 5% in monogomous relationships
- > 50% progress to chronic hepatitis; 20% of these progress to cirrhosis
- incubation 5-10 weeks, but may be as short as 2 weeks
- hepatitis D
- requires hepatitis B virus for replication
- parenteral & permucosal transmission
- incubation period 4-6 months
- may accelerate development of cirrhosis
- occasionally causes fulminant acute hepatitis
- hepatitis E
- epidemic form of non-A, non-B hepatitis
- India, Southeast Asia, North Africa, Soviet Union, Mexico
- self-limited illness
- 20% mortality in pregnant women
- incubation 2-9 weeks
- all reported cases in US have been in immigrants or visitors to endemic areas
- fecal-oral transmission
- epidemic form of non-A, non-B hepatitis
- Cytomegalovirus
- 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
- anti hepatitis A virus
- hepatitis A IgM: indicates current or recent infection
- hepatitis A IgG: indicates immunity to hepatitis A
- Hepatitis B markers
- hepatitis B surface antigen (HBsAg)
- positive in both acute & chronic hepatitis B
- hepatitis B e antigen (HBeAg)
- positive in acute hepatitis B & during active replication in chronic hepatitis B
- reflects infectivity
- IgM antibody to hepatitis B core antigen (anti-HBc IgM)
- marker of acute hepatitis B infection
- IgG antibody to hepatitis B core antigen (anti-HBc IgG)
- marker of chronic hepatitis B & carrier state
- antibody to hepatitis B e antigen (anti-HBe)
- transiently positive in convalescence & in some cases of chronic hepatitis B
- not protective
- antibody to hepatitis B surface antigen (anti-HBs)
- positive late in acute hepatitis B
- protective
- hepatitis B surface antigen (HBsAg)
- hepatitis C markers
- 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
- polymerase chain reaction (PCR)
- useful in equivocal cases
- positive 2 weeks after infection
- antibody to hepatitis C (anti-HCV)
- hepatitis D antibody (anti-HDV)
- hepatitis B e antigen negative for acute hepatitis D[6]
- becomes positive 15 weeks after signs/symptoms
- not protective
- increased liver function tests
- increased serum transaminases (acute: 3+, chronic +)[2]
- increased serum bilirubin, serum conjugated bilirubin
- variable, acute: normal to 3+, chronic: normal to +
- serum alkaline phosphatase (acute or chronic: normal to +)
- see ARUP consult[3]
Management
- hepatitis A
- after exposure
- immune globulin (0.02 mL/kg) IM within 2 weeks
- hepatitis A vaccine (Havrix) 1 mL IM (separate site)
- 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
- after exposure
- hepatitis B
- 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
- prophylaxis
- HBV vaccine (Recombivax HB)
- health workers
- homosexual men
- household & sexual contacts of HBsAg carriers
- all neonates
- liver biopsy
- hepatocellular carcinoma may develop with chronic hepatitis B
- 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
- after exposure
- hepatitis C
- 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
- 3 million units SC or IM 3 times/week
- hepatocellular carcinoma may develop with chronic hepatitis C
- alpha interferon for chronic infection
- hepatitis D
- no treatment
- hepatitis B vaccine is preventative
- hepatitis E
- no treatment
More general terms
More specific terms
- 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
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 369-70
- ↑ Jump up to: 2.0 2.1 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018
- ↑ Jump up to: 3.0 3.1 ARUP Consult Hepatitis Virus Screening https://arupconsult.com/algorithm/hepatitis-virus-screening-algorithm
- ↑ Jump up to: 4.0 4.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27394647 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30579-7/abstract - ↑ 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
- ↑ Jump up to: 6.0 6.1 NEJM Knowledge+ Gastroenterology
- ↑ NIDDK: Viral Hepatitis https://www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis