Family Picornavirus Hepadnaviridae Flavivirus Deltavirus Calcivirus Flaviviridae

Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Hepatitis G

Envelope Non-enveloped/ Naked Enveloped Enveloped
Enveloped
Defective virus (delta virus)
--> req. HBV for replication
--> forms ribozyme intermed. during replication
Noneveloped/ naked Enveloped
DNA/RNA (+) ssRNA
Partially circular dsDNA
Reverse transcribed & integrated into host chromosome
(+) ssRNA
circular ssRNA
HBV envelope
HDV core
(+) ssRNA (+) ssRNA
Source/
Transmission
Fecal/Oral*****
(shellfish/ polluted water)
[Parenteral spread]
High: blood, serum, wound exudates
Moderate: semen, vaginal fluid, saliva
Low: urine, feces, sweat, tears, breask milk
[Parenteral spread]
-Perinatal transmission
--> only if mom HCV-RNA (+) at delivery
--> 6% infection rate, higher if HIV+, role of viral titer unclear
--> no assoc. w/ delivery method or breastfeeding
--> infected infants do well
-Sexual transmission
--> MSM no higher risk vs. heterosexuals
--> Low prevalence amoung long-term partners
--> M to F transmission more efficient
--> Efficiency low (factors unknown)
--> Accounts for 15-20% of acute & chronic infections
[increased risk for infection]
--> Ever injected illegal drugs
--> Intranasal cocaine use
--> Received clotting factors made before '87
--> Received blood/organs before '92
--> Ever had chronic HD
--> Evidence of liver dz
[Parenteral spread]
Fecally contaminated water
Minimal person to person
Parenteral
Tattoos
Clinical
Manifestations
INCUBATION: Long (6 wk.- 6 month)
< 5 yoa
-Asymptomatic at first
-60% will be chronic*******
Adults:
Usually Symptomatic, LESS chronic (5%)
80% of infants born to infected mother get HBV*****
Mortality = 0.8% in acute illness
Hepatocellular carcinoma
INCUBATION: Long (2 - 26 wks)
Acute infection (20%)- Mild anicteric (NO JAUNDICE)
Chronic (80%)
Of the Chronic cases- Cirrhosis in 20%
-Way more Cirrhosis than HBV
Rarely Fulminant Hepatitis
Infected infants do well (unlike HBV)
-Chronic/ severe hepatitis RARE in them
Other presentations:
Cryoglobulinemia (IgM precipitates in cold temps)
Porphyria cutanea tarda, Aplastic anemia (BM stops)
INCUBATION: Long (6 wks - 6 months)
Worsening of HBV
-Leads to Fulminant Cirrhosis (40%
Coinfection (both at same time)
Severe acute disease
Does NOT go chronic
Superinfection (one after the other)
Get Chronic HDV
High risk of Severe Chronic Liver Disease
Incubation: ~40 days (1.5 month)
No chronic disease
Similar to HAV
High mortality in pregnant****
-20% DIE
Similar to Hep C
Histopathology
Ground-glass cytoplasm of hepatocytes******
Hepatocellular necrosis
Fibrosis & Cirrhosis
Portal and lobular inflammation
Portal dense lymphocyte infiltrate w/ follicle forming
Lobular inflammation
Patchy lobar Steatosis
Kuppfer cell hyperplasia
Cholestasis- blocking of biliary tree --> jaundice
Fibrosis & Cirrhosis
Mnemonic: Hep D for Defective
!"#$%&%&' )&*+'"'
INCUBATION: 1 month (2-3 weeks)
-No carrier state or chronic dz
-Mortality 0.1%
-Immunity lifelong
Epidemiology
1.2 million carriers in U.S.
70% - 90% in Asia, Pacific islands, Middle east
Factors Promoting Chronic HCV
Increased alcohol intake- 7X likely******
Age >40 years when get infected
HIV co-infection
Male
Other infections (ex: HBV)
Note: not so much Occupational transmission
15 million cases in world. Italy, middle east, Africa. Endemic in developing countries
(India, Asia, Africa, Mexico)
Lab Diagnosis
Anti-HAV Ig = exposed
Anti-HAV IgM = recently vaccinated
Immunostaining of HBcAg or HBsAg AA
HBV surface antigen (HBsAg): (outer surface envelope)
-Infected/carrier
HBV core antigen (HBcAg): (core protein)
-NO DETECTION/ TEST, don't order
HBV e antigen (HBeAg): (DNA polymerase)
-Means highly infectious due to active viral replication
CHRONIC HBV: NEVER develop anti-HBs (ab to surface ag)
Anti-HCV enzyme immunoassay (EIA) or ELISA
-Screen for infected, chronic cases
Recombinant immunoblot assay (RIBA)
-Needed to confirm infection, chronic case
HCV RT-PCR
-For active infection to determine viral load
Anti-HDV IgM
Need to test Hep B also
Anti-HEV Ig = exposed
Anti-HEV IgM
-use for Acute Infection
Treatment
No treatment available/ needed
Interferon alpha 2B x 48 wks
Entecavir or Tenofovir if resistance
Tenofovir/Emtricitabine- if co-HIV
-Assess for biochemical evidence of CLD
-Assess for severity of dz & possible tx, according to current practice
guidelines
--> 30-40% sustained response to antiviral combo therapy
(IFN alpha, Ribavirin)
-6 Genotypes, 1 most common & hardest to treat
-Ribavirin & IFN alpha-2b & Telapravir or Bocepivir
(if Genotype I)
No treatment available
Can give HBV vaccine to help prevent
No treatment available/ needed
Post-exposure IgG prophylaxis??
Prevention
Routine childhood vaccine
Who needs vaccine:
Travelers, gay men, drug users, chronic liver dz
Immunization of infants required
(@ 0-, 1-, 6- mo)
-Also give to susceptible groups healthcare workers, sexual contacts
of HBV carriers
-Vaccinate vs. Hep A
-Limit or abstain from alcohol
NO immunization
Give HBV though
Ensure safe drinking water
Only eat pealable fruit
Don't eat uncooked shellfish
Notes:
Gotten from oysters and pools Only 1.8% transmitted after needle stick
-Test for anti-HCV on source
-If source positive: Test Anti-HCV & LFTs
-Get baseline of both tests
-Anti-HCV & LFTs @ 4- 6 mo., or PCR @ 4-6 wk.
-Confirm all anti-HCV with RIBA
Defective (needs HBV for replication)
Envelope= Hep B
RNA= Hep D
-Can only infect in someone already infected by
Hep B.
Clinical signs of hepatitis: cirrhosis, jaundice, ascites, splenomegaly, elevated liver enzymes (transaminases), anemia, leukopenia, thrombocytopenia, liver damage, portal hypertension