HEPATITIS

Diah Puspita Rini, dr., SpPK

 Hepatitis is inflammation of the liver which

can be caused by viruses, medications, or
toxic agents.
Non viral : miliary TB, staphylococcal
bacteriemia, salmonelloses, amebiasis,
drugs, etc.
Viral hepatitis :, Hepatitis A,B,C,D,E
CMV, Herpes, Epstein Barr virus, Rubella

Viral Hepatitis

Hepatitis
A Title
Click
to add

Hepatitis E

Hepatitis
B Title
Click to add

Hepatitis G

Hepatitis TT

Hepatitis Sen

Hepatitis C

Hepatitis D

VIRAL HEPATITIS
A
A Major
Major Public
Public Health
Health Problems
Problems

Cause Morbidity & Mortality

Chronic Hepatitis B & C

Liver
Cirrhosis

HCC

SYMPTOMS
a short, mild, flu-like illness
nausea, vomiting and diarrhoea
loss of appetite
weight loss
jaundice (yellow skin and white of eyes,
darker yellow urine and pale faeces)
itchy skin
abdominal pain

Type of
Hepatitis
A
Source of
virus
Route of
transmission
Chronic
infection
Prevention

feces

blood/
blood/
blood/
blood-derived blood-derived blood-derived
body fluids
body fluids
body fluids

feces

fecal-oral

percutaneous percutaneous percutaneous

permucosal
permucosal
permucosal

fecal-oral

no

yes

pre/postexposure
immunization

pre/postexposure
immunization

yes

yes

blood donor
pre/postscreening;
exposure
risk behavior immunization;
modification risk behavior
modification

no

ensure safe
drinking
water

Hepatitis A (HAV)
Due to non enveloped, single stranded
RNA picornavirus
Serum AST and ALT increased to
hundreds for 1 to 3 weeks
Relative lymphocytosis is frequent

Serologic test for HAV

Ig M anti HAV :
appears at the same time as syptoms in > 99% of
cases
peaks within first month, becomes nondetectable in 12
(usually 6)
Presence confirms diagnosis of recent acute infection

Anti HAV total:

Predominantly IgG
Almost always positive at onset of acute hepatitis and
is usually detectable for life
Found in 50% of population, indicaes previous
exposure to HAV

Hepatitis A Infection
Typical Serological Course
Total antiHAV

Symptom
s

Titre

ALT

Fecal
HAV

IgM anti-HAV

Months after exposure

1
2

2
4

Hepatitis B (HBV)
Due to enveloped, double stranded DNA
hepadna virus
Divided into 3 stages:
1. Acute hepatitis: lasts 1-6 months, mild/ no
symptoms
AST & ALT increased > tenfolds
Serum bilirubin is usually normal or slightly
increased
HBsAg gradually arises to high titer and persist,
HBeAg also appears

2. Chronic hepatitis: transaminase increased >

50% for > 6 months, most cases resolve but
some develop cirrhosis and liver failure
AST & ALT fall to 2-10x normal range
HBsAg usually remains high and HBeAg
remains present

3. Chronic carrier: are usually but not always

healthy and asymptomatic
AST and ALT fall to normal or < 2x normal
HBsAg positive > 6 months, HBc IgM negative,
but anti HBc positive

Hepatitis B Virus
Modes of Transmission
Sexual - sex workers and homosexuals are
particular at risk.
Parenteral - IVDA, Health Workers are at
increased risk.
Perinatal - Mothers who are HBeAg positive
are much more likely to transmit to their
offspring than those who are not. Perinatal
transmission is the main means of
transmission in high prevalence populations.

Concentration of Hepatitis B
Virus in Various Body Fluids
High

Moderate

blood
serum
wound exudates

semen
vaginal fluid
saliva

Low/Not
Detectable
urine
feces
sweat
tears
breastmilk

HBV : Structure

Hepatitis B Lab Markers

Marker

Abbreviation

Use

Hepatitis B surface antigen

HBsAg

Detection of acutely or chronically

infected persons; antigen used in
hepatitis B vaccine

M class immunoglobulin
antibody to hepatitis B core
antigen

IgM Anti-HBc

Identification of acute or recent

HBV infections (including those in
HBsAg-negative persons during the
window phase of infection)

Antibody to hepatitis B core

antigen

Anti-HBc
HBcAb

Identification of persons with acute,

resolved, or chronic HBV infection
(not present after vaccination)

Antibody to Hepatitis B surface

antibody

Anti-HBs
HBsAb

Identification of persons who have

resolved infection with HBV;
determination of immunity after
immunization

Hepatitis B e antigen

HBeAg

Identification of infected persons at

increased risk for transmitting HBV

Antibody to Hepatitis B e
antigen

Anti-HBe
HBeAb

Identification of infected person

with lower risk for transmitting HBV

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course

Titer

HBsAg

12 16 20 24 28 32 36

Weeks after Exposure

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course

Titer
HBV DNA

HBsAg

12 16 20 24 28 32 36
Weeks after Exposure

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course

HBeAg
Titer
HBV DNA

HBsAg

12 16 20 24 28 32 36
Weeks after Exposure

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course

HBeAg

anti-HBe

Titer
HBV DNA

HBsAg

12 16 20 24 28 32 36
Weeks after Exposure

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course
Symptoms
HBeAg

anti-HBe

Titer
HBV DNA

IgM anti-HBc

HBsAg

12 16 20 24 28 32 36
Weeks after Exposure

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course
Symptoms
HBeAg
Titer
HBV DNA

anti-HBe
Total anti-HBc
IgM anti-HBc

HBsAg

12 16 20 24 28 32 36
Weeks after Exposure

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course
Symptoms
HBeAg
Titer
HBV DNA

anti-HBe
Total anti-HBc
IgM anti-HBc
anti-HBs

HBsAg

12 16 20 24 28 32 36
Weeks after Exposure

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course
Symptoms
HBeAg
Titer
HBV DNA

anti-HBe
Total anti-HBc
IgM anti-HBc
anti-HBs

HBsAg

Window
Period

12 16 20 24 28 32 36
Weeks after Exposure

52

100

Progression to Chronic Hepatitis B Virus

InfectionTypical Serologic Course
Acute
(6 months)

Chronic
(Years)
HBeAg

anti-HBe
HBsAg
Total anti-HBc

Titr
e
IgM anti-HBc

0 4 8 12 16 20 24 28 32 36

52

Weeks after Exposure

Years

Acute vs. Chronic HBV Infection

Acute
HBsAg+ < 6 mos.
IgM anti-HBc +
positive
Infection will resolve
and person will have
lifelong immunity
HBsAb+ and HBcAb+

Chronic
HBsAg + for at least 6
months
Also known as a
carrier
Infection does not
resolve and the
person remains
infectious
HBsAb- and HBcAB+

Serologic diagnosis of viral hepatitis

Significance

HBsAg

HBeAg

Anti-HBc

Anti-HBc

Anti-HBs

IgG

IgM

IgG

Acute HBV

Chronic HBV,

Resolved HBV

Postvaccine

Active replication

Chronic HBV,
quiescent

Immune HBV
Quiescent = inactive = quiet
26

Possible Outcomes of
Hepatitis B Infection
Possible Outcomes of
Hepatitis B Infection
Acute HBV
infection

Recovery

Chronic HBV
infection
Fulminant
hepatitis

Chronic hepatitis B
HBeAg-positive

HBsAg
carrier

Reactivation

Chronic hepatitis B

HBeAg-positive
Cirrhosis
HCC

Chronic hepatitis B

HBeAg-positive

HDV
superinfection

Prevention
Vaccination - highly effective recombinant vaccines are now
available. Vaccine can be given to those who are at increased risk of
HBV infection such as health care workers. It is also given
routinely to neonates as universal vaccination in many countries.
Hepatitis B Immunoglobulin - HBIG may be used to protect
persons who are exposed to hepatitis B. It is particular efficacious
within 48 hours of the incident. It may also be given to neonates
who are at increased risk of contracting hepatitis B i.e. whose
mothers are HBsAg and HBeAg positive.
Other measures - screening of blood donors, blood and body fluid
precautions.

HEPATITIS C (HCV)

30

Risk Factors
Associated with
Transmission of HCV
Transfusion or transplant from infected donor
Injecting drug use
Hemodialysis (yrs on treatment)
Accidental injuries with needles/sharps
Sexual/household exposure to anti-HCVpositive contact
Multiple sex partners
Birth to HCV-infected mother

HCV INFECTION
INCUBATION
1
PERIOD
6 -7 WEEKS

ACUTE
2
INFECTION
60 -80% ASYMPTOMATIC
20- 30% WITH JAUNDICE

(Range 2 26 weeks)

80 -85%
CHRONIC HEPATITIS

32

Hepatitis C Virus Infection

Typical Serologic Course
antiHCV

Symptom
s

Titr
e

ALT

Normal
0

3
4
Month
s

Time after
Exposure

2
3
Years

PROGRESSION
ACUTE HEPATITIS C
15-40% will spontaneously resolve, generally
within the first 6-18 months after acute onset.
60-85% will progress to chronic infection

CHRONIC
85-90% stable
10-15% progress to cirrhosis

PROGRESSION
CIRRHOSIS
75% slowly progressive
25% progress to HCC
2-4% liver failure

HCC

Factors of poor prognosis:

-Age >40 years
-Alcohol > 50g/Hour
-Male gender
-Duration of infection
-Co-infection HBV/HIV
-Tobacco consumption

Risk increases for every year for a patient with

chronic hepatitis C.
Patients without signs of cirrhosis can develop
HCC

Diagnosis
of HCV
Infection

Indirect tests:
detect
antibody
against HCV
1. Anti HCV
2. RIBA
(recombinant
immunoblot assay)

36

Direct tests :
components of the
HCV particle
1.HCV RNA(PCR)
Qualitative
Quantitative

2. HCV Core antigen

Usefull in detecting
window peroid

Prevention of
Hepatitis C
Screening of blood, organ, tissue
donors
High-risk behavior modification
Blood and body fluid precautions

CASE STUDIES

Jada went to her doctor for a routine

physical. A hepatitis panel was done
and her results were as follows:
HBsAg
anti-HBs
anti-HBc

Negative
Positive
Negative

Question 1
How would you interpret her results?

Answer
She received the hepatitis B vaccine and
is protected (immune)

Jeff went in for a routine annual

physical. His doctor decided to run a
hepatitis panel. His results are as
follows:
HBsAg
Positive
anti-HBs
Negative
anti-HBc
Positive
IgM anti-HBc
Positive
HBeAg
Positive

Question 1
How would you interpret his results?

Answer
He has acute hepatitis B infection.

Soal Kasus
Laki2 datang dengan keluhan demam 14
hari, sklera tampak ikterus, nyeri tekan
abdomen kanan atas
Pemeriksaan Lab apa yg anda usulkan?
HBsAg (-)
HBsAb (+)
IgM anti HAV (+)
anti HBc (-)

Apa diagnosis pasien ini?

??QUESTIONS??