Clinical Features and Differential Diagnosis (Identifying

Clinical Symptoms, Distinguishing Between Types Of

Hepatitis)

Presented By: Mehak Jain Enrollment No.

PRESENTED BY: Mehak Jain
– A0989219052 BSc.(H)-MB, Semester IV
2022-581-004
[AIMT]

CENTRE FOR VIROLOGY, JAMIA PRESENTED TO: Dr. MIRZA SARWAR

HAMDARD BAIG
 CLINICAL SYMPTOMS
• HAV causes an acute, self limiting infection that does not
progress to chronic phase.
• Following exposure, an incubation period of 15-45 days
precedes the development of clinical symptoms.
• Virus is present in blood and shed in stools within a few
days of exposure.
• Symptoms typically occurs abruptly, with liver injury
heralded by fever, myalgia, nausea, anorexia and vomiting
accompanied by right upper quadrant abdominal pain.
• Disruption of hepatobilary metabolism results in passage of
dark coca cola like urine, light gray coloured stool and
frank icterus.

• Appearance of biochemical abnormalities including

abnormal elevation of liver derived enzymes like
Presented By: Mehak Jain Enrollment No.
– 1. ALT- alanine
A0989219052 aminotransferase,
BSc.(H)-MB, Semester IV
[AIMT]
2. ALP- alkaline phosphatase,
3. GGTP- gamma glutamyl transpeptidase and increased
level of serum bilirubin.
 LAB DIAGNOSIS
Sample: blood, stool, bile, liver biopsy, serum

1. Antigen detection
• Detection using PCR and nucleic acid hybridization assay.
2. Antibody detection
• Demonstration of IgM antibodies to the virus, which are almost always present at
the onset of symptoms and which persist for up to 6 months following infection.
• IgG antibody usually persists for many years and is a useful indicator of immunity.
• Antibody detection done by Enzyme linked immunsorbent assay (ELISA).
3. Liver function test
• detection of level of liver enzymes like ALT, ALP, GGTP, and serum bilirubin.
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
 Signs and Symptoms of Hepatitis B
• Only 30% to 50% of adults develop
significant symptoms during acute
infection.
• The incubation period of the hepatitis
B virus is 75 days on average, but can
vary from 30 to 180 days.
• Fever, a flu-like illness
• Fatigue
• Dark urine
• Loss of appetite
• Nause, Vomiting
• Joint pain
• Clay-colored bowel movements
• Jaundice (yellowing of the skin and
eyes)
• Pain in the upper right abdomen (due
to the inflamed liver)
Presented•By: Mehak
People with chronic
Jain Enrollment No. Hepatitis B
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT] develop serious liver conditions, such
as cirrhosis (scarring of the liver) or
liver cancer.
TRANSMISSION
1. blood and infected bodily fluids
2. direct blood-to-blood contact,
3. unprotected sex,
4. use of unsterile needles, and
5. From an infected woman to her
newborn during the delivery
process.
6. Infection can occur during
medical, surgical and dental
procedures, tattooing, or
through the use of razors and
similar objects that are
contaminated with infected
Presented By: Mehak Jain Enrollment No.
blood. BSc.(H)-MB, Semester IV
– A0989219052
[AIMT]
After hepatitis B virus infection, the individual may have acute infection,
which is defined as infection duration less than 6 months, OR chronic
infection, where the
infection duration lasts more than 6 months.
• In acute infection, the patient may be/have:
(a) Asymptomatic:
• the infected persons have no clinical symptoms.
(b) Acute viral hepatitis:
• the infected persons have clinical symptoms such as general
malaise, appetite loss or flu‐like symptoms and usually they
resolve with no treatment or only needing supportive care.
(c) In acute liver failure:
• the infected persons have severe clinical symptoms related to
liver failure, such as jaundice, ascites and hepatic
encephalopathy. In this stage, patients generally will not be able
to recover without liver transplantation (i.e. mortality is high).
• In chronic infection,
Presented By: Mehak Jain Enrollment No.
• – A0989219052
hepatitis B virus
BSc.(H)-MB, infection
Semester IV causes chronic hepatitis and the chronic
[AIMT]
inflammation over the next 20 – 30 years, after which may result in
development of cirrhosis.
 Hepatitis B Natural progression

Presented By: Mehak Jain Enrollment No.

– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
Concentration of HBV in various body
fluid:
High: blood, serum, wound
exudates
Moderate: semen, vaginal fluids,
saliva
Low: urine, feces, sweat, tears,
breast milk

1. IgM antibody to hepatitis B core antigen (IgM anti-HBc):Positivity indicates recent infection with hepatitis B virus
Presented By: Mehak Jain Enrollment No.
(<6 mos).
– A0989219052 Its presence
BSc.(H)-MB, Semester IV indicates acute infection.
2.[AIMT]
total anti-HBc indicates previous or ongoing infection with hepatitis B virus in an undefined time frame.
3. presence of anti-HBs is generally interpreted as indicating recovery and immunity from hepatitis B virus
infection
4. Presence of hepatitis B e antigen (HBeAg) and absence of HBe antibody (anti-HBe) usually indicate active hepatitis
B virus (HBV) replication and high infectivity.
 Lab diagnosis of HBV:

The initial diagnosis of Hepatitis B is made on the basis of clinical features and
laboratory findings on serum bilirubin and enzymes transaminase, ALT and AST

Specimen: Blood, serum, body secretions

Microscopy: Immunofluorescence staining:

Immunofluorescence staining of infected hepatocytes show HBV core
antigen in the nucleus and infectious Dane particle in cytoplasm.

Molecular diagnosis:
Detection of viral DNA by molecular methods such as insitu hybridization
Presented By: Mehak Jain Enrollment No.

and PCR in tissue sample and serum reflects the degree of virus replication
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]

in liver.
 Types of Serological markers

Presented By: Mehak Jain Enrollment No.

– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
 Hepatitis B Serology INTERPRETATION

Presented By: Mehak Jain Enrollment No.

– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
 Symptoms of Hepatitis C
Acute HCV infection Chronic HCV infection also leads to extrahepatic
People with acute hepatitis C virus infection manifestations including:
usually do not have symptoms, or they may have • Depression
mild symptoms including one or more of the • Fatigue
following: • Cryoglobulinemia
• Fever • Diabetes
• Fatigue • Cardiovascular disease
• Loss of appetite • Arthralgias/myalgias
• Nausea • Neuropathy
• Vomiting • Cancer
• Abdominal pain
• Dark urine
• Clay-colored bowel movements
• Jaundice
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]

The average time from exposure to symptoms in people who develop symptoms from acute infection ranges
from 2 to 12 weeks. However, most people who are infected with HCV do not develop symptoms. Even with
no symptoms, a person with Hep C can still spread the disease to others.
 Hepatitis C Natural progression

Presented By: Mehak Jain Enrollment No.

– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
 Hepatitis C Natural progression

Acute infection
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
Chronic infection
[AIMT]

~ 15 – 45 % of infected people spontaneously Chronic HCV infection is characterized by

clear the virus within 6 months of infection persistence of HCV RNA for longer than 6
without any treatment. months.
 Hepatitis C DIAGNOSTICS

Presented By: Mehak Jain Enrollment No.

– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
 INTRODUCTION OF HEPATITIS D
VIRUS
• HDV is the only virus in the genus, Deltaviridae.
• HDV is not classified into a viral family because it
is a unique virus dependent on HBV.
• HDV is a co-infection of HBV.
• The envelope of HDV particles contains the
Hepatitis B surface antigen (HBsAg).
• The production and transmission of HDV is
entirely dependent on HBV to provide HBsAg.
• Thus, HDV is considered a satellite virus of HBV.
• Unlike a classical satellite virus, however, HDV
does not share sequence similarity with HBV,
and it can replicate independently of HBV.
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
 CLINICAL SYMPTOMS
• The symptoms of hepatitis D may not always be present
but if they are, they can be very similar to that of a
hepatitis B infection.

• In some cases of hepatitis D, the infection may make the

symptoms of hepatitis B worse.

• It can also cause symptoms in people who have hepatitis B

but who never had symptoms.

• Some of these symptoms may include:

• yellowing of the skin and eyes, which is called
jaundice.
Presented By:•Mehak
joint pain No.
Jain Enrollment or fever
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT] • abdominal pain
• vomiting or nausea
• loss of appetite
 DIAGNOSIS
• Serological Markers are essential in testing for the
hepatitis D virus (HDV).
• This can determine whether a person has a co-infection or
a chronic super-infection, as they are two different
conditions with different outcomes.

Co-infection:
• Co-infection occurs when both HDV and HBV are contracted
simultaneously.
• This results in acute HDV and HBV infection. Depending on the
relative amounts of HBV and HDV, one or two episodes of hepatitis
occurs.
• Co-infections of HDV and HBV are usually acute and self-limiting
infections.
• HBV/HDV co-infections
Presented By: cause
Mehak Jain Enrollment No. chronic HDV infections in less than
– A0989219052 BSc.(H)-MB, Semester IV
5% of co-infected patients.
[AIMT]
• Although clinical symptoms disappear, fatigue and lethargy may
persist for weeks or months.
 DIAGNOSIS
Superinfection:
• Superinfection occurs when chronic HBV carriers are infected with
HDV.
• This leads to severe acute hepatitis and chronic Hepatitis D infection
in 80% of the cases.
• Superinfection is associated with the fulminant form of viral
hepatitis.
• Fulminant viral hepatitis, the most severe form of acute disease, is
about ten times more common in HDV infections than in the other
types.
• It is characterized by hepatic encephalopathy that is manifested by
changes in personality, disturbances in sleep, confusion, difficulty
concentrating, and sometimes abnormal behavior and coma.
• The mortality rate of fulminant hepatitis is about 80%. Chronic
hepatitis D infection progresses to liver cirrhosis in about 60-70% of
Presented By: Mehak Jain Enrollment No.
patients.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
• Cirrhosis takes about 5-10 years to develop, but can appear two
years after the onset of infection.
• Hepatocellular carcinoma occurs in chronically infected HDV
patients with the same frequency as in patients with ordinary HBV.
 DIAGNOSIS

Presented By: Mehak Jain Enrollment No.

HDV infection is diagnosed by high levels of anti-HDV immunoglobulin G (IgG) and

– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]

immunoglobulin M (IgM), and confirmed by detection of HDV RNA in serum. However,

HDV diagnostics are not widely available.
 Hepatitis E signs and symptoms
• The incubation period occurs following exposure to the hepatitis E virus.
• This ranges from 2 to 10 weeks, with an average of about 5-6 weeks.
• The infected individual is believed to excrete the virus around 3-4 weeks
after the onset of disease. Most individuals infected with hepatitis E have no
symptoms.
• Some people have symptoms from day 15-60 after they become infected
with the virus.
• The signs and symptoms of an hepatitis E virus may include:
• Sudden nausea and vomiting
• Abdominal pain or discomfort, especially on the upper right side
beneath the lower ribs (by the liver)
• Clay-colored bowel stools and
• Dark urine Loss of appetite and
• Fatigue
Presented By: Mehak Jain Enrollment No.
• Low-grade
– A0989219052 feverIV and Joint pain
BSc.(H)-MB, Semester
[AIMT]
• Yellowing of the skin and the whites of the eyes (jaundice)
• Intense itchingEncephalopathy
 Hepatitis E

Presented By: Mehak Jain Enrollment No.

– A0989219052 BSc.(H)-MB, Semester IV
During acute HEV infection, serological studies showed that anti-HEV IgM becomes detectable days
[AIMT]

before the onset of symptoms and vanishes over a 4–6 month period. Anti-HEVIgG appears soon after the
IgM replication and may persist for up to 12 years after infection.
 DIAGNOSIS

Presented By: Mehak Jain Enrollment No.

– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]
 THANK YOU
Presented By: Mehak Jain Enrollment No.
– A0989219052 BSc.(H)-MB, Semester IV
[AIMT]