Harrison’s Hour

Acute Viral Hepatitis

Part 1
 1 2 3
Causative Agents
Virology, characteristics, Epidemiology, Routes of
incubation period, Transmission

4 5
Serologic and viral
Serologic patterns of
markers
HBV infection and
interpretation
Acute Viral Hepatitis

● Systemic infection affecting the liver predominantly

● Caused by:

○ Hepatitis A virus (HAV)

○ Hepatitis B virus (HBV)

○ Hepatitis C virus (HCV)

○ Hepatitis D virus (HDV)

○ Hepatitis E virus (HEV)

Hepatitis A
● Non-enveloped 27 nm single stranded positive-sense RNA
virus
● Genus: Hepatovirus; Family: Picornavirus

● Inactivation of viral activity can be achieved by

○ Boiling for 1 min

○ Contact with formaldehyde and chlorine

○ Ultraviolet radiation

● Incubation period of 3-4weeks

● Replication is limited to the liver

○ But the virus is present in the liver, bile, stools and

blood during the late incubation period and acute
preicteric/presymptomatic phase of illness

● Despite slight longer persistence of virus in the the liver,

fecal shedding, viremia and infectivity diminish rapidly once
jaundice becomes apparent
● anti-HAV can be detected

○ serum aminotransferase activity is

elevated

○ fecal HAV shedding is still occurring

Hepatitis A diagnosis = IgM anti HAV

● Transmitted almost exclusively by: fecal-oral route

● Person-to-person spread is enhanced by poor personal

hygiene and overcrowding
Hepatitis B

● DNA virus

● classified as Hepadnavirus type 1

-represent excess viral
envelope protein

-represent intact hepatitis virion

 product of S gene
● HBsAg

○ first virologic marker detectable in

serum within 1-12weeks

○ preceded elevation of serum

aminotransferase activity and clinical
symptoms by 2-6weeks

○ remains detectable during the entire

icteric or symptomatic phase

● Anti- HBS

○ Detectable after HBsAg disappears

● HBcAg

○ intracellular and, naked

○ not detectable routinely

● Anti-HBc

○ demonstrable in serum beginning

within the first 1-2 weeks after the
appearance of HBsAg
● HBeAg

○ coincides temporally with high levels of virus

replication

○ presence of circulating intact virions and

detectable HBV DNA

○ undetectable shortly after peak elevations in

amino transferase activity, before the
disappearance of HBsAg

● Anti HBe

○ period of relatively lower infectivity

● Percutaneous inoculation has long been recognized as a major route
● HBsAg has been identified in almost every body fluid, most notably are
infectious

○ Semen and saliva

● By contrast, 2 non percutaneous routes considered to have greatest impact
are:

○ Intimate (especially sexual) contact

○ Perinatal transmission
Hepatitis D

● The only member of the genus Delta virus

● Defective RNA virus that co-infects with and require the
helper function of HBV for its replication and expression
● Formalin-sensitive, 35 to 37 nm virus with hybrid structure
● HDAg bears no antigenic
homology with HBV antigens

● HDV core is “encapsidated” by an

outer envelope of HBsAg
● HDV can either:

○ Co-infection

■ infect a person simultaneously with HBV

○ Superinfection

■ Superinfect a person already infected with HBV

● 2 epidemiologic patterns that exist:

○ Endemic areas

■ Nonpercutaneous means especially close

personal contact

○ Nonendemic areas

■ Blood and blood products, primarily injection

drug users and hemophiliacs
Hepatitis C

● Linear, single strand, positive sense RNA virus

● Only member of the genus Hepacivirus in the

family Flaviviridae
● HCV does not integrate into the
host genome

● It circulate in low titer, thus

visualization is difficult

● Replication rate: 1012 virions per

day

● half life is 2.7h

● HCV RNA

○ Most sensitive indicator of HCV

infection

○ Detected within few days of

exposure and persist for the
duration of infection
● Transmission:

○ Transfusion

○ Injection drug use

Hepatitis E

● epidemic or enterically transmitted non-A, non-B hepatitis

● Resembles hepatitis A

● 27 to 34 nm, non enveloped, heat stable

VIRAL REPLICASE: Nucleocapsid protein
Protease
Polymerase
Helicase
Small structural phosphoprotein involved in virus particle secretion
● detected in stool, bile, and liver
● excreted in the stool during the late
incubation period

● Both IgM anti-HEV during early

acute infection and IgG anti-HEV
predominating after the first 3 months
can be detected

● HEV RNA in serum and stool

accompanies acute infection
● Primarily enteric mode of spread

● Contamination of water supplies (eg

Monsoon flooding)

● Unique: Rare secondary person-to-person

spread