Infective Hepatitis

By Dr Upul Udayaraj
Hepatitis may be acute or chronic

Depending on whether it lasts for less than or more than six months
Outcome
• Acute hepatitis
Can sometimes resolve on its own
Progress to chronic hepatitis
Rarely result in acute liver failure

• Chronic hepatitis
May progress to Cirrhosis
Liver failure or hepatic insufficiency
Liver cancer
 Causes

• Infectious

• Metabolic

• Ischemic

• Autoimmune

• Genetic

• Other Ex: Neonatal

Infectious Hepatitis

 Viral hepatitis

 Parasitic hepatitis

 Bacterial hepatitis
• Other

• Cytomegalovirus (CMV),

• Epstein–Barr virus (EBV),

• Yellow fever
Globally, symptomatic HAV infections are believed to occur in around 1.4
million people a year

Hepatitis A is most widespread in parts of the world where standards of

sanitation and food hygiene are generally poor, such as parts of Africa, the
Indian subcontinent, the Far East, the Middle East, and Central and South
America
Better to know about – HAV
Hepatitis A
 Transmission - fecal-oral

 You can get the infection from:

• Eating food prepared by someone with the infection who hasn't washed their hands properly or
washed them in water contaminated with sewage

• Drinking contaminated water (including ice cubes)

• Eating raw or undercooked shellfish from contaminated water

• Close contact with someone who has hepatitis A

• Less commonly, having sex with someone who has the infection (particularly a risk
for homosexual men) or injecting drugs using contaminated equipment

 Someone with hepatitis A is most infectious from around two weeks before their
symptoms appear until about a week after the symptoms first develop
Clinical picture

Incubation period 15 – 50 days

The symptoms of hepatitis A develop, on average,

around four weeks after becoming infected, although not everyone
with the infection will experience them
Clinical picture
Initial symptoms

The initial symptoms of hepatitis A can include:

 Feeling tired and generally unwell
 Joint and muscle pain
 A mild fever – usually no higher than 39’C
 Loss of appetite
 Feeling or being sick
 Right hypochondriac pain
 A headache
 Sore throat and cough
 Constipation or diarrhea
 A raised, itchy rash (hives)

These symptoms usually last from a few days up to a couple of weeks

Late symptoms
After the initial symptoms, the following symptoms may develop:
 Jaundice

 Dark urine

 Pale stools

 Itchy skin

 Right hypochondriac swelling and tenderness

Most people make a full recovery within a couple of months,

although the symptoms can come and go for up to six months
Signs of a serious problem
 Hepatitis A isn't usually a serious illness, but in rare cases it can cause the
liver failure
 In addition to the symptoms above, signs of liver failure can include:
 Sudden, severe vomiting
 A tendency to bruise and bleed easily (for example, frequent epistaxis or bleeding gums)
 Irritability
 Problems with memory and concentration
 Drowsiness and confusion

 Must get medical advice as soon as possible if experience these

symptoms
 Liver failure can be life-threatening if not treated quickly
HEPATITIS B
 Double-stranded DNA Hepadnavirus

 Spread
 Through exposure to infected blood or body fluids
 Vertical transmission from mother to child

 The incubation period is 6-20 weeks

Clinical picture -
 Many people with hepatitis B won't experience any symptoms and may
fight off the virus without realizing they had it
 If symptoms do develop, they tend to occur two or three months after
exposure to the hepatitis B virus.
 Symptoms of hepatitis B include:
 Flu-like symptoms, including tiredness, a fever, and general aches and pains
 Loss of appetite
 Feeling and being sick
 Diarrhea
 Abdominal pain
 Jaundice
 These symptoms will usually pass within one to three months (acute
hepatitis B), although occasionally the infection can last for six months
or more (chronic hepatitis B)
 Chronic hepatitis (5-10%)

 Fulminant liver failure (1%)

 Hepatocellular carcinoma

 Glomerulonephritis

 Polyarteritis nodosa

 Cryoglobulinaemia
 Surface antigen (HBsAg) is the first marker to appear and causes the production of anti-HBs

 HBsAg normally implies acute disease (present for 1-6 months)

 If HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)

 Anti-HBs implies immunity (either exposure or immunization)

It is negative in chronic disease

 Anti-HBc implies previous (or current) infection

IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months

IgG anti-HBc persists

 HbeAg results from breakdown of core antigen from infected liver cells as is therefore a marker of infectivity
 Previous immunization:

anti-HBs positive, all others negative

 Previous hepatitis B (> 6 months ago), not a carrier:

anti-HBc positive, HBsAg negative

 Previous hepatitis B, now a carrier:

anti-HBc positive, HBsAg positive

 There is no specific treatment for acute hepatitis B. Therefore, care is
aimed at maintaining comfort and adequate nutritional balance,
including replacement of fluids lost from vomiting and diarrhea.

 Chronic hepatitis B infection can be treated with drugs, including oral

antiviral agents. Treatment can slow the progression of cirrhosis,
reduce incidence of liver cancer and improve long term survival.

 Treatment options
• Antivirals

• Tenofovir
• Entecavir

• Interferon injections
 HBsAg positive source: if the person exposed is a known responder to HBV
vaccine then a booster dose should be given. If they are in the process of being
vaccinated or are a non-responder they need to have hepatitis B immune
globulin (HBIG) and the vaccine

 Unknown source: for known responders the green book advises considering a
booster dose of HBV vaccine. For known non-responders HBIG + vaccine should
be given whilst those in the process of being vaccinated should have an
accelerated course of HBV vaccine
 All pregnant women are offered screening for hepatitis B
 Babies born to mothers who are chronically infected with hepatitis B or to
mothers who've had acute hepatitis B during pregnancy should receive a
complete course of vaccination + hepatitis B immunoglobulin
 Studies are currently evaluating the role of oral antiviral treatment (e.g.
Lamivudine) in the latter part of pregnancy
 There is little evidence to suggest caesarean section reduces vertical
transmission rates
 Hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
Transmission
 The risk of transmission during a needle stick injury is about 2%

 The vertical transmission rate from mother to child is about 6%.

The risk is higher if there is coexistent HIV

 Breast feeding is not contraindicated in mothers with hepatitis C

 The risk of transmitting the virus during sexual intercourse is

probably less than 5%
Clinical picture

 When symptoms do occur, they can be mistaken for another

condition

 Symptoms can include:

 Flu-like symptoms, such as muscle aches and a high temperature
 Feeling tired all the time
 Loss of appetite
 Abdominal pain
 Feeling and being sick
Complications

 Chronic infection (80-85%) - only 15-20% of patients will clear the virus after
an acute infection and hence the majority will develop chronic hepatitis C

 Cirrhosis (20-30% of those with chronic disease)

 Hepatocellular cancer

 Cryoglobulinemia

 Porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may

develop in patients with hepatitis C, especially if there are other factors such
as alcohol abuse
 Hepatitis C is diagnosed using two blood tests:
• Antibody test
• PCR test

 A positive antibody test indicates that patient has been infected at

some stage. It doesn't necessarily mean the person currently
infected

 The only way to tell if currently infected is to have a second blood

test the PCR
 Who should get tested?
• Ex-drug users and current drug users (particularly injected drugs)

• People who have lived or had medical treatment in an area where hepatitis C is common – high-
risk areas include north Africa, the Middle East and central and east Asia

• Babies and children whose mothers have hepatitis C

• Anyone accidentally exposed to the virus, such as health workers

• People who have received a tattoo or piercing where equipment may not have been properly
sterilized

• Sexual partners of people with hepatitis C

• People who received blood transfusions before September 1991

• Recipients of organ or tissue transplants before 1992

 Treatment with antiviral medication is recommended in all people with
proven chronic hepatitis C who are not at high risk of dying from other
causes

 Hepatitis C medications
 Until relatively recently, treatment for chronic hepatitis C usually involved taking two main
drugs:
o Pegylated interferon
o Ribavirin
 These medications were frequently just taken together

 Nowadays they often combined with a third medication

o Simeprevir
o Sofosbuvir
Hepatitis D
Single stranded RNA virus
Transmitted parenterally
An incomplete RNA virus that requires hepatitis B surface antigen to
complete its replication and transmission cycle
It is transmitted in a similar fashion to hepatitis B
Clinical picture
 Co-infection:
- Hepatitis B and Hepatitis D infection at the same time

 Superinfection:
- A hepatitis B surface antigen positive patient subsequently
develops a hepatitis D infection

 Both superinfection and coinfection with HDV results in more severe

complications compared to infection with HBV alone
Treatment and prevention of HDV

 The vaccine for hepatitis B protects against hepatitis D virus

because of the latter's dependence on the presence of hepatitis B

 Latest evidence suggests that Pegylated interferon alpha is

effective in reducing the viral load
Hepatitis E
 Common in Central and South-East Asia, North and West Africa, and in Mexico

 It is a RNA hepevirus

 Spread by the faecal-oral route as HAV

 Incubation period: 3-8 weeks

 Causes a similar disease to hepatitis A,

 Carries a significant mortality (about 20%) during pregnancy

 Does not cause chronic disease or an increased risk of hepatocellular cancer

 A vaccine is currently in development*, but is not yet in widespread use

 END
THANK YOU