4. Not sexually transmitted well
What viruses can cause hepatitis?
Hep A-E, HSV, CMV, and EBV
What are the possible clinical presentations of viral hepatitis?
1. acute hep
2. fulminant hepatic failure
3. Chronic hep with complications including cirrhosis, liver failure, and possibly hepatocellular carcinoma
How do hep A, B, and E (rare in the US) typiclly present?
Hep A and E can only cause ACUTE hepatitis while Hep B can cause acute or chronic but is more likely to cause acute. Most cases of acute hepatitis resolve with the main complication of unresolved being fulminant liver failure
Note that mild forms of acute hepatitis tend to go unnoticed (subclinical)
Which hepatitis viruses can cause chronic hepatitis?
Hep C only causes chronic and again hep B can cause chronic but is more likely to cause acute. Hep D can only occur in the presence of a Hep B infection. The complications of chronic hepatitis include cirrhosis, and hepatocellular carcinoma
This is acute liver failure (only have 48 hrs!!)
B and E
How does acute hepatitis present?
Acute viral hepatitis follows a pattern of infection that involves three distinct phases:
The initial prodromal phase (preceding symptoms) involves non-specific and flu-like symptoms common to many acute viral infections. This includes fatigue, nausea, vomiting, poor appetite, joint pain, and headaches. Fever, when present, is most common in cases of hepatitis A and E.[ Late in this phase, people can experience liver-specific symptoms, including choluria (dark urine) and clay-colored stools.
Clinical jaundice (yellowing of the skin) and icterus (yellowing of the eyes) follow the prodrome after about 1–2 weeks and can last for up to 4 weeks. The non-specific symptoms seen in the prodromal typically resolve by this time, but people will develop an enlarged liver and right upper abdominal pain or discomfort. 10–20% of people will also experience an enlarged spleen, while some people will also experience a mild unintentional weight loss.
The recovery phase is characterized by resolution of the clinical symptoms of hepatitis with persistent elevations in liver lab values and potentially a persistently enlarged liver. All cases of hepatitis A and E are expected to fully resolve after 1–2 months. A majority of hepatitis B cases are also self-limited and will resolve in 3–4 months. Few cases of hepatitis C will resolve completely (aka theres no such thing as acute Hep C)
How will acute hepatitis look in labs?
-high ALT/ASTs (1000-5000 Iu/L)
-elevated bilirubin and prothrombin time
What is a normal bilirubin level?
A normal level is: Direct (also called conjugated) bilirubin: 0 to 0.3 mg/dL. Total bilirubin: 0.3 to 1.9 mg/dL
What is a normal INR?
In healthy people an INR of 1.1 or below is considered normal
In acute hepatitis, an INR approaching 3-4 suggests what?
progression to fulminant liver failure
What is fulminant liver failure?
The main features of acute liver failure are rapid-onset jaundice, weakness, and eventually changes in mental status that can begin as mild confusion but progress to coma
What is on the Ddx for acute hepatitis?
-Autoimmune liver disease
-Ischemic hepatitis (LEs may get up to 1000)
-Alcohol/drug induced, Tylenol overdose (LEs may get up to 500)
-Wilson disease (LEs up to 500)
What is Wilson Disease?
Wilson's disease is a genetic disorder in which copper builds up in the body. Symptoms are typically related to the brain and liver. Liver related symptoms include vomiting, weakness, fluid build up in the abdomen, swelling of the legs, yellowish skin, and itchiness. Brain related symptoms include tremors, muscle stiffness, trouble speaking, personality changes, anxiety, and seeing or hearing things that others do not
How is the diagnosis of Hep A made?
The diagnosis of acute HAV infection is confirmed during the acute or early convalescent phase of infection by the presence of IgM antibodies to HAV (IgM anti-HAV). IgM anti-HAV is generally present 5-10 days before the onset of symptoms and is no longer detectable in the vast majority of patients 6 months later. IgG anti-HAV, which also appears early in the course of infection, remains detectable for the lifetime of the individual and confers lifelong protection against infection. Commercial tests are available for the detection of IgM and total (IgM and IgG) anti-HAV in serum.
HAV RNA can be detected in the blood and stool of most persons during the acute phase of infection by using nucleic acid amplification methods, such as PCR, and nucleic acid sequencing has been used to determine the relatedness of HAV isolates. These methods, however, are available in only a limited number of research laboratories and are not used generally for diagnostic purposes.
When is Hep A infection most common?
In infected persons, HAV replicates in the liver, is excreted in bile, and is shed in the stool. Peak infectivity occurs during the 2-week period before onset of jaundice or elevation of liver enzymes, when the concentration of virus in stool is highest. The concentration of virus in stool declines after jaundice appears. Children and infants can shed HAV for longer periods than adults, up to several months after the onset of clinical illness. Chronic shedding of HAV in feces does not occur; however, shedding can occur in persons who have relapsing illness. Viremia occurs soon after infection and persists through the period of liver enzyme (alanine aminotransferase [ALT]) elevation.
What are the possible outcomes of acute hepatitis?
1. Spontaneous resolution (most common)- (Both Hep A and Hep E can rarely have a relapsing course with cholestasis) – 95% of Hepatitis B resolve
2. Progression to chronic infection (5% in HBV and ~80% in HCV) 0% chance of chronicity in Hep A or E
3. Fulminant liver failure (<1%)
Which types of acute hep infection are most likely to lead to fulminant liver failure?
All rare but HBV more common than HAV and HEV can only cause in pregnant women (in 3rd trimester most often)
Describe the genome of Hep A
Non-enveloped +strand RNA virus
How is Hep A contracted?
The virus is primarily spread when an uninfected (and unvaccinated) person ingests food or water that is contaminated with the faeces of an infected person. The disease is closely associated with unsafe water or food, inadequate sanitation and poor personal hygiene.
How does hep A cause liver injury?
CD8 T cells and NK cells lead to heaptic injury before clearance
What is the incubation period of Hep A?
T or F. HAV rarely causes acute liver failure
T. Only about 5% of times and 70% of those pts. recover
How does Hep A present?
Many cases have few or no symptoms, especially in the young. The time between infection and symptoms, in those who develop them, is between two and six weeks. When symptoms occur, they typically last eight weeks and may include nausea, vomiting, diarrhea, jaundice, fever, and abdominal pain. Around 10–15% of people experience a recurrence of symptoms during the six months after the initial infection. Acute liver failure may rarely occur, with this being more common in the elderly
What are some atypical presentations of Hep A?
-Extrahepatic manifestations occurring