Viral Hepatitis(Part II)

Hepatitis D Virus
- defective minor strand RNA virus that markedly accelerate disease progression by
superinfection of Hepatitis B carriers
- first evidence came in 1978 when previously unrecognized intranuclear Ag detected by
liver biopsy in Italian patient with chronic HB infection
- virus was shown to be defective requiring helper function from HBV probably because
HDV is enveloped with envelop of HBV

Characteristics
Family : Deltaviridae
Serotype : one
Genotype : three
Nucleic Acid : single-stranded circular RNA
Genome Size : 1.7kb
Envelope : surface Ag of HBV(Hbs Ag)
Replication : hepatocyte membrane and endoplasmic reticulum

- to cause HDV infection: dimere composed of HDV RNA genome and Ag, both enveloped
by Hbs Ag
- 3 genotypes of HDV, only 1 serotype has been identified
- HDV genome consists of circular rod shaped single minor strand RNA
- envelope = Hbs Ag

Epidemiology
- transmission of HDV: - contaminated blood transfusion
- contaminated needle(in drug addicts)
- IV drug use
- multiple sexual partners
- body piercing and tattooing
- perinatal transmission(rare)
- high rates of infection previously reported in drug addicts and hemophiliacs
- the risk of HDV infection in medical personnel, hemodialysis unit(contaminated needle)
and institutionalized patients has varied
- HDV achieves extraordinary high titers of infection dose/ml in blood of infected
individuals
- populations of SEA, South Africa usually with severe and fatal hepatitis
- in developed countries, HD -> high risk in population of drug addicts
- infection also occur in newly implanted liver graft to chronic HBV infection patients
- benign focus of liver disease and asymptomatic can lead to HDV infection
- Venezuela, Columbia, Peru and Central America = endemic HD
- HDV not endemic in Northern Europe and North America and outcome is severe
- analysis of genotype is able to help differentiate severity. Only genotype 3 leads to
severe/fulminant acute HD
- genotype 2: isolated in Onokuba in Japan; only mild form
- genotype 1: Italy and North America; less severe liver disease

Pathogenesis
- replication cycle starts with attachment of virus to hepatocyte membrane and
endoplasmic reticulum with its release from the infected cells
- since HDV virion is coated with envelope proteins over helper HBV, it is likely that HBV
and HDV have a common receptor on hepatocyte membrane that is recognized by pre-S1
domain over Hbs Ag
- inside the cytoplasm HDV enters nucleus where replication occurs. The viral genome is
then replicated by host DNA-dependent RNA polymerase 2
- Hbs Ag protein presents in Dane particles. Infectious HBV required for capsidation and
encapsidation of HDV. This is by budding into ER of Golgi apparatus of hepatocytes. The
role of immune system is incompletely understood
- immune-mediated pathogenesis is supported by histologic evidence of lymphocytic
infiltrative lymphocytes in liver and T-cell response responsible for cytotoxic effects in
liver have been suggested by several evidence. Immune response of IgM and IgG classes
elicited
[direct cytolytic effect of virion]

Clinical Course
- incubation period 35 days(1 month)
- diseases may occur as co-infection of acute HBV infection or superinfection of chronic
HBV infection
- the clinical expression of acute HDV infection is acquired through co-infection of HBV
from subclinical enzymatic alterations to clinical/fulminant disease
- serologic profiles vary with severity of clinical disease(incubation period -> preicteric
-> icteric period)(marked intoxication and marked disease)
- Hbs Ag helper to HDV infection
1st way: correlates with HBV replication -> markers of acute HB
keeps Hbs Ag in serum -> plays role of Hbs as surface Ag -> HDV infection
2nd way: HDV acute infection(anti-HDV IgM, anti-Hbc IgM)
- after 2 weeks/1 month: presence of intoxication and jaundice -> presence of anti-HDV IgM

Clinical Picture
Serologic Profile of HBD-HDV Co-Infection
- 2 ways of HDV infection:
1. by HBV replication
2. by HDV replication which doesn’t take without Hbs Ag because HDV is implanted in
HBV genome
- why 2 ways? -> because Hbs Ag is necessary for HDV infection
- in patients with subclinical and mild hepatitis, there’s no viremia and co-infection by
HDV is recognized only from delayed rise of IgM and IgG to HDV infection
- in patients with severe disease, viremia is manifested in early finding of HDV Ag and HDV
RNA in serum, followed shortly by seroconversion first to IgM and then to IgG Ab to HDV.
The former in a few weeks and latter in few months leaving no evidence of prior HDV
infection
- co-infection rarely leads to chronic HDV. Acute co-infection results in other 95% of cases.
In contrast superinfection is most often severe and advances to chronicity in 70% of
cases
- primary HDV disease is acquired through superinfection(normally occur in
immunocompromised patients), is severe accompanied by jaundice and liver dysfunction
- fulminant HDV disease has worse prognosis than from acquired by co-infection
- subclinical liver disease due to HDV can decompensate due to superimpose acute HDV. In
such patients early HDV viremia is a frequent finding followed by brisk rises in IgM and
IgG
- superinfection that resolves, IgM titer drops in a few weeks and IgG persists for 1-2
weeks
- superinfection can progress to chronicity. Titers increase to high levels which persist in
infinity
- serum HD Ag is not detected in normal immunologic assays because Ag is masked by
immune complex
- presence of HDV RNA in blood = chronic infection
- mortality rate is 2-20%
- chronicity follows 1-3% of co-infection
- chronicity follows 70-70% of superinfection(patient is immunosuppressed)
- chronic infection: detected by seroconversion to anti-HB IgG, increase in anti-HDV IgM
titer and HDV RNA in blood after acute episode
- chronic infection rarely observed in healthy carriers of Hbs Ag(<4-8%)
- chronic HDV leads to cirrhosis more than does HBV alone. Age specific prevalence
- in chronic HDV carrier, HCC develops at about the same rate as in patients with HBV
cirrhosis alone. HCC was the cause of death in 30% of HDV patients
- HDV and other chronic HV can trigger autoimmune reactions shown by detection of
Ab(autoimmune hepatitis)

Serologic Course of HDV Superinfection Evolving To Chronicity

Serologic Markers of HDV
- in co-infection : markers of primary response to HBV(Hbs Ag, Hbe Ag,
anti-Hbc IgM, anti-Hbc IgG, anti-HDV IgM, anti-HDV IgG)
- in superinfcetion : markers of chronic HBV infection(Hbs Ag, anti-Hbc IgG, anti-Hbe,
anti-HDV IgM, anti-HDV IgG)

Prevention and Prophylaxis

Vaccine to HBV

Complications
- HAV, HBV, HDV = acute hepatic encephalopathy

- endotoxin, gram negative bacteria -> portal vein -> endotoxin act on endothelial cells of
hepatocytes, Kupffer cells release TNF-α, IL-1, IL-6 to inferior vena cava
The Stages of Acute Hepatic Encephalopathy
- Precoma I : - unsteady mood, depression is followed by euphoria, decreased
orientation in time and space, tremors, inversion of sleep, increased
sleepiness during the day, irritated, troubled by presentiment of death
- weakness, nausea, vomiting increase
- short time unconsciousness, giddiness, hiccup, yawning, “hepatic
smell”(rotten apples; sweet scent as liver consists of glucose) in
breath
- jaundice increase
- bradycardia followed by tachycardia(due to necrosis). Body
temperature rises
- Precoma II : - more pronounced disturbances of consciousness, which often
becomes confused, loss of memory, attacks of locomotor and sensory
excitement
- during awakening there is disorientation in time and space and action
- tendon reflexes are marked. “bang/flapping” tremor of hand
- respiration rhythm disturbed. Liver size decrease, diuresis decrease.
In 1/3 of patients, nasal hemorrhages, GI hemorrhages, uterine
Bleeding and hemorrhages from other organs are observed. Edemato-
Ascetic syndrome -> from hours to 2 days
- Proper coma : - complete loss of consciousness. Absence of reflexes is marked
- pathologic reflexes. Urination and defecation are involuntary. Rigidity
of extremities muscles, hyperkinesis, convulsive syndrome and
complete areflexia are observed
- expressed tachycardia, hypotonia, disturbance of respiration rhythm
are revealed
- decreased diuresis leads to anuria
- death of patient within 6-24 hours due to massive hemorrhages
(severe metabolic acidosis)
Viral Hepatitis C
- chronic VHC -> chronic liver disease
- HCV 53000 cases(12% of all cases)
- 5% acute(icteric form -> recovery)
- 95% chronic(non-icteric -> chronic)

Epidemiology
- transmitted through contact with blood/blood products, needle sharing, syringes
- most common in IV drug users
- blood screening is present. Therefore, no transfusion-related HC
- renal dialysis and organ recipient
- regular sexual partners transmission
- mother to child(vertical transmission)
- HIV related

Etiology
- HCV is a RNA-genome virus
- classified in Family Flaviridae
- consists of 6 genotypes
- infectivity titer of HCV in blood may be as high as infective dose/ml but is usually
much lower

Pathogenesis
- doesn’t cause direct destruction of hepatic cells, rather it results from intramediated
immune response large enough to stimulate hepatic cell destruction and fibrosis but not
enough to eradicate virus from its reservoirs
- HCV specific CD4+ and CD8+ T-cell response are weaker in chronic than acute phase
- patients with poor response in acute phase is often asymptomatic and more likely to
become chronic
- if immune response effective, presence of clinical picture -> jaundice
- if defective/inadequate response, no clinical picture -> chronic process
- acute VHC -> chronic(mutation of genome: Ab not effective to Ag)
- cyclic immune complex in blood -> sits on tissue -> extrahepatic diseases(arthritis,
vasculitis, thyroiditis)
- effective of interferon and riboflavin for restoration of immune response
- HCV escapes immune system by emergence of B- and T-cells variant epitopes mask viral
particles from Ab. Particles to divert host immune response. Viral agents + mediators of
host immune response result in impairment of Ag-presenting cell functions
- More vigorous CD4+ response in patients resolving an infection

Histology
- HC -> insidious course(manifest mostly in chronic stage)
- Inflammatory infiltrates(lymphocytes and macrophages) can be seen in parenchyma
especially in portal tracts while necrosis is commonly observed in portal areas
- 2 types of chronic infections have been distinguished in the past: chronic persistent and
chronic active hepatitis
Clinical Course
- individuals with acute HCV infection typically are asymptomatic/subclinical symptoms.
Only 20-30% may have jaundice and 10-20% have non-specific symptoms including
anorexia, malaise, nausea, abdominal pain
- HCV characterized by absence of symptoms and subclinical and unicteric course,
diagnosis of HCV infection is often by accident by laboratory investigation. Only 5% cases
proceeds with acute viral hepatitis with mild intoxication symptoms
- cyclic course; in preicteric/prodromal period, presence of arthralgia and hives
- jaundice develops after preicteric period
- incubation period: 1-6 months
- after 6 months -> chronic
- after 10-20 years -> cirrhosis
- after 25-30 years -> HCC
- in acute viral hepatitis, presence of anti-HCV after 1-3 months of illness
- only PCR to detect HCV RNA

Diagnostic Markers of Hepatitis C

- since asymptomatic, it can become chronic

- not characteristic of fulminant form
- anti-HCV(appears from 1st-3rd month of illness), and stays for life if chronic infection
- ALT level increase before clinical symptoms appear
- anti-HCV decreases and finally disappear
- HCV RNA: low during acute symptomatic phase

Clinical Outcome of HCV Infection

20% acute hepatitis
70% chronic hepatitis
40% liver cirrhosis
60% HCC
30% cases of liver transplantation
- in advanced disease: pruritus, weight loss, malaise, abdominal pain
- no relation between severity and ALT level. ALT level increase constantly. Intermittent
only in 2/3 of patients. Remaining 30% normal ALT levels but has viremia
- 3 patterns: chronic HC with normal ALT, mild chronic HC(raised ALT), moderate-severe
chronic HC
- 25% has normal ALT levels. Asymptomatic but has histologic symptoms of mild chronic
HC in liver biopsy. Exception of 10% has cirrhosis
- mild chronic C: raised ALT with fluctuations. 50% of newly diagnosed people
- mild inflammatory lesions with mild fibrosis
- cirrhosis risk: slowly
common type: in young patients
- moderate-severe chronic HC is difficult to distinguish from mild chronic hepatitis. Raised
ALT levels is not a good sign. Thrombocytopenia or raised γ-GT, γ-globulins -> more
advanced disease. Liver biopsy is most accurate way of identification of such form and
confirming prognosis
- HCV infection leads to cirrhosis with complication of ascites, HCC and hepatic
insufficiency
- rapid fibrosis -> cirrhosis in <20 years
- slow fibrosis -> cirrhosis in >50 years
- post-transfusion HC, 20-50% develops cirrhosis, 5-20% develops HCC after 10-30 years
- factors that stimulate liver disease: virus and host-related factors
- co-infection with HIV increases HCV RNA titers by 10-fold, infectivity increases
- vertical infection is rare unless mother infected with HIV

Diagnostic Test
- serologic assays for Ab(presence of Ab against HCV in serum)
- immunofluorescence: detect Ab in 4-10 weeks
- detect HCV RNA introduced
- qualitative HCV RNA based on PCR technique and decreases limit of detection of <100
copies of HCV RNA/ml serum
- molecular test(PCR)

Prevention
- no vaccination because mutation is high
- sterilization of needles

Treatment
- treated as acute viral hepatitis with detoxification and symptomatic treatment
- chronic HC treated with antiviral drugs and interferon for 11 months
Viral Hepatitis E
- fecal-oral mechanism
- occurred first in New Delhi in December 1955
- >20000 cases of jaundice, 3-fold risk among males, prevalence -> 30-40 years old
- pregnant women affected frequently(in 3rd trimester with increase of mortality to 15-
25%)
- source: contaminated/unboiled drinking water
- serological test not available for acute hepatitis
- after HAV, seromarkers were examined. Consequently, with epidemic not caused by HAV
infection, it must have been caused by non-A types
- incubation period and clinical pictures identical to HAV infection
- HEV was discovered in Moscow in 1983(from stool of infected person) by Balayan
- In 1988, HEV was assigned to Calciviridae because it lacks a protein. Therefore it cannot
be Togaviridae(like Rubella)

Characteristics of HEV
Family : Caliciviridae
Serotype : one human
Nucleic Acid : (+) and (-) strand RNA
Genome Size : 7200kb
Open Reading Frame :3
Size : 27-34nm
Envelope : none

Epidemiology
- zoonosis: transmitted to humans mainly by pigs and possibly by other animals(rats,
rodents)
- can be endemic, epidemic or sporadic
- epidemic -> India, Israel, Egypt, Nepal
- sporadic -> Europe and USA
- familial contact
- epidemic of HEV is present in schools
- HEV excreted in stool in lower concentration than HAV; HEV less stable than HAV
- vertical transmission(mother to child) is possible, with increased morbidity and
mortality
- possible through parenteral route of transmission(maybe blood transfusion)
- reinfection with HEV must be expected due to the lack of life-long immunity

Clinical Course
- incubation period: 40-65 days(minimum 30 days)
- symptomatic clinical picture is not able to distinguish from acute HA when IgM is present
- clinical picture regresses in 2-3weeks
- course: acute and self-limiting
- in individual cases, maybe >200IU/L of ALT and pronounced increase in bilirubin
- fulminant hepatitis: 2-3% of cases, in children and pregnant women with HAV and HEV
co-infection
- chronic course of HEV and carrier has not been observed
- HEV in pregnant women leads to abundant uterine bleeding -> death
Serological Diagnosis
- detect anti-HEV IgM(acute HEV infection)
- anti-HEV IgM can only be identified on 41st day following infection(a short time after
appearance of jaundice) and persists for >2 years
- HEV RNA is detectable in serum from 22nd day after infection
- In acute HEV infection, anti-HAV IgM may be present(false diagnosis)

prophylaxis measures and vaccination of HEV is not available

Basic Drugs Used for the Treatment of Acute Viral Hepatitis

1. agents used for detoxification and for the correction of water-electrolyte imbalance
- crystalloid-colloids(3:1)(colloids can cause renal failure and tubular dysfunction)
- drugs for correction of hypokalemia(Aspacardin, Panangin)
- abundant fluid intake
- enterogel
- prescribe enzymes if meteorism presents after meal and unstable stool
2. agents decreasing absorptive function of small intestine(osmotic diarrhea)
(Lactulose/Duphalac)
3. against a background of limited protein intake(per os and IV)
- amino acid solutions used in the treatment of hepatic failures:
- Aminosteril N-Hepa
- Hepasteril A
- Hepasteril B
- Hepatamine
- Aminoplasmal Hepa-10%
4. spasmolytic drugs(Drotaverine(No-Spa), Euphyllin)
5. diuretics: spironolactone derivatives(Verospiron)
6. drugs used for the treatment of cholestasis(Ursodeoxycholic acid(Ursofalk, Ursosan))
7. antibiotics characterized by low resorption from intestine: aminoglycosides(Neomycin)

*if liver encephalopathy present, give chilled plasma and amino acid solutions to correct
hemorrhagic syndrome, osmotic diarrheal drugs to eliminate ammonia