Acute Viral Hepatitis

Dr.Hasibi

Etiology
Major

agents:
HGV TTV HFV

HAV HBV HCV HDV HEV

Etiology
Minor

agents:

EBV,CMV HSV,VZV Rubella,Measles

Coxsackie

B Adenovirus

Transmission
HAV
Fecal-oral
Percutan. Perinatal Sexual

HBV

HCV

HDV

HEV

+
+ +

+ + +

+ + +

+ + +

+
-

Epidemiology
HAV:fecal-oral HEV:fecal-oral Rarely bloodborne HBV:percutaneous contact Mucous membrane contact Sexual contact Perinatal:third trimester and 2 months postpartum HDV : like HBV

Epidemiology

HCV: Percutaneous transmission Transfusion(0.1 %),needle stick(1.8 %) Mucousal transmission (rare) Sexual transmission is rare(monogamy) Perinatal transmission is uncommon (HIV coinfection,less than 5 % )

Sexual transmission of HCV

Multiple

sexual partner HIV and STD Anal sex Open sore Sex during menstruation

Pathology
Infiltration

of mononuclear cells Hepatic cells necrosis Kupfer cells hyperplasia Variable degrees of cholestasis In more severe cases; Bridging necrosis

Clinical Stages
Incubation

period Prodromal (preicteric) phase Icteric phase convalescence

Variation in staging
Asymptomatic Anicteric

Fulminant
Chronic

Incubation Period
HAV:15-45

days(30) HBV: 30-180 days(60-90) HCV: 15-160 days(50) HDV: 30180 days(60-90) HEV: 14-60 days(40)

Incubation Period
Considerable

overlap Asymptomatic period Viral replication& Shedding

Preicteric Phase
Systemic &nonspecific symptoms Flue like &Dyspepsia: Fever,sore throat,cough,headache Fever,anorexia,malaise,nausea Vomiting,abdominal pain Duration : 1-2 weeks

Icteric Phase
Clinical

jaundice Dark urine:1-5 days before jaundice Patient may feel better Resolution of fever pruritus

Icter

Icter

Icter

Icteric Phase
Liver

is enlarged,tender Cervical adenopathy(10-20%) Splenomegaly(10-20%) Fever is absent Venopuncture site Encephalopathy :Irritability Letargy,confusion

Convalescence
Resolution

of symptoms Liver is enlarged Pruritus Complete recovery: 1-2 months A,E 3-4 months B,C (3/4)

Laboratory Findings
CBC:leukopenia,lymphocytosis Atypical

lymphocyte, Normal Hb;except hemorrage Normal platelet;except DIC ESR is normal

Laboratory Findings
Serum

bilirubin:5-20 mg/dl Direct bil =indirect bil SGOT,SGPT=400-4000 iu Alk.phosphatase :mild elevation PT is usually normal:in severe hepatitis,PT is prolonged Hypoglycemia

Serologic Diagnosis
Ig

M anti-HAV HBs Ag and Ig M anti-HBc HCV Ab,HCV RNA PCR anti-HDV anti-HEV

Complications
Hepatitis

A:Relapsing hepatitis Cholestatic hepatitis Hepatitis B:serum sickness Chronicity:HBV,HCV,HDV fulminancy:HAV,HBV,HDV, HEV

Progression of Acute to chronic Hepatitis

Lack of resolution of symptoms (WL,fatigue,anorexia,hepatomegaly) Failure of Bil. ,LFT,Glu to normal (Within 6-12m) Persistence HBs Ag beyond 6 m or HBe Ag beyond 3 m Presence of bridging or multilobular necrosis

Diferential Diagnosis
Viral

hepatitis by minor agent Gram negative Sepsis Cholangitis,cholecystitis Flare up chronic hepatitis Drug-related hepatitis Ischemic hepatitis

Management
Indication

of admission: Bilirubin>20 mg/dl Hypoglycemia Abnormal PT Hypoalbuminemia

Management
Indication

of admission : Poor oral intake Mental change,letargy Low compliance Other chronic disease

Management
CBR

isnot mandatory Restriction activity No special diet &Therapy(HCV ? ) Drug &Alcohol avoidance Isolation isnot necessary except special cases

Monitoring
Regular

physical exam Liver size,mental state,icter Check of LFT,BS,PT,BIL Serial check of HBs Ag and HCV Ab

Prevention
Hand

washing,hygiene Universal percaution

No

sharing of personal items (razor,toothbrush,nail clipper) Sexual barrier

prevention
HAV:
Pre-exposure

prophylaxis: Vaccine ,SIG:0.02 cc/kg Post-exposure prophylaxis: SIG:0.02 cc/kg ;For day care centers,family members Vaccine ?

Prevention
HBV:
Pre-exposure

prophylaxis: Vaccine :months 0,1,6 Booster isnot recommended Post-exposure prophylaxis: HBIG:0.06 cc/kg and complete course of vaccine

Prevention
Post-exposure

prophylaxis in vaccinated person :

Responder:No treatment Nonresponder:HBIG+Vaccine(3) OR HBIG (2) in one month Response:anti-HBs>10miu/ml

Prevention
Ab

response unknown: Check anti-HBs; If adequate:no treatment If inadequate:HBIG(1) + vaccine(1)

Post exposure prophylaxis

HCV

:no treatment HEV: no treatment