Viral Hepatitis

Question 1

Which viral hepatitis are “infectious” and “serum”

Answer 1

A and E are enterically transmitted

BD and C are prenterally transmitted

Question 2

How is HAV infection different in children v. adults

Answer 2

children are often asymptomatic, adults usually have self-limited jaundice

Question 3

Who is at most risk of transmission in US for HEV?

Answer 3

entirely transmitted, often through contact with swine or in pregnant women or immunocompromised who eat meat that is not fully cooked (infection via either zoonotic or ingestion)

PCR serum or stool

Question 4

Hepatic damage in HBV is mediated how?

Answer 4

HLA class 1 restricted CTL response directed at HBcore antigens on HBV infected hepatocytes; HBV integrates into the human genome (can cause activation of protoncogenes)

Question 5

Contrast transmission of HBV in high and low endemic areas.

Answer 5

high endemic: vertical transmission

low endemic: adult transmission through sex, IV use

Question 6

T/F Only those who have developed anti-HBS antibodies are immune.

Answer 6

true: acquired via vaccination or clearing of acute infection

Question 7

Who are most likely to progress to chronic disease from HBV infection

Answer 7

children are much more likely than adults 90%v 10%

Question 8

List risk factors for progression of chronic liver disease.

Answer 8

longer duration of disease
older age, male
family history
aflatoxin (africa)
co-infection HCV, HDV, HIV
alcohol use
higher viral load
reccurent episodes of reactivation
genotype (C worse than A)

leads to higher risk of HCC- higher viral load

Question 9

How do you screen for HCC?

Answer 9

ultrasonography or CT/MRI scanning AND alpha fetoprotein every 6mo (screen with our without fibrosis)

Question 10

Coinfection of ______ usually resolves but superinfection frequently causes chronic disease and chronic hepatitis.

Answer 10

HDV, infection only possible in the presence of HBV

Question 11

How do you treat neonates born to mothers with active HBV infection?

Answer 11

babies get HBIG within 12hr of birth and HBV vaccine at same time at a different site (another arm) is 85-95% protective

Question 12

What are the two classic treatments of HBV?

Answer 12

antivirals aimed at surprising or destroying HBV by interfering with viral replication

immune modulators aimed at helping the human immune system to mount a defense against the virus (serious side effects, expensive, shorter duration)

1st line: pegaylated INFaa2a, enticer and tenofovir
lamivudine inhibits HBV DNA polymerase, resistance develops

Question 13

HCV has 6 major genotypes, in the US the most common genotypes are?

Answer 13

1a and 1b

Question 14

Describe the pathogenesis of HCV.

Answer 14

while it does not integrate into host cell, it does cause a CTL that does not clear the virus, leads to hepatic inflammation, fibrosis and in some cirrhosis

there are many quasi species due to the frequency of gene sequence variation

Question 15

Describe the prevalence of HCV in the US, how is it most commonly acquired?

Answer 15

infection peaked in the late 70’s early 80’s

IV drug use 60%, Sexual 15%, transfusion (before 1992) 10%, 15% other/unknown, dialysis

Question 16

T/F HCV is transmitted more often in vaginal delivery than C-section.

Answer 16

F transmission has no association with delivery method or breast feeding

transmitted only from women who are HCV RNA positive at delivery (infected infants do well)

Question 17

What are the clinical symptoms of HCV?

Answer 17

often asymptomatic

can have mild fatigue, nausea, poor appetite, myalgia, arthralgia and mild RUQ discomfort

Question 18

Who is recommended for HCV screening in the US?

Answer 18

those that have an increased risk for infection or those in need for exposure management

CDC recommends testing baby boomers born between 1945-1965

testing done by EIA detecting antibody, confirm with HCV RNA PCR

Question 19

Do more of those with HBV or HCV go on to develop liver cirrhosis?

Answer 19

~17% of patients with HCV go on to develop cirrhosis
90% of children with HBV develop cirrhosis
and 10% adults with HBV develop cirrohosis

Question 20

Which factors promote progression or severity of HCV infection?

Answer 20

increased alcohol intake
age >40yrs
HIV co-infection
male gender
other co-infeciton
obesity, insulin resistance, increased metabolic syndrome

Question 21

Compare the risk of cirrhosis in HBV and HCV.

Answer 21

patients with HCV only develop HCC after development of cirrhosis, those with HBV can develop it any time

**HCV is the leading indication for liver transplantation in the US, patients should be referred for treatment if they have evidence of decompensated portal HTN

Question 22

How is HCV treated?

Answer 22

combo therapy of direct acting antiviral agents: protease inhibitors, NS5a inhibitors and polymerase inhibitors

most effective tx: DAA+ RBV +/-PEGIFN 12weeks
newer agents have a shorter course and are very well tolerated but are VERY EXPENSIVE

Question 23

T/F After exposure, immunoglobins and vaccine should be administered.

Answer 23

IgG are not effective in preventing HCV after infection, no vaccines are available to prevent hepatitis

Question 24

List other non-hepatotrophic viruses that cause damage to the liver.

Answer 24

EBV
CMV
HIV, HHV6,7 
Parvovirus
HSV
VZV

Question 25

How is EBV and CMV with fulminant hepatic failure addressed.

Answer 25

EBV: acyclovir with or without corticosteroids used, no evidence of clinical efficacy

CMV: supportive in immune-competent unless severe organ damage, immune-suppressed receive ganciclovir or valganciclovir

Question 26

Antibody to surface antibody is significant for what?

Answer 26

exposure with clearance or vaccination