Hepatitis - Self-Learning Package

Question 1

The most obvious sign of hepatitis

Answer 1

Jaundice with hepatic tenderness

Question 2

The most important causes of viral hepatitis in the UK

Answer 2

Hepatitis A, B, C and E

Question 3

Define subclinical illness

Answer 3

Infection with no symptoms

Question 4

Define anicteric illness

Answer 4

Symptoms but no jaundice

Question 5

Define icteric illness

Answer 5

Symptoms with jaundice

Question 6

Define fulminant hepatitis

Answer 6

Severe jaundice with hepatic failure and high mortality

Question 7

Which enzymes will be raised in acute infection? (2)

Answer 7

Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)

Question 8

Common clinical presentation of hepatitis A virus (HAV) infection in children under 5 years old

Answer 8

Mild, often subclinical or anicteric presentation

Question 9

Mean incubation period of hepatitis A virus (HAV)

Answer 9

28 days (ranges from 10-50 days)

Question 10

Common symptoms of hepatitis A virus (HAV) infection in adults (8)

Answer 10

Fever
Malaise
Anorexia
Nausea
Vomiting
Upper abdominal pain
Jaundice and dark coloured urine 3-10 days later

Question 11

What is the main route of infection for hepatitis A virus (HAV)?

Answer 11

Faecal-oral

although faecal contaminated food or water may also play a part

Question 12

When are patients with hepatitis A virus (HAV) most infectious?

Answer 12

From a week before the onset of jaundice to a few days after

Question 13

What kind of antibodies are associated with hepatitis A virus (HAV) infection?

Answer 13

Anti-HAV IgM antibodies (usually present in serum from onset of symptoms to 3-6 months thereafter)
Anti-HAV IgA antibodies, which reflect immunity

Question 14

What is the treatment for hepatitis A?

Answer 14

There is no specific treatment, only supportive management of symptoms

Question 15

What are the three main methods of prevention of hepatitis A infection?

Answer 15

Good personal hygiene and sanitation
Human normal immunoglobulin (HNIG) - prophylaxis for close contacts of infected patients
Active immunisation (vaccine with killed virus)

Question 16

What is the prognosis for hepatitis A?

Answer 16

Good - recovery can be slow but death from fulminant hepatitis is rare
There is no chronic infection or liver damage
Lifelong immunity follows infection

Question 17

What are the common symptoms of acute hepatitis B infection and when can they present? (9)

Answer 17

Anorexia
Lethargy
Nausea
Fever
Abdominal discomfort
Arthralgia
Urticarial skin lesions
Followed by jaundice and dark coloured urine

Can occur any time between a few weeks and 6 months after the initial infection

Question 18

What is the major serum marker for identifying hepatitis B virus?

Answer 18

HBsAg (hepatitis B surface antigen)

Question 19

What are the two main serum markers of viral replication of hepatitis B virus?

Answer 19

HBV-DNA (hepatitis B virus DNA)

HBeAg (hepatitis B “e” antigen - it is split off HBcAg (hepatitis B core antigen) during viral replication)

Question 20

Routes of transmission of hepatitis B virus (4)

Answer 20

Vertical: perinatal (from mother to child during birth)
Horizontal: sexual, parenteral (any method of transmission outside the digestive system) including needlestick injury, inapparent parenteral

Question 21

Why is hepatitis B virus so infectious?

Answer 21

It is stable and able to survive outside the human body for weeks

Question 22

What are some predisposing factors to increased risk of hepatitis B virus infection in the UK? (9)

Answer 22

1. Injecting drug use
2. Multiple sexual partners
3. Immigration from high endemnicity areas
4. Patients with learning disabilities who live in residential care
5. Patients with haemophilia or on haemodialysis
6. Sexual partners of those with the above risks
7. Babies born to at-risk mothers
8. Tattooing/piercing with non-sterile equipment
9. Medical equipment if not adequately decontaminated

Question 23

How is the diagnosis of acute HBV infection made?

Answer 23

Serum HBsAg (unless patient presents very late or in severe fulminant acute disease)
Anti-HBc antibodies are present from the end of the illness onwards, so indicate a previous acute infection

Question 24

Clinical features of chronic HBV infection (5)

Answer 24

Persistence of HBsAg in the serum for more than 6 months
The risk of becoming chronically infected decreases with age
More common in males and immunocompromised patients
Previous mild or asymptomatic acute infection (due to defective cell-mediated immune response)
Jaundice is unusual

Question 25

Prognosis of chronic HBV infection

Answer 25

If left untreated, progression to chronic liver disease, and thus cirrhosis or hepatoma occurs in 25% of patients (Less commonly, can also progress to membranous glomerulonephritis and polyarteritis nodosa)

Question 26

Treatment for chronic HBV infection

Answer 26

Entecavir or tenofovir - recommended over lamivudine, adefovir dipivoxil and telbivudine due to better efficacy and lower level of viral resistance Liver transplantation

Question 27

Prevention of chronic hepatitis B infection (4)

Answer 27

Active immunisation with a vaccine containing HBsAg Passive immunisation with hepatitis B specific immunoglobulin (HBIG) - usually in combination with the vaccine Infection control procedures Screening of blood and transplant donors

Question 28

Clinical features of hepatitis C

Answer 28

Acute infection: - usually subclinical or mild - vague symptoms of malaise, anorexia and fatigue in 20%. Chronic infection: - develops in 60-80%, but many have no symptoms

Question 29

Known routes of transmission of hepatitis C virus (HCV) (8)

Answer 29

(blood-borne virus) 1. Shared "works" associated with intravenous drug use (IDU) including needles, syringes, filters, spoons 2. Blood products prior to heat treatment in 1989 3. Blood transfusion prior to antibody screening in 1991 4. Tattooing, piercing or acupuncture with non-sterile equipment 5. Sexual transmission (<5%) 6. Mother-to-child 7. Household contacts sharing razors or toothbrushes 8. Medical/dental equipment if inadequately decontaminated

Question 30

Diagnostic tests available for hepatitis C virus (5)

Answer 30

``` IgG test - only of value if positive but even then, should be treated with caution HCV antigen test (confirmatory) HCV-RNA test (confirmatory) Viral RNA Sequencing for genotype ```

Question 31

Treatment of hepatitis C

Answer 31

A combination pegylated alpha-interferon and ribavirin (with the addition of an HCV protease-inhibiting drug if the virus is genotype 1)

Question 32

Name and describe the 4 types of response patterns to antiviral therapy

Answer 32

Non-responder - virus remains detectable despite therapy Viral breakthrough - initial response followed by an increase in virus level by a factor of 10 (or 1 log unit) Relapser - virus undetectable during therapy but detectable on stopping treatment Sustained viral response - virus undetectable for 6 months after therapy

Question 33

How can hepatitis C be prevented? (3)

Answer 33

Avoiding contact with infected blood (i.e. avoiding all routes of transmission) Blood, organ and tissue screening Covering cuts and lesions with waterproof dressings There is no prophylaxis or vaccine available!

Question 34

What is the prognosis for hepatitis C?

Answer 34

Of those with chronic HCV, 20-50% develop cirrhosis in 30 years

Question 35

Why is hepatitis D virus (HDV or Delta Hepatitis) termed a "defective" virus?

Answer 35

Because it is always found with hepatitis B virus, which appears to be essential for its transmission.

Question 36

What is the mean incubation period of hepatitis E virus (HEV)?

Answer 36

40 days (range: 3-8 weeks)

Question 37

What are the clinical features of hepatitis E in developing countries?

Answer 37

In developing countries, infection clinically resembles hepatitis A, but there is an increased incidence of fulminant hepatitis with high mortality in pregnant women.

Question 38

What are the clinical features of hepatitis E in developed countries?

Answer 38

Mild or subclinical in women and young people, but more severe in elderly men. Liver failure may develop Extra-hepatic features (arthritis, anaemia, neurological manifestations) may predominate over hepatic features. In most cases, acute infection is self-limiting.

Question 39

What are the routes of transmission of hepatitis E virus (HEV)? (4)

Answer 39

Sewage-contaminated drinking water and probably food Undercooked pork products (85% of pigs in the UK are infected) Occupation related (e.g. abattoir workers) Blood exposure

Question 40

Diagnostic tests for hepatitis E virus (HEV)

Answer 40

There are tests for IgG, IgM and HEV-RNA but it is not known if protective immunoglobulins develop against future infection

Question 41

Treatment for hepatitis E

Answer 41

No licensed treatment In the immunocompromised, reduce immunosuppression if possible, but if not (or in severe infection), give ribavirin monotherapy

Question 42

What are the methods of prevention of hepatitis E?

Answer 42

Good hygiene Good sanitation Adequate cooking of food Passive immunisation with human normal immunoglobulin (HNIG) - doesn't protect tropical travellers (Active immunisation with a subunit vaccine is available in China)