Viral Hepatitis

Question 1

What are the symptoms of viral hepatitis? [10]

Answer 1

non-specific symptoms

1. malaise
2. fever
3. headaches
4. nausea
5. vomiting
6. anorexia
7. right upper quadrant abdo pain
8. dark urine
9. clay coloured faeces
10. jaundice

Question 2

What are the causes of acute hepatitis? [6]

Answer 2

1. infections
   
   • hep A, B, C, D, E
   • EBV, CMV, toxoplasmosis
   • leptospirosis
   • Q fever
   • syphillis
   • malaria
   • VHF
2. toxins
3. drugs
4. alcohol
5. autoimmune
6. Wilson’s disease
7. haemochromatosis

Question 3

What is the difference between acute and chronic viral hepatitis? [8]

Answer 3

1. acute viral hepatitis:
   
   • can be mild or severe
   • fulminant (A, B, C, D or E)
   • usually severe primary with high mortality
   • complications:
     
     • encephalopathy
     • coagulopathy
     • multi-organ failure
2. chronic viral hepatitis:
   
   • B, C, D and rarely E
   • presence of virus for more than 6 months

Question 4

What are the routes of transmission of:

1. Hepatitis A and E? [1]
2. Hepatitis B, C and D? [1]

Answer 4

1. faecal oral
2. parenteral (contact with bodily fluids)

Question 5

What are the incubation periods for Hep…

1. Hep A
2. Hep B
3. Hep C
4. Hep E

Answer 5

1. 3-5wks
2. 6w-6m
3. 6-12wks
4. 6w

Question 6

How do you diagnose viral hepatitis in the lab? [3]

Answer 6

1. detection of specific immune response (IgM or IgG)
2. viral nucleic acid detection (RNA or DNA)
3. antigen detection (HBV and HCV)

Question 7

Hepatitis A (HAV)

1. epidemiology? [2]
2. type of virus (DNA or RNA)? [1]
3. transmission? [1]
4. incubation period? [1]
5. diagnosis? [2]
6. vaccine? [3]

Answer 7

1. epidemiology
   
   • endemic in Africa & South America
   • usually travel related
2. type of virus (DNA or RNA)
   
   • RNA virus
3. transmission
   
   • faeco-oral spread
4. incubation period
   
   • 1 month
5. diagnosis
   
   • by IgM to Hep A or
   • RNA in stool/blood
6. vaccine
   
   • inactivated virus vaccine
   • 2 doses gives life protection
   • pre-exposure vaccine given to travellers/homosexual men/IVDU/chronic liver disease patients

Question 8

Hepatitis E (HEV)

1. epidemiology? [1]
2. type of virus (DNA or RNA)? [1]
3. transmission? [2]
4. incubation period? [1]
5. treatment & vaccine? [2]
6. who gets chronic Hep E and how do you treat it? [2]
7. neurological manifestations? [4]

Answer 8

1. epidemiology
   
   • more common in UK than Hep. A
2. type of virus
   
   • RNA virus
3. transmission
   
   • faeco-oral
   • pork products
4. incubation period
   
   • 40 days
5. treatment & vaccine
   
   • supportive treatment
   • no vaccine
6. who gets chronic Hep E and how to treat it
   
   • seen in very immunosuppressed patients
   • treatment with ribavirin
7. neurological manifestations
   
   • Guillian-Barre syndrome
   • encephalitis
   • ataxia
   • myopathy

Question 9

Hepatitis B (HBV)

1. type of virus (DNA or RNA)? [1]
2. transmission? [5]
3. incubation period of acute HBV? [1]
4. how age at the infection determines prognosis? [4]
5. what does chronic HBV increase risk of? [4]
6. what are the Hep B lab tests? [6]
7. treatment for acute HBV? [1]
8. treatment for chronic HBV? [2]
9. prevention? [3]

Answer 9

1. type of virus (DNA or RNA)
   
   • DNA virus
2. transmission
   
   • transfusion (blood/blood products)
   • fluids (blood/semen)
   • organs and tissue transplantation
   • mother to baby (vertical transmission, usually at birth)
   • contaminated needles and syringes
   • child to child
3. incubation period of acute HBV
   
   • 2-6 months
4. how age at the infection determines prognosis
   
   • it determines severity of acute illness and risk of chronic HBV
   • infection at birth/young child is usually asymptomatic but leads to chronic infection
   • infection as adult is usually symptomatic but is cleared
5. what does chronic HBV increase risk of
   
   • chronic liver disease
     
     • cirrhosis
     • decompensation
     • hepatocellular carcinoma (HCC)
   • presents with weight loss, abdo pain, fever, cachexia, mass in abdomen, blood ascites and HBsAg +ve
6. Hep B lab tests
   
   • sAG - surface antigen - marker of infection
   • sAb - surface antibody - marker of immunity
   • cAb - core antibody
   • eAg - e antigen - suggests high infectivity
   • eAb - e antibody - suggest low infectivity
   • HBV DNA
   • HBV infection is diagnosed if sAg or DNA are detectable
7. treatment for acute HBV
   
   • no treatment
   • usually resolves and clears
8. treatment for chronic HBV
   
   • most do not require treatment
   • only treat those with liver inflammation or biopsy
     
     • immunomodulatory - inferferon
     • suppress viral replication - tenofovir or entecavir
9. prevention
   
   • education (safe sex, injecting etc.)
   • HBV sAg vaccine
   • prevention of mother to child transmission
     
     • HBV vaccine to newborn
     • HBV immunoglobulin if eAg and/or high VL
     • tenofovir during the last trimester if high viral load

Question 10

Hepatitis D (HDV)

1. type of virus (DNA or RNA)? [1]
2. transmission and acquired by? [3]
3. increases risk of? [1]
4. treatment? [1]

Answer 10

1. type of virus (DNA or RNA)
   
   • ssRNA virus that requires HBV to replicate
2. transmission and acquired by
   
   • transmission same as Hep B, but vertical transmission is rare
   • acquired by co-infection with HBV or super-infection of chronic HBV carriers
3. increases risk of
   
   • chronic liver disease
4. treatment
   
   • Peg IFN only

Question 11

Hepatitis C (HCV)

1. type of virus (DNA or RNA)? [1]
2. transmission? [3]
3. vaccine? [1]
4. incubation period? [1]
5. diagnosis? [3]
6. treatment? [1]

Answer 11

1. type of virus (DNA or RNA)
   
   • RNA virus
2. transmission
   
   • ​​injecting drugs
   • transfusion
   • transplant
3. vaccine
   
   • no vaccine and no post-exposure prophylaxis
4. incubation period
   
   • 6-7 weeks
5. diagnosis
   
   • screening of high risk groups (IVDU, immigrants from high prevalence countries)
6. treatment
   
   • _​​_Direct Acting Antiviral (DAAs) inhibit different stages of the viral replication cycle resulting in a cure