Viral Hepatitis (B & D)

Question 1

Definition (hepatitis B)

Answer 1

Hepatitis caused by infection with hepatitis B virus (HBV), which may follow an acute or
chronic course

o Chronic is defined as viraemia and hepatic inflammation continuing for > 6 months

Question 2

Definition (hepatitis D)

Answer 2

Hepatitis D virus (HDV) is a defective virus, that may only co-infect with HBV or
superinfect people who are already carriers of HBV

Question 3

Aetiology

Answer 3

• HBV is an enveloped, partially double-stranded DNA virus
• Transmission: sexual contact, blood and vertical transmission (from mother to baby)

• Various viral proteins are produced such as:
o Core antigen (HBcAg)
o Surface antigen (HBsAg)
o e antigen (HBeAg)
• This is a marker of high infectivity

• HDV is a single-stranded RNA virus coated with HBsAg
• Antibody and cell-mediated immune response to viral replication leads to liver inflammation and hepatocyte necrosis
• Histology can show mild to severe inflammation and changes to cirrhosis

Question 4

Risk factors

Answer 4

o IV drug use
o Unscreened blood and blood products
o Infants of HBeAg-positive mothers
o Sexual contact with HBV carriers
o Younger individuals (particularly babies) are more likely to become chronic carriers
o Genetic factors are associated with varying rates of viral clearance

Question 5

Epidemiology

Answer 5

• Common
• 1-2 million deaths annually
• Common in Southeast Asia, Africa and Mediterranean countries
• HDV is also found worldwide

Question 6

Incubations period

Answer 6

Incubation period: 3-6 months

Question 7

Presenting symptoms (prodrome period)

Answer 7

• 1-2 week prodrome consisting of:

o Malaise 
o Headache
o Anorexia
o Nausea and vomiting
o Diarrhoea
o RUQ pain
o Serum-sickness type illness (e.g. fever, arthralgia, polyarthritis, urticaria,
maculopapular rash)

Question 8

Presenting symptoms (other)

Answer 8

• Jaundice develops with dark urine
• Recovery: 4-8 weeks
• 1% develop fulminant liver failure
• Chronic carriage may be diagnosed after routine LFT testing or if cirrhosis or decompensation develops

Question 9

Signs on physical examination (acute)

Answer 9

o Jaundice
o Pyrexia
o Tender hepatomegaly
o Splenomegaly
o Cervical lymphadneopathy (in 10-20% of patients)
o Occasionally: urticaria and maculopapular rash

Question 10

Signs on physical examination (chronic)

Answer 10

o May be no findings

o May have signs of chronic liver disease or decompensation

Question 11

Investigations (serology)

Answer 11

o Acute HBV:
• HBsAg positive
• IgM anti-HBcAg

o Chronic HBV:
• HBsAg positive
• IgG anti-HBcAg
• HBeAg positive or negative

o HBV Cleared or Vaccinated against HBV:
• Anti-HBsAg antibody positive
• IgG anti-HBcAg

o HDV infection:
• Detected by IgM or IgG against HDV
• PCR is used for detection of HDV

Question 12

Investigations (other)

Answer 12

• LFTs
o High: AST, ALT, ALP, bilirubin

• Clotting
o High PT (in severe disease)

• Liver Biopsy

Question 13

Management plan (prevention)

Answer 13

Blood screening
Safe sex
Instrument sterilisation

Question 14

Management plan (immunisation)

Answer 14

• Passive immunisation
o Hepatitis B immunoglobulin following acute exposure and to neonates born to
HBeAg-positive mothers (in addition to active immunisation)

• Active immunisation
o Recombinant HBsAg vaccine for individuals at risk and neonates born to HB

Question 15

Management plan (in active disease)

Answer 15

• Acute HBV Hepatitis
o Symptomatic treatment (antipyretics, antiemetics and cholestyramine) and bed
rest
o Notifiable disease

• Chronic HBV
o Interferon alpha (standard or pegylated)
• Side-effects: flu-like symptoms such as fever, chills, myalgia, headaches,
bone marrow suppression and depression
o Nucleoside/nucleotide analogues (adefovir, entecavir, telbivudine, tenofovir)

Question 16

Possible complications

Answer 16

• 1% get fulminant hepatic failure
• Chronic HBV infection (10% of adults, much higher in neonates)
• Cirrhosis
• HCC
• Extrahepatic immune complex disorders (e.g. glomerulonephritis, polyarteritis nodosa)
• Superinfection with HDV may lead to acute liver failure or more rapidly progressive disease

Question 17

Prognosis

Answer 17

• Adults: 10% of infections become chronic

* Of the chronic infections, 20-30% will develop cirrhosis