Dr. RABIE IBRAHIMSUPERVISED BY Dr.ABDALLA AL-SHAHRANI
Hepatitis A B C D EVirus HAV HBV HCV HDV HEVFamily Picornavirus Hepadnavirus Flavivirus Satellite Calicivirus cGenome ssRNA dsDNA ssRNA ssRNA ssRNA parenteral, parenteral, parenteral,Spread Fecal-oral sexual,perinat Fecal-oral ?sexual ?sexual al HbsAg,HBcAg,Antigens HAV-Ag HCV-Ag HDV-Ag HEV-Ag HBeAg Anti-HBs,Anti-Antibodies Anti_HAV Anti-HCV Anti-HDV Anti-HEV HBc,Anti-HBe HBV DNA, viruslikeVirus markers HAV RNA DNA HCV RNa HDV RNa partiacles polymerase
serology• HBsAg: surface antigen• HBeAg: e antigen (a component of HBV core); marker ofviral replication• HBcAg: core antigen (cannot be measured in serum)• both HBsAg and HBeAg are present during acute hepatitis B• anti-HBs follows HBsAg clearance and confers long-termimmunity• anti-HBe and anti-HBc appear during the acute and chronicphases of the illness but do notprovide immunity• anti-Hbe indicates low infectivity
Possible Outcomes of HBV Infection Acute hepatitis B infection 3-5% of adult- 95% of infant- acquired infections acquired infections Chronic HBV infection Chronic hepatitis 12-25% in 5 years Cirrhosis 6-15% in 5 years 20-23% in 5 years Hepatocellular Liver failure carcinomaDeath Liver transplant Death
Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms HBeAg anti-HBe Total anti-HBcTitre HBsAg IgM anti-HBc anti-HBs 0 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure
Acute HBV Infection with Progression toChronic Infection: Typical Serologic Course Acute Chronic (6 months) (Years) HBeAg Anti-HBe HBsAg Total anti-HBc IgM anti-HBc 0 4 8 12 16 20 24 28 32 36 52 Years Weeks after Exposure
Hepatitis B virus HBV belongs to the Hepadnaviridae family of viruses. Diagram of hepatitis B virus. Hepatitis B surface Ag. Hepatitis core Ag. Hepatitis e Ag. HBV-DNA. HBV-DNA polymerase.
Laboratory Markers for HBV Infection Hepatitis B surface antigen (HBsAg): present in acute or chronic infection. It appears 4-12 week after infection Hepatitis B surface antibody (anti-HBs):marker of immunity acquired through natural HBV infection, vaccination, or passive antibody (immune globulin) , It appears 4-10 month after infection
Laboratory Markers for HBV Infection Hepatitis B core antibody (anti-H Bc): Ig M--indicative of infection in the previous six months, It appears 6-14 week after infection Ig G--indicative of more distant HBV infection that may have been cleared by the immune system or that may persist. positive HBsAg and anti-HB c Ig G--indicative of persistent chronic HBV infection
Laboratory Markers for HBV Infection Hepatitis B e antigen (HBeAg) :correlates with a high level of viral replication; often called a "marker of infectivity" Hepatitis B e antibody (anti-HBe):correlates with low rates of viral replication.It appears 8-16 week after infection HBV DNA:correlates with active replication; useful in monitoring response to treatment of HBV infection, especially in HBeAg-negative mutants
Interpretation of HBV Tests Test Result Interpretation
Test Result InterpretationHBsAg Negative Susceptible (not immune) toAnti-HBc Negative HBVAnti-HBs Negative infectionHBsAg Negative Immune because of naturalAnti-HBc Positive infectionAnti-HBs PositiveHBsAg Negative Immune because of hepatitisAnti-HBc Negative B vaccinationAnti-HBs PositiveHBsAg Positive Acute HBV infectionAnti-HBc PositiveIgM anti-HBc PositiveAnti-HBs NegativeHBsAg Positive Chronic HBV infectionAnti-HBc PositiveIgM anti-HBc NegativeAnti-HBs NegativeHBsAg NegativeAnti-HBc PositiveAnti-HBs Negative
Possible Interpretations:(1) patient may be recovering from acute infection;(2) patient may be distantly immune--testing does not detect very low level of anti-HBs;(3) patient may be susceptible, with a false- positive anti-HBc; or(4) there may be an undetectable level of HBsAg in the serum, and the patient is actually a carrier
Diagnostic criteria for HBV infection Acute Infection Acute HBV infection is subclinical in 70 percent of adults and 90 percent of children younger than five years. The incubation period after infection lasts one to four months. Symptoms of acute HBV infection include nausea, anorexia, fatigue, low-grade fever, and right upper quadrant or epigastric pain. Clinical jaundice appears as constitutional symptoms are resolving
Hepatic transaminase levels [ALT] and [AST]) reflect hepatocellular injury and range from several hundred to 20,000 IU per L. Serum bilirubin values are usually less than 20 mg per dL (342 µmol per L). Mild anemia is common, as is relative lymphocytosis. More severe disease results in an elevation in the prothrombin time and a decrease in the serum albumin level. HBV is not cytopathic, and liver injury is caused by the hosts immune response against infected hepatocytes
Diagnostic criteria for HBV infectionChronic disease HBsAg positive for longer than six months. Serum HBV DNA > 100,000 copies per mL. Persistent or intermittent elevation of alanine transaminase and aspartate transaminase levels Liver biopsy showing chronic hepatitis
Inactive HBsAg carrier state HBsAg positive for longer than six months. HB e Ag negative, anti-HB e positive Serum HBV DNA < 100,000 copies per mL Persistently normal alanine transaminase or aspartate transaminase levels Liver biopsy to confirm absence of significant hepatitis
Resolved disease History of acute or chronic hepatitis B. Presence of anti-HBc, with or without anti-HBs HBsAg negative Normal alanine transaminase level
CASE 1A 25-yr-old male patient presented to your clinic for pre-employment evaluation and his lab results show the following :HBsAg Negative, Anti-HBc Negative,Anti-HBs Positive.What is your interpretation of his lab results?
Immune because of previous hepatitis B vaccination.
Case 2: A 35 years old man presented with complain of fever, abdominal pain associated with nausea. Investigations showed : CBC : HB 10.5 g%, WBC 8.5, ESR 100, CRP 20 mg/dl . LFT : bilirubin 14 mg/dl , AST (SGOT) 900 u/L, ALT (SGPT) 1500 u/l. Hepatitis profile: HBsAg –ve, Anti HBc IgM –ve, HBeAg +ve, Anti HBs –ve. VDRL +ve.QUESTION:1. What is your interpretation?2. Explain your findings.
Answer : Acute recent hepatitis infection, HBsAg should be positive but in occasional cases it appears later than the HBe Ag. You should repeat the test to detect the HBsAg . VDRL is false positive. Hepatitis is one of the causes of false positive VDRL.
Case 3: A 30 years old healthy hospital worker reported to check the results of his hepatitis screening test: HBsAg –ve. Anti HBs +ve. Anti HBc +ve. HBe Ag -ve. Anti HBe -ve. Anti HCV -ve QUESTION: Interpret this test.
Answer: Past hepatitis infection. Immune and not infective
Case 4: A 20 years old reported for pre-employment examination and investigations, all his systems were free apart from 2cm BCM hepatomeglay and he reported a painless lesion on his penis since 2 weeks. Investigations: CBC HB 12.5mg%, WBC 12.5. LFT : ALT 120 u/l, AST 100 u/l, Alk Phos 300 u/l. Hepatitis profile: HBsAg +ve, Anti HBc IgG +ve, HBe Ag +ve , Anti HBs –ve. HBDNA >100.000 copies. VDRL –ve. Question: How would you interprete this tests. What is the diagnosis?
Answer : Chronic persistent hepatitis, did not develop immunity yet still infective. ? First stage Syphlitic lesion with –ve VDRL in early phase . Needs : Repeat LFT and hepatitis profile regularly. Liver US and liver biobsy. Repeat VDRL after 1 week, if +ve, perform the TP specific tests. Do HIV screening and screen for other STD
Case 5: A 25 years old female who had an attack of fever and epigastric pain 3 months ago, her husband was found to be hepatitis positive. She presented to check her investigations she did last week. CBC HB 10.5 g%, WBC 7.8, ESR 30 LFT ALT 70 U/l , AST 85 U/l, alk phosp 120 U/l Hepatitis profile: HBsAg –ve ,anti HBc+ve , HBeAg –ve , anti HBs –ve. Question:1. How would you interpret her findings?2. What is your next step?
Case 6 A 26 years old woman seen by her GP because she was jaundiced and feeling unwell. She had a history of drug addiction.A hepatitis screen was done, the results are: Anti-HAV NEGATIVE. Anti HBs POSITIVE. Anti-HbsAg NEGATIVE. HbsAg NEGATIVE. Hbe Ag NEGATIVE Anti-HCV NEGATIVE. Anti-HBc POSITIVE.
Questions Which of the following is the most likely cause of her jaundice.A. Acute hepatitis C.B. Chronic hepatitis B and acute hepatitis C.C. Hepatitis ED. Chronic Hepatitis EE. Acute hepatitis B
Answer 6 The picture suggests previous exposure TO hepatitis B but this would not give a clinical picture of jaundice, so another cause needs to be considered. History of drug addiction suggest hepatitis C. Antibody against hepatitis C takes about 3 months, the PCR testing is test used to reach the diagnosis in the acute phase.
Question 7During pre-employment screening. A 26 year old male has the followinghepatitis serology HBs Ag negative HBs Ab positive Hbe Ag negative Hbe Ab positive HBc Ab positive A.What is your interpretation ?