Medicine 6th year, Acute Viral Hepatitis

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September 10th, 2011

September 10th, 2011

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  • 1. Viral Hepatitis Assistant Professor Dr.Mohammed Omer
  • 2. A Long History of Human Misery
    • 500 B.C. written accounts of jaundice in Babylonia
    • 400 B.C. Hippocrate s describes “epidemic jaundice”
    • 1883 jaundice noted to occur after inoculation of human sera
    • 1941 post-vaccination jaundice occurs in >28,000 U.S. soldiers
    • 1947 infectious hepatitis designated Hepatitis A; serum hepatitis designated Hepatitis B
    • 1963 Hepatitis B Surface Antigen identified
    • 1973 Hepatitis A identified by electron microscopy
    • Mid-1970’s Hepatitis D recognized
    • Mid-1970’s Non-A, Non-B hepatitis described
    • Mid-1980’s epidemics of “non-hepatitis A” enteric hepatitis
    • 1989 Hepatitis C cloned and serological tests developed
    • 1990 Hepatitis E cloned and characterized
  • 3. Etiology
    • Major agents:
    • HAV
    • HBV
    • HCV
    • HDV
    • HEV
    • HGV
    • TTV
    • HFV ?
  • 4. Etiology
    • Minor agents:
    • EBV,CMV
    • HSV,VZV
    • Rubella,Measles
    • Coxsackie B
    • Adenovirus
  • 5.  
  • 6. Transmission HAV HBV HCV HDV HEV Fecal-oral + - - - + Percutan. + + + + - Perinatal - + + + - Sexual + + + + -
  • 7. Epidemiology
    • HAV :fecal-oral HEV: fecal-oral
    • Rarely bloodborne
    • HBV :percutaneous contact
    • Mucous membrane contact
    • Sexual contact
    • Perinatal:third trimester and
    • 2 months postpartum
    • HDV : like HBV
  • 8. Epidemiology
    • HCV:
    • Percutaneous transmission
    • Transfusion(0.1 %),needle stick(1.8 %)
    • Mucousal transmission (rare)
    • Sexual transmission is rare(monogamy) Perinatal transmission is uncommon
    • (HIV coinfection,less than 5 % )
  • 9. Sexual transmission of HCV
    • Multiple sexual partner
    • HIV and STD
    • Anal sex
    • Open sore
    • Sex during menstruation
  • 10. Sources of infection for persons with newly-diagnosed Hepatitis C Sexual 15% Other* 5% Unknown 10% Injection drug use 60% Transfusion 10% (before screening) * Nosocomial Health-care work Perinatal CDC
  • 11. Hepatitis C Factors Associated with Disease Progression
    • Age > 40
    • Male
    • Alcohol > 50 gm/d
    • Immunosuppression: HIV, transplant, etc.
    • Infection by blood transfusion
    • Co-infection with HBV
    • Genotype 1
  • 12. Pathology
    • Infiltration of mononuclear cells
    • Hepatic cells necrosis
    • Kupfer cells hyperplasia
    • Variable degrees of cholestasis
    • In more severe cases;
    • Bridging necrosis
  • 13.  
  • 14. Clinical Stages
    • Incubation period
    • Prodromal (preicteric) phase
    • Icteric phase
    • convalescence
  • 15. Variation in staging
    • Asymptomatic
    • Anicteric
    • Fulminant
    • Chronic
  • 16. Incubation Period
    • HAV:15-45 days(30)
    • HBV: 30-180 days(60-90)
    • HCV: 15-160 days(50)
    • HDV: 30180 days(60-90)
    • HEV: 14-60 days(40)
  • 17. Incubation Period
    • Considerable overlap
    • Asymptomatic period
    • Viral replication& Shedding
  • 18. Preicteric Phase
    • Systemic &nonspecific symptoms
    • Flue like &Dyspepsia:
    • Fever,sore throat,cough,headache
    • Fever,anorexia,malaise,nausea
    • Vomiting,abdominal pain,ditate to cigarrete
    • Duration : 1-2 weeks
  • 19. Icteric Phase
    • Clinical jaundice
    • Dark urine:1-5 days before jaundice
    • Patient may feel better
    • Resolution of fever
    • pruritus
  • 20. Icter
  • 21. Icter
  • 22. Icter
  • 23. Icteric Phase
    • Liver is enlarged,tender
    • Cervical adenopathy(10-20%)
    • Splenomegaly(10-20%)
    • Fever is absent
    • Venopuncture site
    • Encephalopathy :Irritability
    • Letargy,confusion
  • 24. Convalescence
    • Resolution of symptoms
    • Liver is enlarged
    • Pruritus
    • Complete recovery:
    • 1-2 months A,E
    • 3-4 months B,C (3/4)
  • 25. Laboratory Findings
    • CBC:leukopenia,lymphocytosis
    • Atypical lymphocyte,
    • Normal Hb;except hemorrage
    • Normal platelet;except DIC
    • ESR is normal
  • 26. Laboratory Findings
    • Serum bilirubin:5-20 mg/dl
    • Direct bil =indirect bil
    • SGOT,SGPT=400-4000 iu
    • Alk.phosphatase :mild elevation
    • PT is usually normal:in severe
    • hepatitis,PT is prolonged
    • Hypoglycemia
  • 27.  
  • 28.  
  • 29. Serologic Diagnosis
    • Ig M anti-HAV
    • HBs Ag and Ig M anti-HBc
    • HCV Ab,HCV RNA PCR
    • anti-HDV
    • anti-HEV
  • 30. Complications
    • Hepatitis A:Relapsing hepatitis
    • Cholestatic hepatitis
    • Hepatitis B:serum sickness
    • Chronicity:HBV,HCV,HDV
    • fulminancy:HAV,HBV,HDV,
    • HEV
  • 31. Progression of Acute to chronic Hepatitis
    • Lack of resolution of symptoms W.Loss,fatigue,anorexia,hepatomegalyFailure of Bil. ,LFT,Glu to normal (Within 6-12m)
    • Persistence HBs Ag beyond 6 m or HBe Ag beyond 3 m
    • Presence of bridging or multilobular necrosis
  • 32. Management
    • Indication of admission:
    • Bilirubin>20 mg/dl
    • Hypoglycemia
    • Abnormal PT
    • Hypoalbuminemia
  • 33. Management
    • CBR is not mandatory
    • Restriction activity
    • No special diet &Therapy(HCV ? )
    • Drug &Alcohol avoidance
    • Isolation is not necessary
    • except special cases
  • 34. Prevention
    • Hand washing ,hygiene
    • Universal precaution
    • No sharing of personal items
    • (razor, toothbrush, nail clipper)
    • Sexual barrier
  • 35. prevention
    • HAV:
    • Pre-exposure prophylaxis:
    • Vaccine ,SIG:0.02 cc/kg
    • Post-exposure prophylaxis:
    • SIG:0.02 cc/kg ;For day care centers, family members
    • Vaccine ?
  • 36. Prevention
    • HBV:
    • Pre-exposure prophylaxis:
    • Vaccine :months 0,1,6
    • Booster is not recommended
    • Post-exposure prophylaxis:
    • HBIG:0.06 cc/kg and complete
    • course of vaccine
  • 37.  
  • 38.  
  • 39. Who should be vaccinated?
    • Everyone 18 years of age and younger
    • over 18 years of age who are at risk for HBV infection, which include :
    • sexually active heterosexual adults with more than one sex partner in the prior 6 months, or have a history of sexually transmitted disease.
    • Homosexual and bisexual men
    • drug users
    • person at occupational risk of infection
    • hemodialysis patients
    • household and sex contacts of persons with chronic HBV infection
  • 40. Prevention
    • Post-exposure prophylaxis in
    • vaccinated person :
    • Responder: No treatment
    • Nonresponder :HBIG+Vaccine(3) OR
    • HBIG (2) in one month
    • Response: anti-HBs>10miu/ml
  • 41. Prevention
    • Ab response unknown:
    • Check anti-HBs;
    • If adequate : no treatment
    • If inadequate : HBIG(1) +
    • vaccine(1)
  • 42. FACTS:
    • Hepatitis B can be prevented with a safe and effective vaccine.
    • You can not get hepatitis B from the hepatitis B vaccine.
    • Hepatitis B virus infects nearly 80,000 people in U.S each year
    • even if a person infected with Hepatitis B virus does not feel sick , he or she can still infect others
  • 43. FACTS:
    • Medicare will pay up to 80% of the cost for hepatitis B vaccination for qualifying individuals
    • Hepatitis B killed over 5,000 in the U.S in 1999
    • HBV is found in blood and other body fluids such as semen and vaginal secretions, it is 100 times more infectious than HIV
    • the hepatitis B vaccine is recognized as the first anti-cancer vaccine , because it can prevent primary liver cancer caused by hepatitis B infection.
  • 44. Post exposure prophylaxis
    • HCV :no treatment
    • HEV : no treatment
  • 45. Local Data
    • Healthy carrier;
    • HBV; 2.3 %
    • HCV; 1.2 %
    • Premarital Screening-HBsAg ; 200-350 /year
  • 46. THANK YOU