The document describes three case studies of patients presenting with hepatitis. The first case involves a man who returned from Thailand with fatigue, nausea and abdominal discomfort. The second case is a pregnant woman who was a former heroin addict and had shared needles. The third case is a man who developed jaundice six months after coronary bypass surgery. The document then provides information about hepatitis A, B and C viruses, including their structures, modes of transmission, clinical presentations and approaches to diagnosis.

1. Fe A. Bartolome, MD, FPASMAP Department of Microbiology Our Lady of Fatima University

2. CASE 1: A 55-year old man was admitted to the hospital with fatigue, nausea, and abdominal discomfort. He had a slight fever, his urine was dark yellow, and his abdomen was distended and tender. He had returned from a trip to Thailand within the previous month.

7. HEPATITIS A (Infectious Hepatitis)

11. Approach to Diagnosis Hepatitis A (HAV) IgM anti-HAV Negative Positive Assay “total” anti-HAV as clinically indicated (-) Not immune to HAV Acute HAV infection (+) Immune to HAV

15. CASE 2: A 28-year-old woman was admitted to the hospital complaining of vomiting, abdominal discomfort, nausea, anorexia, dark urine, and jaundice. She admitted that she was a former heroin addict and that she had shared needles . She was also three months pregnant.

25. Spread of virus: HEPATITIS B (Serum Hepatitis) Source Infection Blood Ab Prevent spread and disease Liver Viremia CMI Symptoms, Resolution HBsAg Ab Immune complexes Immune complex disease Mother’s milk Vaginal secretions Blood Semen Saliva Rash, polyarthritis, fever, GN

26. Symptoms of typical acute HBV infection: Fever, rash, arthritis (15%) Jaundice Dark urine Malaise (95%) Anorexia (90%) Nausea (80%) RUQ pain (60%) Itching (10%) EXPOSURE Incubation Period Pre-icteric Icteric Convalescent period

27. Clinical outcomes of acute HBV infection: Fulminant hepatitis (1%) HBsAg+ > 6 mos (9%) Extrahepatic disease: Polyarteritis nodosum Glomerulonephritis Cirrhosis Hepatic cell carcinoma

29. Approach to Diagnosis of HBV infection Hepatitis B (HBV) HBsAg Negative Positive Assay anti-HBs (total) (-) Consider immunization for appropriate populations Assay IgM anti-HBc (+) Recovered or immunized (-) Chronic HBV infection (+) Acute or reactivated HBV infection

32. Serologic test results in four stages of HBV infection 1 IgM is found in the acute stage; IgG is found in subsequent stages.

33. How will you know if you are protected from HBV? Quick Test Results Results Interpretation HBsAg (+) Anti-HBs (-) Chronic HBV infection if HBsAg remains (+) for six months HBsAg (-) Anti-HBs (+) Immune to HBV HBsAg (-) Anti-HBs (-) Unprotected; need vaccination HBsAg (+) Anti-HBs (+) (rare) Chronic HBV infection

34. Simplified Diagnostic Approach in Patients Presenting with Acute Hepatitis Serologic Tests of Patient’s Serum Diagnostic Interpretation HBsAg IgM Anti-HAV IgM anti-HBc + + + + -- -- -- -- -- -- + + + + -- -- + -- -- + -- + + -- Acute hepatitis B Chronic hepatitis B Acute hep A superimposed on chronic HBV Acute hepatitis A and B Acute hepatitis A Acute hep A and hep B (HBsAg below detection level) Acute hepatitis B (HBsAg below detection level) Test for acute hepatitis C (anti-HCV)

35. Hepatitis B: Serologic Tests of Candidate for HBV Vaccine

36. CASE 3: A 65-year-old man was admitted with jaundice, nausea, and vomiting 6 months after undergoing coronary artery bypass grafting.

41. HEPATITIS C (NANB Post-transfusion Hepatitis) Recovery and clearance (15%) Persistent infection (85%) Chronic hepatitis Liver failure (6%) Cirrhosis (20%) Hepatocellular carcinoma (4%)

47. HEPATITIS D (“Delta Agent”) Consequences of HDV infection: Co-infection: HBV +  Incubation Superinfection: Chronic HBV +  Incubation Acute hepatitis Cirrhosis Fulminant hepatitis Chronic delta infection

49. Comparison of Types of HDV Infections

52. Important Properties of Hepatitis Viruses 1 Interrupted, circular dsDNA 2 Circular, negative-sense ssRNA

53. Comparative Features of Hepatitis Viruses

54. Comparative Features of Hepatitis Viruses