Medicine 6th year, Acute Viral Hepatitis

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September 10th, 2011

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Medicine 6th year, Acute Viral Hepatitis

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

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