Вы находитесь на странице: 1из 5

Pediatrics lecture 44, done by Mohammad Telfah

Hepatitis And Hepatitis A


-Today we will talk about hepatitis A and the approach for it. Hepatitis the word per
say means inflammation of the liver. It may be caused by infectious agents either
viral such as hepatitis viruses (A-F), HSV, Adenoviruses, EBV, CMV, Echoviruses. Or
bacterial such as typhoid, brucella. And Non-infectious causes such as autoimmune,
toxic, vascular, metabolic and others.
- Hepatitis A, B, C , D, E, Fare viruses belong to different viral groups. Hepatitis A
is RNA virus, while Hepatitis B is DNA virus. So they are heterogeneous.
Figure(1)

-From historical point of view (figure 1) it was


know that there is Hepatitis A, the infectious
one ( ) and hepatitis B, the serum one
or the non-infectious, and any other types were
called none-A none-B (NANB). then they could
define hepatitis C, which was called NANB, D, E
and other viruses. And know there are some viral
hepatitis without definite cause and they call it
NON-A,B,C,D,E,F,G.. hepatitis. Or hepatitis (X)!.

Viral Hepatitis - Historical


Perspective
Infectious

Viral hepatitis

Serum

Enterically
transmitted

NANB
Parenterally

B D

C transmitted
F, G,
? other

4-Jan-08

M.Miqdady, M.D.

Figure(2)

-From figure (2) you can note that:


- B & C are similar, they are transmitted
parenterallty and many cases of them
Viral Hepatitis - Overview
lead to chronic infections.
- A & E are similar they are transmitted
Type of Hepatitis
enterically and many cases lead to acute
A
B
C
D
E
viral hepatitis resolved easily.
Source of
feces
blood/
feces
virus
blood-derived like B
like B
- hepatitis E is very dangerous and
body fluids
fulminant in pregnancy, so it has high
Route of
fecal-oral percutaneous
fecal-oral
like B
like B
transmission
permucosal
mortality in pregnant lady.
Chronic
no
yes
yes
yes
no
- Hepatitis A is fecal-oral transmitted, and
infection
there is no chronic hepatitis A, all the
Prevention
pre/postpre/post- blood donor pre/post- ensure safe
exposure
exposure screening; exposure
drinking
cases are acute and resolved easily. And
immunization immunization risk behavior immunization; water
modification risk behavior
it can be prevented either by active
4-Jan-08
M.Miqdady, M.D.
10
modification
(vaccination) or passive (immunoglobulins)
immunity.
- Hepatitis E is similar to A but hepatitis E cant be prevented by immunization.
1

Pediatrics lecture 44, done by Mohammad Telfah

Hepatitis B and C they are transmitted through body fluids by cutaneous or by


mucosa, and they have chronic cases specially C which most of cases are
chronic. B can be prevented by active and passive immunization while C cant be
prevented by immunization.
D is dependent on B.

- (47%) of acute viral hepatitis cases are caused by hepatitis A , (34%) caused by
hepatitis B, (16%) by hepatitis C and about 3% are cased by Non-ABC.
- About (45%) of chronic viral hepatitis cases are cased by hepatitis C, (15%) by B,
(5%) by B&D. and about (35%) of chronic hepatitis cases are of unknown hepatitis
viruses. (NON-A, B, C, D, E, F, G). i.e. hepatitis X.
-So no chronic cases in hepatitis A, most of chronic cases are C, hepatitis B depends
on the age of the patient some one got Hepatitis B infection early, i.e. by vertical
transmition from his mother so s/he will mostly get chronic infection, while if some
one older got the infection, about 5-10% s/he will get chronic case.

**Hepatitis A virus:
- Hepatitis A virus is RNA virus belongs to picornavirus group. And each time you
hear, this is RNA virus this means it leads to acute bad disease, while DNA viruses
usually they lead to chronic bad diseases.
- It is highly endemic , has little genetic variability and it is resistant to usual
cleaning methods. So it is very contagious. It enters through the mouth replicates in
the intestine then goes to the liver where it undergoes its final replication, leads to
some viremia and then to the bile and excreted through the stool. And this excretion
through the bile happens two weeks before jaundice appears. So a patient has
jaundice today, he has been shedding the virus through his stool since two weeks, and
he will shed the virus for one week after the jaundice appearance.
- Virus doesnt injure the liver, it is the body immune response to get rid of the
infection which leads to the signs and symptoms of hepatitis. So anybody with low
immunity will not develop symptoms. For example about 99% of us had hepatitis A in
our life, but only 5 or 6 got jaundice, and this is because most of us were tolerant to
the virus and our bodies didnt fight it.
- Hepatitis A usually comes after eating undercooked or raw shellfish ( this is a
common USMLE question as dr. said)
-It is transmitted in:
Close personal contact (e.g., household contact, sex contact, child day care centers).
Contaminated food, water (e.g., infected food handlers, raw shellfish)
Blood exposure (rare),(e.g., injecting drug use, transfusion).

Pediatrics lecture 44, done by Mohammad Telfah

- Children are the major reservoir of the virus they are tolerant for it, so they infect
people although they are asymptomatic.
-The best way to prevent hepatitis A is good hygiene, second way vaccination. But
proper hygiene is the best way.
- Highest attack rates in 5-14 year olds.
- Persons at increased risk of infection are:
Individuals living in areas where hepatitis A is endemic.
Travelers to Less developed areas of the world where hepatitis A is common.
Homosexual men.
Injecting drug users.

**Clinical features of hepatitis A:


1- most of the cases are asymptomatic.
2- Jaundice
3- Low-grade fever
4- Nausea and vomiting.
- Incubation period of hepatitis A is 2-6 weeks, while hepatitis B is 2-6 months. And
for hepatitis C is 2 weeks- 6 months.! ( incubation periods in children is longer).
- appearance of Jaundice by age group:
6 yrs--------------- <10% develop jaundice.
6-14 yrs--------------40%-50%.
14 yrs --------------70%-80%.
Figure(3)

-To diagnose acute infection you have to see


the IgM , and if you see IgG this means that
this person either got the infection in the
past or s/he got the vaccine.

Hepatitis A Virus Infection


Serologic Course
Symptoms

Total anti-HAV

ALT

Titer

-In figure (3) the patient is infected at time


(0), and after 2-6 weeks incubation period
the infection starts, before two week of
symptoms appearance the patient is
shedding the virus in the stool. Then
symptoms appear and ALT starts to elevate,
first antibodies appear are IgM then IgG.

Fecal
HAV

0
4-Jan-08

IgM anti-HAV

M.D.
Months M.Miqdady,
after exposure

1
2

2
4

30

- The virus is found primarily in the feces, little in the serum and little in salivaso
the main source of transmittion is fecal oral route. (figure 4).

Pediatrics lecture 44, done by Mohammad Telfah

- Hepatitis A is diagnosis by anti-HAV IgM.


- Most of patients recovered in few weeks,
some of them got prolonged and relapsing
symptoms for six months.
- Treatment: it is supportive treatment fluid if
dehydrated, paracetamole. But there is no role
to the diet in treating hepatitis A infections,
no role for decreasing fat or carbohydrate
intakes in order to decrease jaundice.
- Patient with hepatitis A is admitted if he got:
1. Coagulopathy
2. Persistent vomiting & dehydration
3. Encephalopathy
4. WASTAH !!

Figure(4)

-We prevent spread by good hygiene, and giving the contacts immunoglobulins against
hepatitis A, specially if they share the same food or if they are in the daycare
center.

Age-specific Mortality Due to Hepatitis A


Age group
(years)

Case-Fatality

(per 1000)

<5
5-14
15-29
30-49
>49
Total

Figure(5)

3.0
1.6
1.6
3.8
17.5
4.1

0.41%

Source: Viral Hepatitis Surveillance Program, 1983-1989


4-Jan-08

M.Miqdady, M.D.

40

- Complications
are mainly
fulminant hepatitis, which leads to death in 0.41% of cases. (figure 5)
%1.0 ) 0111(

!! ! 01

*Hepatitis A Vaccine:
Inactivated virus.
After the age of 1 year.
Vaccines provide long-term protection.
One initial shot followed by a booster shot in about 6-18 months.
And if you dont want to give the vaccine to all people you can give it to Persons at
4

Pediatrics lecture 44, done by Mohammad Telfah

increased risk for infection and they are:


Travelers to HAV-endemic countries.
Homosexual and bisexual men
Drug users
Persons with chronic liver disease
Occupational risk !

Frequent exposure to blood products


- Communities with high rates of hepatitis A (e.g., Irbid!!!!, ,Alaska Natives,
American Indians)

- It is a very safe vaccine with minimum side effects.


**Immunoglobulins:
Standard pooled human serum globulin.
Neutralizes circulating HAV
Prevents viral attack on hepatocytes
Pre-exposure Immune Globulin
Travelers to intermediate & high HAV-endemic regions (no enough time to vaccinate)
Immune globulin administration, which is effective for about 3-6 months.
Post-exposure Immune Globulin:
Within 14 days
Routine
Household and other intimate contacts
Selected situations
Institutions (e.g., day care centers)
Common source exposure (e.g., food prepared by infected food handler


.... ..