ACUTEVIRALHEPATITIS

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 DEFINITION

AninflammatorydiseaseoftheLiverwhichisusually
associated with complete clinical andhistological
recoverywithinaperiodof46weeks

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 CAUSES
Asacomponentof
multisystemdisease
Hepatotropicviruses Herpessimplexvirus(HSV)
HepatitisA Cytomegalovirus(CMV)
HepatitisB EpsteinBarrvirus(EBV)
HepatitisC Varicellazostervirus,
HepatitisD,and HIV,
HepatitisEviruses Rubella,
Adenoviruses
Enteroviruses,
ParvovirusB19,and
Arboviruses
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 HEPATOTROPICVIRUS

Heterogeneousgroupofinfectiousagentsthatcause
similaracuteclinicalillness.
Usually the acute phase causes no or mildclinical
disease.
Morbidity is related to rare cases of acuteliver
failure(ALF)triggeredinsusceptiblepatientsandto
thechronicdiseasestateandcomplications(hepatitis
B,C,andD)cancause.

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FEATURESOFHEPATOTROPICVIRUS

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 PATHOGENESIS

Direct cytopathic and an immunemediatedinjury

involvingentireliver.
Necrosisisusuallymostmarkedinthecentrilobular
areas.
An acute mixed inflammatoryinfiltrate
predominatesintheportalareasbutalsoaffectsthe
lobules.
Bileductproliferation
Diffuse Kupffer cell hyperplasia is noticeable inthe
sinusoids

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 HEPATITISAINFECTION

Spherical,nonenvelopedEnterovirusofPicorna
virideafamily
EndemicinIndiaandinmostdevelopingcountries.
AccordingtoWHOabout1050personsper1,00,000
areinfectedannuallyandinIndia
5075percentofacutesporadichepatitisinchildren
isduetoHAV

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 HAVishighlycontagious
Faecooralrouteeitherduetoconsumptionof
contaminatedfoodorwater.
ThemeanincubationperiodforHAVis 3wk.
Fecalexcretionofthevirusstartslateinthe
incubationperiod,reachesitspeakjustbeforethe
onsetofsymptoms,andresolvesby2wkafterthe
onsetofjaundiceinoldersubjects.
Infantslongerdurationofexcretion

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 CLINICALMANIFESTATION

Acutehepatitisyellowishdiscolorationofface,body,
sclera,nails,urine
Nausea,vomiting,lowgradefever
Enlargementofregionallymphnodesandspleen
Excellentprognosis

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 DIAGNOSIS

SerumBilirubinincreased,directfraction
SGOT/SGPTupto20times,butdoesnotcorrelate
withdegreeofhepaticinjury
Prothrombintimeimportantpredictorforsevere
infection.
AntibodiestoHAV(IgM)detectedattheonsetof
symptoms,remainpositiveupto46months
StoolPCRviralparticles(notroutinelydone)

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 DIAGNOSIS

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 COMPLICATIONS

AcuteLiverfailureRare
Risk factors for ALFAdolescents,Adults,
immunocompromised&
childrenwithchronicliverdisease
Prolonged cholestatic syndromeresolveswithout
anysequelae

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 EXTRAHEPATICCOMPLICATIONS
Aplasticanemia,Neutropenia
Rarely.Acutepancreatitis,myocarditis,nephritis,
arthritis,vasculitis,andcryoglobulinemiafrom
circulatingimmunecomplexes

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 PREVENTION

Generalmeasurestoimprovehygiene
Handwashing
Cleandrinkingwater&hygienicpreparationoffood
Boilingfor5minkillsthevirus
Sanitation

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 IMMUNIZATION

Activeimmunization
IAPrecommendstwodoses6monthsapartafter1
yearofage
Mandatoryriskgroups
Immunocompromised
Chronicliverdisease
Contactsofinfectedpersonswithin10days

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 PASSIVEIMMUNIZATION

Immunoglobulin0.02ml/kg
withintwoweeksafterexposuretoHAV.
Indicatedfor
NewbornsofHAVinfectedmothers
Childrenwithchronicliverdiseasewhoare
exposedtoHAV.
Theprotectionisimmediate,effectivebuttemporary

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 HEPATITISBINFECTION

Globalcommunicabledisease

Globalprevalenceisdividedinto3zonesbasedonthecarrier
state

lowzone :<2%
intermediatezone:27%

highzone:>7%

Indiacomesunderintermediatezone(35%)

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DoublestrandedDNAhepAdnavirus

DaneparticleVIRION42nm

3antigens
HBsAg(surfaceAg)

HBcAg(coreAg)

HBeAg(nucleocapsidantigen)
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 PATHOGENESIS

Causesinjurymostlybyimmunemediatedprocesses
The severity of hepatocyte injury reflects thedegree
oftheimmuneresponse
The first step in the process of acute hepatitisis
infection of hepatocytes by HBV, resultingin
expressionofviralantigensonthecellsurface.
The most important of these viral antigensthe
nucleocapsidantigensHBcAgandHBeAg.

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 PATHOGENESIS

Theseantigens,incombinationwithclassImajor
histocompatibility(MHC)proteins,makethecella
targetforcytotoxicTcelllysis

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 ROUTESOFTRANSMISSION

HBVpresentinbloodandbodyfluids
(saliva,breastmilk,nasopharyngealsecretions)ofinfectedpersons

Bloodandbloodproducts

Contactwithinfectedandbodyfluidsthroughscratchescuts,bites
orrashes

(infectivedoseextremelyminutejust0.00001ml)

Sexualactivity

Verticaltransmission

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 VERTICALTRANSMISSION

PerinataltransmissionfromHBsAgcarriermothers
to their infants is the most important routeof
transmissionofhepatitisBinchildren

Risk is greatest if mother is also HBeAg+ve

upto90%

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 CLINICALMANIFESTATIONS

Incubationperiod6weeks6months

Coursemaybeacute,chronicorfulminant

Acutehepatitis

SymptomssimilartohepatitisAfever,vomiting,
jaundice,anorexiaetc

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 EXTRAHEPATICMANIFESTATIONS

Arthralgia
Rash
Papularacrodermatits
Gianotticrostisyndrome
Polyateritis
GlomerularNephritis
Aplasticanemia

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 NATURALHISTORYOFHBVINFECTION

Carrierstateriskofchronicityinverselyproportionatetothe
ageofacquisitionoftheillness
adults:10%
children:20%
newborns:90%
Chronichepatitis

Subacutehepaticfailure

Cirrhosis

Hepatocellularcarcinoma

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NATURALHISTORYOFHBVINFECTION

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 SEROLOGICMARKERS

RoutinescreeningforHBVinfectionrequires
assayof3serologicmarkers
HBsAg,antiHBc,antiHBs.

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 HBsAg

Firstserologicmarkerofinfectiontoappear
Foundinalmostallinfectedpersons
Risecloselycoincideswiththeonsetofsymptoms.
Persistence of HBsAg beyond 6 mo definesthe
chronicinfectionstate
During Recovery from Acute infection HBsAglevel
wanesbeforesymptoms

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 HBeAg&AntiHBeantibody

HbeAgmarkerofactiveviralreplication
AntiHbe
Marksimprovementandisagoaloftherapyin
chronicallyinfectedpatients

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 AntiHBcAb

BothantiHBsandantiHBcaredetectedinpersons
withresolvedinfection.

PersonsimmunizedonlyAntiHBsABispresent

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SEROLOGICMARKERS

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 TREATMENT

Acutehepatitis
Onlysymptomaticandsupportive
Monitorforliverfailureandextrahepaticmorbidities

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 TREATMENTCHRONICHEPATITIS

GOAL
ReduceviralreplicationundetectableviralDNA
Indicatedforthosechildrenwithimmuneactive
formofinfectionwithundergoinginflammationand
fibrosisputtingthechildinriskofCirrhosis
DRUGS
Interferon2b(IFN2b)
Lamivudine
Adefovir
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 PREVENTION

Activeimmunization PassiveImmunization
Universalimmunization HBIG
Zerodosefornewborns Thosewhoareexposed
3doses toHBV+blood
0,1m,6m BabiesborntoHB+
0,6w,10w mothers
6w,10w,14w Within12hrsofbirth
0.5mlIM

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 HEPATITISCINFECTION

Bloodborneinfection
AcuteHCVmildandinsidiousinonset
ALFrarelyoccurs
ChronicHCVinfectionHCVisthemostlikelytocause
chronicinfectionwhichisclinicallysilentuntila
complicationdevelops.
Extrahepaticmanifestations(adults)cutaneousvasculitis,
peripheralneuropathy,cerebritis,membranoproliferative
glomerulonephritis,andnephroticsyndrome.Antibodiesto
smoothmuscle,antinuclearantibodies,andlowthyroid
hormonelevelsmayalsobepresent.

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NATURALHISTORYOFHCVINFECTION

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 PREVENTION

Novaccines

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 HEPATITISDINFECTION

HDVcancauseaninfectionatthesametimeasthe
initialHBVinfection(coinfection),orHDVcaninfect
apersonwhoisalreadyinfectedwithHBV(super
infection).

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 CLINICALFEATURES

Incoinfectionacutehepatitis,whichismuchmore
severethanHepBalone
Buttheriskofdevelopingchronichepatitisislow.
Insuperinfectionacuteillnessisrareandchronic
hepatitisiscommon.
TheriskofALFishighestinsuperinfection.
HepatitisDshouldbeconsideredinanychildwho
experiencesALF.

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 Treatmentsymptomatic

Novaccinesavailable

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 HEPATITISEINFECTION

RNAvirus,nonenvelopedsphereshapewithspikes
andissimilarinstructuretothecalicivirus
TheclinicalillnessassociatedwithHEVinfectionis
similartothatofHAVbutisoftenmoresevere.
NOchronicillnessdoesnotoccurbut
decompensationofpreexistingCLD
Majorpathogeninpregnantwomen,andcausesALF
withahighfatalityincidence

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 Nodefinitetreatment
Supportivemeasures
Novaccines

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ThankYou

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