Transcript hepatitis - FK UWKS 2012 C

HEPATITIS
Diah Puspita Rini, dr., SpPK
• Hepatitis is inflammation of the liver which
can be caused by viruses, medications, or
toxic agents.
• Non viral : miliary TB, staphylococcal
bacteriemia, salmonelloses, amebiasis,
drugs, etc.
• Viral hepatitis :, Hepatitis A,B,C,D,E
CMV, Herpes, Epstein Barr virus, Rubella
Viral Hepatitis
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1
Hepatitis
A Title
Click
to add
5
Hepatitis E
2
Hepatitis
B Title
Click to add
6
Hepatitis G
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Hepatitis TT
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Hepatitis Sen
3
Hepatitis C
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Hepatitis D
VIRAL HEPATITIS
A Major Public Health Problems
• Cause Morbidity & Mortality
• Chronic Hepatitis B & C
Liver
Cirrhosis
4
HCC
SYMPTOMS
a short, mild, flu-like illness
nausea, vomiting and diarrhoea
loss of appetite
weight loss
jaundice (yellow skin and white of eyes,
darker yellow urine and pale faeces)
itchy skin
abdominal pain
Type of Hepatitis
A
Source of
virus
Route of
transmission
Chronic
infection
Prevention
B
C
D
E
feces
blood/
blood/
blood/
blood-derived blood-derived blood-derived
body fluids
body fluids
body fluids
feces
fecal-oral
percutaneous percutaneous percutaneous
permucosal
permucosal
permucosal
fecal-oral
no
yes
pre/postexposure
immunization
pre/postexposure
immunization
yes
yes
blood donor
pre/postscreening;
exposure
risk behavior immunization;
modification risk behavior
modification
no
ensure safe
drinking
water
Hepatitis A (HAV)
• Due to non enveloped, single stranded
RNA picornavirus
• Serum AST and ALT increased to
hundreds for 1 to 3 weeks
• Relative lymphocytosis is frequent
Serologic test for HAV
• Ig M anti HAV :
– appears at the same time as syptoms in > 99% of
cases
– peaks within first month, becomes nondetectable in 12
(usually 6)
– Presence confirms diagnosis of recent acute infection
• Anti HAV total:
– Predominantly IgG
– Almost always positive at onset of acute hepatitis and
is usually detectable for life
– Found in ± 50% of population, indicaes previous
exposure to HAV
Hepatitis A Infection
Typical Serological Course
Total antiHAV
Symptoms
Titre
ALT
Fecal
HAV
IgM anti-HAV
0
1
2
3
4
5
6
Months after exposure
12
24
Hepatitis B (HBV)
• Due to enveloped, double stranded DNA
hepadna virus
• Divided into 3 stages:
1. Acute hepatitis: lasts 1-6 months, mild/ no
symptoms
 AST & ALT increased > tenfolds
 Serum bilirubin is usually normal or slightly
increased
 HBsAg gradually arises to high titer and persist,
HBeAg also appears
2. Chronic hepatitis: transaminase increased >
50% for > 6 months, most cases resolve but
some develop cirrhosis and liver failure
 AST & ALT fall to 2-10x normal range
 HBsAg usually remains high and HBeAg
remains present
3. Chronic carrier: are usually but not always
healthy and asymptomatic
 AST and ALT fall to normal or < 2x normal
 HBsAg positive > 6 months, HBc IgM negative,
but anti HBc positive
Hepatitis B Virus
Modes of Transmission
 Sexual - sex workers and homosexuals are
particular at risk.
 Parenteral - IVDA, Health Workers are at
increased risk.
 Perinatal - Mothers who are HBeAg positive
are much more likely to transmit to their
offspring than those who are not. Perinatal
transmission is the main means of
transmission in high prevalence populations.
Concentration of Hepatitis B
Virus in Various Body Fluids
High
Moderate
blood
semen
serum
vaginal fluid
wound exudates
saliva
Low/Not
Detectable
urine
feces
sweat
tears
breastmilk
HBV : Structure
SEROLOGICAL TEST OF HBV
A battery of serological tests are used for the diagnosis of acute
and chronic hepatitis B infection.
• HBsAg - used as a general marker of infection.
• HBsAb - used to document recovery and/or immunity to HBV
infection.
• anti-HBc IgM - marker of acute infection.
• anti-HBcIgG - past or chronic infection.
• HBeAg - indicates active replication of virus and therefore
infectiveness.
• Anti-Hbe - virus no longer replicating. However, the patient can
still be positive for HBsAg which is made by integrated HBV.
• HBV-DNA - indicates active replication of virus, more accurate
than HBeAg especially in cases of escape mutants. Used mainly
for monitoring response to therapy.
Progression to Chronic Hepatitis B Virus
Infection Typical Serologic Course
Acute
(6 months)
Chronic
(Years)
HBeAg
anti-HBe
HBsAg
Total anti-HBc
Titre
IgM anti-HBc
0 4 8 12 16 20 24 28 32 36
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Weeks after Exposure
Years
Serologic diagnosis of viral hepatitis
Significance
HBsAg
HBeAg
Anti-HBc
Anti-HBc
Anti-HBs
IgG
IgM
IgG
Acute HBV
+
+
-
+
-
Chronic HBV,
+
+
+
-
-
+
-
+
-
-
Resolved HBV
-
-
+
+
-
Postvaccine
-
-
-
-
+
Active replication
Chronic HBV,
quiescent
Immune HBV
Quiescent = inactive = quiet
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Possible Outcomes of HBV Infection
Acute hepatitis B infection
3-5% of adultacquired infections
95% of infantacquired infections
Chronic HBV infection
Chronic hepatitis
12-25% in 5 years
6-15% in 5 years
Cirrhosis
Hepatocellular
carcinoma
Death
20-23% in 5 years
Liver failure
Liver transplant
Death
Prevention
• Vaccination - highly effective recombinant vaccines are now
available. Vaccine can be given to those who are at increased risk
of HBV infection such as health care workers. It is also given
routinely to neonates as universal vaccination in many countries.
• Hepatitis B Immunoglobulin - HBIG may be used to protect
persons who are exposed to hepatitis B. It is particular efficacious
within 48 hours of the incident. It may also be given to neonates
who are at increased risk of contracting hepatitis B i.e. whose
mothers are HBsAg and HBeAg positive.
• Other measures - screening of blood donors, blood and body fluid
precautions.
HEPATITIS C (HCV)
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Risk Factors Associated
with Transmission of HCV
 Transfusion or transplant from infected donor
 Injecting drug use
 Hemodialysis (yrs on treatment)
 Accidental injuries with needles/sharps
 Sexual/household exposure to anti-HCVpositive contact
 Multiple sex partners
 Birth to HCV-infected mother
HCV INFECTION
INCUBATION
1
PERIOD
6 -7 WEEKS
ACUTE
2
INFECTION
60 -80% ASYMPTOMATIC
20- 30% WITH JAUNDICE
(Range 2 – 26 weeks)
80 -85%
CHRONIC HEPATITIS
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Hepatitis C Virus Infection
Typical Serologic Course
anti-HCV
Symptoms
Titre
ALT
Normal
0
1
2
3
4
Months
5
Time after
Exposure
6
1
2
3
Years
4
PROGRESSION
• ACUTE HEPATITIS C
– 15-40% will spontaneously resolve, generally
within the first 6-18 months after acute onset.
– 60-85% will progress to chronic infection
• CHRONIC
– 85-90% stable
– 10-15% progress to cirrhosis
PROGRESSION
• CIRRHOSIS
– 75% slowly progressive
– 25% progress to HCC
– 2-4% liver failure
• HCC
Factors of poor prognosis:
-Age >40 years
-Alcohol > 50g/Hour
-Male gender
-Duration of infection
-Co-infection HBV/HIV
-Tobacco consumption
– Risk increases for every year for a patient
with chronic hepatitis C.
– Patients without signs of cirrhosis can develop
HCC
Diagnosis
of HCV Infection
Indirect tests:
detect
antibody
against HCV
1. Anti HCV
2. RIBA
(recombinant
immunoblot assay)
Direct tests :
components of the
HCV particle
1.HCV RNA(PCR)
• Qualitative
• Quantitative
2. HCV Core antigen
Usefull in detecting
window peroid
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Prevention of Hepatitis C
 Screening of blood, organ, tissue
donors
 High-risk behavior modification
 Blood and body fluid precautions
HEPATITIS D
• Double stranded enveloped RNA virus
• Depends upon HBV for expression and replication
• Often severe with relatively high mortality in acute
disease and frequent development of cirrhosis in
chronic disease
• Chronic HDV inf. Is more severe and higher
mortality rate than other types of viral hepatitis
• Serologic test :
Anti HDV in px with HBsAg positive hepatitis
HEPATITIS E
• Unveloped, single stranded enveloped RNA virus
• Endemic area: Mexico, India, Africa, Burma, Russia
• Serologic test:
- Antibody to hepatitis E establish dx.
- IgM antibodies indicate recent infection
- Serologic markers for HVA, HBV, HCV and other cause
of acute hepatiti are absent
Soal Kasus
• Laki2 datang dengan keluhan demam 14
hari, sklera tampak ikterus, nyeri tekan
abdomen kanan atas
• Pemeriksaan Lab apa yg anda usulkan?
– HBsAg (-)
– HBsAb (+)
– IgM anti HAV (+)
– anti HBc (-)
• Apa diagnosis pasien ini?
??QUESTIONS??