Hepatitis ppt

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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Hepatitis A1

2

3

4

Hepatitis E5

Hepatitis G6

Hepatitis TT7

Hepatitis Sen8

Hepatitis B

Hepatitis D

Hepatitis C

VIRAL HEPATITIS

4

Liver Cirrhosis

A Major Public Health ProblemsA Major Public Health Problems

• Cause Morbidity & Mortality• Chronic Hepatitis B & C

HCC

a short, mild, flu-like illnessnausea, vomiting and diarrhoealoss of appetiteweight lossjaundice (yellow skin and white of eyes, darker yellow urine and pale faeces)

itchy skinabdominal pain

SYMPTOMS

Source ofvirus

feces blood/blood-derived

body fluids

blood/blood-derived

body fluids

blood/blood-derived

body fluids

feces

Route oftransmission

fecal-oral percutaneouspermucosal

percutaneouspermucosal

percutaneouspermucosal

fecal-oral

Chronicinfection

no yes yes yes no

Prevention pre/post-exposure

immunization

pre/post-exposure

immunization

blood donorscreening;

risk behaviormodification

pre/post-exposure

immunization;risk behaviormodification

ensure safedrinking

water

Type of HepatitisA B C D E

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

FecalHAV

Symptoms

0 1 2 3 4 5 6 12

24

Hepatitis A Infection

Total anti-HAV

Titre ALT

IgM anti-HAV

Months after exposure

Typical Serological Course

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

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.

Hepatitis B Virus

Modes of Transmission

High ModerateLow/Not

Detectable

blood semen urineserum vaginal fluid feces

wound exudates saliva sweat

tearsbreastmilk

Concentration of Hepatitis B Virus in Various Body Fluids

HBV : Structure

Hepatitis B Lab MarkersMarker Abbreviation Use

Hepatitis B surface antigen HBsAg Detection of acutely or chronically infected persons; antigen used in hepatitis B vaccine

M class immunoglobulin antibody to hepatitis B core antigen

IgM Anti-HBc Identification of acute or recent HBV infections (including those in HBsAg-negative persons during the “window” phase of infection)

Antibody to hepatitis B core antigen

Anti-HBcHBcAb

Identification of persons with acute, resolved, or chronic HBV infection (not present after vaccination)

Antibody to Hepatitis B surface antibody

Anti-HBs HBsAb

Identification of persons who have resolved infection with HBV; determination of immunity after immunization

Hepatitis B e antigen HBeAg Identification of infected persons at increased risk for transmitting HBV

Antibody to Hepatitis B e antigen

Anti-HBe HBeAb

Identification of infected person with lower risk for transmitting HBV

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100

Acute Hepatitis B Virus Infection with RecoveryTypical Serologic Course

Weeks after Exposure

Titer

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100



Titer

HBV DNA

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100



Titer

HBV DNA

HBeAg

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100



Titer

HBeAg anti-HBe

HBV DNA

IgM anti-HBc

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100



Titer

HBeAg anti-HBe

Symptoms

HBV DNA

IgM anti-HBc

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100



Titer

HBeAg anti-HBe

Symptoms

Total anti-HBc

HBV DNA

IgM anti-HBc

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100



Titer

HBeAg anti-HBe

Symptoms

anti-HBs

Total anti-HBc

HBV DNA

IgM anti-HBc

HBsAg

0 4 8 12 16 20 24 28 32 36 52 100



Titer

HBeAg anti-HBe

Symptoms

anti-HBs

Total anti-HBc

HBV DNA

Window Period

IgM anti-HBc

Total anti-HBc

HBsAg

Acute(6 months)

HBeAg

Chronic(Years)

anti-HBe

0 4 8 12 16 20 24 28 32 36 52 Years


Titre

Progression to Chronic Hepatitis B Virus InfectionTypical Serologic Course

Acute vs. Chronic HBV Infection

Acute• HBsAg+ < 6 mos.• IgM anti-HBc + positive• Infection will resolve and person will have lifelong

immunity• HBsAb+ and HBcAb+

Chronic• HBsAg + for at least 6 months • Also known as a “carrier”• Infection does not resolve and the person

remains infectious• HBsAb- and HBcAB+

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Serologic diagnosis of viral hepatitis

Significance HBsAg HBeAg Anti-HBc IgG

Anti-HBc IgM

Anti-HBs IgG

Acute HBV + + - + -

Chronic HBV,

Active replication+ + + - -

Chronic HBV,

quiescent+ - + - -

Resolved HBV - - + + -

Postvaccine

Immune HBV

- - - - +

Quiescent = inactive = quiet

Possible Outcomes of Hepatitis B Infection

Possible Outcomes of Possible Outcomes of Hepatitis B InfectionHepatitis B Infection

Acute HBVinfection

Recovery

Chronic HBVinfection

Fulminanthepatitis

HBsAgcarrier

Reactivation

Cirrhosis

HCC

Chronic hepatitis BHBeAg-positive


HDVsuperinfection


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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Transfusion or transplant from infected donor Injecting drug use Hemodialysis (yrs on treatment) Accidental injuries with needles/sharps Sexual/household exposure to anti-HCV-

positive contact Multiple sex partners Birth to HCV-infected mother

Risk Factors Associated with

Transmission of HCV

HCV INFECTION

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1

6 -7 WEEKS (Range 2 – 26 weeks)

2

60 -80% ASYMPTOMATIC 20- 30% WITH JAUNDICE

80 -85%

CHRONIC HEPATITIS

INCUBATION PERIOD

ACUTE INFECTION

Symptoms

anti-HCV

ALT

Normal

0 1 2 3 4 5 6 1 2 3 4

Hepatitis C Virus InfectionTypical Serologic Course

Titre

Months

Years

Time after Exposure

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– Risk increases for every year for a patient

with chronic hepatitis C.– Patients without signs of cirrhosis can develop

HCC

Factors of poor prognosis:-Age >40 years-Alcohol > 50g/Hour-Male gender-Duration of infection-Co-infection HBV/HIV-Tobacco consumption

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Indirect tests: detect antibody against HCV

1. Anti HCV2. RIBA

(recombinant immunoblot assay)

Diagnosisof HCV Infection

Direct tests : components of the

HCV particle

1.HCV RNA(PCR)• Qualitative• Quantitative

2. HCV Core antigenUsefull in detecting window peroid

Screening of blood, organ, tissue

donors

High-risk behavior modification

Blood and body fluid precautions

Prevention of Hepatitis C

CASE STUDIES

Jada went to her doctor for a routine physical. A hepatitis panel was done and her results were as follows:

HBsAg Negative

anti-HBs Positive

anti-HBc Negative

Question 1

• How would you interpret her results?

Answer

• She received the hepatitis B vaccine and is protected (immune)

Jeff went in for a routine annual physical. His doctor decided to run a hepatitis panel. His results are as follows:

HBsAg Positive

anti-HBs Negative

anti-HBc Positive

IgM anti-HBc Positive

HBeAg Positive

Question 1

• How would you interpret his results?

Answer

• He has acute hepatitis B infection.

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??

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Hepatitis ppt