VIRAL HEPATITIS

Question 1

How many hepatitis viruses are known?

Answer 1

6

Hep A, B, C, D, E, and G (where is F??)

Question 2

Other than the hepatitis viruses, what viruses can cause damage to the liver?

Answer 2

Cytomegalovirus
EBV
Yellow fever
Herpes viruses

Question 3

What is the most common type of hepatitis virus worldwide?

Answer 3

Hepatitis A

Question 4

What age group is most commonly affected by hepatitis A?

Answer 4

Young

Question 5

What is the method of transmission of hepatitis A?

Answer 5

Faecal-oral route

Contaminated water or shellfish

Question 6

What does the icteric phase refer to, with regard to hepatitis?

Answer 6

The time when the patient is jaundiced.

Question 7

What are the symptoms of the prodromal phase (early stages) of hepatitis A infection?

Answer 7

Nausea
Vomiting
Diarrhoea
Headache
Mild fever
Malaise
Abdominal discomfort

Question 8

How does hepatitis A affect smokers?

Answer 8

They have a sudden distaste for cigarettes.

Question 9

How long after infection does the icteric (jaundiced) phase of hepatitis A occur?

Answer 9

10-14 days

Question 10

How long does the icteric (jaundiced) phase in hepatitis A infection last for?

Answer 10

2-3 weeks

Question 11

Other than jaundice, what are the symptoms of the icteric phase of hepatitis A infection?

Answer 11

Malaise and fatigue (which may persists for months)
Hepatomegaly
Splenomegaly in 10%

Question 12

What would give you a definitive diagnosis of on going hepatitis A infection?

Answer 12

Rising titre of anti-hep A IgM

Demonstration of viral particles in stools by electron microscopy

Question 13

What in the blood might reflect previous exposure to hepatitis A infection?

Answer 13

Anti-hep A IgG

Question 14

What would LFTs show in someone with an on going hepatitis infection?

Answer 14

Moderately raised AST and ALT (500-1000 IU/L) which normalise rapidly

Question 15

With reference to the icteric (jaundiced) phase of hepatitis A infection, when is the disease most infectious?

Answer 15

Just before the onset of jaundice

Question 16

What are the complications of hepatitis A and how frequent are they?

Answer 16

They are actually quite rare

Myocarditis
Arthritis
Vasculitis
Fulminant hepatic failure (very rare)
Can precipitate autoimmune hepatitis

Question 17

Does hepatitis A infection ever become chronic?

Answer 17

No and infact previous sufferers have lifelong immunity

Question 18

How are patients with on going hepatitis A infection managed?

Answer 18

Treatment is supportive and hospital admission is not necessary in most cases.
Antiemetics for nausea
IV fluids in vulnerable patients (elderly)
Analgesia for headaches
Maintain calorie intake

Avoid alcohol

Question 19

What is the incidence of symptomless hepatitis B infected individuals in the UK and USA?

Answer 19

0.1%

Question 20

What is the method of transmission of hepatitis B?

Answer 20

Bodily fluid, mostly blood

Contaminated blood products
IV drug user
Sexual transmission
Vertical transmission (at birth) - most common worldwide
(Mosquitoes are possible)

Question 21

Is hepatitis B transmitted by breast feeding?

Answer 21

No

Question 22

What is the basic structure of the hepatitis B virus?

Answer 22

An inner nucleocapsid surrounded by an outer envelope of surface protein.

Question 23

Is hepatitis B infection acute or chronic?

Answer 23

It can be either or it can be symptomless (carrier)

Question 24

What is the incubation time of hepatitis B?

Answer 24

60-160 days

Question 25

What are the symptoms of the prodromal phase (early stages) of acute hepatitis B infection?

Answer 25

Very non-specific Arthralgia Anorexia Abdominal discomfort

Question 26

Other than jaundice, what are the features of the icteric (jaundiced) phase of acute hepatitis B infection?

Answer 26

Fever Hepatomegaly Urticarial or maculopapular rash Polyarthritis

Question 27

What are the clinical features of chronic hepatitis B infection?

Answer 27

Most chronic carriers are asymptomatic May present with features of chronic liver disease or cirrhosis: jaundice, ascites, portal hypertension, hepatic failure

Question 28

What would LFTs of someone with acute hepatitis B infection show?

Answer 28

Very high AST and ALT (1000-5000 IU/L) for the first week but falling rapidly after this

Question 29

What are the first markers to appear in serology of someone with hepatitis B infection and when do they appear?

Answer 29

Surface antigens (HBsAg) - 6 week to 3 months after infection

Question 30

What is the serological marker which indicates increased virus replication and high infectivity of hepatitis B?

Answer 30

The e antigen (HBeAg)

Question 31

What will the serology of someone who has never been exposed to hepatitis B or had the vaccination show in terms of HBsAg, anti-HBc and anti-HBs?

Answer 31

HBsAg - negative Anti-HBc - negative Anti-HBs - negative

Question 32

What will the serology of someone who has had the vaccination against hepatitis B show in terms of HBsAg, anti-HBc and anti-HBs?

Answer 32

HBsAg - negative Anti-HBc - negative Anti-HBs - positive

Question 33

What will the serology of someone who has recovered from a hepatitis B infection show in terms of HBsAg, anti-HBc and anti-HBs?

Answer 33

HBsAg - negative Anti-HBc - positive Anti-HBs - positive

Question 34

What will the serology of someone who is acutely infected with hepatitis B infection show in terms of HBsAg, anti-HBc, IgM anti-HBc and anti-HBs?

Answer 34

HBsAg - positive Anti-HBc - positive IgM anti-HBc - positive Anti-HBs - negative

Question 35

What will the serology of someone who is chronically infected with hepatitis B infection show in terms of HBsAg, anti-HBc, IgM anti-HBc and anti-HBs?

Answer 35

HBsAg - positive Anti-HBc - positive IgM anti-HBc - negative Anti-HBs - negative

Question 36

What does the following serological picture show about the patient in terms of hepatitis B? HBsAg - positive Anti-HBc - positive IgM anti-HBc - positive Anti-HBs - negative

Answer 36

The person is acutely infected with hepatitis B

Question 37

What does the following serological picture show about the patient in terms of hepatitis B? HBsAg - negative Anti-HBc - positive Anti-HBs - positive

Answer 37

The person has recovered from a natural infection of hepatitis B and is now immune.

Question 38

What does the following serological picture show about the patient in terms of hepatitis B? HBsAg - positive Anti-HBc - positive IgM anti-HBc - negative Anti-HBs - negative

Answer 38

The person is chronically infected with hepatitis B.

Question 39

What does the following serological picture show about the patient in terms of hepatitis B? HBsAg - negative Anti-HBc - negative Anti-HBs - positive

Answer 39

The person has been successfully vaccinated against hepatitis B.

Question 40

What is the serological marker which indicates low infectivity of hepatitis B?

Answer 40

Anti-HBe antibodies

Question 41

What method might you use to quantify viral load in someone with hepatitis B?

Answer 41

Polymerase chain reaction (PCR)

Question 42

What are the complications of hepatitis B?

Answer 42

Fulminant (sudden and severe) hepatitis and death occur in 1% Arteritis Glomerulonephritis Cryoglobulinaemia Also predisposes patient to hepatocellular carcinoma

Question 43

How are patients with acute hepatitis B managed?

Answer 43

Symptomatic relief is all that is required, with extra care taken handling bodily fluids Fulminant (sudden and severe) hepatitis carries a grave prognosis and may require liver transplant.

Question 44

What are the anti-viral medications used in the treatment of chronic hepatitis B?

Answer 44

Lamivudine Adefovir Entecavir

Question 45

Apart from anti-virals, what other medications are used in the treatment of chronic hepatitis B?

Answer 45

Alpha-interferon SC

Question 46

How is hepatitis C transmitted?

Answer 46

Contaminated blood IV drug users Sexual transmission (rare) Vertical transmission (rare) Breast milk transmission (rare)

Question 47

What are the clinical features of hepatitis C?

Answer 47

Jaundice only occurs in about 20% of patients Fatigue or malaise are common Cirrhosis Extra-hepatic manifestations are rare

Question 48

What do LFTs of someone with hepatitis C show?

Answer 48

Slightly elevated AST and ALT (50-150 IU/L) Normal bilirubin Raised ferritin

Question 49

What do you look for in the blood in order to make a diagnosis of hepatitis C?

Answer 49

IgM anti-hepatitis C | Hepatitis C RNA (using PCR)

Question 50

What are the complications of hepatitis C infection?

Answer 50

70% develop chronic indolent hepatitis of varying severity | 20% progress to cirrhosis

Question 51

What are the co-factors that might increase the likelihood of developing cirrhosis as a result of hepatitis C?

Answer 51

Advanced age Male gender HIV Hepatitis B Alcohol excess Obesity

Question 52

How are patients with hepatitic C medically managed?

Answer 52

Pegylated interferon Ribavirin Treatment is only really offered to those with mild hepatitis C infection as they will have a better response.

Question 53

What are the three genotypes of hepatitis C and how well does each one respond to medical treatment?

Answer 53

Genotype 1 - 45% successful seroconversion Genotype 2 - 90-100% successful seroconversion Genotype 3 - 60-70% successful seroconversion

Question 54

How long is each genotype of hepatitis C treated for with pegylated interferon and ribavirin?

Answer 54

Genotype 2 and 3 - 24 weeks | Genotype 1 - 48 weeks

Question 55

What is the major side effect of pegylated interferon, used in the treatment of hepatitis C?

Answer 55

Depression

Question 56

What is the major side effect of ribavirin, used in the treatment of hepatitis C?

Answer 56

Anaemia through suppressed haemoglobin synthesis

Question 57

In someone with a liver transplant following hepatitis C infection, what are the chances of recurrence of the hepatitis C?

Answer 57

Almost 100%

Question 58

In what patients might you see a hepatitis D infection?

Answer 58

Hepatitis D occurs as a co-infection with hepatitis B virus and is particularly seen in IV drug users.

Question 59

What are the complications hepatitis D infection?

Answer 59

Increases chances of the hepatitis co-infection causing fulminant hepatitis and cirrhosis.

Question 60

What might indicate that someone has an EBV infection if they are treated for a bacterial infection?

Answer 60

EBV can cause a rash if treated with ampicillin. This does mean patient is allergic to ampicillin in the future.

Question 61

What is the prognosis of someone with hepatitis due to EBV?

Answer 61

Excellent prognosis with majority maintaining normal liver function.

Question 62

Which group are particularly susceptible to hepatitis caused by cytomegalovirus?

Answer 62

Immunosuppressed

Question 63

How is diagnosis of cytomegalovirus made?

Answer 63

May be detected in the urine Most sensitive test is to detect antigen in buffy coat of EDTA treated blood Rising IgM titre to CMV can also aid diagnosis of acute infection

Question 64

What does the liver biopsy of someone with cytomegalovirus show?

Answer 64

Intracytoplasmic inclusion bodies and giant cells