Embed Size (px)
Citation preview
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
3
Click to add Title
Click to add Title
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
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.
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
Weeks after Exposure
Titre
Progression to Chronic Hepatitis B Virus InfectionTypical Serologic Course
18
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 HBV Infection
Acute hepatitis B infection
Chronic HBV infection
3-5% of adult-acquired infections
95% of infant-acquired infections
Cirrhosis
Chronic hepatitis
12-25% in 5 years
Liver failure Hepatocellular carcinoma
Liver transplant
6-15% in 5 years 20-23% in 5 years
DeathDeath
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)
22
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
24
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
28
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
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??
