A C U T E H E P A T I T I - PowerPoint Presentation

Slide1

ACUTE HEPATITIS

Slide2

DefinitionHEPATITIS• Inflammation of liver parenchyma• 2 types• Acute – duration < 6 months• Chronic – duration ≥ 6 months Acute Hepatitis is an inflammatory disorder of the liver which is

usually

associated with a complete clinical and histological recovery within a period of

4 – 6 weeks

Slide3

CAUSES AND DIFFERENTIAL DIAGNOSIS OF HEPATITIS IN CHILDREN Hepatotropic virusesHAVHBVHCVHDVHEVHGV/SEN/TTV

Non

Hepatotropic

viruses

A

denovirus

A

rbovirus

Epstein-

B

arr virus

C

ytomegalovirus

C

oxsackievirus

D

engue virus

E

nterovirus

E

xanthems

(

Paramyxovirus

Rubella

Varicella

zoster )

F

laviviruses

(e.g., yellow

f

ever)

H

erpes

simplex virus

H

uman

immunodeficiency virus

Other

Slide4

Non – Viral InfectionsTuberculosisMalaria Enteric feverLeptospirosisBrucellosisHistoplasmosis AbscessAmebiasisBacterial sepsisOthersAUTOIMMUNE

Autoimmune

hepatitis

SLE

METABOLIC

Wilson

disease

Other

CAUSES AND DIFFERENTIAL DIAGNOSIS OF HEPATITIS IN CHILDREN

Slide5

TOXICDrug induced (e.g., acetaminophen)Environmental (e.g., pesticides)CAUSES AND DIFFERENTIAL DIAGNOSIS OF HEPATITIS IN CHILDREN

Slide6

Viral Hepatitis

Slide7

Viral Hepatitis• Most common cause worldwide• Caused by 5 pathogenic hepatotropic viruses : Hepatitides A (HAV),B(HBV), C(HCV), D(HDV) and E(HEV) viruses.• HAV – most common in India , > 80% children• Although the agents can be distinguished by their antigenic properties , the 5 kinds of viruses may produce clinically similar illness.

Slide8

PathogenesisDirect cytopathicIMMUNE MEDIATED The viruses do not directly cause apoptosis. Rather, infection of liver cells activates the innate and adaptive immune system leading to an inflammatory response which causes cellular damage and death

Slide9

VirusesTypeIncubation

period (days)

Transmission

Chronic

infection

Fulminant

disease

HAV

RNA

15-50

Faeco

-oral

No

Rare

HBV

DNA

50-150

Parenteral

, sexual,

perinatal

Yes

Yes

HCV

RNA

15-150

Parenteral

, sexual,

perinatal

Yes

Rare

HDV

RNA

AROUND

1 MONTH

Parenteral

, sexual,

perinatal

Yes

Yes

HEV

RNA

AROUND

1 AND HALF MONTH

Faeco

-oral

No

Yes

Slide10

HEPATITIS A PICORNAVIRIDAE PRIVATEHEPATITIS B HEPADNAVIRIDAE HOSPITALSHEPATITIS C FLAVIVIRUS FAVOUR HEPATITIS D RNA INCOMPLETE

R

ICH

VIRUS

HEPATITIS E

C

ALCIVIRUS

C

LIENTS

Slide11

Clinical featuresProdromal phaseIcteric phaseRecovery phase

Slide12

Extra-hepatic manifestationsRegional lymphadenopathySplenomegalyBone marrow hypoplasiaGI ulcerationPancreatitisMyocarditisNephritisArthritisVasculitis

Slide13

Natural historyRecoveryLiver morphology returns to normal within 3 monthsFulminant hepatitisChronic hepatitis

Slide14

TREATMENT

Slide15

Hepatitis A

Slide16

Hepatitis AMost common cause of hepatitis in childrenRNA virus, picorna familyFeco-oral transmissionIncubation period : 15 – 50 daysVirus is not directly cytopathic, damage caused by immune responseIllness is usually symptomatic in older children

<6 yrs, <10%

6-14 yrs, 40%-50%

>14 yrs, 70%-80%

Slide17

Laboratory DiagnosisAcute infection is diagnosed by the detection of HAV-IgM in serum by EIA.Past Infection i.e. immunity is determined by the detection of HAV-IgG by EIA.

Direct Detection

– EM, PCR of

faeces

. Can detect illness earlier than serology but rarely performed.

Slide18

Hepatitis A Prevention - Immune Globulin

Pre-exposure

travellers

to intermediate and high HAV-endemic regions

Post-exposure (within 14 days)

Routine

household and other intimate contacts

Selected situations

institutions (e.g., day care centers)

common source exposure (e.g., food prepared by infected food handler)

Slide19

VaccineInactivated vaccineApproved for children > 1 yearDose : 0.5 ml, IM, 2 doses 6 months apartSerconversion : 95 – 100%Live vaccine

Slide20

Hepatitis B

Slide21

Hepatitis B Virus - VirologyDouble stranded DNA virusComplete Dane particle 42 nm, having 3 antigen namely surface(HBsAg), core (HBcAg

),

nucleocapsid

(

HBeAg

)

Hepatitis B virus (HBV) has been classified into 8 genotypes (A-H).

Slide22

Incubation period: Average 60-90 days

Range

50 -150 days

Clinical illness (jaundice): <5

yrs

, <10%

5

yrs

, 30%-50

%

Acute case-fatality rate: 0.5%-1

%

Chronic infection: <5

yrs

, 30%-90%

5

yrs

, 2%-10%

Premature mortality from

chronic liver disease: 15%-25%

Hepatitis B - Clinical Features

Slide23

Natural Course of Hepatitis B

Slide24

HBsAgused as a general marker of infectionHBsAbused to document recovery and/or immunity to HBV infectionanti-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

Diagnosis

Slide25

Symptoms

HBeAg

anti-HBe

Total anti-HBc

IgM anti-HBc

anti-HBs

HBsAg

0

4

8

12

16

20

24

28

32

36

52

100

Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course

Weeks after Exposure

Titre

Slide26

Symptomatic Infection

Chronic Infection

Age at Infection

Chronic Infection (%)

Symptomatic Infection (%)

Birth

1-6

months

7-12

months

1-4

years

Older Children

and Adults

0

20

40

60

80

100

100

80

60

40

20

0

Outcome of Hepatitis B Virus Infection

by Age at Infection

Chronic Infection (%)

Slide27

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

Slide28

ComplicationsAcute liver failureChronic hepatitisHepatocellular carcinomaMembranous glomerulonephritis

Slide29

PreventionVaccination - 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.

Slide30

Hepatitis C VirusRNA virus of flavivirus positive stranded RNA genome

HCV has been classified into a total of six genotypes (type 1 to 6) on the basis of phylogenetic analysis

Genotype 1 and 4 has a poorer prognosis and response to interferon therapy

Slide31

Incubation period:

Average

6-7

wks

Range 15 - 150 days

Clinical illness (jaundice):

30-40

% (20-30

%)

Chronic hepatitis:

70%

Hepatitis C - Clinical Features

Slide32

Natural Course of Hepatitis C

Slide33

Chronic Hepatitis C InfectionThe spectrum of chronic hepatitis C infection is essentially the same as chronic hepatitis B infection.All the manifestations of chronic hepatitis B infection may be seen, i.e. chronic persistent hepatitis, chronic active hepatitis, cirrhosis, and hepatocellular carcinoma.

Slide34

Symptoms

anti-HCV

ALT

Normal

0

1

2

3

4

5

6

1

2

3

4

Hepatitis C Virus Infection

Typical Serologic Course

Titre

Months

Years

Time

after Exposure

Slide35

Transfusion or transplant from infected donor

Injecting drug use

Hemodialysis

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

Slide36

Laboratory DiagnosisHCV antibody - generally used to diagnose hepatitis C infection. Not useful in the acute phase as it takes at least 4 weeks after infection before antibody appears.HCV-RNA - various techniques are available e.g. PCR and branched DNA. May be used to diagnose HCV infection in the acute phase. However, its main use is in monitoring the response to antiviral therapy.

HCV-antigen

- an EIA for HCV antigen is available. It is used in the same capacity as HCV-RNA tests but is much easier to carry out.

Slide37

TreatmentInterferon - may be considered for patients with chronic active hepatitis. The response rate is around 50% but 50% of responders will relapse upon withdrawal of treatment.Ribavirin - there is less experience with ribavirin than interferon. However, recent studies suggest that a combination of interferon and ribavirin is more effective than interferon alone.

Slide38

Screening of blood, organ, tissue donors

High-risk behavior modification

Blood and body fluid precautions

Prevention of Hepatitis C

Slide39

HBsAg

RNA



antigen

Hepatitis D (Delta) Virus

Slide40

Hepatitis D VirusThe delta agent is a defective virus which shows similarities with the viroids in plants. The agent consists of a particle consisting of the delta antigen surrounded by an outer coat of HBsAg. The genome of the virus is very small and consists of a single-stranded RNA

Slide41

Coinfection

Simultaneous exposure to

inoculum

containg

both HBV &HDV

severe acute disease.

High

risk of

ALF (10%)

Superinfection

usually develop chronic HDV infection.

high risk of severe chronic liver disease.

may present as an acute hepatitis.

Hepatitis D - Clinical Features

Slide42

Hepatitis E VirusCalicivirus-like virusesunenveloped RNA virus

Slide43

Incubation period:

Average

40 days

Range 15-60

days

Case-fatality rate:

Overall

, 1%-3%

Pregnant women,

15

%-25

%

Illness severity: Increased with

age

Chronic

sequelae

:

None

identified

Hepatitis E - Clinical Features

Slide44

THANK YOU