Viral Hepatitis

Tutorial

Hepatitis Viruses
FEATURE Family A
Piconavi ridae ssRNA+ Hepato virus

B
Hepadna viridae dsDNA Orthohe padnavirus

C
Flaviviri dae ssRNA+ Hepaci virus

D
Unclssifi ed ssRNA-

E
Hepeviri dae ssRNA+

G
Flaviviri dae ssRNA+

TTV
?Circovi ridae ssDNAAnello virus

Genus

Deltavirus Hepevirus Tentative Hepaci virus

Mean IP (days) Typical onset Age preference

20-30 Sudden
Child young adult

60-90 Slow All

60-90 Slow All

60-90
Variable

20-30 Sudden All

? ? ?

? ? ?

All

Severity

Usually mild <0.5%

Modera te <1-2%

Can be severe 0.5-1%

Severe in HBV+ high

Usually mild 1-2%

Acute Fulminat hepatitis

Hepatitis Viruses (Cont)

FEATURE Chronicity Carrier state Serologic detection Transmission A None None Yes Faecooral B Low-Mod Yes Yes C High yes Yes D Mod-high Yes Yes E None None ? Faecooral G Likely Likely No TTV Likely Likely No

Blood Blood Blood Sexual Sexual Sexual Perinatal Perinatal Yes + ? Yes (B) (B) -

Blood Blood ?Sex ?Faecooral ?Vertical ?Vertical ? ? -

Hyper Ig protection Vaccine Antiviral Treatment

Yes + -

None -

IFN IFN 3TC Ribavirin Adefovir

Hepatitis A Virus Infection

Typical Serologic Course
Symptoms

Total anti-HAV

Titer

ALT

Fecal HAV

IgM anti-HAV

Months after Exposure

12

24

HBV
HBs Ag Hbe Ag Anti-HBc IgM IgG Anti HBe Anti HBs

Interpretation
Incubation period Acute hepatitis B infection Carrier state Carrier state Convalescence Recovery HBV Infection without detectable HBsAg Possibilities: (1) HBV infection in remote pass, (2) low level HBV carrier (3) window bet disappearance of HBsAg and appearance of HBsAb, (4) False positive or non specific reaction Vaccine type response

+ + + + -

+ + + -

+ +/+/+

+ + + + + -

+ + -

+ + -

Common HBV Serology Patterns

Interpretation No evidence of HBV infection Acute HBV infection Chronic HBV (if HBsAg + for >6mths) (1)Window period (2) HBV infection in remote pass, (3) low level HBV carrier (4) False positive Previous HBV infection HBV vaccine response HBsAg + + AntiHBcIgM + Total AntiHBc + + AntiHBS -

+ -

+ +

HDV
HBs Anti HBc Ag Total IgM HBe Ag Anti HBe Anti HBs Anti-Delta Total IgM Interpretation Acute coinfection with HBV and Delta Acute Delta superinfection (anti-Delta low), or chronic Delta superinfection (anti-Delta low) Recovery from acute Delta superinfection (anti-Delta low), or, rarely, chronic Delta superinfection (anti-Delta level high), usually without symptoms Previous HBV and Delta infection with probable recovery Recovery from HBV and Delta infection

+/-

+/-

+/-

+/-

+ +

+ +/-

+ +

INNO-LIA
Streptavidin Level 3+ anti-human IgG, strong positive Level 1+ human IgG, moderate positive Level + human IgG, weak positive C1 C2 E2 NS3 NS4 NS5

HCV Antigens

INNO-LIA
Negative For HCV Ab
-all HCV Ag lines negative -only one HCV Ag lines + (except NS3)

Positive For HCV Ab

-at least 2 HCV Ag lines + or >

Indeterminate for HCV Ab

-one HCV Ag line 1+ or > -NS3 + or >

Interpreting Anti-HCV Test Results

Anti HCV Positive (1) Anti-HCV screening test positive and RIBA/NAT positive; or (2) Anti-HCV screening test positive, NAT negative, RIBApositive Anti-HCV Negative (1) Anti-HCV screening test negative; or (2) Anti-HCV screening test positive, RIBA negative (3) Anti-HCV screening test positive, NAT negative, RIBA negative Anti-HCV Indeterminate An indeterminate anti-HCV result is defined as anti HCV screening test positive, RIBA indeterminate

Algorithm For The Serologic Diagnosis Of HAV, HBV, HCV, HDV & HEV

Request anti-HAV IgG to exclude previous infection*

Negative Anti-HAV Positive IgM

Recent HAV infection

Request anti-HEV IgG to exclude previous infection*

Negative Anti-HEV Positive IgM

Recent HEV infection

*Exclude recent transfusions, Ig, or maternal Ab

Algorithm For The Serologic Diagnosis Of HAV, HBV, HCV, HDV & HEV

HCV infection unlikely Request HCV RNA if indicated

Negative Anti- HCV

Positive

Active or previous HCV infection

HCV RNA assay Negative Positive

Previous HCV suspected

Active HCV

Algorithm For The Serologic Diagnosis Of HAV, HBV, HCV, HDV & HEV Anti-HBc Total Negative No active HBV infection Negative HBsAg Positive

Positive Indicates either active or previous HBV infection

Request anti-HBs test Negative No previous HBV infection Positive Vaccine type response*

Request anti-HBs test Negative Active HBV cannot be excluded Positive Previous HBV infection; immunity confirmed*

*Exclude recent transfusions, Ig, or maternal Ab

Positive +anti-HBc positive HBsAg Anti-HDV IgG Positive Negative No active HDV infection HDV HBeAg Anti-HBe

Negative

Active HBV infection either acute or chronic

Anti-HBc IgM Negative Chronic HBV infection Positive Recent / Ac HBV infection

Anti-HDV Negative IgM/ HDVRNA

Positive

HBeAg positive

Neither positive

Anti-HBe positive

HDV infection acute or chronic

HBV infectivity is relatively high

HBV infectivity is relatively low