Viral hepatitis

Viral hepatitis
Micrograph showing ground glass hepatocytes, which are seen in chronic hepatitis B infections (a type of viral hepatitis), and represent accumulations of viral antigen in the endoplasmic reticulum. H&E stain.
Classification and external resources
Specialty	infectious disease
ICD-10	B15–B19
ICD-9-CM	070
Patient UK	Viral hepatitis
MeSH	D006525

Viral hepatitis is liver inflammation due to a viral infection.^[1] It may present in acute (recent infection, relatively rapid onset) or chronic forms.

The most common causes of viral hepatitis are the five unrelated hepatotropic viruses Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, and Hepatitis E. In addition to the nominal hepatitis viruses, other viruses that can also cause liver inflammation include Cytomegalovirus, Epstein–Barr virus, and Yellow fever. Up to 1997 there has been also 52 cases of Viral hepatitis caused by Herpes simplex virus.^[2]

There is the opportunity to prevent or treat the most common types.^[3] Hepatitis A and hepatitis B can be prevented by vaccination. Effective treatments for hepatitis C are available but expensive.^[3]

In 2013 about 1.5 million people died from viral hepatitis.^[3] Most deaths are due to hepatitis B and hepatitis C.^[3] East Asia is the region of the world most affected.^[3]

Hepatitis viruses

Explanation of viral hepatitis

The most common cause of hepatitis is viral. Although they are classified under the disease hepatitis, these viruses are not all related.

Hepatitis viruses

	HAV	HBV	HCV	HDV	HEV
Transmission	Enteral	Parenteral	Parenteral	Parenteral	Enteral
Classification	Picornavirus	Orthohepadnavirus	Hepacivirus	Deltavirus	Hepevirus
Genome	+ssRNA	dsDNA-RT	+ssRNA	−ssRNA	+ssRNA
Antigens		HBsAg,HBeAg	Core antigen	Delta antigen
Incubation period	20–40 days	45–160 days	15–150 days	30–60 days	15–60 days
Severity/Chronicity[4]	mild; acute	occasionally severe; 5–10% chronic	subclinical; 70% chronic	exacerbates symptoms of HBV; chronic w/ HBV	normal patients, mild; pregnant women, severe; acute
Vaccine	10 year protection	3 injections, lifetime protection	None available	None available	Investigational (approved in China)

Hepatitis A

Hepatitis A or infectious jaundice is caused by hepatitis A virus (HAV), a picornavirus transmitted by the fecal-oral route often associated with ingestion of contaminated food. It causes an acute form of hepatitis and does not have a chronic stage. The patient's immune system makes antibodies against HAV that confer immunity against future infection. People with hepatitis A are advised to rest, stay hydrated and avoid alcohol. A vaccine is available that will prevent HAV infection for up to 10 years. Hepatitis A can be spread through personal contact, consumption of raw sea food or drinking contaminated water. This occurs primarily in third world countries. Strict personal hygiene and the avoidance of raw and unpeeled foods can help prevent an infection. Infected people excrete HAV with their feces two weeks before and one week after the appearance of jaundice. The time between the infection and the start of the illness averages 28 days (ranging from 15 to 50 days),^[5] and most recover fully within 2 months, although approximately 15% of sufferers may experience continuous or relapsing symptoms from six months to a year following initial diagnosis.^[6]

Hepatitis A^[7]

Marker	Detection Time	Description	Significance
Faecal HAV	2–4 weeks or 28days	–	Early detection
Ig M anti HAV	4–12 weeks	Enzyme immunoassay for antibodies	During Acute Illness
Ig G anti HAV	5 weeks – persistent	Enzyme immunoassay for antibodies	Old infection or Reinfection

Hepatitis B

Hepatitis B is caused by hepatitis B virus, a hepadnavirus that can cause both acute and chronic hepatitis. Chronic hepatitis develops in the 15% of adults who are unable to eliminate the virus after an initial infection. Identified methods of transmission include blood (blood transfusion, now rare), unsanitary tattoos, sexually (through sexual intercourse or through contact with blood or bodily fluids), or via mother to child by breast feeding (minimal evidence of transplacental crossing). However, in about half of cases the source of infection cannot be determined. Blood contact can occur by sharing syringes in intravenous drug use, shaving accessories such as razor blades, or touching wounds on infected persons. Needle-exchange programmes have been created in many countries as a form of prevention.

Patients with chronic hepatitis B have antibodies against hepatitis B, but these antibodies are not enough to clear the infection of the affected liver cells. The continued production of virus combined with antibodies is a likely cause of the immune complex disease seen in these patients. A vaccine is available that will prevent infection from hepatitis B for life. Hepatitis B infections result in 500,000 to 1,200,000 deaths per year worldwide due to the complications of chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Hepatitis B is endemic in a number of (mainly South-East Asian) countries, making cirrhosis and hepatocellular carcinoma big killers. There are six treatment options approved by the U.S. Food and Drug Administration (FDA) available for persons with a chronic hepatitis B infection: alpha-interferon, pegylated interferon, adefovir, entecavir, telbivudine and lamivudine. About 65% of persons on treatment achieve a sustained response.

Hepatitis C

Hepatitis C (originally "non-A non-B hepatitis") is caused by hepatitis C virus (HCV), an RNA virus that is a member of the Flaviviridae family. HCV can be transmitted through contact with blood (including through sexual contact if the two parties' blood is mixed) and can also cross the placenta. Hepatitis C usually leads to chronic hepatitis, culminating in cirrhosis in some people. It usually remains asymptomatic for decades. Patients with hepatitis C are susceptible to severe hepatitis if they contract either hepatitis A or B, so all persons with hepatitis C should be immunized against hepatitis A and hepatitis B if they are not already immune, and avoid alcohol. HCV viral levels can be reduced to undetectable levels by a combination of interferon and the antiviral drug ribavirin. The genotype of the virus is the primary determinant of the rate of response to this treatment regimen, with genotype 1 being the most resistant.

Hepatitis C is the most common chronic blood-borne infection in the United States.^[8]

Hepatitis C^[9]

Marker	Detection Time	Description	Significance	Note
HCV-RNA	1–3 weeks or 21 days	PCR	Demonstrates presence or absence of virus	Results may be intermittent during course of infection. Negative result is not indicative of absence.
anti-HCV	5–6 weeks	Enzyme Immunoassay for antibodies	Demonstrates past or present infection	High false positive in those with autoimmune disorders and populations with low virus prevalence.
ALT	5–6 weeks	–	Peak in ALT coincides with peak in anti-HCV	Fluctuating ALT levels is an indication of active liver disease.

Hepatitis D

The Hepatitis D virus (HDV) or hepatitis delta agent is similar to a viroid as it can only propagate in the presence of the hepatitis B virus.

Hepatitis E

The Hepatitis E virus (HEV), from the Hepeviridae family, produces symptoms similar to hepatitis A, although it can take a fulminant course in some patients, particularly pregnant women; chronic infections may occur in immune-compromised patients. It is more prevalent in the Indian subcontinent.

Hepatitis F virus

Hepatitis F virus (HFV) is a hypothetical virus linked to hepatitis. Several hepatitis F virus candidates emerged in the 1990s; none of these reports have been substantiated.

GB virus C

The GB virus C is another potential viral cause of hepatitis that is probably spread by blood and sexual contact.^[10] It was initially identified as Hepatitis G virus.^[11] There is very little evidence that this virus causes hepatitis, as it does not appear to replicate primarily in the liver.^[12] It is now classified as GB virus C.^[13]

Other viruses

The first virus capable of causing hepatitis was the yellow fever virus a mosquito borne flavivirus. Other viruses than can cause hepatitis include:

• • Adenoviruses
  • Arenaviruses: Guanarito virus, Junín virus, Lassa fever virus, Machupo virus and Sabiá virus^[14]
  • Bunyaviruses: Crimean-Congo hemorrhagic fever virus, Dobrava virus, Hantaan virus, Puumala virus, Rift Valley fever virus and Seoul virus
  • Coronavirus: Severe acute respiratory syndrome virus^[15]
  • Erythrovirus: Parvovirus B19^[16]
  • Filoviruses: Ebola virus and Marburg virus
  • Flaviviruses: Dengue, Lujo virus, Kyasanur Forest disease virus, Omsk hemorrhagic fever virus and Yellow fever virus
  • Herpesviruses: Cytomegalovirus,^[17]Epstein–Barr virus,^[18] Varicella-zoster virus,^[19] Human herpesvirus 6, Human herpesvirus 7 and Human herpesvirus 8^[20]
  • Orthomyxoviruses: Influenza^[21]
  • Picornaviruses: Echovirus
  • Reovirus: Colorado tick fever virus, Reovirus 3

KIs-V is a virus isolated in 2011 from four patients with raised serum alanine transferases without other known cause. A causal role is suspected.^[22]

References

1. National Library of Medicine » Medical Subject Headings »Virus Diseases (C02) » Hepatitis, Viral, Human (C02.440) » Scope Note.
2. http://cid.oxfordjournals.org/content/24/3/334.full.pdf
3. Stanaway, Jeffrey D; Flaxman, Abraham D; Naghavi, Mohsen; Fitzmaurice, Christina; Vos, Theo; Abubakar, Ibrahim; Abu-Raddad, Laith J; Assadi, Reza; Bhala, Neeraj; Cowie, Benjamin; Forouzanfour, Mohammad H; Groeger, Justina; Hanafiah, Khayriyyah Mohd; Jacobsen, Kathryn H; James, Spencer L; MacLachlan, Jennifer; Malekzadeh, Reza; Martin, Natasha K; Mokdad, Ali A; Mokdad, Ali H; Murray, Christopher J L; Plass, Dietrich; Rana, Saleem; Rein, David B; Richardus, Jan Hendrik; Sanabria, Juan; Saylan, Mete; Shahraz, Saeid; So, Samuel; Vlassov, Vasiliy V; Weiderpass, Elisabete; Wiersma, Steven T; Younis, Mustafa; Yu, Chuanhua; El Sayed Zaki, Maysaa; Cooke, Graham S (July 2016). "The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013". The Lancet. doi:10.1016/S0140-6736(16)30579-7.
4. Kuo, Infectious Causes of Jaundice, ATSU School of Osteopathic Medicine Arizona, June 2012
5. "CDC Hepatitis A FAQ". Retrieved 2008-03-03.
6. "CDC Hepatitis A Fact Sheet". Retrieved 2008-03-03.
7. "Acute Viral Hepatitis : Introduction Harrison's Principle of Internal Medicine, 17 Edition".
8. "CDC DVH—Hepatitis C Information For the Health Professional". Retrieved 2010-01-14.
9. "WHO | Hepatitis C". Who.int. 2010-12-08. Retrieved 2012-08-26.
10. Stark K, Bienzle U, Hess G, Engel AM, Hegenscheid B, Schluter V (1996). "Detection of the hepatitis G virus genome among injecting drug users, homosexual and bisexual men, and blood donors". J. Infect. Dis. 174 (6): 1320–3. doi:10.1093/infdis/174.6.1320. PMID 8940225.
11. Linnen J, Wages J, Zhang-Keck ZY, et al. (1996). "Molecular cloning and disease association of hepatitis G virus: a transfusion-transmissible agent". Science. 271 (5248): 505–8. doi:10.1126/science.271.5248.505. PMID 8560265.
12. Pessoa MG, Terrault NA, Detmer J, et al. (1998). "Quantitation of hepatitis G and C viruses in the liver: evidence that hepatitis G virus is not hepatotropic". Hepatology. 27 (3): 877–80. doi:10.1002/hep.510270335. PMID 9500722.
13. "00.026. Flaviviridae". ICTVdB Index of Viruses.
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15. Chau TN, Lee KC, Yao H, et al. (February 2004). "SARS-associated viral hepatitis caused by a novel coronavirus: report of three cases". Hepatology. 39 (2): 302–10. doi:10.1002/hep.20111. PMID 14767982.
16. Naides SJ (May 1998). "Rheumatic manifestations of parvovirus B19 infection". Rheum. Dis. Clin. North Am. 24 (2): 375–401. doi:10.1016/S0889-857X(05)70014-4. PMID 9606764.
17. Xiong W (November 2010). "[Clinical efficacy of treating infant cytomegalovirus hepatitis with ganciclovir and impact on cytokines]". Xi Bao Yu Fen Zi Mian Yi Xue Za Zhi (in Chinese). 26 (11): 1130–2. PMID 21322282.
18. Okano M, Gross TG; Gross (November 2011). "Acute or Chronic Life-Threatening Diseases Associated With Epstein-Barr Virus Infection". Am. J. Med. Sci. 343 (6): 483–9. doi:10.1097/MAJ.0b013e318236e02d. PMID 22104426.
19. Anderson, D.R.; Schwartz, J.; Hunter, N.J.; Cottrill, C.; Bissaccia, E.; Klainer, A.S. (1994). "Varicella Hepatitis: A Fatal Case in a Previously Healthy, Immunocompetent Adult". Archives of Internal Medicine. JAMA. 154 (18): 2101–2106. doi:10.1001/archinte.1994.00420180111013. PMID 8092915.
20. Gallegos-Orozco JF, Rakela-Brödner J; Rakela-Brödner (October 2010). "Hepatitis viruses: not always what it seems to be". Rev Med Chil. 138 (10): 1302–11. doi:10.4067/S0034-98872010001100016. PMID 21279280.
21. Papic N, Pangercic A, Vargovic M, Barsic B, Vince A, Kuzman I (September 2011). "Liver involvement during influenza infection: perspective on the 2009 influenza pandemic". Influenza Other Respi Viruses. 6 (3): e2–5. doi:10.1111/j.1750-2659.2011.00287.x. PMID 21951624.
22. Satoh K, Iwata-Takakura A, Osada N, et al. (October 2011). "Novel DNA sequence isolated from blood donors with high transaminase levels". Hepatol. Res. 41 (10): 971–81. doi:10.1111/j.1872-034X.2011.00848.x. PMID 21718400.