VIRAL HEPATITIS

VIRAL HEPATITIS is a topic covered in the Harrison's Manual of Medicine.

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Harrison’s Manual of Medicine

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Acute viral hepatitis is a systemic infection predominantly affecting the liver. Clinically characterized by malaise, nausea, vomiting, diarrhea, and low-grade fever followed by dark urine, jaundice, and tender hepatomegaly; may be subclinical and detected on the basis of elevated aspartate and alanine aminotransferase (AST and ALT) levels. Hepatitis B may be associated with immune-complex phenomena, including arthritis, serum sickness-like illness, glomerulonephritis, and a polyarteritis nodosa–like vasculitis. Hepatitis-like illnesses may be caused not only by hepatotropic viruses (A, B, C, D, E) but also by other viruses (Epstein-Barr, CMV, coxsackievirus, etc.), alcohol, drugs, hypotension and ischemia, and biliary tract disease (Table 155-1).

TABLE 155-1: Clinical and Epidemiologic Features of Viral Hepatitis
FEATUREHAVHBVHCVHDVHEV
Incubation (days)15–45, mean 3030–180, mean 60–9015–160, mean 5030–180, mean 60–9014–60, mean 40
OnsetAcuteInsidious or acuteInsidious or acuteInsidious or acuteAcute
Age preferenceChildren, young adultsYoung adults (sexual and percutaneous), babies, toddlersAny age, but more common in adultsAny age (similar to HBV)Epidemic cases: young adults (20–40 years); sporadic cases: older adults (>60)

Transmission

 Fecal-oral

 Percutaneous

 Perinatal

 Sexual

 

+++

Unusual

±

 

+++

+++

++

 

+++

±a

±a

 

+++

+

++

 

+++

Clinical

 Severity

 Fulminant

Progression to chronicity

 Carrier

 Cancer

 Prognosis

 

Mild

0.1%

None

 

None

None

Excellent

 

Occasionally severe

0.1–1%

Occasional (1–10%)

(90% of neonates)

0.1–30%c

+ (neonatal infection)

Worse with age, debility

 

Moderate

0.1%

Common (85%)

 

1.5–3.2%

+

Moderate

 

Occasionally severe

5–20%b

Commond

 

 

Variableg

±

Acute, good Chronic, poor

 

Mild

1–2%e

Nonef

 

 

 

None

None

Good

ProphylaxisIg, inactivated vaccineHBIG, recombinant vaccineNoneHBV vaccine (none for HBV carriers)Vaccine
TherapyNone

Interferon

Lamivudine

Adefovir

Pegylated interferonh

Entecavirh

Telbivudine

Tenofovirh

Pegylated interferon ribavirin telaprevir,i boceprevir,i simeprevir, sofosbuvir, ledipasvir, paritaprevir/ritonavir ombitasvir, dasabuvir daclatasvir, velpatasvir, grazoprevir, elbasvirPegylated interferon ±Nonej
aPrimarily with HIV co-infection and high-level viremia in index case; more likely in persons with multiple sex partners or sexually transmitted diseases; risk ∼5%.
bUp to 5% in acute HBV/HDV co-infection; up to 20% in HDV superinfection of chronic HBV infection.
cVaries considerably throughout the world and in subpopulations within countries; see text.
dIn acute HBV/HDV co-infection, the frequency of chronicity is the same as that for HBV; in HDV superinfection, chronicity is invariable.
e10–20% in pregnant women.
fExcept as observed in immunosuppressed liver allograft recipients or other immunosuppressed hosts.
gCommon in Mediterranean countries; rare in North America and western Europe.
hFirst-line agents.
iNo longer recommended.
jAnecdotal reports and retrospective studies suggest that pegylated interferon and/or ribavirin are effective in treating chronic hepatitis E, observed in immunocompromised persons; ribavirin monotherapy has been used successfully in acute, severe hepatitis E.
Abbreviation: HBIG, hepatitis B immunoglobulin. See text for other abbreviations.

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