VIRAL HEPATITIS

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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