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Acute Hepatitis B
.

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Epidemiology
Incidence declined in US from 1990 to 2005 70,000 acute Hepatitis B infections in US in 2005 Risk factors: sexual exposure, IVDU <5% of acute infections in immunocompetent adults progress to chronic hepatitis B
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Clinical Manifestations
Incubation period 1-4 mos Prodromal period w/ serum sickness like symptoms Then constitutional sx, anorexia, nausea, jaundice and RUQ discomfort Only 30% develop icteric hepatitis. 70% subclinical or anicteric hepatitis. More severe infections in patients coinfected w/ other hepatitis viruses or underlying liver disease

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Diagnosis

To diagnose acute infection: HBSAg + IgM antiHBc (also suggestive is +HBeAg) Recovery: Normalization of ALT, disappearance of HBV DNA, transition from HBSAg to anti-HBs and transition from IgM anti-HBc to IGG Chronic: persistence of HBSAg > 6 months
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Diagnosis

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Laboratory Testing
Elevated transaminases-values up to 1000-2000 IU/L with ALT > AST Serum bilirubin may be normal Prothrombin time best indicator of prognosis Normalization of transaminases within 1-4 months in patients who recover ALT elevated > 6 months indicates progression to chronic hepatitis
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Fulminant Hepatic Failure

rapid development of severe acute liver injury with impaired synthetic function and encephalopathy in a person who previously had a normal liver or had wellcompensated liver disease unusual in Hep B infections-occurs in 0.1 to 0.5% of pts

due to massive immune-mediated lysis of infected hepatocytes

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Treatment
mostly supportive avoid interferon due to increased risk of hepatic necroinflammation consider antiviral therapy with lamivudine, telbivudine, adefovir, or entecavir as monotherapy for short duration discontinue treatment after two consective tests 4 weeks apart confirm patient has cleared HBSAg
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Treatment
RCT of lamivudine to treat acute Hep B:

71 pts. 31 pts received lamivudine 100 mg daily for 3 mo (group 1), 40 received placebo (group 2) At wk 4, HBV DNA levels significantly lower in treated group (p=0.037), but thereafter levels were similar Improvement in serum bili, ALT, INR values similar in 2 groups
Hepatology. 2007 Jan;45(1):97-101 Copyright @ Forever Medic Online Pvt. Ltd

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Treatment
After 1yr, 93.5% of pts in lamivudine group and 96.7% of pts in placebo group lost HBsAg After 1yr, 21 pts (67.7%) in treatment group and 34 pts (85%) in placebo developed protective anti-HBs titers No deaths in either group Conclusion: No significant biochemical or clinical improvement with lamivudine compared to placebo
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Consider Treatment in:

Pts w/ a coagulopathy (INR >1.5) Those w/ a protracted course (persistent symptoms or marked jaundice w/ bilirubin >10 mg/dl for more than four weeks) Pts with fulminant hepatitis B (to reduce the likelihood of reinfection post-liver transplant) Immunocompromised patients Those with concomitant infection with hepatitis C or D virus or preexisting liver disease Elderly patients
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Prevention
Hepatitis B vaccination! Series of three doses at months 0, 1 to 2, and then 6 to 12 In US, universal vaccination of all newborns is recommended
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Prevention
Vaccinate high risk adults:

Healthcare workers IV drug users Household contacts of people w/ Hep B Pts w/ multiple sexual partners Men who have sex with men HD patients Pts who require repeated transfusions of blood products Pts w/ chronic liver disease

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Efficacy
positive immune response is defined as development of anti-HBs at a titer of >10 IU/L 95% seroconversion in healthy adults Post-vaccination testing in healthcare workers/HD pts/pts who are at risk for recurrent exposure 1-2 mos after completion of vaccination. Nonresponders complete a second 3-dose vaccination series

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