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Revisin Seminarios Clnica de Asma y Alergia Hepatitis A-E APrevencin, Laboratorios, Prevencin, Laboratorios, Algoritmos Diagnstico, Referencia. Diagnstico, Referencia. 1
04/01/2012
Ian Williams, PhD, MS Division of Viral Hepatitis Centers for Disease Control and Prevention
Bibliografa Emedecine
Hepatitis A Author: Richard K Gilroy, MBBS, FRACP; Chief Editor: Julian Katz, MD , updated:25agosto 2011
Hepatology - A Clinical Textbook Second Edition Editors:Stefan Mauss ,Thomas Berg,Jrgen Rockstroh Christoph Sarrazin,Heiner Wedemeyer. Wedemeyer.
Consideraciones generales
One of the more common causes of acute hepatitis is (HAV), which was isolated by Purcell in 1973. Humans appear to be the only reservoir for this virus. Since the application of accurate serologic investigations in the 1980s, the epidemiology, clinical manifestations, and natural history of hepatitis A have become apparent.
Hepatitis A
Ictericia
Manifested here as icterus, or jaundice of the icterus, conjunctivae and facial skin Source: Centers for Disease Control and Prevention
Man with jaundice (yellowing of skin and eyes)Source: Centers for Disease Control and Prevention
Hepatitis A Virus
Naked RNA virus Related to enteroviruses, formerly known as enterovirus 72, 72, now put in its own family: heptovirus family: One stable serotype only Difficult to grow in cell culture: primary marmoset cell culture: culture and also in vivo in chimpanzees and marmosets 4 genotypes exist, but in practice most of them are group 1
Etiologa Epidemiologa
Most patients have no defined risk factors for hepatitis A. Risk factors for the acquisition of hepatitis A include the following: Personal contacts Institutionalization Occupation (eg, daycare) Foreign travel Male homosexuality ( Ano - lingual) Illicit parenteral drug use
Epidemiologa
Problema sobre todo en estacin lluviosa, las innundaciones provocan mezcla de aguas pluviales con aguas negras , ambas contaminan los pozos y la red de agua potable Promiscuidad, sobretodo, prostitucin infantil aumento en homosexuales , no hay datos oficiales del MINSA
Close personal contact (e.g., household contact, sex contact, child day care centers) Contaminated food, water (e.g., infected (e.g., food handlers, raw shellfish) . Conchas negras de los esteros, Nicaragua) esteros, Blood exposure (rare) (e.g., injecting drug use, transfusion)
Low
Very low
Low Young adultsPerson to person; food and waterborne outbreaks Very low Adults Travelers; outbreaks uncommon
NANB
Parenterally C transmitted F, G, ? other
Serum
B D
*linear, single strand; ** circular, double strand; *** circular, single strand
Incubation Period* 4 (2-6) 8-12 (6-24) 6-9 (2-24) ? (2-10) 4-5 (2-9)
63% 28% 8%
Hepatitis A Hepatitis B Hepatitis C Non-ABCDE
1%
Source: Sentinel Counties Study, CDC
PATOFISIOLOGIA
Average 30 Range 15-50 days <6 yrs, <10% 6-14 yrs, 40%-50% >14 yrs, 70%-80% Fulminant Cholestatic
Chronic sequelae:
Evolucin Hepatitis A
Laboratory Diagnosis
Acute infection is diagnosed by the detection of HAV-IgM HAVin serum by EIA. EIA. Past Infection i.e. immunity is determined by the detection of HAV-IgG by EIA. HAVEIA. Cell culture difficult and take up to 4 weeks, not routinely performed Direct Detection EM, RT-PCR of faeces. Can RTfaeces.
Diagnstico diferencial
Hepatitis de otra etiologa
Alcoholic Hepatitis Autoimmune Hepatitis Dermatologic Manifestations of Hepatitis C Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Hepatitis in Pregnancy Pediatric Hepatitis A Pediatric Hepatitis B Pediatric Hepatitis C Viral Hepatitis
Mechanism of Injury
Chronic infection:
immune response probably more important
Jaundice
Case fatality
Chronic infection
Extrahepatic manifestations
Cutaneous vasculitis, artrhitis..related to artrhitis..related cryoglobulinemia Hematological complications: complications: thrombocytopenia, thrombocytopenia, red cell aplasia,
Prognstico
Excelente
Hepatitis C mortalidad
Emedecine
RELATED NEWS AND ARTICLES Updated 2011
What Factors Determine the Severity of Hepatitis AArelated Acute Liver Failure? Hepatitis A Infection Risk in ForeignForeign-Born Adoptees, Their Contacts
Clinical Features of Acute Renal Failure Associated with Hepatitis AVirus Infection
PrePre-exposure
travelers to intermediate HAVHAV-endemic regions and high
Prepared from pooled human plasma Mechanism of action: passive transfer action: of neutralizing antibodies Prevents infection or clinical expression of disease
PostPost-Exposure Prophylaxis
Must be given within 14 days of exposure Used for household and sexual exposures Sometimes used for common source exposures (e.g., infected food handler)
for pre-exposure prophylaxis pre Given as 2-dose series 2 Licensed for use for persons >2 years old Duration of protection: at least 20 years possibly lifelong Unresolved issues:
use for post-exposure prophylaxis post use in community-wide outbreaks community-
to HAV endemic countries Homosexual and bisexual men Drug users (IDU and other street drugs) Persons with chronic liver disease (disease more server in these persons not necessarily at higher risk) Children living in states with high rates of hepatitis A
Algoritmos diagnosticos
1. Clinical Features of Typical Hepatitis A Viral Hepatitis 2. Complications and Extrahepatic Manifestations of Hepatitis A 3. Risk Factors for Becoming Infected with Hepatitis A Virus
Mode
injection drug use needle stick injury blood/ serous fluid sex perinatal
Percutaneous Apparent
Inapparent
Permucosal
HCV
++++ + + +/-
HIV
++ ++ ++ +/-
Risk Factor
Injection drug use MSM Heterosexual partners Transfusion Occupational No Identified Risk
HBV
14% 15% 40% rare 5-7% (past) 30%
HCV
60% 1% 20% Past 7- 20% <<1% 10%
HIV
31% 47% 10% Past 2% <<1% 9%
HBV
~1.2 (million)
HCV
~2.7 (million) ~40,000 8,000
HIV
~0.8 (million) ~40,000 18,000
~120,000 5,000
Chapter 5:The human hepatitis B virus Classification, biology, life cycle, in vitro
and in vivo models Jessika Lsebrink, Verena Schildgen, Oliver Schildgen Lsebrink, Schildgen,
the Dane particle, is of a spherical shape with a diameter of 4242-47 nm these proteins, known by their sizes as small (HBsAg), middle (HBmAg), or large (HBlAg), are HBsAg), (HBmAg), (HBlAg), acquired during budding into the ER
Emedecine.Hepatitis Emedecine.Hepatitis B
Blumberg et al reported the discovery of the hepatitis B surface antigen (HBsAg), also known as Australia
In 1965, antigen, and its antibody,
Patofisiologa
Hepatitis B Author: Nikolaos T Pyrsopoulos, MD, PhD, MBA, FACP; Chief Editor: Julian Katz, MD , updated Nov.2011
Patofisiologa
Liver biopsy specimen showing the ground-glass appearance groundof hepatocytes in a patient with hepatitis B.
Epidemiologa
HighHigh-risk heterosexual men and women Sexually active homosexual men Injection drug users Health care workers Household and sex partners of persons with chronic infection Hemodialysis patients Recipients of blood products Clients and employees of institution for developmentally disabled Families of adoptees from HBV endemic countries Inmates of correctional facilities
>1 sex partner in the past 6 months STD clinic patients Recently acquired STD Commercial sex workers
Reported Risk Factors for Acute Hepatitis B in the U.S. (1991-2000) (1991IDU (20%) MSM (12%)
Unrecognized (14%)
Percutaneous and permucosal e.g., IDU, needle stick injuries Sexual homosexual and heterosexual Perinatal From mother to child during labor and delivery (in utero (in transmission rare)
History
Acute phase Hyperacute phase Chronic phase Hepatic decompensation See notes
HepatitisB
Hepatitis aguda Physical Examination Low-grade fever Low Jaundice (10 d after the appearance of
constitutional symptomatology and lasting for 1-3 1mo)
Cirrosis
Ascites Jaundice History of variceal bleeding Peripheral edema Gynecomastia Testicular atrophy Abdominal collateral veins (caput medusa)
Chronic Hepatitis
High vs low replicative state AlfaAlfa-fetoprotein (AFP) concentrations correlate with disease activity. In exacerbations of hepatitis B concentrations as high as 1000 ng/mL may ng/ be seen. HBeAg (+) ( -) , and HBeAb HBsAg HBsAg clearance favorable prognosis
Staging Estadios
Grados de inflamacion Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
Estadios de cirrosis
Stage 0 No fibrosis Stage 1 Portal fibrosis Stage 2 Periportal fibrosis Stage 3 Septal, bridging Septal, fibrosis
Liver biopsy with trichrome stain showing stage 3 fibrosis in a patient with hepatitis B.
Biopsy with hematoxylin stain showing stage 4 fibrosis (Cirrosis ) in a patient with hepatitis B.
Extrahepatic manifestations
Polyarteritis nodosa Nephropathy/ Nephropathy/ membranous glomerulonephritis ( proteinuria) most cases occurs in childrens. childrens.
80 Chronic Infection 60
80
60
40
40
20
20
0 >5 years
Age at Infection
Chapter 9: Standard of care for hepatitis B virus infection Florian van Bmmel, Johannes Bmmel, Wiegand, Wiegand, Thomas Berg.. Updated 2010 Berg..
Treatment
Diagnstico diferencial
Autoimmune Hepatitis Cholangitis Cirrhosis Hemochromatosis Hepatic Carcinoma, Primary Hepatitis A Hepatitis C Hepatitis D Hepatitis E Hepatitis, Viral
Workup Diagnstico
Approach Considerations
Laboratory evaluation for hepatitis B disease: Liver disease: function tests (LFTs), including levels of alanine LFTs), aminotransferase (ALT) and/or aspartate aminotransferase and/or (AST), alkaline phosphatase (ALP), total and direct serum bilirubin, bilirubin, and urine bilirubin and urobilinogen. urobilinogen. Hematologic and coagulation studies include prothrombin time (PT), total protein level, albumin level, complete level, level, blood cell (CBC) count. Platelets count. Platelets In severe cases, serum ammonia levels may be obtained.
Test diagnsticos
De acuerdo al estadio. Acute Chronic inactive hepatitis B disease Chronic active hepatitis B disease (TissueTissuenonspecific antibodies). Cirrhosis
Radiologic studies, US, MRI (ferrumoxides) for SRE tumors identifications
Medications ( INF a, Lamivudine,Telbivudine,Adefovir, Lamivudine,Telbivudine,Adefovir, Tentecavir, Tentecavir, Tenofovir Algoritms (American Association for the Study of Liver Diseases (AASLD). pdf Transplantation Notes at bottom page
Prognosis
Hepatitis B Prognosis
9% de pacientes con cirrosis desarrollan cancer a 73 meses de seguimiento. HBsAg, HbsAb, HBsAg, HbsAb, HBV, aumento riesgo de cancer. cancer. Variables and survival ( albumin, albumin, plaquetas, splenomegalia, bilirubina, splenomegalia, bilirubina, HB eAg. eAg.
Hepatitis B Vaccine
Pre-exposure prophylaxis Pre Post-exposure prophylaxis Post-
Must be given soon after exposure to be effective Does not protect against future exposures
Hepatitis B Vaccine
Worldwide, plasma-derived and recombinant plasmaformulations available Only recombinant available in U.S. Given as a 3-dose series 3 Highly immunogenic seroconversion ~95% Protection long-lasting booster doses of vaccine longnot recommended
Routine vaccination of infants Routine vaccination of adolescents not vaccinated in infancy Vaccination of high-risk children, highadolescents, and adults
HepB3, DTP3, and Hib3 Coverage, Among 19-35 Month-Old Children, 1992-2000
100 90 80 70 60 50 40 30 20 10 0
DTP3 Hib3
Routine HepB vaccination recommended
Coverage, %
HepB3
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Year
Reported Cases of Acute Hepatitis B in Children United States, 1985-2000 19851 to 4 yrs 200 Reported Cases 150 100 50 0
85 19 86 19 87 19 88 19
5 to 9 yrs
Year
fecal-oral
Percutaneous yes
Percutanous yes
Percutaneous yes
fecaloral no
no
no no
yes** no
no no
Diagnstico D hepatitis
Hepatitis E
HEPATITIS C..