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Hepatitis B

Viral Hepatitis Type B

Hepatitis B is a form of viral hepatitis, caused by the hepatitis B virus, a member of the Hepadnavirus family. It is estimated that worldwide, more than 350 million people have chronic hepatitis B virus infection. The course of the disease may be extremely variable, depending on the patient’s age and immune status. Complications from hepatitis B include progression to hepatocellular carcinoma and cirrhosis. Immunization with hepatitis B vaccine is the most effective means of preventing infection and its consequences.

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Presentation

There is a wide spectrum of clinical manifestation of HBV infection, ranging from an asymptomatic state to mild acute infection to severe chronic disease. The patient may have anicteric hepatitis in which the patients are mostly asymptomatic and usually proceeds to chronic hepatitis. The other form is icteric hepatitis in which the patient may complain of low grade fever, anorexia, nausea, vomiting, myalgia, fatigue and altered sensation to smell and taste. Pain in the epigastric region or right upper quadrant pain might be present. Icterus indicated by yellowing of the sclera, nails and skin is common. The urine might become dark yellow too.

Physical examination and proper history are the guides to a correct diagnosis. Physical findings include low grade fever, jaundice which may last for months but may appear 10 days after constitutional symptoms, palmar erythema, spider naevi, mildly enlarged liver and spleen. Vasculitis may or may not be present. When cirrhosis develops one may find peripheral edema, ascites, icterus, caput medusa, variceal bleeding, testicular atrophy and gynaecomastia.

Patient with chronic hepatitis may be asymptomatic or may have same symptoms as an acute infection. Later in the disease, patient may present with mental confusion, decreased or no sleep, disturbed sleep, hepatic encephalopathy and even coma. They may also have gastrointestinal bleeding and ascites. Multi-organ affection manifests itself in the form of pleural effusion, hepato pulmonary syndrome, myocarditis, pericarditis, arrhythmias and diffuse intravascular coagulopathy (DIC) that can occur in fatal hepatitis.

Patient may develop aseptic meningitis, encephalitis, Guillain-Barré syndrome (GBS) in acute phase. Pancreatitis can also occur. Cutaneous manifestations are more common in women than men.

Easy Bruising
  • Signs of severe liver scarring (cirrhosis) may include: Ascites (accumulation of fluid and swelling of the abdominal cavity) Star-shaped vein pattern developing on the swollen belly Jaundice Itching Easy bruising and bleeding Chronic HBV infection can[sfcdcp.org]
  • Symptoms of severe liver damage include the symptoms of hepatitis B and generalized itching a longer than usual amount of time for bleeding to stop easy bruising swollen stomach or ankles spiderlike blood vessels, called spider angiomas , that develop[transplant.surgery.ucsf.edu]
Splenomegaly
  • CASE REPORT: A 29-year-old man, with no significant prior medical history, presented with fever and massive splenomegaly. A diagnosis of HSTL was established by histologic examination and immunohistochemistry.[ncbi.nlm.nih.gov]
  • If patients with chronic hepatitis B progress to cirrhosis (when the liver becomes severely scarred) they will develop signs and symptoms of liver failure, including: Jaundice Splenomegaly (an enlarged spleen) Ascites (fluid retention in the abdomen)[hopkinsmedicine.org]
  • Table 3 Signs and symptoms of liver cirrhosis Clinical Fatigue Muscle wasting Dupuytren's contracture Palmar erythema Spider naevi Splenomegaly Radiological Coarse echotexture Features of portal hypertension - dilated portal vein - recanalisation of para-umbilical[doi.org]
  • Physical examination features are nonspecific but can include mild enlargement and slight tenderness of the liver, mild splenomegaly, and posterior cervical lymphadenopathy in 15% to 20% of patients.[clevelandclinicmeded.com]
Fever
  • After 4 days, he became oriented, and fever was disappeared then we continued the treatment for 16 days. The patient discharged and followed by daily phone calls.[ncbi.nlm.nih.gov]
  • It is similar to chronic liver disease because of signs and symptoms such as fever, weight loss, hepatosplenomegaly, and pancytopenia.[ncbi.nlm.nih.gov]
  • CASE REPORT: A 29-year-old man, with no significant prior medical history, presented with fever and massive splenomegaly. A diagnosis of HSTL was established by histologic examination and immunohistochemistry.[ncbi.nlm.nih.gov]
  • A 32-year man presented with melena, bleeding from gums and fever. Peripheral blood examination revealed anemia, macrocytosis and severe thrombocytopenia.[ncbi.nlm.nih.gov]
  • This outbreak was linked to specific lots of yellow-fever vaccine stabilized with human serum.[ncbi.nlm.nih.gov]
Fatigue
  • […] pulmonary artery stenosis in the presence of active hepatitis B and latent Mycobacterium tuberculosis infection in a middle-aged Asian woman who initially presented with severe dyspnea on exertion and recurrent syncope, occasional burning chest pains, and fatigue[ncbi.nlm.nih.gov]
  • A previously healthy 44-year-old woman presented with 3 days of worsening petechial rash, epistaxis and fatigue. Admission labs revealed pancytopenia, low reticulocyte index and elevated liver enzymes.[ncbi.nlm.nih.gov]
  • The clinical symptoms were subtle with fatigue and vague right upper quadrant tenderness. We ruled out drug-associated hepatotoxicity and screened for common causes of acute hepatitis.[ncbi.nlm.nih.gov]
  • A 58 years old man under 2'-Deoxy-L-thymidine treatment for his hepatitis B was admitted to our hospital complaining for the last 2 months of recurrent upper abdomen discomfort, fatigue and weight loss of 10 kilograms and general muscular soreness, for[ncbi.nlm.nih.gov]
  • Fatigue: In the acute phase, bed rest and low physical exertion may be advised.[hepmag.com]
Weakness
  • A 68-year-old woman, who underwent long-term treatment with lamivudine and adefovir for chronic hepatitis B, developed proximal muscle weakness in the four extremities.[ncbi.nlm.nih.gov]
  • He subsequently developed dysphagia with proximal limb weakness. Laboratory tests and electromyography demonstrated inflammatory myopathy. We therefore diagnosed the patient with HCC-induced dermatomyositis.[ncbi.nlm.nih.gov]
  • He developed progressive weakness and myalgia, and subsequently experienced palpitations, chest tightness, lethargy, hypotension, and hypoxemia.[ncbi.nlm.nih.gov]
  • He incidentally found his lower limbs little weakness accompanied with his wrist erythema. He was found HBsAg positive for forty years with slightly positive of α-fetal protein (AFP).[ncbi.nlm.nih.gov]
  • We identified 21 randomised trials, all with one or more methodological weaknesses. Four trials demonstrated that PDV versus placebo significantly decreased hepatitis B events at maximum follow-up (RR 0.51, 95% CI 0.35 to 0.73).[ncbi.nlm.nih.gov]
Intravenous Drugs
  • drug use, and medical procedure exposure) and are evident to varying degrees in every country.[ncbi.nlm.nih.gov]
  • drug users and prison inmates), Digestive and Liver Disease, 10.1016/j.dld.2010.12.004, 43, 8, (589-595), (2011).[dx.doi.org]
Dentist
  • Dentists are usually the first medical practitioners to diagnose this condition although it also affects body parts other than the oral mucosa. Several studies have reported an association between the OLP and hepatitis B and C infections.[ncbi.nlm.nih.gov]
  • No cases of dentist-to-patient HBV transmission have been reported since 1987 (Centers for Disease Control and Prevention [CDC], unpublished data).[dx.doi.org]
  • It is important for carriers to inform their dentist and health care providers. How can hepatitis B be prevented? A safe and effective vaccine to prevent hepatitis B is available.[health.ny.gov]
  • […] who injects drugs people who change their sexual partner frequently men who have sex with men male and female sex workers people who work somewhere that places them at risk of contact with blood or body fluids, such as nurses, prison staff, doctors, dentists[nhs.uk]
Cough
  • Babies are already vaccinated against diphtheria, tetanus, whooping cough, Hib and polio. Public Health England said the new vaccine had been "shown to be safe".[bbc.com]
  • HBV cannot be spread in food or water, and, although the virus may occur in saliva, it is not spread through kissing, coughing, sneezing, or contact with shared eating utensils.[britannica.com]
  • […] healthcare workers the blood of someone with hepatitis B getting into an open wound, cut or scratch – in rare cases, being bitten by someone with hepatitis B can also spread the infection Hepatitis B is not spread by kissing, holding hands, hugging, coughing[nhs.uk]
  • It is not spread through: Sharing food or water Sharing eating utensils or drinking glasses Tears, sweat, urine, or stool Coughing or sneezing Hugging or kissing Breastfeeding Mosquitoes[med.stanford.edu]
Dyspnea
  • Sirolimus was effective, as the chylous effusion resolved completely and the dyspnea improved. The sirolimus dosage was increased to 2 mg daily without causing HBV reactivation.[ncbi.nlm.nih.gov]
  • We report a rare case of Takayasu's arteritis with isolated pulmonary artery stenosis in the presence of active hepatitis B and latent Mycobacterium tuberculosis infection in a middle-aged Asian woman who initially presented with severe dyspnea on exertion[ncbi.nlm.nih.gov]
Nausea
  • After ten days of TDF administration, nausea, vomiting and abdominal pain developed. High anion gap acidosis with elevated lactate level (pH 7.341, pCO2 29.7 mmHg, HCO3- 15.6mmHg, lactate 3.2mmol/L, anion gap 15.4 mEq/L) was developed.[ncbi.nlm.nih.gov]
  • Hunger can intensify nausea, so try eating a cracker or other small piece of food every hour or two. Ginger helps with mild to moderate nausea. Peppermint, chamomile or raspberry leaf tea may also alleviate nausea.[hepmag.com]
  • A 58-year-old female lymphoma patient was admitted to our hospital for asthenia, nausea, vomiting, and abnormal liver function lasting over 1 week and diagnosed as acute hepatitis B.[ncbi.nlm.nih.gov]
  • Symptoms include fatigue, jaundice, nausea, vomiting, dark urine, light stools. Diagnosis is by blood test. Treatment is via anti-viral drugs and/or hepatitis B immunoglobulin (HBIG). Chronic hepatitis B may be treated with a variety of medications.[medicinenet.com]
  • Early in the disease, called the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever[hopkinsmedicine.org]
Vomiting
  • After ten days of TDF administration, nausea, vomiting and abdominal pain developed. High anion gap acidosis with elevated lactate level (pH 7.341, pCO2 29.7 mmHg, HCO3- 15.6mmHg, lactate 3.2mmol/L, anion gap 15.4 mEq/L) was developed.[ncbi.nlm.nih.gov]
  • A 58-year-old female lymphoma patient was admitted to our hospital for asthenia, nausea, vomiting, and abnormal liver function lasting over 1 week and diagnosed as acute hepatitis B.[ncbi.nlm.nih.gov]
  • Care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.[web.archive.org]
  • Symptoms include fatigue, jaundice, nausea, vomiting, dark urine, light stools. Diagnosis is by blood test. Treatment is via anti-viral drugs and/or hepatitis B immunoglobulin (HBIG). Chronic hepatitis B may be treated with a variety of medications.[medicinenet.com]
  • If a patient has had a large amount of vomiting or has not been able to take in liquids, blood electrolytes may also be checked to ensure that the patient's blood chemistry is in balance.[emedicinehealth.com]
Loss of Appetite
  • The hepatitis B virus can cause: Acute (short-term) illness, the symptoms of which are flu-like and include loss of appetite, tiredness, joint and muscle pain, diarrhea, vomiting and jaundice.[walgreens.com]
  • Symptoms that can occur include mild fever, headache, fatigue, loss of appetite, nausea and vomiting, diarrhea, muscle and joint pain, abdominal pain, a skin rash, and jaundice.[emoryhealthcare.org]
  • The symptoms of this condition include: Nausea and vomiting Fatigue Loss of appetite General aches and pains Headaches Symptoms of jaundice (yellowing of the skin and eyes) People do not know they ate infected with Hepatitis A at first because symptoms[news-medical.net]
  • When they occur, symptoms can be mistaken for the flu (nausea and vomiting, malaise, loss of appetite and abdominal pain). Some people with hepatitis B also experience jaundice, a yellowing of the eyes or skin.[ashasexualhealth.org]
  • Symptoms include: Achy muscles or joints Stomach pain Loss of appetite Mild fever Loose stool ( diarrhea ) Lack of energy Constipation Yellowing of skin or whites of the eyes Being sick to your stomach Brown urine Cleveland Clinic News & More Cleveland[my.clevelandclinic.org]
Abdominal Pain
  • After ten days of TDF administration, nausea, vomiting and abdominal pain developed. High anion gap acidosis with elevated lactate level (pH 7.341, pCO2 29.7 mmHg, HCO3- 15.6mmHg, lactate 3.2mmol/L, anion gap 15.4 mEq/L) was developed.[ncbi.nlm.nih.gov]
  • As symptoms of abdominal pain and jaundice were presented on the fifth day, he re-admitted. The patient expired because of hepatorenal and cardiac insufficiency.[ncbi.nlm.nih.gov]
  • Symptoms that can occur include mild fever, headache, fatigue, loss of appetite, nausea and vomiting, diarrhea, muscle and joint pain, abdominal pain, a skin rash, and jaundice.[emoryhealthcare.org]
  • However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.[web.archive.org]
  • Most people do not experience any symptoms during acute infection but may have symptoms, such as yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. 4 5 In the U.S., individuals at highest risk[nvic.org]
Diarrhea
  • Symptoms that can occur include mild fever, headache, fatigue, loss of appetite, nausea and vomiting, diarrhea, muscle and joint pain, abdominal pain, a skin rash, and jaundice.[emoryhealthcare.org]
  • Symptoms include: Achy muscles or joints Stomach pain Loss of appetite Mild fever Loose stool ( diarrhea ) Lack of energy Constipation Yellowing of skin or whites of the eyes Being sick to your stomach Brown urine Cleveland Clinic News & More Cleveland[my.clevelandclinic.org]
  • […] the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever Cough Abdominal pain and/or diarrhea[hopkinsmedicine.org]
  • The hepatitis B virus can cause: Acute (short-term) illness, the symptoms of which are flu-like and include loss of appetite, tiredness, joint and muscle pain, diarrhea, vomiting and jaundice.[walgreens.com]
Jaundice
  • Group I consisted of patients who had received the implicated vaccine and had jaundice; Group II had received the implicated vaccine but remained well; Group III had received a new, serum-free vaccine, with no subsequent jaundice.[ncbi.nlm.nih.gov]
  • Symptoms of liver disease emerge as the condition progresses and include dark urine, pale stools, jaundice with icterus (jaundice of the sclera of the eye ), and pain in the abdomen. Acute symptoms last anywhere from one to four months.[britannica.com]
  • As symptoms of abdominal pain and jaundice were presented on the fifth day, he re-admitted. The patient expired because of hepatorenal and cardiac insufficiency.[ncbi.nlm.nih.gov]
  • Generally, the term hepatitis decribes any inflammation of the liver, caused by a virus or a toxin such as alcohol, and characterized by jaundice, liver enlargement, and fever. Today, hepatitis B remains a major global concern.[ppdictionary.com]
  • Jaundice develops at this stage accompanied by dark urine and a pale stool. In the majority of cases recovery starts after about three to four weeks.[tmb.ie]
Scleral Icterus
  • It usually presents as a subclinical, mild illness, with only up to 30% of people developing scleral icterus, nausea, vomiting, and right‐upper quadrant tenderness ( Bodihar 2004 ).[doi.org]
Hepatosplenomegaly
  • It is similar to chronic liver disease because of signs and symptoms such as fever, weight loss, hepatosplenomegaly, and pancytopenia.[ncbi.nlm.nih.gov]
Arthralgia
  • METHODS: A 52-year-old woman presented with unilateral eye pain and photophobia, arthralgia, remnants of a maculopapular rash, and subsequently facial numbness several weeks later.[ncbi.nlm.nih.gov]
  • Numerous extrahepatic manifestations have been reported in patients with both acute and chronic hepatitis B (arthralgias or arthritis, skin rashes, glomerulonephritis and neuritis), all of which are present in polyarteritis nodosa (PAN) which is the most[ncbi.nlm.nih.gov]
  • Abstract Eighteen patients with acute viral hepatitis had initial symptoms of arthralgia, arthritis or urticaria.[doi.org]
  • The onset is usually insidious, with anorexia, abdominal discomfort, nausea, vomiting, lethargy, and occasional rash and arthralgia. It often progresses to dark urine, light stools and jaundice.[ideas.health.vic.gov.au]
  • PAN include the following: Cardiovascular (eg, hypertension [sometimes severe], pericarditis, heart failure) Renal (eg, hematuria, proteinuria, renal insufficiency) Gastrointestinal (GI) (eg, abdominal pain, mesenteric vasculitis) Musculoskeletal (eg, arthralgias[emedicine.medscape.com]
Myalgia
  • The patient was diagnosed with Hepatitis B envelope Antigen positive CHB, cirrhosis, LA and RM characterized by myalgia and elevated myoglobin. He was given tenofovir alone as antiviral treatment instead.[ncbi.nlm.nih.gov]
  • He developed progressive weakness and myalgia, and subsequently experienced palpitations, chest tightness, lethargy, hypotension, and hypoxemia.[ncbi.nlm.nih.gov]
  • Patients might report mild flu-like symptoms such as anorexia, myalgia, nausea, vomiting, fatigue, malaise and low-grade fevers, Ali said.[web.archive.org]
  • Early in the disease, called the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever[hopkinsmedicine.org]
  • The other form is icteric hepatitis in which the patient may complain of low grade fever, anorexia, nausea, vomiting, myalgia, fatigue and altered sensation to smell and taste.[symptoma.com]
Urticaria
  • Abstract Eighteen patients with acute viral hepatitis had initial symptoms of arthralgia, arthritis or urticaria.[doi.org]
  • Local pain and tenderness at the injection site, urticaria, and angioedema might occur; anaphylactic reactions, although rare, have been reported following the injection of human immune globulin (IG) preparations ( 1 ).[cdc.gov]
  • Adverse reactions noticed with HBIG include erythema, pain, tenderness at the injection site, headache, malaise, agitation, amnesia, essential tremor, fatigue, light‐headedness or fainting, pyrexia, angioedema, pruritus, rash, urticaria, nausea, vomiting[doi.org]
Dark Urine
  • Symptoms include fatigue, jaundice, nausea, vomiting, dark urine, light stools. Diagnosis is by blood test. Treatment is via anti-viral drugs and/or hepatitis B immunoglobulin (HBIG). Chronic hepatitis B may be treated with a variety of medications.[medicinenet.com]
  • Symptoms of liver disease emerge as the condition progresses and include dark urine, pale stools, jaundice with icterus (jaundice of the sclera of the eye ), and pain in the abdomen. Acute symptoms last anywhere from one to four months.[britannica.com]
  • However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.[web.archive.org]
Dizziness
  • Tell your provider if you feel dizzy, or have vision changes or ringing in the ears. Some people get shoulder pain that can be more severe and longer-lasting than the more routine soreness that can follow injections. This happens very rarely.[healthychildren.org]
  • Mild-to-moderate problems: Soreness, redness, or swelling where the shot was given Headache, tiredness, fever and loss of appetite Severe problems (rare): Difficulty breathing Wheezing Hives Pale skin Fast heartbeat Dizziness Over-the-counter pain relievers[walgreens.com]
  • Up to 10% of people experience fatigue, dizziness, headache, or a fever over 100ºF. What are the most severe vaccine side effects? The following is a list of severe side effects that have been reported in people who received the Hepatitis B.[immunizationinfo.com]
  • […] occurs in 0.6–3.7% of neonates) medical investigation for sepsis serious outcomes Adults Adverse events after hepatitis B vaccination are transient and minor, and include: 22 soreness at the injection site (5%) fever (usually low grade; 2–3%) nausea dizziness[immunisationhandbook.health.gov.au]
  • The most frequent adverse events were myalgia/arthralgia, skin rashes, and dizziness. No serious adverse events attributable to PDV were reported by this study.[doi.org]

Workup

Patients may present with minimal to wide range of symptoms. Laboratory tests are done to confirm the diagnosis and include, liver function tests, liver enzyme studies like alanine amino transferace (ALT), asparate amino transferace (AST) which are 100 times higher (almost 1000-2000IU/ml) and are the hallmark of acute hepatitis. ALT is usually higher than AST but if AST is higher than ALT, then one must consider cirrhosis. Gamma glutamyl transpeptidase (GGT) and alkaline phosphate levels (ALP) are also elevated.

Complete blood count, platelet count, haematologic and coagulation tests are also done. Serologic tests to determine HBsAg, antibody to HBc and IgM are necessary to diagnose acute hepatitis. HBeAg and HBV DNA quantification should be done to know patient’s level of infection.

Radiographic tests include abdominal ultrasonography, CT scan and MRI to look for biliary obstruction as the echogenecity of the liver parenchyma increases.

Histologic testing is done by performing a liver biopsy especially for chronic hepatitis cases in which the findings show ground glass appearance of hepatocytes due to infiltration of viral cells. In acute phase, one can see dying hepatocytes with lymphocytic infiltration. Once the diagnosis is confirmed, an immediate treatment plan is necessary [7].

Hepatocellular Carcinoma
  • Key words: antiviral drugs, cirrhosis, hepatocellular carcinoma, liver.[web.archive.org]
  • KEYWORDS: AX800134; Hepatitis B virus; Hepatocellular carcinoma; Long non-coding RNA[ncbi.nlm.nih.gov]
  • Potential long-term sequelae include cirrhosis, hepatic decompensation, and hepatocellular carcinoma. Increased viral load is associated with greater risk for cirrhosis, hepatocellular carcinoma, liver-related death, and disease transmission.[doi.org]
  • This reduces inflammation, can improve liver injury and reduces progression to cirrhosis and hepatocellular carcinoma. Long-term monitoring is recommended to detect reactivation of infection and hepatocellular carcinoma.[doi.org]

Treatment

The plan of action for treatment of hepatitis B is to take care of the acute cases by admitting them in the ICU. Patients with acute hepatitis should be given tenofovir disoproxil fumarate (TDF) or entecavir (ETV) as the first line of treatment. Biochemic tests should be done regularly to see the improvement.

National Institute of Health recommends nucleotide therapy for acute phase as well as for those fulminant phases in which complications like cirrhosis, fibrosis, HBV DNA positive and chronic HBV cases which reactivate during chemotherapy. Antiviral treatment is given using pegylated interferon and nucleotide analogues. Patient’s immunity is increased using immunotherapeutic intervention. The goal is to stop the progress of disease.

Patients with chronic hepatitis and eventually hepatic failure should be admitted in the hospital and considered for liver transplant in case the disease progresses to end stage [8] [9].

Vaccine or immunoglobulins should be administered to the newborn of a positive HBsAg mother. Also, if there is an accidental needle prick or contact with a material like blade of the infected person, then they should receive Hepatitis B immunoglobulin and first dose of Hepatitis B vaccine at the same time. These individuals should be kept under observation and regular blood tests should be done to check for the disease [10].

Prognosis

The prognosis is bad as nearly one million people die of hepatitis B globally every year. The fatal outcomes are those related to hepatocellular carcinoma and cirrhosis. Old age, low immunity, alcohol intake, infection, cirrhosis, thrombocytopenia and mutation in the core can increase the risk of HCC.

However, individuals who have negative HBe Antigen and in whom HBV DNA is not detected, have a good prognosis, as in their body the disease progresses slowly and their survival period prolongs. The complications are lesser as well [6].

Etiology

Hepatitis B is caused by the Hepatitis B Virus (HBV) which is a DNA virus. It is transmitted through the infected person via body fluids like blood, saliva, semen and vaginal secretion. Thus sharing of needles, blades, having a sexual contact with the infected person and procedures like blood transfusion and organ transplant can put one at the risk of catching the infection. It is also transmitted to the newborn via infected mother during labour.

Thus proper laboratory tests before any procedure are a must. Various genes are found to be associated with the disease; however the subject is still under research [1] [2] [3].

Epidemiology

  • Author information 1 Department of Epidemiology and Biostatistics, Key Laboratory of Environment and Health of Ministry of Education, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To investigate epidemiological characteristics and HBV genotypes and subgenotypes circulating in a specific city with high HBV prevalence.[ncbi.nlm.nih.gov]
  • Most genotypes are now divided into subgenotypes with distinct virological and epidemiological properties. In addition, recombination among HBV genotypes increases the variability of HBV.[ncbi.nlm.nih.gov]
  • Infection Control & Hospital Epidemiology ISSN: 0899-823X EISSN: 1559-6834 URL: /core/journals/infection-control-and-hospital-epidemiology Metrics Full text views Full text views reflects the number of PDF downloads, PDFs sent to Google Drive, Dropbox[dx.doi.org]
Sex distribution
Age distribution

Pathophysiology

Hepatitis B Virus is a spherical, double shelled particle with rods and spheres and it can withstand extremes of temperature. It is a DNA virus that encodes four genes: surface gene S, core gene C, e antigen, X gene and polymerase gene P. The surface gene encodes viral envelope. The core antigen encloses viral DNA and is found on hepatocytes during immune response. The ‘e antigen’ is a marker of viral replication. The X gene encodes protein that helps in viral replication; thus it is involved in carcinogenesis.

If after the treatment a person develops antibodies to HBsAg, it suggests that the patient has recovered from HBV infection. Also, if a person is vaccinated, he will show anti-HBsAg antibodies positive. If the person has anti-HBcAg antibody, it is suggestive of a previous infection with HBV and has high chances of recurrence as the virus is still present. Anti-HBeAg suggest non-replicative state if HBV DNA is not found. However, HBeAg negative strains have also emerged [4].

When the immune system recognizes HBV on the surface of hepatocytes, it releases cytokines and other antibodies. CD4, CD8 lymphocytes are activated and attack HBV. However, in this the liver is injured and can also get cirrhosed. The patient can develop hepatocellular carcinoma.

Once the virus has entered the host, the disease begins. There are five stages of disease progression:

Stage 1

The incubation period of HBV is 2-4 weeks during which the patient remains asymptomatic. It can even be decades for a new born. The virus replicates itself without any manifestation of symptoms or increase in aminotransferase levels. It is an immune tolerance stage.

Stage 2

This is an active immune stage wherein the body reacts by producing inflammatory changes. It lasts for 3 to 4 weeks and HBeAg can be identified in the serum. HBV DNA starts decreasing in the patients who are clearing the infection.

Stage 3

This is an inactive, chronic stage in which the replication of virus is slow or nil and anti-HBeAg antibodies are detected. However, HBsAg is still present in the serum.

Stage 4

This is chronic disease in which HBeAg-negative disease can occur.

Stage 5

This is a stage of recovery when no HBV DNA or HBsAg is detected in the blood and there are antibodies against HBV antigens.
It can cause polyarteritis nodosa which is a serious complication during the earlier course of disease. In the chronic stage, HBV infection can cause cirrhosis of liver, glomerular nephritis and hepatocellular carcinoma (HCC) [5].

Prevention

The disease is transmitted via body fluids hence people should be educated to not share needles, scissors and shaving blades. One must avoid sexual contact with multiple partners and use contraceptive measure like condoms in case of affected partner.

Hepatitis B is transmitted via mother to the child during delivery hence screening the mother during the pregnancy for Hepatitis B is a must [11]. If the newborn is born to hepatitis B mother he/she is given a hepatitis B immunoglobulin [HBIG] with hepatitis B vaccine within 12 hours of birth. They should then follow the recommended vaccination schedule for children [12].

Also candidates who donate blood or organs are screened for the presence of virus. Healthcare workers are given Hepatitis B vaccine as they have high chances of getting infected with the disease.

Summary

Hepatitis B is a common problem worldwide as one third of the global population is infected with Hepatitis B Virus (HBV). It is transmitted via body fluids.

The patient may remain asymptomatic for months before the clinical symptoms manifest. It is a disease of global concern and the vaccine against HBV is compulsory in nearly all the countries.

Patient Information

Hepatitis B is a viral disease which has affected almost the whole world. It is transmitted via contaminated blood, saliva, semen and vaginal secretion. People in contact with the affected patients should avoid sharing of blades, needles, shaving kit. One should refrain from having sexual contact with infected individuals. Mothers should be screened during pregnancy for Hepatitis B as it is transmitted to the child during the process of delivery.

Hepatitis B symptoms range from no symptoms to the dreaded liver cancer (hepatocellular carcinoma) which can cause death. Patient may complain of low grade fever, reduced appetite, muscular pain, jaundice, nausea, vomiting and pain in the right upper quadrant of abdomen.

Laboratory tests show altered liver function tests and blood counts. Treatment aims at halting the progress of disease which causes liver failure and finally hepatocellular carcinoma.

References

Article

  1. Thursz MR, Thomas HC, Greenwood BM, Hill AV. Heterozygote advantage for HLA class-II type in hepatitis B virus infection. Nat Genet. 1997 Sep;17(1):11-2.
  2. Jouanguy E, Lamhamedi-Cherradi S, Altare F, Fondanèche MC, et al. Partial interferon-gamma receptor 1 deficiency in a child with tuberculoid bacillus Calmette-Guérin infection and a sibling with clinical tuberculosis. J Clin Invest. 1997 Dec 1;100(11):2658-64.
  3. Zhou J, Chen DQ, Poon VK, Zeng Y, et al. A regulatory polymorphism in interferon-gamma receptor 1 promoter is associated with the susceptibility to chronic hepatitis B virus infection. Immunogenetics. 2009 Jun;61(6):423-30.
  4. Gish RG, Locarnini S. Chronic hepatitis B viral infection. In: Yamada T, ed. Textbook of Gastroenterology. 5th ed. Oxford, UK: Blackwell Publishing; 2009:2112-38.
  5. Kuo A, Gish R. Chronic hepatitis B infection. Clin Liver Dis. 2012 May;16(2):347-69.
  6. Heidrich B, Serrano BC, Idilman R, Kabaçam G, et al. HBeAg-positive hepatitis delta: virological patterns and clinical long-term outcome. Liver Int. 2012 Oct;32(9):1415-25
  7. Papatheodoridis G, Buti M, Cornberg M, et al. For the European Association for the Study of the Liver. EASL clinical practice guidelines: Management of chronic hepatitis B virus infection. J Hepatol. 2012 Jul;57(1):167-85.
  8. Liaw YF, Leung N, Kao JH, Piratvisuth T, et al. Asian-Pacific consensus statement on the management of chronic hepatitis B: a 2008 update. Hepatol Int. 2008 Sep;2(3):263-83.
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Last updated: 2019-07-11 22:31