Acute Hepatitis B

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Acute Hepatitis B

• Liz Dehmer
• am report 2/25/08

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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
• lt5 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 anti-HBc
  (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 gt 6 months

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Diagnosis
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Laboratory Testing

• Elevated transaminases-values up to 1000-2000
  IU/L with ALT gt 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 gt 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 well-compensated 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 (p0.037), but thereafter levels
  were similar
• Improvement in serum bili, ALT, INR values
  similar in 2 groups

Hepatology. 2007 Jan45(1)97-101
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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

Hepatology. 2007 Jan45(1)97-101
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Consider Treatment in

• Pts w/ a coagulopathy (INR gt1.5)
• Those w/ a protracted course (persistent symptoms
  or marked jaundice w/ bilirubin gt10 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 gt10 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