Table 304-2 Clinical and Epidemiologic Features of Viral Hepatitis

FeatureHAVHBVHCVHDVHEV

Incubation (days)1545, mean 3030180, mean 609015160, mean 5030180, mean 60901460, mean 40

OnsetAcuteInsidious or acuteInsidiousInsidious or acuteAcute

Age preferenceChildren, young adultsYoung adults (sexual and percutaneous), babies, toddlersAny age, but more common in adultsAny age (similar to HBV)Young adults (2040 years)

Transmission

Fecal-oral++++++

PercutaneousUnusual+++++++++

Perinatal+++a+

Sexual++a++

Clinical

SeverityMildOccasionally severeModerateOccasionally severeMild

Fulminant0.1%0.11%0.1%520%b12%e

Progression to chronicityNoneOccasional (110%) (90% of neonates)Common (85%)CommondNone

CarrierNone0.130%c1.53.2%VariablefNone

CancerNone+(Neonatal infection)+None

PrognosisExcellentWorse with age, debilityModerateAcute, good Chronic, poorGood

ProphylaxisIG, inactivated vaccineHBIG, recombinant vaccineNoneHBV vaccine (none for HBV carriers)Vaccine

TherapyNoneInterferonLamivudineAdefovirPegylated interferonEntecavirTelbivudineTenofovirPegylated interferon plus ribavirin telaprevir boceprevirInterferonNone

Table 304-6 Simplified Diagnostic Approach in Patients Presenting with Acute Hepatitis

Serologic Tests of Patient's Serum

HBsAgIgM Anti-HAVIgM Anti-HBcAnti-HCVDiagnostic Interpretation

++Acute hepatitis B

+Chronic hepatitis B

++Acute hepatitis A superimposed on chronic hepatitis B

+++Acute hepatitis A and B

+Acute hepatitis A

++Acute hepatitis A and B (HBsAg below detection threshold)

+Acute hepatitis B (HBsAg below detection threshold)

+Acute hepatitis C

Table 304-1 Nomenclature and Features of Hepatitis Viruses

Hepatitis TypeVirus Particle, nmMorphologyGenome*ClassificationAntigen(s)AntibodiesRemarks

HAV27Icosahedral nonenveloped7.5-kb RNA, linear, ss, +HepatovirusHAVAnti-HAVEarly fecal sheddingDiagnosis: IgM anti-HAVPrevious infection: IgG anti-HAV

HBV42Double-shelled virion (surface and core) spherical3.2-kb DNA, circular, ss/dsHepadnavirusHBsAgHBcAgHBeAgAnti-HBsAnti-HBcAnti-HBeBloodborne virus; carrier stateAcute diagnosis: HBsAg, IgM anti-HBcChronic diagnosis: IgG anti-HBc, HBsAgMarkers of replication: HBeAg, HBV DNALiver, lymphocytes, other organs

27Nucleocapsid coreHBcAgHBeAgAnti-HBcAnti-HBeNucleocapsid contains DNA and DNA polymerase; present in hepatocyte nucleus; HBcAg does not circulate; HBeAg (soluble, nonparticulate) and HBV DNA circulatecorrelate with infectivity and complete virions

22Spherical and filamentous; represents excess virus coat materialHBsAgAnti-HBsHBsAg detectable in >95% of patients with acute hepatitis B; found in serum, body fluids, hepatocyte cytoplasm; anti-HBs appears following infectionprotective antibody

HCVApprox. 4060Enveloped9.4-kb RNA, linear, ss, +HepacivirusHCVC100-3C33cC22-3NS5Anti-HCVBloodborne agent, formerly labeled non-A, non-B hepatitisAcute diagnosis: anti-HCV (C33c, C22-3, NS5), HCV RNAChronic diagnosis: anti-HCV (C100-3, C33c, C22-3, NS5) and HCV RNA; cytoplasmic location in hepatocytes

HDV3537Enveloped hybrid particle with HBsAg coat and HDV core1.7-kb RNA, circular, ss, Resembles viroids and plant satellite virusesHBsAgHDV antigenAnti-HBsAnti-HDVDefective RNA virus, requires helper function of HBV (hepadnaviruses); HDV antigen present in hepatocyte nucleusDiagnosis: anti-HDV, HDV RNA; HBV/HDV coinfectionIgM anti-HBc and anti-HDV; HDV superinfectionIgG anti-HBc and anti-HDV

HEV3234Nonenveloped icosahedral7.6-kb RNA, linear, ss, +HepevirusHEV antigenAnti-HEVAgent of enterically transmitted hepatitis; rare in USA; occurs in Asia, Mediterranean countries, Central AmericaDiagnosis: IgM/IgG anti-HEV (assays not routinely available); virus in stool, bile, hepatocyte cytoplasm

Harrison'sPRINCIPLES OF INTERNAL MEDICINEEighteenth Edition