hepatitis c in children - wordpress.com · 2014-03-23 · hdv deltaviridae rna* yes hev hepeviridae...
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Viral Hepatitis in Children
DR. HOSSAIN IBRAHIM AGEEL PEDIATRIC GASTROENTEROLOGIST
PEDIATRIC DEPARTMENT KFCH – JAZAN
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General Concepts
• Hepatitis = 'inflammation of the liver'.
• Virus causes:
Hepatotropic and non-hepatotropic
• Hepatotropic viruses:
HAV, HBV, HCV, HDV, HEV, HGV
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ENVELOPE DNA or RNA FAMILY VIRUS
No RNA* Picornaviridae HAV
Yes DNA** Hepadnaviridae HBV
Yes RNA* Flaviviridae HCV
Yes RNA* Deltaviridae HDV
No RNA* Hepeviridae HEV
Yes RNA* Flaviviridae HGV
Classification of Hepatitis Viruses
*Single strand ** Double strand
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Worldwide infection
Transmission of hepatitis A virus:
Fecal-oral route
• Close personal contact
• Contaminated water and food
Parentral (rare)
Incubation: 15-50 days (mean 28)
Hepatitis A Virus Infection
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Pathogenesis
HAV infection is biphasic process:
• Non-cytopathic stage
• Cytopathic stage
Hepatocellular damage is immune mediated
process and not direct cytopathic effect by
hepatitis A virus.
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Clinical manifestations
HAV infection is an acute self-limited illness
• General nonspecific symptoms (fever, malaise, anorexia,
vomiting, nausea, abdominal pain and diarrhea)
• Jaundice
• Choluria (bilirubin in urine)
• Mild hepatomegaly
Symptomatic hepatitis:
30% of infected children younger than six years.
70 – 80% in older children and adults infected with HAV
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Atypical presentations
Hepatic manifestations: • Relapsing hepatitis (3-20%)
• Acute liver failure (<1%)
• Cholestasic hepatitis (30% of adult).
• Autoimmune hepatitis.
Extra-hepatic manifestations (common)
• An evanescent rash (11%)
• Arthralgias (14%)
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Atypical presentations
Extra-hepatic manifestations (rare)
• Vasculitis
• Arthritis
• Optic neuritis
• Transverse myelitis
• Encephalitis
• Bone marrow suppression
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Diagnosis
Serologic tests:
• Anti HAV IgM : indicates an acute infections
• Anti HAV IgG : indicates resolved infections or
vaccine induced immunity.
Other techniques:
• HAV detection in stool and body fluids by electron
microscopy.
• HAV RNA detection in stool, body fluids, serum and
liver tissues by PCR.
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Treatment
Self-limited disease, rarely requires hospitalization
Only supportive measures in uncomplicated cases:
• Bed rest.
• Control fever.
• Increased fluid intake versus intravenous fluids.
• No particular diet is needed.
• Limit hepatotoxic medications, be cautious with
acetaminophen.
Children with HAV infection should be away for 1 wk.
Identify the index case for preventive measures
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If complicated with acute liver failure:
• Hospitalization
• Aggressive supportive therapy
• Early transfer to liver transplantation center.
If HAV triggered secondary disorders
• Treat the specific disease
Treatment
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Prevention and Prophylaxis
General measures:
• Adherence to sanitary practices (hand washing).
• Heating food appropriately.
• Avoidance of water or food from endemic areas.
Active immunization:
Two hepatitis A vaccines (inactivated vaccines)
• HAVRIX (in1995)
• VAQTA (in 1996)
Passive immunization:
• Polyclonal serum immunoglobulin (IgG)
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Hepatitis A Vaccines
Inactivated whole virus vaccines
Pediatric and adult formulations :
• Pediatric formulations vaccines approved for persons 12 months through 18 years
• Adult formulations approved for persons 19 years and older
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Hepatitis A Vaccines
• Adult
1 dose ( >95% seropositive )
booster dose 6-18 months after first dose ( 100% seropositive )
• Children and Adolescents
1 dose ( >97% seropositive )
booster dose 6-18 months after first dose ( 100% seropositive )
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VAQTA HAVRIX Formulation
1–18 years
0.5 ml
1–18 years
0.5 ml
Pediatric:
Age
Dose
≥ 19 years
1.0 ml
≥ 19 years
1.0 ml
Adult:
Age
Dose
Hepatitis A Vaccines
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• Available since 1940s
• Passive immunity lasts for up to six months
• Effective if administered within 2 weeks
post-exposure
• Dose is 0.02 ml per kg IM
Polyclonal serum immunoglobulin (IgG)
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Structure of Hepatitis B Virus
Virion is 42 nm in diameter
Consists of :
An envelop contains viral
derived surface proteins also
known as HBsAg
Nucleocapsid contains
hepatitis core protein or
hepatitis Bc antigen(HBcAg)
Hepatitis Be protein (HBeAg)
Partially ds circular DNA
viral genome.
Viral DNA polymerase
Others
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Hepatitis B genotypes
Geographic Regions Genotype
North America, Western Europe, Central Africa A
China, Indonesia, Vietnam, Taiwan B
East Asia, Korea, China, Japan, Taiwan,
Polynesia, Vietnam C
Mediterranean area, Middle East, India D
Nigeria, West Africa E
Alaska, Polynesia F
North America, France G
Central America H
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Pathogenesis of HBV Infection
Two mechanisms:
• immune-mediated liver injury which is
related to cytotoxic T cell-mediated
lysis of infected hepatocytes.
• Direct cytotoxic liver injury may occur
when the viral load is very high
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Rate Areas Categories
0.1–2% United States, Canada, Western
Europe, Australia, and New
Zealand
Low
3–5%
Mediterranean Countries, Japan,
Central Asia, Middle East, Latin
and South America
Intermediate
10–20% Southeast Asia, China, Sub-
Saharan Africa High
Epidemiology
Prevalence of hepatitis B virus infection
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Concentration of Hepatitis B Virus
in Various Body Fluids
Concentration of Hepatitis B Virus
in Various Body Fluids
High ModerateLow/Not
Detectable
blood semen urine
serum vaginal fluid feces
wound exudates saliva sweat
tears
breastmilk
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High Risk Groups Modes of
Transmission
Infants born to HBeAg-positive mothers Perinatal
Household Close Contacts Horizontal
Injection drug users, Health care
workers, Hemodialysis patients,
Recipients of blood products
Parentral
Heterosexuals and homosexuals Sexual
Transmissions and High Risk Groups
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Incubation Period of HBV
• Average: 60–90 days
• Range: 45–180 days
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Clinical manifestations
Acute Infection:
• Asymptomatic
• Symptomatic : Prodromal (serum sickness like syndrome, Constitutional (anorexia, nausea, jaundice, right upper quadrant pain, fatigue)
• Occasionally develops acute fulminant hepatitis and Gianotti-Crosti syndrome.
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Clinical manifestations
Chronic Infection:
• Asymptomatic
• Vague right upper quadrant pain and fatigue
• Occasionally associated with extrahepatic manifestation including polyarteritis nodosa and glomerulonephropathy
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Investigations
Laboratory tests: • Complete blood count with platelets
• Liver biochemical tests including AST, ALT, total bilirubin, alkaline phosphatase, albumin.
• Prothrombin time.
• Tests for HBV infectivity and immunity including HBsAg and HBsAb.
• Tests for HBV replication including HBeAg and HBeAb.
• Screen for hepatocellular carcinoma with abdominal ultrasound and serum alpha fetoprotein.
• Liver biopsy for patients who meet criteria of chronic hepatitis and who are considered for treatment
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Serologic responses to hepatitis B Virus infection
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90% if perinatal acquisition
20-50% if acquired between
1-5 years of age.
<5% if acquired in adult
Progression to chronic state
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Interpretation Results Tests Susceptible Negative HBsAg
Negative Anti-HBc
Negative Anti-HBs
Immune due to natural
infection
Negative HBsAg
Positive Anti-HBc
Positive Anti-HBs
Immune due to hepatitis
B vaccination
Negative HBsAg
Negative Anti-HBc
Positive Anti-HBs
Acutely infected
Positive HBsAg
Positive Anti-HBc
Positive IgM anti-HBc
Negative Anti-HBs
Chronically infected Positive HBsAg
Positive Anti-HBc
Negative IgM anti-HBc
Negative Anti-HBs
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Natural Course of Chronic Hepatitis B Infection
Lack of effective immune
response and exhibit
immune tolerance
Immune
Tolerance
State
Phase 1
Immune-mediated viral
clearance
Immune
Active
Phase 2
Low replication state Inactive
Carrier
Phase 3
Subsequent reactivation
of chronic hepatitis
Reactivation
State
Phase 4
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Phases of Chronic Hepatitis B Infection
Labs and Histology Phase • Liver biopsy not indicated
• Antiviral Rx is ineffective.
• Risk of drug resistance if
treated with nucleoside.
• ALT Normal
• DNA > 20,000 IU/ml
• HBeAg +ve
• Minimal liver inflammation and fibrosis
Immune
Tolerant
• Liver biopsy is indicated.
• spontaneous conversion
• Resolution of infection.
•Treatment if there is no
spontaneous conversion
• ALT elevated
• DNA level >20,000 IU/ml
• HBeAg +ve
• Liver inflammation & fibrosis develops
Immune
Active
• Liver biopsy not indicated
• Treatment not indicated
• Up to 20% immune active
• 20-30% reactivate
• ALT normal
• DNA < 2,000 IU/ml or undetectable
• HBeAg -ve, Anti-HBe +ve
• No liver inflammation, Fibrosis regress
Inactive
Carrier
(latent)
• 20-30% of patients
• HBeAg-ve chronic HBV
• Usually 2nd to mutant virus
• Liver biopsy is indicated
• Antiviral therapy indicated
• ALT normal or elevated
• DNA levels increase (>2,000 IU/ml)
• HBeAg –ve
• HBeAb +ve or -ve
Reactiva-
tion
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Monitoring of patients
Disease activity:
• ALT every 6-12 months
• HBeAg and HBeAb every 12 months
• If HBeAg is +ve, measure HBV DNA.
HCC surveillance:
• Ultrasound of liver every 12 months
• Alpha fetoprotein every 12 months
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Treatment
Interferon alfa
• First line treatment choice.
• Six month course of interferon alfa-2b, six million units (MU) per m(2) (maximum 10MU) SC. three times a week for 24 weeks.
• Response rate in 30 – 40% of patients.
• Side effects: Flu like symptoms, Bone marrow suppression and changes in personality
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Treatment
Lamivudine
• Second line treatment choice
• Nucleoside analog.
• Dose: 3 mg per kg of body weight (max. 100 mg)
• Limited efficacy.
• Drug resistance with long term use
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Treatment
Newer agents
• Pegylated interferon therapy approved for ≥ 3 years of age.
• Adefovir : licensed for use in patient ≥ 12 years of age.
• Tenofovir : licensed for use in patient ≥ 12 years of age.
• Entecavir: licensed for use in patient ≥ 16 years of age.
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Prevention HBV vaccine
• Universally recommended for all infants.
• Series of 3 doses over 6-9 months.
• Catch up immunizations for older unimmunized children.
• HBV-exposed family members or closed contacts.
HBV immune globulin indication for use
• Infants born to HBsAg positive mothers.
• Post exposure prophylaxis within 24 hours of exposure if no past vaccine.
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Prevention
Other measures
• Household contacts:
Avoid sharing of tweezers, shavers, toothbrush, nail clippers.
• Universal precautions for handling abrasions, bleeding, etc.
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Hepatitis C Virus
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Hepatitis C genotypes Geographic Regions Genotype
United State, Europe 1
United State, Europe 2
India, Far East, Australia 3
Africa, Middle East 4
South Africa 5
Hong Kong, Vietnam, Australia 6
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Mode of transmission
• Vertical
• Parentral
• Sexual
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Perinatal transmission
• Perinatal transmission rates are 5%
• Rates are increased up to 15 – 20% if mother is coinfected with HIV.
• Risk factors:
Use of internal fetal monitoring devices
Prolonged rupture of membranes (>6 hours)
High viral load
HIV coinfection
• Breast feeding and vaginal delivery doesnot increase vertical transmission
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Clinical Features
• Incubation period: 30-150 days
• Chronic infection will develop in 60-80% of exposed children.
• Majority of patients are asymptomatic in childhood.
• End-stage liver disease with decompensated cirrhosis has been described in children.
• Acute liver failure from HCV infection has not reported in immunocompetent patients.
• Comorbidities: Glomerulonephritis, Cryoglobulinemia and Autoimmune hepatitis
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Diagnosis
• Check liver panel
• Screen with HCV IgG antibody after 18 month of age and HCV RNA after 2 month of age.
• HCV genotype analysis indicated if treatment is being considered.
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Treatment
• Subcutaneous weekly pegylated interferon-alpha
injections for 48 weeks (genotypes 1 or 4) or 24 weeks (genotypes 2 or 3), plus oral ribavirin.
• Treatment response: nondetectable HCV RNA by 24 weeks.
• Pegylated interferon/ribavirin therapy approved for ≥ 3 years of age.
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Prevention
• HCV vaccine: none available.
• HCV immunoglobulin: none available.
• Household contacts: avoid sharing of tweezers, shavers, toothbrush, nail clippers.
• Universal precautions for handling abrasions, bleeding, etc.
• Screening for hepatocellular carcinoma (HCC): increased risk for HCC in setting of chronic HCV hepatitis.
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HEPATITIS D VIRUS
• Defective interfering virus, requires HBV co-infection
• Prevalent in Mediterranean basin, North Africa, and
South America
• 10% of HBV infected persons co-infected with HDV
• More severe infection
• Diagnosis: Co-infection with acute HBV showed
positive IgM anti-HDV while super-infection of
chronic HBV showed positive IgG & IgA anti-HDV in
addition to serological markers of HBV.
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HEPATITIS E VIRUS
• Incubation period 15-60 days
• Enteric transmission via fecal-oral route.
• Endemic in Southeast & Central Asia; Middle East,
North and West Africa
• Acute, self-limited hepatitis
• Clinical features range from asymptomatic to mild
to fulminant picture with high mortality rate in
pregnant women in third trimester (20%)
• Diagnosis: Anti-HEV IgM positive for 2-3 months,
Anti-HEV IgG persists long term in haIf of patients.
• Immunoprophylaxis: none
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HEPATITIS G VIRUS
• RNA virus
• Flaviviridae family with 25% homology with HCV.
• Parenterally transmitted agent ; can be transmitted
perinatally .
• Clinical significance is uncertain, majority of
infected patients without liver disease.