Dr.dr.Efrida Warganegara, M.Kes., Sp.

MK
KEY CONCEPTS
Display marked tropism for liver cells
Use either :
hit & run infectious strategy
(Hepatitis virus A & E)
results in acute infection that is
cleared by the immune system
hide & infiltrate strategy
(Hepatitis virus B, C,
Delta, G)
lead to chronic infection
KEY CONCEPTS
Cause similar symptoms during the
acute stage of infection that result of
liver damage
Can be identified by testing for
presence of specific viral proteins,
specific antibodies against these
proteins or viral nucleic acid
Can be treated with agents such as
interferon, however treatment for
chronic carriers of hepatitis B, C, D
and G generally ineffective
Vaccine exist : A & B
Viral Hepatitis - Historical Perspectives
Infectious
Viral hepatitis
Serum
A
NANB
Enterically
transmitted
Parenterally
transmitted
E
F, G, TTV
? other
C
D B
Virus Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Family Picornaviridae Hepadnaviridae Flaviviridae
e
None Caliciviridae
Genus Hepatovirus Orthohepadna
virus
Hep-c-virus Deltavirus
(Unnamed)
Virion Icosahedral
27 nm
Spherical,
42 nm
Spherical,
30-60 nm
Spherical,
35 nm
Icosahedral,
27-34 nm
Envelope No Yes (HBsAg) Yes Yes(HBsAg) No
Genome ssRNA dsDNA ssRNA ssRNA ssRNA
Size 7,8 kb 3,2 kb 9,4 kb 1,7 kb 7,5 kb
Stability Heat & acid
stable
Acid-sensitive Eter-sensitive
Acid-sensitive
Acid-sensitive Heat-stable
Transmission Faecal-oral Parenteral Parenteral Parenteral Faecal-oral
Prevalence High High Moderate Low,
regional
Regional
Fulminant
disease
Rare Rare Rare Rare In
pregnancy
Chronic
disease
Never Often Often Often Never
Oncogenic No Yes Yes ? No
General symptoms of hepatitis virus infection

Acute inflammation chronic

Prodromal signs :
Fever
Gastrointestinal symptoms
Jaundice/ icteric

enteric

acute
parenteral
chronic

cirrhosis
hepatocellular-Ca
Hepatitis virus type A
Hepatitis virus type E
Hepatitis virus type B
Hepatitis virus type C
Hepatitis virus type D
Hepatitis virus type G
HEPATITIS ACUTE
ASYMPTOMATIC
FULMINANT
Severity of the disease depend on :
* virus type
* individual
More than cases asymptomatically

Chronic hepatitis symptoms exist
increasing enzyme levels
> 6 months
Chronic persistent chronic active hepatitis
(mild)


Enzymes level cirrhosis
Normal hepatic failure
hepatocellular-Ca

Control

Screening blood donor for
hepatitis viruses B, C
Immunization (active or passive)
Treatment : Interferon
Antiviral drugs
HEPATITIS A VIRUS (HAV)

Discovered by Cockayne tahun 1912
Cause infectious hepatitis, acute
A distinct member of the Picornaviridae family (previously
Enterovirus 72), a new genus : Hepatovirus
Only 1 serotype
27 32 nm, spherical particle, cubic symetry
Containing a linear ss-RNA genome with a size 7.5 kb,
surround by capsid consist of 4 polypeptide :
VP1 VP4, nonenveloped
The most likely mode of transmission : fecal-oral route
through close personal contact
Acute infection, incubation period 2 6 weeks




Virus stability :

Virus is destroyed by :
Autoclaving 121
o
C, 20 minutes
Boiling in water for 5 minutes
Oven (dry heat 180
0
C), for 1 hour
UV irradiation, 1 minute at 1,1 watts
Treatment with formalin 1 : 4000 for 3 days at 37
0
C
or chlorine 10 15 ppm, 30 minutes
Stable to treatment with 20% ether, acid (pH 1.0 for 2
hours)
Infectivity can be preserved
at least 1 month after being dried, and stores at
25
o
C and 42 % relative humidity
or for years at 20
0
C
LABORATORY DIAGNOSIS

+Virus particles have been detected by immune electron
microscopy in fecal extracts of hepatitis A patients

+Virus appears early in the disease, and disappears
within 2 weeks following onset of jaundice

+HAV can be detected in the liver, stool, bile, and
blood of naturally infected humans and
experimental infected nonhuman primates by :
PCR or
Nucleic acid hybridization assay



+Serology :

IgM specific anti-HAV fraction appears during the
acute phase
peaking about 2 weeks after elevation of liver
enzyme

Anti-HAV IgM usually decline to undetectable
levels within 3 6 months

Anti-HAV IgG appears soon after the onset of the
disease and eventually replace IgM

IgG persist for decades

+Methods for measuring Ab :
RPHA
ELISA
R I A
IMMUNOLOGIC AND BIOLOGIC EVENTS
ASSOCIATED WITH HAV INFECTION

0 2 4 6 8 10 12
Weeks after exposure
IgM
Ig
G
VIB
VIF
Aminotransferases
Jaundice
VIF=virus in feces
VIB=virus in blood
HEPATITIS B VIRUS (HBV)

#Discovered by Blumberg (1923)
#Patients & aborigin
Australian Ag.
#Cause serum hepatitis
#Australian antigen HBsAg
#Family Hepadnaviridae
#Genus Orthohepadna virus
HBV Morphology

Structure & antigen complex
3 shapes in serum
. Dane particles : 42 nm
. Spherical particles : 22 nm
. Filament particles : 22 nm
Genome ds DNA polimerase 3200 bp
Spherical
Molecular weight 2 x 10
6
kd


Virion 42 nm
HBsAg / Dane
particle

Nucleus
virion 28 nm
HBcAg
Lysis nucleus
virion (HBeAg)
Hepatitis B virus particle
Antigen structure :

1. HBsAg Anti-HBs

2. HBcAg Anti-HBc

3. HBeAg Anti-HBe

STABILITY
Temperature 20
o
C more than
20 years
Dry, 25
o
C stay for 1 week
Temperature 100
o
C, 1 minute
pH 2,4 for 6 hours
Sodium hypochlorite 5% for 3
minutes
Viral replication :

Attachment Uncoating DNA
within nucleus (transcription)
mRNA (translation) RNA
(reverse transcription) cDNA re
enter to previous cycle
AAA
AAA
AAA
mRNA
cccDNA

Nucleus
Cytoplasm
Translation
Encapsidation
3.5 kb RNA
Negative-strand
DNA
synthesis
Positive-
strand DNA
synthesis
Attachment
Uncoating
Host DNA repair
HBV replication cycle
Reenter cycle
MODE OF TRANSMISSION

- Parenteral

- Mucosal (per oral & sexual
contact)

- Vertically from mother to baby
Laboratory examination

Isolation : cell culture difficult
Diagnosis :
Serology (Ag Ab)
Transaminase enzyme (LFT)
Histology (biopsy)
PCR (molecular)
Electron Microscopy (virus particle)
Leucopenia during pre jaundice phase
1 2 3 4 5 6 7 8
Level of
detection
HBeAg Anti-HBe
Anti HBs
Anti-HBc
HBsAg
Relative
concentration
of reactants
Important
diagnosis
tests
Month after
exposure
HBsAg HBsAg IgM-anti HBc Anti HBs
IgG anti-HBc
ALT
Symptoms
Clinical and serologic events occurring in patient with acute
hepatitis B infection


1 2 3 4 5 6 7 8 9
Incubation
period
Prodrome,
Acute diseases
Early
Convalescence
SEROLOGICAL INTERPRETATION OF HBV
INFECTION
Results Interpretation
HBsAg (+) Hepatitis B infection active, acute/ chronic
Anti-HBs (+)
HBsAg (-)
Protection to reinfection (immunity)
(+) after > 16 weeks, persist for years
Anti-HBc (+)
Anti-HBs (-)
Might be HBV active infection
Should be confirm IgM anti-HBc, 3 months
Total anti-HBc persist 5-6 years
HBeAg (+)
HBsAg (+)
Infectious active hepatitis, acute / chroni
Potential infectious
Anti-HBe (+) Non infectious blood
Carrier state
Prevaccination screening hepatitis B
HBsAg (+)
Anti-HBs (-)
Anti-HBc (-/+)
HBsAg (-)
Anti-HBs (-)
Anti-HBc (+)
HBsAg (-)
Anti-HBs (+)
Anti-HBc (+/-)
Titer > 10 mU/ml
HBsAg (-)
Anti-HBs (+)
Anti-HBc (+/-)
Titer < 10 mU/ml
HBsAg (-)
Anti-HBs (-)
Anti-HBc (-)
No
Vaccination
Postpone
vaccination
No
vaccination
Booster Vaccination
LFT
examination
Check
anti-HBs
3-6 months
Measure titer
anti-HBs
Measure titer
anti-HBs
Measure titer
anti-HBs
HEPATITIS C VIRUS (HCV)
NANB hepatitis virus parenteral
1960 - 1980 blood screening for HBV
post transfusion hepatitis
First reported by HOUGHTON &BRADLEY
using molecular biology technique, and
virus clone (1984 )
Family Flaviviridae
Genus Hep-C-virus
Mode of transmission
- Blood transfusion
- Sexual contact
Incubation period 2 26 weeks ( 8 weeks)
Structure & composition
} ssRNA genome 9.4 kb, positive
strand
} 6 genotype :
(1a,b, 2a,b,c, 3a,b, 4, 5 and 6)
} enzyme specific to HCV & essential
the replication of the virus
Protease
RNA-dependent RNA Polymerase
Helicase

Helicase :
unwinds the HCV-RNA prior to
transcription to a complementary
RNA molecule, which is the template
fo replication of HCV genome

Quasispecies :
genetic heterogenicity of HCV in
infected patients
P a t h o l o g y

Clinical symptoms mild
Elevation of liver enzymes mild to
moderate
Disease develop to :
-Chronic infection
-Cirrrhosis
-Carcinoma

Laboratory diagnosis

Specimen : blood & liver biopsy
Microscopic : detection of virus particle
Tissue culture : can not grow
Inoculation in chimpansee
Serology : antibody detection anti-HCV
(ELISA)
P C R : Molecular detection of RNA virus


Treatment :
m Interferon
m Ribavirin : synthetic guanosine nucleoside
analog with activity against a number of
viruses

Ribavirin alone :
has only small effect on the biochemical
parameters of hepatic function &
replication of HCV
combination with IFN-2b


Hepatitis D Virus (HDV)

Reported first by RIZETTO, CANESE &
ARICO (1977)
Family?
Genus Deltavirus
Transmission :parenteral
parallel with HBV
Develop to chronic infection
Incubation period : 6 10 weeks
Structure & composition

Genome : ssRNA 1.7 kb, 35 37 nm

Delta antigen surrounding by HBsAg

Defective virus, need hepatitis B virus

for replication
Hepatitis D virus particle surround by hepatitis B
virus particle
Hepatitis E virus(HEV)

_NANB hepatitis virus oral

_Family Caliciviridae

_Incubation period 3 7 weeks

_Mode of transmission oral-fecal
Structure & composition
Genome ssRNA 7.5 kb
32 34 nm
Positive strand
Envelope
Heat stable
Clinical symptoms similar
with HAV infection


Laboratory diagnosis

.Specimen : stool and liver biopsy

.Electron microscopy : detection of virus
particle

.Serology : Specific antibody in serum
fluorescence microscope

.P C R : molecular
Hepatitis F Virus (HFV)

Reported in France at 1997

Morphology

Other
characteristics

unclear
Hepatitis G virus(HGV)

The newest virus identified
Reported at 1995 1996
Family Flaviviridae
3 genotype :
GB-A
plant viruses
GB-B
GB-C human virus


Morphology :
- Genome RNA positive-strand,
2900 bp
- enzyme :
RNA polimerase
Helicase
Protease
Mode of transmission parenteral
- Blood transfusion
- Transplantation
- Sexual contact (probably)
Might be single infection or with HBV/
HBC

Laboratory diagnosis

P C R : molecular

EM : virus particle

Serology : antibody test
under development
T T Virus
Reported in Japan, 1997
Hepatitis post transfusion

o New classification of virus
Family Circinoviridae
Similar with Circinoviridae : palnts &
vertebrates
o Morphology :
DNA virus ss linear, size30 50 nm
Non envelope, 3739 nucleotide
oFulminant hepatitis : chronic hepatitis (unknown
etiology)
oCryptogenic liver disease & pathogenic role ?