IMMUNOLOGY & SEROLOGY CHAPTER 23

VIRAL HEPATITIS
GENERAL INFORMATION Sign(s) and symptoms

 Hepatitis refers to the inflammation of the liver.  Incubation period: 2-6 weeks (15-45 days)
(1) It may be due to Primary hepatitis  it is often a subclinical disease with many patient has
 Viral Hepatitis A, B, C, D (…) no manifestation of jaundice (anicteric) but it is
 This virus only attacks the liver. accompanied by elevated liver enzymes especially ALT
(2) Or rarely, Secondary hepatitis and serum bilirubin level.
 Epstein Barr, Cytomegalovirus, HerpesV  Typical forms like (…)
 This virus attacks including the liver and (1) Subclinical hepatitis (no jaundice) (see above)
other parts of the body (systemic infection).
 Commonly in children
 Hepatitis B and C can result to liver cancer
 Person w/out history of hepa but w/antibodies
(hepatocellular carcinoma).
(2) Acute hepatitis (w/ jaundice)
 Always remember if the patient has HIGH IgM it means
it is diagnostic for newly infected or can be an acute  Phases
Hepatitis but if it’s IgG, it means the patient is indicated (a) incubation
has a previous infection or maybe it is due to prolong (b) pre-icteric
subsequent infection. (c) icteric
 No homology exists among HAV, HBV, HDV AND HCV (d) convalescence
 Hepatitis is Hepatotropic (Likes Liver as a habitat)  Atypical forms like (…)
(1) fulminant hepatitis or a rare form which is
HEPATITIS A associated to hepatic failure.
 Infectious hepatitis or short incubation hepatitis, RNA  Commonly it is accompanied by coinfection with
other hepatitis virus.
virus (lasts a week)
(2) Cholestatic hepatitis where your bilirubin level
 An RNA Picornavirus that can only be cultured.
reached up to >20 mg/dl with matching jaundice.
 RNA is a positive (+) sense/polarity that can only be
(3) Relapsing hepatitis.
replicated in the liver.
(4) Chronic hepatitis- last at least for 6 months with
Transmission accompanied hepatic inflammation.

 It is non-enveloped so it means it is very resistant to Lab diagnosis

outside environment resulting to be transmitted thru
fecal-oral route.
(1) So, you can detect acute-phase stool samples.
(2) Virus shed in feces up to 4 wks.
 Infected food handlers, contaminated food, water and
commonly consumption of raw shellfish.
 International travel as a primary risk factor.
 Can be Saliva or thru sexual transmission but rarely
urine contamination
 Blood transfusion (rare).
(1) During old times; to kill the virus, they tend to put a solvent detergent
as virucidal to inactivate the non-enveloped virus.
(2) Note: during old times, you can get immunized by the virus using a
convalescent-phase serum of HAV infected patient because the
HAV wasn’t enough to produce symptoms because the body can be
able to make antibodies before the HAV will present a manifestation(s).
Epidemiology
 It is commonly in children who are exposed in this virus
since all of the children are developed an Anti-HAV
IgG after 5 years of age.
 Clinical laboratory observations: (Liver enzymes)
o Increased ALT (SGPT)
o Increased serum bilirubin
o Increased alkaline phosphatase
 Anti-HA Ab can be detected using immunoassay.
o An increased in IgM anti-HA during acute infection.
o while IgG anti-HA increases in past infection.
 Serologic Diagnosis
A. Enzyme Immunoassay (EIA) ELISA – for total Ab
B. Radioimmunoassay (RIA) – for IgM Ab & Hepatitis-A Ag
HEPATITIS B
 A DNA hepadnavirus
 A double stranded but 1 strand is incomplete which
encodes HBeAg
 The remaining strand is complete which encodes
HBsAg and HBcAg
 It is known as Australia antigen specifically HBsAg.
 Also known as Serum and long incubation hepatitis
 It has 8 genotypes.
 Virus particles is known as the Dane particle.
Transmission
HBsAg Anti-HBc Anti-HBs
 It is an enveloped virus and it is closed covalently No HBV - -
circular DNA (cccDNA) so it means it is very (susceptible)
susceptible to outside environment that is why it can
Early infection + -
only be transmitted thru (…)
(a) Blood transmission Acute infection + + -
(b) Sexual contract (especially m2m) Window period - + -
(c) Lesions in the body (can’t penetrate intact skin) Past infection - + +
(d) Perinatal route Immunization - - +
(e) Parenteral route
(f) All human excretion except stool
SEROLOGIC MARKERS OF HBV
It has a 3 major structure which contributes
antigenicity.  ANTIGEN (from the virus)
(1) HBsAg
(a) Envelope protein (HBsAg) “s” surface (2) HBeAg
(b) core protein (HBcAg) “c” core  ANTIBODY (from the person)
(c) Nucleocapsid (HBeAg) “e” envelope (1) Anti-HBc
Signs and symptoms (2) Anti HBe
(3) Anti-Hbs
 Typical manifestations include
Notes:
 Atypical manifestations such as vasculitis,
glomerulonephritis arthritis, and dermatitis are  HBV virions remains active in mononuclear cell for
mediated by circulating immune complex deposition in more than 5 years after complete recovery from
blood vessels. virus.
 Liver disease – if you are infected with >10,000 IU/ml
of virus HBsAg (surface antigen
 Less than of it-- you are inactive carrier.
 appear 1 week to 2 months after exposure.
 Can be asymptomatic sometimes and can only
manifest a symptom(s) if the patient is now progresses  first marker detected in the blood sample)
on the chronic stage or on the convalescent phase.  best indicator of early acute infection
 screening of blood donors.
Diagnostic Evaluations  disappears during the convalescent phase of acute
disease
 In a qualitative assay, >1.5 x104 copies of genome can
be detected. HBeAg (envelope antigen)
 (+) HBsAg during pregnancy is at greater risk to be  indicates chronic hepatitis
transmitted to child if there’s no immediate prophylaxis.
 increase infectivity (thru blood/sexual transmission)
 increase vertical transmission
 the most infectious stage (high degree of infectivity)
 in self-limited HBV, HBeAg will the first to disappear
instead of HBsAg.
HBcAg (not a serologic marker
 found only inside the liver and not circulating in the blood
 it can only be detected thru liver biopsy.
 bestows immunity to further HBV infection; detection thru
liver biopsy cell.

Anti-HBc IgM (core antibody)

 indicates acute HBV infection (or current infection)

Recovery from Chronic/Carrier  First antibody to appear.
HBV State  When HBsAg is undetectable, Anti-HBc is the only marker
HBsAg + for hepatitis in acute infection.
HBeAg +  It is when the liver enzymes especially ALT begins to rise.
Anti-HBc + +  HBcAb persist throughout life and are a marker for
Anti-HBs + - previous infection.
Anti-HBe + -  only marker detectable during the window period
 (very sensitive marker; IgM used as screening) (a) Immunocompromised patient
 can be found in asymptomatic carrier (b) Age (determinant of chronicity)
as known as core window. (c) Infected neonates
o Anti-HBc Total (IgG + IgM) (d) Immunosuppression
 indicates acute/chronic (e) Gender (more likely women)
 IgG – lifelong marker to HBV infection.
 two types of carrier state
(a) with HBeAg
Anti-HBe (envelope antibody)
(b) w/out HBeAg
 indicates convalescence/recovery (favorable prognosis)
 very good prognosis (+) Infection with Hepatitis D virus
 production of antibodies for HBe
COINFECTION
 persist thru life.
 It Is when Acute Hepatitis D with concurrent Hepatitis B
SUPERINFECTION
Anti-HBs (surface antibody)  It Is when Acute Hepatitis D and resolved Hepatitis B
 marker of past infection or immune state
 bestows immunity to further HBV infection
 may persist throughout life
 very good prognosis; need immunization HEPATITIS D VIRUS

Hepatitis B viral DNA by PCR  It is associated exclusively with HBV infections,

 a molecular method for the qualitative and quantitative
measurement of HBV DNA.
Chronic infection:
 Progression from acute to chronic is influenced by the
age at the time of acquisition of the virus.
 When it proceeds to chronic infection, viral DNA have
been shown to be incorporated to the host liver cells
which is associated for the development of cancer.
 Hepatocellular necrosis is a manifestation of chronic
infection but it doesn’t mean the virus is the primary
cause of it but it is due to our body itself.
o It is when our cytotoxic T-cell is attached to the
infected cell where the viral antigen is and then it
releases powerful cytokines together with natural
killer cell which leads to necrosis.
 Phases of chronic infection
o More Infectious replicative phase- high levels of
virions.
o Minimally infectious replicative phase- only HBsAg
detectable (detectable until 6 mo.)
 Anti-HBc is present in all chronic infection.
 HBeAg is only present in early phase of infection.
 The presence of circulating HBV DNA is highly
correlated with the presence of whole virus replication,
and thus with the potential infectivity of the patient.
 Presence of anti-HB doesn’t mean you have now a
reduced infectivity rate.
either as a co-infection or as a superinfection.
 No vaccine is available. The only means of preventing
hepatitis D infection is to prevent HBV infection.
 HBsAg will also present.
 Incomplete single stranded RNA virus
Mode of transmission
 Parenteral
 Trans mucosal
Coinfection w/ Hepatitis B
 HDV RNA and HDV Antigen is detected early with a
concurrent detection of HBsAg.
 Self-limited infection is usually transient
 Better to detect the antibodies than antigen for
diagnostics.
 Often, HDV infection becomes chronic.
Diagnostic evaluation
 The HDV appears in the circulating blood as a
particle with a core of delta antigen and a surface
component of HBsAg.
 Can be tested by EIA, Liver biopsy by immunodiffusion
(DIF) and immunoperoxidase method.
 Presence of IgM anti-HBc means coinfection
 Presence of IgM anti-HDV means superinfection.
 Can be detected by this means…
a. Enzyme immunoassay –for total Ab
b. Radioimmunoassay – for IgM Ab
c. Double immunodiffusion – for Ag detection

Carrier state

 It is when you have HBsAg but no clinical

manifestation.

Risk factors
HEPATITIS C
 Known as the agent of non-A Non-B hepatitis.
 Single stranded RNA enveloped Flavivirus/hepacivirus.
 It is also known as post-transfusion hepatitis.
 After binding to the cell surface, HCV particles enter the
cell by receptor-mediated endocytosis.
 Because the virus mutates rapidly, changes in the
envelope protein may help it evade the immune
system.
 there are (6) different genotypes of HCV but does not
play a role in the severity of the disease.
 Genotype 2 and 3 are more likely to respond
medication.
 Genotyping can be done thru liver biopsy.
 Hepatitis C more closely resembles HBV than HAV in
regard to transmission and clinical symptoms
Transmission
 sexual transmission (rare)
 Organ / blood transplantation (frequent)
 Perinatal
Signs and symptoms
 Signs and symptoms are extremely variable.
 HCV infection is a leading cause of chronic hepatitis,
cirrhosis, and liver cancer.
 Chronic hepatitis C appears to be a slowly progressive,
often silent disease.
o It is because the virus can be easily escape
immune response in more than 80%.
 In addition, HCV may be associated with hepatocellular
carcinoma predominantly, if not exclusively, in the
setting of cirrhosis
 Viremia, as detected by HCV RNA assay, may persist
for months to years in patients in whom serum liver
enzyme levels return to normal
 Hepatitis C, as with HBV, can be acute and ranges
from mild anicteric illness to fulminant disease.
 Transfusion-associated hepatitis C can be divided into
short range from 1 or 2 to 5 weeks and long-incubation
ranges from 7 to 12 weeks to 6 months or longer.
 Diagnostic criteria for HCV
o HCV RNA detected in their serum and evidence of
chronic hepatitis on liver biopsy.
o HCV serum liver enzyme and bilirubin level will
range from 200 to 800 U/L but not as high as HBV.
o 20 % will progress to cirrhosis.
o Post-transfusion hepatitis C will develop chronic
liver disease (60%) and cirrhosis (20%)
o Production of Rheumatoid factor (30%)
o Extrahepatic immunologic abnormalities include:
 Sjögren’s syndrome
 Cryoglobulinemia – it where the insoluble
immune complexes (antibody-antigen
complex) are exposed to low temperature.
 Non-Hodgkin’s lymphoma
 As demonstrated increase
proliferation of B-cell
 Others: urticarial, erythema nodosum,
vasculitis, glomerulonephritis, peripheral
neuropathy
TRADITIONAL TESTING
Includes:
 chemiluminescent immunoassay
 qualitative EIA
 qualitative recombinant immunoblot assay
 quantitative real-time PCR assay
 qualitative PCR assay
 quantitative branched chainDNA test
 polymerase chain reaction–nucleic acid
sequencing.
 interleukin 28 B (IL-28B)–associated variants
test,
 single-nucleotide polymorphisms (SNPs)
 PCR–qualitative fluorescence monitoring.
NEW GENERATIONAL TESTING
ELISA or EIA
o For screening test
o
Western blot or RIBA (Recombinant immunoblot assay)
o Used to confirm ELISA since it is prone to false (+)
o used to confirm anti-HCV antibodies
 you can still be positive even you have
no hepatitis C anymore.
o serum is incubated on nitrocellulose strips on which
four recombinant viral proteins are blotted. (+) color
means 2 or more antibodies adhering to antigen.
o 3rd generation RIBA uses three recombinant antigens
(c33c, c100-3, NS5) and one synthetic peptide from
the core region
Polymerase Chain reaction
 It detects HCV RNA (the best to be detected)
 HCV RNA is the earliest detectable marker
o And also Good for if the patient if (…)
 low HCV RNA
 normal liver enzymes (transaminases)
 and no anti-HCV is present (due to
immunodeficient individual cos she/he can/t
make demonstrable amount of antibodies.
 Immunosuppressed patient due to taking
corticosteroids (antibody suppressor)
 Patient undergoing to dialysis and
agammaglobulinemia.
o Testing HCV RNA is more superior than to test anti-
Anti- HCV antibodies due to this factors
 Liver disease, autoimmune disorder and
alcoholic individual can make exhibit anti-HCV
 Soo, false positive is prone to western
blot and of course your ELISA.
o Explainer: It detects only if the patient is having a
current Hepatitis BUT NOT in the case if you are
recently-infected because PCR detects only the virus
and not your antibody.
 Your ELISA and Western blot detects only
Antibody.
Special topic:
HEPATITIS C RNA TITERS in serum
 The usefulness of determining the viral load (by using titer
as an assessment) does not correlate with the severity of
the hepatitis or with a poor prognosis, but viral load does
correlate with the likelihood of a response to antiviral
therapy.
o Rates of response to a course of interferon-α (IFN-α)
and ribavirin are higher in patients with low levels<2
million copies of HCV RNA.
ACUTE HEPATITIS C
 Laboratory manifestations include a significant increase in
serum liver enzyme levels (usually >10-fold) and the
presence or de novo development of anti-HCV
 anti-HCV is not detected until 2 to 8 weeks after the onset
of symptoms.
o If you are (-) for anti-HCV it is recommended to re-test
after 1 month.
 HCV antigen can’t be detected in kupffer cells, sinusoidal
cell, bile duct epithelium and blood vessel but It is
presumptively detected in hepatocytes but not in its
nucleus.
 Liver enzymes may be normal even in viremia (not all)
CHRONIC HEPATITIS
 symptoms
o Episodic fluctuations in serum liver enzyme levels
o Due to reflecting waves of hepatocellular inflammation
and necrosis
o Liver Cirrhosis (30%)- liver cancer
o Liver Failure
 Medications
o Interferon alpha (boosts immune system)
o Ribavirin
o Ribozymes (degrade RNA virus molecules)
o Antisense oligonucleotides (inhibit replication)
o Vaccines (for prevention)
Note:
 Treatment is not based on presence of
absence of symptoms or even in the test
performed but the condition of the patient.
 Ex. People having cirrhosis can’t respond to
interferon alpha medication.
 Ex. Patient w/ fibrosis or w/ severe
inflammation must have its own regimen of
medication.
 Prevention
o removal of blood from donors with anti-HBcAg from
the blood supply and use of third-generation anti-HCV
testing can reduce the incidence of post transfusion
hepatitis C.
o Vaccines and immunoglobulin products do not exist
for the prevention or treatment of hepatitis C.
o It is difficult to make vaccine due to the different
genotypes of Hepatitis C
HEPATITIS E
 The major etiological agent of enterically transmitted non-
A Non-B hepatitis worldwide.
 All have been seen in travelers returning from the Indian
subcontinent, northern Africa, the Far East, portions of
Russia and Mexico.
Mode of transmission
 Hepatitis E virus (HEV) is transmitted by the fecal-oral
route.
 HEV is responsible for large, water-borne outbreaks of
hepatitis in the developing countries
 most common cause of sporadic hepatitis in young
adults in developing nations.
 Clinically apparent disease frequently is found in 15 to 40
years old.
 Household contact (rare)
tests
 diagnosis is dependent on travel history, symptoms and
exclusion of other hepatitis infections.
 (IgM and IgG anti-HEV) but not routinely performed
Signs and symptoms
 Incubation period: 2 to 9 weeks
 Similar to other hepatitis
 HEV particles in stool (viral shedding) may be seen during
prodromal symptoms a week after the onset of jaundice.
 Viral shedding is accompanied with viremia
 Increased fatality among pregnant women (third trimester
in pregnancy)
Immunologic manifestations
 A short-lived, IgM anti-HEV has been found in acute
phase sera.
 IgG anti-HEV appears and replaces IgM anti-HEV about 2
to 4 weeks after symptoms subside.
Treatment
 Supportive care
o Gama-globulin preparation is not effective for
hepatitis e prevention
HEPATITIS G
 RNA virus, identical to GB virus type C (96% homology)
 it is common that Hepatitis C is also co-infected w/ GBV-C.
 chronic disease is veery rare or may not occur at all.
Mode of transmission
 Blood borne agent, common to transfusion recipients and
IV drug users.
 Transmitted sexually
Signs and symptoms
 Chronic HGV infection does not appear to be a common
cause of important liver disease and does not alter the
course of chronic HCV infection.
 The vast majority of patients with acute, non–A-E hepatitis
have no evidence of HGV infection.
 Interestingly, a patient with having hepa B or C with HGV
as a coinfection appears not to cause more severe liver
disease.
 Some studies that hepatitis G may not even replicate in the
liver
 TEST for HGV virus: thru PCR which can be detected as
an overlapping clone of hepatitis C genome.
TRANSFUSION TRANSMITTED VIRUS (TTV)
 A novel non-enveloped single stranded linear RNA with
3739 nucleotides.
 It has 2 groups, (differs only by the 30% of its nucleotide)
 Discovered in 1997 by japan scientists.
 Interestingly, TT in TTV is not originally termed as
Transfusion transmitted hepatitis but it is the initials of the
patient whom the virus was first isolated.
 most remarkable feature of TTV is the extraordinarily
high prevalence of chronic viremia in apparently healthy
people, up to almost 100% in some countries.

Transmission
 Fecal-oral
 Blood transfusion
 Perinatal route