Viral Hepatitis

Bagian Mikrobiologi FK UNDIP

Semarang, April 2018

2 SKDI 2012
3 Learning objectives

• Describe the etiology of viral hepatitis and their

characteristics
• Describe the pathogenesis and disease course
of viral hepatitis Please ask me to
skip it if you have
• Choose the best microbiology diagnostic
had it enough from
examination to confirm viral hepatitis other lectures
• Describe the principal of antiviral therapy of viral
hepatitis
• Describe the mechanism of resistance of
hepatitis viruses
4
5 Hepatitis viruses

• Similar in:
o target organ: the liver
o basic hepatitis symptoms  icteric and  liver
enzymes

• Differ in:
o structure
o mode of replication
o mode of transmission
o the time course
o sequelae of the disease they cause
6 How many hepatitis virus do you
know?
Hepatitis A virus (HAV)
8 Structure

• Picornavirus
• 27-nm, naked, icosahedral capsid
• a positive-sense, single-stranded RNA genome (7470 nt)
• The capsid is even more stable than other picornaviruses to
acid and other treatments
9 Hepatitis A indurance

can survive for

many months
in fresh water and
salt water
10 Pathogenesis

• HAV is ingested enters the bloodstream through the epithelial

lining of the oropharynx or the intestines  parenchymal cells
of the liver.
• The virus replicates in hepatocytes and Kupffer cells. Virus is
produced in these cells and is released into the bile and from
there into the stool.
• Virus is shed in large quantity into the stool approximately 10
days before symptoms of jaundice appear or antibody can be
detected
11 Pathogenesis

• replicates slowly in the liver without producing apparent

cytopathic effects.
• Interferon  limit viral replication
• natural killer (NK) cells and cytotoxic T (CTL) cells 
eliminate infected cells.
• Antibody, complement, and antibody-dependent cellular
cytotoxicity  facilitate clearance of the virus and
induction of immunopathology.
• Icterus, resulting from damage to the liver due to cell-
mediated immune responses and antibody to the virus
can be detected.
• Antibody protection against reinfection is lifelong.
12 Epidemiology

• fecal-oral route
• 40% of acute cases of hepatitis are caused by
HAV
• Readily spread because
o most infected people are contagious 10-14 days
before symptoms occur
o 90% of infected children and 25-50% of infected
adults inapparent but productive infections
• Shellfish (clams, oysters, and mussels)
important sources of the virus (efficient filter
feeders concentrate the viral particles)
13
14 Do you remember this?
Dec 2015
15 Laboratory diagnosis
Specific serologic tests
 anti-HAV IgM by ELISA
or radioimmunoassay

Virus isolation not

routinely performed
16 Treatment, Prevention, and
Control
• Stop the fecal-oral spread of the virus 
 avoiding potentially contaminated water or food,
especially uncooked shellfish
 Proper hand washing
 Chlorine treatment of drinking water
• Prophylaxis with immune serum globulin
o Given before or early in the incubation period
• HAV vaccine
Hepatitis B virus (HBV)
18 Structure
• Hepadnavirus
• small, enveloped DNA virus
with circular, partly double-
preS1
preS2 (LHBs)
stranded DNA of only 3200
SHBs bases in it
• encodes a reverse
HBc
X-prot transcriptase and replicates
pol
DNA through an RNA intermediate
• Virion Dane particle
Tubular / Filament particle
Stable  resist treatment
with ether, low pH, freezing,
Dane particle (intact virus) and moderate heating assist
transmission and hamper
Spherical particle disinfection
19 Replication
20 Pathogenesis and Immunity

• HBV can cause:

Individual’s
o acute or chronic, immune response
o symptomatic or
asymptomatic disease
21

HBV infects the liver but

does not cause direct
cytopathology

Cell-mediated immune
lysis of infected cells
produces the symptoms
and resolves the infection

Insufficient immunity can

lead to chronic disease
22 Pathogenesis (1)

• virus replication in the liver starts within 3 days of

acquisition
• symptoms may not be observed for 45 days/ > depending on:
• infectious dose,
• route of infection
• host immune response
• virus causes minimum cytopathic effect on hepatoytes
• Infection proceeds for a relatively long time without causing
liver damage (i.e., elevation of liver enzyme levels) or
symptoms  during this time, copies of the HBV genome
integrate into the hepatocyte chromatin and remain latent
• Intracellular buildup of filamentous forms of HBsAg can
produce the groundglass hepatocyte cytopathology
characteristic of HBV infection
23 Pathogenesis (2)

• Cell-mediated immunity and inflammation are

responsible for causing the symptoms and effecting
resolution of the HBV infection by eliminating the
infected hepatocytes
• An insufficient T-cell response to the infection 
mild symptoms, an inability to resolve the infection,
development of chronic hepatitis
• Antibody can protect against initial infection by
preventing delivery of the virus to the liver.
24 Pathogenesis (3)

• Large amount of HBsAg can block the neutralizing

antibody  limits the antibody’s capacity to resolve an
infection.
• Immune complexes (HBsAg + anti-HBs) 
hypersensitivity reactions (type III)  vasculitis,
arthralgia, rash, and renal damage
• Infants and young children  immature cell mediated
immune response  less tissue damage and milder
symptoms, but tend to become chronic carriers (90%).
 Indonesia:
25 Epidemiology • intermediate-to-high
endemicity
• 9.4% HBsAg carrier

In the world:
• one out of three people have been infected with HBV
• 350 million people world wide have chronic HBV infection
26 Clinical syndrome (Acute infection)
27 Clinical syndrome (Chronic
infection)
28 Laboratory

Acute hepatitis B Chronic hepatitis B

29 Laboratory

Detection of both the HBsAg and the HBeAg components of

the virion in the blood indicates the existence of an ongoing
active infection
30 Laboratory

HBsAg and HBeAg are secreted into the blood

during viral replication  Detection indicates the
existence of an ongoing active infection

The detection of HBeAg is the

best correlate to the presence of infectious virus

Anti-HBs indicates
resolution of infection or vaccination

Anti-HBc indicates current or prior infection by HBV

and IgM anti-HBc is the best way to diagnose a
recent acute infection, especially during the window
period
31 Laboratory

• Viral load  quantitative PCR

o Follow-up disease progression
o Antiviral drug efficacy
32 Treatment, Prevention, and
Control
• Hepatitis B immune globulin (HBIg) to prevent and
ameliorate disease :
o General : within a week of exposure
o Newborn infants of HBsAg-positive mothers : within
12 hours of delivery
• For chronic HBV infection : drugs targeted at the
polymerase (eg. lamivudine) or nucleoside
analogue (adefovir dipivoxil, famciclovir), or
pegylated interferon-α
• Vaccination (virus-like particle)  schedule?
• Standard precautions
 33 Hepatitis B vaccination in
Indonesia
• Started in 1997 (basic immunization
program)
• Cakupan imunisasi= 86,8% tetapi anti HBs
positif <50%

Riskesdas 2007
Hepatitis C virus (HCV)
35 Introduction

• Identified in 1989 after isolation of a viral

RNA from a chimpanzee infected with blood
from a person with NANBH (Non A Non B
hepatitis)
• major cause of posttransfusion hepatitis
before routine screening
• HCV is transmitted by means similar to
HBV but has an even greater potential for
establishing persistent, chronic hepatitis
36 Structure
• Genus Hepacivirus, Family
Flaviviridae
• 30 to 60 nm in diameter,
• enveloped , positive-sense RNA
genome (9100 nucleotides)
encodes 10 proteins, including two
glycoproteins (E1, E2)
• Viral RNA-dependent RNA
polymerase  error prone
mutations antigenic variability

development of a
vaccine very difficult
37 Replication

• infects only humans and chimpanzees

• binds to CD81 (tetraspanin) surface receptors
expressed on hepatocytes and B lymphocytes
• Can also coat itself with LDL or VLDL and then use
the lipoprotein receptor to facilitate uptake into
hepatocytes
• Replicates like other flaviviruses
• Virion assembles at and buds into the endoplasmic
reticulum, becoming cell associated
38 Pathogenesis
• HCV proteins inhibit apoptosis and interferon-α action
 prevent the death of the host cell  promote
persistent infection
• Cell-mediated immune responses  resolution of
infection and tissue damage
• Chronic infection can exhaust CD8 cytotoxic T cells to
prevent resolution of infection
• Inflammation and continual liver repair and induction
of cell growth occurring during chronic HCV infection
 development of HCC
• Antibody to HCV is not protective  WHY?
39 Epidemiology

• transmitted primarily by contaminated blood

transfusion and sexual activity
• IV drug abusers, tattoo recipients, transfusion
and organ recipients, and hemophiliacs
receiving factors VIII or IX are at highest risk
for infection
• > 90% HIV-infected people who are/were IV
drug users are infected with HCV
• high incidence of chronic asymptomatic
infections  promotes the spread of the virus
in the population
40 Clinical syndrome
41 Laboratory diagnosis

• diagnosis and detection of HCV infection are based

on ELISA recognition of anti-HCV antibody or
detection of the RNA genome
• Seroconversion occurs within 7 to 31 weeks of
infection
• Antibody is not always detectable in
o viremic people,
o immunocompromised patients, or
o in those receiving hemodialysis
• Genome detection and quantitation by RT-PCR,
branched-chain DNA, and related techniques is the gold
standard for confirming a diagnosis of HCV
42 Treatment, Prevention, and
Control
• precautions  similar to that of HBV and
other blood-borne pathogens
• Alcohol drinking should be limited 
exacerbates the liver damage caused by
HCV
43 Clinical case #1
(Scand J Infect Dis 33:116–120, 2001)
35-year-old woman was admitted with malaise and
jaundice. Lab tests :
- bilirubin (71.8 μmol/l (normal value <17 μmol/l)
- aspartate amino transferase (ALT) 410 IU/l (normal
value <30 IU/l) (indicated liver damage)
- Serology was negative for antibodies to hepatitis A,
hepatitis B, hepatitis C, Epstein-Barr virus,
cytomegalovirus, and HIV-1
- However, HCV genomic RNA sequences were detected
by reverse transcriptase polymerase chain reaction
analysis.
44 Clinical case #1 (cont’d)
(Scand J Infect Dis 33:116–120, 2001)
• ALT levels peaked on the 3rd week after admission and
returned to normal by the 8th week
• HCV genomes in blood were undetectable by the eighth
week
• Anti-HCV antibody was (+) the 8th week
• It was suspected that she was infected by her sexual partner
 confirmed by genotyping virus obtained from both
individuals. Confirmation was provided by partial sequence
analysis of the E2 gene from the two viral isolates (The 5%
genetic divergence detected between the isolates, less than
the ≈20% divergence expected for unrelated strains)
Hepatitis D virus (HDV)
46 Introduction

• +15 million people in the world are infected with HDV

(delta agent)
• responsible for causing 40% of fulminant hepatitis
infections
• “Unique” : uses HBV and target cell proteins to
replicate and produce its own protein (only one
protein)
• ≈ “viral parasite” (proving that “even fleas have fleas”)
• HBsAg is essential for packaging the virus
• The delta agent resembles plant virus satellite agents
and viroids in its size, genomic structure, and
requirement for a helper virus for replication
47 Structure

• HDV RNA is circular

• RNA genome is very
small
• virion is ≈ the same size
as the HBV virion (35 to
37 nm in diameter)
• genome is surrounded by
the delta antigen core,
which in turn is
surrounded by an HBsAg
containing envelope
48 Pathogenesis
• delta agent binds to and is internalized by
hepatocytes in the same manner as HBV because
it has HBsAg in its envelope
• it can replicate and cause disease ONLY in people
with active HBV infections
• Because the two agents are transmitted by the
same routes, a person can be co-infected with
HBV and the delta agent. A person with chronic
HBV can also be superinfected with the delta
agent
• Superinfection >> more rapid, severe progression
than co-infection
49 Epidemiology

• Worldwide distribution
• Infecting approximately 5% of the 3x108
HBV carriers
• HDV is spread by the same routes as HBV
50 Clinical syndrome

• The delta agent increases the severity of HBV

infections  Fulminant hepatitis :
o very severe form of hepatitis causes altered brain
function (hepatic encephalopathy), extensive jaundice,
and massive hepatic necrosis
o more likely to develop in people infected with the delta
agent than in those infected with the other hepatitis
viruses
o Fatal 80% of cases

• Chronic infection with the delta agent can occur in

people with chronic HBV.
51 Laboratory diagnosis

• delta antigen
• anti-HDV antibodies
• RT-PCR techniques can be used to detect
the virion genome in blood
Hepatitis E virus (HEV)
53 Characteristics

• HEV (E-NANBH) (the E stands for enteric

or epidemic)  predominantly spread by
the fecal-oral route (especially in
contaminated water)
• Symptoms are similar to HAV infection but
symptoms for HEV may occur later than
HAV infection
• Mortality rate 1-2%
• Serious in pregnant women  mortality rate
+ 20%)
CASE STUDIES
55 patient A

• A 55-year-old man was admitted to the

hospital with fatigue, nausea, and
abdominal discomfort. He had a slight fever,
his urine was dark yellow, and his abdomen
was distended and tender. He had returned
from a trip to Thailand within the previous
month.
• IgM anti HAV (+)
56 patient B

• A 28-year-old woman was admitted to the

hospital complaining of vomiting, abdominal
discomfort, nausea, anorexia, dark urine,
and jaundice. She admitted that she was a
former heroin addict and that she had
shared needles. In addition, she was 3
months pregnant.
• HBsAg (+), HBeAg (+)
57 Patient C

• A 65-year-old man (patient C) was admitted

with jaundice, nausea, and vomiting 6
months after undergoing coronary artery
bypass grafting.
• HCV RNA (+)
58 Questions

1. What clinical or epidemiologic clues would have

assisted in the diagnosis of hepatitis A, B, and C?
2. What laboratory tests would have been helpful in
distinguishing the different hepatitis infections?
3. What was the most likely means of viral acquisition in
each case?
4. What personal and public health precautions should
have been taken to prevent the transmission of virus
in each case?
5. Which of the patients was susceptible to chronic
disease?
6. What laboratory tests distinguish acute from chronic
HBV disease?
7. How can HBV disease be prevented? Treated?
59

Bagian Mikrobiologi Klinik FK UNDIP