Hepatitis

Question 1

Complications of HAV

Answer 1

• Usually improves w/o sequelae w/in 2mos
• relapsing hepatitis - 1 in 7
  
  • during 6mos after acute infection
• prolonged cholestatic hepatitis >12wks
  
  • <5%, resolves spontaneously

Question 2

hepatitis in pregnancy a/w guillain-barre

Answer 2

HEV

Question 3

Most effective therapies for tx cHBV

Answer 3

tenofovir (esp HIV)

entecavir

lamivudine - used in HIV, but has high rate of R development (30%)

Question 4

Important complication of tx of HCV

Answer 4

HBV reactivation w/ flares of hepatitis, occasionally severe enough to require liver transplant or result in death

Question 5

Who to screen for HCC in chronic HBV infection

Answer 5

• all pts w/ cirrhosis
• Asian M >40yo; Asian F >50yo
• African >20yo
• FH of HCC

Question 6

Frequent extrahepatic manifestations of HCV

Answer 6

• AI thyroiditis
• B-cell NHL
• lichen planus
• porphyria cutanea tarda
• cryoglobulinemia: vasculitis, glomerulonephritis

Question 7

Genotypes of HEV

Answer 7

• Genotype 1,2 - Asia, N Africa
  
  • no animal reservoir
• Genotype - endemic in swine - butchers and farmers

Endemic in most of the developing world

Question 8

Infectious related causes of hepatic parenchymal disease

Answer 8

• ART toxicity: ABC, nevirapine (classically). Can be seen with almost all ART
• Malignancy: KS, HCC
• Biliary disease: AIDS cholangiopathy

Question 9

Common cause of hepatitis in children

worsened liver failure w/ chronic HBV/HCV

Answer 9

think parvovirus B19

Question 10

exposure: contaminated water

jaundice, abd pn, + fever/HA/myalgias

Answer 10

consider lepto

Question 11

Travel to SA or Africa

range from mild febrile illness to fulminant liver failure

Answer 11

consider yellow fever

Question 12

Persons w/ isolated HBcAb+ in high-risk groups (BMT, SOT, ritux, HDS)

Answer 12

represents occult HBV most commonly

• need vaccination
• (note: if HBsAg+ –> need ppx always)

Question 13

Tx HBV if…

• GFR 30-60
• GFR 10-30
• GFR <10 (no RRT)
• RRT

Answer 13

• GFR 30-60: TAF
• GFR 10-30: TAF or entecavir
• GFR <10 (no RRT): entecavir
• RRT: TDF or TAF or entecavir (anything)

Question 14

When to tx pregnant women with HBV

Answer 14

*rec all pregnant women have HBV DNA

Tx if DNA >200k

Question 15

The 4 preferred tx for chronic HBV

Answer 15

• Entevacir
• TAF
• TDF
• Peg-IFN

Question 16

When to tx HBV

Answer 16

when high replication plus disease (ie liver damage) - phases 2 and 4 of natural history

• w/ HBeAg positive disease: limits are ALT >2xULN and DNA >20k
• w/ HBeAg negative disease: limits are ALT>2xULN and DNA >2k

Question 17

HBV Disease Phase:

HBsAg negative

HBeAg-

HBV DNA <10

ALT normal

Liver disease none

Answer 17

resolved HBV infection (HBsAg-/anti-HBc Ab+)

(Phase 5)

Question 18

HBV Disease Phase:

HBsAg - intermediate

HBeAg -

HBV DNA >2k

ALT elevated

Liver disease mod/sev

Answer 18

HBeAg- chronic HBV

(Phase 4)

*req tx

Question 19

HBV Disease Phase:

HBsAg low

HBeAg -

HBV DNA <2k

ALT normal

Liver disease none

Answer 19

chronic HBC infection - inactive carrier

(Phase 3)

*latent/nonreplicative phase

Question 20

HBV Disease Phase:

HBsAg high/intermediate

HBeAg +

HBV DNA 10^4-10^7

ALT elevated

Liver disease mod/sev

Answer 20

chronic HBV - immune reactive (Phase 2)

*req tx

Question 21

HBV Disease Phase:

HBsAg high

HBeAg +

HBV DNA >10^7

ALT normal

Liver disease none/minimal

Answer 21

Chronic HBV infection - immune tolerant

(Phase 1)

Question 22

Essential evaluation with chronic HBV

Answer 22

eAg, HBV DNA, HDV, genotype

HIV

stage (LFT, elastrography or bx)

renal status

u/s to r/o HCC (Asian, M>40yo, F>50yo, AA>25-30yo)

Question 23

Which HCV regimen to avoid in pts with HIV on PI

Answer 23

grazoprevir (an HCV PI)

PIs interact (similarly, boosters will effect levels)

Question 24

Which HCV regimens have concern with tenofovir?

Answer 24

sofosbuvir (TDF can increase sofosbuvir)

Question 25

Which HCV regimens are safe with ESRD?

Answer 25

all are

Question 26

Which HCV regimens are pangenotypic?

Answer 26

* glecaprevir/pibrentasvir * sofosbuvir/velpatasvir

Question 27

Usual answers for tx-naive HCV 1a

Answer 27

* \*sofosbuvir/velpatasivir x12 weeks * glecaprevir/pibrentasivir x8wk

Question 28

Equation that could be helpful in determining likelihood of cirrhosis in HCV

Answer 28

**FIB 4** = age (yrs) x AST (U/L) / plt count x ALT^1/2 (FIB4\>fibrosure - though fibrosure still tends to be used for insurance purposes)

Question 29

Accepted staging methods for HCV

Answer 29

liver bx blood markers elastography or any combo of the above

Question 30

HBsAg+ anti-HCV negative

Answer 30

polyarteritis nodosa

Question 31

HCV palpable purpura (often on LEs)

Answer 31

cryoglobulin vasculitis

Question 32

HCV pruritic rash

Answer 32

lichen planus

Question 33

HCV blister in sun-exposed areas

Answer 33

porphyria cutanea tarda

Question 34

Hepatitis in pregnancy

Answer 34

1. Rule out viral hepatitis (including HSV, as, though 50% will have MC lesions, hepatitis can occasionally be only presenting symptom) 2. R/o meds 3. HELLP 4. AFLP - severe + low glucose, low fibrinogen

Question 35

Hepatitis with Travel to Developing Country

Answer 35

Question 36

Bacterial causes of hepatitis

Answer 36

_Cholestatic_ * coxiella burnetti * spirochetes (syphilis, lepto) bacterial sepsis, liver abscess Brucellosis TB Typhus

Question 37

low platelets, leukopenia often hepatitis exposure

Answer 37

Rickettsia/Ehrlicia

Question 38

* acute hepatitis (bili\>LFTs - cholestatic) * multiorgan: kidney, eyes, skin, muscle, lungs * exposure to fresh water (rafting in Hawaii or Costa Rica) OR rats (homeless or cabins)

Answer 38

leptospirosis

Question 39

IDU, HIV + MSM with acute elevated LFTs

Answer 39

think HCV (most likely cause of acute hepatitis in these populations)

Question 40

fulminant hepatitis in someone with either acute or chronic HBV

Answer 40

HDV

Question 41

HAV post-exp ppx

Answer 41

* vaccinate and possibly IG * unless \>40yo or immunocompromised - then maybe just IG) * all close exposures (not casual exposures)

Question 42

MCC of acute hepatitis in the US

Answer 42

HAV

Question 43

extrahepatic complications of HEV

Answer 43

GBS and other neuro manifestations pancreatitis

Question 44

Outbreaks - contaminated water Asia/Africa Sporadic - undercooked meat (BOAR, deer) \*\*Overseas travel typical

Answer 44

Hep E