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Questions and Answers
Which mode of transmission has the highest percentage risk for Acute Hepatitis B?
Feco-oral transmission is a known mode of transmission for Acute Hepatitis B.
False
What is the primary marker that indicates an acute hepatitis infection with high infectivity?
HBsAg
The most reliable test for acute hepatitis is the HBV ______ load.
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Match the following serum markers with their interpretation:
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What condition is characterized by HBsAg conversion after immunosuppressive therapy?
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High replicative hepatitis is always caused by HBeAg positivity.
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What is the most common symptom of chronic hepatitis?
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In low replicative hepatitis, HBV DNA is less than ______ IU/mL.
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Match the following HBV markers with their descriptions:
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Which phase of Hepatitis B infection is characterized by normal ALT levels and positive HBeAg status?
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Phase IV of Chronic Hepatitis is associated with severely symptomatic patients.
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What are the symptoms of Acute Hepatitis B?
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The presence of _____ is indicative of a chronic infection without inflammation and minimal fibrosis.
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Which statement is true regarding the Immune Tolerant Phase of Hepatitis B?
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Match the following hepatitis B phases with their characteristics:
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The HBV DNA level in Phase II is ____.
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What laboratory feature is confirmed in Chronic Hepatitis Phase IV?
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What is the initial investigation used for chronic hepatitis?
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Tenofovir Alafenamide has more side effects compared to Tenofovir Disoproxil.
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What is the target of treatment for HBeAg-negative patients in chronic hepatitis?
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Lamivudine can lead to ______ due to the YMDD mutation.
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Match the following antiviral drugs with their characteristics:
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What is the possible outcome of chronic hepatitis B infection?
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Vertical transmission of Hepatitis B from mother to child can occur at any time during the pregnancy.
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What is the initial percentage risk of transmission through a needle prick from an HBsAg positive patient?
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If Anti HBs levels are between 10 and 100, a ______ dose of the vaccine is required.
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Match the following Hepatitis B transmission methods with their characteristics:
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What is the primary genetic material of the Hepatitis B virus?
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Genotype C of Hepatitis B virus carries a higher risk for hepatocellular carcinoma compared to other genotypes.
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Name the surface protein coded by the S-gene of the Hepatitis B virus.
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The percentage chance of transmission during pregnancy when the mother is HBeAg positive is ______.
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Match the following Hepatitis B genes with their corresponding significance:
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What is the process by which HBV integrates its sub genomic mRNA into host DNA called?
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What type of infection is characterized by Acute HBV infection combined with Acute HDV infection?
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HBV can be easily eradicated due to its ability to integrate into host DNA.
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What is the viral structure that is formed at the end of the HBV life cycle?
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Chronic hepatitis D virus infection typically has a better prognosis than other forms of hepatitis.
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What antibody is present during a superinfection of hepatitis D on top of chronic hepatitis B?
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HBV enters the host cell through the action of the ______ enzyme.
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Match the following stages of the HBV life cycle with their descriptions:
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The presence of _______ is associated with chronic HDV related cirrhosis.
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Match the following features of hepatitis D with their descriptions:
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What is the common cause of portal hypertension in Asia?
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NCPF/IPH has a negligible risk for cirrhosis.
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What is the characteristic appearance of collaterals in EHPVO during investigation?
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The primary treatment approach for EHPVO includes _______ variceal ligation.
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Match the following features with the correct condition (EHPVO or NCPF/IPH):
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What is indicated by an HBV DNA load greater than 20,000 IU/mL?
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The presence of Anti-HBc IgM indicates chronic Hepatitis B infection.
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What does a positive HBsAg and negative Anti-HBs indicate about the patient's Hepatitis B status?
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A pre-core/basal core mutant is associated with an increased risk for __________.
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Match the following marker patterns with their interpretations:
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What does a negative HBsAg and positive Anti-HBc suggest?
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The window period of Hepatitis B infection is characterized by the presence of HBsAg and heterotypic anti-HBs.
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What would indicate a conversion of HBsAg to Anti-HBs after an immunization event?
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Study Notes
Hepatitis B Phases
- Hepatitis B infection phases are categorized by HBeAg status (positive or negative)
- Phase I/HBeAg Positive is characterized by high HBV DNA levels and normal ALT levels, usually lasting 10-30 years
- Phase II/HBeAg Positive involves a decrease in HBV DNA levels and an increase in ALT levels, with mild symptoms
- Phase III/HBeAg Negative is the most common phase, with low levels of HBV DNA and normal ALT levels
- Phase IV/HBeAg Positive is characterized by high levels of HBV DNA and ALT, and associated with chronic hepatitis
- Phase V/HBSAg Negative) is a phase with no inflammation and minimal fibrosis, indicating a chronic infection
- Immune Tolerant Phase lacks an immune response to HBV infection
- Immune Clearance Phase is an optimal time for treatment due to the immune system actively clearing the virus
- Reactivation Phase is another optimal time for treatment, as there is a resurgence of the virus after a period of inactivity
Acute Hepatitis B
- Symptoms include fever, malaise, and vomiting
- Laboratory Features include increased serum bilirubin and liver enzymes
- Mode of transmission can be vertical, percutaneous, sexual, through blood transfusion, and via HCV risk
- No transmission through fecal-oral route or breast milk
- Post Transfusion Hepatitis is hepatitis arising after a blood transfusion
- Anti-HAV IgM is commonly associated with acute hepatitis in children
- Anti-HEV IgM is commonly associated with acute hepatitis in adults
- HBSAg, HBeAg, and anti-HBc IgM are markers used to diagnose acute hepatitis B
Chronic Hepatitis
- Confirmation of Phase IV chronic hepatitis involves high quantitative HBsAg ( >1000 IU/ml), severe symptoms and very high HBV DNA load
- Clinical Features include fatigue, fever, and extrahepatic manifestations like membranous nephropathy and polyarteritis nodosa
- Low Replicative Chronic Hepatitis is characterized by low HBV DNA levels (<20,000 IU/mL) and low risk of liver injury
- High Replicative Chronic Hepatitis is characterized by high HBV DNA level > 20,000 IU/mL and an HBeAg positive status , with increased infectivity and liver injury risk
- High Replicative Chronic Hepatitis with HBeAg Negative status can occur due to precore mutations, indicating high HBV DNA levels > 2000 IU/mL, anti-HBc reactivity, progressive liver injury with a poor prognosis
- Initial Investigations for chronic hepatitis involve a Fibroscan
- Treatment Options include IFN-α, lamivudine, lamivudine + Adefovir, Tenofovir Disoproxil, Entecavir, and Tenofovir Alafenamide
HBV Virus Structure & Progression
- Structure: HBV is a hepadnavirus with partially double-stranded DNA, containing an incomplete (+) strand and a complete (-) strand
- Infective Particle (virion): 42nm Dane particle
- Genotypes: 10 genotypes of HBV exist
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Open Reading Frames (ORFs): Four ORFs are present in the HBV genome
- S-gene: Codes for HBsAg, a surface protein
- C-gene: Codes for HbcAg, a core protein, with intracellular anti-HBcAg found in the blood
- Pre C-gene: Part of the C-gene that codes for HBeAg, a qualitative marker of infectivity and replication
- P-gene: Codes for polymerase, a reverse transcriptase enzyme
- X-gene: Codes for Hbx Ag, associated with hepatocellular carcinoma (HCC)
- Progression: 95-99% of HBV infections result in recovery, while 1-5% progress to chronic hepatitis
- Chronic hepatitis can lead to portal hypertension, cirrhosis, HCC, and liver failure
- Infectivity: HBV is highly infectious, 100x greater than HIV and 10x greater than HCV
- Genotype A is the most common
- Genotype C poses the highest risk for HCC
- Presence in Body Fluids: HBV is found in all body fluids excluding stools
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Pregnancy: 90/10 rule applies for HBV transmission during pregnancy:
- HBeAg(+ve): 90% chance of transmission
- HBeAg(-ve): 10% chance
HBV Life Cycle
- Entry: HBV enters the host cell using host enzymes
- Integration: HBV integrates its sub genomic and pre genomic mRNAs into host DNA
- Transcription: Sub genomic mRNA is translated into x-Protein, while pre genomic mRNA is transcribed into DNA using RNA dependent DNA polymerase
- DNA Replication: DNA replication occurs using DNA-dependent DNA polymerase to create more DNA
- Virion Formation: Virions, 42 nm Dane particles, are formed
Hepatitis D Virus
- Delta virus, RNA is a dependent virus, requiring HBV infection to replicate
- Anti LKM-3 Antibody is associated with chronic HDV infection
- Coinfection: Involves acute HBV and acute HDV infections
- Superinfection (Acute on Chronic): Occurs in patients with chronic HBV and acute hepatitis D
- Fulminant Hepatitis: Potential outcome of HDV coinfection (5-20% chance)
- Chronic HDV related cirrhosis: Outcome of HDV superinfection, carrying a poor prognosis
- Higher Risk of Fulminant Hepatic Failure in Pregnancy: HEV infections in pregnancy carry a higher risk of fulminant hepatic failure
Hepatology
- Serological patterns of Hepatitis B infection are defined by combinations of HBsAg, anti-HBs, anti-HBc IgM, HBeAg, and anti-HBe
- Chronic Hepatitis is diagnosed with HBsAg +ve and anti-HBc IgG +ve
- Acute reactivation of hepatitis B can occur after a period of inactivation.
- Pre-Core/Basal Core Mutant is associated with very poor prognosis, increased risk of HCC, cirrhosis, and decompensation
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Follow-up after 24 weeks from initial exposure or symptoms:
- HBsAg to Anti-HBsAg conversion
- Anti-HBc IgG to Anti-HBc IgM conversion
Non-Cirrhotic Diseases
- EHPVO (Extrahepatic Portal Venous Obstruction) is a condition primarily seen in children (3-8 years)
- NCPF/IPH (Non-Cirrhotic Portal Fibrosis/Idiopathic Portal Hypertension/Hepatoportal Sclerosis) is common in Asian males (20-40 years)
- Outcome: EHPVO has a good prognosis with minimal risk for cirrhosis, while NCPF/IPH has a good prognosis but a negligible risk of cirrhosis
- Portal Vein Involvement: EHPVO primarily affects 1st order portal veins, while NCPF/IPH affects 3rd order portal veins
- Cause: EHPVO is often linked to umbilical sepsis and thrombotic states, while NCPF/IPH is associated with E. coli, arsenic, and hypervitaminosis A
- Presentation: Both conditions present with massive UGI bleeds, massive splenomegaly, anemia, and thrombocytopenia
- Prognosis: EHPVO has a good prognosis with no risk for cirrhosis
- Investigations: In EHPVO, CT is the initial investigation, showing cavernous collaterals.
- Investigations: In NCPF/IPH, Doppler is the initial investigation, and biopsy is considered the gold standard and reveals obliterative portal venopathy.
- Complications: EHPVO can lead to stunted growth and portal biliopathy.
- Treatment: Endoscopic variceal ligation or endoscopic sclerotherapy are used for EHPVO
- Most common cause of PHTN: Asia: EHPVO, World: Biliary atresia
- Images: Images of CECT, color Doppler, and sclerotic portal tracts can be used for diagnosis.
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Description
Test your knowledge on the various phases of Hepatitis B infection. This quiz covers HBeAg status, HBV DNA levels, and associated symptoms during different stages of the infection. Explore the immune response phases as well as treatment opportunities in the context of Hepatitis B.