18.

4 Bacteria and Archaea

Viral hepatitis

Dr. Staar Mohammed Qader

Ph. D. Medical Microbiology
2019
Al-Kitab University-College of Med. Technology
Medical Lab. Dep. Level 3
Lecture 7 and 8
 Viral hepatitis
 Viral hepatitis is viral infection of the liver that
causes hepatic inflammation which is followed by
the classic icteric symptoms of jaundice and the
release of liver enzymes
 Hepatitis, meaning inflammation of the liver, is a
major cause of morbidity in human populations.
Although there are non-viral causes of hepatitis,
 Viral infections represent the major cause of this
disease. As with infections of other organs, there is
a number of unrelated viruses that can infect the
liver to cause hepatitis.
 The liver
 The liver is the largest organ in the
human body, weighing around 1.5 kg in
an adult. Its primary role is as part of the
digestive system,
 The liver is one of the main sites of
glycogen storage and so is critical in
energy homeostasis, maintaining blood
glucose levels within a narrow range by
taking up or releasing glucose in
response to hormonal signals.
 It is also a major site of biosynthesis for
blood proteins, including albumin and
clotting factors.
 The liver is a major site of blood
detoxification.
 The liver also removes other toxins,
such as alcohol, that may be ingested.
 The functions of the liver are carried out
by hepatocytes,
Periods and clinical symptoms of hepatitis
1. Incubation period.
2. Pre-icteric period. 3. Icteric period.

4. Recovery.
Hepatitis B, C or D also cause:
- Skin rash
- Arthralgia
- Weight loss
Icteric symptoms of liver damage
 Classification of Hepatitis Viruses

Virus Family Nucleic acid Envelope

HAV Picornaviridae ss +RNA No

HBV Hepadnaviridae Incomplete circular ds –DNA Yes

HCV Flaviviridae ss +RNA Yes

HGV Flaviviridae ss +RNA Yes

HDV Genus Deltavirus ss –RNA Yes

HEV Hepeviridae ss +RNA No

TTV Circinoviridae ss –DNA No

SEN virus Circoviridae ss –DNA No

 Viral hepatitis

Transmission
FOOD & WATER BORN BLOOD BORN
Incubation period
Hepatitis A: 2-6 weeks Hepatitis B: 2-6 months
Hepatitis E: 2-9 weeks Hepatitis C: 2-26 weeks
Hepatitis D: unlimited
Type of hepatitis
Acute Acute, chronic
 Hepatitis A

• Hepatitis A virus
Family Picornaviridae.
• Small, non-enveloped RNA virus with cubical
symmetry.
• One stable serotype only
 Characteristics of HAV
• Stable to:
– Saltwater, groundwater (months)
– Acid at pH 1
– Solvents (ether, chloroform)
– Detergents
– Drying
– Temperature:
• 40C: weeks
• 560C for 30 minutes
• 610C for 20 minutes
• Inactivated by:
– Chlorine treatment of drinking water
– Formalin
 Hepatitis A (infectious hepatitis)
• 1) is spread:
– by the fecal-oral route by ingestion of
contaminated food and water;
– through close physical contact.
• 2) contagious period extends 2-3 weeks
before and 8-10 days after onset of jaundice.
Virus may cause asymptomatic shedding.
• 3) does not cause chronic liver disease.
• 4) immunity is life-long.
Spread of HAV within the body
HAV enters the body by ingestion and intestinal infection. Then it
spreads by the bloodstream, to the liver, a target organ. Large
numbers of virus particles are detectable in feces during the
incubation period, beginning as early as 10-14 days after exposure.
Pathological changes appear exclusively in the liver.
 Outcomes of Infection with Hepatitis A Virus
Outcome Children Adults

In-apparent (subclinical) infection 80–95% 10–25%

Icteric disease 5–20% 75–90%

Complete recovery > 98% > 98%

Chronic disease None None

Mortality rate 0.1% 0.3–2.1%

 Laboratory diagnosis of hepatitis A
• Biochemical tests to study liver function:
- The Bilirubin.
- Alanine aminotransferase (ALT).
- Aspartate aminotransferase (AST).
• Serology: ELISA
– Acute infection: IgM.
– Past Infection i.e. immunity: IgG.

• Direct demonstration:
– ELISA (detection of antigen in stool),
– RT-PCR of faeces.
 Family Hepeviridae. Hepatitis E virus
• non-enveloped, cubic symmetry, 32-34 nm,
• ss + RNA virus
• 4 genotypes
 Epidemiology of HEV infection
• Contagious period extends from before to
after symptoms.
• Transmission - via fecal-orale route by
ingestion of contaminated food and water.
• It causes only acute disease.
• Life long immunity.
• HEV infection is especially
serious in pregnant women
(mortality rate about 20 %).
• Transmission through placenta results in death of
fetus.
 Family Hepadnaviridae. Hepatitis B virus
The hepatitis B virion (Dane particle):
- outer lipid envelope with the surface antigen (HBsAg).
- an electron-dense core (nucleocapsid): ds circular DNA
and polymerase surrounded by the core antigen
(HBcAg).

The HBsAg is produced in excess by the infected

hepatocytes and is secreted in the form of spherical
and filamentous particles.

HBeAg is the soluble

component of the core, with is
released during active
infection.
 Pathway for the replication of HBV

1. Attachment to the cell surface receptor,

fusion and releasing the core into
the cytoplasm.
2.The core proteins dissociate from the DNA.
3. Completion of ds DNA by DNA polymerase
and entering the nucleus.
4. Formation of a circular episome.
5. Transcription of mRNAs.
6. Translation.
7. RNA is encapsidated by core proteins.
8. Inside the core, the RNA is transcribed to
minus strand DNA by polymerase called
reverse transcriptase.
9.Transcription the minus strand DNA into a
plus strand DNA.
10. Budding the virus through the
endoplasmic reticulum and/or Golgi Body
membranes from which it acquires HBsAg.
11. Shedding of viruses embedded in a lipid
bilayer and empty envelopes from HBsAg.

• 1011 new virions are produced every day

during acute infection
• Stable to:
Characteristics of HBV
– Acid at pH 2,3
– UV radiation
– Phenol
– Temperature:
• 1000 C for 5 minutes retains infectious activity
• 200 C for 3 months
• 40 C (in a refrigerator) for 6 months
– Survival:
• in dried blood for 4-5 months,
• in frozen plasma for 15-20 years,
• the presence of gross amounts of blood may interfere with the germicidal
action of disinfectants.
• Inactivated by:
– Autoclaving (1200 C for 20 min).
– Boiling for 60 minutes.
– Chloramine 1-2% for 2 hours.
– Ethanol 70-80% for 2 min.
– Formalin 1,5 % for 2 min.
– Hydrogen peroxide
 Hepatitis B (serum hepatitis)
• 1) Transmission:
– parenterally,
– sexually,
– vertically (from mother to fetus),
– close contact (hemocontact).
• 2) chronic hepatitis in 10% to 15% of adult
patients, 30-90% of young patients
• 3) is causally associated with primary
hepatocellular carcinoma and cirrhosis.
 Epidemiology of HBV infection
• Virus is shed during both symptomatic
and asymptomatic periods.
• Transmission:
- In blood, semen, and vaginal
secretions, saliva and mother’s milk.
- Via transfusion, needle stick injury,
injecting drug use, sex, child-birth, and
breast-feeding.
Infective dose is 0.000001 ml of blood.
Concentration of hepatitis B virus in body fluids

Low/Not
High Moderate Detectable
blood semen urine
serum vaginal fluid feces
wound exudates saliva sweat
breast milk tears
Spread of
HBV in
the body
Symptoms of typical acute viral hepatitis B infection
Clinical outcomes of acute hepatitis B infection
CLINICAL OUTCOMES OF HEPATITIS B

Principal considerations:

Asymptomatic carrier: the carrier

patient never develops antibodies
against HBsAg and harbors the virus
without liver injury.

Chronic persistent hepatitis: the patient

has a low-grade hepatitis

Chronic active hepatitis: the patient has

an acute hepatitis state that continues
without the normal recovery (last longer
than 6-12 months).

Fulminant hepatitis: severe acute

hepatitis with rapid destruction of the
liver.
 Pathology
Symptoms are immune-
mediated, resulting from
inflammation and cell-mediated
(cytotoxic T cell) responses to
HBsAg on the surface of
hepatocytes. These resolve the
disease.
If the cell-mediated immune
response is weak, symptoms are
mild but the infection does not
resolve and chronic hepatitis
ensues.
Chronic hepatitis leads to
cirrhosis and hepatocellular
carcinoma. Both of these are fatal
in the absence of a liver transplant
 HBsAg window
• “HBsAg window” - the period from about 6 to 8 months when
neither free HBsAg nor its antibody can be detected.
• Anti-HBsAg are undetectable because they are complexed with the large
amount of the antigen that is shed from infected cells.
• The best tool for diagnosis of an acute HBV infection during the
window is
the presence of
anti-HBcIgM
 Laboratory markers for HBV infection and their interpretation
• HBsAg – present in acute or chronic infection. It is detectable
in the blood from 1 to 6 months after infection.
• anti-HBs – marker of recovery and/or immunity to HBV
infection (from about 8 months after infection).

• anti-HBc IgM - marker of recent acute infection

• anti-HBc IgG - past or chronic infection.

• HBeAg - indicates active replication of virus and therefore

infectiveness (from 2 to 6 months after infection).
• anti-HBe - virus no longer replicating. However, the patient can
still be positive for HBsAg which is made by integrated HBV
(from about 4 months after infection).
• DNA - indicates active replication of virus.
Interpretation of Serological Markers of HBV Infection
 Hepatitis D virus (HDV) - delta agent
ss, circular (-) RNA virus similar to certain
plant viroids. It has delta antigen.
- HDV is coated with HBsAg which is needed
for release from the host hepatocyte and for
entry in the next round of infection.
- 3 genotypes.
 Epidemiology of HDV infection
• HDV infects children and adults with underlying
HBV infection.
• Transmission:
- parenterally and sexually;
- vertically (rarely).
- In blood, semen, and vaginal secretions;
- Unsterilized equipment and infusion.

Intravenous drug abusers, transfusion and organ

recipients, and hemophiliacs are at highest risk for
infection.
 Consequences of HDV infection

• Co-infection by HDV and HBV exacerbates the acute disease

(90%) and fulminant hepatitis (2-4%) is more likely than with
HBV alone.
• Superinfection of a person already infected with HBV causes
a more rapid, severe progression than co-infection because
super-infection requires HBV replication before HDV replication
can occur.
– about half of the patients exhibit acute hepatitis that resolves
– about 10-40% get chronic persistent hepatitis
– 7-10% get fulminant hepatitis.
 Laboratory markers for HDV infection
• In an HBV-HDV co-infection:
– HDV antigen is detected in about ¼ of patients.
HDV antigen disappears when HBsAg appears,
– anti-HDV IgG and IgM are usually seen,
– anti-HDV decline as the symptoms resolve and,
unlike anti-HBs, there are no antibodies to show
that the patient was once HDV-infected,
– anti-HBs IgG rises.
• In a super-infection by HDV:
– HBsAg and HDV RNA remain because super-
infection usually leads to chronic infection.
– anti-HDV IgG rises.
 Family Flaviviridae.
Hepatitis C and G viruses
Enveloped ss+RNA viruses, 55-65 nm diameter.
14 genotypes of HCV.
5 genotypes of HGV.

Electron micrograph of
the hepatitis C viruses
 HCV life cycle
• a) Virus binding and internalization,
• b) cytoplasmic release and uncoating,
• c) translation,
• d) RNA replication,
• e) packaging and assembly,
• f) virion maturation and release.
 Epidemiology of HCV and HGV infection
• 85-90% patients will develop chronic disease.
• About 50% of chronic carriers of HCV progress to cirrhosis or liver cancer in 10-40 years.
• Transmission:
- parenterally (through sharing
drug-injection equipment or
from transfusion of unscreened
blood or untreated clotting factors),
- sexually,
- perinatally.
- In blood, semen, and vaginal secretions.

- Contagious period extends 2-3 weeks before and 10 weeks

after onset of symptoms.
Routes of transmission of HCV
 Risk factors of hepatitis C
• Blood-to-blood contact (mainly transfusion):it is estimated that 90% of persons
with chronic HCV infection were infected through transfusion of unscreened blood
or blood products.
• Unsterilized injection equipment and infusion: considered to be the primary
sources of HCV infection.
• Sexual intercourse: although this is rare, and usually only occurs when HIV is also
present and makes blood contact more likely.
• Dental equipment: People can be exposed to HCV via inadequately or improperly
sterilized medical or dental equipment including needles or syringes, oral hygiene
instruments, and jet air guns, etc.
• Hemodialysis: The basic problem is that proper sterilization methods are not
followed.
• Occupational exposure to blood: Medical and dental personnel, first responders
(e.g. surgeons, nurses and emergency medical technicians) can be exposed to HCV
through needle sticks or blood spatter to the eyes or open wounds.
• Tattoos: Tattooing dyes, ink pots, piercing implements can transmit HCV-infected
blood from one person to another if proper sterilization techniques are not followed.
• Shared personal care items: Such as razors, toothbrushes, cuticle scissors, and
other manicuring or pedicure equipment can easily be contaminated with blood
carrying the virus, and take care that HCV can live on dried blood for 15 days.
• Vertical transmission: refers to the transmission of a communicable disease from
an infected mother to her child during delivery.
 Pathogenesis of HCV infection
• Hepatocytes are target cells for HCV.
• CPE – lysis of hepatocytes.
• Sensitive cells: monocytes, macrophages, B-
lymphocytes, neutrophiles, cells of bone marrow.
• HCV can reproduce in cells of pancreas, adrenal
glands, thyroid glands, spleen.
• Immunomediated extrahepatic manifestations:
– vasculitis (malaise, arthralgia, purpura);
– glomerulonephritis;
– altered nervous system (peripheral nerves, brain).
Clinical outcomes
of hepatitis С
infection

Immunity is not strong,

reinfection is possible
 Laboratory diagnosis of viral hepatitis
 Biochemical methods:
 Detection of the level of bilirubin and enzymes
ALT(GPT), AST(GOT) in serum.
 Serology:
 Detection of the Ag and antibodies.
 Rapid test.
 ELISA .
 Detection of a viral genome: PCR
 Rapid immunochromatographic test
 Rapid test
• A direct test for the visual detection of hepatitis viruses antigenes or
antibodies in serum.
• It is based on the principle of sandwich chromatographic immunoassay.
• Its result appears within 15-30 minutes. 
 Rapid test
• The test sample is applied to a thin
strip of nitrocellulose held in a
plastic frame.
• The nitrocellulose is impregnated
with antibodies directed against the
assayed antigen. These antibodies
are labeled with colored gold
spheres to permit visual readout of
the assay.
• The same antibody, minus the
colored spheres, is bound along a
line further down the strip.
• When the clinical sample is applied
to the strip, it migrates by capillary
action towards the opposite end. An antigen that reacts with the
labeled antibodies will also be bound
by the immobilized antibodies as the
complex moves down the strip. The
result is a visible colored line on the
filter indicating that antigen is present
in the sample.
 Treatment of Hepatitis B
• Anti-HBV immune globulin is effective soon after exposure. It
can also be given neonatally to children of HBsAg-positive
mothers. Ideally, the immune globulin should be administered
within 24 hours of birth or exposure and is probably not
effective after one week from exposure.
• Interferon - for HBeAg +ve carriers with chronic active
hepatitis. Response rate is 30 to 40%.
• Lamivudine - a nucleoside analogue reverse transcriptase
inhibitor. Well tolerated, most patients will respond favorably.
However, tendency to relapse on cessation of treatment.
Another problem is the rapid emergence of drug resistance.
• Adefovir – less likely to develop resistance than Lamivudine
and may be used to treat Lamivudine resistance HBV. However
more expensive and toxic
• Entecavir – most powerful antiviral known, similar to Adefovir
• Successful response to treatment will result in the
disappearance of HBsAg, HBV-DNA, and seroconversion to
anti-HBeAg.
 Treatment of Hepatitis C

• Alpha-interferon + Ribavirine
 Vaccines
 Against Hepatitis A
Havrix (inactivated)
 Against Hepatitis B (recombinant)
- Monovaccines (HBsAg – genetic engineering):
Engerix B
H-B-Vax
Recombivax B
- Divaccines:
Twinrix (inactivated HAV + HBsAg)
Recombinant HbsAg vaccine production
 Transfusion Transmitted Virus (TTV)
 Familly Circinoviridae.
 Non-enveloped circular ss (-) DNA virus.
 16 genotypes.
 The virus has been found worldwide with an extraordinarily
high prevalence of chronic viremia in apparently healthy
people.
 TTV-DNA was detected:
 in 47% of patients with fulminant hepatitis,
 In 46% of patients with chronic liver,
 in patients with liver cirrhosis,
 and hepatocellular carcinoma.
 Transfusion Transmitted Virus(TTV)
• Transmission:
- by parenteral exposure to blood,
- sexually,
- enterally (fecal-oral),
- from mother to child.
• The detection of TTV in saliva, nasopharyngeal
secretions, skin and hair might imply that household
contact transmission is also possible.
• The highest detection rates amongst:
– polytransfused,
– thalassemic,
– long-term hemodialysis patients,
– hemophiliacs treated with the nonvirally inactivated clotting-
factor concentrates,
– intravenous drug abusers.
 Hepatitis SEN virus
 Family Circoviridae.
 Non-enveloped circular ss(-) DNA virus.
 8 genotypes.
 Transmission: by
• Blood-product transfusion,
• Parenteral drug use,
• iatrogenic means in a hospital setting,
• Sexually,
• Perinatally, or by other means.
 Hepatitis SEN virus
• The majority of patients who acquire de novo
transfusion-associated SEN-V infection appear to
clear the virus with time.
– About 77% of post-transfusion infected patients cleared
the virus, in the majority within a 6-month period after
infection.
• Nonetheless, a few patients did not clear the virus
for years, and 13% appeared to have chronic
SEN-V infection.
– It is unknown whether these chronically-infected patients
would eventually clear the virus if followed over many
years .
Thank S

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