hepatitis serology
DESCRIPTION
Hepatitis serologyTRANSCRIPT
Dr. RABIE IBRAHIMSUPERVISED BY Dr.ABDALLA AL-SHAHRANI
Hepatitis A B C D E
Virus HAV HBV HCV HDV HEV
Family Picornavirus Hepadnavirus Flavivirus Satellite Calicivirus
Genome ssRNA dsDNA ssRNA ssRNA ssRNA
Spread Fecal-oralparenteral, sexual,perinatal
parenteral, ?sexual
parenteral, ?sexual Fecal-oral
Antigens HAV-Ag HbsAg,HBcAg,HBeAg HCV-Ag HDV-Ag HEV-Ag
Antibodies Anti_HAV Anti-HBs,Anti-HBc,Anti-HBe Anti-HCV Anti-HDV Anti-HEV
Virus markers HAV RNAHBV DNA, DNA polymerase
HCV RNa HDV RNa viruslike partiacles
c
serology
• HBsAg: surface antigen• HBeAg: e antigen (a component of HBV core); marker of viral replication• HBcAg: core antigen (cannot be measured in serum)• both HBsAg and HBeAg are present during acute hepatitis B• anti-HBs follows HBsAg clearance and confers long-term immunity• anti-HBe and anti-HBc appear during the acute and chronic phases of the illness but do notprovide immunity• anti-Hbe indicates low infectivity
Possible Outcomes of HBV Infection
Acute hepatitis B infection
Chronic HBV infection
3-5% of adult-acquired infections
95% of infant-acquired infections
Cirrhosis
Chronic hepatitis
12-25% in 5 years
Liver failure Hepatocellular carcinoma
Liver transplant
6-15% in 5 years 20-23% in 5 years
DeathDeath
Symptoms
HBeAg anti-HBe
Total anti-HBc
IgM anti-HBc anti-HBsHBsAg
0 4 8 12 16 20 24 28 32 36 52 100
Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course
Weeks after Exposure
Titre
IgM anti-HBc
Total anti-HBc
HBsAg
Acute(6 months)
HBeAg
Chronic(Years)
Anti-HBe
0 4 8 12 16 20 24 28 32 36 52 Years
Weeks after Exposure
Tit
erAcute HBV Infection with Progression to
Chronic Infection: Typical Serologic Course
、 Laboratory Diagnosis
Hepatitis B virus
HBV belongs to the Hepadnaviridae family of viruses.
Diagram of hepatitis B virus.
Hepatitis B surface Ag. Hepatitis core Ag. Hepatitis e Ag. HBV-DNA. HBV-DNA polymerase.
Laboratory Markers for HBV Infection
Hepatitis B surface antigen (HBsAg):
present in acute or chronic infection.
It appears 4-12 week after infection
Hepatitis B surface antibody (anti-HBs):
marker of immunity acquired through natural HBV infection, vaccination, or passive antibody (immune globulin) , It appears 4-10 month after infection
Hepatitis B core antibody (anti-H Bc):
Ig M--indicative of infection in the previous six months,
It appears 6-14 week after infection
Ig G--indicative of more distant HBV infection that may have
been cleared by the immune system or that may persist.
positive HBsAg and anti-HB c Ig G--indicative of persistent
chronic HBV infection
Laboratory Markers for HBV Infection
Laboratory Markers for HBV Infection
Hepatitis B e antigen (HBeAg) : correlates with a high level of viral replication;
often called a "marker of infectivity"
Hepatitis B e antibody (anti-HBe): correlates with low rates of viral replication.It appears 8-16 week after infection
HBV DNA: correlates with active replication; useful in
monitoring response to treatment of HBV infection, especially in HBeAg-negative mutants
Interpretation of HBV Tests
Test Result Interpretation
Test Result InterpretationHBsAg Negative Susceptible (not
immune) to HBV infection
Anti-HBc NegativeAnti-HBs NegativeHBsAg Negative Immune because of
natural infectionAnti-HBc PositiveAnti-HBs PositiveHBsAg Negative Immune because of
hepatitis B vaccinationAnti-HBc NegativeAnti-HBs PositiveHBsAg Positive Acute HBV infectionAnti-HBc PositiveIgM anti-HBc PositiveAnti-HBs NegativeHBsAg Positive Chronic HBV infectionAnti-HBc PositiveIgM anti-HBc NegativeAnti-HBs NegativeHBsAg NegativeAnti-HBc PositiveAnti-HBs Negative
Possible Interpretations: (1) patient may be recovering from acute
infection; (2) patient may be distantly immune--testing
does not detect very low level of anti-HBs;(3) patient may be susceptible, with a false-
positive anti-HBc; or(4) there may be an undetectable level of
HBsAg in the serum, and the patient is actually a carrier
Diagnostic criteria for HBV infection
Acute Infection
Acute HBV infection is subclinical in 70 percent of adults and 90 percent of children younger than five years.
The incubation period after infection lasts one to four months. Symptoms of acute HBV infection include nausea, anorexia,
fatigue, low-grade fever, and right upper quadrant or epigastric pain.
Clinical jaundice appears as constitutional symptoms are resolving
Hepatic transaminase levels [ALT] and [AST]) reflect
hepatocellular injury and range from several hundred to
20,000 IU per L.
Serum bilirubin values are usually less than 20 mg per dL (342
µmol per L).
Mild anemia is common, as is relative lymphocytosis.
More severe disease results in an elevation in the prothrombin
time and a decrease in the serum albumin level.
HBV is not cytopathic, and liver injury is caused by the host's
immune response against infected hepatocytes
Diagnostic criteria for HBV infection
Chronic disease HBsAg positive for longer than six
months. Serum HBV DNA > 100,000 copies per
mL. Persistent or intermittent elevation of
alanine transaminase and aspartate transaminase levels
Liver biopsy showing chronic hepatitis
Inactive HBsAg carrier state
HBsAg positive for longer than six months. HB e Ag negative, anti-HB e positive Serum HBV DNA < 100,000 copies per mL Persistently normal alanine transaminase or
aspartate transaminase levels Liver biopsy to confirm absence of significant
hepatitis
Resolved disease
History of acute or chronic hepatitis B. Presence of anti-HBc, with or without
anti-HBs HBsAg negative Normal alanine transaminase level
CASE 1
A 25-yr-old male patient presented to your clinic for pre-employment evaluation and his lab results show the following :
HBsAg Negative, Anti-HBc Negative, Anti-HBs Positive.What is your interpretation of his lab results?
Immune because of previous hepatitis B vaccination.
Case 2: A 35 years old man presented with complain of fever,
abdominal pain associated with nausea. Investigations showed : CBC : HB 10.5 g%, WBC 8.5, ESR 100, CRP 20 mg/dl . LFT : bilirubin 14 mg/dl , AST (SGOT) 900 u/L, ALT
(SGPT) 1500 u/l. Hepatitis profile: HBsAg –ve, Anti HBc IgM –ve, HBeAg
+ve, Anti HBs –ve. VDRL +ve.QUESTION:1. What is your interpretation?2. Explain your findings.
Answer : Acute recent hepatitis infection, HBsAg should be
positive but in occasional cases it appears later than the HBe Ag.
You should repeat the test to detect the HBsAg . VDRL is false positive. Hepatitis is one of the causes of false positive VDRL.
Case 3: A 30 years old healthy hospital worker reported to
check the results of his hepatitis screening test: HBsAg –ve. Anti HBs +ve. Anti HBc +ve. HBe Ag -ve. Anti HBe -ve. Anti HCV -ve
QUESTION: Interpret this test.
Answer: Past hepatitis infection. Immune and not infective
Case 4: A 20 years old reported for pre-employment examination and
investigations, all his systems were free apart from 2cm BCM hepatomeglay and he reported a painless lesion on his penis since 2 weeks.
Investigations: CBC HB 12.5mg%, WBC 12.5. LFT : ALT 120 u/l, AST 100 u/l, Alk Phos 300 u/l. Hepatitis profile: HBsAg +ve, Anti HBc IgG +ve, HBe Ag +ve , Anti HBs –ve. HBDNA >100.000 copies. VDRL –ve. Question: How would you interprete this tests. What is the diagnosis?
Answer : Chronic persistent hepatitis, did not develop immunity
yet still infective. ? First stage Syphlitic lesion with –ve VDRL in early
phase . Needs : Repeat LFT and hepatitis profile regularly. Liver US and liver biobsy. Repeat VDRL after 1 week, if +ve, perform the TP
specific tests. Do HIV screening and screen for other STD
Case 5: A 25 years old female who had an attack of fever and
epigastric pain 3 months ago, her husband was found to be hepatitis positive.
She presented to check her investigations she did last week.
CBC HB 10.5 g%, WBC 7.8, ESR 30 LFT ALT 70 U/l , AST 85 U/l, alk phosp 120 U/lز Hepatitis profile: HBsAg –ve ,anti HBc+ve , HBeAg –ve , anti HBs –ve.
Question:1. How would you interpret her findings?2. What is your next step?
Answer: Window stage. Repeat after 1month
Case 6
A 26 years old woman seen by her GP because she was jaundiced and feeling unwell.
She had a history of drug addiction.
A hepatitis screen was done, the results are: Anti-HAV NEGATIVE. Anti HBs POSITIVE. Anti-HbsAg NEGATIVE. HbsAg NEGATIVE. Hbe Ag NEGATIVE Anti-HCV NEGATIVE. Anti-HBc POSITIVE.
Questions
Which of the following is the most likely cause of her jaundice.
A. Acute hepatitis C.
B. Chronic hepatitis B and acute hepatitis C.
C. Hepatitis E
D. Chronic Hepatitis E
E. Acute hepatitis B
Answer 6
The picture suggests previous exposure TO hepatitis B but this would not give a clinical picture of jaundice, so another cause needs to be considered.
History of drug addiction suggest hepatitis C. Antibody against hepatitis C takes about 3 months, the
PCR testing is test used to reach the diagnosis in the acute phase.
Question 7
During pre-employment screening. A 26 year old male has the following hepatitis serology HBs Ag
negative HBs Ab
positiveHbe Ag
negativeHbe Ab
positiveHBc Ab
positive A.What is your interpretation ?
Immune by past infection
Answer 7
Case 8 :Highly infective chronic hepatitis B is suggested by:
1. normal liver enzymes, HBeAg+, anti-HBc IgG+
2. elevated liver enzymes, HBeAg+, anti-HBc IgM+
3. normal liver enzymes, HBeAg-, anti-HBc IgG+
4. elevated liver enzymes, HBeAg+, anti-HBc IgG+
Highly infective chronic hepatitis B is suggested by:
•1 normal liver enzymes, HBeAg+, anti-HBc IgG+ F
•2 elevated liver enzymes, HBeAg+, anti-HBc IgM+ F
•3 normal liver enzymes, HBeAg-, anti-HBc IgG+ F
•4 elevated liver enzymes, HBeAg+, anti-HBc IgG+ T