Viral Hepatitis: Other Viral Hepatides

© Springer International Publishing Switzerland 2017
Kia Saeian and Reza Shaker (eds.)Liver Disorders

12. Viral Hepatitis: Other Viral Hepatides

Adnan Said  and Aiman Ghufran2

Division of Gastroenterology and Hepatology, Department of Medicine, William S. Middleton VAMC, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

Division of Gastroenterology and Hepatology, William S. Middleton VA Medical Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA



Adnan Said

Non-hepatotropicHepatitisOther hepatitis virusesHerpesvirusesCMVInfluenzaAdenovirusClinical presentationDiagnosisTreatment

Questions from Patients

  1. 1.

    How do I know I have viral hepatitis?

    Hepatitis means inflammation of the liver. Drugs, toxins, heavy use of alcohol, reduced blood supply to the liver, and microorganisms including viruses may cause it. However, signs and symptoms of hepatitis from any virus are similar and the specific cause is often undistinguishable without blood tests. Sometimes patients have no symptoms. When patients do experience symptoms, these may include jaundice (yellowing of the eyes and skin), fatigue, lethargy, nausea, vomiting, loss of appetite, abdominal pain, and fever. In severe cases, patients may start noticing swelling of feet, abdomen, or confusion and drowsiness. If any combination of these symptoms occurs, medical care should be sought immediately.


  2. 2.

    How does it occur? Is it contagious?

    Most viral hepatitis occurs from human-to-human transmission, though animal-to-human transmission may also occur. Different viruses may be transmitted either from contaminated water and food; bodily secretions like blood, semen, and saliva (e.g., herpesviruses); or droplets when people cough or sneeze (influenza). The mechanism of transmission and its contagiousness is specific to each virus.


  3. 3.

    How are these infections treated?

    Hepatitis caused by viruses is usually treated symptomatically, meaning treating the symptoms of liver inflammation rather than the virus itself. However, some viruses may have a specific antiviral that can be used to eradicate it and prevent progression of the disease.


  4. 4.

    How do I know if I am getting better?

    Recovery after viral hepatitis typically starts with gradual resolution of nausea, vomiting, abdominal pain, and return of appetite and energy. The jaundice is usually the last to resolve.



  1. 1.

    Besides the known hepatitis viruses, which other viruses cause hepatitis?

    The hepatotropic viruses are the most common cause of viral hepatitis worldwide, of which hepatitis B and C cause chronic hepatitis. However, non-hepatotropic viruses only cause acute hepatitis and/or acute liver failure, without causing any chronic damage to the liver. These viruses do not primarily target the liver; hence the term non-hepatotropic is used in their description. These viruses include the herpesviruses (Epstein-Barr virus (EBV), cytomegalovirus [CMV], and herpes simplex virus), parvovirus, adenovirus, influenza, and severe acute respiratory syndrome (SARS)-associated coronavirus [1].

    The risk of acquiring infection from any of the non-hepatotropic viruses is specific to each virus and is detailed below. Considerations for determining the risk of infection include sanitary conditions, prior exposure, host immune status, and duration of infection in the contact.


Human Herpesviruses

This class of viruses includes varicella zoster (VZV), EBV, CMV, and herpes simplex virus (HSV).

Herpes Simplex Virus

Approximately 90 % of people worldwide have been exposed to one or both HSV viruses [2]. HSV-1 is more common, with 65 % of persons in the USA being seropositive to HSV-1 [3]. It is almost universal in the developing world, usually acquired in childhood secondary to close contact with infected family members and causes oral cold sores [2]. HSV-2 on the other hand is less ubiquitous and incidence varies from 15 to 80 %, depending on the population. Transmission is almost exclusively during sexual activity [2].

  1. 2.

    Which subgroups are at a particularly high risk for liver involvement with HSV?

    The infection in the liver with HSV is uncommon. However, when it does occur, it frequently leads to acute liver failure with a high mortality. Severe HSV infections are typically associated with impaired cell-mediated immunity that may occur in a transplant recipient or in patients on high-dose steroids. Females in the third trimester of pregnancy are also particularly at risk for acute liver failure.

    The diagnosis is often missed as skin lesions that provide clinical clues to the diagnosis are often lacking in patients with HSV-associated hepatitis. A high degree of suspicion, even in the absence of skin lesions, combined with early diagnostic modalities and early institution of appropriate therapy with parenteral acyclovir may dramatically improve survival [4].

    Four mechanisms of HSV dissemination and resultant hepatitis have been hypothesized [5]: (a) a large HSV inoculant overwhelming the defense system; (b) an impairment in host macrophages, cytotoxic T lymphocytes, and delayed-type hypersensitivity reactions; (c) enhanced virulence; and (d) activation of a latent hepatovirulent strain.

    HSV hepatitis is characterized by rapid development of fulminant hepatic necrosis with serum aminotransferase levels 100- to 1000-fold above normal and hyperbilirubinemia [4]. Positive serology often points at the diagnosis with polymerase chain reaction (PCR) confirming the diagnosis. In the era of widespread availability of PCR testing, a liver biopsy is now less commonly needed to secure the diagnosis. Common findings on liver biopsy include massive liver necrosis with almost complete absence of portal tracts and central veins. Presence of typical intranuclear viral inclusions is the hallmark finding on a liver biopsy, confirmed with immunohistochemical staining.

    Given the time-sensitive nature of the disease, initiation of empiric therapy with acyclovir is indicated while awaiting diagnostic confirmation in a patient with acute liver failure.


Varicella Zoster

Varicella zoster (VZV) causes chicken pox which is a very common, albeit usually benign, contagious disease. It spreads easily from infected people via direct contact and droplets from coughing and sneezing. Individuals at highest risk include those who have never had chicken pox or are unimmunized [6].

Chicken pox occurs in epidemics among preschool and school-aged children and is characterized by generalized vesicular rash which is extremely pruritic. In addition to widespread systemic involvement, varicella may also cause a rare congenital varicella syndrome.

Similar to herpes virus, hepatitis secondary to varicella zoster can be life threatening [7, 8]. The disease severity and pattern of liver injury are similar to those seen in HSV hepatitis, and it usually occurs in the adult population that has not been previously exposed to varicella. Diagnosis is made based on serology, PCR, and liver biopsy, which show diagnostic inclusions on immunohistochemistry. Treatment is with parenteral acyclovir .

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Nov 20, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Viral Hepatitis: Other Viral Hepatides

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