AKT revision - hepatitis

1.You receive a clinic letter regarding a 57 year old man whom you had referred to the local hepatologist for further investigation of abnormal liver function tests. The consultant describes a diagnosis of chronic hepatitis in his clinic letter.
Which ONE of the following viruses is MOST LIKELY to be the cause of chronic hepatitis in this patient? Select ONE option only.

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E

Answer: C

Hepatitis A and E viruses cause an acute hepatitis and do not have a chronic infection state.
Approximately 2-5% of patients infected with hepatitis B virus (HBV) will develop a chronic hepatitis; however, almost 75% of patients infected with hepatitis C virus (HCV) will develop a chronic hepatitis.
Hepatitis D virus (HDV) requires the presence of HBV to replicate; therefore, HDV infection develops only in patients who are positive for hepatitis B surface antigen. The rate of progression to chronic hepatitis is approximately 70-80%. HDV is less common than HCV and therefore HCV would be the most likely cause of chronic hepatitis in this patient.

2.A 36 year old man was seen by your colleague last week with a 10 day history of abdominal pain following a recent family holiday in Africa. He is otherwise well in himself. You are the on-call GP in your surgery today and receive the following results:

Bilirubin 17 µmol/l (3-17 µmol/l)
Alanine aminotransferase 58 IU/l (0-35 IU/l)
Alkaline phosphatase 266 IU/l (30-300 IU/l)
Gamma glutamyl transpeptidase 32 IU/l (11-50 IU/l)
Hepatitis A IgM antibodies POSITIVE
Hepatitis A IgG antibodies NEGATIVE
What is the SINGLE MOST appropriate INITIAL management option for this patient? Select ONE option only.

A. Advice and reassurance
B. Arrange sexual contact tracing
C. Refer for abdominal ultrasound scan
D. Repeat hepatitis serology in three months
E. Routine referral to gastroenterology

Answer: A

The presence of hepatitis A IgM antibodies here indicates acute hepatitis A infection.
If hepatitis A IgG antibodies were present, this would indicate previous hepatitis A infection and these antibodies would be detectable lifelong.
Hepatitis A virus is transmitted faeco-orally through contacts or travel to an endemic area. It has an incubation period of 2-6 weeks and is usually a self-limiting illness. The risk of acute liver failure is very low (less than 0.1%) although this increases with age and in those with pre-existing liver disease. There is no chronic infection state and recovery from an acute infection induces lifelong immunity.

3. A 30 year old lady attends the surgery for preconception advice. She is newly married and is originally from China. She last had sexual intercourse with her husband 14 days ago and he has been abroad on a business trip since that time. He is due to return home today. You elucidate that her husband has chronic hepatitis B. She requests a blood test to determine her Hepatitis B status.
In order to reduce the immediate risk of transmission of disease, which ONE of the following is the most appropriate INITIAL management for this patient? Select ONE option only.

A. Advise the patient about 'safe sex', or to refrain from sexual intercourse
B. Arrange an 'accelerated schedule' preexposure immunisation
C. Arrange for passive immunisation with hepatitis B immunoglobulin (HBIG)
D. Arrange for routine pre-exposure immunisation
E. Arrange serological testing to confirm the patient's hepatitis B status

Answer: A

Ideally, the patient needs to undergo serological testing to ascertain her hepatitis B status.
In the interim, she either needs to practice 'safe sex' or refrain completely.
Both the vaccine and passive immunization with HBIG should be given as soon as possible-preferably within 12 hours, ideally within 24 hours, although it should be considered up to 1 week after exposure.
DoH: The Green Book
www.dh.gov.uk
www.britishlivertrust.org.uk
www.bnf.org

4.A 48 year old man attends the surgery for advice regarding travel vaccinations. After assessing his risks including specific travel destinations, you advise him to receive a hepatitis A vaccination.
Which ONE of the following statements regarding Hepatitis A vaccination is correct? Select ONE option only.

A. A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years
B. A single dose of hepatitis A vaccine confers immunity for up to 2 years
C. A single dose of hepatitis A vaccine confers immunity for up to 3 years
D. Hepatitis A is a live vaccine
E. Hepatitis A vaccine is administered subcutaneously

Answer: A

A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years. A single dose of hepatitis A vaccine confers immunity for up to 1 year. It is an inactivated vaccine and is administered intramuscularly.
www.bnf.org.uk
www.fitfortravel.nhs.uk

5. Which ONE of the following diseases is notifiable under the Public Health (Infectious Diseases) Regulations 1988? Select ONE option only.

A. Creutzfeldt-Jakob disease
B. Hepatitis A
C. HIV
D. Infectious mononucleosis
E. Syphilis

Answerr: B