Hepatitis B

00:01 Quickly here, hepatitis B.

00:03 Now, we’re getting to more chronic users.

00:05 And hepatitis B, obviously, there is going to be vaccination involved.

00:09 And in immunology and microbiology, you’ve covered these topics further.

00:13 What I'm going to provide to you is more of a clinical background for each one of these viral hepatites.

00:20 400 million worldwide.

00:22 Obviously, need to know this quite a bit.

00:24 DNA virus with incubation.

00:26 You need to know that hepatitis B is a DNA virus.

00:30 Last time we talked anything about this, at some point in time, is that there is every possibility in chronicity.

00:38 Two major chronic viral hepatites that are important for you and I, for pathology and cancer will be hepatitis B, which is a DNA virus and hepatitis C which would be an RNA virus.

00:52 It’s important that you know what kind of molecular goes on to cancers.

00:58 Transmission here, parental or sexual routes.

01:02 High risk of vertical transmission.

01:04 What does that mean to you? You are thinking about a pregnant lady that is now giving birth; and during delivery, there is every possibility that through the vaginal canal there might be vertical transmission unfortunately to the newborn.

01:16 Think of this as being part of your torch. Hepatitis B.

01:20 Leading risk factor for liver cancer worldwide.

01:24 Also, keep in mind, hepatitis C – and make sure that you know how to identify hepatitis B or C.

01:30 This is a DNA virus.

01:33 Only 5% of adult infection develop chronic hepatitis, while the majority of perinatal infections are chronic.

01:41 So, there are two populations here.

01:43 Very rarely do adults go on to chronicity.

01:47 That would be more hepatitis C.

01:48 C in hepatitis C – C for chronicity.

01:54 However, could you move on to chronicity in hepatitis B? Sure, you can, but a measly 5%.

02:00 Still important, though.

02:02 Now, if a childhood vertical transmission, ohh, that’s a little bit – that’s difficult.

02:07 That's more challenging and there's every possibility or likelihood of a child going on to chronicity.

02:15 Clinical presentation of hepatitis B: Symptomatic disease more severe than hepatitis A, hence we’re going to elaborate on it further.

02:26 Jaundice rarely lasts greater than four weeks.

02:30 So, you’re thinking about – if you find jaundice in a patient with hepatitis B, you’re thinking about, well, this must've been a timeline of approximately one month.

02:39 1% incidence of fulminant hepatitis.

02:42 Thank goodness.

02:46 Move on to extra hepatic manifestations of hepatitis B.

02:50 Here, you do want to pay attention to (inaudible).

02:52 Angioneurotic edema.

02:56 This is important.

02:57 30% of your patients – this patient may come to you and may complain of – ‘doc, my tummy hurts.’ And also, you notice that there's blood in the urine.

03:11 And you find that upon serology, you find an increase in ALT.

03:17 Wow, that's interesting.

03:18 The liver is involved and I'm finding abdominal pain and I'm finding hematuria.

03:27 Should be thinking about polyarteritis nodosa.

03:29 30% of your patients with hepatitis B might actually be suffering from polyarteritis nodosa.

03:35 These would be adults for the most part and the two symptoms that I gave you – hey, doc, my stomach hurts, the abdominal region.

03:42 Radiate to the back? No, nothing like that.

03:44 And I'm finding hematuria.

03:46 So, you need to be – make sure that you’re quite astute with paying attention to your patient with such symptoms.

03:53 And when we you say polyarteritis nodosa, obviously, this is a vasculitis.

03:57 The vascular system that is being affected here would be the mesenteric blood vessel.

04:03 What does that vasculitis mean to you? Inflammation, inflammation, inflammation of your blood vessel until there's occlusion, lack of blood supply to the abdominal region, mesentery, anytime there's ischemia.

04:16 How is the patient feeling? Pain. Pain. So, pain in the abdomen.

04:20 In addition, you have the renal blood vessels might start undergoing microaneurysms and may result in, as I told you, hematuria.

04:30 Keep that in mind.

04:31 Spend a second on polyarteritis nodosa and its association with hepatitis B.

04:37 Also, association with MPGN (membranoproliferative glomerulonephritis).

04:43 So, what does this mean to you? MPGN, what kind of symptoms? Is it strictly nephritic, is it strictly nephrotic or is it both? Both.

04:55 So, there might be hematuria and hypertension and there might be also massive edema and a greater than 3.5 grams of protein loss.

05:03 Allow for each one of these symptoms to give you amazing information for a particular condition, so that you can choose the correct answer.

05:12 Stick with me and I will get you there.

05:15 MPGN, nephritic, nephrotic, type 1 much more common than type 2.

05:21 Now, we can move on.

05:23 Mononeuritis multiplex, that’s interesting.

05:27 Mononeuritis multiplex, what does that mean? One nerve that's being affected, an inflammatory process in multiple, multiple organs.

05:35 Maybe it’s a radial nerve that’s affected, wrist drop.

05:39 Maybe it's the common peroneal nerve, foot drop.

05:42 Just as an example.

05:43 One nerve in which it may affect multiple systems resulting in the sequelae that you would expect to see.

05:52 Important here as well, cryoglobulinemia.

05:55 This is more so found in hepatitis C. I will tell you that right off the back.

05:59 If it’s any type of viral hepatitis that you’re worried about with cryoglobulinemia, what does that mean to you? Allow the name to speak to you.

06:07 Cryo means cold.

06:09 Upon exposure to cold, because of the immunoglobulins that are involved in viral hepatites, that upon exposure to cold, the globulins will do what? Oh, yes.

06:19 They will then precipitate. Right? When they precipitate, this is then referred to as being your cryoglobulinemia.

06:27 During cold conditions, it then aggregates or precipitates.

06:31 Interesting.

06:32 So, two major cold issues that you want to know for your boards and your wards.

06:36 When you're cold and you find that the fingers are now cyanotic – that's Raynaud's – or if you find cryoglobulinemia, cold.

06:46 And oftentimes, whenever you think about or you hear about a patient in which there is ascending paralysis, it's preceded by infection and usually viral. Viral. Gilliam-Barre syndrome.