hepatitis double infection
Introduction
Introduction to hepatitis double infection Double or multiple infection means that two or more different types of hepatitis viruses can be infected in the same viral hepatitis patient. It is known that hepatitis virus has type 5 and there is no cross-immunization between them. That is, after infecting a hepatitis virus, it can still infect other hepatitis viruses, and can be divided into simultaneous infection (mixed infection) overlapping infection (subsequent infection) according to the infection time. basic knowledge The proportion of illness: 0.003%--0.007% Susceptible people: no specific population Mode of transmission: blood transmission, sexual transmission Complications: fatty liver, liver cirrhosis, liver cancer
Cause
Cause of hepatitis double infection
Regardless of whether the hepatitis virus is a clinical symptom caused by simultaneous infection or overlapping infection, it is generally similar to acute hepatitis or chronic hepatitis caused by a simple hepatitis virus infection, but because of the different combinations of hepatitis virus types, each has its own characteristics, generally Seeing that the patient's condition can be complicated and the symptoms are severe and the curative effect is poor. Therefore, patients with refractory severe chronic active hepatitis, post-hepatitis cirrhosis and severe hepatitis should be considered to have multiple infections.
It is estimated that there are 280 million HBsAg positive infections in the world, and China accounts for about 100 million, of which 2/3 are asymptomatic carriers. Due to the high carrying rate of HBV infection, it is easy to overlap with other hepatitis viruses through different transmission routes. The following are common:
(1) HBV and HAV double infection
1. Simultaneous infection: This type is rare. Because HBV and HAV are primary infections, their clinical manifestations and liver function tests are more obvious than overlapping infections. Except for a few patients with prolonged course, most of them appear as acute jaundice hepatitis with good prognosis. No symptoms and liver damage were aggravated.
2, overlapping infections: domestic reports vary from place to place, the overlap of HBV and HAV in the disseminated acute hepatitis is 0 to 23.4%, during the 1988 Shanghai hepatitis A epidemic, about 10% of HBsAg chronic carriers overlap infection HAV, in areas with high HBsAg carrying rate, there is an outbreak of hepatitis A, and HBV and HAV overlap infection is also more common.
Chronic hepatitis B with overlapping HAV infection has more than half of the symptoms and increased ALT in patients with hepatitis A, especially in chronic active hepatitis. If the original cirrhosis is based on re-infection with HAV, the jaundice is deepened. Liver function damage is aggravated, and ascites and hepatic encephalopathy can occur.
The prognosis of HBV and HAV overlap infection depends on the severity of the original liver lesions. Most of the prognosis is good, but if the development is severe hepatitis or the original severe liver disease, the disease tends to worsen and the prognosis is poor.
(B) Double infection of HBV and HCV
Due to the high carrying rate of HBV and HCV, the chance of overlapping infection is also large. The foreign infection rate of HBV and HCV is 15%-28%. In 1990, HBsAg was positive in China, and anti-HBc IgM was negative. Forty cases of chronic active hepatitis, the anti-HCV positive rate was 17.5% using the Ortho C100-3 diagnostic kit, and the results were basically the same as those in foreign countries.
The clinical symptoms of hepatitis C alone are generally milder than those of hepatitis A or hepatitis B. Most of them are asymptomatic and subclinical. Most of them have no jaundice, single ALT is elevated, and a small number of patients with severe hepatitis C and type B are severe. Hepatitis is difficult to identify. However, when HBV overlaps with HCV, the clinical symptoms are heavier than those of hepatitis C or hepatitis B. The course of disease is prone to chronic disease, the condition is repeated, the liver function continues to be abnormal, and even develops into severe hepatitis, cirrhosis or liver cancer.
(3) Double infection of HBV and HDV
Domestic reports of HDV infection rates vary from 0 to 12%, and regional differences are also large. In 1989, Zhang Yongyuan reported 16 provinces and municipalities, and more than 2000 liver tissue samples showed positive results of 5.33% to 19.77%. Although the rate of HDV infection and HBV infection is close, the rate of HDV infection is not consistent with HBV infection rate. In areas where hepatitis D is endemic, HBV infection rate is higher and HDV infection rate is higher. However, In some countries in China and Southeast Asia, the HBV carrying rate is very high, but the HDV infection rate is very low, and the reason needs to be further clarified.
1. Simultaneous infection of HBV and HDV: The clinical symptoms and liver function tests of acute HDV infection are similar to those of acute HBV infection, but sometimes bimodal ALT is elevated, indicating HBV and HDV infection, respectively. Compared with simple acute HBV infection, the risk of developing chronic hepatitis is small, the course of disease is mostly self-limiting, and the prognosis is good.
2, HBV and HDV overlap infection: more manifested as a chronic process, mostly occult, but the disease progresses rapidly, often develops into chronic active hepatitis and cirrhosis, Rizzetto and other observations of 137 cases of intrahepatic HDAg-positive chronic hepatitis D patients 41% developed cirrhosis.
HBV and HDV can cause severe hepatitis in both simultaneous and overlapping infections. Therefore, it is often believed that HDV infection is one of the causes of severe hepatitis and cirrhosis based on HBV infection.
(4) HBV and HEV double infection
Hepatitis E can be violent or endemic in various parts of the world. There have been outbreaks in Xinjiang in China. Therefore, HBV and HEV overlap infection can not be ignored. The simple HEV infection is a self-limited process with good prognosis. It can lead to fulminant hepatic failure and high mortality. India reports that most severe hepatitis is overlapped with HEV in HBsAg carriers. Therefore, in areas with high HBV infection, overlapping infections of HBV and HEV may lead to severe hepatitis.
(5) HBV and HCV, HDV multiple infection
Multiple infections of three or more hepatitis viruses are rare, and the development and outcome of the disease are obviously related to the degree of liver lesions before overlapping infection. For example, asymptomatic carriers of HBsAg show symptoms and abnormal liver function. Hepatitis or cirrhosis is characterized by progressive exacerbation of clinical symptoms and liver function damage. The efficacy of severe hepatitis in China is mainly caused by overlapping infection of HBV and HCV, HDV, severe liver damage and poor prognosis due to the application of blood transfusion and blood products. It is common to treat chronic liver disease and severe hepatitis. In addition, the HBsAg carrying rate in China is high, up to 10% to 15%. The anti-HCV positive rate in blood donors is also high, so there are many opportunities for HCV infection, and severe hepatitis E is also HAV can be overlapped, but it has no significant effect on its condition and prognosis.
The effect of double infection on viral serological markers
1, at the same time infected. Most studies suggest that there is no mutual interference between hepatitis viruses.
2. After overlapping infection, some replication indexes of HBV can be inhibited, HBsAg titer decreases or disappears, HBsAg in liver tissue even disappears; HBsAg level declines or disappears, and anti-HBs positive conversion, HBV-DNA and DAN-p negative or temporary negative, indicating that HBV replication is inhibited to varying degrees.
The natural disappearance rate of HBsAg is very low, only 1% per year. Whether overlapping hepatitis W virus can accelerate the conversion of HBsAg and inhibit viral replication still needs further study.
The mechanism of the effect of overlapping infection on the serological markers of the original hepatitis virus is still unclear and needs further study.
Prevention
Hepatitis double infection prevention
Dietary intake should be balanced:
The diet of hepatitis patients is most important in terms of fresh natural and balanced nutrition. Avoid eating raw foods that are not fresh, moldy, fried, marinated, pickled, canned, etc., in addition to rejecting the temptation of alcohol, because the liver is the main metabolism of alcohol. At the place, alcohol and its metabolites can damage liver cells, form alcoholic liver disease, and then develop into cirrhosis, which greatly increases the incidence of liver cancer. Therefore, patients with hepatitis should try to reduce alcohol intake, and it is best to refuse drinking.
Develop a good habit of hygiene:
It is necessary to work according to the law, reduce the number of staying up and down; moderate exercise, not to feel fatigue as the standard; avoid sharing razors and toothbrushes with others; if you need assistance from others when you are injured or bleeding, you must remind you to bring gloves and avoid direct contact. Blood; try to buy vegetables with light or no pesticides, and wash them with water. Eat melon peeled, try to eat less or not eat foods containing additives, such as canned food; away from smoked and spoiled food. In addition, to develop the habit of drinking more water, boiled water can increase the amount of circulating blood, improve the vitality of liver cells, and facilitate the elimination of metabolic waste and receive the effect of protecting the liver.
Complication
Hepatitis double infection complications Complications fatty liver cirrhosis liver cancer
1. Hepatogenic diabetes
The clinical manifestations were similar to those of type II diabetes. The difference was that hepatic diabetes was significantly increased in fasting and C-peptide was normal on fasting. After taking sugar, insulin increased significantly and C too peak was still slightly lower than normal. It is because the liver's ability to inactivate insulin is reduced, which promotes insulin elevation; in addition, the inactivation of glucagon in the liver is reduced, the insulin receptor on the liver cells is reduced, and resistance to insulin is produced, so that although insulin is elevated, blood sugar is still high; At the same time, the C peptide is less affected by the liver, so the C peptide is not high, suggesting that the secretion function of the cells is not abnormal. For identification with type 2 diabetes, an insulin release test and a C-peptide release test are available.
2, fatty liver
The mechanism is still unclear, characterized by good general condition, single ALT mild, moderately elevated, elevated blood lipids, B-mode ultrasound examination showed fatty liver waveform, confirmed according to liver biopsy pathological examination.
3, cirrhosis
Chronic hepatitis develops into cirrhosis and is the result of liver fibrosis. The mechanism of occurrence has not been fully elucidated. It is also seen in subacute, chronic severe hepatitis and asymptomatic HBsAg carriers with insidious onset.
4, liver cancer
HBV and HCV infection are closely related to the disease. More common in patients with chronic liver and cirrhosis. It can also be seen that chronic HBV infection develops into liver cancer without cirrhosis. Its mechanism of action is currently thought to be related to HBV-DNA integration, especially X gene integration. HBxAg transactivation of proto-oncogenes plays an important role. In addition, carcinogens such as aflatoxin have a certain synergistic effect.
Symptom
Hepatitis double infection symptoms Common symptoms Huangqi appetite loss liver function abnormal liver disease liver disease face anorexia gradually aggravated right side... Nausea liver HDAg only... Core antibody (anti-H...
According to clinical features: the original chronic HBV infection, recent appearance, liver function abnormalities; or the original chronic active hepatitis, cirrhosis, recent deterioration of the disease and poor treatment, should consider the possibility of overlapping infection with other hepatitis viruses The detection of pathogenic indicators should be carried out in a timely manner. Due to the high rate of HBV infection in China, those with acute hepatitis manifestations, even if they have no history of hepatitis, cannot rule out patients who have previously suffered from hepatitis B or asymptomatic HBsAg carriers. Serum anti-HAV IgM and HBV markers were tested to aid diagnosis.
Examine
Hepatitis double infection check
White blood cell count (WBC), mean red blood cell volume (MCV), anti-liver kidney microsomal antibody assay (LKM), anti-hepatocyte membrane-specific lipoprotein antibody (ALSP), anti-soluble liver antigen antibody (SLA), anti-smooth muscle antibody (ASMA) ), urinary bilirubin (BIL), urobilinogen (URO), serum albumin to globulin ratio (A/G), serum total protein (TP, TP0), euglobulin dissolution time, ultrasound diagnosis of liver disease.
Diagnosis
Diagnosis and diagnosis of hepatitis double infection
diagnosis
It can be diagnosed based on medical history, clinical symptoms and laboratory tests.
Differential diagnosis
1, according to clinical characteristics according to clinical characteristics: the original chronic HBV infection, the appearance of recent signs, liver function abnormalities.
2, the detection of pathogenic indicators of the original chronic active hepatitis, cirrhosis, recent deterioration of the disease and poor treatment, should consider the possibility of overlapping infection of other hepatitis viruses, should promptly carry out the detection of relevant pathogenic indicators.
3, detection of serum anti-HAV IgM and HBV markers Because of the high rate of HBV infection in China, for those with acute hepatitis, even if there is no history of hepatitis, can not rule out the previous hepatitis B or asymptomatic HBsAg carriers, so Serum anti-HAV IgM and HBV markers should be tested simultaneously to aid diagnosis.
