Hepatitis D: diagnosis

Viral hepatitis of mixed etiology can be assumed with the appropriate epidemiological history (blood transfusion, intravenous drug use, etc., multiple parenteral interventions, etc.), more acute than in viral hepatitis B. Early onset of the disease, fever, a short period of pre-jaundice with pain in the right hypochondrium and joints, two-wave and heavier hepatitis, a pronounced hyperfermentemia, an increase in (unsharp) indices of thymol test.

[1], [2], [3], [4],

Specific diagnosis of hepatitis D

It is based on revealing the markers of active replication of both viruses: HBV, HDV. From the first days of jaundice in the serum, HBsAg, anti-HBV IgM in high titre, HBe-antigen, HDAg and / or anti-delta (anti-delta IgM) are detected. Anti-delta IgM are produced already in the acute period and serve as the main marker of delta infection. They can be determined within 1-3 weeks in high titre, then they cease to be detected, anti-delta IgG is detected after 1-3 weeks from the onset of icteric period of the disease. However, approximately 20% of patients can not detect anti-delta IgM, and the detection of anti-HD IgG can be delayed by 30-60 days, in which case the delta infection will not be diagnosed unless the anti-HD IgG in the blood serum is checked . By PCR RNA HDV RNA in serum is determined within 1-3 weeks from the beginning of icteric period.

In the serum of patients with superinfection in the prodromal period and from the early days of icteric period, HBsAg, HBcAg or anti-HBe are detected, but anti-HBc IgM is absent. Also detect anti-delta IgM and a little later (after 1-2 weeks) - anti-delta IgG. HDV RNA is detected in the blood of patients both in the prodromal period and the first day of the icteric period, and then the blood is continuously tested for the development of a chronic infection in isolation or along with HBV DNA. With the development of severe course of hepatitis delta, HBsAg and HBV DNA often disappear from the blood, but HDV RNA is detected. This phenomenon is interpreted by most researchers as a consequence of the suppression of HBV replicative activity by the delta virus.

The assumption of acute viral hepatitis D should occur with a very short pre-heel period, a combination of severe hepatosplenomegaly with pain in the right hypochondrium, edematous-ascitic syndrome, fever, hyperbilirubinemia, hyperfermentemia, low values of the sulemic test, an increase in the thymol test and the level of the y-globulin fraction in blood serum. Acute hepatitis delta should also be assumed when jaundice occurs in "healthy" carriers of HBsAg or with exacerbation of chronic hepatitis B.

Thus, in acute delta-virus infection, differential diagnosis should be carried out, first of all, with acute and exacerbation of chronic viral hepatitis B.

The standard of diagnosis of hepatitis (inpatient care)

Diagnostic procedures	Multiplicity of the survey	Notes
Bilirubin	Once in 10 days	With a heavy form - as necessary
ACT
ALT
General blood analysis
General urine analysis
НВ s Ag
Prothrombin index	1	Repeated, depending on severity of hepatitis
Blood group analysis, Rh factor	1
Anti-HBc IgM	1
Anti-delta IgM	1	The criterion of diagnosis of the OGV with a delta-agent (coinfection) in combination with anti-HB with IgM
Anti-HD Total	1	Criteria for the diagnosis of acute hepatitis B with delta-agent (coinfection) in the case of a negative test in a primary examination and detection in a subsequent study (seroconversion) in combination with anti-HBc IgM. Criterion for the diagnosis of acute delta (super) infection in the absence of anti-HBcIgM
Anti-HCV	1	It is necessary to exclude mixed infection
Anti-HAV IgM	1
Anti-HIV	1

Patient management plan for icteric form of acute viral hepatitis B with delta-agent (coinfection) and acute hepatitis delta in hepatitis B virus carrier (superinfection)

Information about the patient: history of the patient: intravenous administration of psychoactive drugs, parenteral interventions for 1-6 months before the onset of the first signs of the disease, acute or subacute onset of the disease, symptoms of the pre-hepatitis period of viral hepatitis D (fever, abdominal pain, severe intoxication), short prodromal period, the appearance of jaundice, deterioration of the state with the appearance of jaundice.

Blood chemistry. Blood test for markers of viral hepatitis:

• increased activity of ALT and ACT (more than 30-50 norms), an increase in bound and free fractions of bilirubin, normal prothrombin index. Detection of markers of the acute phase of HBV in the blood serum - HBsAg and anti-HBV IgM, detection of anti-delta IgM and / or antiglottin IgG in the blood - diagnosis: "acute viral hepatitis B with delta agent (coinfection), icteric form, moderate severity "(See treatment tactics):
• increased activity of ALT and ACT (more than 30-50 norms), an increase in bound and free fractions of bilirubin, normal prothrombin index. Absence of markers of the acute phase of HBV in the serum (anti-HBV IgM) in the presence of a positive test for HBsAg, detection of anti-delta IgM and / or anti-delta IgG in the blood - diagnosis: "acute viral hepatitis D in the virus carrier of viral hepatitis B (superinfection ), icteric form, moderate severity "(see treatment tactics).

Information about the patient: significant deterioration of the state with the appearance of jaundice (increased nausea, the emergence of vomiting, increasing weakness).

Actions: prothrombin index control daily, extraordinary biochemical blood test

Information about the patient. Reduction of the prothrombin index to 60-50%, the increase in hyperbilirubinemia, the increase in the activity of transaminases or a sharp decrease in their activity. The appearance of dizziness, a decrease in the size of the liver, the appearance of pain in the palpation of the liver, the manifestation of hemorrhagic syndrome.

Diagnosis: "acute viral hepatitis B with delta-agent (coinfection), icteric form, severe course" or "acute hepatitis delta in the virus carrier of viral hepatitis B (superinfection), icteric form, severe course".

Actions: intensification of therapy.

Information about the patient. Further deterioration in the patient's condition, the appearance of excitation or inhibition, a decrease in the prothrombin index of less than 50%), the appearance of symptoms of acute hepatic encephalopathy.

Actions: transfer to the intensive care unit (ward) (see treatment tactics); plasmapheresis, dehydration therapy (reduction of cerebral edema), arrest of excitation, ventilation if necessary.