Hepatitis D

Definition

Hepatitis D (or delta, the Greek letter "D"), is a form of liver inflammation that occurs only in patients who also are infected by the hepatitis B virus. Infection by the hepatitis delta virus (HDV) either occurs at the same time as hepatitis B develops, or develops later when infection by hepatitis B virus (HBV) has entered the chronic (long-lasting) stage.

Description

Delta hepatitis can be quite severe, but it is seen only in patients already infected by HBV. In the late 1970s, Italian physicians discovered that some patients with hepatitis B had another type of infectious agent in their liver cells. Later the new virus—HDV—was confirmed by experimentally infecting chimpanzees. When both viruses are present, acute infection tends to be more severe. Furthermore, patients with both infections are likelier than those with HBV alone to develop chronic liver disease, and, when it occurs, it is more severe.

About 300 million persons worldwide carry HBV. Of them, at least 5% probably also have delta hepatitis. In North America HDV infection appears to be less frequent: 4% of all patients with acute hepatitis B have HDV infection. The delta virus causes an estimated 2% of all cases of acute viral hepatitis in the United States. The rate of HDV infection varies widely in different parts of the world; it is a very serious infection in some countries and quite mild in others. Chronic delta hepatitis is a more serious disease than either chronic hepatitis B alone or hepatitis C.

Certain individuals—the same ones who are at increased risk of developing hepatitis B—are the prime candidates to be infected by HDV. For example:

• Not infrequently, HDV infection occurs in patients with chronic HBV infection who also have hemophilia, a bleeding disease. These patients are at risk because they require large amounts of transfused blood and blood products that may contain HDV.
• In some areas, one-fourth to one-half of patients with chronic HBV infection who inject themselves with illicit drugs become infected by HDV as well. Drug abusers who share contaminated needles are likely to infect one another.
• Patients who get HBV infection by sexual contact may also be infected by HDV, although the delta virus is less often spread in this way than is HBV itself. Between 10-25% of homosexual men with chronic HBV infection harbor the delta virus.
• Like hepatitis B, HDV infection may develop in healthcare workers who are victims of a needle stick, and it also can be spread within households when personal items such as a razor or toothbrush are shared.

Causes and symptoms

The delta virus is a small and incomplete viral particle. Perhaps this is why it cannot cause infection on its own. Its companion virus, HBV, actually forms a covering over the HDV particle. In chronically ill patients (those whose virus persists longer than six months), the combined viruses cause inflammation throughout the liver and eventually destroy the liver cells, which are then replaced by scar tissue. This scarring is called cirrhosis.

When HBV and HDV infections develop at the same time, a condition called coinfection, recovery is the rule. Only 2-5% of patients become chronic carriers (have the virus remain in their blood more than six months after infection). It may be that HDV actually keeps HBV from reproducing as rapidly as it would if it were alone, so chronic infection is less likely.

When HBV infection occurs first and is followed by HDV infection, the condition is called superinfection. This is a more serious situation. Between half and two-thirds of patients with superinfection develop severe acute hepatitis. Once the liver cells contain large numbers of HBV viruses, HDV tends to reproduce more actively. Massive infection and liver failure are more common in superinfection. The risk of liver cancer, however, is no greater than from hepatitis B alone.

As with other forms of hepatitis, the earliest symptoms are nausea, loss of appetite, joint pains, and tiredness. There may be fever (not marked) and an enlarged liver may cause discomfort or actual pain in the right upper part of the abdomen. Later, jaundice (a yellowing of the skin and whites of the eyes that occurs when the liver is no longer able to eliminate certain pigmented substances) may develop.

Diagnosis

HDV infection may be diagnosed by detecting the antibody against the virus. Unfortunately this test cannot detect acute coinfection or superinfection as early as when symptoms first develop. Antibody against HDV usually is found no sooner than 30 days after symptoms appear. Until recently, the virus itself could only be identified by testing a small sample of liver tissue. Scientists now are developing a blood test for HDV that should make diagnosis faster and easier. When HDV is present, liver enzymes (proteins made by the liver) are present in abnormally high amounts. In some patients with coinfection, the enzyme levels peak twice, once when HBV infection starts and again at the time of HDV infection.

Treatment

As in any form of hepatitis, patients in the acute stage should rest in bed as needed, eat a balanced diet, and avoid alcohol. Alpha-interferon, the natural body substance which helps control hepatitis C, has generally not been found helpful in treating hepatitis D. If the liver is largely destroyed and has stopped functioning, liver transplantation is an option. Even when the procedure is successful, disease often recurs and cirrhosis may actually develop more rapidly than before.

Prognosis

A large majority of patients with coinfection of HBV and HDV recover from an episode of acute hepatitis. However, about two-thirds of patients chronically infected by HDV go on to develop cirrhosis of the liver. In one long-term study, just over half of patients who became carriers of HDV had moderate or severe liver disease, and one-fourth of them died. If very severe liver failure develops, the chance of a patient surviving is no better than 50%. A liver transplant may improve this figure to 70%. When transplantation is done for cirrhosis, rather than for liver failure, nearly 90% of patients live five years or longer. The major concern with transplantation is infection of the transplanted liver; this may occur in as many as 40% of transplant patients.

When a child with viral hepatitis develops cirrhosis, HDV infection is commonly responsible. A woman who develops delta hepatitis while pregnant will do as well as if she were not pregnant; and there is no increased risk that the newborn will be malformed in any way.

Prevention

The vaccine against hepatitis B also prevents delta hepatitis, since it cannot occur unless HBV infection is present. Hopefully, a vaccine can be developed that will keep delta infection from developing in chronic HBV carriers. However, if a person already has HBV infection, any exposure to blood should be strictly avoided. A high level of sexual activity with multiple partners is also a risk factor for delta hepatitis.

Resources

ORGANIZATIONS

American Liver Foundation. 1425 Pompton Ave., Cedar Grove, NJ 07009. (800) 223-0179. 〈http://www.liverfoundation.org〉.

KEY TERMS

Alpha-interferon— A natural body substance that now can be made in large quantities and is an effective treatment for some types of viral inflammatory disease, including hepatitis C.

Antibody— A substance formed in the body in response to an invading microorganism, such as a virus, which can attack and destroy the invading virus.

Coinfection— Invasion of the body by two viruses at about the same time.

Hemophilia— A bleeding disease that may call for the transfusion of large amounts of blood and blood products.

Superinfection— Infection by a second virus after a previous infection by a different virus has become well established.