Cases reported • Hepatitis D; Delta Hepatitis; Delta Superinfection; Hepatitis, Delta; Delta Infection

1/15. Severe hepatitis due to HBV-HDV coinfection.

Quadruple hepatic infections are not uncommon in human immunodeficiency virus (HIV) infected patients. Hepatotropic viruses behave differently in immunocompromised patients resulting in varied clinical and serological outcomes. Delta hepatitis, an important cause of acute hepatitis in intravenous drug abusers (IVDAs) and HIV-infected patients, can present as coinfection or superinfection clinically, which influences the prognosis. Prevention of hepatitis D virus (HDV) coinfection is possible with hepatitis b virus (HBV) vaccination. No definitive medical treatment for HDV infection is known to be successful. Interestingly, liver transplantation carries a higher success rate in HDV/HBV infection then in HBV infection alone.

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keywords = superinfection
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2/15. Hepatitis delta superinfection during alpha-interferon treatment for hepatitis B.

Alpha-interferon (IFN) has been used to treat hepatitis b virus carriers with chronic hepatitis delta virus superinfection. Although the drug inhibits hepatitis delta virus replication during administration, long-term clearance of the virus has not been obtained in most patients. The effectiveness of alpha-interferon on chronic HDV infection is therefore questionable. No data are available on acute infection. We report the case of a young, immunocompetent HBsAg carrier in whom hepatitis delta virus superinfection occurred while he was receiving alpha-interferon in order to reduce high level HBV replication, and followed a peculiar course.

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keywords = superinfection
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3/15. hepatitis delta virus super-infection in a co-infected patient with the human immunodeficiency virus type 1 and a surface antigen-negative hepatitis b virus variant.

Human immunodeficiency virus infection has a major impact on the natural history of chronic hepatitis B and favours the emergence of viral mutants. We describe an acute hepatitis D virus superinfection in an hiv-1-infected patient under HAART treatment who was previously a chronic carrier of a surface negative HBV variant resistant to lamivudine.

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keywords = superinfection
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4/15. A long-term follow-up of five patients with hepatitis delta virus in japan.

From 1973 to 1989 five patients with hepatitis delta virus having anti-hepatitis delta antibodies continuously in the serum for more than 5 years were identified among 1019 hepatitis b virus carriers who were being followed-up for more than 3 years (mean 8.9 years). Of the five patients with antibodies, three had a history of blood transfusion, in two cases the transfusion was massive, and one patient had been addicted to narcotics given intravenously 35 years before. In the remaining patient, the route of superinfection could not be determined. Hepatitis delta antigen was detected in hepatocyte nuclei of one of the three patients in whom liver biopsies were performed and there was chronic persistent hepatitis detected by an indirect immunoperoxidase technique. During the follow-up, hepatocellular carcinoma developed in one case but the clinical prognosis was favourable in the remaining four cases.

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ranking = 1
keywords = superinfection
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5/15. Low prevalence of hepatitis D (delta) virus infection in a nephrology unit in south india.

Fifty-five consecutive patients with end-stage renal disease entering haemodialysis programmes over a two-month period and 48 consecutive recipients of renal allografts during a period of 6 months were investigated for hepatitis b virus (HBV) and hepatitis D virus (delta) infection. HBV markers were present in 25 of the former and 40 of the latter. Of the 65 patients with HBV infection, 12 were not available for delta antibody screening. HBV infection was present for a mean of 2.5 months and 45.3% of those infected had clinical hepatitis; none had fulminant hepatitis. All the patients tested were negative for antidelta antibody. An additional patient on dialysis with delta superinfection and hepatic encephalopathy is also reported.

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ranking = 1
keywords = superinfection
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6/15. A 20-year-old man with persistent aminotransferase elevations.

Through intravenous drug abuse, this 20-year-old man contracted chronic active hepatitis due to hepatitis D superinfection of hepatitis B. The correct diagnosis, made after a hiatus of 20 years, awaited advances in the understanding of viral hepatitis, the discovery of the hepatitis D virus, and the development of immunostaining techniques that could be applied to his liver biopsy specimen. The case illustrates how immunoperoxidase staining may be done retrospectively and may be particularly useful in diagnosis of individual cases where serologic testing is not available or possible, as well as in scientific surveys of HBV and HDV infection. Since staining for HBcAg and HDAg can provide clinically useful information not available by other methods, it should be considered as a part of the assessment of the liver biopsy in every patient with HBV infection.

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keywords = superinfection
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7/15. guillain-barre syndrome associated with acute delta hepatitis virus superinfection.

We describe a patient with the clinical characteristics of guillain-barre syndrome, including progressive ascending paresis; cerebrospinal fluid albumino-cytological dissociation; polyphasic small evoked potential, with prolonged latency and slow motor nerve conduction velocity; and active denervation pattern on electromyography, in association with acute delta hepatitis virus superinfection. The patient recovered from guillain-barre syndrome but developed chronic active delta hepatitis.

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ranking = 5
keywords = superinfection
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8/15. Delta hepatitis: first two cases identified in kansas City.

hepatitis delta virus (HDV) was identified in 1977 and has since been found to be a worldwide disease. prevalence in north america is highest among drug abusers. We present two IV drug abusers from the city hospital in kansas City as the first two cases identified in the city, one with apparent superinfection and the other with a chronic HDV infection. We review the various manifestations and diagnosis of HDV, and advocate prevention of spread of HDV infection by hepatitis B vaccination and use of single donor blood products in high-risk patients.

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ranking = 1
keywords = superinfection
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9/15. Acute delta superinfection in a previously unrecognised HBsAg carrier with transient loss of HBsAg simulating acute non-A, non-B hepatitis.

An 18 yr old previously well male Taiwanese was admitted with malaise, anorexia, and jaundice for two weeks. Results of liver tests were compatible with acute hepatitis. On day 1, he was seronegative for HBsAg, IgM anti-HAV, IgM anti-HBc, IgM anti-CMV, and IgM EBV capsid Ab, but positive for anti-delta in association with anti-HBc and anti-HBs. At follow up on day 5 HBsAg converted to positive with decreasing titre of anti-HBs. On day 19, the titre of HBsAg increased concomitantly with loss of anti-HBs. The results of these serological profiles indicated that this patient was a previously unrecognised HBsAg carrier, who developed acute hepatitis delta virus superinfection with transient loss of HBsAg. This phenomenon should be kept in mind in the serodiagnosis of acute viral hepatitis, especially in areas of high HBV prevalence.

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ranking = 5
keywords = superinfection
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10/15. A possible misdiagnosis in patients presenting with acute HBsAg-negative hepatitis: the role of hepatitis delta virus.

We describe here two cases of delta hepatitis (a coinfection and a superinfection) presenting as acute HBsAg-negative hepatitis. The first patient, a parenteral drug abuser, had a biphasic course of the disease, with HBsAg detectable transiently only during the relapse. Testing for delta markers on stored sera gave evidence of HBV/HDV coinfection. The other patient, a hospital nurse, chronic asymptomatic carrier of HBsAg, developed fulminant hepatitis with the transient appearance of antibody to HBsAg. She survived massive liver necrosis, and serological analysis of HDV markers documented a hepatitis delta virus superinfection. These cases demonstrate the possible substantial repression of HBV gene products exerted by the replication of delta virus, with a likely misdiagnosis if delta markers are not determined in serial serum samples.

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ranking = 2
keywords = superinfection
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