Hepatitis D - Symptoms

Acute hepatitis B with delta agent (coinfection) with and without hepatic coma

Symptoms of hepatitis D, developing as a result of coinfection, are extremely similar to those of acute hepatitis B. The incubation period is from 6 to 10 weeks. The course is cyclical.

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Pre-icteric period

It begins more acutely than with viral hepatitis B, with deterioration of health, malaise, weakness, fatigue, headache. At the same time, dyspeptic phenomena are noted: loss of appetite up to anorexia, nausea, vomiting. More often than with viral hepatitis B, migrating pains in large joints occur. Almost half of patients experience pain in the right hypochondrium, which is not typical for viral hepatitis B. Another difference from viral hepatitis B is fever, and in 30% of patients the body temperature rises above 38 C. The duration of the pre-icteric period is shorter than with viral hepatitis B and averages about 5 days.

Jaundice period

With the appearance of jaundice, the symptoms of hepatitis D and intoxication increase. Against the background of jaundice, arthralgia (in 30%) and subfebrile condition persist. Weakness and fatigue increase: skin itching is more often detected; pain in the right hypochondrium, not associated with food intake, persists. Urticarial rashes on the skin are often noted. The most prolonged symptoms of the icteric period are weakness, loss of appetite, pain in the right hypochondrium. In all patients, the liver increases by 1-3 cm, its edge is elastic, smooth, sensitive to palpation. More often than in viral hepatitis B, the spleen increases. The content of bilirubin in the blood serum is increased due to the bound fraction, the activity of transferases is much higher than in acute hepatitis B. The thymol test indicator increases significantly, which is not typical for viral hepatitis B: the sublimate test remains normal. Hyperbilirubinemia lasts on average up to 1.5 months, hyperfermentemia – up to 2-3 months.

The disease often has a two-wave course with clinical and enzymatic exacerbation, which can be explained by the presence of two viruses with different biological properties in the body. It is assumed that the first wave is a manifestation of HBV infection, and the second is due to delta infection, since by this time the body already has enough HBs-antingen molecules necessary for HDV reproduction. However, some researchers explain the presence of the second ALT peak by the activation of HBV replication after a period of suppression of its replication by the delta virus. In 60% of patients, on the 18th-32nd day from the onset of jaundice, against the background of the onset of improvement, weakness, dizziness, pain in the liver increase: the liver enlarges again, the thymol test index and transferase activity increase. Often, AST activity is higher than ALT activity, the de Ritis coefficient is more than 1. A decrease in the sublimate test and prothrombin index is possible. Some patients experience only enzymatic exacerbation without any clinical manifestations. The disease often occurs in moderate to severe forms; in 5-25% of cases, a fulminant (lightning) form develops, ending in death. In adults, 60-80% of fulminant forms of HBsAg-positive hepatitis are caused by HDV infection. With a favorable course of hepatitis of mixed etiology, the duration of the disease is 1.5-3 months. The disease ends in recovery (in about 75% of cases) or death - in the fulminant form of the disease. The development of chronic hepatitis is rare (1-5%). The disappearance of HBsAg also indicates recovery from delta infection.

Acute delta (super)-infection of a hepatitis B virus carrier

This variant of the disease can proceed both manifestly and clinically latent, however, 60-70% of patients still record either an episode of jaundice or a classic picture of the icteric variant of acute hepatitis. The incubation period lasts 3-4 weeks. The pre-icteric period is characterized by an acute, sometimes violent onset. Its duration does not exceed 3-4 days. Unlike acute viral hepatitis B, more than half of patients have a body temperature above 38 C, arthralgia and pain in the right hypochondrium appear, and some patients note urticarial rash on the skin. After 2-3 days, the urine becomes dark, feces become discolored, the liver and spleen enlarge, and yellowness of the sclera and skin appears.

During the icteric period, the patients' health worsens, symptoms of hepatitis D and intoxication increase, body temperature remains elevated for another 3-4 days, joint pain does not stop, and pain in the right hypochondrium is recorded more often than before the appearance of jaundice, and it is of a permanent nature.

When examining patients, significant enlargement and density of both the liver and spleen are noticeable. More than 40% of patients develop edematous-ascitic syndrome. In the blood serum - hyperbilirubinemia (usually persists for more than 2 months). hyperfermentemia (often with a distortion of the de Ritis coefficient). The activity of ALT and AST remains high longer than in viral hepatitis B and hepatitis of mixed etiology, and in almost no patient does the level of enzyme activity reach the norm.

Unlike other viral hepatitis, acute hepatitis delta in HBAg carriers significantly disrupts the protein-synthetic function of the liver, which is manifested by a decrease in the sublimate test in the first 10 days of the icteric period and an increase in the thymol test. The amount of albumins decreases, the content of the y-globulin fraction increases. The development of edematous-ascitic syndrome in this variant of HDV infection is associated with both a decrease in albumin synthesis and a qualitative change in them. In the overwhelming majority of patients, the disease proceeds in waves with repeated clinical and enzymatic exacerbations, accompanied by an increase in jaundice, symptoms of intoxication, the development of edematous-ascitic syndrome, short-term (1-2-day) waves of fever with chills, the appearance of an ephemeral rash on the skin. The severity of clinical symptoms in some patients decreases with each new wave, while in others the disease takes on a progressive character: subacute liver dystrophy, hepatic encephalopathy develop, and death occurs.

Recovery occurs extremely rarely, the outcomes are almost always unfavorable: either a fatal outcome (in the fulminant form or in the severe form with the development of subacute liver dystrophy), or the formation of chronic viral hepatitis D (in approximately 80%) with high activity of the process and rapid transition to cirrhosis of the liver.

Another possible variant of superinfection is infection with the delta virus in patients with chronic hepatitis B. Clinically, this is manifested by an exacerbation of previously favorable hepatitis, the appearance of intoxication, jaundice, hyperfermentemia, and progression to liver cirrhosis.

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