In superinfection, an individual already infected with the hepatitis B virus becomes infected with hepatitis D virus. This might occur in a drug user who already has chronic hepatitis B and continues to inject drugs. Superinfection with the hepatitis D virus may be associated with a sudden worsening of liver disease and symptoms such as jaundice. The blood ALT and AST activities may become more elevated. Individuals with chronic hepatitis B who are superinfected with hepatitis D virus usually become chronically infected with hepatitis D virus, too. The risk of developing cirrhosis is greater in individuals chronically infected with both the hepatitis B and hepatitis D viruses compared to those infected with hepatitis B virus alone. As many as 80 percent of individuals chronically infected with both of these viruses may ultimately develop cirrhosis.
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The hepatitis D virus is transmitted in ways similar to the hepatitis B virus. One mode of transmission is intravenous drug use. Transmission from multiple blood transfusions is also possible, but screening of the blood supply for hepatitis B virus eliminates the hepatitis D virus. Sexual transmission of the hepatitis D virus is less efficient than for the hepatitis B virus. Although hepatitis D virus can be transmitted from mothers to their newborn babies, transmission by this route is rare.
The global distribution of hepatitis D virus infection is similar to that for hepatitis B virus. In some parts of the world, such as southern Italy and Russia, hepatitis D virus infection is fairly common among individuals chronically infected with hepatitis B. It is found in about 20 percent of so-called chronic carriers and in as many as 60 percent of individuals with clinical hepatitis caused by hepatitis B virus. In northern Italy, Spain, and Egypt, about 10 percent of asymptomatic chronic carriers infected with hepatitis B and about 30 to 50 percent of symptomatic patients with hepatitis B are infected with the hepatitis D virus. In most of China and other parts of Southeast Asia where the prevalence of chronic hepatitis B virus infection approaches 10 percent of the entire population, hepatitis D virus infection is rare.
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Diagnosis of hepatitis D virus infection is determined by blood testing. In acute co-infection, IgM and IgG antibodies to hepatitis D virus are detectable during the course of infection. IgM antibodies will be detected earlier after acute infection and IgG later or while the patient is recovering. IgG antibody concentrations in blood generally fall to levels that cannot be detected after the acute infection resolves. There is no reliable marker that persists to indicate past infection with hepatitis D virus. In hepatitis D virus superinfection, high levels of both IgxVI and IgG antibodies against the hepatitis D virus become detectable after infection. Both IgM and IgG antibodies persist in serum as long as the patient remains infected.
Hepatitis D virus co-infection often is not diagnosed. In cases in which acute hepatitis B is not too severe, the doctor will not search for hepatitis D co-infection. If liver disease is unusually severe in a highrisk individual, testing for antibodies against hepatitis D virus may be performed and the diagnosis of acute co-infection made. In chronic hepatitis D, which occurs usually as superinfection, the presence of IgG antibodies in blood against hepatitis D virus, in a patient with detectable blood HBsAg, establishes the diagnosis. Testing will usually be performed in a patient with known chronic hepatitis B whose condition deteriorates.
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