Hepatitis dual infection

　　The clinical symptoms caused by hepatitis viruses, whether they are simultaneous or overlapping infections, are generally similar to those caused by acute or chronic hepatitis by a single type of hepatitis virus infection. However, due to the different combinations of hepatitis virus types, each has its own characteristics, which can make the patient's condition more complicated and the symptoms more severe, leading to poor efficacy. Therefore, when encountering intractable severe chronic active hepatitis, post-hepatitis liver cirrhosis, and severe hepatitis patients, it should be considered that there may be multiple infections.

　　It is estimated that there are 280 million HBsAg positive carriers worldwide, with China accounting for about 100 million, of which two-thirds are asymptomatic carriers. Due to the high prevalence of HBV infection, it is easy to have overlapping infections with other types of hepatitis viruses through different transmission routes. Commonly, the following types are found:

　　(1) Dual infection with HBV and HAV

　　1. Simultaneous infection: This type is less common, as HBV and HAV are both primary infections. The clinical manifestations and liver function tests are more pronounced than in overlapping infections. In addition to a few patients with prolonged disease course, most patients present with acute jaundice hepatitis, with a good prognosis and no worsening of symptoms or liver damage.

　　2. Overlapping infection: The overlapping infection rate of HBV and HAV in scattered acute hepatitis in China varies, ranging from 0 to 23.4%. During the outbreak of hepatitis A in Shanghai in 1988, about 10% were chronic HBsAg carriers who were co-infected with HAV. It can be seen that in areas with a high HBsAg carriage rate and outbreaks of hepatitis A, overlapping infection of HBV and HAV is also more common.

　　Chronic hepatitis B with overlapping infection of HAV shows more severe symptoms and increased ALT levels in half of the patients after the onset of hepatitis A, especially in patients with chronic active hepatitis. If HAV is reinfected on the basis of pre-existing liver cirrhosis, jaundice deepens, liver function damage worsens, and symptoms may appear.

　　(2) Dual infection with HBV and HCV

　　Due to the high carriage rates of HBV and HCV, the opportunity for their co-infection is also relatively large. Foreign reports indicate that the co-infection rate of HBV and HCV is 15% to 28%. In 1990, China reported 40 cases of chronic active hepatitis with positive HBsAg and negative anti-HBcIgM, with a positive rate of 17.5% for anti-HCV detected by the OrthoC100-3 diagnostic kit, which is basically consistent with the situation abroad.

　　The clinical symptoms of acute hepatitis C are generally milder than those of acute hepatitis A or B, with asymptomatic and subclinical cases being more common. Most patients do not have jaundice, and there is a single increase in ALT. A few severe cases of hepatitis C are difficult to differentiate from hepatitis B. However, when HBV co-infection with HCV occurs, the clinical symptoms are more severe than those of acute hepatitis C or B, and the course of the disease is prolonged, leading to chronicization, recurrent symptoms, persistent abnormal liver function, and even progressing to severe hepatitis, liver cirrhosis, or liver cancer.

　　(3) Dual infection with HBV and HDV

　　The HDV infection rate reported in various regions of China varies from 0 to 12%, with significant differences between regions. In 1989, Zhang Yongyuan reported the detection results of HDAg in more than 2,000 liver tissue samples from 16 provinces and cities, with a positive rate of 5.33% to 19.77%. Although the infection rates of HDV and HBV are closely related, the HDV infection rate is not necessarily consistent with the HBV infection rate. In areas where hepatitis D is endemic, the HBV infection rate is high, and so is the HDV infection rate. However, in some countries in China and Southeast Asia, the HBV carriage rate is very high, but the HDV infection rate is low, and the reason for this needs further clarification.

　　1. Simultaneous infection with HBV and HDV: The clinical symptoms and liver function characteristics of acute HDV infection are similar to those of acute HBV infection, but sometimes a bimodal increase in ALT can be seen, indicating HBV and HDV infection respectively. Compared with acute HBV infection, this type of acute hepatitis D has a lower risk of developing chronic hepatitis, and the course of the disease is mostly self-limiting with a good prognosis.

　　2. Overlapping infection of HBV and HDV: It usually presents as a chronic process, mostly concealed, but the disease progresses quickly, often developing into chronic active hepatitis and liver cirrhosis. Rizzetto et al. observed 137 chronic hepatitis D patients with intrahepatic HDAg positivity, 41% of whom developed liver cirrhosis.

　　Both simultaneous infection and overlapping infection of HBV and HDV can lead to severe hepatitis, so it is often considered that the co-infection of HDV on the basis of HBV infection is one of the causes of the development of severe hepatitis and liver cirrhosis.

　　(IV) Dual infection of HBV and HEV

　　Hepatitis E can present as an explosive epidemic or an endemic in various parts of the world. There was an explosive epidemic in Xinjiang, China, so the co-infection of HBV and HEV should not be ignored. A single HEV infection usually presents as a self-limiting process with a good prognosis. However, it can lead to fulminant liver failure in pregnant women with a high mortality rate. Most severe hepatitis cases reported in India are HBsAg carriers co-infected with HEV. Therefore, in areas with a high prevalence of HBV infection, co-infection of HBV and HEV can lead to the occurrence of severe hepatitis.

　　(V) Multiple infection of HBV, HCV, and HDV

　　Multiple infections of 3 or more hepatitis viruses are rare, and the course and outcome are obviously related to the degree of liver lesions before overlapping infection, such as asymptomatic HBsAg carriers may manifest with symptoms, abnormal liver function, if it is chronic active hepatitis or liver cirrhosis, it will manifest as progressive worsening of clinical symptoms and significant liver function damage, prognosis is poor. Due to the widespread use of blood transfusion and blood products for the treatment of chronic liver disease and severe hepatitis in China, and again, the high prevalence of HBsAg carriers in China, reaching 10% to 15%, and a high positive rate of anti-HCV in blood donors, there are also many opportunities for HCV infection. Severe hepatitis E can also be co-infected with HAV, but it has no significant impact on the condition and prognosis.

　　Patients with dual hepatitis infection generally will also have complications such as hepatic diabetes, fatty liver, liver cirrhosis, and liver cancer.

　　1. Hepatic diabetes

　　The clinical manifestations are similar to type 2 diabetes, with the difference that in hepatic diabetes, insulin levels are significantly elevated during fasting while C-peptide remains normal. After glucose intake, insulin levels rise significantly, but the C-peptide peak is still slightly lower than normal. This is because the liver's ability to inactivate insulin is reduced, promoting insulin elevation; in addition, glucagon inactivation in the liver is reduced, and insulin receptors on liver cells decrease, producing resistance to insulin, so although insulin levels increase, blood glucose remains high; at the same time, C-peptide is less affected by the liver, so C-peptide levels are not elevated, indicating that there is no obvious abnormality in the secretion function of cells. To differentiate from type 2 diabetes, insulin and C-peptide release tests can be used.

　　2. Fatty liver

　　The mechanism is not yet clear, characterized by good general condition, mild to moderate elevation of ALT, increased blood lipids, fatty liver waveforms visible on B-ultrasound examination, and diagnosis is based on liver biopsy pathological examination.

　　3. Liver cirrhosis

　　The development of chronic hepatitis into liver cirrhosis is the result of liver fibrosis. The mechanism has not been fully elucidated. It also occurs in subacute, chronic severe hepatitis, and asymptomatic HBsAg carriers with concealed onset.

　　4. Liver cancer

　　HBV and HCV infections are closely related to the disease. Liver cancer is more common in patients with chronic active liver disease and liver cirrhosis. It can also occur in chronic HBV infection without the stage of liver cirrhosis developing into liver cancer. The mechanism of occurrence is currently believed to be related to HBV-DNA integration, especially X gene integration. The transactivation of HBxAg plays an important role in the transactivation of proto-oncogenes. In addition, carcinogens such as aflatoxins have a certain synergistic effect.

　　Dual hepatitis infection, according to clinical characteristics, is the original chronic HBV infection with recent symptoms exacerbation and liver function abnormalities; or the original chronic active hepatitis and liver cirrhosis with recent deterioration and poor treatment response, all should consider the possibility of superimposed infection with other hepatitis viruses. It is necessary to perform relevant etiological indicator tests in a timely manner. Due to the high prevalence of HBV infection in China, even without a history of hepatitis, those presenting with acute hepatitis cannot be ruled out from having previously suffered from hepatitis B or being asymptomatic HBsAg carriers. Therefore, simultaneous detection of serum anti-HAVIgM and HBV markers should be performed to assist in diagnosis.

　　Patients with dual hepatitis infection may develop severe hepatitis, liver cirrhosis, and liver cancer, so preventing dual hepatitis infection is quite crucial.

　　1. Pay attention to dietary hygiene, avoid close contact with hepatitis patients, avoid iatrogenic infection, protect wounds, and childbearing women must avoid pregnancy. Timely vaccination against hepatitis B vaccine is necessary.

　　2. Hepatitis patients should pay special attention to dietary taboos, consume foods rich in protein and vitamins. Avoid alcohol and also avoid spicy foods such as scallions, garlic, and chili.

　　3. Pay attention to personal hygiene, protect water sources, improve environmental hygiene, and develop good living habits. Maintain a positive mindset and stable emotions, adopt a healthy diet, and eat more fruits and vegetables to enhance self-immunity.

　　The dietary intake of patients with dual infections of hepatitis should be balanced. Fresh, natural, and balanced nutrition is the most important, avoiding the intake of unrefined, moldy, fried, smoked, preserved, canned and other processed foods. In addition, it is necessary to refuse the temptation of alcohol, because the liver is the main metabolic site of alcohol, and alcohol and its metabolites will damage liver cells, form alcoholic liver disease, and then develop into liver cirrhosis, greatly increasing the incidence of liver cancer. Therefore, patients with hepatitis should try to reduce alcohol intake and preferably avoid drinking. In addition to general diet, symptoms can also be relieved through dietary remedies.

　　1) Chicken bone grass and date pork stew

　　30 grams of chicken bone grass, 7-8 dates, 100 grams of lean pork. Boil with an appropriate amount of water, season with a small amount of salt, remove the dregs, drink the soup and eat the meat, once a day. This recipe has the effects of clearing dampness and heat, detoxifying, reducing jaundice, and strengthening the body to protect the liver. It is suitable for patients with acute and chronic hepatitis with obvious dampness and heat.

　　2) Mud shrimp tofu soup

　　Fresh tofu 100 grams, mud shrimp a few. After breeding the mud shrimp in a basin for 1-2 days, take them out, clean and wash them, cut them into 3.3 cm long pieces, and cook them with tofu in a pot, add an appropriate amount of water, and cook until they are soft. Eat the mud shrimp tofu and drink the soup, once a day, once a small bowl. It is used for acute and chronic jaundice type hepatitis, and has a lowering effect on elevated transaminases.

　　The treatment of dual infections of hepatitis varies, mainly determined by the type of hepatitis infection. Taking the original drugs for treating hepatitis, protecting liver cells, keeping alt, asa, etc. normal, and taking health products to improve the body's immune function.