Hepatitis D


  • Enveloped RNA virus
  • Infection only occurs in patients with concurrent hepatitis infection (acute, chronic or carrier state), as virus requires presence of HBV for replication
  • Rare in developed countries, transmission similar to HBV (blood-borne)
  • HDV-HBV co-infection considered most severe variant of chronic viral hepatitis due to rapid progression to liver failure and HCC[1]

Clinical Features

  • Acute hepatitis, ranging from mild to fulminant hepatitis with acute liver failure
  • Chronic superinfection (HDV+HBV)
    • Accelerates progression of chronic HBV to cirrhosis

Differential Diagnosis

Causes of acute hepatitis


  • High anti-HDV IgG/IgM titers plus confirmation with serum HDV RNA definitively diagnose, however not widely available[3]

Acute Hepatitis Evaluation

  • LFTs
    • AST, ALT > 1000s
    • Elevated bilirubin
    • Elevated alk phosphatase
  • INR
  • Consider acetaminophen level
  • Acute hepatitis panel
    • Hep A Ab IgM
    • Hep B cAb IgM
    • Hep B sAg
    • Hep B sAb
    • Hep C Ab
Anti-hepatitis A, IgM Hepatitis B surface antigen Anti-hepatitis B core, IgM Anti-hepatitis C Interpretation
Positive Negative Negative Negative Acute hepatitis A
Negative Positive Positive Negative Acute hepatitis B
Negative Positive Negative Negative Chronic hepatitis B infection
Negative Negative Positive Negative Acute hepatitis B; quantity of hepatitis B surface antigen is too low to detect
Negative Negative Negative Positive Acute or chronic hepatitis C; additional tests are required to make the determination


  • Acute management is supportive
  • Consider liver transplant consultation if approaching liver failure
  • Outpatient treatment with Interferon-α


  • Consider admission for:
  1. Bilirubin > 20
  2. PT 50% above normal, INR >2
  3. Hypoglycemia
  4. Hypoalbuminemia
  5. Any GI bleeding
  6. Uncontrolled nausea/vomiting, pain
  7. Significant comorbidity, immunocompromised, elderly

See Also


  1. WHO Fact Sheet https://www.who.int/news-room/fact-sheets/detail/hepatitis-d
  2. Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
  3. WHO Fact Sheet https://www.who.int/news-room/fact-sheets/detail/hepatitis-d
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