Hepatite B na infância
Autor: SPRS/PreparandoproTEP | Publicado: 2012-10-01T11:47:00-07:00

Renata Rostirola Guedes

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Introdução:

Estima-se que existam em todo
mundo 300 milhões de indivíduos portadores do vírus da hepatite B. Com a
aplicação da vacinação universal em muitos países, esse problema diminuiu muito
na faixa etária pediátrica. &nbsp;O curso da
infecção pelo HBV pode ser agudo, fulminante ou crônico, sendo que este último
pode evoluir para cirrose ou hepatocarcinoma.

Transmissão:

A transmissão pode ocorrer por
via parenteral (transfusões de hemoderivados ou uso de drogas injetáveis),
sexual, vertical (habitualmente no momento do parto) e horizontal (convivência
continuada com um portador). A entrada do vírus pode ocorrer por meio de sangue
ou secreções, através de erosões da pele e mucosas e/ou por meio de mordeduras.
O contágio também pode ocorrer por meio de materiais contaminados não
esterilizados.

O período de incubação varia de 1
a 12 semanas e o intervalo desde o inóculo até o aparecimento do quadro de
hepatite é de 45 dias a 6 meses.

Formas clínicas e diagnóstico:

Hepatite Aguda

Há um período prodrômico de duas
semanas onde a inflamação hepática pode ser subclínica ou associar-se a dor
abdominal, dor articular, exantema, astenia e anorexia. A fase aguda da
infecção pode apresentar-se com ou sem icterícia. Assim como ocorre com adultos,
a maioria das crianças nesta fase são assintomáticas. As provas de função
hepática demonstram elevação das aminotransferases (AST e ALT), com graus
variáveis de elevação de gamaglutamil transpeptidase (GGT) e das bilirrubinas.

No período de incubação,
detectam-se o HBsAg, o HBeAg e o DNA do HBV, sem a presença de anticorpos e de
disfunção hepática. Na fase inicial da hepatite aguda surge o anti-HBc IgM. A
negativação do HBeAg é observada após um mês de doença, seguida com o
surgimento do anti-HBe. Na fase de convalescença e de recuperação, ocorre a
negativação do HBsAg, seguida do aparecimento do anti-HBs, nos casos de cura (clearance viral). Em alguns pacientes,
esse processo de desaparecimento do HBsAg é rápido e ocorre antes do
aparecimento do anti-HBs. Nesses casos, o diagnóstico de hepatite aguda
fundamenta-se na positividade isolada do Anti-HBc IgM, período denominado
janela imunológica.

Após a resolução da hepatite B, o
anti-HBc IgG fica permanentemente positivo. Se a positividade dos antígenos virais
(HBsAg) persistirem por período maior que seis meses, a infecção deixa de ser
classificada como aguda, passando a ser crônica.

Hepatite crônica B

Em adultos,
a cronificação ocorre em 5 a 10% dos casos. Essa taxa é
maior em crianças e depende da idade no momento da infecção: 65 a 90% nas infecções perinatais, 50% nos
lactentes, 30% entre 1 e 5 anos&nbsp; e 5% &nbsp;nos maiores
de&nbsp; 5 anos.
A evolução crônica
ocorre preferentemente em indivíduos assintomáticos no início
da infecção.&nbsp; 

Fases:

1)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Fase de alta replicação: presença de HBeAg com alta carga viral. Crianças infectadas por
via perinatal podem apresentar durante
os primeiros anos um estado de normalidade funcional
e histológica atribuído à imunotolerância. A duração
desta fase é, em geral, inferior a 10 anos, podendo chegar a 25 anos nos casos de infecção vertical.

2)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Fase de
imunoeliminação: é a que precede a
negatividade do HBeAg e o aparecimento
do anti-HBe (“soroconversão”). Nesta
fase há diminuição da carga viral e ocorrem, em maior intensidade,
a necroinflamação e a disfunção hepática. A soroconversão marca o início da melhora da
enfermidade, com
remissão das alterações bioquímicas.

3)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Fase de baixa replicação (estado de portador
inativo HBsAg): negatividade do HBeAg,
positividade do anti-HBe e HBsAg e DNA-VHB baixo
ou indetectável. A função hepática é normal.

4)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Reativação:
reaparecimento de uma disfunção
hepática associada à maior replicação
viral. A reativação da replicação viral
pode ocorrer com
reversão ao estado
de HBeAg+ ou, mais
frequentemente, mantendo a positividade do anti-HBe. 



A Hepatite crônica
HBeAg negativo é definida pela presença de disfunção hepática
em picos ou cronicamente, com DNA-VHB
&gt;2000 UI/ml ou
&gt;104-5 cópias/ml (não necessariamente contínuo)
em um indivíduo HBeAg negativo. Na infância, isso
é pouco observado
e afeta 5% dos pacientes.&nbsp; 



Prevenção:

É recomendação da OMS vacinação
contra hepatite B para todos os recém nascidos. Profilaxia
com imunoglobulina específica é indicada naqueles casos de transmissão
vertical.

Tratamento:

A hepatite
aguda B não
tem indicação de tratamento,
salvo nos
casos de curso
fulminante. As indicações de tratamento limitam-se a casos
seleccionados em crianças com hepatite B crônica, sendo os fármacos utilizados
nesta faixa etária: interferon alfa, lamivudina e adefovir.