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Understanding hepatitis D

What are the forms of hepatitis D and their respective symptoms?

Hepatitis D virus (HDV) can cause acute hepatitis (liver inflammation), usually in the event of simultaneous co-infection with the hepatitis B virus (HBV).1HDV can also induce chronic viral hepatitis D, usually following superinfection in someone already suffering from hepatitis B.1,2

Acute viral hepatitis D

It is difficult to distinguish the symptoms of acute viral hepatitis D from another form of acute hepatitis, although it often takes a more severe course.1

After an incubation period of three to seven weeks, during which the virus replicates, the following symptoms may appear: Fatigue, loss of appetite and nausea.1

From a clinical point of view, the increased number of liver enzymes in the blood indicates the destruction of the liver cells. Accompanying or secondary symptoms of this disease include jaundice, nausea and persistent fatigue, dark urine, pale stools and an increase in the concentration of bilirubin in the blood, which explains the yellow colouring of the skin.1

Fulminant viral hepatitis D

In exceptional cases, HDV-HBV superinfection (even rarer the simultaneous infection) can lead to fulminant hepatitis, which can be fatal in 2 to 10 days.1

It is characterised by sudden and massive destruction of the liver cells. As the destruction of the liver cells progresses, the number of liver enzymes also drops rapidly.2 Fulminant viral hepatitis D is usually manifested by jaundice, blood clotting disorders and brain damage (disorders of consciousness in the form of hepatic encephalopathy with confusion, personality changes, drowsiness and coma).1

In these cases, emergency admission to a specialised centre is absolutely necessary. Liver transplantation may then be suggested as an emergency intervention.

Chronic viral hepatitis D 

Superinfection of viral hepatitis B with HDV leads to chronic viral hepatitis D infection in up to 90 % of all cases. The latter can cause liver cirrhosis in 70% of cases, with a course of disease lasting 5 to 10 years.1,2 Liver cirrhosis is usually asymptomatic for years. In the long term, the main risk factor of cirrhosis is the occurrence of liver cancer. There is also a risk of hepatic decompensation, characterised by abdominal dropsy, loss of consciousness or gastrointestinal bleeding due to rupture of varices in the oesophagus.1,3,5Chronic viral hepatitis D may begin with acute hepatitis, probably corresponding to the superinfection phase. The disease may be asymptomatic or have accompanying symptoms such as fatigue, malaise and loss of appetite. Finally, chronic hepatitis D can cause various so-called autoimmune reactions due to a disturbance of the immune system.1,3

Overview of possible symptoms of hepatitis D

Depending on whether it is an acute or chronic HDV infection, different symptoms can occur.6 

Symptoms of Hepatitis D


  1. Farci P., Niro GA. Clinical Features of Hepatitis D. Semin Liver Dis. 2012 Aug;32(3):228-36.
  2. Rizzetto M. Hepatitis D Virus: Introduction and Epidemiology. Cold Spring Harb Perspect Med. 2015 Jul 1;5(7):a021576. doi: 10.1101/cshperspect.a021576
  3. Romeo R. et al. 28-Year Study of the Course of Hepatitis Delta Infection: A Risk Factor for Cirrhosis and Hepatocellular Carcinoma. Gastroenterology 2009;136:1629–1638.
  4. Robert Koch Institut. Epidemiologisches Bulleting Nr. 29. Virushepatitis B und D im Jahr 2018. https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2019/Ausgaben/29_19.pdf?__blob=publicationFile. Juni 2020.
  5. Fattovich G.et al. Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B. The European Concerted Action on Viral Hepatitis (Eurohep) Gut. 2000 Mar;46(3):420-6. doi: 10.1136/gut.46.3.420.