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Viruses other than HAV and HBV that can cause hepatitis are hepatitis C virus (HCV), hepatitis D virus (HDV) (delta agent), and hepatitis E virus (HEV) (an enterically transmitted hepatitis seen in epidemic form in Asia, the Middle East, and North Africa and sporadically in Western countries). Human pegivirus (formerly hepatitis G virus [HGV]) rarely, if ever, causes frank hepatitis. A related virus has been named human hepegivirus-1. A DNA virus designated the TT virus (TTV) has been identified in up to 7.5% of blood donors and found to be transmitted readily by blood transfusions, but an association between this virus and liver disease has not been established. A related virus known as SEN-V has been found in 2% of US blood donors, is transmitted by transfusion, and may account for some cases of transfusion-associated non-ABCDE hepatitis. In immunocompromised and rare immunocompetent persons, cytomegalovirus, Epstein-Barr virus, and herpes simplex virus should be considered in the differential diagnosis of hepatitis. Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), Ebola virus infection, and influenza may be associated with marked serum aminotransferase elevations. Unidentified pathogens account for a small percentage of cases of acute viral hepatitis.

1. HEPATITIS C

HCV is a single-stranded RNA virus (hepacivirus) with properties similar to those of flaviviruses. Seven major genotypes of HCV have been identified. In the past, HCV was responsible for over 90% of cases of posttransfusion hepatitis, yet only 4% of cases of hepatitis C were attributable to blood transfusions. Over 50% of cases are transmitted by injection drug use, and both reinfection and superinfection of HCV are common in people who actively inject drugs. Body piercing, tattoos, and hemodialysis are risk factors. The risk of sexual and maternal–neonatal transmission is low and may be greatest in a subset of patients with high circulating levels of HCV RNA. Having multiple sexual partners may increase the risk of HCV infection, and HIV coinfection, unprotected receptive anal intercourse with ejaculation, and sex while high on methamphetamine increase the risk of HCV transmission in men who have sex with men. Transmission via breastfeeding has not been documented. An outbreak of hepatitis C in patients with immune deficiencies has occurred in some recipients of intravenous immune globulin. Hospital- and outpatient facility–acquired transmission has occurred via multidose vials of saline used to flush Portacaths; through reuse of disposable syringes; through drug “diversion” and tampering with injectable opioids by an infected health care worker; through contamination of shared saline, radiopharmaceutical, and sclerosant vials; via inadequately disinfected endoscopy equipment; and between hospitalized patients on a liver unit. In the developing world, unsafe medical practices lead to a substantial number of cases of HCV infection. Covert transmission during bloody fisticuffs has even been reported, and incarceration in prison is a risk factor, with a frequency of 26% in the United States. In many patients, the source of infection is unknown. Coinfection with HCV is found in at least 30% of HIV-infected ...

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