Diagnosing Acute Hepatitis C

Tools



Introduction

The hepatitis C virus (HCV) is the most common blood borne infection in the United States. It is a major cause of acute and chronic hepatitis as well as cirrhosis world- wide. According to the Centers for Disease Control and Prevention, an estimated 4.1 million Americans are infected with Hepatitis C, of which 3.2 million are chronically infected. 21% of all acute viral hepatitis in the United States may be attributed to hepatitis C. 80%  of infected patients have no signs of this disease.  Approximately 85 % of infected people develop chronic hepatitis. 1- 5 % of infected may die, and hepatitis C is the leading cause of liver transplant.

Injection drug users are the largest group of persons infected with hepatitis C virus with a prevalence of 50%-90%. The virus spreads mainly through sharing contaminated needles or needle sticks at medically related jobs. As far as therapy is concerned, patients at highest risk for cirrhosis should be treated. Some studies have shown that treatment for HCV infection in injection drug users during substitution treatment for drug dependency is as successful as is treatment of patients who are not using drugs. Screening and early treatment of injection drug users could play an important role in controlling HCV infection. 1 2   In addition, clean needle programs have reduced the risk of Hepatitis C spread.

Although determination of antibody to HCV is a reliable and inexpensive test for diagnosing hepatitis C, it takes approximately six to twelve weeks for seroconversion.  The diagnostic “gold standard” is the presence of HCV RNA in serum. 3

This case emphasizes that in patients with hepatitis with high risk behaviors, an HCV RNA should be checked as the HCV antibody may be negative in the acute setting.

Case Report

A 42 year old male with a past medical history of carpel tunnel syndrome, hypertension, polysubstance abuse, active heroin sniffer, came to emergency department complaining of headache, nausea, vomiting, and right upper quadrant abdominal pain for 3 days.  The headache was frontal, started while at rest, sharp in nature, was severe in intensity, non radiating associated with tactile fevers, but no blurry vision or photophobia. The patient also had right upper quadrant abdominal pain, was dull in character, non radiating, associated with non bilious vomiting.

The patient smokes tobacco (1 pack of cigarette per day for 10 years) and was recently incarcerated.  He received a tattoo 2 months prior to presentation with a used needle while in prison.  He drinks alcohol occasionally and is in a methadone maintenance program though he continues to sniff heroin intermittently.  The patient has no known drug allergies and takes Hydrochlorothiazide 25 mg once a day.

On physical exam, the patient was in no acute distress with stable vital signs. No icterus was appreciated.  He had mild epigastric tenderness on examination with no rebound or guarding and normoactive bowel sounds. The rest of examination was normal including his neurologic status.

A CT scan of the brain and lumbar puncture were ordered to rule out subarachnoid hemorrhage. Labwork is seen below.  He was admitted for evaluation of headache and acute abdominal pain. The differential diagnosis was acute viral hepatitis, acute autoimmune hepatitis, toxin ingestion or medication induced. The following labs were sent:  Hepatitis A, B and C serologies including HepB surface antibody, HepB surface antigen, HepB core antibody – both IgG and IgM, Hep C antibody, Hep A IgM and IgG, Hep C RNA level, Anti-nuclear antibody, Iron studies, Anti-smooth muscle antibody, acetaminophen, alcohol and salicylate levels. An abdominal sonogram showed hepatomegaly with no ascites.

Daily monitoring of his liver function tests was done while awaiting the work up mentioned above. He became mildly jaundiced.  His serologies for Hepatitis A and C were nonreactive.  HepB core IgG was reactive with a negative core IgM, HepB surface antibody reactive.  Since we had a high index of suspicion for Acute Hepatitis C based on the history of a recent tattoo while in prison, Hep C PCR RNA was ordered and came back positive at 13200000IU/ml.  All other serologic tests were negative including HIV and Hepatitis B DNA <160. The patient was diagnosed with Acute Hepatitis C. By day 8, his liver function tests were trending down.

Labs Day 1-8.
LAB TESTS DAY1 DAY5 DAY8
RBC 4900/ml
WBC 2009/ml
Platelets 126000/ml
Neutrophils (%) 52
Lymphocytes(%) 35
Monocytes(%) 11
Basophils (%) 0.5
Eosinophils(%) 1.1
Creatinine 1.1mg/dl
BUN 16mg/dl
Albumin 3.6g/dl 3.1g/dl 3.1g/dl
AST 747U/L 3251U/L 8091U/L
ALT 941U/L 3692U/L 1616U/L
Total BILI 1.4 mg/dl 4.3 mg/dl 5.7 mg/dl
ALK 196 IU/ml 215 IU/ml 222 IU/ml

 

The patient felt clinically better with supportive care and was discharged home on day 9 to follow up as outpatient in Gastroenterology-Liver clinic.

Discussion

This patient presented with acute viral hepatitis. He had high risk behavior for contracting viral hepatitis, specifically, having a tattoo with shared needles 8 weeks before presentation; therefore, there was a high index of suspicion for acute hepatitis C.

Because the antibody takes weeks to months to develop; it can be falsely negative, especially early after exposure. Immunocompromised patients may test negative for anti-HCV despite having HCV infection because they may not produce enough antibodies for detection with the conventional assay. Antibody is present in almost all patients by 1 month after onset of acute illness; thus, patients with acute hepatitis who initially test negative, may need follow up testing. In these situations, HCV RNA is usually present and confirms the diagnosis. This case emphasizes the importance of measuring HCV PCR RNA when there is a high clinical suspicion.  A biopsy was not necessary in the acute setting as the patient improved clinically and a diagnosis was made.  He is to follow up in clinic in 3 months to check HCV PCR RNA.  If it is still present after week 12, treatment with pegylated Interferon and Ribavirin will be considered.  Compliance with these medications is a consideration before treatment can begin.

Conflicts of interest: none
Funding: none

References

  1. Gerlach JT, Diepolder HM, Zachoval R, Gruener NH, Jung MC, Ulsenheimer A et al. Acute hepatitis C: high rate of both spontaneous and treatment-induced viral clearance. Gastroenterology. 2003; 125:80-8.

  2. Backmund M, Reimer J, Meyer K, Gerlach JT, Zachoval R. Hepatitis C virus infection and injection drug users: prevention, risk factors, and treatment. Clinical Infectious Diseases. 2005;40 Suppl 5:S330-5.

  3. Tedeschi V, PhD, Seeff LB, MD. Diagnostic Tests for Hepatitis C: Where Are We Now?Annals of Internal Medicine. 1995; 123: 383-385.