Hepatitis C presentation

Dr. BASHEER ELTAYEB

HCVMEDICAL COMMISION DEPARTMENT- CPD

Topics • Background Hepatitis • Transmission• Standard Precautions• Testing• Natural History• Symptoms• Treatment• Disclosure / Discrimination

Definition• The hepatitis C virus is a small,

enveloped, single-stranded, RNA virus.• The half life of the virus particles in the

serum is around 3 hours and may be as short as 45 minuts . In an infected person, about 1012 virus particles are produced each day. In addition to replicating in the liver the virus can multiply in lymphocytes.

Background

• WHO estimates about 3% of the world’s population has been infected with HCV.

• More than 170 million chronic carriers who are at risk of developing liver cirrhosis and/or liver ca.

• The prevalence of HCV infection varies throughout the world.

• Egypt had the highest number of reported infections, largely attributed to the use of contaminated parenteral antischistosomal therapy, with a mean prevalence of 22%.

Background

• In USA, the incidence of acute HCV infection has sharply decreased. Its prevalence remains high (2.7 million)

• chronic hepatitis C infection develops in approximately 75% of patients after acute infection.

Background

In Qatar• In 2010 at HMC a total of 13,704 people were screened

272 (two percent) were found with hepatitis C antibodies.• nine were found to have minimal disease, and 60 people

underwent liver biopsy. • 68 people were given treatment for hepatitis C and 45

responded to the treatment. • In Qatar,anti-hepatitis C viral antibodies among blood

donors 0.06 percent. • In Bahrain this figure is 0.30 percent.• in the UAE it is 0.11 percent.• in Saudi Arabia is 0.65 percent and .• in Kuwait 3.1 percent.

Genotypes• There are about 6 genotypes.• The major HCV genotype worldwide is • genotype 1, which accounts for 40-

80% of all isolates. • Genotype 1 also may be associated

with more severe liver disease and a higher risk of HCC.

• Genotype 4 it is most prevalent in the Middle East and Africa

• Within a region, a specific genotype may also be associated with a specific mode of transmission, such as genotype 3 among persons in Scotland who abuse intravenous drugs.

Genotypes

Transmission• Transfusion of blood was once an

important source of transmission. • Since 1990, however, the screening

of donated blood for HCV antibody has decreased the risk of transfusion-associated HCV infection to less than 1 case in 103,000 transfused units.

• Persons who inject illegal drugs with nonsterile needles or who snort cocaine with shared straws are at highest risk for HCV infection.

• In developed countries, most new HCV infections are related to intravenous drug abuse (IVDA).

Transmission

• Transmission of HCV to health care workers may occur via needle-stick injuries or other occupational exposures.

• Nosocomial patient-to-patient may occur by colonoscope, dialysis, during surgery, including organ transplantation before 1992.

Transmission

• tattooing, sharing razors, and acupuncture.

• high-risk sexual activity and maternal-fetal transmission.

• Coinfection with human immunodeficiency virus (HIV) type 1 appears to increase the risk of both sexual and maternal-fetal transmission of HCV

Transmission

Race-, sex-, and age-related differences in incidence

• HCV is more common among black and Hispanic, in association with lower economic status and educational levels.

• In addition, in the US, genotype 1 is more prevalent in blacks than in other racial groups.

• No sex preponderance occurs with HCV infection.

CLINICAL MANIFESTATIONS 

•  Acute hepatitis typically develops 2 to 26 weeks after exposure to hepatitis C virus with a mean onset of 7 to 8 weeks .

• In patients who experience symptoms, the acute illness usually lasts for 2 to 12 weeks.

Physical Examination

• Most patients do not have findings until they develop portal hypertension or decompensated liver disease.

• One exception is patients with extrahepatic manifestations of HCV infection, such as porphyria cutanea tarda or necrotizing vasculitis.

• Signs include the following: • Palmar erythema, Dupuytren contracture,

asterixis,leukonychia,clubbing • Icteric sclera, temporal muscle wasting,

enlarged parotid,cyanosis • Fetor hepaticus ,Gynecomastia, small

testes .

Physical Examination

• Paraumbilical hernia - ascites, caput medusae, hepatosplenomegaly, abdominal bruit

• Ankle edema • Scant body hair • Spider nevi, petechiae, excoriations

due to pruritus

Physical Examination

Who Should be Screened?

• Ever injected illegal drugs• Received clotting factors made before 1987• Received blood/organs before July 1992 • Ever on chronic hemodialysis• Evidence of liver disease• HIV-positive

• Healthcare and emergency personnel after exposure• Children born to HCV-positive women

Based on increased risk for infection

Based on need for exposure management

screening• For a patient presenting following a known

exposure to HCV, we obtain the following tests:

• ●Immediately/baseline: Anti-HCV antibody, HCV RNA, and serum aminotransferases

• ●Four weeks after exposure: HCV RNA and serum aminotransferases.

• ●Three months after exposure: Anti-HCV antibody, HCV RNA, and serum aminotransferases

• ●Six months after exposure: Anti-HCV antibody.

screening

Approach Considerations• screening for hepatitis C virus (HCV)

involves an enzyme immunoassay (EIA). These assays are 97% specific but cannot distinguish acute from chronic infection.

• Health care personnel who sustain a needle-stick injury should undergo (PCR) immediately and then every 2 months for 6 months.

• HCV genotyping as an aid for guiding treatment

• Quantitative HCV RNA assay • Screening tests for coinfection with

HIV or hepatitis B virus (HBV) • Screening for alcohol abuse, drug

abuse, and/or depression

Approach Considerations

Hepatitis C Antibody Test• False-negative results for the presence of

HCV antibody can occur in persons with compromised immune systems, such as those with HIV type 1 infection, renal failure, or HCV-associated essential mixed cryoglobulinemia.

• False-positive EIA results can occur; the likelihood of a false-positive result is greater in persons without risk factors.

Recombinant Immunoblot Assay

• The recombinant immunoblot assay is used to confirm HCV infection. A positive immunoblot assay result is defined as the detection of antibodies against 2 or more antigens and an indeterminate assay result defined as the detection of antibodies against a single antigen.

Recombinant Immunoblot Assay

• A positive immunoblot assay result followed by 2 or more instances of undetectable HCV RNA suggests HCV infection has resolved. A positive anti-HCV immunoassay result followed by a negative immunoblot assay result represents a false-positive immunoassay, and no further testing is required.

Qualitative and Quantitative Assays for HCV RNA

• Qualitative assays can be used to test for HCV RNA. such as PCR or transcription-mediated amplification (TMA).

Quantitative assays ascertain HCV RNA quantity in blood, using signal amplification (branched DNA [bDNA] assay) or target amplification techniques (PCR, TMA). Reverse transcriptase PCR (RT-PCR) is more sensitive than bDNA testing.

Liver Biopsy• some experts recommend biopsy only in the

following situations: • The diagnosis is uncertain • Other coinfections or disease may be

present .• The patient being considered for treatment

has normal liver enzyme levels and no extrahepatic manifestations .

• The patient is immunocompromised.

Radiologic Studies

• A liver stiffness test (FibroScan) is available as a noninvasive method of staging liver disease in persons with chronic hepatitis C. Obesity, female sex, operator experience, and age older than 52 may give invalid results.

Standard Precautions

• Hand Hygiene• Use of Personal Protective Equipment

(PPE’s)• Waste Management ,care with sharps.• Reprocessing of Equipment• Environmental Controls

Routine preoperative testing of patients is not recommended

Treatment• Patients with acute hepatitis C virus (HCV)

infection appear to have an excellent chance of responding to 6 months of standard therapy with interferon (IFN).

• the highest priority for treatmentPatients with advanced fibrosis, those with

compensated cirrhosis, liver transplant recipients, and those with severe extraheptic hepatitis.

• Treatment decisions should balance the anticipated reduction in transmission versus the likelihood of reinfection in patients whose risk of HCV transmission is high and in whom HCV treatment may result in a reduction in transmission (eg, men who have high-risk sex with men, active injection drug users, incarcerated persons, and those on hemodialysis)

Treatment

• Treatment of chronic HCV infection has 2 goals.

The first is to achieve sustained eradication of HCV.

The second goal is to prevent progression to cirrhosis, hepatocellular carcinoma (HCC), and decompensated liver disease requiring liver transplantation.

Treatment

• Antiviral therapy for chronic hepatitis C should be determined on a case-by-case basis. However, treatment is widely recommended for patients with elevated serum alanine aminotransferase (ALT) levels who meet the following criteria :

Treatment

• Age greater than 18 years • Positive HCV antibody and serum HCV RNA test

results • Compensated liver disease (eg, no hepatic

encephalopathy or ascites) .• No contraindications for treatment .

Treatment

• Acceptable hematologic and biochemical indices (hemoglobin at least 13 g/dL for men and 12 g/dL for women; neutrophil count >1500/mm 3, serum creatinine < 1.5 mg/dL)

• Willingness to be treated and to adhere to treatment requirements .

Treatment