Hepatitis C

Question 1

acute hepatitis C

Answer 1

infection that develops during the first 6 months following the exposure

Question 2

chronic hepatitis C

Answer 2

HCV infection that persists beyond 6 months following exposure

Question 3

Hep C virus pathogen

Answer 3

Hepacivirus C
RNA virus
risk of chronic infection depends on hosts ability to clear infection through activation of innate pathway
6 genotypes
reinfection with another HCV genotype is possible

Question 4

transmission methods

Answer 4

parenteral - needle shharing among IVDU, needlestick injury, blood transfusion, dialysis
organ transplantation
sexual - rare in contrast to HBV and HIV
perinatal (vertical)

Question 5

risk factors for HCV infection

Answer 5

injection drug use
HBV or HIV
Hx of incarceration
recieved blood transfusion or organ transplant before 1992

Question 6

incubation period

Answer 6

2 weeks to 6 months

Question 7

acute course of disease

Answer 7

asymptomatic in 80% of cases
malaise, fever, myalgias, arthralgias
RUQ pain, tender hhepatomegaly
nausea, vomitng, diarrhoea
jaundice, possibly pruritis (due to elevated bilirubin)

Question 8

chronic course of disease

Answer 8

seen especially in asymptomatic individuals as treatment may be delayed or not initiated
findings often mild and non specific eg. fatigue
liver cirrhosis
extrahepatic features

Question 9

extrahepatic features of HCV

Answer 9

haem: mixed cryoglobulinaemia, lymphoma, immune tyhrombocytopaenic purpura, autoimmune hemolytic anaemia, monoclonal gammopathies
renal - membranoproliferative GN, membranous GN
rheum - polyarteritis nodosa, sjogren syndrome
dermatological - porphyria cutanea tarda, lichen planus
endocrine - T2DM, autoimmune thhyroiditis
vascular - leukocytoclastic vasculitis
other - sialadenitis

Question 10

screening for HCV in people without risk factors

Answer 10

everyone at least once per lifestime age >18
once per pregnancy
the CDC recommends against universal screening in settings where HCV disease prevelance is <0.1%

Question 11

screening for people with risk factors

Answer 11

one time:
- upon diagnosis with HIV
- individuals <18 years with risk factors
- infants born to HCV pos mothers
repeat screening
- after exposure to HCV within 48 hours and then >6 months
- annual for people who inject drugs, Men with HIV who have unprotected sex with men, Men who have sex with men taking HIV preexposure prophylaxis

Question 12

Hepatitis C tests for people who are HCV naive

Answer 12

Anti-HCV antibodies (EIA/ELISA immunoassay): as initial test for immunocompetant individuals who are HCV naive

Question 13

Hepatitis C tests for people with prior HCV infection or immunocompromise

Answer 13

HCV RNA qualitative PCR
after seroconversion from prior HCV infection, HCV antibodies wil;l remain positive for life and have no further diagnostic utility

Question 14

why are antibody tests less effective in immunocompromise

Answer 14

immunocompromise may prevent people from being able to produce antibodies
seroconversion may be delayed or absent

Question 15

interpretation of hepatitis C tests

Answer 15

Question 16

how to tell between acute or chronic infection

Answer 16

in contrast to Hep A and Hep B infections, there is no serologic or virology assay for HCV that distinguishes between acute and chronic infection

Question 17

how long until antibodies are detectable on immunoassay

Answer 17

as long as 6 weeks

Question 18

how long until RNA HCV is detectable on qualitative PCR

Answer 18

as long as 2-3 weeks

Question 19

laboritory studies for workup

Answer 19

quantitative PCR for HCV RNA viral load
routine studies: FBC, UECs
hepatocellular enzymes
cholestasis parameters
liver synthetic function tests
HIV, HAV, HBV for coinfection
serum pregnancy test

Question 20

hepatocellular enzyme changes

Answer 20

transaminases (ALT and AST)
are involved in amino acid metabolism and used clinically as parameters of hepatocellular injury
will be normal or raised
fluctuating ALT peaks indicate acute HCV infection

Question 21

cholestasis parameters changes

Answer 21

raised GGT
raised alk phos
raised bilirubin

Question 22

liver synthetic function tests

Answer 22

alterations indicate cirrhosis
decreased albumin
decreased total protein
increased PT/INR

Question 23

liver biopsy

Answer 23

consider if aeitiology of hepatitis is unknown
consider if liver fibrosis staging would alter treatment

Question 24

acute phase pathology

Answer 24

focal areas of macrovesicular steatosis
bile duct injury
sinusoidal inflammation of hepatic cells
lobular involvement in the form of eosinophillic single cell necrosis

Question 25

chronic phase pathology

Answer 25

lymphoid follicles in portal triad
necroinflammation of periportal liver cells
variable degree of fibrosis
severe hepatocyte injury

Question 26

general principles of treatment

Answer 26

the goal of treatment is sustained virological response (SVR)
refer patients with end-stage liver disease for liver transplant evaluation

Question 27

antiviral therapy

Answer 27

always treated with multidrug approach (no antivirals approved for monotherapy)
- direct acting antvirals: antivirals target and inhibit HCV encoded proteins that are essential for the HCV replication cycle
- interferon plus ribavirin was the preferred treatment before the development of DAAs

acute and chronic infections are treated the same

Question 28

are DAAs or interferon or ribavirin based therapies preferred

Answer 28

DAAs have superior efficacy and safety profiles

Question 29

supportive care

Answer 29

in all individuals with HCV:
- avoid hepatotoxic drugs and alcohol
- counsel about HIV and hep B prevention
- counsel regarding adherance, reinfection prevention, and medication risks
offer Hep A and B vaccination for Hep A and B seronegative individuals
give harm reduction strategies and refer for treatment for substance abuse for IVDU