Viral Hepatitis (C)

Question 1

Definition

Answer 1

• Hepatitis caused by infection with hepatitis C virus (HCV), often following a chronic
course (in 80% of cases)

Question 2

Aetiology

Answer 2

• HCV is a small, enveloped, single-stranded RNA virus
• RNA viruses have poor fidelity of replication and mutation rates are high
• So, there are lots of HCV genotypes (which can co-exist in a single patient)

Question 3

Transmission

Answer 3

• Transmission: PARENTERAL

o Sexual transmission
o Vertical transmission

Question 4

Risk factors

Answer 4

At risk patients:

o Recipients of blood and blood products
o IV drug users
o Non-sterile acupuncture 
o Tattooing
o Haemodialysis
o Health care workers

Question 5

Pathogenesis

Answer 5

o The virus is not thought to be directly hepatotoxic
o It is the humoral and cell-mediated responses to the viral infection that leads to
hepatic inflammation and necrosis

o Liver biopsy shows:
• Chronic hepatitis
• Lymphoid follicles in portal tracts
• Fatty change
• Cirrhosis may be present

Question 6

Epidemiology

Answer 6

• COMMON

* Different genotypes of HCV have different geographical prevalence

Question 7

Presenting symptoms

Answer 7

• 90% of acute infections are ASYMPTOMATIC
• 10% become jaundiced with mild flu-like illness
• May be diagnosed after incidental abnormal LFT

Question 8

Signs on physical examination

Answer 8

• May be NO SIGNS
• There may be signs of chronic liver disease (if long-standing HCV infection)

• Extra-hepatic manifestations (rare) include:
o Skin rash
o Renal dysfunction (due to glomerulonephritis)

Question 9

Investigations (bloods)

Answer 9

• Bloods

o HCV Serology
• Anti-HCV antibodies - IgM (acute) or IgG (past exposure or chronic)

o Reverse-transcriptase PCR
• Allows detection and genotyping of HCV

o LFT
• Acute infection: High ALT, AST and bilirubin
• Chronic infection: 2-8 x elevation of AST + ALT (often fluctuates over time)

Question 10

Investigations (biopsy)

Answer 10

• Liver Biopsy

o Assess the degree of inflammation and liver damage
o NOTE: transaminase (AST and ALT) levels bear little correlation to histological changes
o Useful for diagnosing cirrhosis

Question 11

Management plan (prevention)

Answer 11

o Screen blood, blood products and organ donors
o Needle exchange schemes for IV drug users
o Instrument sterilisation

o NO VACCINE AVAILABLE

Question 12

Management plan (medical)

Answer 12

o Acute - mainly supportive (antipyretics, antiemetics, cholestyramine)

o Chronic
• Pegylated interferon-
• Ribavirin (guanosine nucleotide analogue)
• Duration:
▪ HCV Genotype 1 or 4: 24-48 weeks
▪ HCV Genotype 2 or 3: 12-24 weeks

o Regular US of the liver may be needed if the patient has cirrhosis

Question 13

Possible complications

Answer 13

• Fulminant hepatic failure
• Chronic carriage of HCV
• Hepatocellular carcinoma
• Less common: porphyria cutanea tarda, cryoglobulinaemia, glomerulonephritis

Question 14

Prognosis

Answer 14

• 80% of exposed will progress to chronic carriage

* Of these, 20-30% will develop cirrhosis over 10-20 years