Topic Resources
Hepatitis C is caused by an
RNA virus that is often parenterally transmitted. It sometimes causes
typical symptoms of viral hepatitis, including anorexia, malaise, and
jaundice but may be asymptomatic. Fulminant hepatitis and death rarely
occur. Chronic hepatitis develops in about 75% and can lead to cirrhosis
and rarely hepatocellular carcinoma. Diagnosis is by serologic testing.
Treatment is supportive. No vaccine is available.
In the US, almost 3000 cases of acute hepatitis C infection were
reported in 2016. However, because many cases are not recognized or not
reported, the Centers for Disease Control and Prevention (CDC) estimates
that the actual number of new infections was over 41,000 in 2016 (1).
Hepatitis C virus (HCV) is a single-stranded RNA flavivirus that causes acute viral hepatitis and is a common cause of chronic viral hepatitis.
Six major HCV subtypes exist with varying amino acid sequences
(genotypes); these subtypes vary geographically and in virulence and
response to therapy. HCV can also alter its amino acid pattern over time
in an infected person, producing quasispecies.
HCV infection sometimes occurs simultaneously with specific systemic disorders, including the following:
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Porphyria cutanea tarda (about 60 to 80% of porphyria patients have HCV infection, but only a few patients infected with HCV develop porphyria)
The mechanisms are uncertain.
Up to 20% of patients with alcoholic liver disease
harbor HCV. The reasons for this high association are unclear because
concomitant alcohol and drug use accounts for only a portion of cases.
In these patients, HCV and alcohol act synergistically to worsen liver
inflammation and fibrosis.
Transmission of hepatitis C
Infection is most commonly transmitted through blood, primarily
when parenteral drug users share needles, but also through tattoos or
body piercing.
Sexual transmission and vertical transmission of hepatitis C from mother to infant are relatively rare.
Transmission of hepatitis C through blood transfusion has become
very rare since the advent of screening tests for donated blood.
Some sporadic cases occur in patients without apparent risk factors.
HCV prevalence varies with geography and other risk factors.
General reference
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1. CDC: Hepatitis C Questions and Answers for Health Professionals. Accessed 9/4/19.
Symptoms and Signs
Hepatitis C may be asymptomatic during the acute infection. Its
severity often fluctuates, sometimes with recrudescent hepatitis and
roller-coaster aminotransferase levels for many years or even decades. Fulminant hepatitis is extremely rare.
HCV has the highest rate of chronicity (about 75%). The resultant chronic hepatitis C is usually asymptomatic or benign but progresses to cirrhosis in 20 to 30% of patients; cirrhosis often takes decades to appear. Hepatocellular carcinoma can result from HCV-induced cirrhosis but results only rarely from chronic infection without cirrhosis (unlike in hepatitis B).
Diagnosis
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Serologic testing
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HCV RNA measurement
In the initial diagnosis of acute hepatitis, viral hepatitis should be differentiated from other disorders causing jaundice (see figure Simplified diagnostic approach to possible acute viral hepatitis).
If acute viral hepatitis is suspected, the following tests are done to screen for hepatitis viruses A, B, and C:
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IgM antibody to hepatitis A virus (IgM anti-HAV)
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Hepatitis B surface antigen (HBsAg)
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IgM antibody to hepatitis B core (IgM anti-HBc)
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Antibody to HCV (anti-HCV) and HCV RNA
If the anti-HCV test is positive, HCV RNA is measured to distinguish active from past hepatitis C infection (see table Hepatitis C Serology).
In hepatitis C, serum anti-HCV represents chronic, past, or acute
infection; the antibody is not protective. When cases are unclear or
when suspicion for hepatitis C is high, HCV RNA is measured. Anti-HCV
usually appears within 2 weeks of acute infection but is sometimes
delayed; however, HCV RNA is positive sooner.
Other tests
Liver tests are needed if not previously done; they include serum
alanine aminotransferase (ALT), aspartate aminotransferase (AST),
alkaline phosphatase, and bilirubin.
Other tests should be done to evaluate liver function; they
include serum albumin, platelet count, and prothrombin
time/international normalized ratio (PT/INR).
Treatment
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Supportive care
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In certain situations, antiviral drugs
There are a number of new, highly effective direct-acting antiviral drugs
(DAAs) for hepatitis C that may decrease the likelihood of developing
chronic infection. However, the regimens are very expensive and have not
been studied as treatment for acute infection. Current recommendations
are to follow patients for 6 months to allow spontaneous HCV clearance
and then treat those who have persistent viremia (ie, chronic hepatitis C
[1]).
In certain situations, clinicians may decide that the benefits of
early antiviral treatment outweigh the recommendation to wait for HCV
clearance (1), as when the following are present:
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Prevention of HCV transmission is important (eg, for surgeons, IV drug users, or people with a high risk of sexually transmitting the infection).
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Risk of clinical consequences of acute HCV infection is high (eg, for patients with cirrhosis).
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Patients are likely to be lost to follow-up.
Alcohol should be avoided because it can increase liver damage.
Restrictions on diet or activity, including commonly prescribed bed
rest, have no scientific basis.
For cholestatic hepatitis, cholestyramine 8 g orally once or twice a day can relieve itching.
Viral hepatitis should be reported to the local or state health department.
Treatment reference
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1. American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA): HCV Guidance: Recommendations for testing, managing, and treating hepatitis C: Management of acute HCV infection. Accessed 9/4/19.
Prevention
Patients should be advised to avoid high-risk behavior (eg,
sharing needles to inject drugs, getting tattoos and body piercings).
Blood and other body fluids (eg, saliva, semen) are considered
infectious. Risk of infection after a single needlestick exposure is
about 1.8%. Barrier protection is recommended, but isolation of patients
is of no value in preventing acute hepatitis C.
Risk of transmission from HCV-infected medical personnel appears
to be low, and there are no CDC recommendations to restrict health care
workers with hepatitis C infection.
Posttransfusion infection is minimized by avoiding unnecessary
transfusions and screening all donors for hepatitis B and C. Screening
has decreased the incidence of posttransfusion hepatitis B and hepatitis
C, which are now extremely rare in the US.
No product exists for immunoprophylaxis of HCV. The propensity of HCV for changing its genome hampers vaccine development.
Key Points
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Hepatitis C is usually transmitted by parenteral contact with contaminated blood; transmission from mucosal contact with other body fluids and perinatal transmission from infected mothers are rare.
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About 75% of patients with acute hepatitis C develop chronic hepatitis C, which leads to cirrhosis in 20 to 30%; some patients with cirrhosis develop hepatocellular carcinoma.
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Diagnose by testing for antibody to HCV and HCV RNA.
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Treat supportively.
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There is no vaccine for hepatitis C.
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