History

Fact Explanation
Asymptomatic It is asymptomatic in many patients. [1,8]
Icterus [1] About 10—20% of patients with acute infection develop jaundice. [4,5]
Dark urine and clay coloured stools [6] Acute hepatitis C sometimes result in cholestasis, resulting dark urine and pale stools.
Symptoms of fulminant hepatic failure [1] This is very rare with acute hepatitis C. [1]
Low-grade fever [9] This is a non-specific feature.
Right upper quadrant pain [1,6,7] Due to hepatic congestion and inflammation.
Nausea, and or vomiting [1,6,7] These are non-specific symptoms.
Joint pain [8] Extra hepatic manifestations are relatively rare in acute hepatitis C.
Influenza-like illness [6] These are non-specific symptoms. Patients present with fever and respiratory symptoms.
History of blood transfusion [1,8] All the donated blood samples are screened for the presence of hepatitis C virus. But still there is a possibility of acquiring the infection with blood transfusion.
Use of contaminated medical equipment [2,8] Hepatitis C is spread by contact with infected blood.
Intravenous substance use [1,8] When the needles are shared among infected and non-infected persons there is risk of infection.
Unprotected sexual contact [1,8] The risk of hepatitis C transmission through sexual contacts is relatively low. However the risk increases with increased number of sexual partners. [8] Symptoms begin to appear 2—12 weeks after the exposure. [1]
Babies born to infected mothers. [1] HCV is vertically transmitted through the placenta, from an infected mother to fetus. In women with detectable viraemia the rate of vertical transmission is 4—7% per pregnancy. [2,3]
References
  1. ANURAG MAHESHWARI, STUART RAY, PAUL J THULUVATH. Acute hepatitis C. The Lancet, [online]26 July 2008 372, (9635), 321 - 332, [viewed 10 April 2014] Available from: doi:10.1016/S0140-6736(08)61116-2
  2. MAST EE, HWANG LY, SETO DS, et al. Risk factors for perinatal transmission of hepatitis C virus (HCV) and the natural history of HCV infection acquired in infancy. J Infect Dis [online]2005; 192: 1880-1889. [viewed 10 April 2014] Available from: doi: 10.1086/497701
  3. European Paediatric Hepatitis C Virus Network. A significant sex—but not elective cesarean section—effect on mother-to-child transmission of hepatitis C virus infection. J Infect Dis [online] 2005: 192 (11): 1872-1879. [viewed 10 April 2014] Available from: doi: 10.1086/497695
  4. ALTER MJ, MARGOLIS HS, KRAWCZYNSKI K, et al. The natural history of community-acquired hepatitis C in the United States. The Sentinel Counties Chronic non-A, non-B Hepatitis Study Team. N Engl J Med [online] 1992; 327: 1899-1905. [viewed 10 April 2014] Available from: DOI: 10.1056/NEJM199212313272702
  5. MOORE A, HERRERA G, NYAMONGO J, et al. Estimated risk of HIV transmission by blood transfusion in Kenya. Lancet [online] 2001; 358: 657-660. [viewed 10 April 2014] Available from: doi:10.1016/S0140-6736(01)05783-X
  6. GERLACH JT, DIEPOLDER HM, ZACHOVAL R, et al. Acute hepatitis C: high rate of both spontaneous and treatment-induced viral clearance. Gastroenterology [online] 2003; 125: 80-88. [viewed 10 April 2014] Available from: doi:10.1016/S0016-5085(03)00668-1
  7. WIEGAND J, BUGGISCH P, BOECHER W, et al. German HEP-NET Acute HCV Study Group. Early monotherapy with pegylated interferon alpha-2b for acute hepatitis C infection: the HEP-NET acute-HCV-II study. Hepatology [online] 2006; 43: 250-256. [viewed 10 April 2014] Available from: DOI: 10.1002/hep.21043
  8. Hepatitis C Information for the Public. [online][viewed 10 April 2014] Available from: http://www.cdc.gov/hepatitis/c/cfaq.htm
  9. RAYMOND T. C. Acute Hepatitis C Virus Infection. Clin Infect Dis. [online] 2005 41(1): S14-S17. [viewed 10 April 2014] Available from: doi: 10.1086/429490

Examination

Fact Explanation
Fever [1] Release of pyrogen causes fever.
Icterus [1] Due to increased bilirubin levels.
Right upper quadrant tenderness [2,3] Due to inflammation and hepatic congestion.
Needle marks of intravenous drug abuse Intravenous drug users are at risk of acquiring hepatitis C. [2,4]
Tattoos [2] Provides clue to the diagnosis.
References
  1. RAYMOND T. C. Acute Hepatitis C Virus Infection. Clin Infect Dis. [online] 2005 41(1): S14-S17. [viewed 10 April 2014] Available from: doi: 10.1086/429490
  2. ANURAG MAHESHWARI, STUART RAY, PAUL J THULUVATH. Acute hepatitis C. The Lancet, [online]26 July 2008 372, (9635), 321 - 332, [viewed 10 April 2014] Available from: doi:10.1016/S0140-6736(08)61116-2
  3. GERLACH JT, DIEPOLDER HM, ZACHOVAL R, et al. Acute hepatitis C: high rate of both spontaneous and treatment-induced viral clearance. Gastroenterology [online] 2003; 125: 80-88. [viewed 10 April 2014] Available from: doi:10.1016/S0016-5085(03)00668-1
  4. Hepatitis C Information for the Public. [online][viewed 10 April 2014] Available from: http://www.cdc.gov/hepatitis/c/cfaq.htm

Differential Diagnoses

Fact Explanation
Acute exacerbation of chronic HCV infection [1] Chronic hepatitis C can have acute exacerbations even after complete clearance of hepatitis C RNA. [3]
Alcoholic hepatitis [1] Causes symptoms and signs of liver dysfunction. Liver transaminases are elevated in both conditions. Positive hepatitis C serological tests and history of harmful alcohol use will help to differentiate the two.
Drug-induced liver dysfunction [1] Acetaminophen overdose [4], valproate overdose are common causes. [5]
Viral influenza [2] Low grade fever and respiratory symptoms can occur in both conditions.
Hepatitis A Transmitted feco-orally. Patients develop jaundice and fever with many extra-hepatic manifestations. [6]
Hepatitis B,D and E Serology will help to establish the definitive diagnosis.
Hemochromatosis Results due to chronic iron overload. [7]
Autoimmune Hepatitis Common in females and other features of autoimmune diseases may present. Diagnosis is often favored by exclusion of other possible etiologies and by demonstrating the presence of autoantibodies. [8,9] The definitive diagnosis is made according to the diagnostic criteria of the International Autoimmune Hepatitis Group. [6]
Wilson Disease Presence of neurological manifestations (Chorea, parkinsonism), Kayser-Fleischer rings, low serum caeruloplasmin, and increased 24 hour urinary copper excretion will help in diagnosis. [10]
References
  1. ANURAG MAHESHWARI, STUART RAY, PAUL J THULUVATH. Acute hepatitis C. The Lancet, [online]26 July 2008 372, (9635), 321 - 332, [viewed 10 April 2014] Available from: doi:10.1016/S0140-6736(08)61116-2
  2. GERLACH JT, DIEPOLDER HM, ZACHOVAL R, et al. Acute hepatitis C: high rate of both spontaneous and treatment-induced viral clearance. Gastroenterology [online] 2003; 125: 80-88. [viewed 10 April 2014] Available from: doi:10.1016/S0016-5085(03)00668-1
  3. MAHALE P, KONTOYIANNIS DP, CHEMALY RF, JIANG Y, HWANG JP, DAVILA M, TORRES HA. Acute exacerbation and reactivation of chronic hepatitis C virus infection in cancer patients. J Hepatol. [online] 2012 Dec;57(6):1177-85. [viewed 10 April 2014] Available from: doi: 10.1016/j.jhep.2012.07.031
  4. POLSON J, LEE WM. AASLD position paper: the management of acute liver failure. Hepatology [online] 2005;41:1179-1197. [viewed 4 April 2014] Available from:DOI: 10.1002/hep.20703
  5. VICTOR J. N, JOHN R. S., Drug-Related Hepatotoxicity. N Engl J Med [online] 2006; 354:731-739. [viewed 4 April 2014] Available from:DOI: 10.1056/NEJMra052270
  6. NAGA C. NORMAN G. ACUTE HEPATITIS A: WHAT'S NEW WITH IT? American Journal of Gastroenterology [online] (1998) 93, 2305–2306; [viewed 4 April 2014] Available from:doi:10.1111/j.1572-0241.1998.02305.x
  7. ANTONELLO P. Hereditary Hemochromatosis: Pathogenesis, Diagnosis, and Treatment. Gastroenterology. [online]August 2010 139(2): 393-408. [viewed 4 April 2014] Available from:doi:10.1053/j.gastro.2010.06.013
  8. ALBERT J. C. Autoimmune Hepatitis – Approach to Diagnosis. MedGenMed. [online] 2006; 8(2): 55. [viewed 4 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1785222/#!po=8.82353
  9. CZAJA AJ, FREESE DK. Diagnosis and treatment of autoimmune hepatitis. Hepatology. [online] 2002;36:479–497. [viewed 4 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12143059
  10. GOWA P J, SMALLWOODA R A, ANGUSA P W, SMITHB A L, WALLC A J, SEWELLA R B. Diagnosis of Wilson's disease: an experience over three decades. Gut [online] 2000;46:415-419 [viewed 4 April 2014] Available from: doi:10.1136/gut.46.3.415

Investigations - for Diagnosis

Fact Explanation
Alanine aminotransferase (ALT) [1] Increased due to damage to hepatocytes. This is not very high and usually less than 10 times the upper limit of normal. [1]
Total bilirubin [1] It may or may not be increased. [1]
Hepatitis C virus (HCV) RNA [1] If the patient has a history of exposure to HCV within 2–12 weeks positive HCV RNA can diagnose HCV infection. [1] This is more sensitive in diagnosis. [4]
Anti-HCV antibodies [1] May not be positive in the initial stages of the illness [1] because the sero-conversion takes some time to develop. [1,2] The anti-HCV IgM cannot be used in the differentiation of acute and chronic infection because it remains in a same range in both conditions. [3] So the diagnosis of acute hepatitis C is made with the new detection of anti-HCV antibodies in a patient who did not have HCV-RNA previously. [1]
References
  1. RAYMOND T. C. Acute Hepatitis C Virus Infection. Clin Infect Dis. [online] 2005 41(1): S14-S17. [viewed 10 April 2014] Available from: doi: 10.1086/429490
  2. FARCI P, ALTER HJ, WONG D, et al. A long-term study of hepatitis C virus replication in non-A, non-B hepatitis. N Engl J Med [online] 1991; 325: 98-104. [viewed 10 April 2014] Available from: DOI: 10.1056/NEJM199107113250205
  3. QUIROGA JA, CAMPILLO ML, CATILLO I, et al. IgM antibody to hepatitis C virus in acute and chronic hepatitis C. Hepatology [online] 1991; 14: 38-43. [viewed 10 April 2014] Available from: DOI: 10.1002/hep.1840140107
  4. ANURAG MAHESHWARI, STUART RAY, PAUL J THULUVATH. Acute hepatitis C. The Lancet, [online]26 July 2008 372, (9635), 321 - 332, [viewed 10 April 2014] Available from: doi:10.1016/S0140-6736(08)61116-2

Investigations - Followup

Fact Explanation
None There are factors associated with spontaneous clearance of HCV. Favorable factors include age less than 40 years, female sex, and symptomatic illness. [1]
Liver transaminases Liver transaminases are elevated in chronic hepatitis. [2,4]
Anti-HCV antibodies Low levels of anti-HCV antibodies indicate that the spontaneous viral clearance is most likely. [3]
Alpha feto protein Hepatocellular carcinoma is a recognized complication of chronic hepatitis C. [4]
Ultrasound scan of the abdomen Provides evidence of hepatocellular carcinoma. [4]
Hepatitis C virus RNA Persistent viremia beyond 6 months is most likely to progress in to chronic hepatitis. [4]
References
  1. GERLACH JT, DIEPOLDER HM, ZACHOVAL R, et al. Acute hepatitis C: high rate of both spontaneous and treatment-induced viral clearance. Gastroenterology [online] 2003;125 (1):80-8. [viewed 10 April 2014] Available from: doi:10.1016/S0016-5085(03)00668-1
  2. ALTER MJ, MARGOLIS HS, KRAWCZYNSKI K, et al. The natural history of community-acquired hepatitis C in the United States. The Sentinel Counties Chronic non-A, non-B Hepatitis Study Team. N Engl J Med [online] 1992; 327: 1899-1905. [viewed 10 April 2014] Available from: DOI: 10.1056/NEJM199212313272702
  3. LIA L. L. X.,GEORG M. L., JULIAN S. W., PAULO S. F. S., CLEBER F. G., et al. Prospective Follow-Up of Patients with Acute Hepatitis C Virus Infection in Brazil. Clin Infect Dis. [online] 2010: 50 (9):1222-1230. [viewed 10 April 2014] Available from: doi: 10.1086/651599
  4. KAMAL SM. Acute hepatitis C: a systematic review. Am J Gastroenterol [online] 2008;103:1283-1297. [viewed 10 April 2014] Available from: doi:10.1111/j.1572-0241.2008.01825.x
  5. Thomas DL, Seeff LB. Natural history of hepatitis C. Clin Liver Dis [online] 2005;9:383-398. [viewed 10 April 2014] Available from: http://www.sciencedirect.com/science/article/pii/S1089326105000358

Management - General Measures

Fact Explanation
Antipyretics Fever can be managed with antipyretics.
Health education of people at risk Health care workers should be educated about the personal protection equipment and should be encouraged to adhere to standard precautions when handling body fluids. [1]
Health education of patients Education of patients about the importance of regular follow up for early detection of chronic hepatitis and hepatocellular carcinoma. [1]
References
  1. Guidelines for the screening, care and treatment of persons with hepatitis C infection, WHO [online] [viewed 10 April 2014] Available from:http://www.who.int/hiv/pub/hepatitis/hepatitis-c-guidelines/en/

Management - Specific Treatments

Fact Explanation
Conservative Up to about one third of patients will clear the virus and develop immunity against HCV. [1,5]
Pegylated interferon [3] This is used as the first line therapy. [2] Both interferon alpha and beta can be used. [1,4]
Ribavirin Although not widely used combination of ribavirin and interferon or ribavirin monotherapy are equally effective. [3] Combination therapy is used frequently in patients with poor response to initial treatment. [1]
Telaprevir or boceprevir These are antiviral drugs and can be used alone or in combination with interferon. [6]
Sofosbuvir [6] Sofosbuvir can be given in combination with ribavirin with or without pegylated interferon. [6]
References
  1. ANURAG MAHESHWARI, STUART RAY, PAUL J THULUVATH. Acute hepatitis C. The Lancet, [online]26 July 2008 372, (9635), 321 - 332, [viewed 10 April 2014] Available from: doi:10.1016/S0140-6736(08)61116-2
  2. Takano S, Satomura Y, Omata M. Effects of interferon beta on non-A, non-B acute hepatitis: a prospective, randomized, controlled-dose study. Japan Acute Hepatitis Cooperative Study Group. Gastroenterology [online]1994; 107: 805-811. [viewed 10 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8076768
  3. KAMAL SM, ISMAIL A, GRAHAM CS, et al. Pegylated interferon alpha therapy in acute hepatitis C: relation to hepatitis C virus-specific T cell response kinetics. Hepatology [online] 2004; 39: 1721-1731. [viewed 10 April 2014] Available from: DOI: 10.1002/hep.20266
  4. SANTANTONIO T, FASANO M, SINISI E, et al. Efficacy of a 24-week course of PEG-interferon alpha-2b monotherapy in patients with acute hepatitis C after failure of spontaneous clearance. J Hepatol [online] 2005; 42: 329-333. [viewed 10 April 2014] Available from: doi:10.1016/j.jhep.2004.11.021
  5. KAMAL SM. Acute hepatitis C: a systematic review. Am J Gastroenterol [online] 2008;103:1283-1297. [viewed 10 April 2014] Available from: doi:10.1111/j.1572-0241.2008.01825.x
  6. Guidelines for the screening, care and treatment of persons with hepatitis C infection, WHO [online] [viewed 10 April 2014] Available from: http://www.who.int/hiv/pub/hepatitis/hepatitis-c-guidelines/en/