Updated: 1/13/2019

Hepatitis C Virus

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Snapshot
  • A 35-year-old man presents to his primary care physician for worsening abdominal pain and "yellowing" of the skin. He reports that his symptoms began a few weeks ago and is associated with pale stools and dark urine. He denies any sick contacts and cannot identify a likely cause of his symptoms. He endorses to using opiates use via injection and is sexually active with multiple men and inconsistently using condoms. On physical exam, scleral icterus is appreciated in an uncomfortable appearing man. Abdominal exam is notable for tenderness to palpation in the right upper quadrant with mild hepatomegaly. Laboratory testing is notable for elevated aspartate and alanine aminotransferases and HCV RNA and anti-HCV antibody levels.
Introduction
  • Classification
    • Hepacivirus virus from the Flaviviridae family
      • a linear, positive-sense single-stranded RNA with an icosahedral capsid
  • Epidemiology
    • risk factors
      • intravenous drug use
      • healthcare-related exposure (e.g., needlestick injuries and blood transfusions)
      • HIV infection
      • men who have sex with men
      • incarceration
  • Pathogenesis
    • not fully understood
    • HCV does not have a 3'-5' exonuclease activity
      • this impairs genomic proofreading, leading to the production of new mutant strains
  • Associated conditions
    • membranoproliferative and membranous nephropathy
    • hepatocellular carcinoma/hepatoma
    • essential mixed cryoglobulinemia 
    • B-cell non-Hodgkin lymphoma
    • leukocytoclastic vasculitis
    • autoimmune hemolytic anemia
    • sporadic porphyria cutanea tarda
    • lichen planus
    • autoimmune hypothyroidism
  • Prognosis
    • most cases result in chronic hepatitis C virus (HCV) infection
Presentation
  • Symptoms
    • typically asymptomatic
    • fatigue
    • myalgia
    • right upper quadrant abdominal pain
  • Physical exam
    • jaundice
    • dark urine
    • clay colored stools
Studies
  • Serologic studies
    • anti-HCV antibodies and HCV RNA
      • initial test when there is a concern for an acute HCV infection
    • elevated aminotransferase levels
Differential
  • Hepatitis A infection
    • differentiating factor
      • presence of anti-hepatitis A antibodies in serological testing
  • Hepatitis B infection
    • differentiating factor
      • presence of anti-hepatitis B antibodies in serological testing
Treatment
  • Medical
    • hepatitis C therapy
      • indication
        • first-line treatment for acute and chronic hepatitis C infection
      • medical regimens
        • viral phosphoprotein (NS5A) inhibitor ("-asvir")
          • e.g., ledipasvir
        • HCV RNA-dependent RNA polymerase (NS5B) inhibitor ("-buvir")
          • e.g., sofosbuvir 
        • guanine nucleotide synthesis inhibitor 
          • e.g., ribavirin
        • HCV protease (NS3/4A) inhibitor ("-previr")
          • e.g., simeprevir
Complications
  • Advanced hepatic fibrosis
  • Cirrhosis
  • Hepatic decompensation
  • Hepatocellular carcinoma
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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