Acute Hepatitis C: The Lancet

Acute Hepatitis C

Anurag Maheshwari, Stuart Ray, PJ Thuluvath Dept of Gastroenterology and Hepatology JOHNS HOPKINS University

The Lancet, Review article, jul 26, 2008

Introduction 

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Symptomatic acute Hepatitis C is uncommon15% of infected RNA virus, hypervariable envelope protein Transmission- parenteral, BT (1 in 2.3 M), injection drug abuse, tattoos, HD, rarely sexually and perinatally Prevalance- 3% (WHO), Egypt- 20%, India1.8% Cure- clearance of virus, spontaneous or by T/t

Epidemiology 

Incidence declining since 1990s

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Needle stick injury- 1.8%, perinatal- 4-7%

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Elective caesarean- coinfection with HIV

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Higher prevalance in HIV patients, high risk sexual behavior

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In India only 6% blood donors screened for HCV RNA

Immunobilogy 

Seroconversion- 6-8weeks in healthy patients; upto 12 weeks in immunocompromised

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Patients with jaundice- higher rates of virus clearance

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Anti-HCV may become undetectable after recovery

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Anti-HCV- no immunity against reinfection

Clinical features    

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Asymptomatic in most (80%) Incubation period- 7 weeks (2-12 weeks) Jaundice – 10-20% Jaundice is preceded by prodrome- nausea, vomitting, fatigue, arthralgia, low grade fever, right upper quadrant pain Extrahepatic manifestations- not seen in acute hepatitis C

Natural history 

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Only 15 % patients are symptomatic, 85-90% remain asymptomatic In most studies 80% patients have persistent viremia- chronic hepatitis C High rates of clearance- jaundice, female sex, low viral loads, decrease viral load in 4 weeks Fulminant hepatitis is hardly ever seen

Diagnosis 

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Circumstantial evidence alongwith anti-HCV are sufficient; but not reliable to exclude diagnosis Rarely antibodies do not occur and spontaneous clearance occurs Anti-HCV IgM does not indicate acute infection, levels remain elevated in chronic infection also HCV RNA is more sensitive (PCR better than bDNA assays) TMA assays- 5IU/ml

Diagnosis 

Post exposure- Anti-HCV and ALT at baseline, HCV RNA at 4-6weeks (CDC)

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JHU- anti-HCV at 3 mths and 6 mths HCV RNA at 4 weeks and 3 mths

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ALT- upto 10 times upper limit

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Bilirubinemia- both fractions equally raised

Treatment 

Undetectable HCV RNA 6 mths after end of treatment indicates cure

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All studies so far have shown that treat is beneficial and cost effective

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Initiation- 12 weeks after first symptoms; in asymptomatic patients earlier treatment

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Duration- daily pegylated interferon alfa 3MU for 4 weeks

Treatment 

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Many authoritis opt for longer 12-24 week regimes In a Japanese study higher doses of interferon 5-6MU daily for 24 weeks showed 100% SVR Ribavarin is well tolerated and increase rates of clearance in those infected with genotype 1 or coinfected with HIV- evidence lacking

Summary 

Acute Hepatitis C under diagnosed

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Anti HCV unreliable, HCV RNA should be used

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Symptomatic patients more likely to be cured

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Antiviral therapy should be delayed

Dr. Sandeep Shelke Medicine resident