Review Question - QID 104826

This patient present with chronic HCV. The indications for initiating treatment for HCV include: age > 18, detectable level of serum HCV RNA, well-compensated liver disease, and biopsy-proven chronic hepatitis with fibrosis.

HCV is an enveloped, single-stranded, positive-sense RNA virus which affects the liver and can cause cirrhosis, liver failure, and liver cancer in severe cases. It is usually transmitted through intravenous drug use, sexual practices, and in rare cases blood transfusions (Illustration A). Up to 50-80% of patients infected with HCV will progress to chronic infection requiring treatment. Treatment indications include age > 18, detectable level of serum HCV RNA, well-compensated liver disease, and biopsy-proven chronic hepatitis with fibrosis. Typical treatment in the past was usually pegylated interferon alpha and ribavirin for 24 or 48 weeks. However, recently oral regimens including HCV NS5B polymerase inhibitor sofosbuvir and the protease inhibitor simeprevir have become FDA approved and have to emerged as an important component of recommended regimens.

Wilkins et al. review the diagnosis and management of HCV. They state that HCV is a common chronic bloodborne infection and is found in approximately 2 percent of adults in the United States. Chronic infection is associated with serious morbidity and mortality (ex: cirrhosis, hepatocellular carcinoma). Current therapy for chronic HCV includes pegylated interferon and ribavirin. Therapy is based on factors that predict sustained virologic response, and the goal of therapy is to slow or halt progression of fibrosis and prevent the development of cirrhosis.

Johnston reviews the interpretation and significance of liver enzyme testing. He states they can be normal in patients with chronic hepatitis or cirrhosis. The normal range for aminotransferase levels is slightly higher in males, nonwhites and obese persons. Severe alcoholic hepatitis is sometimes confused with cholecystitis or cholangitis. Conversely, patients who present soon after passing common bile duct stones can be misdiagnosed with acute hepatitis because aminotransferase levels often rise immediately, but alkaline phosphatase and gamma-glutamyltransferase levels do not become elevated for several days.

Figure A demonstrates a normal liver biopsy. Note that biopsy-proven cirrhosis, which is not seen in this case, is an indication for HCV treatment. Illustration A demonstrates the risk factors for HCV. Illustration B and C demonstrate typical stigmata of liver disease including scleral icterus and ascites, respectively. Illustration D is a liver biopsy demonstrating cirrhosis which would be an indication for HCV treatment.

Incorrect answers:
Answer 1: This patient's liver biopsy findings are normal and are not an indication for treatment. Biopsy-proven chronic hepatitis with fibrosis is an indication for HCV treatment.
Answer 3: This patient's age > 18 is an indication for treatment and should be included as a correct choice. Furthermore, this patient's liver biopsy findings are normal and are not an indication for treatment. Biopsy-proven chronic hepatitis with fibrosis is an indication for HCV treatment.
Answer 4: This patient's compensated liver disease is an indication for treatment and should be included as one of the correct choices.
Answer 5: This patient's age > 18 and detectable serum HCV RNA are indications for treatment and should be included as correct choices. Furthermore, this patient's liver biopsy findings are normal and are not an indication for treatment. Biopsy-proven chronic hepatitis with fibrosis is an indication for HCV treatment.