Hepatitis C presentation

Hepatitis C presentation

1. Dr. BASHEER ELTAYEB
HCV
MEDICAL COMMISION
DEPARTMENT- CPD

2. Topics
•Background Hepatitis
•Transmission
•Standard Precautions
•Testing
•Natural History
•Symptoms
•Treatment
•Disclosure / Discrimination

3. Definition
•The hepatitis C virus is a small,
enveloped, single-stranded, RNA virus.
•The half life of the virus particles in the
serum is around 3 hours and may be as
short as 45 minuts . In an infected person,
about 10
12
virus particles are produced
each day. In addition to replicating in the
liver the virus can multiply in lymphocytes.

4. Background
•WHO estimates about 3% of the
world’s population has been infected
with HCV.
•More than 170 million chronic carriers
who are at risk of developing liver
cirrhosis and/or liver ca.

5. •The prevalence of HCV infection
varies throughout the world.
•Egypt had the highest number of
reported infections, largely attributed
to the use of contaminated parenteral
antischistosomal therapy, with a
mean prevalence of 22%.
Background

6. •In USA, the incidence of acute HCV
infection has sharply decreased. Its
prevalence remains high (2.7 million)
•chronic hepatitis C infection develops
in approximately 75% of patients after
acute infection.
Background

8. In Qatar
•In 2010 at HMC a total of 13,704 people were screened
272 (two percent) were found with hepatitis C antibodies.
• nine were found to have minimal disease, and 60
people underwent liver biopsy.
•68 people were given treatment for hepatitis C and 45
responded to the treatment.
•In Qatar,anti-hepatitis C viral antibodies among blood
donors 0.06 percent.
•In Bahrain this figure is 0.30 percent.
• in the UAE it is 0.11 percent.
• in Saudi Arabia is 0.65 percent and .
•in Kuwait 3.1 percent.

9. Genotypes
•There are about 6 genotypes.
•The major HCV genotype worldwide
is
•genotype 1, which accounts for 40-
80% of all isolates.
•Genotype 1 also may be associated
with more severe liver disease and a
higher risk of HCC.

10. •Genotype 4 it is most prevalent in the
Middle East and Africa
•Within a region, a specific genotype
may also be associated with a
specific mode of transmission, such
as genotype 3 among persons in
Scotland who abuse intravenous
drugs.
Genotypes

11. Transmission
•Transfusion of blood was once an
important source of transmission.
•Since 1990, however, the screening
of donated blood for HCV antibody
has decreased the risk of transfusion-
associated HCV infection to less than
1 case in 103,000 transfused units.

13. •Persons who inject illegal drugs with
nonsterile needles or who snort
cocaine with shared straws are at
highest risk for HCV infection.
• In developed countries, most new
HCV infections are related to
intravenous drug abuse (IVDA).
Transmission

14. •Transmission of HCV to health care
workers may occur via needle-stick
injuries or other occupational
exposures.
•Nosocomial patient-to-patient may
occur by colonoscope, dialysis, during
surgery, including organ
transplantation before 1992.
Transmission

15. •tattooing, sharing razors, and
acupuncture.
•high-risk sexual activity and maternal-
fetal transmission.

•Coinfection with human
immunodeficiency virus (HIV) type 1
appears to increase the risk of both
sexual and maternal-fetal
transmission of HCV
Transmission

16. Race-, sex-, and age-related
differences in incidence
•HCV is more common among black and
Hispanic, in association with lower
economic status and educational levels.
•In addition, in the US, genotype 1 is more
prevalent in blacks than in other racial
groups.
•No sex preponderance occurs with HCV
infection.

17. CLINICAL MANIFESTATIONS
• Acute hepatitis typically develops 2
to 26 weeks after exposure to
hepatitis C virus with a mean onset of
7 to 8 weeks .
•In patients who experience
symptoms, the acute illness usually
lasts for 2 to 12 weeks.

18. Physical Examination
•Most patients do not have findings until
they develop portal hypertension or
decompensated liver disease.
• One exception is patients with
extrahepatic manifestations of HCV
infection, such as porphyria cutanea
tarda or necrotizing vasculitis.

19. • Signs include the following:
•Palmar erythema, Dupuytren
contracture,
asterixis,leukonychia,clubbing
•Icteric sclera, temporal muscle
wasting, enlarged parotid,cyanosis
•Fetor hepaticus ,Gynecomastia, small
testes .
Physical Examination

20. •Paraumbilical hernia - ascites, caput
medusae, hepatosplenomegaly,
abdominal bruit
•Ankle edema
•Scant body hair
•Spider nevi, petechiae, excoriations
due to pruritus
Physical Examination

21. Who Should be Screened?
•Ever injected illegal drugs
•Received clotting factors made before 1987
•Received blood/organs before July 1992
•Ever on chronic hemodialysis
•Evidence of liver disease
•HIV-positive
•Healthcare and emergency personnel after exposure
•Children born to HCV-positive women
Based on increased risk for infection
Based on need for exposure management

22. screening
•For a patient presenting following a known
exposure to HCV, we obtain the following
tests:
•●Immediately/baseline: Anti-HCV
antibody, HCV RNA, and serum
aminotransferases
•●Four weeks after exposure: HCV RNA
and serum aminotransferases.

23. •●Three months after exposure: Anti-
HCV antibody, HCV RNA, and serum
aminotransferases
•●Six months after exposure: Anti-
HCV antibody.
screening

24. Approach Considerations
•screening for hepatitis C virus (HCV)
involves an enzyme immunoassay
(EIA). These assays are 97% specific
but cannot distinguish acute from
chronic infection.
• Health care personnel who sustain a
needle-stick injury should undergo
(PCR) immediately and then every 2
months for 6 months.

25. •HCV genotyping as an aid for guiding
treatment
•Quantitative HCV RNA assay
•Screening tests for coinfection with
HIV or hepatitis B virus (HBV)
•Screening for alcohol abuse, drug
abuse, and/or depression
Approach Considerations

26. Hepatitis C Antibody Test
•False-negative results for the presence of
HCV antibody can occur in persons with
compromised immune systems, such as
those with HIV type 1 infection, renal
failure, or HCV-associated essential mixed
cryoglobulinemia.
•False-positive EIA results can occur; the
likelihood of a false-positive result is
greater in persons without risk factors.

27. Recombinant Immunoblot Assay
•The recombinant immunoblot assay is
used to confirm HCV infection. A positive
immunoblot assay result is defined as the
detection of antibodies against 2 or more
antigens and an indeterminate assay
result defined as the detection of
antibodies against a single antigen.

28. Recombinant Immunoblot Assay
•A positive immunoblot assay result
followed by 2 or more instances of
undetectable HCV RNA suggests
HCV infection has resolved. A
positive anti-HCV immunoassay
result followed by a negative
immunoblot assay result represents a
false-positive immunoassay, and no
further testing is required.

29. Qualitative and Quantitative Assays for HCV RNA
•Qualitative assays can be used to test for
HCV RNA. such as PCR or transcription-
mediated amplification (TMA).
Quantitative assays ascertain HCV RNA
quantity in blood, using signal
amplification (branched DNA [bDNA]
assay) or target amplification techniques
(PCR, TMA). Reverse transcriptase PCR
(RT-PCR) is more sensitive than bDNA
testing.

30. Liver Biopsy
•some experts recommend biopsy only in the
following situations:
•The diagnosis is uncertain
•Other coinfections or disease may be
present .
•The patient being considered for treatment
has normal liver enzyme levels and no
extrahepatic manifestations .
•The patient is immunocompromised.

31. Radiologic Studies
•A liver stiffness test (FibroScan) is
available as a noninvasive
method of staging liver disease in
persons with chronic hepatitis C.
Obesity, female sex, operator
experience, and age older than 52
may give invalid results.

32. Standard Precautions
•Hand Hygiene
•Use of Personal Protective
Equipment (PPE’s)
•Waste Management ,care with
sharps.
•Reprocessing of Equipment
•Environmental Controls
Routine preoperative testing of
patients is not recommended

33. Treatment
•Patients with acute hepatitis C virus (HCV)
infection appear to have an excellent
chance of responding to 6 months of
standard therapy with interferon (IFN).
• the highest priority for treatment
Patients with advanced fibrosis, those with
compensated cirrhosis, liver transplant
recipients, and those with severe
extraheptic hepatitis.

34. •Treatment decisions should balance the
anticipated reduction in transmission
versus the likelihood of reinfection in
patients whose risk of HCV transmission is
high and in whom HCV treatment may
result in a reduction in transmission (eg,
men who have high-risk sex with men,
active injection drug users, incarcerated
persons, and those on hemodialysis)
Treatment

35. •Treatment of chronic HCV infection
has 2 goals.
The first is to achieve sustained
eradication of HCV.
The second goal is to prevent
progression to cirrhosis,
hepatocellular carcinoma (HCC), and
decompensated liver disease
requiring liver transplantation.
Treatment

36. •Antiviral therapy for chronic hepatitis
C should be determined on a case-
by-case basis. However, treatment is
widely recommended for patients with
elevated serum alanine
aminotransferase (ALT) levels who
meet the following criteria

:
Treatment

37. •Age greater than 18 years
•Positive HCV antibody and serum HCV
RNA test results
•Compensated liver disease (eg, no
hepatic encephalopathy or ascites) .
•No contraindications for treatment .

Treatment

38. •Acceptable hematologic and
biochemical indices (hemoglobin at
least 13 g/dL for men and 12 g/dL for
women; neutrophil count >1500/mm
3
,
serum creatinine < 1.5 mg/dL)
•Willingness to be treated and to
adhere to treatment requirements .
Treatment