Case study "Hepatitis C”

1. Patient History

 James Fisher, 55 years old, male, working as an artist. No surgery and recent
hospitalization history. Alcohol drinks consumed occasionally. Most of patient’s body is
covered with tattoos.
 Complaining on fever, abdominal pain, fatigue, nausea, vomiting, loss of appetite, and
joint pain.
 Upon admission the patient was icteric (jaundiced).
2. Diagnosis

 Chronic Hepatitis C Virus (HCV)

infection with early stage of cirrhosis
(scarring of the liver)
 Hepatitis C virus – virus that causes
hepatitis (an inflammation of the liver)
[1]
. The virus can cause both acute and
chronic hepatitis, ranging in severity
from a mild illness to a serious,
lifelong illness including liver
cirrhosis and cancer [5]
Possible causes of the hepatitis

 Viral hepatitis can be caused by Hepatitis A, B,C,D or E virus [5]

 Hepatitis is an occasional result of infections by other viruses such as Epstein-Barr virus
(EBV) or cytomegalovirus (CMV) [1[.
 Heavy alcohol use, toxins, some medications, and certain medical conditions can all cause
hepatitis [2].
Possible causes of the hepatitis

 If the cause of hepatitis is a bloodborne hepatitis C virus, then most infection occur
through exposure to blood from:
-unsafe injection practices
-tattoo or body piercing with unsterilized tool
-unsafe health care (infected razor, toothbrush),
-unscreened blood transfusions or organ transplants
-injection drug
-sexual practices that lead to exposure to blood [5].
 Signs and symptoms

 HCV infection is often not recognized until asymptomatic people are identified as HCV-positive when
screened for blood donation or when elevated alanine aminotransferase (ALT, a liver enzyme) levels
are detected during routine examinations [2].

 The first sign of chronic Hepatitis C might be from scarring of the liver, called cirrhosis, that
sometimes even happens in advanced stages of hepatitis [6].

 All the symptoms and signs the patient shows (fever, abdominal pain, fatigue, nausea, vomiting, loss
of appetite, joint pain and especially jaundice) coincide with the symptoms of a chronic Hepatitis C.

 Patients also can have foul breath, a bitter taste in the mouth, dark urine, clay-colored stool and
diarrhea [7] as other signs of Hepatitis C.
How a diagnosis is made

 In order to make a right diagnosis, first blood tests must be performed which can show
what type of viral hepatitis it is, how severe the infection is, if it is acute or chronic, and if
a patient is currently contagious.
 Types of tests utilized (1) 

 Hepatitis C testing can distinguish HCV from other causes of hepatitis, including hepatitis
A and hepatitis B
 Blood tests are used to detect HCV infection
1. Screening tests for antibody to HCV (anti-HCV) (at-home HCV test are available too)
2. Qualitative nucleic acid tests to detect presence HCV RNA
3. Quantitative nucleic acid tests to detect levels of HCV RNA [2].
4. Genotype test.
 Types of tests utilized (2)

Genotype test:
 There are at least six types of hepatitis C, which are also called strains or genotypes.
 In the United States, three out of seven possible genotypes are common: 1,2 and 3
 Treatment for hepatitis C depends on the strain [9].
 A person's hepatitis C genotype does not change over time [10].
  With the advent of hepatitis C therapies that are effective against many genotypes,
genotyping is no longer required prior to treatment initiation. However, pre-treatment
genotyping continues to be recommended for patients with evidence of cirrhosis [2].
 Types of tests utilized (3)

Tests for liver damage - typically one or more of the following tests are used to assess
liver damage in chronic hepatitis C.
 Magnetic resonance elastography (MRE). A noninvasive alternative to a liver biopsy
(see below). Stiff liver tissue indicates the presence of scarring of the liver (fibrosis) as a
result of chronic hepatitis C.
 Transient elastography. Another noninvasive test, is a type of ultrasound that estimates
liver’s stiffness.
 Liver biopsy.  involves inserting a thin needle through the abdominal wall to remove a
small sample of liver tissue for laboratory testing.
 Blood tests. A series of blood tests can indicate the extent of fibrosis in the liver [8].
 Patients may have associated lab tests of kidneys (creatinine level), blood counts
(hematocrit, hemoglobin), and testing for other infections [10].
 Results which determine the infectious agent (1)

 HCV Antibody determines whether or not a patient has

been exposed to the hepatitis C virus at some point in
their life.
 If this test is positive, the next step is to test for hepatitis
C RNA
 HCV RNA can tell you if you have a current infection.
(RNA is a type of genetic material from the hepatitis C
virus that can be detected in the blood.)

[4]
 Results which determine the infectious agent (2)

1. Qualitative HCV RNA tests can detect the presence

of HCV RNA
2. Quantitative HCV RNA tests measure the amount
of HCV RNA.
Understanding the amount of HCV in the blood
helps to monitor response to treatment [9].
 Our patient’s HCV Antibody test was reactive,
HCV RNA was detected and he was confirmed to
carry genotype 1 of HCV.
 Suspected cause of the patient’s infection by HCV
is tattoo with unsterilized tool.

[4]
 Stages of cirrhosis

 With the help of tests for liver damage a stage of cirrhosis can be identified
 There are 2 clinical stages of cirrhosis: compensated and decompensated
Compensated cirrhosis is the asymptomatic stage
• Compensated patients do not have ascites, variceal hemorrhage, hepatic encephalopathy, or
jaundice
• Median survival time of patients with compensated cirrhosis is > 12 years
Decompensated cirrhosis is the symptomatic stage
• Decompensated cirrhosis is characterized by the presence or development of overt
complications: ascites, jaundice, variceal hemorrhage, or hepatic encephalopathy
• Median survival time of patients with decompensated cirrhosis is approximately 2 years [18]
 Characteristics of the infectious agent (1)
 Identified in 1989 when the genome of the virus was cloned
 HCV is not related to any of the other known hepatitis viruses
[14]

 Classified in the Hepacivirus genus

 Belongs to the Flaviviridae, a large family of enveloped,
single-stranded RNA viruses [13]
 Viral elements: the envelope glycoproteins, a lipid membrane,
the nucleocapsid, and single positive-strand RNA genome [16]
 The HCV genome consists of approximately 9500 nucleotides
[14]

 Viral particle is approximately 55-65 nm in diameter [11]

Characteristics of the infectious agent (2)
 HCV RNA polymerase enzyme lacks ability to
proofread so cannot correct copying errors made
during viral replication which results in
nonfunctional genome
 However, others persist and account for the
tremendous genomic diversity that is characteristic of
HCV[14]
 the cell to cell spread of HCV
 high mutation rate
 Develops infectious lipoviral particles, which
facilitate HCV entry into hepatocytes and protect
from antibody neutralization [15]
 HCV life cycle and host-cell interaction
1. Binding – attaches to the surface receptors of
hepatocytes
2. Endocytosis
3. Fusion between the viral and host membranes
and uncoating of the capsid 
4. Translation resulting in single polyprotein that
is approximately 3,000 amino acids long
5. Proteolytic processing in ER - result is 10
mature HCV proteins, including structural and
nonstructural proteins.
6. RNA replication - supported by HCV
nonstructural proteins 
7. Assembly
8. Maturation in the Golgi apparatus
9. Release- transport to the cell surface and
release of the lipoviral particle.
 Immunology

 Host and viral factors play a role in host–viral interactions that could result in a spontaneous
resolution of the acute infection or a progression to a chronic HCV infection
 NK cells provide innate cellular immunity via the secretion of type II IFN and TNFα that inhibit
viral replication as well as secrete perforin and granzyme that destroy infected cells
 An adaptive cellular response to HCV infection is mainly mediated by CD8+ T cells that clear
the virus
 CD4+ T cells provide help to CD8+ T cell, APC, and B cells.
 A failure of cellular immunity correlates with an impaired control of HCV infection [15]
 Epidemiology
 The estimated number of annual acute HCV infections in the United States increased significantly
from 11,800 in 2010 to 57,500 in 2019.
 The recent increases in new HCV infections have primarily resulted from the ongoing opioid epidemic
and the associated injection drug use.
 Based on CDC estimates, 2.4 million persons are living with active HCV infection, corresponding to a
1.0% HCV prevalence among the adult population in the United States.
 From 2013 through 2019, the highest number and rates of new HCV infections have occurred in
persons 20 through 39 years of age.
 In 2019, the highest number of new HCV infections occurred among White persons, but the highest
rate was among American Indian/Alaska Native persons.
 The number of annual deaths attributed to HCV has declined significantly in recent years, falling from
19,613 in 2014 to 14,242 in 2019, with the majority of the deaths involving males [16]
Characteristics of the infectious agent that makes it
susceptible to the treatment

 Interferons - were the standard treatment for hepatitis C for many years, but can cause a
lot of side effects, and they’re not as effective for treating chronic HCV infection.
(Interferon is a protein that your body makes. It helps your immune system develop an
immune response to viruses)
 Direct-acting antivirals are more targeted than older treatments such as interferons
1. Protease inhibitors work by preventing the spread of infection within the body by stopping
viruses from multiplying.
2. Nucleotide/nucleoside and non-nucleoside polymerase inhibitors work by blocking a protein
called NS5B. The hepatitis C virus needs this protein to replicate itself and survive [17]
 3. Current Treatment Breakthrough
 Hepatitis C infection is treated with antiviral medications intended to clear the virus from the body
 Direct acting antivirals (DAAs) are beneficial and effective
 In 2019, the Food and Drug Administration (FDA) approved new antiviral drugs Glecaprevir and Pibrentasvir for an 8-week
treatment period for people with all genotypes of hepatitis C. 
For adults without Cirrhosis
Daily fixed-dose combination of Glecaprevir (300 mg) / Pibrentasvir (120 mg) to be taken with food for a duration of 8 weeks; or
Sofosbuvir (400 mg) / Velpatasvir (100 mg) for a duration of 12 weeks
For adults with Cirrhosis
1. Genotype 1-6:
Glecaprevir (300 mg) / Pibrentasvir (120 mg) to be taken with food for a duration of 8 weeks; or
Ledipasvir (90 mg)/sofosbuvir (400 mg) for a duration of 12 weeks
2. Genotype 1, 2, 4, 5, or 6
Sofosbuvir (400 mg) / Velpatasvir (100 mg) for a duration of 12 weeks [3]
 If the patient developed serious complications from chronic hepatitis C infection, liver transplantation may be an option
 Vaccines against the hepatitis A and B viruses are recommended to avoid complications of chronic hepatitis C in case of
contraction of hepatitis A or B
 Emerging treatments

 Ongoing research is being conducted that could lead to a vaccine that effectively prevents
hepatitis C. 
 A clinical trial is underway to study the safety and effectiveness of a DNA (deoxyribonucleic
acid) vaccine that may boost the immune system’s ability to clear the virus. 
 The goal of using a DNA vaccine would be to treat chronic hepatitis C in people who already
have the condition [17]
The goals of treatment for our patient

 Prevent and treat symptoms.

 Prevent and treat complications
 Slow further damage to the liver, prevent decompensation, and death
 Case study patient
 Confirmed case of Chronic Hepatitis C Virus (HCV) infection genotype 1(possibly
acquired through tattooing) with early stage of cirrhosis
 The diagnosis is made utilizing the following tests: anti-HCV, HCV RNA, Genotype
testing and Magnetic resonance elastography (MRE). 
 Prescribed - Antiviral treatment Sofosbuvir / Velpatasvir  for a duration of 12 weeks
 After the treatment further damage to the liver was minimized
 Life changes should be adopted by the patient
 In the future if the cirrhosis progresses to the advanced stage, liver transplantation will be
an option
 Lifestyle changes for a hepatitis C patient

 Stop drinking alcohol. Alcohol speeds the progression of liver disease

 Follow a healthy diet and stay physically active
 Avoid medications that may cause liver damage. 
 Help prevent others from coming in contact with patient’s blood
1. Cover any wounds and not share razors or toothbrushes.
2. No donation of blood, body organs or semen
3. Inform health care workers and sex partners about the virus
Likely prognosis or long term effects of the disease

 Of every 100 people infected with HCV,

approximately 5–25 will develop
cirrhosis within 10–20 years.
 Patients who develop cirrhosis have a
1%–4% annual risk of developing
hepatocellular carcinoma and a 3%–6%
annual risk of hepatic decompensation;
 for the latter patients, the risk of death in
the following year is 15%–20% [2]
 References (1)

1. https://plus.pearson.com/courses/carr94322/products/3DBBMOLFWWY/pages/a5430cf0d1cd1d88279e920249cf1b17ebad38045?loc
ale=&key=21395218861352588361082021&iesCode=p0xdqbkSq5
2. https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#c1
3. https://www.hcvguidelines.org
4. https://www.fda.gov/vaccines-blood-biologics/complete-list-donor-screening-assays-infectious-agents-and-hiv-diagnostic-assays#Ant
i-HCV%20Assays%20(detect%20antibodies%20to%20Hepatitis%20C%20Virus%20Encoded%20Antigen)

5. https://www.who.int/en/news-room/fact-sheets/detail/hepatitis-c
6. https://www.webmd.com/hepatitis/acute-vs-chronic-hepatitis-c
7. https://www.rchsd.org/health-articles/hepatitis-3/
8. https://www.mayoclinic.org/diseases-conditions/hepatitis-c/diagnosis-treatment/drc-20354284
9. https://labtestsonline.org/tests/hepatitis-c-testing
 References (2)

10. https://www.hepatitis.va.gov/hcv/patient/diagnosis/labtests-associated-tests.asp
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880646/
12. https://www.healthcentral.com/slideshow/ways-hep-c-affects-body
13. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)30364-0/fulltext
14. https://www.uptodate.com/contents/characteristics-of-the-hepatitis-c-virus
15. https://www.mdpi.com/2073-4409/8/4/376/htm
16. https://www.hepatitisc.uw.edu/biology/structure#x-section-virion
17. https://www.healthline.com/health/hepatitis-c/can-it-be-cured#current-treatments
18. https://www.hepatitis.va.gov/cirrhosis/background/stages.asp