Most cases of hepatitis C are transmitted percutaneously, particularly through intravenous drug use or blood transfusion. Sexual transmission is extremely rare, although not impossible. In persons with a long-term monogamous partner infected with HCV, the risk for transmission is 0%-0.6% per year. However, in those who participate in high-risk sexual behavior (eg, multiple short-term partners, presence of other sexually transmitted infections, nonuse of barrier contraception, or sex practices involving trauma), increases the risk up to 1.8% per year. Patients with HIV coinfection are at highest risk for transmission.
Approximately 15%-45% of patients who have acute hepatitis C clear the infection without treatment; however, the remainder will develop a chronic infection, which is defined as the persistence of infection for longer than 6 months. In patients with chronic hepatitis C, 15%-30% will develop significant liver dysfunction, such as cirrhosis, within 20 years. Figure 2 is a light micrograph that shows hepatic cirrhosis in a different patient.
In patients with an active HCV infection, the treatment of choice is the use of direct acting antiviral (DAA) agents. Further details about treatment indications, duration, and success rates are beyond the scope of this discussion.[1,5] The ultimate goal of treatment is disease cure, which can be accomplished in over 90% of patients. Thus, early recognition of HCV infection is crucial.
In patients with suspected HCV infection, screening is accomplished with a hepatitis C antibody test (Figure 3). In those with suspected recent exposure, or for those who test positive on the antibody test, follow-up testing for hepatitis C RNA is performed. A positive antibody test with the presence of hepatitis C RNA confirms an active infection, although it can be difficult to determine whether this represents an acute or chronic infection.[1,7] A positive antibody test without the presence of hepatitis C RNA suggests a prior HCV infection; however, hepatitis C RNA testing should be repeated in 2-3 weeks to account for the possibility of undetectable viral load in the early stages of infection.
Liver enzymes are frequently (but not necessarily) elevated, usually reaching a peak of 10 times the upper limit of normal in acute infection. Chronic infection is often characterized by alanine aminotransferase levels that may either remain persistently elevated or fluctuate between normal and elevated levels. As many as 30% of patients with chronic hepatitis C have normal liver enzyme levels when screened.
Because of the frequency of asymptomatic infection, proper routine screening is vital to detect HCV infection before the development of liver damage. According to guidelines from the Centers for Disease Control and Prevention, all adults aged 18 years or older who live in areas where the prevalence of hepatitis C is greater than 0.1% or where the prevalence is unknown should be tested at least once in their lifetime for hepatitis C. One-time screening is also recommended for patients of any age at high risk for hepatitis C, such as those who received clotting factor concentrates before 1987 or blood product transfusions or organ transplants prior to July 1992. Patients who have been exposed to hepatitis C via blood transfusion from a confirmed HCV-positive patient, by needle-stick/sharps or mucosal exposure to HCV-positive blood, or by being born to an HCV-positive mother should also undergo one-time testing. Patients with ongoing risk factors for hepatitis C, such as those with HIV infection, those who are using intravenous drugs or sharing needles/syringes or drug preparation equipment, those who are receiving maintenance dialysis, and those who have persistently elevated alanine aminotransferase levels, should receive periodic hepatitis C testing. Any patient who requests hepatitis C testing should not be denied, even in the absence of any risk factors.
In addition, all pregnant women who live in areas where the prevalence of hepatitis C is greater than 0.1% or where the prevalence is unknown should receive screening for hepatitis C. This recommendation applies to each pregnancy, regardless of prior testing in earlier pregnancies.[9,10] HCV infection was diagnosed in the patient in this case as a result of universal screening recommendations for pregnant women.
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