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Key Features

Essentials of Diagnosis

  • Often asymptomatic

  • Prodrome of anorexia, nausea, vomiting, malaise, aversion to smoking

  • Fever, enlarged and tender liver, jaundice

  • Markedly elevated aminotransferases early in the course

  • Liver biopsy shows hepatocellular necrosis and mononuclear infiltrate

  • Source of infection is unknown in many

General Considerations

  • The hepatitis C virus (HCV) is a single-stranded RNA virus (hepacivirus) with properties similar to those of flavivirus

  • Seven major genotypes of HCV have been identified

  • Coinfection is found in at least 30% of persons infected with HIV

  • HIV leads to more rapid progression of chronic hepatitis C to cirrhosis

  • Anti-HCV is not protective; in patients with acute or chronic hepatitis, its presence in serum generally signifies that HCV is the cause


  • In the past, HCV caused over 90% of cases of posttransfusion hepatitis, yet only 4% of cases of hepatitis C were attributable to blood transfusions

  • Over 50% of cases are transmitted by injection drug use

  • Body piercing, tattoos, and hemodialysis may be risk factors

  • The risk of sexual and maternal-neonatal transmission is low and may be greatest in those with high circulating levels of HCV RNA

    • Multiple sexual partners may increase the risk of HCV infection

    • Transmission via breast-feeding has not been documented

  • Hospital-acquired transmission may occur between patients on a liver unit or via

    • Multidose vials of saline

    • Reuse of disposable syringes

    • Contamination of shared saline, radiopharmaceutical, and sclerosant vials

Clinical Findings

Symptoms and Signs

  • The incubation period averages 6–7 weeks

  • Clinical illness

    • Often mild

    • Usually asymptomatic

    • Characterized by waxing and waning aminotransferase elevations and a high rate (> 80%) of chronic hepatitis

  • In patients with the CC genotype,

    • Spontaneous clearance of HCV following acute infection is more common (64%)

    • Jaundice is more likely to develop during the course of acute hepatitis C

Differential Diagnosis

  • Hepatitis A, B, D, E virus

  • Hepatitis G virus (HGV) rarely, if ever, causes frank hepatitis

  • TT virus (TTV)

    • Found in up to 7.5% of blood donors

    • Readily transmitted by blood transfusions

    • However, an association between this virus and liver disease has not been established

  • A related virus known as SEN-V has been found in 2% of US blood donors

    • Is transmitted by transfusion

    • May account for some cases of transfusion-associated non-ABCDE hepatitis

  • Cytomegalovirus, Epstein-Barr virus, and herpes simplex virus, particularly in immunocompromised hosts


Laboratory Tests

  • Antibodies to HCV (Figure 16–3)

    • The immunoassay has moderate sensitivity (false-negatives) for the diagnosis early in the course and in healthy blood donors and has low specificity (false-positives) in persons with elevated γ-globulin levels


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