Hepatitis C

Key Features

Essentials of Diagnosis

• Majority of childhood cases, especially those acquired vertically, are asymptomatic despite development of chronic hepatitis

• Incubation period is 1–5 months, with insidious onset of symptoms

• Flu-like prodromal symptoms and jaundice occur in < 25% of cases

General Considerations

• Risk factors in adults and adolescents include

  • Injection drug use

  • Occupational or sexual exposure

  • History of transfusion of blood products prior to 1992

• Vertical transmission occurs more commonly when mothers with HCV are coinfected with HIV

• Approximately, 0.2% of children, 0.4% of adolescents, and 1.5% of adults in the United States have serologic evidence of infection

Clinical Findings

Symptoms and Signs

• Mild inflammation and fibrosis on liver biopsy

• Hepatosplenomegaly may or may not be evident

• Ascites, clubbing, palmar erythema, or spider angiomas are rare and indicate progression to cirrhosis

• Cirrhosis may develop rapidly in rare cases

Differential Diagnosis

• Hepatitis A

• Hepatitis B

• Wilson disease

• α₁-Antitrypsin deficiency

• Autoimmune hepatitis

• Primary sclerosing cholangitis

• Drug-induced hepatitis

• Steatohepatitis

Diagnosis

Laboratory Findings

• Anti-HCV IgG

• Not informative until the infant is 18 months old, at which time antibody testing should be performed

• Patients older than 18 months with positive anti-HCV IgG should have subsequent testing for serum HCV RNA in order to determine active infection

• Serum HCV RNA

  • Can be tested prior to 18 months of age, but should not be tested before 2 months old

  • If positive in infancy, it should be rechecked when the infant is 12 months of age in order to determine presence of chronic infection

• Fluctuating mild to moderate elevations of aminotransferases over long periods are characteristic of chronic HCV infection; however, normal aminotransferases are common in children

• Generally cirrhosis develops in adults after 20–30 years of chronic HCV infection, but it has occasionally developed sooner in children

Treatment

• Subcutaneous injections of pegylated interferon-α and oral ribavirin

• End-stage liver disease secondary to HCV responds well to liver transplantation, although reinfection of the transplanted liver is very common

Outcome

Prevention

• At present, the only effective means of prevention is avoidance of exposure through elimination of risk-taking behaviors such as illicit use of intravenous drugs.

• There is no effective prevention for vertical transmission, but avoidance of fetal scalp monitoring in infant of mothers with HCV has been suggested

• Elective Caesarean section is not recommended for HCV-monoinfected women, as it confers no reduction in the rate of mother-to-infant HCV transmission

• Breast-feeding

  • Does not promote HCV transmission from mother to infant

  • Should be avoided if the nipples are bleeding, mastitis is present, or the mother is experiencing a flare of hepatitis with jaundice

• There ...