1/13/17 Intern Morning Report – Acute Hepatitis C

CC: 3 days of RUQ abdominal pain

ID: 41 yo incarcerated male with HIV (last CD4 711 2 years ago), Hepatitis C (s/p treatment with peg-IFN with documented SVR 2 years ago), bipolar disorder, substance abuse presents with 3 days of RUQ abdominal pain, non-bloody non-bilious vomiting, jaundice, and darkened urine.  He reports having taken a few tabs of Tylenol for the abdominal pain starting 3 days ago, but otherwise denies any new tattoos or recent IV drug use.  He does endorse a history of MSM and was recently started on methocarbamol and amiriptyline about 4 weeks ago in addition to his HAART therapy (darunavir, emtricitabine, tenofovir, ritonavir).  On presentation, patient was diffusely jaundiced and found to have AST/ALT of 2004/1540.  Alkphos was 249, total bilirubin was 8.6 with direct bilirubin at 6.9, albumin was 4.2, PT and INR were 15.8 and 1.27.  All medications were stopped for concern of DILI and further workup was significant for elevated actin antibody, negative anti-mitochondrial Ab, and markedly elevated Hep C RNA levels, consistent with Hepatitis C reinfection.

r-value

R- value ≥ 5 indicates hepatocellular injury
R-value 2-5 indicates mixed hepatocellular/cholestatic injury
R- value < 2 indicates cholestatic injury

Don’t forget:

  • Causes of hepatocellular injury include:
    • viral hepatitis (A, B, C, D, E, CMV, EBV)
    • DILI (drug-induced liver injury)
    • alcoholic liver injury
    • autoimmune hepatitis
    • NASH (non-alcoholic steatohepatitis) and hepatic steatosis
    • Wilson’s Disease
    • Budd-Chiari
    • veno-occlusive disease
    • malignant infiltration (breast, small cell lung cancer, lymphoma, melanoma, myeloma)
    • sepsis

Pearls from morning report:

  • To diagnose Acute liver failure, the patient must fulfill 3 criteria
    • impaired synthetic function (INR > 1.5)
    • no pre-existing liver disease
    • encephalopathy
  • The differential for AST or ALT > 1000 should include: toxins (acetaminophen, mushroom – usually Amanita phalloides), ischemia, viral hepatitis
  • Total bilirubin levels cannot reliably differentiate between hepatocellular or cholestatic liver injury (and is therefore not part of the equation for calculating R-value)

Random trivia:

Notable celebrities with Hepatitis C include Pamela Anderson (reportedly successfully treated), Ken Watanabe (reportedly successfully treated), Etta James, Steven Tyler, and Jack Kevorkian.


Want to read more?

ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries (American Journal of Gastroenterology)
Acute Liver Failure (New England Journal of Medicine)


References:

Pratt DS, Kaplan MM. Evaluation of abnormal liver-enzyme results in asymptomatic patients. N Engl J Med. 2000;342(17):1266-71.

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