Hepatitis C with mixed cryoglobulinemia. Pinto-Almeida T, An Bras Dermatol (2013 Nov-Dec). CC BY-NC 3,0

Definition

Liver inflammation (hepatitis) caused by virus. The infection becomes chronic (more than 6 months duration) in 70-80% of the infected (reference: Public Health Institute, 2017). Caused by Hepatitis C virus (HCV). Hepatitis C is not a classic "Opportunistic infection"but may be important to consider if treatment with medication that cause immunosuppression (impaired immune system) is planned.

• Hepatitis C infection can also cause rheumatic symptoms (please see below)

Contamination

Blood: Blood transfusions. Unclean (contaminated) syringes (syringe-drug addicts)

• In Norway, between 20.000 and 30.000 people are infected with Hepatitis C
• Particularly high occurrence in Egypt, Alaska and Italy
• It is uncommon for HCV to be reactivated by immunodeficiency antirheumatic therapy

Symptoms

• Newly infected
  • 15-30% newly infected get symptoms
    • Fatigue, nausea, abdominal pain, diarrhea, fever
  • Icterus (jaundice) at 10%
• Chronic infected can have symptoms with
  • Exhaustion
  • Some cognitive symptoms (decreased concentration and memory etc)
• After (20 year: 20%) develope liver cirrhosis and the risk of liver cancer (Hepatocellular cancer)

Rheumatic symptoms

• Reduced function in salivary gland and dermatitis can cause dry mouth and dry eyes, which may remind of Sjögren's syndrome
• Arthritis (arthralgia) is rare, but can occur in two different forms (reference; Palazzi C, 2014):
  • Small joints are attacked in both hands and feet, similar to Rheumatoid arthritis (arthritis)
  • Big joints are attacked, especially knees and hips
• Cryoglobulinemia (blood test) and symptoms of cryoglobulinemia syndrome

Medical investigation and investigations

• Hepatitis C antibody in blood test (Microbiological Institute, viral studies)
• HCV RNA is detected at PCR and genotyping
• Check also Hepatitis BS antibody, Hepatitis B Core antibody and Hepatitis BsAg.
• Check for HIV infection
• Ultrasound examinations of liver and spleen
• Alpha phoetoprotein in blood test
• Consider whether it is an indication of liver biopsy
• It is not uncommon for Hepatitis C to produce several types Antibodies (" rheumatic testes") without rheumatic disease present

MSIS message (Norwegian Institute of Public Health) on Hepatitis C

Treatment

No vaccine or immunoglobulins. Previously, PEGylert Interferon in combination with Ribavirin (more than 50% is being virus-free) was the first choice, but interferon often produces significant side effects. Newer cost effective (but expensive) treatment regimes without interferon are relevant. Twelve weeks of tablet treatment is effective at over 90%. Check Hepatitis C-RNA 6 month after discontinuation (neg = healed).

Literature

• Easterbrook PJ, 2017 (diagnosis of hepatitis)
• The Norwegian Public Health Institute
• Wikipedia

Opportunistic infections, BINDEVEVSSYKDOMMER.no

• Bindevevssykdommer.no
• Vaskulitt.no