A 42-year-old man comes to the office after attempting to donate blood, when he was found to have abnormal viral serologic results for hepatitis. The patient feels well and takes no medications. He has no history of liver disease, but his father died of complications of alcoholic cirrhosis. The patient drinks 1 or 2 beers on weekdays and 5 or 6 on the weekends. He used injection drugs for several years in his 20s but not recently. The patient does not use tobacco. He has had several lifetime sexual partners but is now in a monogamous relationship. Temperature is 37.1 C (98.8 F), blood pressure is 136/85 mm Hg, and pulse is 84/min. BMI is 34.2 kg/m2. A smooth, nontender liver edge is palpable 3 cm below the right costal margin; otherwise, the physical examination is unremarkable. Laboratory results are as follows:
| Aspartate aminotransferase (SGOT) | 156 U/L |
| Alanine aminotransferase (SGPT) | 214 U/L |
| Hepatitis panel | |
| Hepatitis B surface antibody | positive |
| Hepatitis B surface antigen | negative |
| Hepatitis C virus antibody | positive |
Which of the following is the most appropriate next step in management of this patient?
This patient has elevated transaminases, hepatomegaly, and a positive serologic test for hepatitis C virus (HCV) antibody. This suggests exposure to HCV and warrants testing to confirm the diagnosis of chronic HCV infection. Because the virus may spontaneously clear in some patients, the diagnosis of chronic HCV infection is a 2-step process requiring both a positive serologic test for the anti-HCV IgG antibody and a confirmatory molecular test for circulating HCV RNA.
Once the diagnosis has been confirmed, patients should undergo further evaluation to determine candidacy for treatment with direct-acting antiviral agents (eg, ledipasvir-sofosbuvir) (Choice D). This often involves noninvasive tests (eg, laboratory tests, ultrasound-based transient elastography) to assess the extent of liver fibrosis and, sometimes, HCV genotype testing. Pregnancy testing is recommended if a ribavirin-based regimen is under consideration.
(Choice A) In patients with established chronic HCV (ie, HCV RNA positive), ultrasound-based transient elastography, rather than CT scan, can be used to assess for fibrosis. Ultrasound is also preferred over CT scan for screening for hepatocellular carcinoma in patients who have advanced HCV and cirrhosis.
(Choice B) This patient shows evidence of immunity to hepatitis B virus (positive hepatitis B surface antibody), making vaccination unnecessary.
(Choice E) Although liver biopsy was once used to assess the extent of fibrosis in patients with confirmed chronic HCV, noninvasive laboratory tests and ultrasound-based transient elastography are now preferred. There is no need to assess for liver fibrosis in this patient unless HCV RNA testing is positive.
Educational objective:
Because hepatitis C virus may spontaneously clear in some patients, the diagnosis of chronic infection requires both a positive serologic antibody test and a confirmatory molecular test for circulating hepatitis C virus RNA.