Hepatitis C is a problem in many countries, and even developed countries have a high prevalence of this problem. According to the World Health Organization, chronic hepatitis C is a severe problem and one of the leading causes of liver cancer and cirrhosis.
Up to $95,000 is spent every year to treat hepatitis C infections, and that is only in the United States. If we translate this into a worldwide scenario, medical care costs can reach $370 billion annually.
But it all comes down to how patients experience this disease. What do you need to know about hepatitis C? In this article, we’re going through the basics of the disease, what happens in your body during a hepatitis C infection, the signs and symptoms, and much more.
What is hepatitis C?
Hepatitis C is a viral infection caused by a hepatitis C virus. This virus is prevalent in the liver tissue and causes severe inflammation in this organ. The genetics of the hepatitis C virus is similar to yellow fever and dengue. But this is a chronic disease virus and produces around 10 trillion new viruses every day.
Blood transfusions were the primary cause of hepatitis C transmission for many years. But after 1992, new screening methods before blood transfusions reduced hepatitis C transfusions via donated blood. Nowadays, transfusion risk is around one transmission per 1-2 million units.
Who is at a higher risk?
If blood transfusions are not the primary transmission method, who is at a higher risk? Infection risk is very high in people who inject recreational drugs and share needles. Using nonsterile needles carries the hepatitis C virus from one drug user to another. According to recent information from the United States, one-third of patients infected with the hepatitis C virus have a drug injection history. Additionally, there is some risk of hepatitis C transmission in cocaine users.
Needle-stick injuries are the main reason why healthcare workers are also at a higher risk. They often endure occupational exposure and have a higher risk of hepatitis C and other diseases. Patient-to-patient exposure in a healthcare environment is also possible during surgery, via dialysis, or through a contaminated colonoscope.
Another via of transmission is sexual intercourse, but it is not very common in heterosexual couples.
Finally, there is a transmission risk by getting a tattoo and sharing razors. Acupuncture can be a transmission route if the needles are not properly sterilized. Breastfeeding does not increase transmission risk, and the risk of maternal-fetal transmission is no more than 5%. Saliva and other casual contacts rarely lead to an infection.
Is it common nowadays?
As the transmission of hepatitis C through blood transfusions reduced, infections in injection drug users increased through the years. Between 2004 and 2014, there was a two-fold increase in the incidence in this group.
Nowadays, hepatitis C is the most important cause of chronic hepatitis in America. It is also responsible for 20% of cases of acute hepatitis. In the United States, there are currently an estimated 3.9 million people infected with the hepatitis C virus. Some of them have an acute infection, but 2.7 million are expected to have a chronic disease.
Every year, hepatitis C causes 30,000 new infections and up to 10,000 deaths. 60% of the infections happen in drug users, 20% result from sexual exposure, and the rest include a variety of causes, including hemodialysis and perinatal exposure.
There are an estimated 170 million people infected with the hepatitis C virus worldwide, and 71 million have a chronic disease. The highest prevalence is found in Eastern Europe, Saudi Arabia, and Jeddah City. The virus is more common in Hispanic and Black populations in the United States.
What happens during hepatitis C infections?
After being infected with the hepatitis C virus, it travels through the blood via B lymphocytes. They reach the liver, which is the primary site of infection. Resolution of the infection only happens when cytotoxic T lymphocytes develop a response specific to this particular strand of hepatitis C virus.
As the viral infection continues, the liver undergoes severe inflammation. When this inflammation is sustained for a long time, it causes fibrosis, which is the formation of scar tissue in the organ, replacing healthy tissue. During ongoing infection with hepatitis C, a very high proportion of hepatocytes will ultimately be infected with the virus. At least 50% of these cells will be affected in case of chronic disease.
Viral infection depends on the genetic machinery of the hepatitis C virus. One of the most important proteins is the core protein. It modulates cell cycle regulation in hepatocytes and helps the hepatitis C virus use the cell’s metabolism to its advantage. There is also an RNA polymerase and other essential proteins for the propagation of the virus.
Signs and symptoms of hepatitis C
Hepatitis C is a chronic infection in around 70% of cases. In other words, most patients will have a chronic infection, which does not feature very severe symptoms at first. In fact, most patients are initially asymptomatic and only refer to non-specific symptoms such as malaise and fatigue without clear signs of hepatic dysfunction.
Hepatitis C symptoms are more apparent when patients reach a late stage of the disease and cirrhosis. These patients have more clear symptoms of a hepatic problem, including pruritus and sleep inversion. Other symptoms point to portal hypertension and other signs of decompensated liver disease—for example, melena, hematemesis, ankle edema, abdominal distention, and mental status changes.
There are also extrahepatic manifestations of the disease. They are mainly found in the skin, joints, and muscle tissue, and they are ubiquitous. Around 74% of patients are expected to experience at least one of them. Such manifestations include arthralgia (joint pain), myalgia (muscle pains), paresthesias (a sensation of tingling in the skin), and pruritus. Many of them also experience sensory neuropathy and urticaria. Skin manifestations are particularly common in organ donor receptors, and these patients more commonly report pruritus, palmar erythema, and skin dryness.
Of course, one of the most critical manifestations of hepatitis C and other types of hepatitis is jaundice, which is a yellowish coloration of the skin and mucosa. The white portion of the eyes takes a yellowish taint because bilirubin starts to build up in the blood and accumulates in the skin tissue as liver damage increases. Along with jaundice, patients experience pruritus because bilirubin stimulates nerve terminals in the skin.
In a physical exam, patients with advanced disease may present with:
● Hand signs, especially palmar erythema. Some patients will also experience a contracture of the hand muscles known as Dupuytren contracture. Other manifestations in the hand include clubbing of the fingers.
● Various head signs, especially jaundice as evident in the white portion of the eyes. In some patients, the temporal muscle starts to change and experiences muscle wasting. Some patients may also have cyanosis or a purple coloration in the skin as the oxygen saturation reduces. In some cases, we can also see an enlargement of the parotid gland.
● Patients with advanced liver disease have a characteristic odor known as fetter hepaticus. It is a musty and strong breath smell that happens when the liver is not filtering sulfur as it should.
● In males, there can be plenty of hormonal problems, including a reduction of the testes and gynecomastia. These patients may experience hair loss and reduced the volume of body hairs.
● Patients with hepatitis C in the late stage of the disease have a higher chance of suffering from paraumbilical hernias. As the disease progresses, liquid buildup becomes noticeable, and there is a sign known as ascites, which is an accumulation of liquid in the abdominal cavity. There is also edema in the ankles and other parts of the body.
Is hepatitis C a dangerous disease?
To answer this question, let us consider the prognosis of the disease. It is basically what is expected to happen after getting infected, including the worst-case scenarios.
In some cases, the hepatitis C virus turns out to be a self-limited disease. In other words, it resolves by itself, but this only happens in 15 to 50% of patients, depending on their genetics, immune system, and other variants. This is not the most common scenario. The infection progresses in 70 to 80% of patients, and 20% develop a severe liver health alteration known as cirrhosis. This happens in chronic liver disease, and the symptoms show up after 20 years of chronic disease.
The age of onset is also essential to consider prognosis, and early infection in young patients is usually associated with less severe symptoms and complications. Another variant that changes the course of the disease is coinfection. In other words, whether hepatitis C comes by itself or is accompanied by the hepatitis B virus. In the latter case, the virus is more likely to progress into chronic infection and cirrhosis.
Liver cancer is also a possibility after being infected with hepatitis C, and decompensation is probably the worst complication in the late stage of the disease. The risk of liver cancer in infected patients is around 10%, and the risk of decompensation is close to 20%.
Another way to know if a disease is more or less dangerous is by looking at the survival rate of patients after 5 and 10 years. In hepatitis C, the 5-year survival rate is 89%, and the 10-year survival rate is 79%. It sounds like a pretty good number, but it means that 11 out of 100 patients die in the first five years, and 21 out of 100 patients are expected to die within the first ten years.
The severity of the disease and the likelihood of progression into a late-stage are both influenced by variants such as immunosuppression, age of onset, alcohol use, iron status, and concomitant infection with other hepatitis viruses.
In a nutshell, hepatitis C can be a very dangerous disease. It is at first an asymptomatic disease in most cases, but it doesn’t remain asymptomatic forever. The virus will inadvertently destroy the hepatic tissue bit by bit and every year until reaching a state of no return where patients may even need liver transplantation to stay alive. However, the course of the disease is modulated by different aspects, including your lifestyle habits and health parameters.
Studies and exams for hepatitis C
The diagnosis of hepatitis C can be very difficult at an early stage of the disease in chronic patients because they are entirely asymptomatic. That is why antibody tests are so necessary to diagnose the condition. However, there are many other exams to do. This is an overview of the most important:
- Hepatitis C antibody test: This is ultimately the best way to diagnose patients with hepatitis C infections. This test uses antibodies that bind to proteins in the hepatitis C virus. One of the problems is that this antibody assay does not tell you if the infection is still ongoing or has happened in the past. Different antibody tests bind different proteins, and the more sensitive test detects the hepatitis C virus eight weeks after the infection. Thus, you may have the condition during this time and still be negative in antibody tests. False-negative antibody tests may also happen in people with HIV and other types of immunocompromised. Since 2010 there has been a quick antibody test that uses a strip with blood collected from a puncture in your finger. It is a useful way to screen for hepatitis C in high-risk patients.
- PCR test: This is a more specific way to tell if you’re infected or not when there is a doubt about it. This test is also helpful in predicting the response to the treatment and monitoring the disease in follow-ups.
- Hepatitis C virus genotyping: In some cases, genotyping tests can help guide the treatment course. This is particularly the case in patients at a very high risk of complications.
- Other exams: Your doctor may decide to run a few extra exams to check for vasculitis, arterial hypertension, and other conditions. These exams are also helpful in ruling out other diseases before diagnosing hepatitis C. They include rheumatoid factor, antinuclear antibodies, and anti-smooth muscle antibodies, among others.
- Liver biopsy: It is possible when the diagnosis is uncertain and the doctor suspects multiple infections from different hepatitis viruses. It is also a diagnostic option in some immunocompromised patients and to rule out liver cancer.
Treatment options
After being diagnosed with hepatitis C, you might undergo a period of follow-ups because 15-50% of patients experience spontaneous clearance of the infection. If you are still positive for hepatitis C after six months or experience symptoms that require immediate treatment, these are the options you can consider with your doctor:
- Antiviral agents: This is the most effective way to clear the infection. It works in 90% of people. They are oral medications you need to take for 8 to 12 weeks. It can be a single pill or several pills taken at once, depending on the type of hepatitis and your health parameters.
- Supportive treatment: Depending on your symptoms, your doctor may give you a specific treatment to solve a variety of conditions—for example, creams for pruritus and pain medications to reduce joint pain.
- Treatment of hepatitis C complications: Some patients already have advanced disease and require specialized treatment for cirrhosis or liver cancer.
- Lifestyle modifications: Throughout this time, it is also important to eat a balanced diet, cut alcohol, quit smoking, and exercise regularly. Be careful when you have sexual intercourse, and do not share razors, syringes, needles, or razors with other people to prevent the spread of the disease.