Hepatitis C Clinical Presentation

  • Author: Sandeep Mukherjee, MB, BCh, MPH, FRCPC; Chief Editor: Julian Katz, MD   more...
 
Updated: Feb 29, 2012
 

History

Acute hepatitis C (HCV) infection becomes chronic in 70% of patients, which represents a high rate of chronicity for a viral infection. Most patients with chronic hepatitis C infection are asymptomatic or may have nonspecific symptoms such as fatigue or malaise in the absence of hepatic synthetic dysfunction. Patients with decompensated cirrhosis from HCV infection frequently have symptoms typically observed in other patients with decompensated liver disease, such as sleep inversion and pruritus.

Symptoms characteristic of complications from advanced or decompensated liver disease are related to synthetic dysfunction and portal hypertension. These include mental status changes (hepatic encephalopathy), ankle edema and abdominal distention (ascites), and hematemesis or melena (variceal bleeding).

Symptoms often first develop as clinical findings of extrahepatic manifestations of HCV and most commonly involve the joints, muscle, and skin. In a large study of the extrahepatic manifestations of HCV, 74% of medical workers with HCV infection demonstrated extrahepatic manifestations.[28] The most commonly occurring extrahepatic manifestations were as follows:

  • Arthralgias (23%)
  • Paresthesias (17%)
  • Myalgias (15%)
  • Pruritus (15%)
  • Sicca syndrome (11%)

In addition, sensory neuropathy has been reported as an extrahepatic manifestation in 9% of patients with HCV infection.[29] Risk factors for manifestations of extrahepatic chronic hepatitis C infection include advanced age, female sex, and liver fibrosis.

Patients also present with symptoms that are less specific and are often unaccompanied by discrete dermatologic findings. Pruritus and urticaria are examples of less specific clues to underlying HCV infection in the appropriate setting (eg, posttransfusion, organ transplantation, surgery, intravenous drug use, injury of the nasal mucosa from snorting cocaine through shared straws).

Patients with ongoing pathology associated with chronic hepatitis C that eventually results in organ failure can present with symptoms and signs in the skin. Pruritus, dryness, palmar erythema, and yellowing of the eyes and skin are examples of less specific findings in patients with end-stage liver disease with cirrhosis; these findings provide clues that lead to further evaluation of the underlying causes. Patients with the mucosa-associated lymphoma tumors (MALT) syndrome itself tend to have bowel symptoms.

Chronic hepatitis C has a strong association with pruritus. Indeed, some authorities believe that all patients with unexplained pruritus should be investigated for HCV infection.[30]

Next

Physical Examination

Most patients with HCV infection do not have abnormal physical examination findings until they develop portal hypertension or decompensated liver disease. One exception is patients with extrahepatic manifestations of HCV infection, such as porphyria cutanea tarda or necrotizing vasculitis. Signs in patients with decompensated liver disease include the following:

  • Hand signs - Palmar erythema, Dupuytren contracture, asterixis, leukonychia, clubbing
  • Head signs - Icteric sclera, temporal muscle wasting, enlarged parotid, cyanosis
  • Fetor hepaticus
  • Gynecomastia, small testes
  • Abdominal signs - Paraumbilical hernia - ascites, caput medusae, hepatosplenomegaly, abdominal bruit
  • Ankle edema
  • Scant body hair
  • Skin signs - Spider nevi, petechiae, excoriations due to pruritus

Other common extrahepatic manifestations include the following:

  • Cryoglobulinemia: Membranoproliferative glomerulonephritis
  • Idiopathic thrombocytopenic purpura
  • Lichen planus[31] (see the images below) Lichen planus. Courtesy of Walter Reed Army MedicaLichen planus. Courtesy of Walter Reed Army Medical Center Dermatology. Lichen planus (oral lesions). Courtesy of Walter RLichen planus (oral lesions). Courtesy of Walter Reed Army Medical Center Dermatology. Lichen planus (volar wrist). Courtesy of Walter ReLichen planus (volar wrist). Courtesy of Walter Reed Army Medical Center Dermatology.
  • Keratoconjunctivitis sicca
  • Raynaud syndrome
  • Sjogren syndrome
  • Porphyria cutanea tarda
  • Necrotizing cutaneous vasculitis
  • Non-Hodgkin lymphoma

Approximately 10-15% of affected patients have symptoms such as weakness, arthralgias, and purpura; these are often related to vasculitis. The precise pathogenesis of these extrahepatic complications has not been determined, although most are the clinical expression of autoimmune phenomena.

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Contributor Information and Disclosures
Author

Sandeep Mukherjee, MB, BCh, MPH, FRCPC  Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Coauthor(s)

Vinod K Dhawan, MD, FACP, FRCP(C), FIDSA  Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Infectious Diseases, Rancho Los Amigos National Rehabilitation Center

Vinod K Dhawan, MD, FACP, FRCP(C), FIDSA is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada

Disclosure: Pfizer Inc Honoraria Speaking and teaching

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

George Y Wu, MD, PhD Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine

George Y Wu, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Medical Association, American Society for Clinical Investigation, and Association of American Physicians

Disclosure: Springer Consulting fee Consulting; Gilead Consulting fee Review panel membership; Gilead Honoraria Speaking and teaching; Bristol-Myers Squibb Honoraria Speaking and teaching; Springer Royalty Review panel membership

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Hepatitis C. Causes of chronic liver disease. Courtesy of the US Centers for Disease Control and Prevention.
Hepatitis C viral genome. Courtesy of Hepatitis Resource Network.
Natural history of hepatitis C virus infection.
Diagnostic algorithm for hepatitis C virus infection.
Evolution of the treatment of hepatitis C virus infection.
Pegylated interferon alfa-2b plus ribavirin therapy for chronic hepatitis C.
Cold agglutinin disease indistinguishable from cryoglobulinemia. Courtesy of Walter Reed Army Medical Center Dermatology.
Cryoglobulinemia, palpable purpura, dysproteinemic purpura, and leukocytoclastic vasculitis (small vessel vasculitis). Courtesy of Walter Reed Army Medical Center Dermatology.
Cutis marmorata. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema multiforme, bull's-eye lesions. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema dyschromicum perstans. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema dyschromicum perstans. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema nodosa. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema nodosa. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema multiforme. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema multiforme. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema multiforme. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema multiforme of the oral mucosa. Courtesy of Walter Reed Army Medical Center Dermatology.
Erythema multiforme (Stevens-Johnson syndrome). Courtesy of Walter Reed Army Medical Center Dermatology.
Palmar erythema. Courtesy of Walter Reed Army Medical Center Dermatology.
Granuloma annulare. Courtesy of Walter Reed Army Medical Center Dermatology.
Disseminated superficial (actinic) porokeratosis. Courtesy of Walter Reed Army Medical Center Dermatology.
Disseminated superficial (actinic) porokeratosis. Courtesy of Walter Reed Army Medical Center Dermatology.
Lichen planus. Courtesy of Walter Reed Army Medical Center Dermatology.
Lichen planus. Courtesy of Walter Reed Army Medical Center Dermatology.
Lichen planus. Courtesy of Walter Reed Army Medical Center Dermatology.
Lichen planus (hypertrophic type). Courtesy of Walter Reed Army Medical Center Dermatology.
Lichen planus (oral lesions). Courtesy of Walter Reed Army Medical Center Dermatology.
Lichen planus (volar wrist). Courtesy of Walter Reed Army Medical Center Dermatology.
Lymphoma cutis. Courtesy of Walter Reed Army Medical Center Dermatology.
Henoch-Schönlein purpura. Courtesy of Walter Reed Army Medical Center Dermatology.
Palpable purpura. Courtesy of Walter Reed Army Medical Center Dermatology.
Purpura in hemophilia (factor VIII deficiency). All ecchymoses and bland petechiae are in the differential diagnosis of thrombocytopenic purpuras, including thrombocytopenia secondary to hepatitis C virus in which an autoantibody to platelets is present. Courtesy of Walter Reed Army Medical Center Dermatology.
Progressive pigmented purpuric eruption. Courtesy of Walter Reed Army Medical Center Dermatology.
Progressive pigmented purpura (photo rotated 90°). Courtesy of Walter Reed Army Medical Center Dermatology.
Progressive pigmented purpura (Gougerot-Blum disease). Courtesy of Walter Reed Army Medical Center Dermatology.
Progressive pigmented purpura (Schamberg disease). Courtesy of Walter Reed Army Medical Center Dermatology.
Thrombocytopenic purpura. Courtesy of Walter Reed Army Medical Center Dermatology.
Prurigo nodularis. Courtesy of Walter Reed Army Medical Center Dermatology.
Prurigo nodularis. Courtesy of Walter Reed Army Medical Center Dermatology.
Prurigo nodularis. Courtesy of Walter Reed Army Medical Center Dermatology.
Chronic urticaria. Courtesy of Walter Reed Army Medical Center Dermatology.
Urticaria (secondary to penicillin). Courtesy of Walter Reed Army Medical Center Dermatology.
Nodular vasculitis. Courtesy of Walter Reed Army Medical Center Dermatology.
Henoch-Schönlein purpura, palpable purpura, and leukocytoclastic vasculitis. Courtesy of Walter Reed Army Medical Center Dermatology.
Vitiligo. Courtesy of Walter Reed Army Medical Center Dermatology.
Vitiligo. Courtesy of Walter Reed Army Medical Center Dermatology.
Waldenström hypergammaglobulinemic purpura. Courtesy of Walter Reed Army Medical Center Dermatology.
 
 
 
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