Hepatitis C Clinical Presentation

Updated: Mar 28, 2016
  • Author: Vinod K Dhawan, MD, FACP, FRCPC, FIDSA; Chief Editor: BS Anand, MD  more...
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Presentation

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. [32] 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. [33] 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. [34]

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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
  • Lichen planus [1] (see the images below)
    Lichen planus. Courtesy of Walter Reed Army Medica Lichen planus. Courtesy of Walter Reed Army Medical Center Dermatology.
    Lichen planus (oral lesions). Courtesy of Walter R Lichen planus (oral lesions). Courtesy of Walter Reed Army Medical Center Dermatology.
    Lichen planus (volar wrist). Courtesy of Walter Re Lichen 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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