The Pathophysiology and Symptoms of Hepatitis C

Caroline Derrick, PharmD, BCPS, provides an understanding of the pathophysiology of hepatitis C and shares some common symptoms.

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Christian B. Ramers, MD, MPH, AAHIVS: Let’s get into the pathophysiology. Caroline, can you go through the difference between acute and chronic infection and what the parameters are?

Caroline Derrick, PharmD, BCPS: Thank you. Hepatitis C is an RNA virus that we now know is completely curable, which is very exciting. But when we’re curing these patients in clinical practice these days, we’re using direct-acting antivirals, or DAAs. Before you start someone on treatment, you really need to differentiate between acute and chronic infection. We define acute infection as an infection that occurs less than 6 months from diagnosis, so when you have that surface antigen, if you wait 6 months and the surface antigen and viral load are present, that would be defined as a chronic infection. A chronic infection is what we historically have been treating, and there are some nuances of when you may want to treat an acute infection, but chronic infection rate typically uses the definition of an infection after 6 months.

Christian B. Ramers, MD, MPH, AAHIVS: Can you walk me through what happens to a person from the time that they’re exposed to hepatitis C? Do they immediately have symptoms? Does the antibody turn positive right away? What’s the sequence of things?

Caroline Derrick, PharmD, BCPS: When a patient is exposed to the virus, they may be very often asymptomatic. During that waiting period, they may be very unaware of their infection. Then patients are often able to cure the virus themselves, so there are about 25% of patients who may naturally clear the infection on their own without the use of therapy. During this acute phase, patients are often asymptomatic, and the chronically infected patients may start to experience extrahepatic manifestations and experience symptoms such as fatigue or weakness.

Then some of the signs: their blood sugars may go up, so they may be diagnosed with diabetes or other things like that. There are often extrahepatic manifestations—porphyria cutanea tarda [PCT], glomerular nephritis—that these patients may have and completely not attribute to hepatitis C.

Christian B. Ramers, MD, MPH, AAHIVS: A minority of patients will be symptomatic with that acute infection, but if you are going to have symptoms of the acute hepatitis C, what does that look like?

Caroline Derrick, PharmD, BCPS: Often patients may experience some fatigue, weakness, their liver enzymes going up in terms of a sign on laboratory monitoring that we could see, jaundice possibly. That’s typically what we’re seeing in clinical practice.

Christian B. Ramers, MD, MPH, AAHIVS: How is it different from hepatitis C? Or do they kind of look the same as an acute hepatitis syndrome?

Caroline Derrick, PharmD, BCPS: They may look the same. Hepatitis A patients may be more pronounced. They may be often easier to diagnose, but on laboratory monitoring they may look similar.

Christian B. Ramers, MD, MPH, AAHIVS: Jaundice, elevated liver enzymes, maybe some nausea, vomiting, GI [gastrointestinal]—related symptoms.