Question about Acute Hep

[mom64]

My son (21yo) is suffering from acute hep (IV Drug user since Sept ’14) He was tested this past Monday at the detox he was at before heading to long-term sober living.They told us his AST was at 900 and ALT at 1300, but no discernible VL. He’s suffering from fatigue and pain in abdomen and constipation. 3 days later he heads to the sober living and his counselor wants his him retested so they head to a clinic. AST was now 1300 and ALT 2300. We (parents and counselor) decide he needs to go to e.r. to check liver function and be sure there is no start of liver damage (we have no idea about Hep C and how fast or slow it takes).  ER doc was not concerned with those numbers and said kidneys are fine which is a good sign. They ran the liver function test but hadn’t gotten the result yet, but said the way my son looks he was sure they would be fine. Still no viral load. They sent him home with a plan to get a PCP (he’s in another state) so they can continue monitoring his numbers and take liver function tests.

I know he has a 20% chance of curing this on his own. I think it’s doubtful but with no viral load (no hep c diagnosis yet) we can’t move on any treatment until there is a diagnosis. I’m sure it’s forthcoming. However, do acute symptoms (fatigue, pain, pale yellow eyes, constipation) just go away as it turns into chronic with no symptoms?
 
Thanks!

[lporterrn]

Hi Mom64,
First, a big hug - as a mother, I can relate to the anguish this might be causing. Your son is very fortunate to have his parents in his corner.

Has he been tested for hep B and HIV? These both need to be ruled out too. An HIV diagnosis will, albeit rarely, confuse the hep C results. In fact, all liver diseases need to be ruled out.

Assuming that his docs are thinking hep C only, then his body may actually be trying to spontaneously resolving infection. The intensity of symptoms and the lack of viral load suggest this (if and only if he does not have HIV or hep B). Also, viral load may be undetectable during this time - it is uncommon, but again, a positive sign of his robust immune system. Some studies have challenged the data, suggesting that up to 50% resolve hep C spontaneously.

If you have spent any time on the Internet, you may have seen that studies suggest that the best time to treat acute hep C in in the first 6 months. That advice is outdated. All the acute research is based on using peginterferon treatment. However, with the new interferon-free treatments, why would we subject anyone to those when we know that shorter, easier treatments are available.

I just heard an expert speak who is on the panel that wrote the guidelines (link below). They are still flushing out the details, but he (Mark Sulkowski) said that his practice is to wait a year, then if hep C hasn't resolved, then treat.

Here is good info on acute hep C http://www.hcvguidelines.org/full-report/management-acute-hcv-infection

In the scheme of things, his recovery is a bigger priority than his hep C. That will hurt him much more quickly than hep C will.

Finally, to answer your question, the acute symptoms will go away, usually by 12 weeks, sometimes 24. Most people with chronic hep C are asymptomatic, but I actually think that they just feel so much better that they don't notice some of the common hep C symptoms, such as mild joint and muscle pain. Essentially, most of us don't notice we have hep C when it is in its early stages.

[Mike]

HCV waxes and wanes when it is in the chronic stage. An individual can have periods of relative calm when the virus isn't  damaging the liver, followed by a period when the liver is being significantly damaged.

Some folks experience lots of symptoms with no measurable liver damage; while others have no symptoms and significant liver damage

Likewise, some present with a high viral load with no liver damage (VL of 6 million+); while others present with a low viral load (300,000) and have significant liver damage.

In the acute phase,  the virus generally causes flu like symptoms for a week or two, while it tries to get a foothold. The immune system in some can fight off the infection and clear the virus. 

Once the initial infection resolves - by either clearing the virus or progressing to a chronic infection - it seems like the any initial symptoms wane (subside).

However, the research is very limited regarding the acute phase, as the vast majority of those newly diagnosed with HCV have been infected for years and/or decades. Because of this, very few people are diagnosed in the acute phase, making it difficult to study the effects of HCV during the initial incubation period.

I would note that most individuals who contract HCV do not develop significant symptoms during the acute phase (liver pain, fatigue, jaundice et. al.), which is why most diagnoses occur years or decades after the initial infection.

Hope this helps.

Best wishes, Mike

[Mike]

Hi Mom64,

Here's some additional information regarding acute HCV infections:

"Symptomatic or Asymptomatic Presentation: Most patients with acute HCV infection do not have a distinct symptomatic illness and most are not aware of their recent exposure to hepatitis C. When patients develop symptomatic acute HCV infection, the clinical manifestations typically resemble those that occur with other types of viral hepatitis—jaundice, influenza-like symptoms, dark urine, nausea, abdominal pain, and malaise. Symptoms may consist of malaise only, without jaundice or gastrointestinal symptoms (Figure 1). If symptoms from acute infection develop, they usually do so within 4 to 12 weeks (mean 6 to 7 weeks) after infection has occurred and persist for 2 to 12 weeks. Only 15 to 20% of symptomatic acute liver disease in the United States is thought to result from acute HCV. Fulminant hepatic failure due to acute HCV infection very rarely occurs, but preexisting chronic hepatitis B infection increases this risk.


Frequency of Clinical Illness: For patients with acute HCV infection in the United States, an estimated 60 to 70% will have no obvious symptoms, 20 to 30% will have jaundice, and 10 to 20% will have non-specific symptoms.  More recent data suggest that only 17% of patients with acute hepatitis C infection present with a symptomatic illness. In addition, most chronically infected patients cannot recall a time when they were acutely symptomatic.

Relationship of Clinical Symptoms and Spontaneous Clearance: Several studies have shown that patients who present with acute HCV infection and jaundice have higher rates of spontaneous clearance of HCV. The presence of jaundice is believed to represent a more robust initial immune response against HCV. 

Clinical Scenarios that Suggest Acute HCV infection:

Symptomatic Presentation: Symptomatic individuals could present with the new onset of jaundice, fatigue, nausea, abdominal pain, and malaise.  Acutely infected persons may have more limited symptoms, such as slight malaise and fatigue without jaundice.

History of a Recent HCV Exposure but without Symptoms: Since acute HCV is usually asymptomatic, clinicians need to test patients as soon as possible following a new incident in which infection could have taken place. Since most cases of acute hepatitis C are asymptomatic, clinicians should not rely on patients to appear clinically ill in order to decide to test patients for acute HCV infection. Providers should suspect the disease in patients exposed to potentially infectious sources  and understand that prompt testing can be critical to making the diagnosis of a new infection and distinguishing acute from chronic infection.  Recent injection-drug use with shared needles or equipment would be the most common recent exposure to HCV. Although the risk of HCV transmission through sexual contact is controversial, recent sexual exposure should be considered as a possible risk.  The risk of sexual transmission appears to be highest with male-male exposures, particularly if this involves HIV-infected persons engaging in physically traumatic or rough sex."

Best wishes, Mike

[mom64]

Thank you both so much for your quick and thorough responses. We are awaiting the newest test results to see if any VL is noticeable. He was told it could take up to 6 months. I am assuming they tested for HIV (mono, etc.) and will have him ask about that. They did mention that it could be Hep B also. He was vaccinated as a baby so not sure if it is still effective 20 years later. But mostly I wanted to know if these symptoms were going to go away. Like I said he just moved into his sober living home and it would be nice if he could take advantage of all the things these guys do. Lucinda, thank you, I did impress upon him the necessity of taking care of his sobriety as that is more  serious right now than the liver pain.