A 48-year-old man with a 15-year history of intravenous drug use presents with progressive jaundice, ascites, and splenomegaly. He reports a single episode of acute hepatitis 12 years ago. Laboratory findings: ALT 120 IU/L, AST 240 IU/L, albumin 2.8 g/dL, total bilirubin 6.5 mg/dL, platelet count 85,000/μL, PT-INR 1.8. HBsAg is negative, anti-HBc is positive, anti-HCV is positive, HCV RNA is detectable. What is the most likely diagnosis?
A. Hepatitis B reactivation with hepatitis C coinfection
B. Occult hepatitis B with chronic hepatitis C
C. Acute hepatitis C superimposed on resolved hepatitis B
D. Chronic hepatitis C with cirrhosis
Explanation
Clinical Diagnosis: Chronic Hepatitis C with Cirrhosis
Key Diagnostic Features
Key Point
This patient has chronic hepatitis C with established cirrhosis, evidenced by portal hypertension (ascites, splenomegaly, thrombocytopenia) and hepatic synthetic dysfunction (low albumin, coagulopathy).
Serological Interpretation
Table
Marker
Result
Interpretation
HBsAg
Negative
No active HBV infection
Anti-HBc
Positive
Past HBV exposure/resolved infection
Anti-HCV
Positive
HCV exposure (past or present)
HCV RNA
Detectable
Active HCV replication — chronic infection
High-YieldNEET PG
Detectable HCV RNA in the presence of anti-HCV confirms chronic hepatitis C. The negative HBsAg with positive anti-HBc indicates resolved hepatitis B (immunity or past infection), not active disease.
Evidence of Cirrhosis
Mnemonic: ASPEN — features of portal hypertension and liver failure:
Ascites (present)
Splenomegaly (present)
Platelet count <100,000/μL (85,000 — present)
Elevated PT-INR (1.8 — present)
Normal/low albumin (2.8 — present)
Pathophysiology of Chronic HCV
1.
HCV establishes persistent infection in ~80% of acutely infected individuals
2.
Chronic inflammation → hepatic fibrosis over 10–30 years
3.
Progressive cirrhosis with portal hypertension and synthetic dysfunction
4.
This patient's 15-year IVDU history with detectable HCV RNA confirms chronic infection
Clinical Pearl
The combination of detectable HCV RNA, clinical signs of portal hypertension (ascites, splenomegaly), thrombocytopenia, and coagulopathy indicates cirrhosis. The negative HBsAg excludes active hepatitis B.
Distinction from Other Diagnoses
Occult HBV would show detectable HBV DNA despite negative HBsAg — not present here
Acute HCV superinfection would show acute transaminitis (ALT/AST >1000) — not seen
HBV reactivation requires positive HBsAg — absent in this case
Robbins 10e Ch 18
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