This patient present with cirrhosis (Figure C) most likely caused by hepatitis C due to his IV drug use. All patients with chronic liver disease should be vaccinated against HAV and HBV. HAV vaccine is either a live attenuated or inactivated vaccine. HBV vaccine is a subunit vaccine.
HCV is an enveloped, single-stranded, positive-sense RNA virus which affects the liver and can cause cirrhosis, liver failure, and liver cancer in severe cases. It is usually transmitted through intravenous drug use, sexual practices, and in rare cases blood transfusions (Illustration A). Up to 50-80% of patients infected with HCV will progress to chronic infection requiring treatment. Traditional treatment has been pegylated interferon alpha and ribavirin for 24 or 48 weeks. However, new medications such as sofosbuvir, a nucleoside analog polymerase inhibitor that is administered along with peg interferon and ribivarin, have shown great promise and have produced cures in some cases. In addition to medical therapy, patients with chronic liver disease should be vaccinated against HAV and HBV. HAV vaccine is either a live attenuated or inactivated vaccine. HBV vaccine is a subunit vaccine, a vaccine that includes only the antigens that best stimulate the immune system.
Wilkins et al. review the diagnosis and management of HCV. They state that HCV is a common chronic bloodborne infection and is found in approximately 2 percent of adults in the United States. Chronic infection is associated with serious morbidity and mortality (e.g. cirrhosis, hepatocellular carcinoma). Current therapy for chronic HCV includes pegylated interferon and ribavirin. Therapy is based on factors that predict sustained virologic response, and the goal of therapy is to slow or halt progression of fibrosis and prevent the development of cirrhosis.
Johnston reviews the interpretation and significance of liver enzyme testing. He states they can be normal in patients with chronic hepatitis or cirrhosis. The normal range for aminotransferase levels is slightly higher in males, nonwhites, and obese persons. Severe alcoholic hepatitis is sometimes confused with cholecystitis or cholangitis. Conversely, patients who present soon after passing common bile duct stones can be misdiagnosed with acute hepatitis because aminotransferase levels often rise immediately, but alkaline phosphatase and gamma-glutamyltransferase levels do not become elevated for several days.
Figure A demonstrates scleral icterus characteristic of jaundice seen in liver failure. Figure B demonstrates severe ascites which is observed in severe cases of cirrhosis and liver failure. Figure C demonstrates asterixis, the characteristic slapping of hands seen in liver failure, or in states of hyperammonemia. Figure D demonstrates the histologic findings of cirrhosis which can be caused by chronic hepatitis C infection. Illustration A demonstrates the risk factors associated with HCV.
Answer 2: While HAV can be an inactivated vaccine, HBV is a subunit vaccine and must also be administered to patients with chronic liver disease.
Answer 3: Neither HAV or HBV vaccines are toxoid vaccines. Diphtheria and tetanus are examples of toxoid vaccines.
Answer 4: Neither HAV or HBV vaccines are toxoid or conjugate vaccines. Diphtheria and tetanus are examples of toxoid vaccines. Haemophilus influenzae type B (Hib) is an example of a conjugate vaccine.
Answer 5: While HAV vaccine can be a live attenuated vaccine, HBV is a subunit vaccine and must also be administered to patients with chronic liver disease.
Wilkins T, Malcolm JK, Raina D, Schade RR. Hepatitis C: diagnosis and treatment. Am Fam Physician. 2010 Jun 1;81(11):1351-7. Review. PubMed PMID: 20521755
PMID:20521755 (Link to Abstract)
Johnston DE. Special considerations in interpreting liver function tests. Am Fam Physician. 1999 Apr 15;59(8):2223-30. Review. PubMed PMID: 10221307
PMID:10221307 (Link to Abstract)