WBR0625

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 32 year old female, comes to your office for routine physical examination. Her past history is insignificant and his family history is unremarkable. She occasionally smokes cigarettes, but denies alcohol consumption or any illicit drug use. She is sexually active and is on oral contraceptive pills. Her general physical examination is normal. You run a battery of blood tests on her blood and the results are as follows. Haemoglobin : 12.2 g/dl Alanine aminotransferase : 45 U/L Aspartate aminotransferase : 40 U/L Alkaline phosphatase : 100 U/L Total bilirubin : 0.8 mg/dl Direct bilirubin : 0.4 mg/dl Prothrombin time : 10 sec Anti-HAV : negative HbsAg : negative Anti HBsAg : negative HCV RNA : positive Urine analysis shows bacteria, RBC’s, RBC cast without WBC’s. Liver biopsy done after these tests shows mild degree of hepatic inflammation. What is the best line of management at this time for the patient ?]]
Answer A	AnswerA::Give her hepatitis B vaccine
Answer A Explanation	[[AnswerAExp::Incorrect : Hepatitis B vaccine is not indicated for chronic hepatitis C patients.]]
Answer B	AnswerB::Monitor ALT every 6-12 months
Answer B Explanation	[[AnswerBExp::Incorrect : Patients with a persistently normal serum ALT who acquired the disease under the age of 35 years, are women, do not drink alcohol, and have no or minimal fibrosis on liver biopsy may have a slow rate of hepatic fibrosis progression and it is reasonable to monitor the patient without specific treatment.]]
Answer C	AnswerC::Start the patient on interferon
Answer C Explanation	[[AnswerCExp::Incorrect : Standard interferon monotherapy now a day is almost never used for treatment of chronic HCV.]]
Answer D	AnswerD::Give her hepatitis A vaccine
Answer D Explanation	[[AnswerDExp::Incorrect : Hepatitis A vaccine is given to all unimmunized patients with underlying liver disease; however this patient has extra hepatic manifestation and should be treated for chronic hepatitis C before initiating vaccines.]]
Answer E	AnswerE::Start the patient on peginterferon and ribavarin
Answer E Explanation	[[AnswerEExp::Correct : In patients with normal serum ALT concentrations and who have serious extrahepatic manifestations of infection such as cryoglobulinemia with vasculitis or glomerulonephritis, we usually start such patients on combination therapy with peginterferon alfa plus ribavirin.]]
Right Answer	RightAnswer::E
Explanation	[[Explanation::Hepatitis C virus (HCV) infection with a normal serum alanine aminotransferase (ALT) concentration is defined by detectable HCV RNA with serum ALT concentration that is persistently within the normal range. Patients with chronic HCV infection and normal serum ALT concentrations are usually asymptomatic. Most patients are discovered incidentally when anti-HCV antibodies are found after blood donation. Patients with a persistently normal serum ALT who acquired the disease under the age of 35 years, are women, do not drink alcohol, and have no or minimal fibrosis on liver biopsy may have a slow rate of hepatic fibrosis progression. In such patients, it is reasonable to monitor the patient without specific treatment. In contrast, patients who do not fit this profile, and whose initial biopsy shows moderate activity or some degree of fibrosis, may be at increased risk of disease progression. We usually treat such patients using combination therapy with peginterferon alfa plus ribavirin. In addition to treating the liver disease, therapy might be indicated, and life-saving, in patients with normal serum ALT concentrations who have serious extrahepatic manifestations of infection such as cryoglobulinemia with vasculitis or glomerulonephritis. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Chronic hepatitis C
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