Effect of HCV Infection on Liver: Case Study

Introduction (400-600 words): 538

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 Hepatitis C virus (HCV) was first identified in patients with transfusion-associated hepatitis in which Feinstone and team in 1975 found no relation to viral hepatitis type A or B and so classifying HCV as non-A, non-B hepatitis (Feinstone et al., 1975). HCV is a positive-sense single stranded RNA belonging to the Flaviviridae family and Hepacivirus genus (Chevaliez and Pawlotsky, 2008) and due to its RNA nature and the absence of proofreading activity (Tsukiyama-Kohara and Kohara, 2018), HCV can suffer genetic mutations which can evade the host immune response as well as antiviral medication during a viral infestation. This prolonged evasion may result in viral resistance leading to chronic hepatitis C (Thomson, Smith and Klenerman, 2011). Chronic hepatitis can also be caused due to infected people being unaware of the problem as HCV usually does not show any symptoms until the liver sustain a certain degree of damage (Volk et al., 2009).

 According to WHO (World Health Organization), approximately 71 million people suffer from chronic hepatitis C infection, of which many of these cases will further develop into cirrhosis and hepatocellular carcinoma which can lead to death. Hepatitis C is responsible for nearly 400,000 deaths per year and to date there is no preventive vaccine (WHO, 2018).

 Nowadays, HCV is classified into 7 different genotypes which further divided into 67 subtypes (Smith et al., 2014). The prevalence of different genotypes varies in different countries. The genotype 1 being the most common worldwide and predominant in Europe, North and Latin America. Genotype 3 is the next most recurrent worldwide, of which a good proportion is seen in south Asia. Genotype 2 and 6 are commonly seen in east Asia and genotype 4 is largely present in North Africa and Middle East. Genotype 5 accounts for the least common genotype of all and it is most commonly found in Southern and Eastern sub-Saharan Africa (Messina et al., 2015).

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 The diagnosis of HCV is done by detecting the presence of anti-HCV antibodies and HCV RNA load in the serum, which can be achieved by enzyme immunoassay for the first and molecular amplification for the second. Real-time reverse-transcriptase PCR is a reliable technique used for HCV RNA quantification and genotype detection nowadays (Chevaliez and Pawlotsky, 2008)

 For many years the standard treatment given to patients was the combination of pegylated interferon and ribavirin, with and average success rate of 50% varying from genotype to genotype (Webster, Klenerman and Dusheiko, 2015), additionally it is an expensive and prolonged treatment which can cause adverse reactions, the usual timeframe of this treatment for genotype 1 and 4 is 48 weeks while genotypes 2 and 3 require half of that time(Halliday, Klenerman and Barnes, 2011). From 2014 onwards, a new generation of therapy called Direct Acting Antivirals (DAA) were developed with success rates above 90% including patients with chronic HCV (Pawlotsky, 2014).

 For a treatment to be considered successful and the patient “cured”, the patient needs to achieve sustained virologic response (SVR) which is defined by the undetectable levels of the virus RNA 24 weeks after the end of treatment, furthermore, relapse after achieving SVR is less than 1% in patients with chronic HCV (Lindsay, 2002). Nonetheless, reinfection can occur, especially in ongoing injecting drug users (Grebely et al., 2012).

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Results: (600-1000 words) 946

 The blood analysis of the patient in his first visit seen in table 1 revealed that the total bilirubin present in the blood was 3.9mg/dL indicating hyperbilirubinemia and explaining the patient’s jaundice; Liver enzyme ALT (Alanine transaminase) was 136 U/L and were also above the normal range which indicated liver damage; The presence of hepatitis C virus was positive, the titre for the anti HCV antibody was 1/80 dilution which shows the presence of antibodies against HCV in a higher dilution than the cut-off of 1/20 and the levels of HCV RNA in the bloodstream were 100,000 IU/ml, well above the cut-off limit of 200 IU/ml. Anti-Hepatitis A virus (anti-HAV) was negative for the presence of immunoglobulin M (IgM) antibody to HAV, and Hepatitis B surface antigen (HBsAg) was also negative, both results excluded the presence of Hepatitis A or B; Antinuclear antibody (ANA) was negative for the presence of autoantibody which means that there’s no evidence of an autoimmune disorder; Anti-mitochondrial antibody (AMA) were negative for the presence of autoantibodies against liver cells and thus excluding the presence of the autoimmune disease Primary Biliary Cirrhosis (PBC).

Table 1. Lab investigations of the patient X at the time of his first visit to his physician. Highlighted in red are the results well above the limit of normal range, which shows that the patient is positive for HCV and presented abnormal liver function. The negative results for anti-HAV and HBsAg rules out the presence of Hepatitis A or B; ANA and AMA results were negative for the presence of autoantibodies and primary biliary cirrhosis (PBC) respectively.

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 The HCV sample from the patient (isolate) were identified in the first screen by sequencing the hypervariable region of envelope E2 gene and analysed on nucleotide sequence BLAST search. The analysis in seen on table 2. The patient isolate had a 100% identity match with “Hepatitis C virus subtype 1a polyprotein gene, complete cds” (sequence ID: AF009606) and 99% identity match with the complete genome of Hepatitis C virus subtype 1a (sequence ID: M67463.1), both indicating that the patient’s HCV genotype was 1a.

Table 2. Sequence analysis of patient HCV isolate. Patient HCV isolate have a high identity match with the genotype 1a. Highlighted in yellow is the percentage of identity match of each comparison.

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 The patient HCV load was recorded over a period of 42 weeks and presented in log10 with a linear graph (table 3). The results showed a substantial reduction of HCV RNA in the first 4 weeks of treatment starting from log₁₀(550,000) = 5.75 IU/ml on the first week down to log₁₀(15,000) = 4.18 IU/ml on week 4. The viral load kept reducing significantly until week 12, going from log₁₀(15,000) = 4.18 IU/ml on week 4 to log₁₀(980) = 2.99 IU/ml on week 6 down to log₁₀(110) = 2.04 IU/ml on week 12. From week 18 onwards the values were bellow the cut-off value of log₁₀(200) = 2 UI/ml and thus considered bellow the limit of the detection.

Table 3. Effect of pegylated interferon and ribavirin on serum viral load in patient X (detection limit for HCV RNA is log₁₀(100) = 2 IU/ml). The results seen on the linear graph are represented in Log10. The graph shows substantial reduction of the viral RNA from week 0 to 12; From week 18 onwards the virus is considered undetectable because it is below the cut-off limit.

 The liver biopsy (fig. 1) done during the patient’s second visit to the hospital (2 years after the first diagnosis) shows significant necrosis of hepatocytes. There’s a great number of infiltrating lymphocytes, especially in the portal areas, causing inflammation – this is a characteristic of chronic hepatitis, and the presence of regenerative nodules that lost their normal architecture and high level of fibrotic tissue extending between portal tracts surrounding the regenerative nodules, these are the main characteristics of cirrhosis. Within the fibrotic tissue it is possible to see lymphocytes scattered all around along with proliferated bile ducts. The section also shows the presence of disorganised sinusoids which impairs the normal flow of the liver, swollen hepatocytes due to inflammation, few fat deposits, and no evidence of hepatocellular carcinoma.