A 32-year-old white female was referred to a hepatologist for a liver biopsy following presentation to an emergency department (ED) where she had complained of fever and flank pain secondary to pyelonephritis from obstructive renal calculi. Past history was remarkable for a needle stick injury (the patient was a registered critical care nurse), sustained 10 years earlier in 1982 from a patient believed to be infected with non-A, non-B hepatitis. Six weeks subsequent to the needle stick, she became ill with a mild flu-like syndrome. She was not icteric and no laboratory tests were obtained. Routine physical exams following this exposure revealed sporadic elevations in liver function tests (LFTs). No further workup was obtained until her visit to the ED.
On physical exam in the ED, the patient was found to be well developed, well nourished, and in no acute distress. She was anicteric. Lymph nodes were negative, chest was clear to auscultation, and there was no hepatosplenomegaly.
No spider angioma or palmar erythema was present, and there was no edema of the extremities. The patient was very active and did not complain of fatigue or malaise. There was no evidence or history of decompensated liver disease or cirrhosis.
At the ED visit, laboratory values revealed a markedly elevated white blood cell count. Urinalysis was positive for blood, white blood cells, and bacteria.
Liver function tests were abnormal, with an aspartate aminotransferase (AST) of 48 U/L and an alanine aminotransferase (ALT) of 60 U/L. In light of these elevated LFTs, a complete hepatitis profile was obtained. The patient was found to be hepatitis C (HCV) antibody positive. She subsequently tested positive for HCV by polymerase chain reaction (PCR).
The patient was referred to a hepatologist who procured a percutaneous liver biopsy to establish baseline liver condition. Interferon alpha (IFN) therapy was initiated after careful consideration of side effects versus possible benefits. The patient began a drug regimen of 3 million international units (MIU) administered subcutaneously three times a week.