Post by adapted on Jul 12, 2005 4:49:00 GMT -5
Since very few can seem to get a diagnosis of Morgellons, and in some situations, Lyme Disease too, I thought I'd post this info as a possible thing to mention to doctors, if anyone still goes to those kinds of people anymore. Because, all along, I can't keep myself from wondering how many people may have other medical conditions, as well as Morgellons, that are not being addressed. I'm just offering this as food-for-thought.
HEPATITIS C VIRUS -- IT'S NOT ALL IN YOUR HEAD
Some doctors (but thankfully fewer than there used to be) insist on believing that HCV usually has no symptoms, and dismiss the patient's complaints as being "all in their head". Some HCV+ patients have been treated for depression for many years before their actual diagnosis of HCV was uncovered. Much is still unknown about the hepatitis C virus, and many physicians have not had much experience treating it. Many doctors are not yet familiar with the research which legitimizes the various symptoms which go along with this virus.
Emerging illnesses such as HCV typically go through a period of many years before they are accepted by the medical community, and during that interim time patients who have these new, unproven symptoms are all too often dismissed as being "psychiatric cases". This has been the experience with HCV as well.
(That sounds familiar, huh)
OTHER MEDICAL PROBLEMS RELATED TO HCV
Chronic hepatitis C infection occasionally causes problems for parts of the body beyond the liver. The organs most often affected include the blood vessels, skin, joints, kidneys, and thyroid gland. If chronic hepatitis C infection causes liver cirrhosis (severe scarring of the liver rarely caused by hepatitis C), many problems may arise from the cirrhosis, per se. Potential problems from cirrhosis include fluid accumulation in the abdomen, bleeding into the stomach, jaundice, confusion, poor blood clotting, and susceptibility to infection.
Hepatitis has so many symptoms that it's easy to ascribe all new anomalies to this disease. But HCV patients are not exempt from getting other illnesses also, therefore it is important to regularly monitor your health and to consult with your doctor about the changes as they progress.
CHRONIC PERSISTANT OR CHRONIC ACTIVE -WHAT'S THE DIFFERENCE?
Hepatitis C is considered to be "chronic" if it has persisted for longer than 6 months. The term "Chronic Persistent" used to be used to define hepatitis which persisted for longer than 6 months, but which was not currently causing active damage to the liver. The term "Chronic Active" was used to define hepatitis which persisted for longer than 6 months, and which was actively destroying the liver. The differentiation between "persistant" and "active" is not commonly used any more, with the assumption being that if the virus exists, it is causing damage whether it is moving quickly or not.
CRYOGLOBULINEMIA
Symptoms most often associated with cryoglobulinemia include mild fatigue, joint pains, or itching. Occasionally, people with cryoglobulinemia develop vasculitis (inflammation of the blood vessels) which can cause purpura (purple skin lesions), Raynaud's phenomenon (the hands turn white, then blue, and then red from constriction and subsequent dilation of the blood vessels), or numbness in the hands and feet.
THYROID AND AUTOIMMUNE PROBLEMS
Chronic hepatitis C infection is also associated with many autoimmune diseases (where the body develops antibodies which attack parts of itself). For example, about one-tenth of people with chronic hepatitis C infection (more often in women and older people) have antibodies to the thyroid gland, one-half of whom may develop hypothyroidism (an underactive thyroid gland).
People with hypothyroidism may suffer from fatigue poor memory, weakness, constipation, weight gain, muscle cramps, intolerance to cold, hoarse voice, coarse skin, and brittle hair. People with hyperthyroidism may suffer from anxiety, insomnia, weakness, diarrhea, weight loss, intolerance to heat, velvet-like skin, and brittle nails. Hypothyroidism can be treated with thyroid hormone pills. Hyperthyroidism can be treated with pills that block thyroid hormone synthesis.
RHEUMATOID ARTHRITIS-LIKE SYMPTOMS
Hepatitis C infection can present with rheumatic manifestations indistinguishable from rheumatoid arthritis.
FIBROMYALGIA
Fibromyalgia is the name for a condition that typically includes widespread muscle pain, fatigue and abnormal sleep patterns. Until a few years ago, doctors called the condition fibrositis or muscular rheumatism and believed that for the most part, the condition was "all in the patient's head". Today, fibromyalgia is recognized by medical organizations as a genuine and serious problem.
The symptoms of fibromyalgia typically include pain in many muscles, and around ligaments and tendons, persistent fatigue, waking up feeling tired even after a full night's sleep, headaches, bouts of constipation and diarrhea, abdominal pain, painful menstrual periods, sensitivity to cold, numbness or tingling, and difficulty exercising.
Symptoms vary widely among patients and tend to wax and wane over time. An illness, injury, cold weather or emotional stress may trigger a fibromyalgia episode or make ongoing symptoms worse.
A study at the Oregon Health Sciences University and Portland Adventist Hospital suggests hepatitis C may trigger fibromyalgia ( "Fibromyalgia: A prominent feature in patients with musculoskeletal problems in chronic hepatitis C, A report of 12 patients," by A. Barkhuizen, G.S. Schoepflin, and R.M. Bennett, Journal of Clinical Rheumatology, Vol. 2, No. 4, August 1996 ) . This study is the first to show a link between the two illnesses.
It was determined that the between the hepatitis C virus and fibromyalgia followed three distinct patterns:
-In nine patients, fibromyalgia developed as a long-term complication of the hepatitis, arising on average 13.4 years after the virus was acquired.
-In two patients, fibromyalgia arose simultaneously with the hepatitis C infection.
-In one patient, pre-existing fibromyalgia was significantly worsened by the hepatitis C.
It is unknown why the hepatitis C virus and fibromyalgia may be linked, but the authors suggest that hepatitis C causes chronic activation of the immune system that leads to muscle aching, fatigue, mental changes, sleep abnormalities, and alterations of the neuroendocrine system.
The patients with both hepatitis C and fibromyalgia could be distinguished from most other patients with fibromyalgia alone because they had symptoms unusual to fibromyalgia. These symptoms included synovitis (inflammation of the membrane around a joint, bursa, or tendon) and vasculitis (inflammation of a blood or lymph vessel). In addition, laboratory findings pointed to a disease process other than fibromyalgia.
DERMATOLOGICAL MANIFESTATIONS
The main dermatologic disorders in HCV infection include
(1) vasculitis (mainly cryoglobulin-associated vasculitis, the cause of which is HCV in most cases, and, possibly, some cases of polyarteritis nodosa)
(2) sporadic porphyria cutanea tarda
(3) cutaneous and/or mucosal lichen planus
(4) salivary gland lesions, characterized by lymphocytic capillaritis, sometimes associated with lymphocytic sialadenitis resembling that of Sjogren's syndrome.
Hepatitis C virus is the cause of, or is associated with, various dermatologic disorders. In patients with such disorders, HCV infection must be sought routinely because antiviral therapy may be beneficial in some of them. - Arch Dermatol. 1995; 131:1185-1193
PORPHYRIA CUTANEA TARDA (PCT)
Porphyrins are a group of compounds that are mainly synthesized in the bone marrow. They play an important role in many chemical reactions in the body, e.g. with proteins to build hemoglobin. They are later converted to bile pigments mainly in the liver. Porphyrinuria increase of porphyrins in the urine) may be caused by chronic liver diseases. Hepatitis C is a major cause of porphyria throughout the world and may cause many symptoms, including excess blood iron - important in conjunction with an interferon therapy (since elevated blood iron seems to reduce the effect of interferon).
Porphyria cutanea tarda is a rare deficiency of a liver enzyme essential for cellular metabolism. The enzyme deficiency may cause sun exposed skin to blister, ulcerate, turn dark, or bruise. Hair may increase on the forehead, cheeks, or forearms, and the urine may turn pink or brown. It now appears that hepatitis C is the most common trigger of porphyria in people who are predisposed. Topical sunscreens do not prevent the skin lesions. Avoidance of alcohol and removal of iron by repeated phlebotomy (blood removal) or taking medication that binds to iron sometimes helps. Chloroquine (an anti-malaria drug), which removes a toxic by-product of the enzyme deficiency, may help, as well.
LICHEN PLANUS
Occasionally, people with chronic hepatitis C develop a skin condition called lichen planus. It is a grouping of small, itchy, irregular, flat-topped reddened bumps. The bumps often have a network of very fine gray lines on their tops. The bumps show up most often on the wrists, shins, lower back, or genitals. Lichen planus also frequently occurs in the mouth, where it looks like a white, net-like plaque. It sometimes shows up as mouth ulcers and can be treated with a steroid mouth rinse called Dexamethasone Elixir or Nystatin tablets.
CYCLES AND FLAREUPS
Hepatitis flareups tend to occur in cycles, where for a while you may feel pretty good, then bad (maybe days to weeks for each period), then good again. It can be frustrating to obtain some relief, but then not know whether you have recovered or if you are merely between cycles.
Some people claim that they begin to feel better in the Spring, then start to feel worse again in August/September, with a low point usually around November/December.
HCV AND WOMEN'S CONCERNS
Women can be affected by hepatitis C in a different way from men. This is possibly due to hormonal effects and liver damage.
MENSTRUATION
The hormonal effects of HCV can involve menstrual irregularities, particularly if you are experiencing significant hepatitis C symptoms. It is important that your general health is checked as well as your hepatitis C monitored.
HORMONE REPLACEMENT THERAPY
If you have severe hepatitis symptoms you may need to discuss with your doctor whether hormones should be used for menopausal symptoms. Dysfunctional uterine bleeding and premature menopause, and most any other sort of hormonal aberration is pretty common with chronic liver disease. The liver processes these hormones, and they tend to not get processed properly when the liver is damaged.
HOW DOES HCV AFFECT CHILDREN?
Children with chronic hepatitis cannot be treated simply like miniature adults. Specific issues and questions need to be addressed when dealing with the pediatric age group.
Pediatric patients are less likely than adults to have symptoms of infection with hepatitis C, leaving the viruses undetected and possibly unknowingly spread. According to information available on the natural history of HCV, the percentage of children who become chronic and the long-term outcomes are similar to the percentage of adults. Children who are chronic carriers of HCV have normal growth patterns.
WHAT ARE THE DIFFERENT CLINICAL INDICATIONS OF HCV?
ELEVATED LIVER ENZYMES
There are two general categories of "liver enzymes." The first group includes the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST), sometimes referred to as the SGPT and SGOT. These are enzymes that are indicators of liver cell damage. The other frequently used liver enzymes are the alkaline phosphatase and gamma-glutamyltranspeptidase (GGT and GGTP) that indicate obstruction to the biliary system, either within the liver or in the larger bile channels outside the liver.
The ALT and AST are enzymes that are located in liver cells and leak out and make their way into the general circulation when liver cells are injured. The ALT is thought to be a more specific indicator of liver inflammation, since the AST may be elevated in diseases of other organs such as heart disease or muscle disease. ALT and AST are often used to monitor the course of chronic hepatitis and the response to treatments, such as prednisone and interferon. The alkaline phosphatase and the GGT are elevated in a large number of disorders that affect the drainage of bile, such as a gallstone or tumor blocking the common bile duct, or alcoholic liver disease or drug-induced hepatitis, blocking the flow of bile in smaller bile channels within the liver. The alkaline phosphatase is also found in other organs, such as bone, placenta, and intestine. For this reason, the GGT is utilized as a supplementary test to be sure that the elevation of alkaline phosphatase is indeed coming from the liver or the biliary tract. In contrast to the alkaline phosphatase, the GGT tends not to be elevated in diseases of bone, placenta, or intestine. Mild or moderate elevation of GGT in the presence of a normal alkaline phosphatase
is difficult to interpret and often caused by changes in the liver cell enzymes induced by alcohol or medications, but without causing injury to the liver.
ELEVATED ALFHA-PHETOPROTEIN LEVELS
It is fairly common for alfa-phetoprotein markers to be elevated in patients with hepatitis C. Alfaphetoprotein is a marker for tumors, but unless your numbers are extremely high (for example, in the hundreds), there is no need for alarm. Your doctor will probably want to perform further studies, such as an ultrasound or CT scan, just to be on the safe side
JAUNDICE
Jaundice (yellow skin) may appear as a symptom occasionally, but is most common during an acute attack. Jaundice is caused by the buildup of bile pigment that is passed by the liver into the intestines. This same bile buildup can also cause intense itching.
HEPATOMEGALY, SPLENOMEGALY
Some people experience a swelling of the liver (hepatomegaly) or the spleen (splenomegaly) as a result of hepatitis.
SPIDER NEVI
Spider nevi are small capillaries that are seen on the surface of your skin. Branches form (grow) from the one capillary and it can either look like a small red spider or a splat (kind of like a squashed spider). They are also referred to as spider angiomas. If you have less than 10 that can be considered normal, more than that and it's an indication of chronic liver disease. They can be found only above the waist, usually on the chest, upper arms, shoulders, face, neck and upper back.
ASCITES
Occurring in cirrhosis, the accumulation of fluid in the abdominal cavity, or ascites, is related to portal hypertension, significant reduction in serum albumin, and renal retention of sodium. The volume of abdominal ascites in adults with cirrhosis may reach levels as great as 10 to 12 liters (10.6 to 12.7 quarts). Ascitic fluid may accumulate in the scrotum and in the chest cavity, where its presence, combined with the upward pressure on the diaphragm from the abdominal fluid, may severely affect breathing. Appetite also is often reduced by the abdominal distention.
Ascites are treated by the removal of enough fluid directly from the abdomen by needle puncture to ease discomfort and breathing. Patients are placed on diets low in salt, and they are given diuretic drugs to increase the output of water by the kidneys. If these measures do not control massive ascites, ascites can be drained internally into the general venous blood system by running a plastic tube from the abdominal cavity, under the skin of the chest, into the right internal jugular vein of the neck (peritoneovenous shunt of LeVeen).
PORTAL HYPERTENSION / VARICES
Sometimes occurring in cirrhosis, portal hypertension is the increased pressure in the portal vein and its tributaries resulting from blockages to the blood flow into the liver. It is usually caused by the scarring processes of cirrhosis. The increased pressure causes varices, or dilations of the veins leading into the portal vein. When varices are located in superficial tissues, they may rupture and bleed profusely. Two such locations are the lower esophagus and the perianal region.
Esophageal varices are likely to bleed most heavily, and this bleeding is frequently associated with the onset of hepatic encephalopathy or coma. Because of their location at the lower end of the esophagus or the upper portion of the stomach, bleeding from varices is often difficult to control. If variceal bleeding persists, surgical formation of a shunt, or artificial passageway, from the portal vein to an abdominal vein may be done.
HEPATIC ENCEPHALOPATHY
Hepatic encephalopathy refers to the changes in the brain that occur in patients with advanced acute or chronic liver disease. If liver cells are damaged, certain substances that are normally cleansed from the blood by the healthy liver are not removed (mainly ammonia, or possibly certain fatty acids). A patient with chronic hepatic encephalopathy may develop progressive loss of memory, disorientation, untidiness, and muscular tremors, leading to a form of chronic dementia. The ingestion of protein invariably aggravates these symptoms.
The treatment of hepatic encephalopathy involves, first, the removal of all drugs that require detoxification in the liver and, second, the reduction of the intake of protein. Restricting the amount of protein in the diet will generally lower the levels of amino acids and ammonia in the bloodstream and brain. Most physicians advise their patients with this condition to eat only about 40 grams of protein a day, and will prescribe lactulose or neomycin to lower amino acid production. Non-meat proteins, such as those found in vegetables and milk, are also recommended. Certain amino acids are used in treatment, since they are considered less likely to cause mental impairment. A dietary supplement rich in these amino acids is used at many liver treatment centers.
CIRRHOSIS
When chronic diseases cause the liver to become permanently injured and scarred, the condition is called cirrhosis. The scar tissue that forms in cirrhosis harms the structure of the liver, blocking the flow of blood through the organ. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also slowed is production of proteins and other substances made by the liver.
People with liver cirrhosis may develop many problems beyond the liver. When the liver is scarred, the blood cannot easily get through the liver, and backs up under higher than normal pressure (portal hypertension). This often causes ascites, which is yellow fluid that leaks out of the bloodstream into the abdominal cavity.
If the ascites becomes tense, it can cause an umbilical hernia (a protruding belly button). The backed-up blood also often creates varices, in which the pressure causes the blood vessels around the esophagus to burst causing significant blood loss. Varices can be treated with beta blockers, or can be obliterated using endoscopically-placed rubber bands or injections of liquid that cause the varices to scar. If endoscopy fails to stop bleeding, a TIPS (transjugular intrahepatic portosystemic shunt) can be created by inserting a short metal mesh tube through a neck vein into the liver and connecting the portal vein in the liver to a regular vein in the liver. Another alternative is to surgically redirect some of the blood flow around the liver.
People with cirrhosis sometimes may develop jaundice (a yellowing of the whites of the eyes or the skin) due to an accumulation of bilirubin in the blood. If the bilirubin is excreted in the urine, the urine may turn dark.
People with cirrhosis are also at risk for hepatic encephalopathy, which is fatigue or confusion caused by ammonia and other products of protein digestion which are inadequately cleared from the bloodstream by the liver.
People with cirrhosis often bruise easily because the liver manufactures reduced amounts of clotting factors. Additionally, platelets may be lower than normal in the circulation if the spleen is enlarged. A spleen enlarged from portal hypertension may hold onto too many platelets.
Chronic HCV infection leads to cirrhosis in at least 20 percent of patients within 2 decades of the onset of infection. Cirrhosis and end-stage liver disease may occasionally develop rapidly, especially among patients with concomittant alcohol use. - National Institutes of Health Consensus Statement on Hepatitis C 1997
FULMINANT HEPATITIS
In very rare cases hepatitis symptoms develop quickly and become very severe. This less common form of hepatitis is called fulminant hepatitis or fast-progressing hepatitis, and it requires prompt medical attention. It can be fatal in up to 70 to 80 percent of cases. The kidneys may fail, and the liver shrinks as cells are killed. The person may fall into a coma and die. Fulminant liver failure following HCV infection has been reported but is a rare occurrance.
DOES HCV INCREASE THE LIKELIHOOD OF CANCER?
Chronic infection by HCV is associated with an increased risk of liver cancer. The prevailing concept is that hepatocellular carcinoma (HCC) occurs against a background of inflammation and regeneration associated with chronic hepatitis over the course of approximately 3 or more decades. Most cases of HCV-related HCC occur in the presence of cirrhosis. The risk for a person with chronic HCV hepatitis developing HCC appears to be 1-5 percent after 20 years, with striking variations in rates in different geographic areas of the world. Once cirrhosis is established, the rate of development of HCC is 1-4 percent per year. - National Institutes of Health Consensus Statement on Hepatitis C 1997
Chronic infection with hepatitis C virus (HCV) is regarded as a risk factor for hepatocellular cancer, mostly in patients with liver cirrhosis. We looked for HCV genomes in the livers of patients with hepatocellular cancer who did not have cirrhosis to see whether HCV was directly oncogenic. Cancerous and non-cancerous liver tissue, and serum samples from 19 patients negative for hepatitis B surface antigen were analysed by polymerase chain reaction for the presence of HCV genome, HCV replication, HCV genotyping, and HBV genome. 13 of 19 patients were HCV RNA-positive in cancerous and non-cancerous liver tissue; 8 of 17 tested were anti-HCV positive. Among the 13 HCV RNA-positive patients, 11 had genotype 1b and 2 had genotype 2a. 7 of 13 serum samples were HCV RNA positive. 7 of 19 patients were HBV DNA positive in cancerous and non-cancerous liver tissue, 5 of them anti-HBc positive. 4 patients were both HCV RNA and HBV DNA positive and 3 were both HCV RNA and HBV DNA negative. The results provide evidence for the association of HCV, mostly genotype 1b, with hepatocellular cancer without the intermediate step of cirrhosis. - "HCV-associated liver cancer without cirrhosis", De Mitri MS; Poussin K; Baccarini P; Pontisso P; D'Errico A; Simon N; Grigioni W; Alberti A; Beaugrand M; Pisi E; et al, Department of Internal Medicine, University of Bologna, Italy, Lancet 345: 413-5 (1995 )
Previously, we reported the high prevalence of hepatitis C virus (HCV) infection in patients with oral cancer or oral lichen planus in Kyushu, Japan. We now report a 61-year-old man with chronic hepatitis C and no oral lesions who developed oral cancer 6 months after interferon therapy (interferon alpha, 6 million units (MU) daily for 2 weeks and then 3 times a week for 14 weeks). This case emphasizes the need for periodic oral cavity examinations of hepatitis C patients and contributed to the investigation of oral cancer and HCV. - "Oral cancer and hepatitis C virus (HCV): can HCV alone cause oral cancer?--a case report." Kurume Medical Journal, 1996 Vol 1, Issue 43, pp 97-100
It is thought that treatment with interferon reduces the risk of later developing liver cancer. "The low incidence of hepatocellular carcinoma in patients treated with interferon suggests that interferon may prevent the development of hepatocellular carcinoma." - "Risk Factors and the Effect of Interferon Therapy in the Development of Hepatocellular Carcinoma," Journal of Gastroenterology and Hepatology 1997 Feb;12(2):149-155
An association between chronic hepatitis C infection and non-Hodgkin's lymphoma has been reported. " HCV Infection and Extrahepatic Malignancies," Journal of Clinical Gastroenterology 1997 Mar;24(2):87-89
HOW MANY OF US ARE THERE?
Hepatitis C accounts for 20% of community-acquired hepatitis in the US. Approximately 200 case of hepatitis C are reported in New York State each year. -- "Prevention, Diagnosis, and Management of Viral Hepatitis", AMA
Each year, 150,000 new cases of hepatitis C infection occur in the United States. -- " Hepatitis C & E: how much of a threat?" Special Issue: Emerging Infectious Diseases, Brown, Edwin A., May 15 1994, v28, n9, p105(8)
The (US) Center for Disease Control and Prevention, estimates that at least 17 1/2 million people (in the US) are living with chronic hepatitis C infections and as many as 150,000 Americans are newly infected with hepatitis C each year.
HEPATITIS C VIRUS -- IT'S NOT ALL IN YOUR HEAD
Some doctors (but thankfully fewer than there used to be) insist on believing that HCV usually has no symptoms, and dismiss the patient's complaints as being "all in their head". Some HCV+ patients have been treated for depression for many years before their actual diagnosis of HCV was uncovered. Much is still unknown about the hepatitis C virus, and many physicians have not had much experience treating it. Many doctors are not yet familiar with the research which legitimizes the various symptoms which go along with this virus.
Emerging illnesses such as HCV typically go through a period of many years before they are accepted by the medical community, and during that interim time patients who have these new, unproven symptoms are all too often dismissed as being "psychiatric cases". This has been the experience with HCV as well.
(That sounds familiar, huh)
OTHER MEDICAL PROBLEMS RELATED TO HCV
Chronic hepatitis C infection occasionally causes problems for parts of the body beyond the liver. The organs most often affected include the blood vessels, skin, joints, kidneys, and thyroid gland. If chronic hepatitis C infection causes liver cirrhosis (severe scarring of the liver rarely caused by hepatitis C), many problems may arise from the cirrhosis, per se. Potential problems from cirrhosis include fluid accumulation in the abdomen, bleeding into the stomach, jaundice, confusion, poor blood clotting, and susceptibility to infection.
Hepatitis has so many symptoms that it's easy to ascribe all new anomalies to this disease. But HCV patients are not exempt from getting other illnesses also, therefore it is important to regularly monitor your health and to consult with your doctor about the changes as they progress.
CHRONIC PERSISTANT OR CHRONIC ACTIVE -WHAT'S THE DIFFERENCE?
Hepatitis C is considered to be "chronic" if it has persisted for longer than 6 months. The term "Chronic Persistent" used to be used to define hepatitis which persisted for longer than 6 months, but which was not currently causing active damage to the liver. The term "Chronic Active" was used to define hepatitis which persisted for longer than 6 months, and which was actively destroying the liver. The differentiation between "persistant" and "active" is not commonly used any more, with the assumption being that if the virus exists, it is causing damage whether it is moving quickly or not.
CRYOGLOBULINEMIA
Symptoms most often associated with cryoglobulinemia include mild fatigue, joint pains, or itching. Occasionally, people with cryoglobulinemia develop vasculitis (inflammation of the blood vessels) which can cause purpura (purple skin lesions), Raynaud's phenomenon (the hands turn white, then blue, and then red from constriction and subsequent dilation of the blood vessels), or numbness in the hands and feet.
THYROID AND AUTOIMMUNE PROBLEMS
Chronic hepatitis C infection is also associated with many autoimmune diseases (where the body develops antibodies which attack parts of itself). For example, about one-tenth of people with chronic hepatitis C infection (more often in women and older people) have antibodies to the thyroid gland, one-half of whom may develop hypothyroidism (an underactive thyroid gland).
People with hypothyroidism may suffer from fatigue poor memory, weakness, constipation, weight gain, muscle cramps, intolerance to cold, hoarse voice, coarse skin, and brittle hair. People with hyperthyroidism may suffer from anxiety, insomnia, weakness, diarrhea, weight loss, intolerance to heat, velvet-like skin, and brittle nails. Hypothyroidism can be treated with thyroid hormone pills. Hyperthyroidism can be treated with pills that block thyroid hormone synthesis.
RHEUMATOID ARTHRITIS-LIKE SYMPTOMS
Hepatitis C infection can present with rheumatic manifestations indistinguishable from rheumatoid arthritis.
FIBROMYALGIA
Fibromyalgia is the name for a condition that typically includes widespread muscle pain, fatigue and abnormal sleep patterns. Until a few years ago, doctors called the condition fibrositis or muscular rheumatism and believed that for the most part, the condition was "all in the patient's head". Today, fibromyalgia is recognized by medical organizations as a genuine and serious problem.
The symptoms of fibromyalgia typically include pain in many muscles, and around ligaments and tendons, persistent fatigue, waking up feeling tired even after a full night's sleep, headaches, bouts of constipation and diarrhea, abdominal pain, painful menstrual periods, sensitivity to cold, numbness or tingling, and difficulty exercising.
Symptoms vary widely among patients and tend to wax and wane over time. An illness, injury, cold weather or emotional stress may trigger a fibromyalgia episode or make ongoing symptoms worse.
A study at the Oregon Health Sciences University and Portland Adventist Hospital suggests hepatitis C may trigger fibromyalgia ( "Fibromyalgia: A prominent feature in patients with musculoskeletal problems in chronic hepatitis C, A report of 12 patients," by A. Barkhuizen, G.S. Schoepflin, and R.M. Bennett, Journal of Clinical Rheumatology, Vol. 2, No. 4, August 1996 ) . This study is the first to show a link between the two illnesses.
It was determined that the between the hepatitis C virus and fibromyalgia followed three distinct patterns:
-In nine patients, fibromyalgia developed as a long-term complication of the hepatitis, arising on average 13.4 years after the virus was acquired.
-In two patients, fibromyalgia arose simultaneously with the hepatitis C infection.
-In one patient, pre-existing fibromyalgia was significantly worsened by the hepatitis C.
It is unknown why the hepatitis C virus and fibromyalgia may be linked, but the authors suggest that hepatitis C causes chronic activation of the immune system that leads to muscle aching, fatigue, mental changes, sleep abnormalities, and alterations of the neuroendocrine system.
The patients with both hepatitis C and fibromyalgia could be distinguished from most other patients with fibromyalgia alone because they had symptoms unusual to fibromyalgia. These symptoms included synovitis (inflammation of the membrane around a joint, bursa, or tendon) and vasculitis (inflammation of a blood or lymph vessel). In addition, laboratory findings pointed to a disease process other than fibromyalgia.
DERMATOLOGICAL MANIFESTATIONS
The main dermatologic disorders in HCV infection include
(1) vasculitis (mainly cryoglobulin-associated vasculitis, the cause of which is HCV in most cases, and, possibly, some cases of polyarteritis nodosa)
(2) sporadic porphyria cutanea tarda
(3) cutaneous and/or mucosal lichen planus
(4) salivary gland lesions, characterized by lymphocytic capillaritis, sometimes associated with lymphocytic sialadenitis resembling that of Sjogren's syndrome.
Hepatitis C virus is the cause of, or is associated with, various dermatologic disorders. In patients with such disorders, HCV infection must be sought routinely because antiviral therapy may be beneficial in some of them. - Arch Dermatol. 1995; 131:1185-1193
PORPHYRIA CUTANEA TARDA (PCT)
Porphyrins are a group of compounds that are mainly synthesized in the bone marrow. They play an important role in many chemical reactions in the body, e.g. with proteins to build hemoglobin. They are later converted to bile pigments mainly in the liver. Porphyrinuria increase of porphyrins in the urine) may be caused by chronic liver diseases. Hepatitis C is a major cause of porphyria throughout the world and may cause many symptoms, including excess blood iron - important in conjunction with an interferon therapy (since elevated blood iron seems to reduce the effect of interferon).
Porphyria cutanea tarda is a rare deficiency of a liver enzyme essential for cellular metabolism. The enzyme deficiency may cause sun exposed skin to blister, ulcerate, turn dark, or bruise. Hair may increase on the forehead, cheeks, or forearms, and the urine may turn pink or brown. It now appears that hepatitis C is the most common trigger of porphyria in people who are predisposed. Topical sunscreens do not prevent the skin lesions. Avoidance of alcohol and removal of iron by repeated phlebotomy (blood removal) or taking medication that binds to iron sometimes helps. Chloroquine (an anti-malaria drug), which removes a toxic by-product of the enzyme deficiency, may help, as well.
LICHEN PLANUS
Occasionally, people with chronic hepatitis C develop a skin condition called lichen planus. It is a grouping of small, itchy, irregular, flat-topped reddened bumps. The bumps often have a network of very fine gray lines on their tops. The bumps show up most often on the wrists, shins, lower back, or genitals. Lichen planus also frequently occurs in the mouth, where it looks like a white, net-like plaque. It sometimes shows up as mouth ulcers and can be treated with a steroid mouth rinse called Dexamethasone Elixir or Nystatin tablets.
CYCLES AND FLAREUPS
Hepatitis flareups tend to occur in cycles, where for a while you may feel pretty good, then bad (maybe days to weeks for each period), then good again. It can be frustrating to obtain some relief, but then not know whether you have recovered or if you are merely between cycles.
Some people claim that they begin to feel better in the Spring, then start to feel worse again in August/September, with a low point usually around November/December.
HCV AND WOMEN'S CONCERNS
Women can be affected by hepatitis C in a different way from men. This is possibly due to hormonal effects and liver damage.
MENSTRUATION
The hormonal effects of HCV can involve menstrual irregularities, particularly if you are experiencing significant hepatitis C symptoms. It is important that your general health is checked as well as your hepatitis C monitored.
HORMONE REPLACEMENT THERAPY
If you have severe hepatitis symptoms you may need to discuss with your doctor whether hormones should be used for menopausal symptoms. Dysfunctional uterine bleeding and premature menopause, and most any other sort of hormonal aberration is pretty common with chronic liver disease. The liver processes these hormones, and they tend to not get processed properly when the liver is damaged.
HOW DOES HCV AFFECT CHILDREN?
Children with chronic hepatitis cannot be treated simply like miniature adults. Specific issues and questions need to be addressed when dealing with the pediatric age group.
Pediatric patients are less likely than adults to have symptoms of infection with hepatitis C, leaving the viruses undetected and possibly unknowingly spread. According to information available on the natural history of HCV, the percentage of children who become chronic and the long-term outcomes are similar to the percentage of adults. Children who are chronic carriers of HCV have normal growth patterns.
WHAT ARE THE DIFFERENT CLINICAL INDICATIONS OF HCV?
ELEVATED LIVER ENZYMES
There are two general categories of "liver enzymes." The first group includes the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST), sometimes referred to as the SGPT and SGOT. These are enzymes that are indicators of liver cell damage. The other frequently used liver enzymes are the alkaline phosphatase and gamma-glutamyltranspeptidase (GGT and GGTP) that indicate obstruction to the biliary system, either within the liver or in the larger bile channels outside the liver.
The ALT and AST are enzymes that are located in liver cells and leak out and make their way into the general circulation when liver cells are injured. The ALT is thought to be a more specific indicator of liver inflammation, since the AST may be elevated in diseases of other organs such as heart disease or muscle disease. ALT and AST are often used to monitor the course of chronic hepatitis and the response to treatments, such as prednisone and interferon. The alkaline phosphatase and the GGT are elevated in a large number of disorders that affect the drainage of bile, such as a gallstone or tumor blocking the common bile duct, or alcoholic liver disease or drug-induced hepatitis, blocking the flow of bile in smaller bile channels within the liver. The alkaline phosphatase is also found in other organs, such as bone, placenta, and intestine. For this reason, the GGT is utilized as a supplementary test to be sure that the elevation of alkaline phosphatase is indeed coming from the liver or the biliary tract. In contrast to the alkaline phosphatase, the GGT tends not to be elevated in diseases of bone, placenta, or intestine. Mild or moderate elevation of GGT in the presence of a normal alkaline phosphatase
is difficult to interpret and often caused by changes in the liver cell enzymes induced by alcohol or medications, but without causing injury to the liver.
ELEVATED ALFHA-PHETOPROTEIN LEVELS
It is fairly common for alfa-phetoprotein markers to be elevated in patients with hepatitis C. Alfaphetoprotein is a marker for tumors, but unless your numbers are extremely high (for example, in the hundreds), there is no need for alarm. Your doctor will probably want to perform further studies, such as an ultrasound or CT scan, just to be on the safe side
JAUNDICE
Jaundice (yellow skin) may appear as a symptom occasionally, but is most common during an acute attack. Jaundice is caused by the buildup of bile pigment that is passed by the liver into the intestines. This same bile buildup can also cause intense itching.
HEPATOMEGALY, SPLENOMEGALY
Some people experience a swelling of the liver (hepatomegaly) or the spleen (splenomegaly) as a result of hepatitis.
SPIDER NEVI
Spider nevi are small capillaries that are seen on the surface of your skin. Branches form (grow) from the one capillary and it can either look like a small red spider or a splat (kind of like a squashed spider). They are also referred to as spider angiomas. If you have less than 10 that can be considered normal, more than that and it's an indication of chronic liver disease. They can be found only above the waist, usually on the chest, upper arms, shoulders, face, neck and upper back.
ASCITES
Occurring in cirrhosis, the accumulation of fluid in the abdominal cavity, or ascites, is related to portal hypertension, significant reduction in serum albumin, and renal retention of sodium. The volume of abdominal ascites in adults with cirrhosis may reach levels as great as 10 to 12 liters (10.6 to 12.7 quarts). Ascitic fluid may accumulate in the scrotum and in the chest cavity, where its presence, combined with the upward pressure on the diaphragm from the abdominal fluid, may severely affect breathing. Appetite also is often reduced by the abdominal distention.
Ascites are treated by the removal of enough fluid directly from the abdomen by needle puncture to ease discomfort and breathing. Patients are placed on diets low in salt, and they are given diuretic drugs to increase the output of water by the kidneys. If these measures do not control massive ascites, ascites can be drained internally into the general venous blood system by running a plastic tube from the abdominal cavity, under the skin of the chest, into the right internal jugular vein of the neck (peritoneovenous shunt of LeVeen).
PORTAL HYPERTENSION / VARICES
Sometimes occurring in cirrhosis, portal hypertension is the increased pressure in the portal vein and its tributaries resulting from blockages to the blood flow into the liver. It is usually caused by the scarring processes of cirrhosis. The increased pressure causes varices, or dilations of the veins leading into the portal vein. When varices are located in superficial tissues, they may rupture and bleed profusely. Two such locations are the lower esophagus and the perianal region.
Esophageal varices are likely to bleed most heavily, and this bleeding is frequently associated with the onset of hepatic encephalopathy or coma. Because of their location at the lower end of the esophagus or the upper portion of the stomach, bleeding from varices is often difficult to control. If variceal bleeding persists, surgical formation of a shunt, or artificial passageway, from the portal vein to an abdominal vein may be done.
HEPATIC ENCEPHALOPATHY
Hepatic encephalopathy refers to the changes in the brain that occur in patients with advanced acute or chronic liver disease. If liver cells are damaged, certain substances that are normally cleansed from the blood by the healthy liver are not removed (mainly ammonia, or possibly certain fatty acids). A patient with chronic hepatic encephalopathy may develop progressive loss of memory, disorientation, untidiness, and muscular tremors, leading to a form of chronic dementia. The ingestion of protein invariably aggravates these symptoms.
The treatment of hepatic encephalopathy involves, first, the removal of all drugs that require detoxification in the liver and, second, the reduction of the intake of protein. Restricting the amount of protein in the diet will generally lower the levels of amino acids and ammonia in the bloodstream and brain. Most physicians advise their patients with this condition to eat only about 40 grams of protein a day, and will prescribe lactulose or neomycin to lower amino acid production. Non-meat proteins, such as those found in vegetables and milk, are also recommended. Certain amino acids are used in treatment, since they are considered less likely to cause mental impairment. A dietary supplement rich in these amino acids is used at many liver treatment centers.
CIRRHOSIS
When chronic diseases cause the liver to become permanently injured and scarred, the condition is called cirrhosis. The scar tissue that forms in cirrhosis harms the structure of the liver, blocking the flow of blood through the organ. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also slowed is production of proteins and other substances made by the liver.
People with liver cirrhosis may develop many problems beyond the liver. When the liver is scarred, the blood cannot easily get through the liver, and backs up under higher than normal pressure (portal hypertension). This often causes ascites, which is yellow fluid that leaks out of the bloodstream into the abdominal cavity.
If the ascites becomes tense, it can cause an umbilical hernia (a protruding belly button). The backed-up blood also often creates varices, in which the pressure causes the blood vessels around the esophagus to burst causing significant blood loss. Varices can be treated with beta blockers, or can be obliterated using endoscopically-placed rubber bands or injections of liquid that cause the varices to scar. If endoscopy fails to stop bleeding, a TIPS (transjugular intrahepatic portosystemic shunt) can be created by inserting a short metal mesh tube through a neck vein into the liver and connecting the portal vein in the liver to a regular vein in the liver. Another alternative is to surgically redirect some of the blood flow around the liver.
People with cirrhosis sometimes may develop jaundice (a yellowing of the whites of the eyes or the skin) due to an accumulation of bilirubin in the blood. If the bilirubin is excreted in the urine, the urine may turn dark.
People with cirrhosis are also at risk for hepatic encephalopathy, which is fatigue or confusion caused by ammonia and other products of protein digestion which are inadequately cleared from the bloodstream by the liver.
People with cirrhosis often bruise easily because the liver manufactures reduced amounts of clotting factors. Additionally, platelets may be lower than normal in the circulation if the spleen is enlarged. A spleen enlarged from portal hypertension may hold onto too many platelets.
Chronic HCV infection leads to cirrhosis in at least 20 percent of patients within 2 decades of the onset of infection. Cirrhosis and end-stage liver disease may occasionally develop rapidly, especially among patients with concomittant alcohol use. - National Institutes of Health Consensus Statement on Hepatitis C 1997
FULMINANT HEPATITIS
In very rare cases hepatitis symptoms develop quickly and become very severe. This less common form of hepatitis is called fulminant hepatitis or fast-progressing hepatitis, and it requires prompt medical attention. It can be fatal in up to 70 to 80 percent of cases. The kidneys may fail, and the liver shrinks as cells are killed. The person may fall into a coma and die. Fulminant liver failure following HCV infection has been reported but is a rare occurrance.
DOES HCV INCREASE THE LIKELIHOOD OF CANCER?
Chronic infection by HCV is associated with an increased risk of liver cancer. The prevailing concept is that hepatocellular carcinoma (HCC) occurs against a background of inflammation and regeneration associated with chronic hepatitis over the course of approximately 3 or more decades. Most cases of HCV-related HCC occur in the presence of cirrhosis. The risk for a person with chronic HCV hepatitis developing HCC appears to be 1-5 percent after 20 years, with striking variations in rates in different geographic areas of the world. Once cirrhosis is established, the rate of development of HCC is 1-4 percent per year. - National Institutes of Health Consensus Statement on Hepatitis C 1997
Chronic infection with hepatitis C virus (HCV) is regarded as a risk factor for hepatocellular cancer, mostly in patients with liver cirrhosis. We looked for HCV genomes in the livers of patients with hepatocellular cancer who did not have cirrhosis to see whether HCV was directly oncogenic. Cancerous and non-cancerous liver tissue, and serum samples from 19 patients negative for hepatitis B surface antigen were analysed by polymerase chain reaction for the presence of HCV genome, HCV replication, HCV genotyping, and HBV genome. 13 of 19 patients were HCV RNA-positive in cancerous and non-cancerous liver tissue; 8 of 17 tested were anti-HCV positive. Among the 13 HCV RNA-positive patients, 11 had genotype 1b and 2 had genotype 2a. 7 of 13 serum samples were HCV RNA positive. 7 of 19 patients were HBV DNA positive in cancerous and non-cancerous liver tissue, 5 of them anti-HBc positive. 4 patients were both HCV RNA and HBV DNA positive and 3 were both HCV RNA and HBV DNA negative. The results provide evidence for the association of HCV, mostly genotype 1b, with hepatocellular cancer without the intermediate step of cirrhosis. - "HCV-associated liver cancer without cirrhosis", De Mitri MS; Poussin K; Baccarini P; Pontisso P; D'Errico A; Simon N; Grigioni W; Alberti A; Beaugrand M; Pisi E; et al, Department of Internal Medicine, University of Bologna, Italy, Lancet 345: 413-5 (1995 )
Previously, we reported the high prevalence of hepatitis C virus (HCV) infection in patients with oral cancer or oral lichen planus in Kyushu, Japan. We now report a 61-year-old man with chronic hepatitis C and no oral lesions who developed oral cancer 6 months after interferon therapy (interferon alpha, 6 million units (MU) daily for 2 weeks and then 3 times a week for 14 weeks). This case emphasizes the need for periodic oral cavity examinations of hepatitis C patients and contributed to the investigation of oral cancer and HCV. - "Oral cancer and hepatitis C virus (HCV): can HCV alone cause oral cancer?--a case report." Kurume Medical Journal, 1996 Vol 1, Issue 43, pp 97-100
It is thought that treatment with interferon reduces the risk of later developing liver cancer. "The low incidence of hepatocellular carcinoma in patients treated with interferon suggests that interferon may prevent the development of hepatocellular carcinoma." - "Risk Factors and the Effect of Interferon Therapy in the Development of Hepatocellular Carcinoma," Journal of Gastroenterology and Hepatology 1997 Feb;12(2):149-155
An association between chronic hepatitis C infection and non-Hodgkin's lymphoma has been reported. " HCV Infection and Extrahepatic Malignancies," Journal of Clinical Gastroenterology 1997 Mar;24(2):87-89
HOW MANY OF US ARE THERE?
Hepatitis C accounts for 20% of community-acquired hepatitis in the US. Approximately 200 case of hepatitis C are reported in New York State each year. -- "Prevention, Diagnosis, and Management of Viral Hepatitis", AMA
Each year, 150,000 new cases of hepatitis C infection occur in the United States. -- " Hepatitis C & E: how much of a threat?" Special Issue: Emerging Infectious Diseases, Brown, Edwin A., May 15 1994, v28, n9, p105(8)
The (US) Center for Disease Control and Prevention, estimates that at least 17 1/2 million people (in the US) are living with chronic hepatitis C infections and as many as 150,000 Americans are newly infected with hepatitis C each year.