The patient was a 45-year-old woman, divorced, without known pathological antecedents and without any usual medication. She consumed about 24-48 g of alcohol per day, for several years and without any recent increase. She denied previous or current use of tobacco or recreational drugs and had never been subjected to blood transfusions. Her current sexual partner had active HCV and HIV infection, both without ongoing treatment.
The patient presented to the emergency department with an acute epigastric pain and food vomiting. She denied other changes in gastrointestinal transit, bilirubinuria or light colored stools, pruritus, fever, anorexia, and asthenia. There was no history consistent with consumption of any other hepatotoxic agent. Upon physical examination she had jaundice of the skin and mucous membranes and hepatomegaly with regular borders on the abdominal palpation. The rest of the physical examination was normal.
Analytically the patient presented mild anemia (hemoglobin 11.5 g/dL, macrocytic and normochromic), platelets 135000/uL, without changes in the leukocyte series; hyperbilirubinemia at the expense of direct bilirubin (total bilirubin (TB) 7.46 mg/dL - 7 times above the upper limit of normal - and direct bilirubin (DB) 6.81 mg/dL); elevation of hepatic cytolysis enzymes (aspartate aminotransferase (AST) 862 U/L - 32 times above the upper limit of normal - and glutamate-pyruvate transaminase (ALT) 317 U/L - 9 times above the upper limit of normal); normal albumin (3.3 g/dL); INR of 1.00; antibodies for HIV-1 positive; anti-HBc and HBs negative; anti-HCV negative; anti-HAV IgM negative and IgG positive. Abdominal ultrasound (Fig. 1) showed hepatomegaly (17.5 cm in diameter at the mid-clavicular line), with the parenchyma being globally homogenous and with increased echogenicity, with no other changes of relief. She was hospitalized for acute hepatitis of unknown cause.
During the first 4 days of hospitalization the patient presented progressive aggravation of hepatic cytolysis (AST 4042 U / L and ALT 1050 U / L, always maintaining a AST approximately 3 times greater than ALT) and, until the 13th day of hospitalization, worsening of hepatic cholestasis parameters (maximum values of TB 19.13 mg / dL and DB 17.6 mg / dL). Transient changes in liver function were observed between the 4th and 9th day of hospitalization, with hypoalbuminemia most abnormal value - 2.6 g / dL) and changes in coagulation parameters (most abnormal value of INR - 1.69). The patient remained asymptomatic throughout the hospitalization and objectively only presented worsening jaundice of the skin and mucous membranes. Of the remaining analytical study carried out during hospitalization: CD4 + T lymphocytes 388 cells / mL and HIV RNA polymerase chain reaction (PCR) 54,652 copies / mL. On the 10th day of hospitalization, for diagnostic clarification, a percutaneous liver biopsy was performed and blood was collected for HCV PCR evaluation, in spite of anti-HCV negative. Due to the clinical and analytical improvement (AST 103 U / L, ALT 52 U / L, TB 11.78 mg / dL, DB 11.16 mg / dL, albumin 3.8 g / dL and INR 0.92), patient was discharged on the 17th day of hospitalization.
At the re-evaluation internal medicine appointment, about one week after discharge, the HCV RNA PCR collected during hospitalization was already available and was> 10,000,000 IU/mL. The hepatic biopsy revealed irregular expansion of portal spaces by moderate inflammatory lymphocytic infiltrate with formation of lymphoid aggregates and rare associated neutrophils, with no evidence of plasma cells; proliferated bile ducts, but apparently not involved by the inflammatory process; slight portal fibrosis, with thin septa surrounding individual hepatocytes; interface necrosis of moderate intensity; intralobular necro-inflammatory foci of mild to moderate intensity; balloonized hepatocytes with reticulation and numerous Mallory-denk hyaline bodies and intense mixed steatosis with xanthelasmic hepatocytes; cholestasis in sinusoidal and portals Kupffer cells, minimal in hepatocytes; no epithelioid granulomas were identified; and absence of signs of malignancy. These findings were compatible with active toxic / alcoholic steatohepatitis. New serum samples for anti-HCV was obtained and demonstrated seroconversion to positive. In view of the presented, the diagnosis of acute HCV hepatitis with risk factor of heterosexual transmission was established. The virus genotype, subsequently determined, was the 3a, the same as that of his sexual partner. The patient started antiretroviral therapy for HIV infection and presented spontaneous clearance of HCV, with undetectable HCV RNA PCR about 11 weeks after discharge from hospital.