Case study 021

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Question 1

Mr. B is a 65-year-old male presented to the clinic with the chief complaint of right-sided abdominal discomfort, loss of appetite, nausea, and fatigue for more than 2 weeks. He noticed a yellowish discoloration of his eye 3 days ago. He had an HCV infection several years ago for which he completed a course of interferon treatment. His family history is irrelevant. On examination:

Height: 171 cm, Weight: 85 Kg, BMI: 29.1
BP: 126/83 mmHg, Heart rate: 84/min, Respiratory rate: 18/min, Temperature: 37.1°C, O₂ SAT: 96%
Yellow discoloration of sclera.
Liver is palpated below the right costal margin. Spleen is palpable at the left costal margin. Mild pitting edema on lower extremities bilaterally. Ascites

Why is the past HCV infection significant?

Question 1 Explanation:

Hepatocellular carcinoma is the primary cancer of the liver, and the major risk factor is liver cirrhosis which can be associated with chronic HCV infections. Unfortunately, about 80% of the hepatitis C virus infections lead to long-term liver damage (cirrhosis and cancer).

Question 2

Mr.B' s laboratory investigation showed:

Blood analysis:
- CBC:
  - RBCs: 4.8 x 10¹²/ L, Hemoglobin: 136 g/L, Hematocrit: 0.40,
  - MCV: 80 fL, MCH: 30 pg, RDW: 12%, Reticulocytes: 65 x 10⁹ (1.4%) ESR: 15 mm/hour,
  - WBC: 8 x 10⁹/l, (Neutrophils: 6.2 x 10⁹/L, Lymphocytes: 2.4 x 10⁹/L, Basophils: 0.06 x 10⁹/L, Eosinophils: 0.22 x 10⁹/L, Monocytes: 0.12 x 10⁹/L),
  - Platelet counts: 161 x 10⁹/L
- Na: 137 mmol/L, K: 3.4 mmol/L, Ca: 2.22 mmol/L
- Glucose: 3.8 mmol/L, Creatinine: 116.2 umol/L, Uric Acid: 359 mmol/L
- Triglycerides: 3.3 mmol/L, Cholesterol: 6.2 mmol/L, LDL: 3.6 mmol/L, HDL: 1.0 mmol/L
- Total bilirubin: 113 umol/L, conjugated bilirubin: 73 umol/L
- AST: 96 U/L, ALT: 85 U/L, ALP: 98 IU/L, GGT: 86 IU/L, 5’NTD: 13 IU/L, Albumin: 32 g/L, Globulin: 52 g/L, LDH: 199 U/L
- INR: 2.45, Prothrombin time: 28 sec
- Alpha fetoprotein: 420 ng/mL
- Viral serology: HBsAg negative, HCV Ab: positive, anti-HAV IgG: negative, EBV, CMV, VCA negative
Stool analysis: color: light brown, urobilin: +
Urine analysis: color: dark yellow, pH: 5.9, specific gravity: 1020, osmolarity: 549 mmol/kg; glucose, ketones: negative, bilirubin: ++, urobilinogen: +, bile salts: negative, WBCs and RBCs: 0-0/HPF, squamous epithelial cells, casts, bacteria, yeast: negative.

Based on the laboratory results, what type of jaundice does Mr. B. most likely have?

Question 2 Explanation:

Hyperbilirubinemia with dark urine and light brown stool occurs in both hepatocellular and post-hepatic (obstructive) jaundice. However, in post-hepatic obstructive jaundice, the stool and urine colours would be paler and darker respectively and alkaline phosphatase (ALP) enzyme would be more elevated.

Question 3

All of the following statements are among the characteristics of the HCV (Hepatitis C virus), EXCEPT:

The incubation period of hepatitis C varies between 2 weeks to 6 months.
The HCV virus is transmitted through direct contact with blood and bodily fluids of the infected person.
HCV is the only hepatitis virus that contains DNA; all the other types of hepatitis viruses are RNA viruses.
Intravenous drug users are at high risk of hepatitis C virus infection by sharing needles or syringes.
HCV infection often results in chronic hepatitis and increases the risk of liver cirrhosis and liver cancer.

Question 3 Explanation:

HCV is an RNA virus; the only DNA virus is the HBV (hepatitis B virus). All other statements are true.

Question 4

What is alpha-fetoprotein?

Question 4 Explanation:

The alpha-fetoprotein (AFP) is a glycoprotein normally produced by the fetal liver and can only be found in very low levels in non-pregnant adults. It is also the most commonly used tumor marker for liver cancer (hepatocellular carcinoma), and embryonal cell tumors. However, as with tumor markers in general, it is important to consider that AFP has low sensitivity and low specificity and cannot be used as the primary diagnostic tests for HCC. For example, higher serum levels can also be found in liver cirrhosis.

Question 5

What diagnostic tests should be done next to confirm the diagnosis for Mr. B?

Question 5 Explanation:

Considering his previous Hepatitis C infection, the current clinical symptoms, and his laboratory results (including the high alpha-fetoprotein level), it is likely that Mr. B has hepatocellular carcinoma. The next diagnostic steps would include imaging, such as ultrasound, CT scan and if needed, liver biopsy for histopathological identification of the tumor.

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