Hepatitis C Case Study

Author/s

Sean Fizer, Patrick Fleming, Grant Idlewine, Kyle Kelley from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

100 word limit, non-structured description

Patient Characteristics

• Demographic Information: Brandt Widelline is 52 year old Caucasian, female working as a Medical Laboratory Scientist.  (occupation/vocation, gender, age, etc.)
• Medical diagnosis: Chronic Hepatitis C diagnosed 6 years ago. Patient was unaware of acute infection due to asymptomatic presentation. Patient medically diagnosed with hepatitis C hemotologically through positive HCV antibody testing. PCR testing confirmed chronic Hepatitis C diagnosis.
  
• Co-morbidities: Diabetes, Hypertension, Alcoholism
• Previous care or treatment: liver function testing, cardiovascular treadmill stress testing (previous to chronic Hepatitis C diagnosis) 
• Medication: Ribavirin BID, protease inhibitor (boceprevir), metrormin (Glucophag), Insulin glulisine (Apidra), vitamin D
  

== Examination == *Upon examination, Brandt Widelline reported constant fatigue and muscle aches throughout the day, accompanied by mild pain in her right upper quadrant. She also reports intermittent nausea^1,2. Her medical history shows that she has been diagnosed with Hepatitis C, Type II DM1, hypertension (HTN), and alcoholism¹. A Fibro Test/Acti Test (FT-AT) was performed four years ago to determine the stage of liver fibrosis^2,5, which concluded a Metavir fibrosis score of 2, meaning scarring has occurred and extends outside the areas in the liver that contain blood vessels⁶. The patient’s current treatment for the Hepatitis C and associated comorbidities consists of vitamin D supplements beginning 2 years after the diagnosis of Hepatisis C, Ribavirin², Sofosbuvir³ and insulin. She began treatment with pegylated interferon treatment two years the Hepatitis C diagnosis, which was a 48 week treatment, but it was replaced with Sofosbuvir beginning in January of 2014³.
The patient reported goals for her treatment are to achieve sustained viral responses (SVR) near 80%², weight loss to improve her quality of life, improve fitness and decrease fatigue, and decrease the risk of osteoporis⁴.

• ** ***Self Report Outcome Measures:  SF36 QOL measure:  29.0 physical health score; 36.5 mental health score (Sean's article); depression/anxiety, fatigue, flu-like symptoms, cognitive function, insomnia are the five key concepts looked at in:  http://www.ncbi.nlm.nih.gov/pubmed/22871087

• Physical Performance Measures    

    • Dynamic Gait Index score of 19 (normal score range is 22-24)
    • Community Balance and Mobility Scale score of 62 (mean score is 77.43)

• Objective : Physical Examination Tests and Measures
  Posture Examination
  • Forward head
  • Rounded shoulders
  • Anterior pelvic tilt
  • Mild knee valgus
  BP: 136/86
  HR: 92
  ROM
  • UE AROM WNL
  • B hip flexion WNL
  • B hip extension decreased 50%
  • B ankle dorsiflexion decreased 75% due to right plantarflexors
  • B hamstring flexibility decreased 20%
  MMT
  • B shoulder abduction 3+/5
  • L elbow flexion 4/5
  • R elbow flexion 4+/5
  • R hip flexion 4-/5
  • L hip flexion 4-/5
  • R hip extension 4-/5
  • L hip extension 3+/5
  • B knee flexion 4+/5
  • R knee extension 4/5
  • L knee extension 4-/5
  • R ankle dorsiflexion 4-/5
  • L ankle dorsiflexion 4/5
  • All other MMT were WNL
  Sensation
  • Decreased sensation in B LE distal to the knee due to diabetes

Summarization of Examination Findings

Working Diagnosis and Targeted Interventions

Intervention

• No vaccine or postexposure prophylaxis is currently available.  Thus main focus of management is prevention awareness. 
• First 6 months (acute phase) patient was asymptomatic and thus, received no treatment.    
• In the chronic phase, patient was prescribed pegylated interferon and ribavirin, which sustains the viral response. 
  • • All of the above was found at http://cid.oxfordjournals.org/content/50/11/1505.long
      
    • All below was found at http://www.em-consulte.com/showarticlefile/198936/main.pdf
• Physical activity and education was also found to be helpful in QOL measures for the patient. 
• The patient participated in these 3 physical activities and educational program: 
  • Individual physical activity for 90 minutes (walking, running, swimming, etc.)
  • Physical activity in a team setting for 90 minutes (frisbee, volleyball, racket ball, etc.)
  • Recreational activity for 90 minutes (ballroom dancing, archery, etc.)
  • Lectures on topics such as hepatitis and treatment, history of jaundice, and evaluation in sports medicine were provided as well. 
• The patient experienced increased QOL measures 1 month after participating in these events 5 days a week. 
  • • (Article from Pat) These increases in QOL measures can be attributed due to decreases in pain and disability because of improvements in cardiovascular fitness and musculoskeletal function. 

Outcomes

Stage 1 - Incubation [10-50 days]

• Patient did not report any symptoms (not yet diagnosed).

Stage 2 - Preicteric [1-3 wks]

• Patient had c/o fatigue, unplanned weight loss, and diarrhea ⁹
• Reports of intermittent itching and joint pain ⁹

Stage 3 - Icteric [2-4 wks]

• Symptoms from preicteric stage still present, but reduced in severity.

• Palpation revealed enlarged spleen and post cervical lymph nodes ⁹
  

Stage 4 - Recovery [3-4 mos]

• All symptoms reduced or absent, but reports of being easily fatigued ⁹
• After 20 visits of physical therapy intervention... 6MWT distance increased significantly and QOL measure (SF-36) showed statistically significant improvements in quality of life.
• At 6 month follow up.. Patient reports continuing home-based exercise program and having increased tolerance to physical activity.

National Statistics

About 15-45% of persons infected clear the virus within 6 months without medical treatment. The remaining 55-85% develop chronic hepatitis C infection (HCV). Those wich chronic HCV, have a 15-30% chance of developing liver cirrhosis within 20 years.⁷

• 350,000 to 500,000 people die each year from hepatitis C-related liver diseases.⁷
• Antiviral treatments are successful at reducing the risk of liver cirrhosis and cancer in 50-90% of persons treated.⁷

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

As of 2012, it is estimated that 21,870 cases of acute Hepatitis C infections occurred in the United States and 75-85% of these individual develop chronic Hepatitis C. An estimated 3.2 million people in the United States have chronic Hepatitis C virus infection.90 As physical therapists it is important to not only look for the signs and symptoms of undiscovered Hepatitis C but to also work with a multiple-disciplinary team to insure best patient care.

As direct access providers, it is important for physical therapists to thoroughly screen for systemic diseases that may mimic or affect the musculoskeletal or neuromuscular systems. An understanding of the various signs and symptoms that present with Hepatitis C is important as it is estimated that 40-85% percent of individuals infected with the disease are aware of their status.91 Hepatitis C, unlike other forms of the pathology, is often undiagnosed due to the initially being asymptomatic. Minor flu-like symptoms are generally the first presentation of the disease. Other symptoms include fatigue, nausea, muscle and joint pain, inching, dark urine, and abdominal pain.
Though Hepatitis C is a medically treated disease, it is also associated with various co-morbidities including but not limited to diabetes, obesity, poor quality of life, liver disease, hypertension, and non-traumatic joint disorders. Many of these co-morbidities may have musculoskeletal ramifications that are within scope of practice for physical therapy to treat. It is important to not only treat Hepatitis C medically but to treat the various effects the disease process may have on the musculoskeletal system. Patient education and improvement of lifestyle habits are paramount for quality of life for patients with chronic diseases such as hepatitis C.

Related Pages

Hepatitis A, B, C General Information

Center for Disease Control 

References

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2. Malnick S, Maor Y, Melzer E, Tal S. Chronic Hepatitis C in the Aged: Much Ado About Nothing or Nothing to Do?. Drugs & Aging [serial online]. May 2014; 31(5):339-347. Available from: CINAHL with Full Text, Ipswich, MA. Accessed March 18, 2015.
3. Sturm D, Gurevitz S, Davidson C, Fritchley A, Wagaman A. Chronic Hepatitis C Infection. Clinician Reviews [serial online]. November 2014; 24(11):24-32. Available from: Academic Search Complete, Ipswich, MA. Accessed March 18, 2015.
4. McKenna O, Blake C. Management of hepatitis C: the potential benefits of exercise. Physical Therapy Reviews [serial online]. December 2007;12(4):271-276. Available from: Academic Search Complete, Ipswich, MA. Accessed March 21, 2015.
5. Poynard T, Imbert-Bismut F, Benhamou Y, et al. Biomarkers as non-invasive assessment of hepatic fibrosis in chronic hepatitis C. Journal Of Gastroenterology & Hepatology [serial online]. December 3, 2004;19:S236-S245. Available from: Academic Search Complete, Ipswich, MA. Accessed March 22, 2015.
6. HCV Diagnostic Tools: Grading & Staging a Liver Biopsy. HCV Advocate website. http://www.hcvadvocate.org/hepatitis/factsheets_pdf/grade_stage.pdf. Published October 2007. Accessed March 22, 2015.
   
7. Kleinman L, Mannix S, Yuan Y, Kummer S, L'italien G, Revicki D. Review of patient-reported outcome measures in chronic hepatitis C. Health Qual Life Outcomes. 2012;10:92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22871087. Accessed March 18, 2015.
8. World Health Organization. Hepatitis C. http://www.who.int/mediacentre/factsheets/fs164/en/. Accessed March 26, 2015.
9. Center for Disease Control and Prevention. Hepatitis C Information for the public. http://www.cdc.gov/hepatitis/c/cfaq.htm. Accessed 18 March 2015.
10. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists. 5th ed. St Louis, MO: Elsevier; 2013.