UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

成人急性丙型肝炎的临床表现、诊断和治疗

Authors
Reinhard Lorenz, MD
Stefan Endres, MD
Section Editor
Adrian M Di Bisceglie, MD
Deputy Editor
Allyson Bloom, MD
Translators
朱亮, 主治医师

引言

根据惯例，急性丙型肝炎病毒(hepatitis C virus, HCV)感染是指据推测HCV暴露后6个月内出现肝炎的临床体征或症状[1]。在美国，据估计急性HCV感染在有症状的急性肝病病例中占15%，但大多数急性HCV感染患者未被检测到[2,3]。这在很大程度上归因于急性HCV感染患者通常无症状这一事实。美国疾病预防控制中心估计，2010年美国约有17,000例新发的HCV感染病例，而表现为急性肝炎症状的患者仅有2800例(16%)[4]。如果诊断了(通过症状或筛查高危患者)急性HCV感染，那么对于无法自发清除病毒的患者，早期治疗是合适的且与高持续病毒学应答(sustained virologic response, SVR)率相关。 (参见下文‘治疗’)

本专题将总结成人急性HCV感染。与HCV传播、HCV筛查以及慢性HCV感染患者处理相关的问题将在别处讨论。 (参见“丙型肝炎病毒感染的流行病学与传播”和“慢性丙型肝炎病毒感染的临床表现和自然病程”和“慢性丙型肝炎病毒感染的筛查”和“慢性丙型肝炎病毒感染的处理概述”和“慢性丙型肝炎病毒感染的诊断与评估”)

临床表现

急性肝炎通常在HCV暴露后2-26周发生，平均起病时间为7-8周[5]。对于有症状的患者，这一急性疾病通常持续2-12周。其症状可能包括：黄疸、恶心、尿色深和右上腹疼痛。然而，大多数急性感染HCV的患者是无症状的。急性HCV患者的氨基转移酶通常中度升高，但是无症状患者可能检测不出氨基转移酶升高。急性HCV导致的暴发性肝功能衰竭极罕见，但暴发性肝功能衰竭可能更常见于具有潜在的慢性乙型肝炎病毒(hepatitis B virus, HBV)感染的患者中[6,7]。 (参见“成人急性肝功能衰竭：病因、临床表现和诊断”)

症状 — 尽管大部分急性HCV患者无症状，但部分患者可出现急性肝炎的症状。一篇研究纳入了5项来自美国国家心、肺和血液研究所的输血相关性非甲、非乙型肝炎和丙型肝炎的研究，超过2/3的急性HCV感染患者在急性发作期无症状[8]。

黄疸是表现为症状性急性HCV感染的患者报告的常见症状。在一项纳入了51例症状性急性HCV感染患者的研究中，68%的患者报告了黄疸，39%的患者报告了深色尿和白陶土样大便，34%的患者报告了恶心，25%的患者报告了腹痛(主要是右上腹疼痛)[9]。其他研究中报告的另外一些症状包括：乏力、低热和寒战、食欲不振、瘙痒、肌痛、心境障碍、关节痛、消化不良以及意识模糊[10]。

                      

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2017-05-10.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Blackard JT, Shata MT, Shire NJ, Sherman KE. Acute hepatitis C virus infection: a chronic problem. Hepatology 2008; 47:321.
  2. Williams I. Epidemiology of hepatitis C in the United States. Am J Med 1999; 107:2S.
  3. Armstrong GL, Alter MJ, McQuillan GM, Margolis HS. The past incidence of hepatitis C virus infection: implications for the future burden of chronic liver disease in the United States. Hepatology 2000; 31:777.
  4. http://www.cdc.gov/hepatitis/hcv/StatisticsHCV.htm (Accessed on September 19, 2012).
  5. Marcellin P. Hepatitis C: the clinical spectrum of the disease. J Hepatol 1999; 31 Suppl 1:9.
  6. Hoofnagle JH, Carithers RL Jr, Shapiro C, Ascher N. Fulminant hepatic failure: summary of a workshop. Hepatology 1995; 21:240.
  7. Chu CM, Yeh CT, Liaw YF. Fulminant hepatic failure in acute hepatitis C: increased risk in chronic carriers of hepatitis B virus. Gut 1999; 45:613.
  8. Seeff LB. Natural history of hepatitis C. Hepatology 1997; 26:21S.
  9. Gerlach JT, Diepolder HM, Zachoval R, et al. Acute hepatitis C: high rate of both spontaneous and treatment-induced viral clearance. Gastroenterology 2003; 125:80.
  10. Loomba R, Rivera MM, McBurney R, et al. The natural history of acute hepatitis C: clinical presentation, laboratory findings and treatment outcomes. Aliment Pharmacol Ther 2011; 33:559.
  11. Jaeckel E, Cornberg M, Wedemeyer H, et al. Treatment of acute hepatitis C with interferon alfa-2b. N Engl J Med 2001; 345:1452.
  12. Maheshwari A, Ray S, Thuluvath PJ. Acute hepatitis C. Lancet 2008; 372:321.
  13. Deterding K, Wiegand J, Grüner N, et al. The German Hep-Net acute hepatitis C cohort: impact of viral and host factors on the initial presentation of acute hepatitis C virus infection. Z Gastroenterol 2009; 47:531.
  14. Maheshwari A, Thuluvath PJ. Management of acute hepatitis C. Clin Liver Dis 2010; 14:169.
  15. Corey KE, Ross AS, Wurcel A, et al. Outcomes and treatment of acute hepatitis C virus infection in a United States population. Clin Gastroenterol Hepatol 2006; 4:1278.
  16. Vega Palomares R, Planas Vilà R, Durández Lazaro R, Fábregas Puigtió S. [Acute hepatitis C: response to treatment with interferon-alpha plus ribavirin]. Gastroenterol Hepatol 2002; 25:483.
  17. National Institutes of Health. National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002--June 10-12, 2002. Hepatology 2002; 36:S3.
  18. Hoofnagle JH. Hepatitis C: the clinical spectrum of disease. Hepatology 1997; 26:15S.
  19. Farci P, Alter HJ, Wong D, et al. A long-term study of hepatitis C virus replication in non-A, non-B hepatitis. N Engl J Med 1991; 325:98.
  20. Wang TY, Kuo HT, Chen LC, et al. Use of polymerase chain reaction for early detection and management of hepatitis C virus infection after needlestick injury. Ann Clin Lab Sci 2002; 32:137.
  21. Haydon GH, Jarvis LM, Blair CS, et al. Clinical significance of intrahepatic hepatitis C virus levels in patients with chronic HCV infection. Gut 1998; 42:570.
  22. Beld M, Penning M, van Putten M, et al. Low levels of hepatitis C virus RNA in serum, plasma, and peripheral blood mononuclear cells of injecting drug users during long antibody-undetectable periods before seroconversion. Blood 1999; 94:1183.
  23. Wiese M, Grüngreiff K, Güthoff W, et al. Outcome in a hepatitis C (genotype 1b) single source outbreak in Germany--a 25-year multicenter study. J Hepatol 2005; 43:590.
  24. Nikolaeva LI, Blokhina NP, Tsurikova NN, et al. Virus-specific antibody titres in different phases of hepatitis C virus infection. J Viral Hepat 2002; 9:429.
  25. Wawrzynowicz-Syczewska M, Kubicka J, Lewandowski Z, et al. Natural history of acute symptomatic hepatitis type C. Infection 2004; 32:138.
  26. McGovern BH, Birch CE, Bowen MJ, et al. Improving the diagnosis of acute hepatitis C virus infection with expanded viral load criteria. Clin Infect Dis 2009; 49:1051.
  27. Santantonio T, Sinisi E, Guastadisegni A, et al. Natural course of acute hepatitis C: a long-term prospective study. Dig Liver Dis 2003; 35:104.
  28. Nguyen TT, Sedghi-Vaziri A, Wilkes LB, et al. Fluctuations in viral load (HCV RNA) are relatively insignificant in untreated patients with chronic HCV infection. J Viral Hepat 1996; 3:75.
  29. Gordon SC, Dailey PJ, Silverman AL, et al. Sequential serum hepatitis C viral RNA levels longitudinally assessed by branched DNA signal amplification. Hepatology 1998; 28:1702.
  30. Fanning L, Kenny-Walsh E, Levis J, et al. Natural fluctuations of hepatitis C viral load in a homogeneous patient population: a prospective study. Hepatology 2000; 31:225.
  31. Barrera JM, Bruguera M, Ercilla MG, et al. Persistent hepatitis C viremia after acute self-limiting posttransfusion hepatitis C. Hepatology 1995; 21:639.
  32. Hofer H, Watkins-Riedel T, Janata O, et al. Spontaneous viral clearance in patients with acute hepatitis C can be predicted by repeated measurements of serum viral load. Hepatology 2003; 37:60.
  33. Wiese M, Berr F, Lafrenz M, et al. Low frequency of cirrhosis in a hepatitis C (genotype 1b) single-source outbreak in germany: a 20-year multicenter study. Hepatology 2000; 32:91.
  34. Rodger AJ, Roberts S, Lanigan A, et al. Assessment of long-term outcomes of community-acquired hepatitis C infection in a cohort with sera stored from 1971 to 1975. Hepatology 2000; 32:582.
  35. Thomas DL, Astemborski J, Rai RM, et al. The natural history of hepatitis C virus infection: host, viral, and environmental factors. JAMA 2000; 284:450.
  36. Villano SA, Vlahov D, Nelson KE, et al. Persistence of viremia and the importance of long-term follow-up after acute hepatitis C infection. Hepatology 1999; 29:908.
  37. Seeff LB, Hollinger FB, Alter HJ, et al. Long-term mortality and morbidity of transfusion-associated non-A, non-B, and type C hepatitis: A National Heart, Lung, and Blood Institute collaborative study. Hepatology 2001; 33:455.
  38. Alter HJ, Conry-Cantilena C, Melpolder J, et al. Hepatitis C in asymptomatic blood donors. Hepatology 1997; 26:29S.
  39. Kenny-Walsh E. Clinical outcomes after hepatitis C infection from contaminated anti-D immune globulin. Irish Hepatology Research Group. N Engl J Med 1999; 340:1228.
  40. Vogt M, Lang T, Frösner G, et al. Prevalence and clinical outcome of hepatitis C infection in children who underwent cardiac surgery before the implementation of blood-donor screening. N Engl J Med 1999; 341:866.
  41. Nunnari G, Montineri A, Portelli V, et al. The use of peginterferon in monotherapy or in combination with ribavirin for the treatment of acute hepatitis C. Eur Rev Med Pharmacol Sci 2012; 16:1013.
  42. Pérez-Álvarez R, García-Samaniego J, Solá R, et al. Acute hepatitis C in Spain: a retrospective study of 131 cases. Rev Esp Enferm Dig 2012; 104:21.
  43. Morin T, Pariente A, Lahmek P, Investigator Group of ANGH, SPILF, FNPRH. Favorable outcome of acute occupational hepatitis C in healthcare workers: a multicenter French study on 23 cases. Eur J Gastroenterol Hepatol 2011; 23:515.
  44. Grebely J, Pham ST, Matthews GV, et al. Hepatitis C virus reinfection and superinfection among treated and untreated participants with recent infection. Hepatology 2012; 55:1058.
  45. Ferreira Ade S, Perez Rde M, Ferraz ML, et al. Acute hepatitis C in Brazil: results of a national survey. J Med Virol 2011; 83:1738.
  46. Kamal SM, Fouly AE, Kamel RR, et al. Peginterferon alfa-2b therapy in acute hepatitis C: impact of onset of therapy on sustained virologic response. Gastroenterology 2006; 130:632.
  47. Tremolada F, Casarin C, Alberti A, et al. Long-term follow-up of non-A, non-B (type C) post-transfusion hepatitis. J Hepatol 1992; 16:273.
  48. McDonald SA, Hutchinson SJ, Cameron SO, et al. Examination of the risk of reinfection with hepatitis C among injecting drug users who have been tested in Glasgow. Int J Drug Policy 2012; 23:353.
  49. Missale G, Bertoni R, Lamonaca V, et al. Different clinical behaviors of acute hepatitis C virus infection are associated with different vigor of the anti-viral cell-mediated immune response. J Clin Invest 1996; 98:706.
  50. Diepolder HM, Zachoval R, Hoffmann RM, et al. Possible mechanism involving T-lymphocyte response to non-structural protein 3 in viral clearance in acute hepatitis C virus infection. Lancet 1995; 346:1006.
  51. van den Berg CH, Grady BP, Schinkel J, et al. Female sex and IL28B, a synergism for spontaneous viral clearance in hepatitis C virus (HCV) seroconverters from a community-based cohort. PLoS One 2011; 6:e27555.
  52. Grebely J, Petoumenos K, Hellard M, et al. Potential role for interleukin-28B genotype in treatment decision-making in recent hepatitis C virus infection. Hepatology 2010; 52:1216.
  53. Cerny A, Chisari FV. Pathogenesis of chronic hepatitis C: immunological features of hepatic injury and viral persistence. Hepatology 1999; 30:595.
  54. Corey KE, Mendez-Navarro J, Gorospe EC, et al. Early treatment improves outcomes in acute hepatitis C virus infection: a meta-analysis. J Viral Hepat 2010; 17:201.
  55. Ghany MG, Strader DB, Thomas DL, et al. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 2009; 49:1335.
  56. Deterding K, et al. Early versus delayed treatment of acute hepatitis C: The German HEP-NET acute HCV III study – a randomized controlled study. 44th EASL meeting, Copenhagen 22-26th April 2009, Abstract 1047.
  57. Dore GJ, Hellard M, Matthews GV, et al. Effective treatment of injecting drug users with recently acquired hepatitis C virus infection. Gastroenterology 2010; 138:123.
  58. Broers B, Helbling B, François A, et al. Barriers to interferon-alpha therapy are higher in intravenous drug users than in other patients with acute hepatitis C. J Hepatol 2005; 42:323.
  59. Licata A, Di Bona D, Schepis F, et al. When and how to treat acute hepatitis C? J Hepatol 2003; 39:1056.
  60. Deterding K, Grüner N, Buggisch P, et al. Delayed versus immediate treatment for patients with acute hepatitis C: a randomised controlled non-inferiority trial. Lancet Infect Dis 2013; 13:497.
  61. Vogel W, Graziadei I, Umlauft F, et al. High-dose interferon-alpha2b treatment prevents chronicity in acute hepatitis C: a pilot study. Dig Dis Sci 1996; 41:81S.
  62. Lampertico P, Rumi M, Romeo R, et al. A multicenter randomized controlled trial of recombinant interferon-alpha 2b in patients with acute transfusion-associated hepatitis C. Hepatology 1994; 19:19.
  63. Gürsoy M, Gür G, Arslan H, et al. Interferon therapy in haemodialysis patients with acute hepatitis C virus infection and factors that predict response to treatment. J Viral Hepat 2001; 8:70.
  64. Delwaide J, Bourgeois N, Gérard C, et al. Treatment of acute hepatitis C with interferon alpha-2b: early initiation of treatment is the most effective predictive factor of sustained viral response. Aliment Pharmacol Ther 2004; 20:15.
  65. Rocca P, Bailly F, Chevallier M, et al. [Early treatment of acute hepatitis C with interferon alpha-2b or interferon alpha-2b plus ribavirin: study of sixteen patients]. Gastroenterol Clin Biol 2003; 27:294.
  66. Nomura H, Sou S, Tanimoto H, et al. Short-term interferon-alfa therapy for acute hepatitis C: a randomized controlled trial. Hepatology 2004; 39:1213.
  67. Calleri G, Colombatto P, Gozzelino M, et al. Natural beta interferon in acute type-C hepatitis patients: a randomized controlled trial. Ital J Gastroenterol Hepatol 1998; 30:181.
  68. Takano S, Satomura Y, Omata M. Effects of interferon beta on non-A, non-B acute hepatitis: a prospective, randomized, controlled-dose study. Japan Acute Hepatitis Cooperative Study Group. Gastroenterology 1994; 107:805.
  69. Hwang SJ, Lee SD, Chan CY, et al. A randomized controlled trial of recombinant interferon alpha-2b in the treatment of Chinese patients with acute post-transfusion hepatitis C. J Hepatol 1994; 21:831.
  70. Wiegand J, Buggisch P, Boecher W, et al. Early monotherapy with pegylated interferon alpha-2b for acute hepatitis C infection: the HEP-NET acute-HCV-II study. Hepatology 2006; 43:250.
  71. Santantonio T, Fasano M, Sinisi E, et al. Efficacy of a 24-week course of PEG-interferon alpha-2b monotherapy in patients with acute hepatitis C after failure of spontaneous clearance. J Hepatol 2005; 42:329.
  72. Kamal SM, Ismail A, Graham CS, et al. Pegylated interferon alpha therapy in acute hepatitis C: relation to hepatitis C virus-specific T cell response kinetics. Hepatology 2004; 39:1721.
  73. Kamal SM, Moustafa KN, Chen J, et al. Duration of peginterferon therapy in acute hepatitis C: a randomized trial. Hepatology 2006; 43:923.
  74. De Rosa FG, Bargiacchi O, Audagnotto S, et al. Twelve-week treatment of acute hepatitis C virus with pegylated interferon- alpha -2b in injection drug users. Clin Infect Dis 2007; 45:583.
  75. Broers B, Helbling B, François A, et al. Barriers to interferon-alpha therapy are higher in intravenous drug users than in other patients with acute hepatitis C. J Hepatol 2005; 42:323.
  76. Poynard T, Regimbeau C, Myers RP, et al. Interferon for acute hepatitis C. Cochrane Database Syst Rev 2002; :CD000369.
  77. Wiegand J, Jäckel E, Cornberg M, et al. Long-term follow-up after successful interferon therapy of acute hepatitis C. Hepatology 2004; 40:98.
  78. Serpaggi J, Chaix ML, Batisse D, et al. Sexually transmitted acute infection with a clustered genotype 4 hepatitis C virus in HIV-1-infected men and inefficacy of early antiviral therapy. AIDS 2006; 20:233.
  79. Danta M, Dusheiko GM. Acute HCV in HIV-positive individuals - a review. Curr Pharm Des 2008; 14:1690.
  80. Laguno M, Martínez-Rebollar M, Perez I, et al. Low rate of sustained virological response in an outbreak of acute hepatitis C in HIV-infected patients. AIDS Res Hum Retroviruses 2012; 28:1294.
  81. Matthews GV, Hellard M, Haber P, et al. Characteristics and treatment outcomes among HIV-infected individuals in the Australian Trial in Acute Hepatitis C. Clin Infect Dis 2009; 48:650.
  82. Dominguez S, Ghosn J, Valantin MA, et al. Efficacy of early treatment of acute hepatitis C infection with pegylated interferon and ribavirin in HIV-infected patients. AIDS 2006; 20:1157.
  83. Piroth L, Larsen C, Binquet C, et al. Treatment of acute hepatitis C in human immunodeficiency virus-infected patients: the HEPAIG study. Hepatology 2010; 52:1915.
  84. Götz HM, van Doornum G, Niesters HG, et al. A cluster of acute hepatitis C virus infection among men who have sex with men--results from contact tracing and public health implications. AIDS 2005; 19:969.
  85. Fabrizi F, Dixit V, Messa P, Martin P. Interferon therapy of acute hepatitis C in dialysis patients: meta-analysis. J Viral Hepat 2012; 19:784.