Jenna Herman, DNP, APRN, FNP-BC

About 3% of the global population, or about 170 million people, are infected with the hepatitis C virus (HCV), according to World Health Organization estimates.

HCV causes liver inflammation and often results in the blood-borne infection hepatitis C.

In the United States, hepatitis C has been the prevailing blood-borne infection, with about 30,000 to 35,000 new cases diagnosed annually.

million people have chronic hepatitis C, and many of those who are infected do not know about their condition. Chronic hepatitis C is the most frequent

reason for mortality associated with liver complications as well as the need for liver transplants. Hepatitis C causes 10,000 to 12,000 deaths

 Recently, hepatitis C surpassed HIV infection as a leading cause of death.

Hepatitis C has an incubation period of 2 to 12 weeks.

 Clinical presentations of patients with acute hepatitis C are often variable, ranging from asymptomatic to mild, nonspecific symptoms. Reported symptoms may include anorexia, fatigue, fever, inflammation, intolerance to alcohol or fatty foods, mild hepatomegaly, nausea, night sweats, pale stools, pruritis, right upper quadrant pain, upper respiratory infection symptoms, and vomiting.

 Acute hepatitis C will progress to chronic infection in the majority of patients, and about two-thirds of those will develop chronic liver disease.

HCV is a ribonucleic virus that infects the functional units of the liver (hepatocytes).6 Six HCV genotypes exist, with significant variations in geographical locations. In the United States, the most common are genotype 1 (about 70%) and genotypes 2 and 3 (about 30%).

 Genotype 4 is uncommon in the United States and seen mostly in Africa and the Middle East. Genotype 5 is found primarily in South Africa, and genotype 6 is prevalent mainly in Southeast Asia. Specific genotypes do not predict disease outcomes, though they are helpful in determining medication regimens, treatment duration, and the probability of treatment response.

The primary mode of transmission of hepatitis C is via infected blood or bodily fluids. In new cases, about 60% are from intravenous (IV) drug users, particularly through shared needles and indirectly shared drug paraphernalia, and 20% are from intercourse, especially high-risk sexual activity and male-to-male sex.

 Other risk factors include household exposure (eg, using the same razors or toothbrushes), occupational exposure (eg, workers in health care facilities or needle stick injuries), other types of drug use (eg, intranasal drug use), and piercings or tattoos from unsterilized tools. The number of hepatitis C cases due to blood transfusion or solid organ transfusion and hemophilia concentrates has drastically declined from the early 1990s and late 1980s, respectively, with improved blood screening tests starting in the 1990s. Less common is mother-to-fetus transmission.

 In the developing world, childhood vaccinations and male circumcision are potential risk factors.5 Rural populations have a 2-times-higher rate of hepatitis C than urban populations, due in part to more exposure to the aforementioned risk factors.

Baby boomers account for nearly three-quarters of all patients with chronic hepatitis C in the United States. However, results of new reports show a new group of IV drug users with rapidly rising hepatitis C numbers: urban Caucasian people 24 years or younger who have taken oral prescription opioids prior to using heroin.

 Even with all the recognized risk factors, 10% of patients with hepatitis C have none,

 and many patients cannot determine an infection source.1

Diagnosis, Differentials, and Complications

Clinicians often make a diagnosis through serologic assays for hepatitis C antibodies, as well as via molecular tests for viral nucleic acids.

 HCV antibody presence is indicative of contact with HCV, though it does not prove active infection.

 Additional tests to consider are a complete blood count, liver function tests, and a comprehensive metabolic panel to rule out other causes.

 A liver biopsy may also be required to evaluate the extent of liver damage.

 Differential diagnoses to consider include α1-antitrypsin deficiency; autoimmune hepatitis; hemochromatosis; hepatitis A, B, D, or E; HIV infection; mononucleosis; portal hypertension; and Wilson disease. Known complications of hepatitis C include aplastic anemia, B-cell lymphoma, cardiovascular issues, hepatocellular carcinoma, liver cirrhosis, Sjögren syndrome, and type 2 diabetes.

Hepatitis C may resolve on its own, but treatment is suggested for those with chronic hepatitis C or cirrhosis and liver transplant patients.

 Treatment consists of avoiding medications metabolized by the liver, using specific direct-action antivirals, and supportive care. Watch for adverse effects and treatment effectiveness, with laboratory testing and follow-up. Cure rates are almost 95% when hepatitis C is treated appropriately.

 There is no vaccine for hepatitis C, though ones for hepatitis A and B exist.1,2 Educate patients about infection control, lifestyle changes, signs and symptoms, and ways to prevent transmission.

Wong R, Russell C, Kruger D. Hepatitis C virus infection: signs, symptoms, and screening. 

Hepatitis C. CDC website. cdc.gov/hepatitis/hcv/index.htm. Updated October 22, 2019. Accessed October 11, 2019

Olson M, Jacobson IM. Role of the nurse practitioner in the management of patients with chronic hepatitis C. 

 2011;23(8):410-420. doi: 10.1111/j.1745-7599.2011.00603.x.

Guss D, Sherigar J, Rosen P, Mohanty SR. Diagnosis and management of hepatitis C infection in primary care settings. 

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Miller MH, Dillon JF. Early diagnosis improves outcomes in hepatitis C. 

Olson MC, Gardenier DG, Jacobson IM. The revolution of hepatitis C treatments: review for nurse practitioners. 

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Gordon SC. Hepatitis C virus detection and treatment in rural communities. 

Articles

Educate patients about infection control, lifestyle changes, signs and symptoms, and ways to prevent transmission

Identifying and Properly Treating Hepatitis C Are Keys to a Cure

Distinguishing between respiratory infections with clinical presentation similarities can be a challenge for providers.

Tonsillitis and influenza infections are common reasons patients seek care, especially during peak season (November to April).

 Influenza is a well-known and well-documented viral infection that causes widespread outbreaks.

 Three subtypes of the influenza virus exist: A, B, and C,

 with type A possessing the greatest virulence.

 In an influenza season, prevalence estimates are 20% to 30% in children and less than half of that in adults, at 5% to 10% worldwide. Three million to 5 million influenza cases are considered severe, and the infection claims an estimated 250,000 to 500,000 lives each year.

 Although these statistics can be startling, influenza death and illness rates vary greatly from year to year, subject to the virulence of the present strains and the associated population immunity to these strains.

Acute tonsillitis is an infection and inflammation of the tonsils. Tonsillitis is often included in pharyngitis statistics, as the average person may have 2 to 6 sore throats annually.

 Causes of tonsillitis are idiopathic (30%-65%), viral (30%-60%), and bacterial (5%-10%).

 Clinicians need to consider group A streptococcus infection (GAS) as a reason for tonsillitis. Of patients with tonsillitis, 5% to 10% of adults and 20% to 30% of pediatric patients have GAS.

Tonsillitis and influenza share several risk factors, including age, dry air, environmental allergies, smoking, upper respiratory infection symptoms, and time of year, according to the CDC. More risks specific to tonsillitis are exposure to secondhand smoke or pollution and a history of acid reflux disease.

Both illnesses are usually transmitted from person to person in one of 2 ways: through airborne droplets spread from secretions generated by coughing, sneezing, or talking and indirectly via fomites, such as cups, doorknobs, tissues, and utensils. Incubation lasts between 1 and 4 days. Influenza is generally most infectious for 24 to 48 hours, whereas tonsillitis can be contagious for 7 to 10 days.

Many influenza cases present with symptoms of other common respiratory infections, including abrupt onset of fever (greater than 101°F), chills, cough, headache, and myalgia.

 Sinus problems and sore throat may also be present. Children are likely to have gastrointestinal symptoms of abdominal pain, diarrhea, and vomiting.

Tonsillitis also has several general symptoms, including chills, fever, painful swallowing, sore throat, swollen tonsils, and tonsillar exudate.

 Major criteria that must be present for tonsillitis comprise sore throat in conjunction with erythema and/or tonsillar exudate, which may or may not be accompanied by a scarlatiniform rash. Minor criteria are fever and malaise.

 The aforementioned criteria, with the addition of cervical adenopathy, palatal petechiae, and vomiting, increase the likelihood of developing GAS to more than 50%.

 Symptoms that may signal a more serious condition include drooling, limited neck movement or stiffness, respiratory distress, and toxic appearance.

Given the similar clinical pictures, risk factors, and transmission, providers must ponder the differentials. The Centor criteria can be helpful for distinguishing viral infections.

 Clinicians should consider anaphylaxis, angioedema, croup, epiglottis, foreign body ingestion, lateral/retropharyngeal abscess, mononucleosis infection, otitis media, peritonsillar abscess, pharyngitis, and pneumonia.

Several laboratory methods exist to diagnosis influenza and tonsillitis. Practitioners can perform all influenza tests via a nasopharyngeal swab or wash from the patient. The gold standard is the viral culture, though results take at least 48 hours, and it is used more for research purposes.

 Practitioners most commonly use rapid antigen testing, or point-of-care testing, though sensitivity is estimated at 40% to 80%,

 so a negative test does not eliminate the possibility of influenza.

 The same type of testing has a lower sensitivity in bacterial tonsillitis diagnosis than the throat culture, a more accurate test, which takes longer to show results.

 The throat culture helps rule in GAS and identifies >90% of cases.

 Except in the case of GAS-associated tonsillitis, practitioners rarely culture bacteria from patients with tonsillitis.

 A complete blood count and C-reactive protein are sometimes suggested but are not significant parameters.

Most cases of both influenza and tonsillitis are self-limiting and viral. Clinicians can treat these cases with OTC medications, such as nonsteroidal anti-inflammatory drugs and Tylenol, or topical therapies, such as oral rinses, sprays, and lozenges. Numerous episodes of tonsillitis in an illness season may require a tonsillectomy,

 whereas multiple episodes of influenza are uncommon.

Patients may require prescription treatment for more severe illness, such as GAS tonsillitis and severe influenza. Antibiotics are necessary for GAS tonsillitis (amoxicillin, penicillin V potassium, or single-dose intramuscular penicillin G). For patients who are allergic to penicillin, clinicians should use clindamycin or macrolides. Fluoroquinolones, sulfonamides, and tetracyclines are not indicated for GAS.

 However, antibiotics are still prescribed unnecessarily for tonsillitis and influenza at high rates.

Two medication classes, adamantanes and neuraminidase inhibitors (NIs), are approved to treat influenza.

However, practitioners use NIs more frequently because amantadines have greater resistance, though NI resistance is also growing.

 These medications generally decrease symptom severity, lower complication/hospitalization risk, and reduce illness by 24 hours.

 Importantly, providers should educate patients about the adverse effects of any prescriptions as well.

Complications are uncommon. Occasionally, GAS tonsillitis causes acute glomerulonephritis and/or rheumatic fever without appropriate antibiotic treatment.

 Influenza can cause organ shutdown and death, though these are rare.

 is the family nurse practitioner program coordinator and an assistant professor at the University of Mary in Bismarck, North Dakota. Her clinical practice includes the emergency department of a level II trauma center, correctional medicine, and locum tenens in primary care clinics, nursing homes, and hospitals across rural North Dakota.

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Krein PM. Clinical diagnosis of influenza-like illness: the flu and beyond. MLO Med Lab Obs. 2012;44(11):32,34.

Li-Kim-Moy J, Dastouri F, Rashid H, et al. Utility of early influenza diagnosis through point-of-care testing in children presenting to an emergency department. J Paediatr Child Health. 2016;52(4):422-429. doi: 10.1111/jpc.13092.

During flu season, a sore throat can signal another illness&mdash;Here is how to tell the difference.