What's behind fatigue, elevated liver enzymes?

'I'm more tired than usual, doctor," the patient said, though she really thought nothing was wrong. At 60, she assumed age was catching up with her, and was at the doctor's office for her routine checkup.

Indeed, all her blood work was normal - except for the panel revealing elevated liver enzymes. A liver ultrasound suggested the damage had been going on for some time.

Aside from hypertension, she had no other active medical conditions. The only drugs she took were a diuretic and a multivitamin.

Having worked as an office manager for a medical office for more than 30 years, she had recently retired and hoped to travel extensively with her husband. But she hadn't been out of Pennsylvania recently, was a lifelong nonsmoker and denied any recreational drug use. As for alcohol, she enjoyed a glass of wine or two with dinner on weekends.

On physical exam, the doctor observed the woman's liver was enlarged but noted no swollen veins or skin changes that could be seen with very advanced liver disease. The doctor checked additional lab results to evaluate the liver's function, such as its ability to make important proteins involved in transport and clotting. Fortunately, the woman had normal platelet counts, albumin and coagulation parameters, indicating she had not yet developed cirrhosis, or end-stage liver disease. Because the woman's history and physical did not point to an obvious etiology for her liver disease, her doctor sent off a series of tests searching for a cause. Soon, the woman had an answer.

Liver disease can be caused by bacterial or viral infections, heavy alcohol use, toxins, drugs, and autoimmune diseases. Some of these causes can be identified by blood tests; others require sampling of liver tissue under a microscope for diagnosis. In this case, the first set of tests returned an answer.

To her shock, the woman tested positive for hepatitis C, a virus that infects and damages the liver. It can be transmitted by blood or body fluids carrying the virus.

The main risk factors are: injection-drug use; receipt of blood products or organ transplantation before July 1992, when screening started for hepatitis C; unprotected sex; long-term hemodialysis treatment; and HIV infection. 

This woman had had an emergency C-section when her only child was born in the 1980s. She'd lost so much blood she needed a transfusion but never had cause to worry about it until now.

The U.S. Centers for Disease Control and Prevention recently recommended that everyone born between 1945 and 1965 should be screened at least once for hepatitis C because of the higher prevalence of infection in that age group compared to others. 

An estimated 3.5 million people in the U.S. have chronic hepatitis C, but up to half may not know they are infected because they do not feel ill.

The most common symptom associated with chronic hepatitis C is fatigue, but this may go unrecognized. Chronic hepatitis C can lead to serious medical problems, including liver failure, liver cancer, even death.

Until recently, treatment options were limited to preventing further insults to the liver and trying some injected medicines that were not well-tolerated. Now, several costly new drugs have revolutionized the treatment of chronic hepatitis C.

The woman elected to start a three-month course of drug therapy. She and her doctor were optimistic that, before long, she would be cured.

Charitha Gowda and Vincent Lo Re III are physicians and researchers at the Penn Center for Viral Hepatitis at Penn Presbyterian Medical Center.