Introduction: Significant liver injury related to acetaminophen overdose is more common in patients with preexisting liver disease. We present a patient with newly diagnosed acute hepatitis C infection with acute liver injury treated successfully with N-acetylcysteine despite negative acetaminophen levels.
Case Description/Methods: A 29-year-old male with history of spontaneously cleared HCV two years ago and polysubstance use presented with abdominal pain, anorexia, and jaundice. He admitted to taking less than 2 g of acetaminophen for tooth ache and chronic back pain along with recent IV drug use, alcohol use, and marijuana use. Examination revealed scleral icterus and right upper quadrant tenderness. Labs revealed normal acetaminophen level, elevated bilirubin 9.4, transaminases AST 1,023; ALT 1,941; alkaline phosphatase (ALP) 202, and INR of 1.4. Hepatitis C antibody returned positive. Hepatitis C genotype was 1a or 1b with an HCV RNA level of 10,917. Evaluation for other etiologies for acute liver injury including alpha-1 antitrypsin, ceruloplasmin, autoimmune, and other infectious work up was negative. MRCP was normal without biliary pathology. He was given 140 mg/kg oral N-acetylcysteine for suspected acetaminophen overdose as the etiology for liver injury. His symptoms improved and liver tests showed an improvement in the next few days (total bilirubin 5.1, mg/dL, AST 100, ALT 731, ALKP 218). The patient was prescribed Sofosbuvir-Velpatasvir at discharge for the treatment of acute hepatitis C.
Discussion: In patients with hepatitis C infection the rate of liver injury with acute or chronic infection is about 16.7%. This case highlights the importance of having a low threshold for treating patients for acetaminophen toxicity in acute hepatitis C patients based on history. This case also highlights further studies are needed to determine the incidence and implications of acute liver injury in acute hepatitis C patients as there are no studies in this group of patients so far.
