Case Presentation: A 69yo female with hypertension and type 2 diabetes presented to the emergency room with several days of malaise and fatigue and 2 days of chest pain. In the emergency room, her blood pressure was 201/121 and she had clinical signs of hypervolemia, with pitting dependent edema and crackles on lung exam. Lab studies were significant for a troponin of 0.15 and a creatinine of 2.5; liver enzymes and coagulation studies were within normal limits. Early in her hospitalization, her creatinine rise was suspected to be secondary to chronic kidney disease due to her underlying medical conditions. Her diabetes had been fairly well controlled for the past year, with her most recent hemoglobin A1c of 6.6 on this admission. Chart review revealed normal renal function 6 months prior, with creatinine 0.8; it had slowly uptrended over the course of several presentations to our hospital. Her creatinine failed to return to baseline after resolution of her hypertensive crisis. Further investigation into the case of her progressive renal dysfunction revealed nephrotic range proteinuria and low C3 and C4. This patient was found to be hepatitis C positive, with a viral load >700K with cryoglobulinemia. Renal biopsy showed membranoproliferative glomerulonephritis (MPGN). Workup excluded other causes including multiple myeloma. She was discharged with plans to start hepatitis C treatment.
Discussion: The CDC estimates that there are more than 2 million people in the US with chronic hepatitis C. While recent guideline updates encourage screening for people born during certain decades, many patients present to urban emergency rooms with undiagnosed hepatitis C. While a large percentage of people are diagnosed after developing liver cirrhosis, this patient never had any abnormalities of liver function tests. Hospitalists must be aware of the less common manifestations of chronic hepatitis C, which may affect almost any organ system such as the development of MPGN in this patient.This patient with known HTN presented to the emergency room with hypertensive emergency and progressive renal disease over the past several months. Her blood pressure was easily controlled in the hospital, but she continued to have lower extremity swelling with persistent kidney injury and proteinuria. She had no clinical or laboratory findings to suggest liver dysfunction or cirrhosis. While her kidney disease could have easily been attributed to her other medical conditions, her nephrotic range proteinuria warranted further investigation and revealed the true cause to be HCV-related MPGN.
Conclusions: Chronic hepatitis C is believed to affect more than 2 million Americans, particularly in the cohort of people born 1945-1965. While most are diagnosed by asymptomatic screening or diagnosis after the development of liver cirrhosis, a subset of patients may present with less common manifestations and be diagnosed during hospital admission.