Case Presentation: A 39-year-old male with a past medical history significant for PTSD, depression, and asthma presented to the hospital secondary to suicidal ideation. Patient was reportedly found on an overpass by the police where he was intending to jump. Medications that the patient was currently prescribed were clonazepam, prazosin, sertraline, and zolpidem; however, patient states that he is currently out and has not been taking them. Patient has no other complaints at time of admission. Lab results completed in the ED showed an AST of 1829 and an ALT of 1510. Patient’s alkaline phosphatase and total bilirubin were within normal limits. Patient denied any abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematochezia, fever or chills. Patient had cholecystectomy approximately 5 years prior. Further work-up in the ED showed that the patient was negative for alcohol, salicylate, and acetaminophen as well as a negative Hepatitis panel. CT scan of the abdomen and pelvis were unremarkable apart from a 6.5 cm renal cyst. Urine drug screen did show positive for methamphetamine however patient denied any usage. The next day, patient’s AST and ALT levels continued to rise as patient’s AST was 2463 and ALT was 2094. Patient’s bilirubin now was 2.4. Patient still was asymptomatic, and his physical exam was unremarkable. On day four, patient’s AST was 2,944 and ALT was 2,477 as well as a serum ferritin level of 5900. Suspicion for hemochromatosis arose. Out of concern for unknown elevating transaminitis levels, patient was transferred to tertiary care center. Prior to transfer, patient’s HCV-RNA was drawn and set out for analysis. Post patient transfer, those results came back as positive indicating that patient had acute hepatitis C.
Discussion: The diagnosis of Hepatitis C is typically done by checking serology for hepatitis C antibody (Ab). If the antibody is positive, then hepatitis C RNA viral load is checked to confirm infection. The window period for Hepatitis C is defined as a short amount of time in which the antibodies for Hepatitis C are undetectable while the hepatitis C virus is present. This time period is approximately between week 6 and week 9 post infection. If a basic hepatitis C antibody comes back as completely negative, the diagnosis of Hepatitis C could be missed if the patient is in the window period.
Conclusions: Our case illustrates that while hepatitis C Ab is typically sufficient to diagnose acute hepatitis C infection, if liver enzyme levels are elevated without another cause, RNA viral load of Hepatitis C should be checked. This is due to the fact that the patient could be in the window period where hepatitis C Ab would be undetectable.