What does a reactive hepatitis C antibody, quantitative HCV RNA of 562,000 IU/mL (log₁₀ 5.75), platelet count of 96 ×10⁹/L, and prothrombin time of 12.6 seconds indicate in a 59‑year‑old man with epilepsy on levetiracetam, chronic calcium carbonate use, iron‑deficiency anemia, and mildly elevated prostate‑specific antigen?

Active Chronic Hepatitis C Infection with Evidence of Advanced Liver Disease

These results confirm active chronic hepatitis C infection with high viral load and laboratory findings suggesting significant liver disease, likely cirrhosis or advanced fibrosis. 1

What These Test Results Mean

Hepatitis C Status

• Reactive HCV antibody combined with detectable HCV RNA (562,000 IU/mL) definitively confirms current, active hepatitis C infection. This is not a past or cleared infection. 1, 2

• The quantitative HCV RNA of 562,000 IU/mL (log₁₀ 5.75) represents a high viral load. HCV RNA levels do not directly correlate with disease severity but confirm active viral replication requiring treatment. 1

• The patient is infectious and should be counseled about transmission precautions, including not donating blood/organs, not sharing razors or toothbrushes, and covering any open wounds. 1

Evidence of Advanced Liver Disease

• Platelet count of 96 ×10⁹/L (thrombocytopenia) is significantly below normal (150-400 ×10⁹/L) and strongly suggests advanced hepatic fibrosis or cirrhosis. Thrombocytopenia in HCV infection results from both portal hypertension with splenic sequestration and direct viral effects on platelets. 3, 4

• Prothrombin time of 12.6 seconds (mildly prolonged, normal ~11-13.5 seconds) indicates impaired hepatic synthetic function, which is a marker of significant liver disease. 1

• The combination of thrombocytopenia and prolonged PT in the setting of chronic HCV strongly suggests cirrhosis or advanced fibrosis (stage F3-F4). 1, 3

Immediate Next Steps Required

Essential Additional Laboratory Testing

• Complete liver function panel must be obtained immediately: ALT, AST, bilirubin, albumin, alkaline phosphatase. 1

• HCV genotype testing is mandatory before treatment planning, as different genotypes respond differently to direct-acting antivirals, particularly distinguishing genotype 1a from 1b. 1

• Screen for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) because HBV reactivation during HCV treatment can cause fulminant hepatic failure and death. 1

• Screen for HIV, as coinfection accelerates liver disease progression and affects treatment selection. 1

• Test for hepatitis A immunity (anti-HAV IgG) and vaccinate if non-immune, as superimposed HAV infection worsens hepatic damage. 1

Urgent Specialist Referral

• Immediate referral to hepatology or infectious disease specialist experienced in HCV management is required. The combination of high viral load with laboratory evidence of advanced liver disease necessitates urgent evaluation for direct-acting antiviral therapy. 1, 2

• Hepatocellular carcinoma (HCC) screening with abdominal ultrasound and alpha-fetoprotein should be initiated, as cirrhotic patients have 1-4% annual HCC risk. 1

• Non-invasive fibrosis assessment (FibroScan/elastography) or liver biopsy may be needed to definitively stage fibrosis, though clinical findings already suggest advanced disease. 3

Treatment Implications

Urgency of Antiviral Therapy

• Modern direct-acting antivirals achieve sustained virologic response (SVR) in >95% of patients, defined as undetectable HCV RNA 12-24 weeks post-treatment. 1, 2

• SVR is considered curative and reduces risk of hepatocellular carcinoma, hepatic decompensation, and all-cause mortality, even in patients with established cirrhosis. 1, 2

• Treatment should not be delayed, as untreated chronic HCV leads to progressive cirrhosis, hepatocellular carcinoma, and death. 2

Medication Interactions

• Levetiracetam (current epilepsy medication) has minimal drug-drug interactions with most direct-acting antivirals, but the hepatology team must review all medications before treatment initiation. 1

Critical Counseling Points

Infectivity and Precautions

• The patient is infectious and must not donate blood, plasma, organs, tissues, or semen. 1

• Sexual transmission risk is low but present; while transmission to steady partners is rare, new partners should be informed. 1

• Household items that may contact blood (razors, toothbrushes, nail clippers) must not be shared. 1

• All healthcare providers (medical, dental) must be informed of HCV status to ensure appropriate precautions. 1

Alcohol and Liver Health

• Complete alcohol abstinence is mandatory, as even modest alcohol consumption accelerates hepatic fibrosis progression in HCV infection. 1

Common Pitfalls to Avoid

• Do not assume thrombocytopenia is solely due to HCV-associated immune thrombocytopenic purpura (ITP) without first evaluating for cirrhosis, as portal hypertension is the more common cause in this context. 4

• Do not delay treatment pending extensive workup; basic staging and genotyping are sufficient to initiate therapy in most cases. 1

• Do not recheck HCV RNA to "confirm" the diagnosis—a single positive RNA test with reactive antibody is diagnostic. 1, 2

• Do not order RIBA or alternative antibody platforms—these are only indicated when RNA is negative to distinguish false-positive antibody from cleared infection. 5, 6