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The hepatitis C virus - often referred to as HCV - is the leading cause of liver failure and the top reason for needing a liver transplant. Besides hepatitis (liver inflammation), this virus can also cause arthritis (joint inflammation), muscle pain and weakness, and vascular (blood vessel) problems. The HCV infection often has no symptoms. Most people do not know they have it.
It is common for HCV-positive patients to have related rheumatic diseases. In fact, these problems can appear before you even know you have HCV.
Rheumatic diseases are problems, including pain in the joints, muscles, and connective tissue (the tissue that supports and binds many other parts of the body). HCV-related rheumatic diseases result from infection with HCV. Painful joints and muscles combined with fatigue are usually the first and most common complaints. Less often, joint swelling and inflammation of blood vessels (vasculitis) can occur.
The joint and muscle pain can be caused by the HCV infection itself. The infection activates the body’s immune system, which fights against the virus. The immune system activation can also cause the joint and muscle pain. In someone with HCV, the virus constantly multiplies in the blood and liver. The immune system is constantly turned “on” causing a wide variety of rheumatic problems to potentially occur over time. They range from arthritis and “cryoglobulinemia” to kidney failure.
Cryoglobulinemia occurs when certain abnormal proteins in the blood (cryoglobulins) solidify in the cold. It may cause blood vessel problems, mostly during cold weather. This can result in Raynaud’s phenomenon, which causes fingers to whiten in the cold.
HCV-related rheumatic disorders can affect HCV-positive people of both sexes and all ages and races. The main way HCV spreads today is through intravenous drug abuse using contaminated needles or other tainted drug equipment. HCV can even spread through another type of drug abuse - when persons share instruments to “‘snort” cocaine.
Unlike human immunodeficiency virus - also known as HIV or the AIDS virus - unprotected sex with infected partners is a less common cause of getting HCV. Yet, there are reports of HCV spreading in those engaging in high-risk sex behaviors. Thus, patients who test positive for HCV should also get a test for HIV. Likewise, those with HIV should have HCV testing.
It is also possible for the baby of an HCV-infected mother to get HCV during birth. This is rare though.
The first hurdle in diagnosing HCV-related disease is the HCV diagnosis itself. Symptoms of HCV infection are often absent, so a doctor must know about the connection between hepatitis C and rheumatic disease in order to know which tests to run.
The HCV diagnosis is made by finding antibodies (immune proteins) against the virus in the blood serum. Then, a second blood test to find the virus in the blood confirms the diagnosis. This blood test lets doctors determine the virus replication, which is how fast the virus is making copies, a sign of how active the virus is. This is useful to know for follow-up visits, when the patient may repeat the test. Once the HCV diagnosis is confirmed, diagnosing HCV-related disease is fairly straightforward.
The best approach to care is when several health care providers from different medical specialties work as a team to take care of the patient. All patients with HCV infection need to see a liver specialist (a hepatologist or a gastroenterologist). This doctor will assess how severe the liver damage is and whether to screen for liver cancer. The doctor also will decide whether the patient can start HCV therapy. Some patients who have other infections, mental health issues, or drug or alcohol problems may not be ready to start treatment right away.
The past few years has witnessed one of the most remarkable revolutions in the development of highly effective and well tolerated therapies for HCV than now can afford cure in nearly all people. In the past, therapy was centered on the use of a drug known as interferon that had carried unpleasant side effects and had the potential to start or worsen induce or make worse many rheumatic diseases. Today the new “interferon free” therapies can be given and effect cure in as little as two or three months though some people have to be treated longer.
With proper use of HCV medicines, 97% of patients completing treatment can be cured of HCV. The downside is that the treatment is long and has many side effects. Yet, successful treatment of HCV (which is now nearly possible in everyone) often results in excellent control, or possible cure, of rheumatic problems.
Treatment of Joint Problems
Better control of HCV joint problems also is possible through drugs used to treat other forms of arthritis. However, some of these drugs can have their own toxic effects on the liver or can worsen the viral infection. Therefore, rheumatologists and liver doctors should work together to treat these patients.
Anti-tumor necrosis factor drugs (commonly called
anti-TNF drugs) have improved the treatment of
rheumatoid arthritis. Their use in HCV-positive patients with this type of arthritis appears to be safe. There seems to be no harm to the liver or increase in viral replication. Another rheumatoid arthritis drug,
rituximab (MabThera, Rituxan), also is being tested in patients with HCV.
Better screening of blood transfusions has greatly reduced the spread of HCV in this way. It is now an extremely rare cause of new infections. There should be little worry of contracting HCV from a blood transfusion. The Center for Disease Control and Prevention now recommends that all Americans born between 1945 and 1965 be tested for HCV.
If you have risk factors for HCV, reducing them can help prevent the spread of the virus. Given the advances in therapy, there is a need for more widespread screening for HCV. If you are at risk for HCV, ask your doctor about testing.
HCV-related joint and muscle problems can cause discomfort and make it harder to do daily activities. Thus, it is important to see a rheumatologist, who is an expert in detecting and treating problems of the joints and muscles. Because treatment is complex, make sure there is contact between your doctor in charge of treating liver disease and your doctors who treat the non-liver symptoms of HCV. Also, make sure you get long-term follow-up care. This is vital, since the liver disease can become worse, leading to liver failure or liver cancer.
Support groups also provide helpful support and coping suggestions. You can find other tips in the fact sheet, Managing Your Rheumatic Disease.
Updated March 2017 by Jennifer Murphy, MD and reviewed by the American College of Rheumatology Committee on Communications and Marketing. This information is provided for general education only.
Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.
© 2017 American College of Rheumatology