Strange symptoms

[tashka]

Dear Dr Schiano,

I hope, you can help me to make sense of my husband's symptoms. He was diagnosed with chronic hepatitis C 2 years ago. He has this disease for 25 years. He had no symptoms and his labs were normal for the most part, just ALT/AST slightly up. Genotype 1.  Biopsy results were encouraging: stage I, minimal inflammation, minimal fibrosis, adequate size (3.5 cm). We were very happy and decided to postpone the tretment. No other tests were suggested at that time.
A few months ago he started experiencing strange symptoms: severe itching, dark urine, pale stool, weakness, indigestion, nausea.  He lost 15 lbs in 6 months (he is monitored every 6 months). Symptoms come and go, itching eventually resolves and he feels OK again. Labs at the hight of itching: bilirubin 3.0; ALT 150; AST 200; platelets 136,000 (lower range of normal is 140,000), albumin, total protein, globulin, GGT, alkaline phosphatase, electrolytes, kidney functions, and all other parameters are normal. Ultrasound revealed mildly enlarged spleen (13.8 cm), and diffuse mild increase in liver echogenicity. IVC, common bile duct, goldbladder, pancreas, kidneys, aorta all normal. No hepatomegaly, no ascites.
Now his doctor says it could be cirrhosis or advanced fibrosis. It is hard for me to understand how biopsy could make such gross mistake.  The doctor convinced us to undergo biopsy and explained that it is a golden standard of diagnostics. I am sure, it is impossible for him to progress from stage I to cirrhosis in less than 2 years. I am just desperate for the answer-could these symptoms combined with  test results indicate something that is NOT cirrhosis? Maybe flare up of his hepatitis? I have all of his labs since diagnosis and found that in 2007, 6 months after the biopsy, he had normal ALT/AST and bilirubin 1.5. Next labs 6 months later showes ALT 180, AST 198, and bilirubin 0.8. There were no symptoms back then.
I would really appreciate your answer.

[Thomas D Schiano, MD]

unless there was sampling error with the first biopsy (15-20% of the time) he would not have advanced to cirrhosis in this short of time.  It is possible that he could have developed an intercurrent HAV or HBV infection (he should receive the vaccinations if not already done).  HCV doesn't ususally flare like this--maybe he had some type of hemolytic disorder which could have affected the platelets, etc.  Another biopsy might be helpful.  i would feel better if the platelet count had returned to normal and then maybe he can just get a fibrosure blood test.

[tashka]

Thank you very much for response. He is vaccinated against other forms of hepatitis. I noticed in his labs that over the last 15 years platelets were slowly going from about 190,000 down lower and lower. But he never had them over 190,000. We'll redo labs in July and see what happens. Another question: if it is cirrhosis, can symptoms come and go like this? Because he feels OK now and even gained some weight.
Thank you again for your expertise.

[Thomas D Schiano, MD]

symptoms from cirrhosis really should not come and go like this.  i agree with your plan.