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40 m a s s a g e & b o d y w o r k m a r c h / a p r i l 2 0 1 5 SYMPTOMS AND COMPLICATIONS While viral activity inside hepatocytes is aggressive, the symptoms of a hepatitis C infection can be delayed for 20 years or more because the liver compensates for lost cells by replacing them with new ones. When at last the liver can no longer keep up with the damage, we begin to feel the effects of lost function. These symptoms and complications include debilitating fatigue, general malaise, and headache. More advanced liver damage can involve the accumulation of fluid in the peritoneum, a condition called ascites. The liver itself, under both viral and immune system attack, can accumulate scar tissue, leading to cirrhosis (Image 1). When the highly organized channels between hepatocytes are blocked with scar tissue, bilirubin (a golden-brown component of bile and the coloring agent for feces) can back up into the circulatory system, staining the skin, mucous membranes, and eyes yellow in jaundice (Image 2). Other liver functions that are frequently interrupted with cirrhosis include the metabolism of toxic materials into less toxic substances, the removal of excessive male and female hormones, the production of clotting factors, and the management of blood sugar. Not everyone who is exposed to the hepatitis C virus (HCV ) gets sick; the infection spontaneously clears in up to 25 percent of all cases. Of all the people exposed to HCV, 75–85 percent develop chronic infection and are communicable for the rest of their lives; 60–70 percent will develop liver disease; 5–20 percent will develop cirrhosis; and 1–5 percent will die of cirrhosis or liver cancer. Chronic hepatitis C is the leading cause for liver transplant today, but the reinfection rate of the transplanted livers approaches 100 percent. THE CURE? Until about two years ago, the only treatment option for hepatitis C patients was a 24-week course of interferon (a synthetic form of a natural protein that stimulates immune system activity against viruses) and ribavirin, a drug that helps to stop or slow RNA synthesis. This protocol helped many people with the hepatitis C genotype 1 (the most common in the United States), but the side effects were so severe that many patients were forced to stop treatment—these included flu-like symptoms with joint pain, nausea, diarrhea, insomnia, and low blood-cell count. Over a six-month treatment period, these problems can become unmanageable, and when treatment is not completed, it allows the virus to mutate into drug-resistant forms. More recently, new options have become available. A drug called sofosbuvir and its analogues, used with interferon and ribavirin, are capable of completely clearing the virus from the system—in short, curing hepatitis C—with fewer side effects and a shorter course of treatment. This appears to work in up to 75 percent of all patients, compared to 44 percent with the older treatment. This protocol was approved for hepatitis C treatment in 2013. There's just one hitch: it costs up to $100,000 for a complete course of treatment. We can only hope that with the high rates of hepatitis C infection, the volume of potential customers may help to bring the price down. MASSAGE? Can massage therapists catch hepatitis C from clients with open, uncovered lesions? The risk is low, but not zero. This infection is yet another reason it is absolutely critical to observe standard precautions to the best of our ability. We should treat every client as though it were possible he or she is carrying a blood-borne disease. For a refresher on good hygienic practices for massage therapists, read "Hygiene Fact and Fiction" (Massage & Bodywork, May/June 2012, page 36). 1 This autopsy liver specimen shows diffuse pallor due to a dense network of scar tissue, known as fibrosis or cirrhosis. Image courtesy of CDC/Dr. Edwin P. Ewing, Jr. 2 This hepatitis A patient has jaundice of the conjunctivae and facial skin. Hepatitis C can lead to the same result. Image courtesy of CDC/Dr. Thomas F. Sellers; Emory University.