A 43-year-old woman comes to the office due to elevated aminotransferase levels, which were identified during routine blood work. She feels well and reports no symptoms. She has no known medical conditions, and her family history is unremarkable. She used heroin 10 years ago but completed rehabilitation and has not used it since. She does not use tobacco or alcohol. Temperature is 37.5 C (99.5 F), blood pressure is 120/80 mm Hg, and pulse is 87/min. BMI is 24.5 kg/m². There is no scleral icterus or asterixis. Skin and cardiopulmonary examinations are unremarkable. The abdomen is soft and nontender; there is no ascites. Laboratory results are as follows: Abdominal ultrasonography reveals a nodular, shrunken liver without evidence of ascites. Upper endoscopy is negative for esophageal or gastric varices. In addition to providing antiviral therapy to treat this patient's hepatitis C infection, which of the following would be recommended at this time?

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11ec25c8_d0d0_bbdd_bc81_67ae0e897fbb_MD0003_00 This patient has hepatitis C virus (HCV) cirrhosis confirmed by positive HCV antibodies, elevated HCV RNA levels, and a nodular, shrunken liver on ultrasound. Although chronic HCV infection is often asymptomatic and may cause only mild elevations in aminotransferases, some infected individuals (~20%) develop cirrhosis. Laboratory findings suggestive of cirrhosis include thrombocytopenia, hypoalbuminemia, and coagulopathy (eg, elevated PT/INR). Liver biopsy showing extensive fibrosis and regenerative nodules can confirm the diagnosis if necessary. chronic HCV infection A priority of cirrhosis management is to protect patients from further hepatic insult. Patients should be vaccinated against both hepatitis A virus (HAV) and hepatitis B virus (HBV) if there is no evidence of immunity (eg, positive HAV IgG, positive HBV surface antibody). Acute HAV or HBV infection in unvaccinated/nonimmune patients with cirrhosis can cause severe acute or chronic liver failure. This patient has evidence of immunity to HBV but not HAV and therefore should be vaccinated against HAV. (Choices A and E) This patient does not require vaccination against or treatment for HBV because she does not have active infection (eg, negative HBV surface antigen) and is already immune (eg, positive HBV surface IgG antibody). (Choice B) Patients with cirrhosis should be frequently assessed for features of hepatic encephalopathy (eg, abnormal mental status, sleep disturbance, asterixis), but asymptomatic patients do not require treatment (eg, lactulose, rifaximin). (Choice C) Cirrhosis predisposes to ascites, which is treated with diuretics (eg, spironolactone, furosemide), but prophylactic therapy is not recommended for patients without ascites. (Choice F) This patient with cirrhosis requires vaccination against HAV. Educational objective: Patients with cirrhosis from any cause, including chronic hepatitis C virus, should be vaccinated against both hepatitis A virus (HAV) and hepatitis B (HBV) virus unless they have serologic evidence of immunity. Acute HAV or HBV infection in unvaccinated/nonimmune patients with cirrhosis can cause severe acute or chronic liver failure. References: Diagnosis and management of hepatitis C. (http://www.ncbi.nlm.nih.gov/pubmed/26131943)

A 43-Year-Old Woman Comes to the Office Due to Elevated