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Apparently Healthy Man With History of Injection Drug Use: The Initial Approach

Apparently Healthy Man With History of Injection Drug Use: The Initial Approach

A 45-year-old man comes to see you for a routine physical.
He has no complaints and no significant medical history.
However, while questioning him you discover that he used
intravenous heroin until about 10 years ago-and sometimes
shared needles. He also drank 6 or more beers a day for about 20 years, a practice
he stopped at the same time that he quit using illicit drugs. He has multiple tattoos,
which were done at commercial parlors. He is married but has no children. His wife has
no history of hepatitis. Physical examination is unremarkable.

THE RISK OF HEPATITIS C

This patient's history prompts consideration of infection
with hepatitis C virus (HCV). HCV is a leading cause
of chronic liver disease in the United States. Populationbased
studies indicate that 50% of chronic liver disease in
this country is HCV-related. Between 8000 and 10,000
deaths each year are attributed to HCV liver disease.1 An
estimated 2.7 million Americans are chronically infected
with HCV.2

This patient's injection drug use is a known risk factor
for the infection and is one of the criteria established
by the Centers for Disease Control and Prevention for
HCV screening (Table 1). His history contains only this
one definite risk factor; however, tattooing and body piercing
may increase risk of HCV infection, although this has
not been definitely established. Other behaviors in the latter
category-and for which routine screening for HCV
infection is of uncertain value-include:

  • Noninjection drug use.
  • history of multiple sex partners.
  • A history of sexually transmitted diseases.
  • Long-term sexual relationship with a partner who is
    infected with HCV.

WHAT WOULD YOU DO NOW?
A. Order an enzyme-linked immunosorbent
assay (ELISA) to screen for the presence of
HCV antibodies and, if positive, follow with a
recombinant immunoblot assay (RIBA) to
confirm the result.
B. Order liver function tests (LFTs). If normal,
recommend that the patient have these tests
repeated every 6 months.
C. Order an ELISA to screen for HCV antibodies.
There is no need for confirmatory testing, since
the patient has a known risk factor for HCV
infection.
D. Assume that hepatitis C is likely, since several
risk factors are present; schedule biopsy of the
liver to assess disease severity.

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