There is no set symptom pattern with hepatitis C. For some people symptoms are severe enough to significantly affect their quality of life whilst others may experience none at all. Sometimes they will be barely noticeable, but for many people they will come and go and their severity varies. People who have cleared the virus with treatment often only realise that they were experiencing symptoms afterwards once they begin to feel better. Symptoms related to the chronic stage of the disease can include:
Fatigue with non-refreshing sleep • Depression • Headaches • Short-term memory problems • Difficulty concentrating • Mood swings • Digestive problems • Joint and muscle aches and pains • Flu-like symptoms • Discomfort or pain in the liver area • Abdominal pain • Itching
Click here to read an article on symptons written by Professor Graham Foster
Most research has tended to focus on looking at liver damage rather than at symptoms or associated extra-hepatic illnesses (illnesses outside of the liver). It is only recently that the medical profession has started to accept that symptoms and associated illness are indeed caused by the virus, although the reasons for them are not fully understood yet.
Symptoms which do not relate directly to liver damage or any of the associated illnesses the virus can trigger are referred to by doctors as ‘non-specific symptoms.’ The cause of many of these non-specific symptoms is not clear, but there is some evidence to show that hepatitis C may cross the blood/brain barrier and infect neural tissue in the brain. This could at least provide an explanation for some of the symptoms.
One study has shown that fatigue, depression and feelings of anger are more severe in HCV sufferers than when these symptoms are experienced by people with non liver-related chronic diseases.
Brain fog (confusion and impaired memory) has been reported by many people with hepatitis C. A comparison between people with chronic HCV and those who had cleared the virus showed greater mental impairment amongst those with the chronic infection. HCV has been found in cerebrospinal fluid and it is believed this might be linked to brain fog. This study revealed several things which suggest an underlying mechanism for cognitive impairment:
- Those with HCV demonstrated greater mental impairment than those who had cleared the virus
- The choline/creatine ratio shown on MRI brain scans was higher in this group. A significantly higher ratio was also found in the white matter and basal ganglia of the brain in people with HCV as opposed to HBV.
- Autopsied brain tissue showed HCV replication
- HCV was found in the cerebrospinal fluid of 8 out of 13 individuals with HCV.
Jaundice is a common sign of decompensated cirrhosis. It affects only a few patients during acute hepatitis and very few patients during chronic hepatitis C. The yellow appearance of the skin associated with jaundice comes from the pigment bilirubin. This pigment gives bile its green/yellow colour. It is formed during the breakdown of old blood cells. If the liver loses the ability to remove bile pigment it builds up in the blood and the skin. The whites of the eyes then go yellow, the skin takes on a yellow hue, urine goes brown and the stools can turn white.
Extra-hepatic complications of HCV
Extra-hepatic disorders are found outside of the liver. But for people with hepatitis C they can be triggered by the virus. Having chronic HCV does not mean these disorders will develop but they are a risk. Some of these include:
- Dryness of the mucous membrane lining the eyelids and outer eye surface caused by insufficient secretion of tears (keratoconjunctvitis sicca)
- Dryness of the mouth and eyes and a feeling of grittiness in the eyes. This is caused by the progressive destruction of sweat, saliva and tear glands (a form of keratoconjunctvitis called Sjogrens syndrome).
- Flat, itchy patches of skin, usually found on the wrists, shins, lower back, genitalia and sometimes the scalp (lichen planus).
- Inflammation of the tiny blood vessels the kidneys use for filtering waste (glomerulonephritis)
- Sensitivity to light, leading to blisters and ulcerations of the skin in areas such as the face, ears and backs of the hand (porphyria cutanea tarda).
Autoimmune thyroid dysfunction
The thyroid gland is the largest of the endocrine glands. These glands secrete hormones directly into the bloodstream. The thyroid gland’s main function is to increase the rate at which the body’s cells chemically react, especially the energy and protein reactions. There are two conditions associated with HCV infection where the immune system can either attack or stimulate thyroid tissue. Over-reactive thyroid production (hyperthyroidism) can cause insomnia, weight loss, palpitations and ankle swelling. Under-active thyroid production (hypothyroidism) which can cause physical and mental sluggishness. With hepatitis C, thyroid autoimmune dysfunction is more common amongst women. Treatment can also trigger thyroid malfunction. During treatment your thyroid function will be checked regularly
This is a disorder in which abnormal proteins may cause damage to the skin, the nervous system and the kidneys. Symptoms include mild fatigue, joint pains, or itching and increased sensitivity to temperature changes.
Occasionally, people with cryoglobulinemia develop inflammation of the blood vessels (vasculitis). This can cause purple skin lesions (purpura) or numbness in the hands and feet or Raynaud’s phenomenon, where the hands turn white, then blue, and then red from constriction and dilation of the blood vessels.
Lymphoma is cancer of the cells in the lymphatic system (part of the body’s immune and elimination system). There are two main types of lymphoma. One is called Hodgkin’s disease (after Dr Hodgkin, who first described it). The other is called non-Hodgkin’s lymphoma or NHL. NHL is a group of around twenty types of cancer which affect the body’s lymphatic system. HCV frequently inhabits the lymphatic system in very low quantities.
As HCV was often seen as only infecting the liver, until recently the connection between it and NHL was not made. This resulted in cases of lymphoma being underreported.
The primary symptoms of Lymphatic diseases are:
- Painless swellings of the lymph nodes, usually in the neck, armpits or groin.
- Excessive sweating or fever.
- Persistent itching all over the body.
- Weight loss and loss of appetite.
Lymphoma is detected by taking a biopsy from a suspect lymph node. It has been known for some time that people infected with HCV and long-term cryoglobulinemia are at greater risk of NHL. NHL is now also known to develop in people with HCV who do not suffer from cryoglobulinemia. The exact mechanism involved in HCV-associated lymphoma is still unknown.
Insulin Resistance and Diabetes
Insulin resistance is a condition in which there is too much insulin in the blood. The blood cells that normally absorb the insulin begin to refuse it. This results in your body not being able to absorb or process sugars properly. The exact mechanism of insulin resistance in relation to hepatitis C is unknown. It is likely that insulin resistance is an early abnormality that can lead to type-2 diabetes in people with HCV. Some people have also developed diabetes as a result of treatment. 
 http://www.hcvadvocate.org/hcsp/articles/Azocar-1.html - accessed 10.42am, 04.04.2014
Gall Bladder Disease
Some people with hepatitis C will develop problems with their gall bladder. This takes the form of inflammation and pain causing nausea and possibly vomiting and difficulty eating certain foods, especially fatty foods. Gall stones can develop but not in all cases. It is not uncommon for people with hepatitis C to have their gall bladder removed as a result.
 http://www.ncbi.nlm.nih.gov/pubmed/15770666 - accessed 04.04.2011, 10.51am.
In a few rare cases different forms of arthritis have been linked to HCV infection. The type most commonly associated with hepatitis C is rheumatoid arthritis (RA) . People with HCV often show elevated levels of rheumatoid factor in their blood. It is thought that this may be a trigger to the development of rheumatoid arthritis. RA normally affects the synovial joints. These are joints with a space between filled with a liquid called synovial fluid. Most joints in the body are of this type. RA causes membranes in these joints to overgrow leading to inflammation of the linings of the joints. Symptoms include pain, swelling, redness and stiffness.
As the condition progresses, invading proteins may damage the surrounding cartilage, tendons and bone, affecting joint movement. It is generally thought that HCV related RA is an autoimmune disorder that results in antibodies starting to attack normal body tissue. Some doctors also think it may be more closely related to liver damage. The fact that the condition usually affects people who have developed cirrhosis seems to support this.
Treatment can be a problem as some anti-inflammatory drugs used to treat autoimmune diseases suppress the immune system. This may then lead to increased viral replication. Another concern is that many of the drugs used to treat RA are metabolised by the liver. People with liver damage may find that toxins build up in the liver. There is evidence that drug treatment which reduces the viral load can also decrease arthritic symptoms.
 http://www.hcvadvocate.org/hcsp/articles/Bonkovsky-2.html - accessed 04.04.2011, 11.05am