A 52-year-old woman presents to her GP as she has gained weight over the last eight months. On examination, she has yellow sclera, track marks in the antecubital fossae, reddened palms, abdominal distension with shifting dullness, hepatomegaly and bilateral ankle oedema. Auscultation of the chest is normal. She has a past medical history of HIV diagnosed ten years ago, for which she takes antiretroviral therapy. She regularly uses heroin, but she does not drink.

What is the most likely diagnosis?

Options:
explanation: HIV-associated nephropathy is a disease of the kidneys caused by infection with HIV. It presents with a nephrotic syndrome picture; however, this would not explain this patient's jaundice or palmar erythema. This patient is also currently taking antiretroviral treatment, which is protective against developing HIV-associated nephropathy
name: HIV-associated nephropathy
label: d
answer: no
explanation: Chronic and excessive use of alcohol can damage hepatic tissue and lead to hepatitis and eventually cirrhosis. However, in this case, the patient is adamant that they do not drink alcohol. Patients are of course not always honest about their intake of alcohol. However, this patient has a history of intravenous drug use with a co-diagnosis of HIV. These are risk factors for hepatitis C, and therefore at this stage, this is the most likely diagnosis
name: Harmful alcohol use
label: b
answer: no
explanation: This patient is presenting clinically with chronic liver disease, most likely cirrhosis. This is indicated primarily by their examination findings. They have ascites and peripheral oedema, with excessive water retention likely causing them to gain weight. Heart failure, renal failure, and liver failure can all present with peripheral oedema and ascites; however, only liver failure would present with jaundice and palmar erythema. This patient doesn't report drinking alcohol, they have evidence of intravenous drug use, and it is likely they are not using clean needles as they also have a diagnosis of HIV (although it is possible this is not related to their IV drug use). This supports the diagnosis of viral hepatitis. Acute hepatitis B infection leads to chronicity in about 5% of adults, whereas acute hepatitis C infection leads to chronicity in 75% of adults. Hepatitis C is also the most common viral hepatitis found in the UK. This makes hepatitis C infection the most likely diagnosis
name: Chronic hepatitis C
label: a
answer: yes
explanation: Although this is a typical picture of liver cirrhosis and this patient has multiple risk factors for viral hepatitis, hepatitis C is the most common viral hepatitis in the UK and is also more likely to become chronic than hepatitis B. Therefore, hepatitis C is the more likely diagnosis. It is important to note that although the rate of chronicity is low in adults (around 5%), it is significantly higher in children (up to 90%)
name: Hepatitis B
label: e
answer: no
explanation: Heart failure can present with ascites, peripheral oedema and hepatomegaly (a consequence of congestion of the systemic vasculature due to right heart failure). However, this would not explain why this patient is jaundiced and has palmar erythema. In combination with clear risk factors for hepatitis C infection, this makes hepatitis C the most likely diagnosis
name: Right sided heart failure
label: c
answer: no

Correct answer: a