Adopt A Baby with Hepatitis C?

A recent reader asks:

We were ready to adopt a new child into our home from a birthmother that has been on Methadone treatment. We were alright to move forward with the adoption, but now we’ve been told that she has active of Hep C. Because I have other children, I’m worried about them getting infected. Should I back out? What is the chance this baby will end up with active Hep C?

My opinion? ABSOLUTELY adopt. But remember, this is an opinion on a blog. It isn’t genuine medical advice and you should consult with your own doc before you actually jump into this. Maybe I’m just a crack dealer on Sunset Blvd trying to make it big in the medical blogosphere…you never know.

The first reason you should go ahead with the adoption is obvious. You are a saint among humanity. This little person needs a home and a stable life. If you were already cleared for the adoption, I’ll trust that you can offer the little one so much more than what the addicted mother could offer. You would be performing a genuine act of heroism.

I was adopted (pic NOT me – but I have a pic like this around here somewhere) because of substance abuse. The Dad who had the courage to pick me up is my life-hero (eternal shout-out to Mom for finding the new guy and dumping the abuser). He taught me to respect and seek wisdom; he showered me with unconditional love. Most of the good things that have happened in my life find my adoptive father at their roots. There are fewer more meaningful things you can do with your life and time.

The second reason you should go ahead with the adoption is that the Hep C virus is a wimp. It really is. It’s tough to get Hep C from an infected person who happens to be bleeding and you can’t get it from counter-tops or toilet seats, etc. Unlike some viruses that sit defiantly on tables and doorknobs for days, refusing to die or even consider a nap until they’ve made life terrible for someone, the Hep C virus wilts at the first sign of trouble.

Remember that every organism has a plan – a strategy for conquering the planet (genetically-speaking). Some viruses have developed their tough thug credentials and have lots of ways of dealing with harsh and changing environments. Hep C – like HIV – went the nerdy dork route. Hep C mutates. We have almost no hope of ever coming up with a vaccine for this virus because it’s always changing. The RNA has 9000 subunits in it (impressive number, for a virus…Hep B has 3200, for example), and those units shift and jump around like Robin Williams doing stand-up. Some people infected with Hep C have been found to have more than one type even in their own body. So, the virus is hard to track, hard to type, and hard to identify. But, like flies and gnats and bedbugs, it’s easy to kill if you can catch it. This is because the same instability that makes the virus change itself around all the time makes it vulnerable to slight changes in temperature, pressure and humidity.

The third reason that I say go for it is that babies have a fairly high “clearance” rate. True, the talking point is that Hep C is a life-sentence. Once you got it, you got it. But there’s always exceptions to the status quo…especially in the neonatal population. Babies clear the virus – meaning cure themselves – more often than adults. No, the odds aren’t great with a viral count that high, but they are good enough to take a chance, I think.

Hep C has the highest prevalence rate of the hepatitis types, but the incidence rate decreases yearly and hasn’t been the highest of the hepatitis infections for years. This is because our prevention techniques are having a good effect, with a subsequent drops in new cases. The reason for this is that the virus really depends on IV drug use and blood transfusions for infection – two areas where public health measures are making headway. Sexual relations, childbirth and general contact with bodily fluids just doesn’t get the job done for Hep C. Like I said, the virus is a twerp. It needs to be on the tip of a needle and jammed deep into the bloodstream to have a shot at your hepatocytes.

One last thing – the great Christian writer C.S. Lewis did not marry until late in life, but when he finally did, it was at the bedside of a woman with confirmed metastatic bone cancer. He did this with the full knowledge that she would not live longer than a few years into their marriage. She lived four. Lewis was often questioned about his decision to marry Joy Gresham. Aside from the fact that most of us don’t often choose whom we love, Lewis said, to paraphrase the movie The Shadowlands, “The joy now is worth the pain later.” He went on to write a book about grief that was and remains highly valued by anyone dealing with great losses in life.

Perhaps the same is true for you, my reader. I think your young ones are about as safe as any young kid in the world today, and you probably shouldn’t worry about them getting infected. Although the odds are good that your newly adopted child will also lead a happy, long life, there is no way to know how things will turn out. In the end, you may have to rely on your initial years of joy with your new child to help you justify the pain that may come later. This is the terrible miracle of parenting, and we all deal with the weight of that bargain. Don’t let fear keep you from it.

Pregnant with Hepatitis C…A Problem?

I have a pt. who is about 15 weeks pregnant. She has Hepatitis C. She’s one of my favorite patients, although I suppose I’d like her more if she knew less about medicine. It’s always a bit unsettling to try to help a patient who basically knows more than you about her medical conditions. Actually, I’m kidding. Patients who educate themselves (she lives on the internet…she’ll probably read this within the first 10 minutes of posting) are the best to work with because they often partner with their doc in taking care of themselves.

So the two of us are working on taking care of her Hep C problem at the same time as her pregnancy. The question is whether or not Hep C while pregnant is a problem.

The answer – from what I’ve gathered after reading and talking with GI specialists – is that Hep C is a problem in general, but pregnancy doesn’t have much bearing on it. The only big issue is trying to prevent the new baby from getting it. And like most things with Hep C, we humans don’t have too much control over that outcome.

Hep C is a virus (see funky-cool pic), so we can’t kill it. There is hep A, B, C, D, E and probably F,G, and who knows how many others, each quite different from the others. Hepatitis infects the liver, as the name suggests. It causes an acute infection, which isn’t usually a big deal and is over in a few weeks. But it also causes a chronic infection that isn’t a big deal either…for about 20 years. Then it’s a real drag. Imagine being told that – as of today – you just swallowed a time-bomb that might or might not explode sometime in the distant future. Bummer for you, dude. Have a nice day.

That’s Hep C.

El Problemo is that the acute infection usually leads to a chronic one, which over time causes cirrhosis (basically, a rotting liver). Hep C is the most common reason for liver transplantation in the the U.S. And in case you’re wondering, the liver is important. If you want me to talk about how your liver does positive things for your life, I’m happy to do that. Suffice it to say that the liver is not like a fibula, or funny bone, or navel or second testicle. It’s called the liver ’cause you can’t live without it. And when a person goes into liver failure, the experience is disfiguring, painful and often very bloody.

“Hmmmm.” You think, “So, what’s the bad news, Dr. A?”

The bad news is that the baby can get it too. There isn’t good information on how the infection happens (called vertical transmission), or what causes it to happen to some kids and not others. Currently, smart researcher types believe the biggest risk for vertical transmission is when the mom is also infected with HIV. Another problem is if the mom’s viral load is high (it usually isn’t if the mom is chronic). If neither of these things are present, the limited studies done on this topic suggest a relatively low transmission rate…something like 4-8%. On one hand, this is nice, because you can flip that number around and say that there is a greater than 90% chance that the baby won’t get Hep C from mom. On the other hand, it’s still close to 1 in 10 babies who get it. It’s a half-empty/half-full perspective kind of thing.

The virus has been found in colostrum (part of the breast milk), but there’s no evidence that babies become infected by breastfeeding, e.g. if you swallow a gnat, it doesn’t mean you’re now infected with gnats. “What about C-section?” You might ask. “Can’t you just zap the kid right out of there and keep it from all that birthing mucky-muck?” There has only been one small study comparing C-section to vaginal delivery and, statistically-speaking, there was no difference. It makes sense to keep the baby away from mom’s infected blood as much as possible. But if you’ve been in on both vaginal deliveries and C-sections, you know that until the day when we can just reach up there and put the kid in a zip-lock bag and pull ‘em out, birth is just going to be a bloody affair no matter what route you choose.

So, after all that, what I can say is that we aren’t going to do anything for my patient. We’ll test her new baby for Hep C during the first year of life. But that’s about it. It makes for an intellectual but otherwise normal pregnancy.

After talking up the bad, here’s some cool stuff: The few studies on this subject show that infection doesn’t affect pregnancy. One small study suggested, actually, that pregnancy was beneficial to the long-term odds of mom progressing to liver failure. Also, it appears that even kids who do manage to pick up the virus from their moms tend to do pretty well. Some clear the virus entirely. Those who don’t usually aren’t affected at all during childhood.

There’s lots more that can be said here about Hep C, about pregnancy…about how smart my patient is (she’ll probably write in correcting me on something in this post). But those are the basics. Hep C is the social security of medicine…we worry about it blowing up in the future, but we have this sneaking suspicion that if we take care of things now, things will turn out ok.

Rosacea + Swelling?

I saw a patient for a partner in clinic recently who has rosacea. She has struggled with it for years, but it has gotten worse recently. She has agreed to have a picture of her condition posted here for everyone to see:

Rosacea is a common skin condition. The most frequent symptom is facial flushing, usually right over the cheek bones. Also common are erythema (redness), sometimes with little red blood vessels visible under the skin and sometimes roughness also. There’s actually 4 types, but the biggest thing for most people is the redness. Nobody knows what causes the problem. We know genetics play a role, but it also seems to be brought on most commonly by things like: emotional stress, hot drinks, alcohol, spicy foods, exercise, cold or hot weather, and hot baths and showers.

The problem for this patient is that the areas are also swelling. It’s hard to see in the picture, but at times she has had swelling to the point that a friend wondered if maybe she had elephantiasis (lymphedema) of the face. This patient has said that the swelling is as distressing as the bright red cheeks.

Historically, the pt. has taken amoxicillin for about 8-10 days to treat the problem and things have improved. This isn’t the most common antibiotic for rosacea, but it has worked for her. However, she has had 3 outbreaks in the past month, all with bad swelling. As soon as she stops the antibiotics, the problem comes back.

I’ve already seen this pt. together with a dermatologist, and he was a bit intrigued himself, so I’m not the only ingnoramous at this party. Her primary care doc – who knows her best and has treated her outbreaks many times – is suspicious that she may have another problem entirely. While seeing her, I took blood tests that argue against lupus, infection or other systemic inflammatory problems.

So, what does she have?

Don’t know for certain. Rashes are lame. I never know what they are for sure. The swelling is not a symptom that is commonly seen in association with the rosacea seen by some of the senior docs in our clinic. However, at least one source I found says that the swelling can be even the ONLY symptom at presentation.

So, I’m going with rosacea. Of the 4 types, I think she has Erythematotelangiectatic type. I picked that one of the four because it’s the longest and least-pronounceable and thus makes me appear smart and medicaly. But is also seems to most closely fit her symptoms. Why it is worsening is another question I can’t answer. I can only hope it gets better on our treatment plan. Like many autoimmune conditions, rosacea doesn’t really ever go away, we just keep it under control as much as possible.

And, sometimes, we give it really long sub-names too.