Clinical Scenario:
A 16-year-old boy is referred for evaluation of persistently abnormal liver function tests with HCV RNA remaining detectable for more than 6 months.. He received multiple blood transfusions during infancy for aplastic anemia. He is asymptomatic. Examination is unremarkable with no stigmata of chronic liver disease.
Investigations reveal:
- ALT: 186 U/L (normal <40 U/L)
- AST: 142 U/L
- Total bilirubin: 0.8 mg/dL
- Albumin: 4.3 g/dL
- INR: 1.0
- HBsAg: Negative
- Anti-HCV antibody: Positive
- HCV RNA (PCR): Positive, 2.4 × 10⁶ IU/mL
- Transient elastography: Mild fibrosis (F1)
Which of the following is the most appropriate treatment?
A. Interferon alfa plus ribavirin for 48 weeks
B. Entecavir
C. Sofosbuvir/velpatasvir
D. Prednisolone
E. Observe without treatment because fibrosis is minimal
Correct answer & Explanation:
Correct answer: C. Sofosbuvir/velpatasvir
Explanation: Chronic Hepatitis C Treatment
This adolescent has Chronic Hepatitis C infection with mild hepatic fibrosis (F1). His positive HCV RNA confirms active infection, while persistent viremia establishes chronic infection. The presence of F1 fibrosis indicates early liver injury but is not a reason to defer treatment. Current pediatric guidance recommends direct-acting antiviral therapy for children and adolescents with chronic HCV infection. Sofosbuvir/velpatasvir is a pangenotypic direct-acting antiviral regimen and is an appropriate treatment option.
Sofosbuvir/velpatasvir is a pangenotypic DAA regimen approved for children aged 3 years and older and achieves sustained virologic response (SVR) rates exceeding 95% across all HCV genotypes. Early treatment prevents progression to cirrhosis, hepatocellular carcinoma, and ongoing viral transmission.
Why the other options are incorrect
A. Interferon alfa plus ribavirin
- Previously the standard of care but has been replaced by DAAs because of lower efficacy, longer treatment duration, and significant adverse effects.
B. Entecavir
- Active against hepatitis B virus, not hepatitis C.
D. Prednisolone
- Has no role in chronic hepatitis C and may increase viral replication.
E. Observe without treatment
- Current recommendations advise treating all eligible children with chronic HCV infection, even in the presence of minimal fibrosis.
High-yield pearl
Confirmation of chronic hepatitis C requires persistent detection of HCV RNA for more than 6 months; anti-HCV antibody positivity alone does not confirm active or chronic infection. Once chronic infection is confirmed, direct-acting antiviral therapy is recommended for children and adolescents aged ≥3 years, regardless of disease severity.
Reference
AASLD-IDSA. HCV guidance: recommendations for testing, managing, and treating hepatitis C – HCV in children [Internet]. Alexandria (VA): American Association for the Study of Liver Diseases; 2023 [cited 2026 Sep 18].
You can also practice another MCQ on Chronic Liver Disease.
