A 33-year-old woman presents seeking advice. She is concerned regarding the appearance of spider angiomas that are present on her trunk and face. She states that spider angiomas appeared during pregnancy and that they persist now, 9 months after delivery. Before pregnancy, she was treated with imipramine because of depression and she is currently still taking this drug. She denies alcohol intake, however she tells you that 3 years ago, she had acute infection with hepatitis C virus. She was also frequently treated with flucloxacillin during the past couple of years for recurrent respiratory tract infections. In addition, she started taking oral contraceptives after delivery. The remainder of her personal history is unremarkable.
Physical examination reveals the presence of multiple spider angiomas on the patient's face, forearms, and back. The remainder of the patient's general physical findings are unremarkable.
Routine laboratory analyses reveal normal AST (26 IU/l, reference values 8 to 27 IU/l) and ALT (22 IU/l, reference value 8 to 23 IU/l) levels. Alkaline phosphatase level is normal (43 IU/l, reference value 23-71 IU/l) and other routine laboratory analyses reveal no abnormalities. HbSAg, HbeAg, and antiHbc antibodies are not present in patient's serum. IgG antibodies to hepatitis C are present, but testing for hepatitis C virus (HCV) does not reveal the presence of HCV RNA in patient's serum.
What is the most likely cause of the patient's spider angiomas?
A) Flucloxacillin-induced hepatitis
B) Imipramine-induced hepatitis
C) Oral contraceptives
D) Chronic hepatitis caused by hepatitis C virus
E) Pregnancy-related appearance
