Exacerbation of an unrecognized autoimmune hepatitis and sustainedvirologic response in the caseof antiviral therapy for chronic hepatitis C MD PhD Oleksandra Popovych MD PhD Larysa Moroz MD Felix Chabanov MD PhD Svetlana Kulias Vinnytsia National Medical University Ukraine
Patient history Sex: male Age: 26 years (DOB: 19/JAN/1983) First detection of anti-HCV: 24/NOV/2008(accidentally during examination due tointense hair loss) Epidemiological risks: 23 operations have performed since 1986 to 1989 (1 for congenital hypospadias and 22 for postoperative fistula) Approximate duration of epidemiological anamnesis – 20 years
Physical examination Height: 160 cm Weight: 60 kg Ps: 68 beats per minute Arterial pressure: 120/80 mmHg The lower edge of the spleen is palpated Other organs without significant deviations from the norm
Preliminary findings anti-HCV, Epidemiological risks 20 years ago Intense hair loss, allergic dermatitis Thrombocytopenia Enlargement of spleenAcute problem? Chronic problem? Probably not Probably yes Autoimmune process? Hypersplenism? Other reasons?
Laboratory evaluation (continued ) ASAT 142 U/L ALAT 143 U/L three times the upper limit of normal, ALAT≈ASAT(1 episode was presented with tenfold increase of ALAT and ASAT three years ago )
Laboratory evaluation (continued ) Anti-HCV - positive HCV RNA, PCR, QUANT - 70 000 IU/ML HCV genotype (LIPA) – 1b Anti HIV ½ - negative HBsAg – negative, Anti HBcor - negative ANA – negative
Ultrasound Increased echogenicity of liver with irregular appearing areas SPLENOMEGALY V.PORTAE – 14mm upper limit of normal V.LIENALIS – 10mm Esophagogastroduodenoscopy Esophageal varices, stage II !!! ECG Without clinically significant changes
DiagnosisLiver cirrhosis of HCV etiology(anti-HCV-positive, low viral load, 1b genotype),Child-Pugh class A with moderate inflammatoryactivity. Esophageal varices II, moderatethrombocytopenia. The patient needs treatment(The patient refused liver biopsy, FibroScan - !!!!!!!!!!)
TREATMENT Thrombopoietin PegInterferon Ribavirin receptor α-2b agonistDose dependently on 80mkg 400mg platelets’ levelFrequency q.d. once a week b.i.dRoute of po sc poadministrationDuration dependently on 48 weeks 48 weeksof treatment platelets’ level
Week 9 (stop antiviral therapy) ALAT 250 U/L ASAT 289 U/L HCV RNA, PCR, QUANT - negative Anti HAV-, Anti Bcor-, Anti HEV- CMV-, Epstein-Barr VCA- IgM, ANA, ActionAb, SMA, AMA IgG – negative LKM-1 ANTIBODY IGG 46.1 UNITS (positive >=25). Manifestation of autoimmune hepatitis II type Ultrasound (New changes): mild thickening of caudate lobe, V.Portae – 15mm, V.Lienalis – 11mm, Ascites – 300-350ml
U/L B ef or St e ar tre t 0 100 200 300 400 500 600 of at m 700 an en tiv t ira lt he ra py W treatment 1(s W to 2 p W an 4 (s ti v ta ir W rt al 6 Pr t h e d er W ni ap 8 so y) lo W n) 9 W 12 W 14 W 15 W 16 W 17 W ALAT 612 U/L ASAT 585 U/L 21 W 29 W 41 Dynamics of ALAT and ASAT for the ALAT ASAT
Preliminary results of the treatment Ascites was resolved in a 2 weeks after Prednisolone therapy All the biochemical data were normalized after 2 month of Prednisolone therapy Prednisolone therapy lasted 1 year Normal biochemical data and negative HCV RNA have been retained till now Total duration of virologic remission is 1 year 3 months LKM-1 ANTIBODY IGG - negative
Key issues ???Overlap syndrome is Avowed duration a contraindication ANA examination is enough of antiviral therapy for antiviral therapy of HCV-infection to start of is 48 weeks ? antiviral therapy ? ?