Hcv

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Hcv

  1. 1. 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
  2. 2. 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
  3. 3. Life history Vision: mild myopia (current) Skin: allergic dermatitis (past), intense hair loss (past) Urogenital system: urolithiasis (current) Respiratory system: Pneumonia (past) Blood: thrombocytopenia (65-80 THOU/mkl)(since 1989, current)
  4. 4. 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
  5. 5. 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?
  6. 6. Laboratory evaluation (primary data) CBC RBC 4,72 TI/L MCV 79,54 FL HB 135,2 G/L Ht 37,5% WBC 4,1Gi/L PLT Neutrophils 2,42/mkl 67 THOU/mkl Lymphocytes 1,27/mkl Monocytes 0,33/mkl Eosinophils 0,08/mkl 0,08
  7. 7. Laboratory evaluation (primary data) Coagulation tests APTT 59 sec INR 1,37 MILD INCREASE PT 21,6 sec Urine analysis Without clinically significant changes
  8. 8. Laboratory evaluation (primary data) Urea nitrogen 3.5 mmol/l  Protein total 73 G/L Creatinine 61umol/l  Albumin 46 G/L Glucose 5.1 mmol/l  Calcium 2.36 mmol/l Sodium 139 mmol/l  Chloride 104 mmol/l Potassium 3.7 mmol/l  Magnesium 0.74 mmol/l Alkaline Posphatase 117 u/l  Uric Acid 368 umol/l Bilirubin total 24 umol/l  Phosphorus inorganic Bilirubin indirect 18 umol/l 0.98mmol/l Bilirubin direct 6 umol/l  Insulin 42 PMOL/L Serum iron 18.5 umol/l  ATTPO 6 ME/ml Ferritin 153.9 ng/ml  TSH 0,983 mkME/ml
  9. 9. 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 )
  10. 10. 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
  11. 11. 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
  12. 12. 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 - !!!!!!!!!!)
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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 ? ?
  18. 18. THANK YOU !

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