Successful treatment of HCV-associated cryoglobulinemia with ombitasvir/paritaprevir/ritonavir, dasabuvir and ribavirin: A case report
Section snippets
Why this case is important
Lymphoproliferative diseases, such as cryoglobulinemia and B-cell non-Hodgkin lymphoma (NHL) are important extrahepatic manifestations of chronic hepatitis C virus (HCV) infection. Cryoglobulins can be detected in up to 30% of chronic HCV infected patients but symptomatic illness occurs in only 10–15% of the affected individuals [1]. Complications can range from mild to life-threatening and may affect all major organ systems. Immunosuppressive, chemo-immuno and antiviral therapies have been
Case description
A 40 year old male patient with hereditary factor VIII hemophilia was diagnosed with chronic HCV infection in 2003. PR dual therapy initiated in 2010 was suspended because of IFN intolerance and sudden elevation of transaminases. In 2013 severe polyarthritis began, affecting the shoulders and small joints in the hands and feet, with symmetrically distributed palpable purpura on lower extremities. At the beginning of 2014 gradual onset of abnormal gait and decrease in muscle power in the upper
Other similar and contrasting cases in the literature
To our knowledge, this is the first report of a patient with severe symptomatic MC successfully treated with an IFN-free, anti-HCV DAA combination.
Previous data on DAAs as part of IFN containing combinations are also limited in MC. A study by Saadoun et al. [2] reported high effectivity of PR and telaprevir/boceprevir in the treatment of MC. At treatment week 24, the overall virologic response was 69.6% and the clearance of cryoglobulin was observed only in 22.2% of patients [2]. In another
Discussion
Extrahepatic manifestations of chronic HCV infection, such as MC, represents a significant proportion of the disease burden of HCV [8]. Despite the growing knowledge about the pathogenesis, the availability of several therapeutic options and improvements, complete disease remission in MC is suboptimally achieved. The side effects of PR-based treatments are often serious in patients with MC limiting the use of this combination. Moreover, MC is a negative prognostic factor of virological
Conflict of interest
None.
Funding
Research was funded by Semmelweis University, Budapest, Hungary. Further financial support in form of medications was provided by AbbVie, in the context of Viekira® Early Access Program, Hungary.
Ethical approval
Not appropriate, consent was taken from the patient.
Competing interests
MS has been an investigator in clinical trials supported by Novartis, Bristol–Myers Squibb, Janssen-Cilag, Roche, Boehringer-Ingelheim, Merck Sharp & Dohme and AbbVie Pharmaceuticals. MM has been an investigator in clinical trials supported by Novartis, Bristol–Myers Squibb, Janssen-Cilag, AbbVie, Roche, Boehringer-Ingelheim, and Merck Sharp & Dohme. He has received lectures and consultant fees from Janssen-Cilag, AbbVie, Roche, Boehringer-Ingelheim, Merck Sharp & Dohme, and Gilead. All authors
Acknowledgement
We are indebted to Jessica Brosnahan for providing language help.
References (11)
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Peg-IFNα/ribavirin/protease inhibitor combination in hepatitis C virus associated mixed cryoglobulinemia vasculitis: results at week 24
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Persistence of mixed cryoglobulinemia despite cure of hepatitis C with new oral antiviral therapy including direct-acting antiviral sofosbuvir: a case series
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Extrahepatic manifestations of HCV where do we stand?
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2018, EBioMedicineCitation Excerpt :The introduction of DAAs had greatly altered HCV therapy in the past few years [38]. Most of the available studies included patients receiving SOF-based treatment combinations [14, 15, 17] but there is a lack of follow up studies that can rule out the efficacy and safety of DAAs treatment regimen. HCV-MCV results from B-cell expansion and B cell activating factors such as BAFF and APRIL, which are predicted to play a role in disease progression and treatment outcomes [6–11].
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2017, Clinics in Liver DiseaseCitation Excerpt :IFN-free regimens are expected to increase SVR and provide a safe treatment course to previously IFN-contraindicated patients. Reports concerning DAA-based treatment of patients with MC account for approximately 100 patients, with optimal virologic response rates.13–16 Sise and colleagues15 reported 83% SVR in 12 patients with MCS receiving sofosbuvir (SOF)-based combinations: of note, the only two patients failing antiviral treatment received suboptimal combinations according to current international guidelines.
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2017, Journal of HepatologyCitation Excerpt :Finally, NS5A inhibitors (daclatasvir, ledipasvir, ombitasvir, velpatasvir, elbasvir, pibrentasvir) have been shown to be potent antivirals, although the exact mechanism by which they interact with the NS5A protein and inhibit HCV replication remains unclear [22]. Table 1 summarizes the main results obtained by the different antiviral therapeutic regimens [23–54]. In addition to the new generation of antiviral therapies, biological therapies targeting B cells (rituximab) have increasingly been used in HCV-induced cryoglobulinaemia vasculitis [55].
Virologic, Clinical, and Immune Response Outcomes of Patients With Hepatitis C Virus–Associated Cryoglobulinemia Treated With Direct-Acting Antivirals
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