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Abdel-Samiee M, Youssef MI, Elghamry F, Bazeed M, Al-Shorbagy M, Shalaby H, Shabana H, Abdelsameea E, Lashin HES, El Zamek HMF, Esam T, Alwaseef MAA, Helmy HA, Almarshad F, Khalaf FA, Yossef BWA, Kassem A, Gabr BM, Abdelfattah A, S AboShabaan H, Aboufarrag GA, Omar MM, Bakeer MS, Imam MS, Ibrahim ES, Kamel SY, Allisy T, Mohammed OS, Farahat A, El-Khayat MM, Sekeen MAH, Zaher EM, Said A, Abuamer A, Elmahdi E. A multicentric and nationwide predictive study role of T cell sub-population in the prevalence and prognosis of cryoglobulinemia among genotype 4 chronic hepatitis C patients. J Med Virol 2023; 95:e29248. [PMID: 38108641 DOI: 10.1002/jmv.29248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/01/2023] [Accepted: 11/11/2023] [Indexed: 12/19/2023]
Abstract
The infection caused by the hepatitis C virus (HCV) is a significant global health concern. The prevailing genotype of HCV in Egypt is 4a, commonly referred to as GT-4a. A significant proportion exceeding 50% of patients infected with HCV experience extrahepatic manifestations (EHMs), encompassing a diverse range of clinical presentations. These manifestations, including essential mixed cryoglobulinemia (MC), can serve as initial and solitary indicators of the disease. The complete understanding of the pathogenesis of EHM remains unclear, with autoimmune phenomena being recognized as the primary causative factor. In this study, we examined the predictive significance of T-cell subpopulations in relation to the occurrence and prognosis of cryoglobulinemia in HCV patients. A total of 450 CHC genotype four treatment naïve patients were enrolled in this analytic cross-sectional study after thorough clinical, laboratory, and radiological examinations. All patients underwent laboratory investigations, including testing for cryoglobulin antibodies and measurements of CD4 and CD8 levels; two groups were described according to their test results: Group 1 consists of patients who have tested positive for cryoglobulin antibodies and Group 2 consists of patients who have tested negative for cryoglobulin antibodies. The exclusion criteria encompassed individuals with HIV infection or chronic HBV infection. Additionally, pelvi-abdominal ultrasonography was performed. Our study included 450 treatment naïve CHC patients (59% male, mean age 50.8 years). The patients were categorized according to their cryoglobulin antibodys test results into two groups: group A, CHC patients with cryoglobulin antibodies (Abs) negative (364 patients), and group B, CHC patients with cryoglobulin Ab positive (86 patients). Group B demonstrated a higher average age, elevated international normalized ratio, more prolonged duration of HCV infection, lower albumin, higher alanine aminotransferase, higher aspartate aminotransferase, higher bilirubin, lower CD8, lower CD4, and lower CD4:CD8 ratio. In contrast, 27 out of 86 (31.40%) patients in group B had symptoms; 85.8% had purpura and arthralgia, 74.3% had paresthesias, 86.7% had weakness, and 12.2% had non-Hodgkin's lymphoma. The levels of CD4 and CD8 were found to be decreased in chronic HCV patients with MC. T-cell subpopulation serves as a reliable indicator for assessing the prevalence and prognosis of MC in individuals with genotype 4 chronic hepatitis C. However, additional research is needed to further understand the development and spread of various emerging infectious diseases. Nevertheless, it is noteworthy that a critical threshold may exist beyond which EHM reaches a point of no return.
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Affiliation(s)
- Mohamed Abdel-Samiee
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Mohamed I Youssef
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Fathy Elghamry
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mahmoud Bazeed
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Al-Shorbagy
- Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Helmy Shalaby
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Hossam Shabana
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Department of Internal Medicine, College of Medicine, Shaqra University, Dawadmi, Saudi Arabia
| | - Eman Abdelsameea
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | | | - Tarek Esam
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | - Housam Ahmed Helmy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Feras Almarshad
- Department of Internal Medicine, College of Medicine, Shaqra University, Dawadmi, Saudi Arabia
| | - Fatma A Khalaf
- Department of Clinical Biochemistry, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | - Arafat Kassem
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Basant Mostafa Gabr
- Department of Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed Abdelfattah
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Hind S AboShabaan
- Department of Clinical Pathology, National Liver Institute, Menoufia University, Menoufia, Egypt
| | | | - Marwa M Omar
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Mohammed Saied Bakeer
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohammed S Imam
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Shimaa Y Kamel
- Department of Tropical Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Talaat Allisy
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Omima Sayed Mohammed
- Department of Microbiology, College of Medicine, Najran University, Najran, Saudi Arabia
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ali Farahat
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohsen M El-Khayat
- Department of Tropical Medicine, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
| | | | - Eman Mohammed Zaher
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Ashraf Said
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Abuamer
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Essam Elmahdi
- Department of Internal Medicine, College of Medicine, Shaqra University, Dawadmi, Saudi Arabia
- Department of Internal medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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2
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Sharma P, Sawtell R, Wang Q, Sise ME. Management of Hepatitis C Virus and Hepatitis B Virus Infection in the Setting of Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:343-355. [PMID: 37657881 PMCID: PMC10479952 DOI: 10.1053/j.akdh.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 09/03/2023]
Abstract
Treatment of chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infection poses unique challenges in patients with kidney disease. Direct-acting antivirals have been a major breakthrough in eradicating HCV infection, and several pangenotypic regimens are available for patients with chronic kidney disease or end-stage kidney disease requiring dialysis with high cure rates and no need for dose adjustment. Direct-acting antiviral therapy alone can treat HCV-associated cryoglobulinemic glomerulonephritis; concurrent antiviral and immunosuppressive therapy is needed for cases of severe, organ-threatening manifestations of cryoglobulinemia. Immunosuppression may be needed for HBV-associated kidney disease (polyarteritis nodosa or membranous nephropathy) when there is evidence of severe immune-mediated injury while weighing the risk of potential viral activation. Most HBV antiviral agents need to be dose-adjusted in patients with chronic kidney disease or end-stage kidney disease requiring dialysis, and drug-drug interactions need to be carefully evaluated in patients with kidney transplants. Considerations for accepting HCV- and HBV-infected donors for kidney transplantation are discussed.
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Affiliation(s)
- Purva Sharma
- Department of Medicine, Division of Nephrology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Glomerular Disease Center at Northwell Health, Hempstead, NY
| | - Rani Sawtell
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Qiyu Wang
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA.
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3
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Origa R. Hepatitis C and Thalassemia: A Story with (Almost) a Happy Ending. Pathogens 2023; 12:pathogens12050683. [PMID: 37242353 DOI: 10.3390/pathogens12050683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/28/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023] Open
Abstract
Donor screening has nearly eliminated the risk of hepatitis C virus post-transfusion transmission in resource-rich settings. Moreover, the use of direct antiviral agents made it possible to treat the majority of patients with thalassemia and hepatitis C. However, this achievement, while extremely significant, does not erase the effects of the virus in terms of fibrogenesis and mutagenic risk, and adult patients with thalassemia are facing the long-term consequences of the chronic infection both on the liver and extrahepatically. As in the general population, it is in mainly patients with cirrhosis who are increasing in age, even though they are now HCV RNA-negative, who are at risk of hepatocellular carcinoma, which continues to be statistically much more frequent in individuals with than without thalassemia. In certain resource-limited settings, the World Health Organization has estimated that up to 25 percent of blood donations do not undergo screening. It is therefore not surprising that hepatitis virus infection is still the most prevalent in patients with thalassemia worldwide.
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Affiliation(s)
- Raffaella Origa
- Ospedale Pediatrico Microcitemico, Via Jenner Sn, 09121 Cagliari, Italy
- Department of Medical Sciences and Public Health, University of Cagliari, Cittadella Universitaria di Monserrato Strada Provinciale 8, 09042 Cagliari, Italy
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4
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Đorđević Betetto L, Luzar B, Pipan Tkalec Ž, Ponorac S. Cutaneous leukocytoclastic vasculitis following COVID-19 vaccination with Ad26.COV2.S vaccine: a case report and literature review. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2022. [DOI: 10.15570/actaapa.2022.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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5
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Isobe M, Amano K, Arimura Y, Ishizu A, Ito S, Kaname S, Kobayashi S, Komagata Y, Komuro I, Komori K, Takahashi K, Tanemoto K, Hasegawa H, Harigai M, Fujimoto S, Miyazaki T, Miyata T, Yamada H, Yoshida A, Wada T, Inoue Y, Uchida HA, Ota H, Okazaki T, Onimaru M, Kawakami T, Kinouchi R, Kurata A, Kosuge H, Sada KE, Shigematsu K, Suematsu E, Sueyoshi E, Sugihara T, Sugiyama H, Takeno M, Tamura N, Tsutsumino M, Dobashi H, Nakaoka Y, Nagasaka K, Maejima Y, Yoshifuji H, Watanabe Y, Ozaki S, Kimura T, Shigematsu H, Yamauchi-Takihara K, Murohara T, Momomura SI. JCS 2017 Guideline on Management of Vasculitis Syndrome - Digest Version. Circ J 2020; 84:299-359. [PMID: 31956163 DOI: 10.1253/circj.cj-19-0773] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University
| | - Yoshihiro Arimura
- Department of Rheumatology and Nephrology, Kyorin University School of Medicine.,Internal Medicine, Kichijoji Asahi Hospital
| | - Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | | | - Yoshinori Komagata
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Graduate School of Medicine
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Kei Takahashi
- Department of Pathology, Toho University Ohashi Medical Center
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology, and Infectious Diseases, Ehime University Graduate School of Medicine
| | - Masayoshi Harigai
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki
| | | | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center
| | - Hidehiro Yamada
- Medical Center for Rheumatic Diseases, Seirei Yokohama Hospital
| | | | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Graduate School of Medical Sciences, Kanazawa University
| | | | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hideki Ota
- Department of Advanced MRI Collaboration Research, Tohoku University Graduate School of Medicine
| | - Takahiro Okazaki
- Vice-Director, Shizuoka Medical Center, National Hospital Organization
| | - Mitsuho Onimaru
- Division of Pathophysiological and Experimental Pathology, Department of Pathology, Graduate School of Medical Sciences, Kyushu University
| | - Tamihiro Kawakami
- Division of Dermatology, Tohoku Medical and Pharmaceutical University
| | - Reiko Kinouchi
- Medicine and Engineering Combined Research Institute, Asahikawa Medical University.,Department of Ophthalmology, Asahikawa Medical University
| | - Atsushi Kurata
- Department of Molecular Pathology, Tokyo Medical University
| | | | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Eiichi Suematsu
- Division of Internal Medicine and Rheumatology, National Hospital Organization, Kyushu Medical Center
| | - Eijun Sueyoshi
- Department of Radiological Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine
| | | | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine Department of Internal Medicine, Faculty of Medicine, Kagawa University
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University
| | | | - Shoichi Ozaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hiroshi Shigematsu
- Clinical Research Center for Medicine, International University of Health and Welfare
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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6
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Ajiboye O, Vohra I, Attar B, Katiyar V, Mba B. Cryoglobulinemic Vasculitis Masquerading as Bilateral Carpal Tunnel Syndrome. Cureus 2019; 11:e6423. [PMID: 31988822 PMCID: PMC6970103 DOI: 10.7759/cureus.6423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/15/2019] [Indexed: 11/05/2022] Open
Abstract
Cryoglobulinemic vasculitis (CV) is a systemic inflammatory syndrome involving small- to medium-sized vessels. Almost half of hepatitis C-infected patients have detectable cryoglobulins levels, but only very few develop clinical manifestations. In this case report, we bring forth a diagnostic challenge of CV. A 52-year-old man with untreated hepatitis C (high viral load), diabetes mellitus, hypertension, and chronic kidney disease 4 (CKD) with solitary left kidney presented with one month of bilateral hand pain that started in his right hand, progressed to involve the left with numbness more on the palmer aspects and lateral three fingers. Physical exam was significant for bilateral positive Phalen and Tinel's sign. CV occurs due to precipitation of immune complexes within the vessels. Palpable purpura, arthralgia, and weakness have been described as the core symptoms of CV. However, progressive acute to subacute neuropathy, especially bilateral, should raise concerns for vasculitic neuropathy.
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Affiliation(s)
- Oyintayo Ajiboye
- Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Ishaan Vohra
- Internal Medicine, John H Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Bashar Attar
- Gastroenterology and Hepatology, Rush University Medical Center, Chicago, USA
| | - Vatsala Katiyar
- Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Benjamin Mba
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
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7
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Mariscal-Rodríguez A, Villar Guimerans L, López-Trascasa M, Hernández González M, Moga Naranjo E. Guía de laboratorio para el diagnóstico de pacientes con síndrome crioglobulinémico. Rev Clin Esp 2019; 219:505-513. [DOI: 10.1016/j.rce.2018.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022]
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8
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Laboratory guidelines for the diagnosis of patients with cryoglobulinemic syndrome. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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9
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Mohammad S, Chandio B, Soomro AA, Lakho S, Ali Z, Shaukat F. The Frequency of Cutaneous Manifestations in Hepatitis C: A Cross-sectional Study in a Tertiary Care Hospital in Pakistan. Cureus 2019; 11:e6109. [PMID: 31777699 PMCID: PMC6857831 DOI: 10.7759/cureus.6109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction Even though the liver is the main targeted organ in hepatitis C, the manifestations of the disease are not limited to hepatic involvement. Other tissue types are often involved as well. Hepatitis C has dermatological and mucocutaneous manifestations. Methods This study was conducted from May 2016 to April 2017 in the gastroenterology unit of Ghulam Muhammad Mahar Medical College, Sukkur, Sindh, Pakistan. All participants with a clinical diagnosis of hepatitis C with cutaneous manifestations were included in the study after securing informed consent. Demographic data and detailed cutaneous examination results with full morphological descriptions were recorded in patient-completed questionnaires. Results Of the 212 participants, 141 (66.6%) were males and 71 (33.4%) were females. The mean age was 32 (±9) years (range: 17-58 years). The most common cutaneous manifestation was pruritus (33.96%), followed by lichen planus (LP) (23.5%). Conclusion Physicians should try to recognize extrahepatic manifestations of a hepatitis C infection as it may help in early diagnosis efforts. While managing hepatitis C, we recommend a multidisciplinary approach to tackle cutaneous and other extrahepatic manifestations.
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Affiliation(s)
- Saleh Mohammad
- Gastroenterology, Ghulam Muhammad Mahar Medical College and Hospital, Sukkur, PAK
| | - Bashir Chandio
- Internal Medicine, Ghulam Muhammad Mahar Medical Hospital, Sukkur, PAK
| | - Aftab A Soomro
- Pathology, Ghulam Muhammad Mahar Medical Hospital, Sukkur, PAK
| | - Salma Lakho
- Internal Medicine, Ghulam Muhammad Mahar Medical College and Hospital, Sukkur, PAK
| | - Zamanat Ali
- Internal Medicine, Ghulam Muhammad Mahar Medical Hospital, Sukkur, PAK
| | - Faizan Shaukat
- Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
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10
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Silva F, Pinto C, Barbosa A, Borges T, Dias C, Almeida J. New insights in cryoglobulinemic vasculitis. J Autoimmun 2019; 105:102313. [PMID: 31383568 DOI: 10.1016/j.jaut.2019.102313] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/24/2019] [Accepted: 07/28/2019] [Indexed: 01/08/2023]
Abstract
Cryoglobulins are antibodies that precipitate at low temperatures and dissolve after rewarming. Cryoglobulinemia refers to the presence of circulating cryoglobulins and generally leads to a systemic inflammatory syndrome characterized by fatigue, arthralgia, purpura, ulcers, neuropathy and/or glomerulonephritis. The disease mainly involves small to medium-sized blood vessels and causes vasculitis due to cryoglobulin-containing immune complexes. Cryoglobulinemia is classified into three types (I, II and III) on the basis of immunoglobulin composition. Predisposing conditions include lymphoproliferative, autoimmune diseases and hepatitis C virus infection. The diagnosis of cryoglobulinemic syndrome is predominantly based on the presence of clinical features and laboratorial demonstration of serum cryoglobulins. The treatment strategy depends on the cause of cryoglobulinemia. For patients with chronic HCV infection, antiviral therapy is indicated. Immunosuppressive or immunomodulatory therapy, including steroids, plasmapheresis and cytotoxic agents, is reserved for organ-threatening manifestations. In this review, we discuss the main clinical presentations, diagnostic approach and treatment options.
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Affiliation(s)
- Filipa Silva
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Claudemira Pinto
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Arsénio Barbosa
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Tiago Borges
- Internal Medicine Department, Hospital Privado de Gaia, Gaia, Portugal
| | - Carlos Dias
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Coordinator of Autoimmune Diseases Unit, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jorge Almeida
- Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
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11
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Eloumou SAFB, Mefo'o JPN, Nga WTB, Kenfack GU, Yakana L, Malongue A, Okalla C, Kowo M, Andoulo FA, Tzeuton C, Bidja MSD, Namme HL, Adiogo D, Noah DN. [Cryoglobulin and factors associated with it in patient with anti-hepatitis-C antibodies living in resource-limited countries]. Pan Afr Med J 2019; 33:169. [PMID: 31565130 PMCID: PMC6756798 DOI: 10.11604/pamj.2019.33.169.19162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/18/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction hepatitis C virus (HCV) has several extra-hepatic manifestations including cryoglubulinemia. Cryoglobulinemia is defined as the abnormal presence in the blood of one or several proteins (cryoglobulins) that can precipitate at low temperatures. Method We conducted a cross-sectional analytical study in the Laboratory of Biology and in the Unit of Hepatology of the General Hospital in Douala (HGD) over a period of 6 months. All patients agreeing to participate to the study and with anti-hepatitis-C antibodies under treatment or not were enrolled. Cryoglobulins were detected using biuret method and the classification was performed using Brouet immunoelectrophoresis. A multivariate analysis was conducted, confounding factors such as age, sex and the length of time after Hepatitis C Virus screening were adjusted. Results The study enrolled 116 patients. The average age of patients was 58.47±9.95 years. Male sex accounted for 50.86% of cases. Arthralgia was found in 69.80% of cases. Cryoglobulin was found in 63.80% of patients. After adjustment, female sex (OR =2.18; CI 95% [0,97-4,90]; p= 0.059), asthenia alone (OR =2.45;CI 95% [1,04-5,80]; p= 0.041), asthenia combined with arthralgia (OR =2.84;CI 95% [1,13-7, 10]; p= 0.026) and the presence of HCV RNA (OR =2.84;CI 95% [1,13-7,10]; p= 0.028) were factors independently associated with the presence of cryoglobulin. Conclusion The prevalence of cryoglobubin is high in patients with anti-hepatitis-C antibodies at the HGD. Simple biological methods are used to detect it. Cryoglobulin test in patients with HCV is essential in resource-limited countries.
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Affiliation(s)
- Servais Albert Fiacre Bagnaka Eloumou
- Service de Médecine Interne, Hôpital Général de Douala, Douala, Cameroun.,Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun
| | - Jean Pierre Nda Mefo'o
- Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun.,Service de Biologie, Hôpital Général de Douala, Douala, Cameroun
| | - Winnie Tatiana Bekolo Nga
- Service de Médecine Interne, Hôpital Général de Douala, Douala, Cameroun.,Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun
| | - Gabin Ulrich Kenfack
- Faculté de Médecine et des Sciences Biomédicales, Université de Yaoundé I, Cameroun
| | - Linus Yakana
- Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun
| | - Agnès Malongue
- Service de Médecine Interne, Hôpital Général de Douala, Douala, Cameroun
| | - Cecile Okalla
- Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun.,Service de Biologie, Hôpital Général de Douala, Douala, Cameroun
| | - Mathurin Kowo
- Faculté de Médecine et des Sciences Biomédicales, Université de Yaoundé I, Cameroun
| | | | - Christian Tzeuton
- Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun.,Centre Médical des Capucines, Douala, Cameroun
| | - Marie Solange Doualla Bidja
- Service de Médecine Interne, Hôpital Général de Douala, Douala, Cameroun.,Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun
| | - Henry Luma Namme
- Service de Médecine Interne, Hôpital Général de Douala, Douala, Cameroun.,Faculté de Médecine et des Sciences Biomédicales, Université de Yaoundé I, Cameroun
| | - Dieudonne Adiogo
- Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun
| | - Dominique Noah Noah
- Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroun
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12
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Rutledge SM, Chung RT, Sise ME. Treatment of hepatitis C virus infection in patients with mixed cryoglobulinemic syndrome and cryoglobulinemic glomerulonephritis. Hemodial Int 2019; 22 Suppl 1:S81-S96. [PMID: 29694729 DOI: 10.1111/hdi.12649] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cryoglobulinemia is a common extrahepatic manifestation of infection with hepatitis C virus (HCV). When signs and symptoms of systemic vasculitis or glomerulonephritis occur in the presence of circulating cryoglobulins, this syndrome is called "mixed cryoglobulinemia syndrome" (MCS). Historically, interferon-based therapies in HCV have been associated with lower rates of viral cure in patients with MCS than in the general HCV-infected population. The advent of direct-acting antiviral therapies have revolutionized the treatment of HCV, dramatically increasing rates of cure. Early studies of first-generation protease inhibitors (telaprevir and boceprevir) in combination with interferon and ribavirin demonstrated HCV cure rates of 67% and complete clinical response rates of vasculitis symptoms in 60% of patients with MCS; however, regimens were poorly tolerated by patients, 22% discontinued treatment early. More recently, all-oral, interferon-free regimens have become available and combination therapies are now being approved for patients with and without renal impairment. Patients with HCV-MCS achieved sustained virologic response in 297 out of 313 patients (95%) treated with direct-acting antiviral therapy, and 85% had a complete or partial clinical response of MCS symptoms. Current direct-acting antiviral therapies are well tolerated in patients with HCV-MCS and only 1.6% discontinued treatment early. Patients with cryoglobulinemic glomerulonephritis also had an excellent cure rate (94%). The majority improved; 17/52 (33%) experienced full remission and 15/52 (29%) experienced partial remission. There were no reports of worsening kidney function in patients treated with direct-acting antiviral therapies. Less than 5% of patients with HCV-MCS treated with IFN-free direct-acting antiviral therapy required immunosuppression. However, patients with severe vasculitis appear to still require concomitant immunosuppression.
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Affiliation(s)
- Stephanie M Rutledge
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond T Chung
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meghan E Sise
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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13
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Sise ME, Chute DF, Gustafson JL, Wojciechowski D, Elias N, Chung RT, Williams WW. Transplantation of hepatitis C virus infected kidneys into hepatitis C virus uninfected recipients. Hemodial Int 2019; 22 Suppl 1:S71-S80. [PMID: 29694722 DOI: 10.1111/hdi.12650] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Long wait times for kidney transplant and the high risk of mortality on dialysis have prompted investigation into strategies to increase organ allocation and decrease discard rates of potentially viable kidneys. Organs from hepatitis C virus (HCV) antibody positive donors are often rejected; nearly 500 HCV-infected kidneys are discarded annually in the United States. Due the opioid epidemic, the number of HCV-infected donors has increased because of a rise in both new HCV infections and drug-related deaths. In the past 5 years, HCV has been transformed into a curable illness with direct-acting antiviral therapies (DAAs) that are effective in >95% of patients treated and are extremely well tolerated. Recent data has shown several direct-acting antiviral combinations are safe and effective after kidney transplant, and can achieve the same high cure rate seen in the general population and without increasing the rate of acute rejection. Because of this, strategies to decrease discard of HCV-infected organs have been devised. Two recent studies have transplanted HCV-uninfected dialysis patients with kidneys from donors actively infected with HCV; recipients were treated with DAA in the peri-transplant period. More research is needed to determine the safety and efficacy of this approach, but it has the potential to dramatically increase the donor pool of available kidneys, shorten waitlist times and ultimately decreases mortality in patients waiting for kidney transplant.
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Affiliation(s)
- Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donald F Chute
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jenna L Gustafson
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nahel Elias
- Department of Transplant Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond T Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Winfred W Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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14
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Long JD, Rutledge SM, Sise ME. Autoimmune Kidney Diseases Associated with Chronic Viral Infections. Rheum Dis Clin North Am 2018; 44:675-698. [PMID: 30274630 DOI: 10.1016/j.rdc.2018.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Autoimmune kidney diseases triggered by viruses are an important cause of kidney disease in patients affected by chronic viral infection. Hepatitis B virus (HBV) infection is associated with membranous nephropathy and polyarteritis nodosa. Hepatitis C virus (HCV) infection is a major cause of cryoglobulinemic glomerulonephritis. Patients with human immunodeficiency virus (HIV) may develop HIV-associated nephropathy, a form of collapsing focal segmental glomerulosclerosis, or various forms of immune-complex-mediated kidney diseases. This article summarizes what is known about the pathogenesis, diagnosis, and management of immune-mediated kidney diseases in adults with chronic HBV, HCV, and HIV infections.
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Affiliation(s)
- Joshua D Long
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, 55 Fruit Street, GRB 7, Boston, MA 02114, USA
| | - Stephanie M Rutledge
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, 55 Fruit Street, GRB 7, Boston, MA 02114, USA
| | - Meghan E Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, 55 Fruit Street, GRB 7, Boston, MA 02114, USA.
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Abstract
Cryoglobulins are immunoglobulins that undergo reversible precipitation at low temperatures. They can induce systemic vasculitis, characterized by purpuric cutaneous lesions, arthritis, peripheral neuropathy, hypocomplementemia and glomerular disease. Renal pathology reveals membranoproliferative glomerulonephritis, with particularly intense mesangial cell proliferation and infiltration by macrophages, associated with intracapillary thrombi. This renal disease presents as a nephritic syndrome, with heavy proteinuria, haematuria severe hypertension and rapidly progressive kidney failure that can lead to end-stage renal disease. Hepatitis C is the main cause of mixed (type 2 or 3) cryoglobulinemia and requires the initiation of a specific antiviral therapy, together with immunosuppressive drugs. Rituximab is now considered as the best immunosuppressive therapy in this situation, inducing B-cell depletion, clearance of circulating cryoglobulin and resolution of renal symptoms. Monoclonal (type 1) cryoglobulinemia, is a rare condition, but it usually reveals an B-cell or a plasma cell proliferation, that require a specific hematological treatment to obtain remission of the renal disease.
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16
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Bunchorntavakul C, Mitrani R, Reddy KR. Advances in HCV and Cryoglobulinemic Vasculitis in the Era of DAAs: Are We at the End of the Road? J Clin Exp Hepatol 2018; 8:81-94. [PMID: 29743799 PMCID: PMC5938331 DOI: 10.1016/j.jceh.2017.11.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 11/30/2017] [Indexed: 12/12/2022] Open
Abstract
Hepatitis C Virus (HCV)-related Mixed Cryoglobulinemia (MC) is a unique condition with complex pathogenesis that involves HCV antigen-driven B-lymphocyte clonal proliferation and mutagenesis. Clinical spectrum of MC ranges from asymptomatic state to clinically-apparent vasculitis involving multiple organs. In the era of Direct-Acting Antiviral (DAA) therapy, patients with HCV-related MC achieve high rates of viral clearance that is commonly accompanied by an improvement in clinical symptoms as well as immunological profiles. Rituximab, either alone or in combination with DAA, has also been shown to be effective. Nevertheless, there have been limited and somewhat conflicting data, particularly over the long-term, regarding the rate and degree of clinical response of MC following DAA therapy. It appears that we have come quite a long way in the last decade with this condition. As with non-MC related HCV, undoubtedly long term outcome data will be forthcoming over the next few years. As we move forward successful therapy of HCV is not likely to be a challenge in contrast to access to therapy.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand
| | - Robert Mitrani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
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17
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Park H, Chen C, Wang W, Henry L, Cook RL, Nelson DR. Chronic hepatitis C virus (HCV) increases the risk of chronic kidney disease (CKD) while effective HCV treatment decreases the incidence of CKD. Hepatology 2018; 67:492-504. [PMID: 28873225 PMCID: PMC5814730 DOI: 10.1002/hep.29505] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 08/23/2017] [Accepted: 08/29/2017] [Indexed: 12/24/2022]
Abstract
We assessed the risk of chronic kidney disease (CKD) in chronic hepatitis C virus (HCV)-infected patients and the incidence reduction of CKD after receipt of HCV treatment. We also evaluated the risk of membranoproliferative glomerulonephritis (MPGN) and cryoglobulinemia in chronic HCV patients. A retrospective cohort analysis of the Truven Health MarketScan Database (2008-2015) in the United States was conducted. In a cohort of 56,448 HCV-infected patients and 169,344 propensity score (1:3)-matched non-HCV patients, we examined the association of HCV infection with the incidence of CKD. Of 55,818 HCV patients, 6.6 % (n = 3666), 6.3% (n = 3534), and 8.3% (n = 4628) patients received either interferon-based dual, triple, or all-oral direct acting antiviral agent therapy, respectively, whereas 79% of patients did not receive any HCV treatment. Cox proportional hazards models were used to compare the risk of developing CKD in HCV patients compared with non-HCV patients and treated patients compared with untreated HCV patients. In a multivariate time-varying Cox regression model, HCV-infected patients had a 27% increased risk of CKD compared with non-HCV patients (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.18-1.37). Among HCV patients, individuals who received the minimally effective HCV treatment for dual, triple, or all-oral therapy had a 30% decreased risk of developing CKD (HR, 0.70; 95% CI, 0.55-0.88). In addition, HCV-infected patients experienced a twofold and a nearly 17-fold higher risk of MPGN (HR, 2.23; 95% CI, 1.84-2.71) and cryoglobulinemia (HR, 16.91; 95% CI, 12.00-23.81) respectively, compared with non-HCV patients. Conclusion: HCV-infected individuals in the United States are at greater risk of developing CKD, MPGN, and cryoglobulinemia. Minimally effective treatment of HCV infection can prevent the development of CKD, although the association was not significant for all-oral therapy. (Hepatology 2018;67:492-504).
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Affiliation(s)
- Haesuk Park
- Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Chao Chen
- Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Wei Wang
- Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Linda Henry
- Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Robert L. Cook
- Department of MedicineUniversity of FloridaGainesvilleFL
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18
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Hepatitis C Virus-Associated Aortitis Caused by Type I Cryoglobulins. ACG Case Rep J 2017; 4:e114. [PMID: 29090238 PMCID: PMC5658650 DOI: 10.14309/crj.2017.114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/13/2017] [Indexed: 11/17/2022] Open
Abstract
Chronic hepatitis C virus infection (HCV) can present with cryoglobulinemic vasculitis, which is primarily associated with type II/III cryoglobulins. Type I cryoglobulins are usually seen in lymphoproliferative disease, and large vessel involvement with this type of vasculitis is rare. A 70-year-old man with chronic HCV presented with abdominal pain, leukocytosis, and rash. Computed tomography angiography showed thickening of the abdominal aorta consistent with large-vessel vasculitis. He was found to have type I cryoglobulinemia and was treated with corticosteroids and ledipasvir/sofosbuvir with rapid resolution of his aortitis. This case emphasizes the need to recognize HCV as a potential etiology of large-vessel vasculitis.
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Thrombocytopenia in Patients with Chronic Hepatitis C Virus Infection. Mediterr J Hematol Infect Dis 2017; 9:e2017019. [PMID: 28293407 PMCID: PMC5333732 DOI: 10.4084/mjhid.2017.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/07/2017] [Indexed: 12/11/2022] Open
Abstract
Thrombocytopenia in patients with chronic hepatitis C virus (HCV) infection is a major problem. The pathophysiology is multifactorial, with auto-immunogenicity, direct bone marrow suppression, hypersplenism, decreased production of thrombopoietin and therapeutic adverse effect all contributing to thrombocytopenia in different measures. The greatest challenge in the care of chronic HCV patients with thrombocytopenia is the difficulty in initiating or maintaining IFN containing anti-viral therapy. Although at present, it is possible to avoid this challenge with the use of the sole Direct Antiviral Agents (DAAs) as the primary treatment modality, thrombocytopenia remains of particular interest, especially in cases of advanced liver disease. The increased risk of bleeding with thrombocytopenia may also impede the initiation and maintenance of different invasive diagnostic and therapeutic procedures. While eradication of HCV infection itself is the most practical strategy for the remission of thrombocytopenia, various pharmacological and non-pharmacological therapeutic options, which vary in their effectiveness and adverse effect profiles, are available. Sustained increase in platelet count is seen with splenectomy and splenic artery embolization, in contrast to only transient rise with platelet transfusion. However, their routine use is limited by complications. Different thrombopoietin analogues have been tried. The use of synthetic thrombopoietins, such as recombinant human TPO and pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMDGF), has been hampered by the development of neutralizing antibodies. Thrombopoietin-mimetic agents, in particular, eltrombopag and romiplostim, have been shown to be safe and effective for HCV-related thrombocytopenia in various studies, and they increase platelet count without eliciting any immunogenicity Other treatment modalities including newer TPO analogues-AMG-51, PEG-TPOmp and AKR-501, recombinant human IL-11 (rhIL-11, Oprelvekin), recombinant human erythropoietin (rhEPO), danazol and L-carnitine have shown promising early result with improving thrombocytopenia. Thrombocytopenia in chronic HCV infection remain a major problem, however the recent change in DAAs without IFN, as the frontline therapy for HCV, permit to avoid the dilemmas associated with initiating or maintaining IFN based anti-viral therapy.
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Toyonaga E, Iwata H, Hotta M, Yoshimoto N, Izumi K, Shimizu H. Keep It Cool: Cryoglobulinemic Purpura. Am J Med 2016; 129:1163-1165. [PMID: 27566501 DOI: 10.1016/j.amjmed.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 08/04/2016] [Accepted: 08/04/2016] [Indexed: 11/20/2022]
Affiliation(s)
- Ellen Toyonaga
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Moeko Hotta
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Norihiro Yoshimoto
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kentaro Izumi
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Shimizu
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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21
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Shachaf S, Yair M. Correlação entre a síndrome antifosfolipídica e a crioglobulinemia: série de quatro casos e revisão da literatura. REVISTA BRASILEIRA DE REUMATOLOGIA 2016. [DOI: 10.1016/j.rbr.2014.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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22
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Ghetie D, Mehraban N, Sibley CH. Cold Hard Facts of Cryoglobulinemia. Rheum Dis Clin North Am 2015; 41:93-108, viii-ix. [DOI: 10.1016/j.rdc.2014.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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23
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Shachaf S, Yair M. The correlation between antiphospholipid syndrome and cryoglobulinemia: case series of 4 patients and review of the literature. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 56:2-7. [PMID: 27267327 DOI: 10.1016/j.rbre.2014.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 09/14/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cryoglobulinemia is an immune-complex-mediated small vessel vasculitis that classically involves the skin, kidneys and peripheral nerves. Antiphospholipid syndrome (APS) is an autoimmune hypercoagulable disorder which causes blood vessel thrombosis. It can present as a multi-organ microthrombotic disorder which is called catastrophic APS. OBJECTIVE In this case series we aim to describe the diagnostic and management challenges that arise when these two severe disorders simultaneously present in the same patient. METHODS We describe four patients who were admitted to our hospital due to multi-organ life threatening damage mediated by cryoglobulinemic vasculitis with concurrent APS. RESULTS Clinical manifestations included leg ulcers, livedo reticularis, renal failure, and peripheral neuropathy. Suggested etiologies for the combined syndromes were hepatitis C, systemic lupus erythematosus and myeloproliferative disease rectal maltoma. All of our patients were treated with anticoagulation, high-dose corticosteroids, rituximab, intravenous gammaglobulins and plasma exchange. CONCLUSION The rare association of severe or catastrophic APS with cryoglobulinemia in patients should be considered by physicians who treat patients with multi-organ ischemia or necrosis.
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Affiliation(s)
- Shiber Shachaf
- Rheumatology Unit, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Molad Yair
- Rheumatology Unit, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zignego AL, Wojcik GL, Cacoub P, Visentini M, Casato M, Mangia A, Latanich R, Charles E, Gragnani L, Terrier B, Piazzola V, Dustin LB, Khakoo SI, Busch MP, Lauer GM, Kim AY, Alric L, Thomas DL, Duggal P. Genome-wide association study of hepatitis C virus- and cryoglobulin-related vasculitis. Genes Immun 2014; 15:500-5. [PMID: 25030430 PMCID: PMC4208981 DOI: 10.1038/gene.2014.41] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 01/12/2023]
Abstract
The host genetic basis of mixed cryoglobulin vasculitis is not well understood and has not been studied in large cohorts. A genome-wide association study was conducted among 356 hepatitis C virus (HCV) RNA-positive individuals with cryoglobulin-related vasculitis and 447 ethnically matched, HCV RNA-positive controls. All cases had both serum cryoglobulins and a vasculitis syndrome. A total of 899 641 markers from the Illumina HumanOmni1-Quad chip were analyzed using logistic regression adjusted for sex, as well as genetically determined ancestry. Replication of select single-nucleotide polymorphisms (SNPs) was conducted using 91 cases and 180 controls, adjusting for sex and country of origin. The most significant associations were identified on chromosome 6 near the NOTCH4 and MHC class II genes. A genome-wide significant association was detected on chromosome 6 at SNP rs9461776 (odds ratio=2.16, P=1.16E-07) between HLA-DRB1 and DQA1: this association was further replicated in additional independent samples (meta-analysis P=7.1 × 10(-9)). A genome-wide significant association with cryoglobulin-related vasculitis was identified with SNPs near NOTCH4 and MHC Class II genes. The two regions are correlated and it is difficult to disentangle which gene is responsible for the association with mixed cryoglobulinemia vasculitis in this extended major histocompatibility complex region.
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Affiliation(s)
| | - Genevieve L. Wojcik
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore MD, United States
| | | | | | | | - Alessandra Mangia
- Liver Unity, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Rachel Latanich
- Department of Medicine, Johns Hopkins Medical Institution, Baltimore MD, United States
| | - Edgar Charles
- Rockefeller University, New York City NY, United States
| | | | | | - Valeria Piazzola
- Liver Unity, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | | | - Salim I. Khakoo
- University of Southampton, Southampton, England, United Kingdom
| | - Michael P. Busch
- Blood Systems Research Institute, San Francisco CA, United States
| | - George M. Lauer
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Arthur Y. Kim
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Laurent Alric
- Toulouse III University, CHU Purpan Hospital, Toulouse, France
| | - David L. Thomas
- Department of Medicine, Johns Hopkins Medical Institution, Baltimore MD, United States
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore MD, United States
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Ahmad D, Ilias Basha H, Towfiq B, Bachuwa G. Resolution of neurological deficits secondary to spontaneous intracranial haemorrhage and posterior reversible encephalopathy syndrome (PRES) in a patient with hepatitis C-associated cryoglobulinaemia: a role for plasmapheresis. BMJ Case Rep 2014; 2014:bcr-2013-202717. [PMID: 24445850 DOI: 10.1136/bcr-2013-202717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Essential mixed cryoglobulinaemia or type II cryoglobulinaemia is an important extrahepatic manifestation of chronic hepatitis C. Cryoglobulinaemia results in the deposition of immune complexes in small or medium-sized blood vessels leading to palpable purpura, arthralgia, renal disease and peripheral neuropathy. Posterior reversible encephalopathy syndrome (PRES) is a distinct phenomenon characterised by vasogenic oedema in the posterior circulation of brain. Cryoglobulinaemic vasculitis leading to spontaneous intracranial haemorrhage and PRES syndrome is rarely reported in the medical literature. In this report, we present an unusual case of spontaneous intracranial haemorrhage and PRES secondary to hepatitis C-associated cryoglobulinaemia presenting as right dense hemiplegia. Prompt institution of plasmapheresis resulted in successful resolution of symptoms in our patient, followed by full neurological recovery. To the best of our knowledge, this case describes the first successful use of plasmapheresis in alleviating neurological complications resulting from cryoglobulinaemic vasculitis and PRES secondary to chronic hepatitis C.
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Affiliation(s)
- Delshad Ahmad
- Department of Internal Medicine, Michigan State University, Flint, USA
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26
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Fallahi P, Ferrari SM, Politti U, Giuggioli D, Ferri C, Antonelli A. Autoimmune and neoplastic thyroid diseases associated with hepatitis C chronic infection. Int J Endocrinol 2014; 2014:935131. [PMID: 25374602 PMCID: PMC4211174 DOI: 10.1155/2014/935131] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/24/2014] [Indexed: 12/17/2022] Open
Abstract
Frequently, patients with hepatitis C virus (HCV) chronic infection have high levels of serum anti-thyroperoxidase and/or anti-thyroglobulin autoantibodies, ultrasonographic signs of chronic autoimmune thyroiditis, and subclinical hypothyroidism, in female gender versus healthy controls, or hepatitis B virus infected patients. In patients with "HCV-associated mixed cryoglobulinemia" (MC + HCV), a higher prevalence of thyroid autoimmune disorders was shown not only compared to controls, but also versus HCV patients without cryoglobulinemia. Patients with MC + HCV or HCV chronic infection show a higher prevalence of papillary thyroid cancer than controls, in particular in patients with autoimmune thyroiditis. Patients with HCV chronic infection, or with MC + HCV, in presence of autoimmune thyroiditis, show higher serum levels of T-helper (Th)1 (C-X-C motif) ligand 10 (CXCL10) chemokine, but normal levels of Th2 (C-C motif) ligand 2 chemokine, than patients without thyroiditis. HCV thyroid infection could act by upregulating CXCL10 gene expression and secretion in thyrocytes recruiting Th1 lymphocytes that secrete interferon-γ and tumor necrosis factor-α. These cytokines might induce a further CXCL10 secretion by thyrocytes, thus perpetuating the immune cascade, which may lead to the appearance of autoimmune thyroid disorders in genetically predisposed subjects. A careful monitoring of thyroid function, particularly where nodules occur, is recommended in HCV patients.
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Affiliation(s)
- Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Ugo Politti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Dilia Giuggioli
- Department of Medical, Surgical, Maternal, Pediatric and Adult Sciences, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100 Modena, Italy
| | - Clodoveo Ferri
- Department of Medical, Surgical, Maternal, Pediatric and Adult Sciences, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100 Modena, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
- *Alessandro Antonelli:
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Marconcini ML, Fayad L, Shiozawa MBC, Dantas-Correa EB, Lucca Schiavon LD, Narciso-Schiavon JL. Autoantibody profile in individuals with chronic hepatitis C. Rev Soc Bras Med Trop 2013; 46:147-53. [PMID: 23740063 DOI: 10.1590/0037-8682-0039-2013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 04/08/2013] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Autoantibodies are often produced during infection with chronic hepatitis C virus (HCV), but it remains controversial whether they influence the biochemical profile and histological features of this disease. Therefore, this current study sought to describe these autoantibodies and evaluate their impact on the clinical and histological presentation of hepatitis C. METHODS This cross-sectional analytical study assessed patients with HCV (RNA+) from October 2011 to July 2012. RESULTS This study included 66 patients, with a mean age of 53.2±10.5 years. Of these patients, 60.6% were male, and 54.3% presented with genotype 1. Non-organ-specific autoantibodies (NOSA) were detected in 24% of the patients; of these, 7.6% were anti-mitochondrial antibodies (AMA+), 26.7% were anti-smooth muscle antibodies (SMA+) and 6.8% were liver kidney microsomal type 1 antibodies (LKM1+). With respect to the thyroid autoantibodies, 7.4% were anti-peroxidase (ATPO+) antibodies, and none were anti-thyroglobulin (ATG+) antibodies. Regarding celiac disease autoantibodies, 5.8% were endomysial antibodies (EMA+), and no transglutaminase (TTG+) antibodies were detected. Cryoglobulins were found in 2.1% of patients. When NOSA+ individuals were compared to patients without the presence of NOSAs, they exhibited higher median alkaline phosphatase (0.7 vs. 0.6 xULN; p=0.041), lower median platelet counts (141,500.0 vs. 180,500.0/mm 3 ; p=0.036), lower mean prothrombin activity (72.6±11.5% vs. 82.2±16.0%; p=0.012) and an increased prevalence of significant fibrosis (E≥2) (45.5% vs. 18.2%; p=0.012). There was also a tendency for a greater proportion of NOSA+ cases to have marked periportal activity (APP≥3) (44.5% vs. 15.6%; p=0.087). CONCLUSIONS In addition to the high prevalence of autoantibodies associated with HCV infection, it was observed that NOSA positivity was associated with a more severe histological and biochemical profile of hepatitis C infection.
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Affiliation(s)
- Maíra Luciana Marconcini
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Universidade Federal de Santa Catarina, Florianópolis, SC
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Infectious serologies and autoantibodies in hepatitis C and autoimmune disease-associated mixed cryoglobulinemia. Clin Rev Allergy Immunol 2012; 42:238-46. [PMID: 21633930 DOI: 10.1007/s12016-011-8275-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Mixed cryoglobulinemia (MC) syndrome is an immune complex-mediated vasculitis characterized by the clinical triad of purpura, weakness, and arthralgias, the morbidity of which is mainly related to kidney and peripheral nervous system dysfunction as well as to the development of a secondary lymphoma (Ferri et al. Autoimmun Rev 7:114-120, 2007, Lidar et al. Ann N Y Acad Sci 1173:649-657, 2009, Trejo et al. Semin Arthritis Rheum 33:19-28, 2003). MC is associated with infectious and systemic disorders, principally autoimmune and lymphoproliferative diseases. Since the 1990s, a striking association (>90%) between MC and hepatitis C virus (HCV) infection has been established (Ferri and Bombardieri 2004; Pascual et al. J Infect Dis 162:569-570, 1990). However, information regarding the etiopathogenesis of HCV-negative MC is scant (Mascia et al. Dig Liver Dis 39:61-64, 2007). We hereby present our findings, as well as previously published data, regarding the presence of antibodies against infectious agents and autoantibodies in patients with MC in an attempt to establish novel associations which may shed light on the etiopathogenesis of this disease.
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Choudhry M, Rao N, Juneja R. Successful treatment of cryoglobulinaemia with rituximab. CASE REPORTS IN NEPHROLOGY AND UROLOGY 2012. [PMID: 23197959 PMCID: PMC3482085 DOI: 10.1159/000339400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cryoglobulinaemia is a systemic inflammatory condition characterised by immune complex-mediated small-to-medium-sized vasculitis. It has a wide variety of presentations ranging from bruising, neuropathy, and hepatosplenomegaly to acute renal failure. Mixed cryoglobulinaemia is the most common type and is strongly associated with hepatitis C. Management approaches include use of cyclophosphamide, prednisolone, and plasmapheresis, with differing views on alternative treatments in resistant cases. Rituximab has emerged as an attractive option in resistant cases on account of its potent immunosuppressive effects on B cells. We describe a case of type 2 mixed cryoglobulinaemia in association with non-Hodgkin's lymphoma resistant to standard treatments which responded well to rituximab. This case is remarkable as mixed cryoglobulinaemia associated with non-Hodgkin's lymphoma presenting with nephritis is unusual, and, contrary to the high rate of recurrence in lymphoma-related cryoglobulinaemia, our patient has not shown any recurrence over 24 months. This highlights an alternative treatment modality which can be used in patients not responsive to existing managements for this condition with benefits of minimal side effects and no oncogenetic potential.
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Affiliation(s)
- M Choudhry
- Department of Renal Medicine, Flinders Medical Centre, Bedford Park, S.A., Australia
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Louie KS, Micallef JM, Pimenta JM, Forssen UM. Prevalence of thrombocytopenia among patients with chronic hepatitis C: a systematic review. J Viral Hepat 2011; 18:1-7. [PMID: 20796208 DOI: 10.1111/j.1365-2893.2010.01366.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Thrombocytopenia (TCP) is a haematological condition known to occur in chronically infected hepatitis C (HCV) patients and may interfere with diagnostic procedures, such as liver biopsy, because of risk of bleeding. It may also exclude patients from effective antiviral treatment. We conducted a systematic literature review of articles and conference abstracts, to assess the prevalence of TCP among those with HCV and to describe demographics, liver disease stage and treatment characteristics of these patients. Studies of individuals with confirmed chronic HCV infection were included in the review if the study had a clear definition of thrombocytopenia and a sample size of at least 50 subjects. The final selection included 27 studies (21 articles and six abstracts). The definitions of thrombocytopenia varied between studies and were based either on platelet counts, with threshold levels ranging between ≤ 100 × 10(9) and ≤ 180 × 10(9) /L, or on criteria set in haematological guidelines. The prevalence of TCP ranged from 0.16% to 45.4% and more than half of the studies reported a TCP prevalence of 24% or more. Because of the different TCP definitions, heterogeneity in study design and insufficient data on study characteristics such as age, gender, HCV treatment rates and disease severity an overall summary estimate of TCP prevalence among patients with HCV was not feasible. However, the relatively large prevalence in the majority of the studies suggests that there may be a substantial number of HCV patients at risk of bleeding complications and reduced likelihood of successful HCV antiviral treatment.
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Affiliation(s)
- K S Louie
- Worldwide Epidemiology, GlaxoSmithKline, Stockley Park, Middlesex, UK
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Terrier B, Sène D, Dechartres A, Saadoun D, Ortonne N, Rouvier P, Musset L, Rigon MR, Maisonobe T, Cacoub P. Systemic vasculitis in patients with hepatitis C virus infection with and without detectable mixed cryoglobulinemia. J Rheumatol 2010; 38:104-10. [PMID: 20952479 DOI: 10.3899/jrheum.100191] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE to describe hepatitis C virus (HCV)-related systemic vasculitis in patients without detectable mixed cryoglobulinemia (MC) and to compare them to typical cases of HCV-MC vasculitis. METHODS twelve HCV RNA+ patients with histologically proven vasculitis in the absence of detectable MC (cases) were retrospectively compared with 48 HCV RNA+ patients with MC vasculitis (controls). Each case was matched with 4 controls for age and sex. RESULTS the main epidemiological and virologic features were similar between cases and controls. No clinical difference was found, except for lower rates of arthralgias (33% vs 71%; p = 0.02) and purpura (50% vs 83%; p = 0.03) in cases. Cases showed higher mean serum C3 (1.17 ± 0.21 vs 0.93 ± 0.23 g/l; p = 0.01) and median C4 levels (0.25 vs 0.04 g/l; p < 0.001), lower median serum IgM levels (0.6 vs 1.9 g/l; p < 0.001), and lower rates of rheumatoid factor positivity (8% vs 82%; p < 0.001) than controls. The main histologic features were similar between cases and controls. Immunofluorescence analysis of skin biopsy from 1 case revealed perivascular deposits of C3 and IgA. After treatment, overall clinical response of vasculitis (75% vs 83%) and sustained virological response (40% vs 64%; p = 0.3) were similar between cases and controls, except for higher complete clinical response (42% vs 73%; p = 0.05) in controls. CONCLUSION HCV-related systemic vasculitis may occur in the absence of detectable MC. Our findings suggest that such vasculitis probably results from immune complex-mediated mechanisms, and that the therapeutic management of such vasculitis should be similar to that of HCV-MC vasculitis.
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Affiliation(s)
- Benjamin Terrier
- Department of Internal Medicine, APHP Groupe Hospitalier Pitié-Salpétrière, 47 boulevard de l'Hôpital, 75013 Paris, France
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Abstract
In this review we discuss the clinical manifestations, pathogenesis, and treatment of hepatitis C virus (HCV)-related cryoglobulinemia. HCV is a major cause of liver-related morbidity and is increasingly recognized as an instigator of B-cell lymphoproliferative disorders such as mixed cryoglobulinemia and non-Hodgkin lymphoma. Cryoglobulinemia is characterized by the clonal expansion of rheumatoid factor-expressing B cells in the liver, lymph nodes, and peripheral blood, resulting in the presence of cryoglobulins in the circulation. Cryoglobulins are cold-insoluble immune complexes containing rheumatoid factor, polyclonal IgG, and HCV RNA that precipitate and deposit on vascular endothelium, causing vasculitis in organs such as the skin, kidneys, and peripheral nerves. A subset of patients develops a low-grade lymphoma composed of B cells that are immunophenotypically similar to the expanded B cells seen in cryoglobulinemia. HCV-related B-cell lymphoproliferative disorders likely comprise a spectrum of disease, ranging from asymptomatic clonal B-cell expansions to pathogenic cryoglobulinemia and lymphoma. It is unclear how B cells become dysregulated during the course of chronic HCV infection, and continued patient-centered research is necessary to elucidate the pathogenesis of HCV-related B-cell dysregulation.
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Affiliation(s)
- Edgar D Charles
- Center for the Study of Hepatitis C, The Rockefeller University, New York, New York 10065, USA.
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Persisting mixed cryoglobulinemia in Chikungunya infection. PLoS Negl Trop Dis 2009; 3:e374. [PMID: 19190731 PMCID: PMC2629124 DOI: 10.1371/journal.pntd.0000374] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 01/06/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chikungunya virus (CHIKV), an arbovirus, is responsible for a two-stage disabling disease, consisting of an acute febrile polyarthritis for the first 10 days, frequently followed by chronic rheumatisms, sometimes lasting for years. Up to now, the pathophysiology of the chronic stage has been elusive. Considering the existence of occasional peripheral vascular disorders and some unexpected seronegativity during the chronic stage of the disease, we hypothesized the role of cryoglobulins. METHODS From April 2005 to May 2007, all travelers with suspected CHIKV infection were prospectively recorded in our hospital department. Demographic, clinical and laboratory findings (anti-CHIKV IgM and IgG, cryoglobulin) were registered at the first consultation or hospitalization and during follow-up. RESULTS Among the 66 travelers with clinical suspicion of CHIKV infection, 51 presented anti-CHIKV IgM. There were 45 positive with the serological assay tested at room temperature, and six more, which first tested negative when sera were kept at 4 degrees C until analysis, became positive after a 2-hour incubation of the sera at 37 degrees C. Forty-eight of the 51 CHIKV-seropositive patients were screened for cryoglobulinemia; 94% were positive at least once during their follow-up. Over 90% of the CHIKV-infected patients had concomitant arthralgias and cryoglobulinemia. Cryoglobulin prevalence and level drop with time as patients recover, spontaneously or after short-term corticotherapy. In some patients cryoglobulins remained positive after 1 year. CONCLUSION Prevalence of mixed cryoglobulinemia was high in CHIKV-infected travelers with long-lasting symptoms. No significant association between cryoglobulinemia and clinical manifestations could be evidenced. The exact prognostic value of cryoglobulin levels has yet to be determined. Responsibility of cryoglobulinemia was suspected in unexpected false negativity of serological assays at room temperature, leading us to recommend performing serology on pre-warmed sera.
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34
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Acute type II cryoglobulinaemic vasculitis mimicking atherosclerotic peripheral vascular disease. Ir J Med Sci 2008; 179:435-7. [DOI: 10.1007/s11845-008-0203-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2008] [Accepted: 07/15/2008] [Indexed: 10/21/2022]
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Viganò M, Lampertico P, Rumi MG, Folli C, Maggioni L, Morabito A, Del Ninno E, Cicardi M, Colombo M. Natural history and clinical impact of cryoglobulins in chronic hepatitis C: 10-year prospective study of 343 patients. Gastroenterology 2007; 133:835-42. [PMID: 17678923 DOI: 10.1053/j.gastro.2007.06.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 05/25/2007] [Indexed: 01/17/2023]
Abstract
BACKGROUND & AIMS Serum cryoglobulins (CGs) are present in patients with chronic hepatitis C virus (HCV) infection, but their long-term clinical importance has not been established. We assessed the development rates, morbidity, and influence on the evolutionary course of hepatitis C of CG. METHODS A cohort of 343 HCV-RNA seropositive outpatients (173 men; age, 58 y; 82 with cirrhosis; 61 treated with interferon) with persistently increased aminotransferase levels and histologically defined liver disease was investigated. Patients initially were investigated for the presence, amount, and type of CG and prospectively followed up with clinical and laboratory examinations every 6 months. RESULTS At enrollment, CGs were found in 163 (47%) patients at a mean level of 173 +/- 142 mg/L; 80% were type III, and associated to female sex (61% vs 40%, P = .0002) and cirrhosis (29% vs 19%, P = .04). Over the course of 17-130 months (median, 116 mo), de novo CG developed in 25 patients (2.3% per year), including 5 with cryoglobulinemic syndrome (.3% per year). The 10-year rates of progression to cirrhosis and of liver and extrahepatic complications were similar in CG (+) and CG (-) patients (32% vs 34%; 23% vs 16%; 5% vs 3%). The 10-year survival rates were lower for cirrhotic than for noncirrhotic patients (57% vs 91%, P < .00001), independently of CGs. CONCLUSIONS CGs are common in patients with chronic HCV infection, mainly are type III, and do not influence the clinical course of hepatitis C during the first decades, except for the few rare cases of cryoglobulinemic syndrome.
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Affiliation(s)
- Mauro Viganò
- Division of Gastroenterology, Istituto di Ricovero e Cura a Carattere Scientifico Maggiore Hospital Fondazione Policlinico, Mangiagalli e Regina Elena, Centro A. M. & A. Migliavacca, University of Milan, Milan, Italy
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Newkirk MM, Nowak U, Skamene E, Iera D, Desbarats J. Agonistic antibodies to Fas induce a breach in the endothelial lining of the liver and a breakdown in B cell tolerance. Clin Exp Immunol 2007; 147:346-51. [PMID: 17223977 PMCID: PMC1810459 DOI: 10.1111/j.1365-2249.2006.03279.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Liver disease can be associated with a breakdown in self-tolerance and the production of autoantibodies such as rheumatoid factors (RF), which bind to IgG. Here we investigated whether primary, non-infectious liver damage was sufficient to induce autoantibody production. We established a model of targeted liver damage induced by weekly sublethal injections of pro-apoptotic anti-Fas (CD95) antibodies. Liver damage, monitored by measurements of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, was minimal 1 week after anti-Fas injection. However, the sublethal Fas stimulation was sufficient to trigger significant haemorrhage in the liver, as assessed by Evans Blue dye leakage into the organ 5 h after anti-Fas antibody injection. We observed an induction of RF in response to the weekly injections of sublethal anti-Fas antibodies but not of isotype control antibodies, indicating a breakdown of self-tolerance induced by Fas engagement. RF induction was unlikely to be due to direct activation of B cells, as splenocytes stimulated with anti-Fas antibodies in vitro did not produce RF. These studies show that sublethal damage to the liver by Fas engagement leads to liver haemorrhage and is sufficient to trigger the breakdown of self-tolerance.
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Affiliation(s)
- M M Newkirk
- Research Institute of McGill University Health Centre, Department of Medicine, Montreal, Quebec, Canada.
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37
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Nowak U, Gill K, Skamene E, Newkirk MM. Rheumatoid factor induction in murine models of liver injury. Clin Exp Immunol 2007; 147:324-9. [PMID: 17223974 PMCID: PMC1810466 DOI: 10.1111/j.1365-2249.2006.03277.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Alcoholic liver disease and hepatitis C are associated with the production of autoantibodies such as rheumatoid factors (RF), which bind to IgG and can aid in host defence, but are also associated with pathological conditions such as rheumatoid arthritis. Because little is known about the role of RF in liver disease, we characterized the RF production that either occurred spontaneously in response to alcohol consumption or was induced by injection of an Escherichia coli glycolipoprotein in C57Bl/6 mice. Whereas severe liver damage was induced by carbon tetrachloride (CCl(4)), minimal damage was caused by chronic alcohol consumption. Liver damage was monitored by measurements of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Circulating RF was induced in response to chronic alcohol consumption; the latter probably involved Toll-like receptor ligation. In contrast, CCl(4)-induced damage was not associated with RF induction. However, concurrent treatment with an E. coli glycolipoprotein macromolecule that induced RF, protected against CCL(4)-induced liver damage as measured by a highly significant decrease (P = 0.008) at 4 weeks in AST and ALT. RF induced by E. coli glycolipoprotein correlated with 'protection' from liver damage, indicating that the RF autoimmune response does not necessarily exacerbate liver disease.
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Affiliation(s)
- U Nowak
- Research Institute of the McGill University Health Centre, Departments of Medicine, Microbiology and Immunology, Montreal, Quebec, Canada
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El-Sayed HH, Amin Husse N, Yousef Gha L, Megeed Lot AA, Raouf Raaf MA. Clinical Spectrum of Hepatitis-Associated Cryoglobulinemia: Cross-Link between Hematological and Immunological Phenomena. JOURNAL OF MEDICAL SCIENCES 2006. [DOI: 10.3923/jms.2007.31.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sène D, Saadoun D, Limal N, Piette JC, Cacoub P. [Update in Hepatitis C virus associated extrahepatic manifestations]. Rev Med Interne 2006; 28:388-93. [PMID: 17137683 DOI: 10.1016/j.revmed.2006.10.321] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Revised: 10/09/2006] [Accepted: 10/18/2006] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Since the discovery of the hepatitis C virus, many manifestations, so called extra-hepatic manifestations (EHM), are largely reported with more or less relationship proofs. ACTUALITIES AND MAIN POINTS This article proposes a review of the main extra-hepatic manifestations associated with the Hepatis C Virus infection and which remain a topical subject, more than fifteen years after the discovery of this virus. Mixed cryoglobulin and its vasculitic manifestations are still one of the more frequent Hepatis C Virus associated-extra-hepatic manifestations. Its management may be critically changed due to the increasing use of anti-CD20 therapy. Among other HCV-EHM, the following extra-hepatic manifestations are still of interest: the chronic fatigue syndrome, the sicca syndrome, the non-insulin-dependent diabetes mellitus, malignant B cell proliferations, mainly the Hepatis C Virus-related splenic lymphoma with villous lymphocytes and the production of auto-antibodies. PERSPECTIVES AND PROJECTS The mechanisms underlying these HCV-associated EHM are ill-elucidated and still remain of great interest as proved by current studies. The use of anti-CD20 antibodies in the treatment of cryoglobulinemic vasculitis is also under investigation.
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Affiliation(s)
- D Sène
- Service de Médecine Interne, Hôpital de la Pitié-Salpêtrière, 91, boulevard de l'Hôpital, 75651 Paris cedex 13, France
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Mohan S, Jaitly M, Cheng JT, D'Agati VD, Pogue VA. Unusual biopsy findings in a hepatitis C-infected white man with cryoglobulinemia, purpuric rash, and renal failure. Am J Kidney Dis 2006; 48:513-7. [PMID: 16931228 DOI: 10.1053/j.ajkd.2006.03.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 03/27/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Harlem Hospital Center, New York, NY 10037, USA.
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De Re V, De Vita S, Sansonno D, Gasparotto D, Simula MP, Tucci FA, Marzotto A, Fabris M, Gloghini A, Carbone A, Dammacco F, Boiocchi M. Type II mixed cryoglobulinaemia as an oligo rather than a mono B-cell disorder: evidence from GeneScan and MALDI-TOF analyses. Rheumatology (Oxford) 2006; 45:685-93. [PMID: 16399842 DOI: 10.1093/rheumatology/kei278] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To identify and characterize rheumatoid factor (RF)-producing B-cells and cryoprecipitate immunoglobulin (Ig) M in hepatitis C virus (HCV)-positive patients. METHODS We purified and characterized, by peptide mass fingerprinting integrated with an NCBI IgBlast data bank search, the IgM component of cryoprecipitate and analysed the VDJ pattern of bone marrow B-cells by gene scan analysis of 17 HCV-positive patients with type II mixed-cryoglobulinaemia. RESULTS IgM purified from all of the patients presented an RF specificity. In three of these patients a high and predominant B-cell clone (>or=30%) was found in the bone marrow. B-cell-receptor sequences were determined and immunophenotyping of these clones was performed. Peptide masses originating after tryptic digestion of the B-cell-receptor combinatory regions and those originating by tryptic digestion of the cryoprecipitated IgM from the same patient were comparable. In the remaining patients an oligoclonal/polyclonality was found. However, in some of these patients we were able to find peptides that matched with the B-cell-receptor sequences of overexpanded B cells, indicating that, even in the absence of a clear monoclonal expansion, a fraction of total cryoprecipated IgM may derive from overexpanded B-cell clones found in patients' bone marrow. CONCLUSIONS In the majority of mixed cryoglobulinaemia-HCV-positive patients, both in the serum and in B cells from the bone marrow, an oligoclonal pattern is the main molecular picture. When a monoclonal B-cell clone is found, its B-cell-receptor shows an antigen-binding fragment identical to that of cryoprecipitable RF-IgM. Phenotypically, B cells are CD20-positive but CD5-negative, suggesting that the B-1 B-cell subset is not likely to produce high-affinity IgM-RF molecules.
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Affiliation(s)
- V De Re
- Division of Experimental Oncology I, Centro di Riferimento Oncologico Via Pedemontana Occidentale 12, 33081 Aviano (PN), Italy.
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Sens YAS, Malafronte P, Souza JF, Bruno S, Gonzalez RBC, Miorin LA, Jabur P, Forte WCN. Cryoglobulinemia in Kidney Transplant Recipients. Transplant Proc 2005; 37:4273-5. [PMID: 16387095 DOI: 10.1016/j.transproceed.2005.11.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2005] [Indexed: 11/18/2022]
Abstract
The aim of this study was to assess the presence of cryoglobulins, the constitution of the cryoprecipitate, as well as the possible etiology and clinical features in kidney transplant recipients. We excluded patients with clinical or laboratory evidence of autoimmune, liver or neoplasm disease, infections, blood transfusions or immunizations in the previous 3 months. Detection of cryoglobulins was obtained from the peripheral venous blood. In cases of cryoprecipitate formation it was analyzed using anti-IgG, anti-IgM, anti-IgA, anti-C3, and anti-C4 antibodies. The hepatitis C virus (HCV) was detected by the polymerase chain reaction. Thirty-nine patients were selected, of whom 23 were men and the overall mean age was 40.6 +/- 12.7 years. Cryoprecipitate was detected in 74.4% (29/39) patients. Among patients with or without cryoprecipitate formation, the serum creatinine values, the percentage of patients with proteinuria, and the posttransplantation times were similar. In patients with cryoglobulins, 37.9% (11/29) were HCV positive. The etiology was not determined for the other patients. The IgG, IgM, and IgA immunoglobulins and the complement fractions C3 and C4 were found in the cryoprecipitate. Their compositions were similar among patients with or without HCV. Few clinical features were associated with the presence of cryoglobulins, including deep venous thrombosis, cutaneous purpura and peripheral neuropathy. In conclusion, cryoglobulinemia was prevalent in kidney transplant recipients, but appeared to not affect graft function. HCV infection was the most frequently associated etiology and clinical features were infrequent.
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Affiliation(s)
- Y A S Sens
- Santa Casa of Sao Paulo School of Medical Sciences, Sao Paulo, Brazil.
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Rayhill SC, Kirby PA, Voigt MD, La Brecque DR, Lutz CT, Katz DA, Mitros FA, Kalil RS, Miller RA, Stolpen AH, Heisey D, Wu YM, Schmidt WN. Positive Serum Cryoglobulin Is Associated with Worse Outcome after Liver Transplantation for Chronic Hepatitis C. Transplantation 2005; 80:448-56. [PMID: 16123717 DOI: 10.1097/01.tp.0000164826.84041.f0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Recurrent hepatitis C virus (HCV) infection in patients after liver transplantation is an important clinical problem. Because serum cryoglobulins (CG) are known to be associated with an increased incidence of cirrhosis in nontransplant patients, the authors tested the hypothesis that CG would also predict aggressive recurrent HCV in patients after liver transplantation. METHODS Using a longitudinal database, the outcomes of 105 allografts transplanted into 97 HCV-positive patients from 1991 through 2002 were analyzed on the basis of CG status using a retrospective cohort design. Fifty-nine CG-negative and 38 CG-positive patients were identified. Histologic outcomes and graft survival were analyzed using Kaplan-Meier estimates and Cox univariate and multivariate analyses. Both overall survival and HCV-specific survival (non-HVC-related deaths and graft losses censored) were analyzed. RESULTS By Kaplan-Meier estimates, CG-positive patients showed earlier graft failure with decreased time to severe histologic activity and fibrosis as compared with CG-negative patients (P<0.05 for all outcomes). By univariate analysis, CG-positive patients had significantly higher risk ratios for shortened HCV-specific graft survival, severe activity-free survival, and severe fibrosis-free survival as compared with CG-negative patients (P<0.05 for all outcomes). In the multivariate model, CG was an independent predictor for severe activity-free, severe fibrosis-free, and HCV-specific graft survival (P<0.05 for all outcomes). CONCLUSIONS CG-positivity is associated with severe recurrent HCV disease in liver transplant recipients.
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Affiliation(s)
- Stephen C Rayhill
- Department of Surgery, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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Abstract
The hepatitis C virus (HCV) infection is a worldwide disease that is characterized by a preferential chronic evolution with mild to severe liver disease, including cirrhosis and, in lesser proportion, hepatocarcinoma. Out of these complications, HCV is frequently reported to complicate extrahepatic manifestations. Among those associated to HCV infection with a high degree of certainty, mixed cryoglobulinemia and its complications (skin, neurological, renal, rheumatological involvement) are the most prevalent (50%) in HCV-infected patients. The other diseases include noncryoglobulinemic systemic vasculitis, splenic lymphoma with villous lymphocytes, fatigue, porphyria cutanea tarda, sicca syndrome, and autoantibodies production. The extrahepatic manifestations that share mild-degree certainty of association with HCV infection include B-cell non-Hodgkin lymphoma, autoimmune thrombocytopenia, pruritus, and type II diabetes mellitus. The other diseases such as autoimmune thyroiditis, lichen planus are more questionable for their eventual association with HCV and others (pulmonary fibrosis with or without polymyositis, progressive encephalomyelitis, Mooren's corneal ulcers, erythema nodosum, chronic polyradiculonevritis) are mostly case reports. Howerver, even in cases of tight association, the mechanisms through which HCV may promote or induce extrahepatic manifestations remain unclear and merit further investigations.
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Affiliation(s)
- Damien Sène
- Department of Internal Medicine, Boulevard de l'hôpital, Paris, France
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Wang S, Yang T, Zhang J, Xiao S, Peng X. C3/Ig and Ig/C3 two-component-determined circulating immune complexes (TCIC) in patients with HCV infection. FEMS IMMUNOLOGY AND MEDICAL MICROBIOLOGY 2003; 36:77-82. [PMID: 12727369 DOI: 10.1016/s0928-8244(03)00062-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the present study, we measured the levels of immunoglobulin (Ig)- and complement 3 (C3)-determined circulating immune complexes (two-component-determined CIC, or TCIC) in hepatitis C virus (HCV)-infected patients. TCIC was dissected into C3/Ig-TCIC and Ig/C3-TCIC by a reciprocal use of coating and detecting antibodies. The current study was carried out in 117 infected HCV patients and 252 healthy controls. We found that C3/Ig-TCIC elevation was a common feature in patients with HCV infection. Positive rates and levels of C3/IgG-TCIC and C3/IgM-TCIC were significantly higher in the patients with abnormal alanine aminotransferase (ALT) than patients with normal ALT (70.6% vs. 17.0%, 0.56 OD vs. 0.47 OD and 0.71 OD vs. 0.65 OD, respectively, P<0.001). However, the levels of IgM/C3-TCIC and IgA/C3-TCIC were significantly higher in individuals with HCV infection than in healthy controls, whereas the level of IgG/C3-TCIC was significantly lower in the former group than in the latter group. In summary, our results suggest that IgG and C3 TCIC may play an important role in liver cell injury during the course of HCV infection and may be a hallmark for hepatitis C pathogenesis. Elevated C3/Ig-TCIC, accompanied by decreased Ig/C3-TCIC, forms a peculiar trait in HCV infection. Our findings thus provide new insights into HCV pathogenesis.
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Affiliation(s)
- Sanying Wang
- The Key Laboratory of Education Ministry for Cell Biology and Tumor Cell Engineering, Department of Biology, School of Life Sciences, Xiamen University, Xiamen, Fujian 361005, PR China
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Fabris P, Tositti G, Giordani MT, Romanò L, Betterle C, Pignattari E, Tagliaferri C, Muratori P, Manfrin V, de Lalla F. Prevalence and clinical significance of circulating cryoglobulins in HIV-positive patients with and without co-infection with hepatitis C virus. J Med Virol 2003; 69:339-43. [PMID: 12526043 DOI: 10.1002/jmv.10294] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Although hepatitis C virus (HCV) is a recognized cause of circulating cryoglobulins, the role of human immunodeficiency virus (HIV) in the pathogenesis of cryoglobulinemia has not been investigated extensively. To evaluate the prevalence of circulating cryoglobulins and to assess the relationship with clinical and virological parameters, 162 HIV-positive subjects (84 anti-HCV(+)) were tested for cryoglobulins, C3, C4, RF, autoantibodies, HIV-viral titer, and CD4(+) count. Anti-HCV-positive subjects were tested for HCV-RNA, HCV-viral titer, and HCV genotype. All patients were examined for the presence of signs or symptoms of vasculitis and tested for cryoglobulins using a standard biochemical assay. Cryoglobulins were found in 30 (18.5%) cases. Of the 30 positive cases, 29 (96.7%) were anti-HCV-positive and 28 (93.3%) HCV-RNA-positive. The presence of cryoglobulins was significantly associated (P < 0.01) with HCV-RNA positivity (OR = 27), liver cirrhosis (OR = 16), decreased levels of C3 (OR = 8.6), C4 (OR = 13.6), increased levels of IgG and IgM (OR = 6.1 and 7.9, respectively), and RF positivity (OR = 6.3), but was unrelated to CD4(+) cell count, HIV viral load, diagnosis of AIDS, HCV viral load and the presence of autoantibodies. Interestingly, the presence of cryoglobulins was not significantly associated with signs and symptoms commonly associated with cryoglobulinemia. In conclusion, HIV infection does not seem to play a significant role in the production of circulating cryoglobulins, which strongly correlates with HCV co-infection and liver cirrhosis. Typical signs and symptoms of cryoglobulinemia do not correlate with the detection of circulating cryoglobulins in HIV and HCV patients.
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Affiliation(s)
- Paolo Fabris
- Department of Infectious Diseases and Tropical Medicine, S. Bortolo Hospital, Vicenza, Italy.
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Wilson LE, Widman D, Dikman SH, Gorevic PD. Autoimmune disease complicating antiviral therapy for hepatitis C virus infection. Semin Arthritis Rheum 2002; 32:163-73. [PMID: 12528081 DOI: 10.1053/sarh.2002.37277] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To review autoimmune disease complicating therapy with type I interferons (IFNs), specifically in the setting of hepatitis C virus (HCV) infection. METHODS This study describes 13 reported cases of drug-induced systemic lupus erythematosus (SLE) associated with IFN therapy for the period reported during 1990-2002 by searching MEDLINE. In addition, 2 additional patients are presented, 1 with SLE and 1 with an antineutrophil cytoplasmic antibody (ANCA)-positive nephritis, with long-term follow-up. RESULTS Of 13 cases of SLE-like syndromes caused by IFN, 2 occurred in patients being treated for HCV infection. Two occurred in patients with rheumatoid arthritis (RA); 1 had Sjogren's syndrome (SS), and 1 laryngeal papillomatosis. The rest were receiving IFN for hematologic malignancies. Symptoms developed between 2 weeks and 7 years after initiation of therapy. Most developed fever and arthralgias/arthritis. Other findings included serositis manifested by tachycardia, dyspnea and pleural effusions, headaches, and hair loss. All had a positive antinuclear antibody (ANA), and the majority had double stranded (ds) DNA antibodies. Two additional patients with chronic HCV infection developed autoimmune disease after combination treatment with IFN-alpha and ribavirin. In each patient, autoimmune disease manifested as severe joint pains, myalgias, fever, rash, and proteinuria. Skin and renal biopsy specimens showed vasculitis and crescentic glomerulonephritis (GN) in the first case, and typical histologic findings of lupus nephritis in the second; clinical and laboratory features were consistent with Wegener's granulomatosis and SLE, respectively. Although both patients had mixed polyclonal cryoglobulins, they were HCV RNA and HCVAb negative. Both received corticosteroids, with gradual clinical and biochemical improvement and without recurrence of viremia. CONCLUSIONS Autoimmune disorders occur in 4% to 19% of patients receiving IFN-alpha, though SLE-like syndromes are only seen in 0.15% to 0.7%. Clinical and laboratory features of SLE in this setting resemble idiopathic disease, with a generally good outcome after discontinuance of the drug. RELEVANCE Type I IFNs may cause autoimmune disease such as SLE. As the armamentarium of drugs expands to include other biologics, such as the tumor necrosis factor (TNF)-alpha-inhibiting drugs, the development of autoimmune diseases induced by these drugs is an important consideration for diagnosis and appropriate treatment. Semin Arthritis Rheum 32:163-173.
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Affiliation(s)
- Leslie E Wilson
- Departments of Medicine and Pathology, Mount Sinai School of Medicine, New York, NY 10029-6574, USA
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Abstract
Rheumatoid factors (RFs), autoantibodies that bind to the Fc portion of IgG, are important in the immune response. RF-committed B-cells exist in the circulating lymphocyte pool in a high frequency (approximately 1-2 %) in normal individuals and in patients with pathological conditions associated with the sustained levels of circulating RF, such as rheumatoid arthritis (RA), Sjogren's syndrome (SS), and mixed cryoglobulinemia, associated with hepatitis C virus infection. RFs are induced by many infectious entities (viruses, bacteria, parasites) as a consequence of a secondary immune response to the pathogen, but usually the response is transient. It is likely that RFs play an important role in the host's defense against infection, both at the cellular level, where the RF B-cell can be an antigen presenting cell which can promote the antipathogen response, and at the humoral level, where RFs can contribute to the mopping up of the IgG antipathogen antibodies by contributing to immune complex formation and clearance. There has been much research on RFs in chronic pathological conditions, and the literature pertaining to their origin, structure, binding specificities, and possible roles in disease are discussed. The importance of the host defense, sometimes at the expense of an autoimmune response, is a balance that needs to be considered in light of a possible outcome of health or disease.
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Affiliation(s)
- Marianna M Newkirk
- Department of Medicine, The McGill University Hospital Centre, The Montreal General Hospital, Montreal, Quebec, Canada
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Segerer S, Hudkins KL, Taneda S, Wen M, Cui Y, Segerer M, Farr AG, Alpers CE. Oral interferon-alpha treatment of mice with cryoglobulinemic glomerulonephritis. Am J Kidney Dis 2002; 39:876-88. [PMID: 11920357 DOI: 10.1053/ajkd.2002.32011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Cryoglobulins are associated with the development of a membranoproliferative glomerulonephritis, often referred to as cryoglobulinemic glomerulonephritis, particularly in the setting of hepatitis C virus infection. Parenteral interferon-alpha (IFN-alpha) commonly is used therapeutically in humans with cryoglobulinemic glomerulonephritis. We tested the therapeutic impact of oral IFN-alpha treatment in thymic stromal lymphopoietin (TSLP) transgenic mice, a strain that develops mixed cryoglobulinemia with glomerulonephritis closely resembling the disease that occurs in humans. A total of 41 female mice were treated for 21 days with daily ingestion of either 500 IU of Universal type I IFN or placebo. The studied groups included TSLP transgenic mice treated with IFN-alpha (n = 13), TSLP transgenic mice treated with placebo (n = 13), wild-type mice treated with IFN-alpha (n = 5), and wild-type mice treated with placebo (n = 10). A total of 39 mice completed the study; two TSLP transgenic mice treated with IFN-alpha died during the study period. Placebo-treated TSLP transgenic mice showed significantly increased mean glomerular tuft areas, mean glomerular areas occupied by macrophages, and mean cell numbers per glomerulus compared with wild-type controls. All three parameters were decreased in IFN-alpha-treated TSLP transgenic mice, although the differences compared with placebo-treated mice did not reach significance. The changes in glomerular matrix deposition were the same in IFN-alpha-treated and placebo-treated mice. The oral ingestion of IFN-alpha seemed to reduce glomerular macrophage influx, but this did not result in decreased glomerular matrix deposition. The limited positive effect provides experimental support for clinical studies that indicate the beneficial effects of IFN-alpha therapy observed in humans with glomerulonephritis might be attributable to its antiviral effect rather than modulation of intrarenal pathophysiologic pathways.
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Affiliation(s)
- Stephan Segerer
- Department of Pathology, University of Washington, Seattle, WA, USA
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Vassilopoulos D, Calabrese LH. Hepatitis C virus infection and vasculitis: implications of antiviral and immunosuppressive therapies. ARTHRITIS AND RHEUMATISM 2002; 46:585-97. [PMID: 11920393 DOI: 10.1002/art.10107] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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