Acute pericarditis due to pegylated interferon alpha therapy for chronic HCV hepatitis - case report

Triple Combination with Direct Acting Antivirals in the Treatment of Hepatitis C Does not Prolong the QT Interval

AIMS

Antiviral drugs are considered as potentially cardiotoxic, due to prolongation of QT interval which may affect incidence of severe ventricular arrhythmias. The main aim of this retrospective study was to assess the influence of treatment by three antiviral drugs on QT interval and to find patients who are at an increased risk of developing malignant ventricular arrhythmias.

METHODS

The study included 23 patients (14 men, 9 women) who were treated with a combination of interferon alpha, ribavirin, and an NS3/4A protease inhibitor. The parameters from the 12 leads electrocardiograms were evaluated before treatment, and then 3 ± 1 and 6 ± 1 months after treatment.

RESULTS

Heart rate (HR) 69 ± 12 / min and corrected QT interval (QTc) 412 ± 35 ms were obtained before the treatment and there was not observed a significant prolongation of intervals after 3 months (HR 72 ± 11 / min, QTc 412 ± 33 ms) and after 6 months (HR 64 ± 12 / min, QTc 405 ± 28 ms) respectively. In total QTc interval was prolonged from the baseline in 53% and in 43% of the patients 3 months respectively 6 months after treatment. A QTc prolongation over of 450 ms and new treatment-related repolarization change was noted in 1 (4%) patient.

CONCLUSION

The study demonstrates that a combination therapy of 3 antiviral drugs does not significantly prolong the QTc interval and does not cause severe pathological changes on the ECG. Patients undergoing this treatment are not at risk of developing heart disease as an undesirable side effect.

An overview of human pericardial space and pericardial fluid

The pericardium is a double-layered fibro-serous sac that envelops the majority of the surface of the heart as well as the great vessels. Pericardial fluid is also contained within the pericardial space. Together, the pericardium and pericardial fluid contribute to a homeostatic environment that facilitates normal cardiac function. Different diseases and procedural interventions may disrupt this homeostatic space causing an imbalance in the composition of immune mediators or by mechanical stress. Inflammatory cells, cytokines, and chemokines are present in the pericardial space. How these specific mediators contribute to different diseases is the subject of debate and research. With the advent of highly specialized assays that can identify and quantify various mediators we can potentially establish specific and sensitive biomarkers that can be used to differentiate pathologies, and aid clinicians in improving clinical outcomes for patients.

Liver disease and heart failure: Back and forth

In their clinical practice, physicians can face heart diseases (chronic or acute heart failure) affecting the liver and liver diseases affecting the heart. Systemic diseases can also affect both heart and liver. Therefore, it is crucial in clinical practice to identify complex interactions between heart and liver, in order to provide the best treatment for both. In this review, we sought to summarize principal evidence explaining the mechanisms and supporting the existence of this complicate cross-talk between heart and liver. Hepatic involvement after heart failure, its pathophysiology, clinical presentation (congestive and ischemic hepatopathy), laboratory and echocardiographic prognostic markers are discussed; likewise, hepatic diseases influencing cardiac function (cirrhotic cardiomyopathy). Several clinical conditions (congenital, metabolic and infectious causes) possibly affecting simultaneously liver and heart have been also discussed. Cardiovascular drug therapy may present important side effects on the liver and hepato-biliary drug therapy on heart and vessels; post-transplantation immunosuppressive drugs may show reciprocal cardio-hepatotoxicity. A heart-liver axis is drafted by inflammatory reactants from the heart and the liver, and liver acts a source of energy substrates for the heart.

Interferon related pericarditis: Review

AIM

To conduct a review of “interferon related pericarditis”.

METHODS

We searched MEDLINE, EMBASE, Cinahl, and the Cochrane Database from the earliest available date through September 2016. A search strategy using the Medical Subject Headings and text keywords “interferon” and ”pericarditis” were used.

RESULTS

Nine case reports were eligible for the present study. Six of 8 cases were women and the mean age was 43.8 ± 13.8 years with chronic hepatitis C in 6 cases, malignant melanoma in 2 cases and chronic myelogenous leukemia in 1 case. The patients complained of chest pain in 6 cases, dyspnea in 5 cases and edema in 2 cases. Pericardial friction rub was heard in 3 of 9 cases. Congestive heart failure occurred in 3 of 9 cases. Two mechanisms for pericarditis were demonstrated, one is autoimmune included lupus like syndrome in 2 cases and the other is cardio toxicity in 4 cases. Treatment of interferon related pericarditis is discontinuation of Interferon treatment. Four of 9 cases were treated with prednisone and 4 with nonsteroidal anti-inflammatory drugs.

CONCLUSION

Interferon related pericarditis still remains uncertain. Treatment of interferon related pericarditis rests mainly on early recognition and drug discontinuation. Interferon related pericarditis was treated with steroid and/or nonsteroidal anti-inflammatory drugs.

Recurrent Pericarditis, an Unexpected Effect of Adjuvant Interferon Chemotherapy for Malignant Melanoma

Drug-induced pericarditis is a well-described cardiac pathology that can result from a variety of medications; however, interferon-mediated pericarditis is extremely rare. We present a case of a young female with recurrent pericarditis due to interferon therapy. The role of interferon in adjuvant chemotherapy is well known and yields good effect, but this case highlights the very uncommon phenomena of interferon induced pericarditis and the significant distress it can cause.

Intrapericardial Delivery of Cardiosphere-Derived Cells: An Immunological Study in a Clinically Relevant Large Animal Model

Introduction

The intrapericardial delivery has been defined as an efficient method for pharmacological agent delivery. Here we hypothesize that intrapericardial administration of cardiosphere-derived cells (CDCs) may have an immunomodulatory effect providing an optimal microenvironment for promoting cardiac repair. To our knowledge, this is the first report studying the effects of CDCs for myocardial repair using the intrapericardial delivery route.

Material and Methods

CDCs lines were isolated, expanded and characterized by flow cytometry and PCR. Their differentiation ability was determined using specific culture media and differential staining. 300,000 CDCs/kg were injected into the pericardial space of a swine myocardial infarcted model. Magnetic resonance imaging, biochemical analysis of pericardial fluid and plasma, cytokine measurements and flow cytometry analysis were performed.

Results

Our results showed that, phenotype and differentiation behavior of porcine CDCs were equivalent to previously described CDCs. Moreover, the intrapericardial administration of CDCs fulfilled the safety aspects as non-adverse effects were reported. Finally, the phenotypes of resident lymphocytes and TH1 cytokines in the pericardial fluid were significantly altered after CDCs administration.

Conclusions

The pericardial fluid could be considered as a safe and optimal vehicle for CDCs administration. The observed changes in the studied immunological parameters could exert a modulation in the inflammatory environment of infarcted hearts, indirectly benefiting the endogenous cardiac repair.

Autoimmunity in picornavirus infections

Enteroviruses are small, non-enveloped, positive-sense single-strand RNA viruses, and are ubiquitously found throughout the world. These viruses usually cause asymptomatic or mild febrile illnesses, but have a propensity to induce severe diseases including type 1 diabetes and pancreatitis, paralysis and neuroinflammatory disease, myocarditis, or hepatitis. This pathogenicity may result from induction of autoimmunity to organ-specific antigens. While enterovirus-triggered autoimmunity can arise from multiple mechanisms including antigenic mimicry and release of sequestered antigens, the recent demonstration of T cells expressing dual T cell receptors arising as a natural consequence of Theiler's virus infection is the first demonstration of this autoimmune mechanism.

Side effects of cytokines approved for therapy

Cytokines, currently known to be more than 130 in number, are small MW (<30 kDa) key signaling proteins that modulate cellular activities in immunity, infection, inflammation and malignancy. Key to understanding their function is recognition of their pleiotropism and often overlapping and functional redundancies. Classified here into 9 main families, most of the 20 approved cytokine preparations (18 different cytokines; 3 pegylated), all in recombinant human (rh) form, are grouped in the hematopoietic growth factor, interferon, platelet-derived growth factor (PDGF) and transforming growth factor β (TGFβ) families. In the hematopoietin family, approved cytokines are aldesleukin (rhIL-2), oprelvekin (rhIL-11), filgrastim and tbo-filgrastim (rhG-CSF), sargramostim (rhGM-CSF), metreleptin (rh-leptin) and the rh-erythropoietins, epoetin and darbepoietin alfa. Anakinra, a recombinant receptor antagonist for IL-1, is in the IL-1 family; recombinant interferons alfa-1, alfa-2, beta-1 and gamma-1 make up the interferon family; palifermin (rhKGF) and becaplermin (rhPDGF) are in the PDGF family; and rhBMP-2 and rhBMP-7 represent the TGFβ family. The main physicochemical features, FDA-approved indications, modes of action and side effects of these approved cytokines are presented. Underlying each adverse events profile is their pleiotropism, potency and capacity to release other cytokines producing cytokine 'cocktails'. Side effects, some serious, occur despite cytokines being endogenous proteins, and this therefore demands caution in attempts to introduce individual members into the clinic. This caution is reflected in the relatively small number of cytokines currently approved by regulatory agencies and by the fact that 14 of the FDA-approved preparations carry warnings, with 10 being black box warnings.

Treatment of hepatitis C virus infection and associated vascular complications: a literature review

Interferon (IFN)-based therapy, the cornerstone for treatment of hepatitis C virus (HCV) infection, is generally considered to be the single most effective treatment strategy for this infection. Although most adverse effects of IFN therapy respond very well to the cessation of this drug, there are reports of serious irreversible adverse effects. This review article evaluates the adverse effects of IFN therapy in HCV-infected patients. We have undertaken an extensive search for articles regarding IFN and pegylated-IFN (PEG-IFN) therapy and their vascular complications using multiple sources that include PubMed, publishers' websites, and Google Scholar. The prevalence of ocular disorders in the early period (first 8 weeks) after IFN administration was high with over half of the patients experiencing these adverse effects. Several authors strongly propose screening programs for retinopathy in the early period after IFN administration. Pulmonary hypertension due to IFN therapy is a serious side effect due to its irreversible nature in most patients. Patients who develop signs of acute abdomen up to months after IFN administration should be rapidly assessed for potential adverse effects of IFN. The literature suggests a broad spectrum of vascular injuries to different organs in humans as adverse effects of IFN therapy in HCV-infected patients.

Interferon-α and pericardial injury: a case report and literature review

Interferon- α (IFN-α) alone or in combination with other chemotherapeutic agents has been used in the management of many malignant and non-malignant conditions. Pericarditis with or without pericardial effusion has been reported with IFN-α therapy, and available literature is limited to case reports. Pericardial constriction after interferon use has not been described in the published literature to date. We performed a systematic review of literature to address the demographic features, clinical presentation, diagnosis, treatment and outcome of interferon-related pericardial injury.

Dilated cardiomyopathy and hypothyroidism associated with pegylated interferon and ribavirin treatment for chronic hepatitis C: case report and literature review

Pegylated interferon alpha (Peg IFN-α) in combination with ribavirin is the backbone of treatment in chronic hepatitis C (CHC). Cardiotoxicity due to interferon therapy is rare. The most frequent cardiovascular complications are arrhythmias and ischemic manifestations. Cardiomyopathy is extremely rare but can be life threatening. We present the case of a 41-year-old female patient with CHC in whom Peg IFN-α induced dilated cardiomyopathy and hypothyroidism. Chest radiography showed an enlarged and globular cardiac silhouette and pulmonary congestion. Echocardiography showed decreased left ventricular systolic function with an ejection fraction of 32% and fractional shortening of 15%. Cardiomyopathy had a complete remission after cessation of antiviral therapy with short-term heart failure medications and supportive care. Then we review the current literature about interferon induced cardiomyopathy in patients with HCV infection, as well as share our clinical experience in diagnosing and managing this rare complication.

Intra-abdominal localisation of a buschke-lowenstein tumour: case presentation and review of the literature

Giant condyloma acuminatum or Buschke-Lowenstein tumour is a very rare disease which usually is located in the genital, anorectal, and perianal regions. It is regarded as a type of verrucous carcinoma occurring on anogenital mucosal surfaces where it is locally invasive but displays a benign cytology. We describe a case of a 24-year-old woman with persisting condyloma acuminata progressing to a large intra-abdominal Buschke-Lowenstein tumour. To our knowledge such an advanced stage has only been reported once before. The severity and extent of the tumour both determine the treatment and patient outcome. Treatment was impeded by cachexia, an immunosuppressive state after kidney transplantation and difficulties in establishing a reliable diagnose. Interferon treatment was started which initially led to tumour reduction but was complicated by an interferon-induced pancreatitis, pneumonia, and fasciitis necroticans resulting in death. We present a literature overview on the treatment options for a Buschke-Lowenstein tumour, with emphasis on interferon therapy, with all the advantages and disadvantages.