Spontaneous Clearance of Hepatitis C Virus during Pregnancy

Spontaneous clearance of serum HCV-RNA after splenectomy in a patient with HCV-related liver cirrhosis and portal hypertension: a case report

BACKGROUND

Spontaneous clearance of chronic hepatitis C virus (HCV) is rare in adults. A T-lymphocyte response is thought to be involved in HCV-RNA clearance. Splenectomy reportedly has a beneficial effect on T cell immune function in patients with cirrhosis. To the best of our knowledge, the present report is the first to describe spontaneous clearance of serum HCV-RNA within 1 year after splenectomy in a patient with cirrhosis.

CASE PRESENTATION

A 55-year-old man with HCV cirrhosis was transferred to our institution with advanced pancytopenia, splenomegaly, and gastric varices. He had a 1-year history of ascites, edema, and general fatigue. The patient had a Child-Pugh score of 8 and serological type 1 HCV; the HCV-RNA level was 4.7 log IU/mL. Contrast-enhanced computed tomography showed gastric varices and marked splenomegaly (estimated spleen volume of 2175 mL). Esophagogastroduodenoscopy revealed enlarged gastric varices with no red color sign, and the varices were larger than those 1 year prior. He was diagnosed with decompensated HCV-related liver cirrhosis and portal hypertension. We considered direct-acting antiviral (DAA) therapy; however, DAA therapy was not approved in Japan for patients with decompensated cirrhosis at that time. Hand-assisted laparoscopic splenectomy was performed to improve the worsening portal hypertension. Further, we planned the initiation of DAA therapy after surgery, when such therapy would become available. DAA therapy was approved 1 year after splenectomy. At that time, we measured the HCV-RNA level before the initiation of DAA therapy; unexpectedly, however, serum HCV-RNA was not detectable, and the virus continued to disappear during the following 4 years. His liver function (total bilirubin, albumin, and prothrombin time) and pancytopenia improved during the 5 years postoperatively. The serum aspartate and alanine aminotransferase levels normalized between 1 and 5 years postoperatively. Esophagogastroduodenoscopy showed no change in the gastric varices during the 5 years after surgery. The patient remained asymptomatic and continued to do well.

CONCLUSIONS

We have presented a case of spontaneous clearance of HCV-RNA after splenectomy in a patient with cirrhosis and portal hypertension. Splenectomy may be associated with disappearance of HCV-RNA based on previous reports. More cases should be accumulated and evaluated.

Update on hepatitis C and implications for pregnancy

Mother-to-child transmission of hepatitis C virus infection occurs in a significant minority of cases and the diagnosis, treatment and cure of hepatitis C virus infection with direct acting antivirals prior to pregnancy can eliminate this risk in almost all cases. Women with hepatitis C virus infection have increased risks of adverse events in pregnancy and poor perinatal outcomes for their children, although the contribution of hepatitis C virus per se is difficult to determine. Altering the mode of delivery does not reduce mother to child transmission of hepatitis C virus infection, although avoidance of fetal scalp electrodes and other potential high risk procedures is recommended during pregnancy and delivery. Breast feeding has not been demonstrated to be a risk for mother-to-child transmission and avoidance of breast feeding is not recommended, although breast feeding with cracked or bleeding nipples is generally avoided. Safety of the currently available hepatitis C virus antivirals in pregnancy and breastfeeding has not yet been established.