Acute inflammatory demyelinating polyneuropathy associated with pegylated interferon α 2a therapy for chronic hepatitis C virus infection

New evidence for secondary axonal degeneration in demyelinating neuropathies

Development of peripheral nervous system (PNS) myelin involves a coordinated series of events between growing axons and the Schwann cell (SC) progenitors that will eventually ensheath them. Myelin sheaths have evolved out of necessity to maintain rapid impulse propagation while accounting for body space constraints. However, myelinating SCs perform additional critical functions that are required to preserve axonal integrity including mitigating energy consumption by establishing the nodal architecture, regulating axon caliber by organizing axonal cytoskeleton networks, providing trophic and potentially metabolic support, possibly supplying genetic translation materials and protecting axons from toxic insults. The intermediate steps between the loss of these functions and the initiation of axon degeneration are unknown but the importance of these processes provides insightful clues. Prevalent demyelinating diseases of the PNS include the inherited neuropathies Charcot-Marie-Tooth Disease, Type 1 (CMT1) and Hereditary Neuropathy with Liability to Pressure Palsies (HNPP) and the inflammatory diseases Acute Inflammatory Demyelinating Polyneuropathy (AIDP) and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). Secondary axon degeneration is a common feature of demyelinating neuropathies and this process is often correlated with clinical deficits and long-lasting disability in patients. There is abundant electrophysiological and histological evidence for secondary axon degeneration in patients and rodent models of PNS demyelinating diseases. Fully understanding the involvement of secondary axon degeneration in these diseases is essential for expanding our knowledge of disease pathogenesis and prognosis, which will be essential for developing novel therapeutic strategies.

Neurological manifestations of COVID-19, SARS and MERS

Since December 2019, the world is affected by an outbreak of a new disease named COVID-19, which is an acronym of ‘coronavirus disease 2019’. Coronaviruses (CoV) were assumed to be associated with mild upper respiratory tract infections, such as common cold. This perception changed in time due to occurrence of the Severe Acute Respiratory Syndrome (SARS) caused by SARS-CoV in 2002 and the Middle East Respiratory Syndrome (MERS) caused by MERS-CoV in 2012, both inducing an epidemic severe viral pneumonia with potentially respiratory failure and numerous extra-pulmonary manifestations. The novel coronavirus, SARS-CoV-2, is likewise a causative pathogen for severe viral pneumonia with the risk of progression to respiratory failure and systemic manifestations. In this review, we will give a summary of the neurological manifestations due to SARS and MERS, as those might predict the neurological outcome in the novel COVID-19. Additionally, we provide an overview of the current knowledge concerning neurological manifestations associated with COVID-19, to the extent that literature is already available as the pandemic is still ongoing.

Reactivation of Chronic Hepatitis C as a Potential Trigger for Guillain-Barré Syndrome

A 74-year-old man with a past medical history of chronic low back pain presented with two to three weeks of progressive weakness starting in the lower extremities and then spreading to the upper extremities. Distal muscles were more affected than proximal muscles; weakness was accompanied by numbness and paresthesias. There was no preceding acute viral, respiratory, or gastrointestinal illness. Initial workup revealed hepatitis C antibody reactivity, and cerebrospinal fluid (CSF) analysis showed albuminocytologic dissociation. MRI demonstrated multilevel degenerative changes and diffuse enhancement of the cauda equina nerve roots compatible with Guillain-Barré syndrome (GBS). Repeat testing confirmed ongoing hepatitis C infection with increasing quantitative hepatitis C virus (HCV) levels. This case illustrates an interesting presentation of GBS potentially triggered by hepatitis C reactivation. This is the first case, to our knowledge, with serologic evidence demonstrating acute hepatitis C reactivation concurrent with GBS which presented in the absence of immunomodulatory interferon treatment. The patient continues to recover with ongoing rehabilitation at the time of this case report.

Severe Guillain-Barré syndrome associated with chronic active hepatitis C and mixed cryoglobulinemia: a case report

Background

We describe a case of severe Guillain-Barre syndrome (GBS) associated with chronic active hepatitis C and mixed cryoglobulinemia (MC). To our knowledge, this association between GBS and hepatitis C virus (HCV) infection has been rarely reported.

Case presentation

A 56-year-old man developed symmetrical muscle weakness in all extremities, areflexia and sensorial disorder followed by acute respiratory failure associated with chronic active hepatitis C, which was confirmed by the presence of anti-HCV antibodies in the serum and persistence of HCV RNA viral load for more than 6 months. Chronic hepatitis C was further complicated by type 3 MC. Electromyography showed peripheral nerve injury (mainly in axon). A severe acute motor sensory axonal neuropathy (AMSAN) was diagnosed. After treatment with intravenous immunoglobulin and plasma exchange followed by antiviral therapy by direct-acting antiviral agent, patient showed progressive recovery and was transferred 3 months after his first admission to a rehabilitation center.

Conclusions

Our case reported a severe GBS associated with HCV infection and MC. EMG classified for the first time the subtype of GBS (severe AMSAN) correlated with severe clinical form. HCV infection should be screened in high-risk patients to prevent silent progression of the chronic hepatitis C and its potentially severe extra-hepatic manifestations.

Neurological Complications during Treatment of Middle East Respiratory Syndrome

Background and Purpose

Middle East respiratory syndrome (MERS) has a high mortality rate and pandemic potential. However, the neurological manifestations of MERS have rarely been reported since it first emerged in 2012.

Methods

We evaluated four patients with laboratory-confirmed MERS coronavirus (CoV) infections who showed neurological complications during MERS treatment. These 4 patients were from a cohort of 23 patients who were treated at a single designated hospital during the 2015 outbreak in the Republic of Korea. The clinical presentations, laboratory findings, and prognoses are described.

Results

Four of the 23 admitted MERS patients reported neurological symptoms during or after MERS-CoV treatment. The potential diagnoses in these four cases included Bickerstaff's encephalitis overlapping with Guillain-Barré syndrome, intensive-care-unit-acquired weakness, or other toxic or infectious neuropathies. Neurological complications did not appear concomitantly with respiratory symptoms, instead being delayed by 2–3 weeks.

Conclusions

Neuromuscular complications are not rare during MERS treatment, and they may have previously been underdiagnosed. Understanding the neurological manifestations is important in an infectious disease such as MERS, because these symptoms are rarely evaluated thoroughly during treatment, and they may interfere with the prognosis or require treatment modification.

Pharmacological treatment other than corticosteroids, intravenous immunoglobulin and plasma exchange for Guillain-Barré syndrome

BACKGROUND

Plasma exchange and intravenous immunoglobulin, but not corticosteroids, are beneficial in Guillain-Barré syndrome (GBS). The efficacy of other pharmacological agents is unknown. This review was first published in 2011 and updated in 2013 and 2016.

OBJECTIVES

To assess the effects of pharmacological agents other than plasma exchange, intravenous immunoglobulin and corticosteroids for GBS.

SEARCH METHODS

On 18 January 2016, we searched the Cochrane Neuromuscular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for treatments for GBS. We also searched clinical trials registries.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) or quasi-RCTs of acute GBS (within four weeks from onset) of all types and degrees of severity, and in individuals of all ages. We discarded trials that investigated only corticosteroids, intravenous immunoglobulin or plasma exchange. We included other pharmacological treatments or combinations of treatments compared with no treatment, placebo or another treatment. We also identified a number of non-randomised studies during the search, the results of which we considered in the Discussion.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology.

MAIN RESULTS

We identified no new trials during this update of the review. In previous versions of this review we identified only very low quality evidence for four different interventions published in four studies. Each study had a high risk of bias in at least one respect. One RCT with 19 participants comparing interferon beta-1a and placebo showed no clinically important difference in any outcome between groups. Another with 10 participants comparing brain-derived neurotrophic factor and placebo showed no clinically important difference in any outcome between groups. A third with 37 participants comparing cerebrospinal fluid filtration and plasma exchange also showed no clinically important difference in any outcome between groups. In a fourth with 43 participants, the risk ratio for an improvement by one or more disability grade after eight weeks was greater with the Chinese herbal medicine tripterygium polyglycoside than with corticosteroids (risk ratio 1.47; 95% confidence interval 1.02 to 2.11); other outcomes in this trial showed no difference. Serious adverse events were uncommon with each of these treatments and in the control groups.

AUTHORS' CONCLUSIONS

The quality of the evidence was very low. Three small RCTs, comparing interferon beta-1a or brain-derived neurotrophic factor with placebo, and cerebrospinal fluid filtration with plasma exchange, showed no significant benefit or harm for any of the interventions. A fourth small trial showed that the Chinese herbal medicine, tripterygium polyglycoside, hastened recovery in people with GBS to a greater extent than corticosteroids, but this result needs confirmation. We were unable to draw any useful conclusions from the few observational studies we identified.

HCV-related central and peripheral nervous system demyelinating disorders

Chronic infection with hepatitis C virus (HCV) is associated with a large spectrum of extrahepatic manifestations (EHMs), mostly immunologic/rheumatologic in nature owing to B-cell proliferation and clonal expansion. Neurological complications are thought to be immune-mediated or secondary to invasion of neural tissues by HCV, as postulated in transverse myelitis and encephalopathic forms. Primarily axonal neuropathies, including sensorimotor polyneuropathy, large or small fiber sensory neuropathy, motor polyneuropathy, mononeuritis, mononeuritis multiplex, or overlapping syndrome, represent the most common neurological complications of chronic HCV infection. In addition, a number of peripheral demyelinating disorders are encountered, such as chronic inflammatory demyelinating polyneuropathy, the Lewis-Sumner syndrome, and cryoglobulin-associated polyneuropathy with demyelinating features. The spectrum of demyelinating forms also includes rare cases of iatrogenic central and peripheral nervous system disorders, occurring during treatment with pegylated interferon. Herein, we review HCV-related demyelinating conditions, and disclose the novel observation on the significantly increased frequency of chronic demyelinating neuropathy with anti-myelin-associated glycoprotein antibodies in a cohort of 59 consecutive patients recruited at our institution. We also report a second case of neuromyelitis optica with serum IgG autoantibody against the water channel aquaporin-4. The prompt recognition of these atypical and underestimated complications of HCV infection is of crucial importance in deciding which treatment option a patient should be offered.

Deregulated Fcγ receptor expression in patients with CIDP

Objective:

To evaluate the expression of activating and inhibitory Fc-gamma receptors (FcγRs) before and during clinically effective therapy with IV immunoglobulin (IVIg) in patients with chronic inflammatory demyelinating polyneuropathy (CIDP).

Methods:

Peripheral blood leukocyte subsets, including classical CD14^highCD16⁻ and nonclassical inflammatory CD14^lowCD16⁺ monocytes as well as naive CD19⁺CD27⁻ and memory CD19⁺CD27⁺ B cells, were obtained at baseline and monitored at 2 and 4–8 weeks after initiation of IVIg therapy.

Results:

Compared with healthy donors matched by age and sex, patients with CIDP showed increased expression levels of the activating high-affinity FcγR1 on CD14^highCD16⁻ (p < 0.001) and CD14^lowCD16⁺ monocytes (p < 0.001). Expression of the activating low-affinity FcγRIIA was increased on CD14^lowCD16⁺ monocytes (p = 0.023). Conversely, expression of the inhibitory FcγRIIB was reduced on naive (p = 0.009) and memory (p = 0.002) B cells as well as on CD14^highCD16⁻ monocytes (p = 0.046). Clinically effective IVIg therapy partially restored deregulated FcγR expression on B cell subsets and monocytes.

Conclusions:

The FcγR regulatory system is disturbed in patients with CIDP. Balancing activating vs inhibitory FcγR expression might provide a clinical benefit for patients with CIDP.

Multiple Sclerosis Like Condition in a Patient of Hepatitis C after Treatment with Interferon Alpha: A Case Report

Hepatitis C virus affects millions of people around the world. The primary therapy comprises of interferon alpha and ribavarin. The most common side effects of this treatment include flu like symptoms and psychiatric issues. One of the rare complications of the combined therapy is the development of demyelinating lesions in the central nervous system. Our case report presents a 35-year-old man who was a known case of Hepatitis C presenting to us with altered level of consciousness and decreased vision. He had been treated as per the standard therapy for Hepatitis C infection with interferon alpha and ribavarin. During the course of this therapy, he developed significant loss of vision. This was in fact due to serious and rare complication of the treatment which was demonstrated on the MRI as demyelinating lesions in the deep periventricular white matter bilaterally. Visual Evoked Potential study was performed which concluded bilateral dysfunction of the optic pathway. The treatment of Hepatitis C with interferon alpha and ribavarin may present with a wide array of adverse effects which includes a rare complication of central nervous system demyelination as well. Research suggests that early treatment of Multiple Sclerosis (MS) is beneficial in the long run with a better prognosis and minimal changes on MRI of the patient. Therefore this complication of the treatment should be kept in mind as one of the main differential diagnosis. By finding the extent of the inflammation, and consequently doing an MRI alongside a lumbar puncture, can serve to diagnose a rare condition mimicking multiple sclerosis while treating with interferon alpha.

Infectious and noninfectious triggers in Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is the commonest cause of acquired flaccid paralysis in the world and regarded by many as the prototype for postinfectious autoimmunity. Here the authors consider both infectious and noninfectious triggers of GBS and determine where possible what immunological mechanisms may account for this association. In approximately two-thirds of cases, an infectious trigger is reported in the weeks that lead up to disease onset, indicating that the host's response to infection must play an important role in disease pathogenesis. The most frequently identified bacteria, Campylobacter jejuni, through a process known as molecular mimicry, has been shown to induce cross-reactive anti-ganglioside antibodies, which can lead to the development of axonal-type GBS in some patients. Whether this paradigm can be extended to other infectious organisms or vaccines remains an important area of research and has public health implications. GBS has also been reported rarely in patients with underlying systemic diseases and immunocompromised states and although the exact mechanism is yet to be established, increased susceptibility to known infectious triggers should be considered most likely.

Bell's palsy during interferon alpha 2a treatment in a case with Behçet uveitis

Purpose: To present a case who developed Bell’s palsy while using interferon alpha 2a for Behçet uveitis.

Methods: A patient with Behçet disease presented with decreased vision in his right eye. Ophthalmic examination, fundus fluorescein angiography and optical coherence tomography were performed. After developing facial paralysis while on interferon therapy, the patient was referred to our neurology service for differential diagnosis and treatment.

Results: Examination of right eye revealed panuveitis with branch retinal vein occlusion, so high dose steroids were prescribed. In three days there was no improvement in terms of vitreous inflammation and so steroids were replaced with interferon. At the seventh month, patient experienced a facial paralysis. After eliminating other causes, including viral infections, trauma, cold exposure and neurological evaluation with cranial MRI, the patient was diagnosed to have Bell’s palsy by a neurologist. Interferon was replaced with mycophenolate mofetil and the Bell’s palsy was treated with oral steroids.

Conclusion: It is important to be alert to both common and rare complications while treating with interferon.

Pegylated interferon induced myasthenia crisis--a case report

Interferons (IFNs) have antiviral, antimitogenic, and immunostimulatory effects and are often used in the treatment of viral hepatitis and some neoplasms. Combination pegylated IFN-alpha and ribavirin therapy is currently recommended for the treatment of hepatitis C. Triple therapy, with the addition of a protease inhibitor, such as telaprevir or boceprevir, has recently become a mainstay of therapy for certain genotypes. There have also been reports outlining side effects associated with conventional IFN therapy and its immunostimulatory effects, which may cause autoimmune phenomena, including but not limited to Guillain-Barre syndrome, polymyositis, acute and chronic demyelinating polyneuropathy, and myasthenia gravis. Although a number of cases of interferon-induced myasthenia gravis have been reported, we present a case of interferon-induced myasthenia crisis that developed soon after retreatment of hepatitis C with combination interferon, ribavirin, and telaprevir.

Pharmacological treatment other than corticosteroids, intravenous immunoglobulin and plasma exchange for Guillain-Barré syndrome

BACKGROUND

Plasma exchange and intravenous immunoglobulin, but not corticosteroids, are beneficial in Guillain-Barré syndrome (GBS). The efficacy of other pharmacological agents is unknown. This review was first published in 2011 and this update in 2013. 

OBJECTIVES

To review systematically the evidence from randomised controlled trials (RCTs) for pharmacological agents other than plasma exchange, intravenous immunoglobulin and corticosteroids.

SEARCH METHODS

On 28 August 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register CENTRAL (2012, Issue 8 in The Cochrane Library), MEDLINE (January 1966 to August 2012) and EMBASE (January 1980 to August 2012) for treatments for GBS. We considered evidence from non-randomised studies in the Discussion.

SELECTION CRITERIA

We included all randomised or quasi-RCTs of acute (within four weeks from onset) GBS of all types, ages and degrees of severity. We discarded trials which only tested corticosteroids, intravenous immunoglobulin or plasma exchange. We included other pharmacological treatments or combinations of treatments compared with no treatment, placebo treatment or another treatment.

DATA COLLECTION AND ANALYSIS

Change in disability after four weeks was the primary outcome. Two authors checked references and extracted data independently. One author entered and another checked data in Review Manager (RevMan). We assessed risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated mean differences and risk ratios with their 95% confidence intervals. We assessed strength of evidence with GradePro software.

MAIN RESULTS

Only very low quality evidence was found for four different interventions. This update of the review found no new trials. One RCT with 13 participants showed no significant difference in any outcome between interferon beta-1a and placebo. Another with 10 participants showed no significant difference in any outcome between brain-derived neurotrophic factor and placebo. A third with 37 participants showed no significant difference in any outcome between cerebrospinal fluid filtration and plasma exchange. In a fourth with 20 participants, the risk ratio of improving by one or more disability grades after eight weeks was significantly greater with the Chinese herbal medicine tripterygium polyglycoside than with corticosteroids (risk ratio 1.47; 95% confidence interval 1.02 to 2.11). Serious adverse events were uncommon with each of these treatments and not significantly commoner in the treated than the control groups.

AUTHORS' CONCLUSIONS

The quality of the evidence was very low. Three small RCTs, of interferon beta-1a, brain-derived neurotrophic factor and cerebrospinal fluid filtration, showed no significant benefit or harm. A fourth small trial showed that the Chinese herbal medicine tripterygium polyglycoside hastened recovery significantly more than corticosteroids but this result needs confirmation. It was not possible to draw useful conclusions from the few observational studies.

Chronic inflammatory demyelinating polyneuropathy due to the administration of pegylated interferon α-2b: a neuropathology case report

We report a 35-year-old man who developed weakness in his extremities five months after pegylated interferon α (IFNα)-2b was administered. The serum tumor necrosis factor-α (TNFα) was elevated and nerve conduction studies revealed demyelination both in the distal and intermediate segments. The sural nerve pathology showed mild demyelinating process. The cessation of IFNα and administration of intravenous immunoglobulin improved both his clinical symptoms and the temporal dispersion in motor nerve conduction study. IFNα-induced CIDP is presumably a transient immunological condition that requires immunomodulatory therapy. The elevated serum TNFα may implicate the degree of downstream autoimmunity induced by IFNα.

Guillain-Barrè syndrome after treatment with human anti-tumor necrosis factorα (adalimumab) in a Crohn's disease patient: case report and literature review

Anti-tumor necrosis factor alpha antibodies have been used with increasing frequency despite the number of reported adverse effects. Further new information is still emerging. Here we report the case of a 71-years-old patient affected by Crohn's disease and HCV-positive who developed Guillain-Barrè syndrome after four injections of fully human anti-tumor necrosis factor alpha antibodies (adalimumab). Indication for the treatment was severe clinical recurrence of Crohn's disease following intestinal resection. Guillain-Barrè syndrome was treated by intravenous immunoglobulins, and methylprednisolone and plasmapheresis were started with a progressive partial resolution of neurological symptoms. To date, Crohn's disease was maintained in clinical remission with low dose steroid therapy.

Pharmacological treatment other than corticosteroids, intravenous immunoglobulin and plasma exchange for Guillain Barré syndrome

BACKGROUND

Plasma exchange and intravenous immunoglobulin, but not corticosteroids, are beneficial in Guillain-Barré syndrome (GBS). The efficacy of other pharmacological agents is unknown.  

OBJECTIVES

To review systematically the evidence from randomised controlled trials for pharmacological agents other than plasma exchange, intravenous immunoglobulin and corticosteroids.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register (5 July 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to June 2010) and EMBASE (January 1980 to June 2010) for treatments for GBS. We considered evidence from non-randomised studies in the Discussion.

SELECTION CRITERIA

We included all randomised or quasi-randomised controlled trials of acute (within four weeks from onset) GBS of all types, ages and degrees of severity. We discarded trials which only tested corticosteroids, intravenous immunoglobulin or plasma exchange. We included other pharmacological treatments or combinations of treatments compared with no treatment, placebo treatment or another treatment.

DATA COLLECTION AND ANALYSIS

Change in disability after four weeks was the primary outcome. Two authors checked references and extracted data independently. One author entered and another checked data in Review Manager (RevMan). We assessed risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated mean differences and risk ratios with their 95% confidence intervals. We assessed strength of evidence with GradePro software.

MAIN RESULTS

Only very low quality evidence was found for four different interventions. One randomised controlled trial with 13 participants showed no significant difference in any outcome between interferon beta-1a and placebo. Another with 10 participants showed no significant difference in any outcome between brain-derived neurotrophic factor and placebo. A third with 37 participants showed no significant difference in any outcome between cerebrospinal fluid filtration and plasma exchange. In a fourth with 20 participants, the risk ratio of improving by one or more disability grades after eight weeks was significantly greater with the Chinese herbal medicine tripterygium polyglycoside than with corticosteroids (risk ratio 1.47; 95% confidence interval 1.02 to 2.11).

AUTHORS' CONCLUSIONS

The quality of the evidence was very low. Three small randomised controlled trials, of interferon beta-1a, brain-derived neurotrophic factor and cerebrospinal fluid filtration, showed no significant benefit or harm. A fourth small trial showed that the Chinese herbal medicine tripterygium polyglycoside hastened recovery significantly more than corticosteroids but this result needs confirmation. It was not possible to draw useful conclusions from the few observational studies.

Diagnosis and treatment of serum HCV RNA-negative patients with chronic hepatitis C

AIM: To investigate the diagnosis and the treatment of serum HCV RNA-negative patients with chronic hepatitis C (CHC).

METHODS: Eleven consecutive serum HCV RNA-negative CHC patients treated since February 2004 were collected. HCV RNA could be detected in the liver of five patients. There was no evidence of other causes of viral hepatitis. The patients were treated with interferon (IFN) alpha-2b 300 MU, intramuscularly, 1/2 d, in combination with ribavirin 900 mg/d for 12 mo and then followed up regularly.

RESULTS: Of the 11 patients, 10 completed the 12-mo treatment, and 1 discontinued the treatment at 9 mo. The levels of serum ALT and AST in all the patients declined to normal range within 4 wk. No exceptional adverse events occurred. The levels of serum ALT and AST were maintained within the normal range during 17-35 mo of follow-up. HCV-RNA and anti-HCV status remained unchanged during the follow-up.

CONCLUSION: A diagnosis of serum HCV RNA-negative CHC should be considered when a patient has a history of injury and a current or past history of positive serum anti-HCV with incessantly or repeatedly elevated ALT and AST for more than 6 mo after excluding other liver diseases. Anti-HCV treatment with IFN and ribavirin should be promptly given to serum HCV RNA-negative CHC patients.

Pericarditis and chronic inflammatory demyelinating polyneuropathy during therapy with pegylated interferon alfa-2a for chronic hepatitis C

We report a case of pericarditis and chronic inflammatory demyelinating polyneuropathy with biological signs of a lupus-like syndrome due to pegylated interferon alfa-2a therapy during treatment for chronic hepatitis C. The patient developed moderate weakness in the lower limbs and dyspnea. He was hospitalized for congestive heart failure. An electrocardiogram showed gradual ST-segment elevation in leads V(1) through V(6) without coronary artery disease. A transthoracic cardiac ultrasonographic study revealed moderate pericardial effusion with normal left ventricular function. Anti-DNA antibody and antids DNA IgM were positive. Neurological examination revealed a symmetrical predominantly sensory polyneuropathy with impairment of light touch and pin prick in globe and stoking-like distribution. Treatment with prednisolone improved the pericarditis and motor nerve disturbance and the treatment with intravenous immunoglobulin improved the sensory nerve disturbance.

Guillain-Barre syndrome associated with peginterferon alfa-2a for chronic hepatitis C: A case report

The recommended therapy for chronic hepatitis C (CHC) infection is the combination of a Pegylated interferon and Ribavirin. Almost all such patients on combination therapy experience one or more adverse events during the course of treatment. Significant neurological side effects are rare. A few cases of Bell's Palsy, chronic inflammatory demyelinating polyneuropathy and even one case of acute demyelinating polyneuropathy with atypical features for Guillain-Barre syndrome (GBS) associated with Interferon therapy have been reported but no report of GBS with typical features has been published. We present a case report of typical GBS associated with Peginterferon alfa-2a and Ribavirin used for treatment of CHC infection.

Polineuropatia desmielinizante inflamatória crônica pós-tratamento com interferon peguilado alfa 2b em um paciente co-infectado HIV/HCV: relato de caso

A polineuropatia desmielinizante inflamatória cônica possui forte associação com a infecção pelo HIV e HCV. Uma rara associação entre PDIC e o tratamento da hepatite C com interferon peguilado alfa foi descrita recentemente. Nós descrevemos o primeiro caso de polineuropatia desmielinizante inflamatória crônica em um paciente branco, sexo masculino infectado por HIV e HCV associado a interferon peguilado alfa 2b. O paciente recuperou-se completamente após o uso de imunoglobulina hiperimune endovenosa. Infectologistas e hapatologistas devem estar atentos à esta rara e grave associação, que exige imediata descontinuação da droga e tratamento precoce.

Hepatitis C virus as a multifaceted disease: a simple and updated approach for extrahepatic manifestations of hepatitis C virus infection

Hepatitis C virus infection is an emerging disease and a public health problem in the world. There are accumulating data regarding extra hepatic manifestation of HCV, such as rheumatologic manifestations, endocrine, hematologic, dermatologic, renal, neurologic, and systemic manifestations. The therapy of them needs more attention to some exacerbations of extra hepatic manifestation and in some situation it needs different approaches. In this review we tried to provide latest evidence for extra hepatic manifestation and management of them.

Iatrogenic neuropathies

PURPOSE OF REVIEW

This review discusses the literature on peripheral neuropathy caused by medication-induced toxicity or immunological mechanism with special attention to recent advancements.

RECENT FINDINGS

The number of reports of immune-mediated neuropathies associated with antitumor necrosis factor alpha (anti-TNFalpha) therapy is increasing. But long-term follow-up suggests that the cessation of anti-TNFalpha therapy is not always necessary. The cases of acute inflammatory demyelinating polyneuropathy induced by polyethylene glycol-interferon alpha-2a and of polyradiculoneuropathy induced by polyethylene glycol-interferon alpha-2b were reported for the first time, and the latter was associated with antiganglioside antibodies. The mechanism of chemotherapy-induced peripheral neuropathy is still in the process of being elucidated with the use of animal models or axonal excitability techniques. In the phase III Assessment of Proteasome Inhibitor for Extending Remissions trial, it proved that dose modification using a specific guideline improved bortezomib-induced peripheral neuropathy management.

SUMMARY

Peripheral neuropathy can be associated with anti-TNFalpha therapy or interferon alpha therapy, and to the contrary, anti-TNFalpha therapy or interferon alpha therapy may have potential as a treatment option for a spectrum of immune-mediated neuropathy, similar to a double-edged sword. To take advantage of the effect of chemotherapy and to reduce neurotoxicity, a guideline of dose modification is useful.