Ballester-Ferré Maria Pilar, Martínez Fernando, Garcia-Gimeno Natalia, Mora Francisco, Serra Miguel A
Maria Pilar Ballester-Ferré, Gastroenterology and Hepatology Department, University Clinic Hospital of Valencia, University of Valencia, 46010 Valencia, Spain.
World J Hepatol. 2017 Jan 28;9(3):161-166. doi: 10.4254/wjh.v9.i3.161.
Chronic hepatitis C virus (HCV) infection is one of the main causes of chronic liver disease worldwide. In the last 5 years, treatment for HCV infection has experienced a marked development. In 2014, the use of ledipasvir/sofosbuvir with or without concomitant weight-based ribavirin was approved with a very significant increase in the sustained virological response. However, new side effects have been associated. We report the first case of an HCV infected patient treated for 12 wk with the combination of sofosbuvir/ledipasvir plus ribavirin who developed a miliary tuberculosis (TB) infection while on therapy. The patient was a 65-year-old woman, who referred malaise, asthenia, hyporexia, 7 kg weight loss, productive cough, evening fever and night sweats, right after finishing the treatment. The chest computed tomography-scan revealed a superior mediastinal widening secondary to numerous lymphadenopathies with extensive necrosis and bilateral diffuse lung miliary pattern with little subsequent bilateral pleural effusion, highly suggestive of lymph node tuberculosis with lung miliary spread. A bronchoscopy was performed and bronchial suction showed more than 50 acid-alcohol resistant bacillus per line. A DNA was detected in blood by polymerase chain reaction, which confirmed the diagnosis of miliary tuberculosis. Some cases of TB infection have been identified with α-interferon-based therapy and with the triple therapy of pegylated interferon, ribavirin and boceprevir or telaprevir. However, significant infection has not been reported with sofosbuvir/ledipasvir plus ribavirin. We believe that the case is relevant to increase awareness of opportunistic infections and particularly TB infection. Although the international guidelines offer no recommendation regarding TB screening, we wonder whether it would be advisable to screen for opportunistic infections prior to the introduction of HCV therapy.
慢性丙型肝炎病毒（HCV）感染是全球慢性肝病的主要病因之一。在过去5年中，HCV感染的治疗取得了显著进展。2014年，来迪派韦/索磷布韦联合或不联合基于体重的利巴韦林的使用获得批准，持续病毒学应答率显著提高。然而，也出现了新的副作用。我们报告了首例接受索磷布韦/来迪派韦联合利巴韦林治疗12周的HCV感染患者，该患者在治疗期间发生了粟粒性结核（TB）感染。患者为一名65岁女性，在完成治疗后不久出现不适、乏力、食欲减退、体重减轻7千克、咳痰、午后发热和盗汗。胸部计算机断层扫描显示上纵隔增宽，继发于大量淋巴结病伴广泛坏死，双侧弥漫性肺粟粒样改变，随后双侧胸腔少量积液，高度提示淋巴结结核伴肺粟粒播散。进行了支气管镜检查，支气管吸出物每视野显示50多个抗酸杆菌。通过聚合酶链反应在血液中检测到结核杆菌DNA，确诊为粟粒性结核。在基于α干扰素的治疗以及聚乙二醇化干扰素、利巴韦林和博赛匹韦或特拉匹韦的三联治疗中，已发现一些TB感染病例。然而，尚未有索磷布韦/来迪派韦联合利巴韦林导致严重感染的报道。我们认为该病例对于提高对机会性感染尤其是TB感染的认识具有重要意义。尽管国际指南未就TB筛查提出建议，但我们想知道在开始HCV治疗前筛查机会性感染是否可取。
