Stubbs Aaron, Kowal Corinne, Askari Ali, Anthony Donald D, Mattar Maya
Department of Medicine, Division of Rheumatic Diseases, Case Western Reserve University, Cleveland, Ohio, USA.
Rheumatology section, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.
J Clin Cell Immunol. 2018 Oct 3;9(5):562. doi: 10.4172/2155-9899.1000562.
We aim to describe the persistence of symptoms associated with HCV-associated cryoglobulinemic vasculitis following achievement of (SVR) with IFN- free direct acting antiviral (DAA) therapy. In particular, we describe the persistence of C4 hypocomplementemia and positive Rheumatoid Factor (RF).
We analyzed a case series of four patients enrolled from the Cleveland VA and known to have chronic HCV infection complicated by mixed cryoglobulinemia. The study included patients treated with interferon (IFN) based treatment and IFN free direct acting antiviral (DAA) therapy.
Of the four patients, patients 1 and 2 experienced decline of RF without resolution following DAA therapy. Patient 1 continues to have evidence of disease following treatment. Patient 3 did not have resolution of RF during IFN-based treatment and experienced stabilization of kidney function while on treatment. Patient 4, previously a non-responder to IFN based treatment, experienced significant decline in RF titers along with resolution of cryoglobulin-associated rash with DAA therapy. C4 remained low following treatment in patients 1 and 3. Of the four patients, only patient 1 had prolonged persistence of cryoglobulinemia, measured at 3%, 17 months following achievement of SVR.
We highlight the complexity of the viral-mediated immunologic mechanism that causes cryoglobulinemic vasculitis. Our cases also emphasize the need to consider cryoglobulinemic vasculitis as part of the differential diagnosis even with treated HCV infection. Recognizing these findings are important in our understanding of the pathophysiology of the disease and management in the era of IFN-free DAA therapy.
我们旨在描述在使用无干扰素直接作用抗病毒药物（DAA）治疗实现持续病毒学应答（SVR）后，与丙型肝炎病毒（HCV）相关的冷球蛋白血症性血管炎相关症状的持续情况。特别是，我们描述了C4低补体血症和类风湿因子（RF）阳性的持续情况。
我们分析了一组来自克利夫兰退伍军人事务部的4例患者的病例系列，这些患者已知患有慢性HCV感染并伴有混合性冷球蛋白血症。该研究包括接受基于干扰素（IFN）治疗和无干扰素直接作用抗病毒（DAA）治疗的患者。
在这4例患者中，患者1和2在接受DAA治疗后RF下降但未消退。患者1在治疗后仍有疾病证据。患者3在基于IFN的治疗期间RF未消退，且在治疗期间肾功能稳定。患者4以前对基于IFN的治疗无反应，在接受DAA治疗后RF滴度显著下降，同时冷球蛋白相关皮疹消退。患者1和3在治疗后C4仍低。在这4例患者中，只有患者1在实现SVR后17个月，冷球蛋白血症持续时间延长，检测值为3%。
我们强调了导致冷球蛋白血症性血管炎的病毒介导免疫机制的复杂性。我们的病例还强调，即使在HCV感染已治疗的情况下，也需要将冷球蛋白血症性血管炎作为鉴别诊断的一部分来考虑。认识到这些发现对于我们理解该疾病的病理生理学以及在无干扰素DAA治疗时代的管理非常重要。
