1. Exacerbation of an
unrecognized autoimmune
hepatitis and sustained
virologic response in the case
of antiviral therapy for chronic
hepatitis C
MD PhD Oleksandra Popovych
MD PhD Larysa Moroz
MD Felix Chabanov
MD PhD Svetlana Kulias
Vinnytsia National Medical University
Ukraine

2. Patient history
 Sex: male
 Age: 26 years (DOB: 19/JAN/1983)
 First detection of anti-HCV: 24/NOV/2008
(accidentally during examination due to
intense hair loss)
 Epidemiological risks: 23 operations have
performed since 1986 to 1989 (1 for
congenital hypospadias and 22 for
postoperative fistula)
 Approximate duration of epidemiological
anamnesis – 20 years

3. Life history
 Vision: mild myopia (current)
 Skin: allergic dermatitis (past),
intense hair loss (past)
 Urogenital system: urolithiasis (current)
 Respiratory system: Pneumonia (past)
 Blood: thrombocytopenia (65-80 THOU/mkl)
(since 1989, current)

4. Physical examination
 Height: 160 cm
 Weight: 60 kg
 Ps: 68 beats per minute
 Arterial pressure: 120/80 mmHg
 The lower edge of the spleen is palpated
 Other organs without significant deviations
from the norm

5. Preliminary findings
anti-HCV, Epidemiological risks
20 years ago
Intense hair loss, allergic dermatitis
Thrombocytopenia
Enlargement of spleen
Acute problem? Chronic problem?
Probably not Probably yes
Autoimmune process?
Hypersplenism?
Other reasons?

6. Laboratory evaluation (primary data)
CBC
 RBC 4,72 TI/L
 MCV 79,54 FL
 HB 135,2 G/L
 Ht 37,5%
 WBC 4,1Gi/L PLT
 Neutrophils 2,42/mkl 67 THOU/mkl
 Lymphocytes 1,27/mkl
 Monocytes 0,33/mkl
 Eosinophils 0,08/mkl
0,08

7. Laboratory evaluation (primary data)
Coagulation tests
 APTT 59 sec
 INR 1,37 MILD INCREASE
 PT 21,6 sec
Urine analysis
Without clinically significant changes

8. Laboratory evaluation (primary data)
 Urea nitrogen 3.5 mmol/l  Protein total 73 G/L
 Creatinine 61umol/l  Albumin 46 G/L
 Glucose 5.1 mmol/l  Calcium 2.36 mmol/l
 Sodium 139 mmol/l  Chloride 104 mmol/l
 Potassium 3.7 mmol/l  Magnesium 0.74 mmol/l
 Alkaline Posphatase 117 u/l  Uric Acid 368 umol/l
 Bilirubin total 24 umol/l  Phosphorus inorganic
 Bilirubin indirect 18 umol/l 0.98mmol/l
 Bilirubin direct 6 umol/l  Insulin 42 PMOL/L
 Serum iron 18.5 umol/l  ATTPO 6 ME/ml
 Ferritin 153.9 ng/ml  TSH 0,983 mkME/ml

9. Laboratory evaluation (continued )
ASAT 142 U/L
ALAT 143 U/L
three times the upper limit of normal,
ALAT≈ASAT
(1 episode was presented with tenfold increase of
ALAT and ASAT three years ago )

10. Laboratory evaluation (continued )
 Anti-HCV - positive
 HCV RNA, PCR, QUANT - 70 000 IU/ML
 HCV genotype (LIPA) – 1b
 Anti HIV ½ - negative
 HBsAg – negative, Anti HBcor -
negative
 ANA – negative

11. Ultrasound
 Increased echogenicity of liver with irregular
appearing areas
 SPLENOMEGALY
 V.PORTAE – 14mm upper limit of normal
 V.LIENALIS – 10mm
Esophagogastroduodenoscopy
 Esophageal varices, stage II !!!
ECG
Without clinically significant changes

12. Diagnosis
Liver cirrhosis of HCV etiology
(anti-HCV-positive, low viral load, 1b genotype),
Child-Pugh class A with moderate inflammatory
activity. Esophageal varices II, moderate
thrombocytopenia.
The patient needs treatment
(The patient refused liver biopsy, FibroScan - !!!!!!!!!!)

13. TREATMENT
Thrombopoietin PegInterferon Ribavirin
receptor α-2b
agonist
Dose dependently on 80mkg 400mg
platelets’ level
Frequency q.d. once a week b.i.d
Route of po sc po
administration
Duration dependently on 48 weeks 48 weeks
of treatment platelets’ level

14. Week 9 (stop antiviral therapy)
 ALAT 250 U/L ASAT 289 U/L
 HCV RNA, PCR, QUANT - negative
 Anti HAV-, Anti Bcor-, Anti HEV- CMV-,
Epstein-Barr VCA- IgM, ANA, ActionAb,
SMA, AMA IgG – negative
 LKM-1 ANTIBODY IGG 46.1 UNITS
(positive >=25). Manifestation of autoimmune
hepatitis II type
 Ultrasound (New changes): mild thickening
of caudate lobe, V.Portae – 15mm, V.Lienalis
– 11mm, Ascites – 300-350ml

15. U/L
B
ef
or
St e
ar tre
t
0
100
200
300
400
500
600
of at
m 700
an en
tiv t
ira
lt
he
ra
py
W
treatment
1
(s W
to 2
p W
an 4
(s ti v
ta ir W
rt al 6
Pr t h
e d er W
ni ap 8
so y)
lo W
n) 9
W
12
W
14
W
15
W
16
W
17
W
ALAT 612 U/L ASAT 585 U/L
21
W
29
W
41
Dynamics of ALAT and ASAT for the
ALAT
ASAT

16. Preliminary results of the treatment
 Ascites was resolved in a 2 weeks after
Prednisolone therapy
 All the biochemical data were normalized after 2
month of Prednisolone therapy
 Prednisolone therapy lasted 1 year
 Normal biochemical data and negative HCV
RNA have been retained till now
 Total duration of virologic remission is 1 year 3
months
 LKM-1 ANTIBODY IGG - negative

17. Key issues
???
Overlap syndrome is Avowed duration
a contraindication
ANA examination
is enough of antiviral therapy
for antiviral therapy
of HCV-infection to start of is 48 weeks
? antiviral therapy
?
?

18. THANK YOU !