Polyarteritis nodosa and cryoglobulinemic glomerulonephritis related to chronic hepatitis C

Renal Manifestations of Chronic Hepatitis C: A Review

Hepatitis C virus (HCV) has emerged as a major global health concern and, if left untreated, can lead to significant liver damage, including cirrhosis, decompensated liver disease, and hepatocellular carcinoma (HCC). Approximately 40% of patients with HCV infection experience extrahepatic manifestations, including renal involvement. HCV-related renal disease is of significant importance among patients with chronic kidney disease (CKD), leading to higher morbidity and mortality. The renal damage due to HCV infection primarily results from cryoglobulinemia and glomerulonephritis, with conditions such as membranoproliferative glomerulonephritis (MPGN) and membranous nephropathy (MN) being most prevalent. Despite advancements in treatment, including the use of directly acting antiviral agents (DAAs), renal complications remain a significant burden in untreated patients. HCV-positive patients on hemodialysis (HD) or those who have undergone kidney transplantation face increased mortality rates compared to their HCV-negative counterparts. Managing HCV infection before kidney transplantation is crucial to mitigate the risk of HCV-related renal complications. Conversely, kidney transplantation from HCV-infected donors is well established, as post-transplant treatment for HCV is safe and effective, potentially reducing mortality and morbidity for patients on transplant waiting lists. This review aims to provide a comprehensive analysis of the renal manifestations of HCV, emphasizing the importance of early diagnosis and treatment to improve patient outcomes.

A case of microscopic polyangiitis in an elderly patient presenting predominantly with cholecystitis successfully treated with mizoribine

An 82-year-old woman was previously diagnosed with cholecystitis and treated with antibiotics at another hospital. Because her fever and inflammation persisted, therapeutic cholecystectomy was performed. Histopathology of the gallbladder revealed periarterial vasculitis. After transfer to our hospital, an elevated titer of myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) was observed (47 U/mL). The patient's renal dysfunction had previously been thought to be sequelae of her cholecystectomy. We diagnosed microscopic polyangiitis (MPA) and began treatment with 40 mg orally of prednisolone daily. The titer of MPO-ANCA decreased with the treatment, but fever recurred with prednisolone taper. We, therefore, added 50 mg orally of mizoribine (MZR) daily as an immunosuppressant and increased the MZR to 100 mg daily while monitoring its blood peak concentration. The peak level of MZR was 1.58 μg/mL at 6 h after administration. After adding MZR, we successfully tapered the orally dosed prednisolone without recurrent fever or complications. We describe this case of MPA in an elderly patient manifesting predominantly with cholecystitis and successfully treated with orally dosed prednisolone and MZR.

Life-Threatening Cryoglobulinemic Patients With Hepatitis C: Clinical Description and Outcome of 279 Patients

Cryoglobulinemia is characterized by a wide range of causes, symptoms, and outcomes. Hepatitis C virus (HCV) infection is detected in 30%-100% of patients with cryoglobulins. Although more than half the patients with cryoglobulinemic vasculitis present a relatively benign clinical course, some may present with potentially life-threatening situations. We conducted the current study to analyze the clinical characteristics and outcomes of HCV patients presenting with life-threatening cryoglobulinemic vasculitis. We evaluated 181 admissions from 89 HCV patients diagnosed with cryoglobulinemic vasculitis consecutively admitted to our department between 1995 and 2010. In addition, we performed a systematic analysis of cases reported to date through a MEDLINE search.The following organ involvements were considered to be potentially life-threatening in HCV patients with cryoglobulinemic vasculitis: cryoglobulinemic, biopsy-proven glomerulonephritis presenting with renal failure; gastrointestinal vasculitis; pulmonary hemorrhage; central nervous system (CNS) involvement; and myocardial involvement. A total of 279 patients (30 from our department and 249 from the literature search) fulfilled the inclusion criteria: 205 presented with renal failure, 45 with gastrointestinal vasculitis, 38 with CNS involvement, 18 with pulmonary hemorrhage, and 3 with myocardial involvement; 30 patients presented with more than 1 life-threatening cryoglobulinemic manifestation. There were 146 (52%) women and 133 (48%) men, with a mean age at diagnosis of cryoglobulinemia of 54 years (range, 25-87 yr) and a mean age at life-threatening involvement of 55 years (range, 25-87 yr). In 232 (83%) patients, life-threatening involvement was the first clinical manifestation of cryoglobulinemia. Severe involvement appeared a mean of 1.2 years (range, 1-11 yr) after the diagnosis of cryoglobulinemic vasculitis. Patients were followed for a mean of 14 months (range, 3-120 mo) after the diagnosis of life-threatening cryoglobulinemia. Sixty-three patients (22%) died. The main cause of death was sepsis (42%) in patients with glomerulonephritis, and cryoglobulinemic vasculitis itself in patients with gastrointestinal, pulmonary, and CNS involvement (60%, 57%, and 62%, respectively). In conclusion, HCV-related cryoglobulinemia may result in progressive (renal involvement) or acute (pulmonary hemorrhage, gastrointestinal ischemia, CNS involvement) life-threatening organ damage. The mortality rate of these manifestations ranges between 20% and 80%. Unfortunately, this may be the first cryoglobulinemic involvement in almost two-thirds of cases, highlighting the complex management and very elevated mortality of these cases.

Lupus-like glomerulonephritis: an autoimmune complication of hepatitis C infection

Lupus-like glomerulnephritis in patients with negative lupus serologies and no extra-renal manifestations of lupus can create a diagnostic dilemma. We describe a 53-year-old gentleman with chronic hepatitis C virus (HCV) infection who presented with dialysis-requiring renal failure, renal histologic findings of "full-house" immunofluorescence label and tubuloreticular inclusions on electronic microscopy, but no extra-renal or laboratory signs of systemic lupus erythematosis. Attempted treatment with cyclophosphamide and corticosteroids was limited by cyclophosphamide hypersensitivity. The patient remained dialysis-dependent over 18 months of observation and did not develop extra-renal clinical or biological manifestations of lupus. Mimics of seronegative lupus with isolated renal involvement can include HCV-related autoimmunity. Treatment of acute glomerulonephritis may be similar initially, but other concerns in patients with HCV infection include excluding cryoglobulinemia, the potential impact of immunosuppression therapy on liver disease and consideration of subsequent use of antiviral therapy. Given the increasing prevalence of HCV globally, the recognition of extra-hepatic autoimmune manifestations of HCV infection will likely increase.

Life-threatening hepatitis C virus-associated polyarteritis nodosa successfully treated by rituximab

By contrast to cryoglobulinemic vasculitis, polyarteritis nodosa associated with hepatitis C virus (HCV) infection is rare and still a controversial entity. The best treatment for this condition is not established. Cases reported in the literature have been treated with various combinations of corticosteroids, antiviral therapy, and immunosuppressants. We report a case of severe life-threatening HCV-associated polyarteritis nodosa successfully treated with rituximab and a short course of corticosteroids without antiviral therapy. This case, along with recently published data, emphasizes the value of B-cell-targeted therapy in this unusual form of HCV-associated vasculitis.

Vasculitis of dental pulp associated with cryoglobulinemia in hepatitis C virus patients: case report

INTRODUCTION

This report presents a case of impacted lower third molar extracted for surgical reasons in patient with uncontrolled hepatitis C. After decalcification, dental pulp vasculature and its tissue quality were investigated.

METHODS

Serial sections of 4-μm thickness along the midline buccolingually for the demineralized specimen were obtained, mounted on a glass slide, stained with hematoxylin-eosin, covered, and viewed under the light microscope.

RESULTS

The histologic investigation of the pulp tissue revealed thickening, stenosis, and occlusion of the vessel wall, ectopic calcification of the pulp tissue in close association with pulpal blood vessels, interrupted and vacuolated odontoblastic layer in the coronal pulp chamber, with an inflammatory cell infiltrate throughout the pulpal tissue.

CONCLUSIONS

Cryoglobulinemia associated with uncontrolled hepatitis C virus infection in patients endangers the dental pulp vasculature and alters its normal tissue architecture.

Anti-glutamic Acid decarboxylase antibody-associated ataxia as an extrahepatic autoimmune manifestation of hepatitis C infection: a case report

Extrahepatic immunological manifestations of hepatitis C virus (HCV) are well described. In addition, antiglutamic acid decarboxylase (GAD) antibody-associated cerebellar ataxia is well-established entity. However, there have been no reports in the literature of anti-GAD antibody-associated ataxia as an extrahepatic manifestation of HCV infection. We report the case of a young woman with chronic hepatitis C virus and multiple extrahepatic autoimmune diseases including Sjögren syndrome and pernicious anemia who presented with subacute midline cerebellar syndrome and was found to have positive antiglutamic acid decarboxylase (GAD) antibody in the serum and cerebrospinal fluid. An extensive diagnostic workup to rule out neoplastic growths was negative, suggesting the diagnosis of nonparaneoplastic antiglutamic acid decarboxylase antibody-associated cerebellar ataxia as an additional extrahepatic manifestation of hepatitis C virus infection. The patient failed to respond to high-dose steroids and intravenous immunoglobulin. Treatment with the monoclonal antibody rituximab stabilized the disease. We postulate that anti-GAD associated ataxia could be an extrahepatic manifestation of HCV infection.

Polyarteritis nodosa associated with essential mixed cryglobulinemia revealed by subarachnoid hemorrhage

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis mediated by intravascular deposition of immune complexes. We report a 55-year-old man with PAN revealed by CNS vasculitis with subarachnoid hemorrhage and brainstem vasogenic oedema, associated with essential mixed cryoglobulinemia. In spite of aggressive treatment (steroids and cyclophosphamide), the patient became tetraplegic. A pathophysiological relationship between cryoglobulin and PAN can be suspected. Mixed cryoglobulinemia may trigger vasculitis with PAN features, possibly explaining the lack of treatment response.

Interferon therapy in rheumatic diseases: state-of-the-art 2010

PURPOSE OF REVIEW

Interferons are natural glycoproteins that have antiviral, antiproliferative and immune regulatory functions. They are not only involved in the pathogenesis of certain autoimmune conditions but are also useful in the treatment of some rheumatologic disorders, notably Behçet's syndrome.

RECENT FINDINGS

Interferon alpha (IFNalpha) has been recommended for severe eye involvement in Behçet's syndrome, especially when there is a significant drop in visual acuity and/or retinal involvement. It can induce a high rate of complete remission that may also persist after its discontinuation. When given early at the beginning, interferon might be effective in ameliorating the attacks of familial Mediterranean fever resistant to colchicine treatment. The combination of PEGylated IFNalpha with ribavirin and rituximab emerges as a novel and promising treatment providing complete clinical response and viral clearance in hepatitis C virus-associated mixed cryoglobulinemia. Limited data also suggest that interferon may induce remissions in Churg-Strauss patients who fail to respond to conventional immunosuppressive treatment.

SUMMARY

Among several rheumatologic diseases, IFNalpha has found more widespread use in Behçet's syndrome and hepatitis C virus-associated mixed cryoglobulinemia despite a paucity of formal studies. Patients should be carefully monitored for the frequent and dose-dependent adverse effects.

The challenge of managing patients with polyarteritis nodosa

PURPOSE OF REVIEW

In this short review we focus on the problems faced by clinicians caused by the changing definitions of polyarteritis nodosa.

RECENT FINDINGS

The term polyarteritis nodosa has been used for more than 100 years as a diagnostic term for patients with systemic vasculitis; however, specific vasculitides have been singled out like branches being chopped off a tree. Now, so little is left of the trunk of that tree that it is questionable to what extent we can trust older literature with respect to clinical features, natural history and response to treatment. Many authors of case reports, as well as authors of reviews and book chapters, claim they adhere to the Chapel Hill Consensus Conference definition of polyarteritis nodosa, yet still cite almost exclusively studies using older definitions without highlighting this dilemma. In the past year, two proposals affecting classification have been published: one stating that cutaneous polyarteritis nodosa and hepatitis-associated polyarteritis nodosa are diseases distinct from classical polyarteritis nodosa, and one providing an algorithm to separate microscopic polyangiitis from classical polyarteritis nodosa.

SUMMARY

There is hope that a wide acceptance of the new classification principles will lead to a more uniform way to diagnose classical polyarteritis nodosa, which will facilitate clinical studies and eventually improve management.