Posttransplant liver granulomatosis associated with hepatitis C?

Development of hepatic granulomas in patients receiving pegylated interferon therapy for recurrent hepatitis C virus post liver transplantation

Infrequently, hepatitis C (HCV) appears to be the cause of hepatic granulomas. Interferon therapy for HCV has been increasingly associated with the development of sarcoidosis.

AIMS

We sought to determine the incidence of hepatic granulomas in patients with recurrent HCV post liver transplantation (LT).

METHODS

Between 1994 and 2005, 820 patients were transplanted for HCV at our institution. The pathology database was searched for patients having recurrent HCV and granulomas. At Mount Sinai Medical Center, protocol biopsies have been performed for the last 2 years in patients receiving pegylated interferon-alpha2b and ribavirin (PEG) for recurrent HCV. Review of slides from explanted livers, pre- and post-perfusion biopsies, and all allograft biopsies were evaluated. Lipogranulomas were excluded because of their frequent association with steatosis.

RESULTS

A total of 10,225 liver biopsies were performed on HCV patients, and 25 (0.24%) showed non-caseating epithelioid granulomas. Hepatic granulomas were detected in 14 post-LT HCV patients; 9 patients received PEG. Typically, only 1 lobular granuloma was found. None of these patients had granulomas in the native liver or in any biopsy before interferon therapy; 6/9 patients had undetectable HCV-RNA levels, and 4 had sustained viral response. No other cause for granuloma formation was identified in the 6 patients.

CONCLUSIONS

Hepatic granulomas are infrequently found in HCV liver biopsies and rarely found in post-LT biopsies with recurrent HCV. When present, they occur more commonly in patients receiving and virologically responding to PEG therapy. The presence of granulomas in patients with HCV being treated with PEG may not warrant an extensive etiologic work-up for granulomatous hepatitis unless otherwise clinically indicated.

The prevalence of hepatic granulomas in chronic hepatitis C

OBJECTIVES

Hepatic granulomas are not usual findings in chronic hepatitis C. A few studies addressing the frequency of hepatic granulomas in chronic hepatitis C reported it as less than 10%. The presence of it has been suggested to predict a favorable response to interferon treatment. Also, case reports described the development of hepatic granulomas after interferon treatment. In this study, we aimed to detect the prevalence of hepatic granulomas in chronic hepatitis C and to identify the causes other than chronic hepatitis C, if present, to search whether there is an association between the presence of granuloma and response to interferon treatment and also to see whether interferon leads to the formation of hepatic granulomas.

METHODS

Patients from 3 university clinics were included. All patients with chronic hepatitis C were determined. All patients with hepatic granulomas were screened for the other causes of hepatic granuloma with tuberculin skin test, chest X-ray and computed tomography, Venereal Disease Research Laboratory, and Brucella agglutination tests. The histologic assessment of liver biopsies was done by the same pathologist in each center.

RESULTS

A total of 725 liver biopsies of 605 patients with chronic hepatitis C were screened. In 8 patients, hepatic granulomas were detected in the initial liver biopsies. Four patients had repeat biopsies, and all had hepatic granulomas again. The prevalence of hepatic granulomas in patients with chronic hepatitis C was calculated as 1.3% (8 of 605) in reference to patient population. Presence or absence of hepatic granulomas was seemingly stable. All patients with hepatic granulomas had negative results of tuberculin skin test, Venereal Disease Research Laboratory, chest X-ray and computed tomography, and Brucella agglutination tests. All repeat biopsies were obtained after interferon (+/- ribavirin) in varying doses and duration. Four of 8 patients with hepatic granulomas were found to respond interferon therapy. No patient was found to develop hepatic granulomas after interferon therapy.

CONCLUSION

Hepatic granulomas are a rare finding in HCV infection. The presence of it does not seem to predict the response to interferon therapy. The development of hepatic granulomas during interferon therapy is not usual.