Hepatitis C, collagenous colitis, and dermatomyositis occurring in the same patient

Hepatitis B virus-related liver cirrhosis complicated with dermatomyositis: A case report

BACKGROUND

Twenty percent of patients infected with hepatitis B virus (HBV) develop extrahepatic manifestations with HBV detected in the lymph nodes, spleen, bone marrow, kidneys, and skin. HBV infection has been associated with some autoimmune disorders. Dermatomyositis (DM) is an idiopathic inflammatory myopathy, which involves a viral infection, and DM has been identified in patients infected with HBV, but there is no direct histological evidence for an association between HBV and DM.

CASE SUMMARY

We describe a familial HBV-infected patient admitted with liver function abnormality, rashes, a movement disorder, and an elevated level of creatine kinase (CK). A computed tomography scan of the lung showed pulmonary fibrosis, and a liver biopsy identified nodular cirrhosis. An electromyogram revealed myogenic damage, and a muscle biopsy showed nuclear migration in local sarcolemma and infiltration of chronic inflammatory cells. Immunohistochemical staining showed negative results for HBsAg and HBcAg. Fluorescence in situ hybridization showed a negative result for HBV DNA. The patient was diagnosed with HBV-related liver cirrhosis complicated with DM and was treated with methylprednisolone, mycophenolate mofetil, and lamivudine. Eight months later, the patient was readmitted for anorexia and fatigue. The blood examination showed elevated levels of aminotransferases and HBV DNA, however, the CK level was within the normal range. The patient developed a virological breakthrough and lamivudine was replaced with tenofovir.

CONCLUSION

DM in chronic HBV-infected patients does not always associate with HBV. Antiviral and immunosuppressive drugs should be taken into consideration.

Dermatomyositis as an extrahepatic manifestation of hepatitis B virus-related hepatocellular carcinoma: A case report and literature review

RATIONALE

Dermatomyositis is an idiopathic inflammatory myopathy with specific cutaneous manifestations, which is closely associated with malignancy. However, the exact mechanism remains elusive. Even less is known about dermatomyositis with hepatocellular carcinoma (HCC).

PATIENT CONCERNS

We reported a case of dermatomyositis with hepatitis B virus (HBV) infection. He incidentally found his lower limbs little weakness accompanied with his wrist erythema. He was found HBsAg positive for forty years with slightly positive of α-fetal protein (AFP).

DIAGNOSES

A dermapathology from his hand-wrist lesions demonstrated a scattered inflammatory infiltrate around the capillaries of the dermis. Abdominal enhanced computer tomography (CT) revealed infiltrative HCC affecting the whole liver, accompanied by liver metastasis and liver cirrhosis. Liver tumor needle biopsy pathology showed HCC with moderate differentiation. The left supraclavicular lymph node needle biopsy pathology confirmed metastasic HCC.

INTERVENTIONS

Prednisolone was gradually withdrawn with the introduction of Entecavir 0.5 mg daily. Radiofrequency ablation therapy for liver tumor was performed once in order to decrease the tumor load.

OUTCOMES

His muscle power improved to grade 4+/5 in the lower limb one month after anti-HBV treatment. However, this patient died finally from liver failure due to the development of liver tumor.

LESSONS

In the coming clinic work, we must pay more attention to the extrahepatic disorder induced by HBV. On treating experience, glucocorticoid administration is often contraindicated for HBV infected patients because of its potential promotion of HBV replication. Thus, it is necessary to administrate high-effective anti-HBV drug prior to glucocorticoid treatment in order to prevent liver failure.

HBV vaccine and dermatomyositis: is there an association?

The etiology of dermatomyositis is unknown, but immune mechanisms play an important role. Several dermatological manifestations have been reported among carriers of hepatitis B surface antigen, and after vaccination with the HBV vaccine. Almost all the skin reactions described were peculiar skin eruptions suggestive of an immune complex reaction. Some authors described the occurrence of dermatomyositis after BCG and influenza vaccination. We report a case of a 6-year-old child, who was vaccinated for hepatitis B virus and developed a flu-like disease accompanied by a skin rash, which had the typical features of dermatomyositis. The association of vaccination with autoimmunity is discussed.

Dermatomyositis associated with hepatocellular carcinoma in an elderly female patient with hepatitis C virus-related liver cirrhosis

A 79-year-old female patient with hepatitis C virus-related liver cirrhosis was diagnosed as having hepatocellular carcinoma (HCC) with a diameter of 2.0 cm. She refused therapy for HCC. Nine months after the diagnosis, she developed dermatomyositis when the HCC enlarged to a diameter of 6.0 cm. She underwent therapy for dermatomyositis, and then transcatheter arterial chemoembolization for HCC. Although the manifestations of dermatomyositis improved and entire tumor necrosis was achieved, she died of pneumonia 2 mo after the treatment of HCC. HCC and/or chronic hepatitis C virus infection might be involved in the pathogenesis of dermatomyositis.