Hand-foot syndrome due to hepatitis C therapy

SUMMARY INTRODUCTION Direct-acting antivirals are new drugs for chronic hepatitis C treatment. They are usually safe and well tolerated, but can sometimes cause serious adverse effects and there is no consensus on how to treat or prevent them. We described a case of hand-foot syndrome due to hepatitis C virus interferon-free therapy. METHODS We report the case of a 49-year-old man with compensated liver cirrhosis due to chronic hepatitis C genotype 1, treatment-naïve, who started viral treatment with sofosbuvir, simeprevir and ribavirin for 12 weeks. RESULTS At the sixth week of treatment he had anemia, requiring a lower dose of ribavirin. At the tenth week, he had erythematous, pruritic, scaly and flaky lesions on hands and feet, which showed a partial response to oral antihistamines and topical corticosteroids. It was not necessary to discontinue antiviral treatment, but in the first week after the end of treatment, there was worsening of injuries, including signs of secondary infection, that required hospitalization, antibiotics and oral corticosteroid, with progressive improvement. Biopsy of the lesions was consistent with pharmacodermia. The patient had sustained a virological response, despite the side effect. He had a history of pharmacodermia one year ago attributed to the use of topiramate, responsive to oral corticosteroid. CONCLUSION Interferon-free therapies can rarely lead to severe adverse reactions, such as skin lesions. Patients receiving ribavirin combinations and those who had a history of pharmacodermia or skin disease may be more susceptible. There is no consensus on how to prevent skin reactions in these patients.

RESUMO INTRODUÇÃO Antivirais de ação direta são as novas drogas utilizadas no tratamento da hepatite C crônica. São geralmente seguros, com boa tolerância, mas eventualmente podem causar efeitos adversos graves, e não há consenso sobre como tratá-los ou preveni-los. Descrevemos um caso de síndrome mão-pé secundária à terapia livre de interferon para hepatite C crônica. Materiais e métodos Relatamos o caso de um paciente de 49 anos com cirrose hepática compensada secundária à hepatite C crônica, genótipo 1, virgem de tratamento, que iniciou terapia com sofosbuvir, simeprevir e ribavirina por 12 semanas. Resultados Na sexta semana de tratamento, apresentou anemia, sendo necessária redução de dose da ribavirina. Na 20a semana, apresentou lesões eritematosas e descamativas, com prurido em mãos e pés, que teve resposta parcial ao uso de anti-histamínico oral e corticoide tópico. Não foi necessário descontinuar os antivirais, mas na primeira semana após o término do tratamento, houve piora das lesões, com sinais de infecção secundária, sendo necessárias hospitalização e terapia com antibiótico e corticoide oral, com melhora progressiva. Biópsias das lesões foram compatíveis com farmacodermia. O paciente teve resposta virológica sustentada, apesar dos efeitos adversos. Tinha história de farmacodermia há um ano, atribuída ao uso de topiramato, responsiva a corticoterapia oral. Conclusão Os tratamentos livres de interferon raramente causam eventos adversos graves, como lesões cutâneas. Pacientes em uso de ribavirina e com história de farmacodermia ou doença cutânea prévia podem ser mais susceptíveis. Não existe consenso sobre como prevenir reações cutâneas nesses pacientes.

Retrospective analysis of hepatitis B virus chronic infection in 247 patients: clinical stages, response to treatment and poor prognostic factors

Abstract Background: Chronic hepatitis B is a major cause of cirrhosis, and the natural history of the disease has several clinical stages that should be thoroughly understood for the implementation of proper treatment. Nonetheless, curing the disease with antiviral treatment remains a challenge. Aims: To describe the clinical course, response to treatment, and poor prognostic factors in 247 hepatitis B virus chronic infection patients treated in a tertiary hospital in Brazil. Methods: This was a retrospective and observational study, by analyzing the medical records of HBV infected patients between January 2000 and January 2015. Results: Most patients were male (67.2%) and 74.1% were HBeAg negative. Approximately 41% had cirrhosis and 8.5% were hepatitis C virus coinfected. The viral load was negative after two years on lamivudine, entecavir and tenofovir in 86%, 90.6%, and 92.9% of the patients, respectively. The five-year resistance rates for lamivudine, adefovir, entecavir, and tenofovir were 57.5%, 51.8%, 1.9%, and 0%, respectively. The overall seroconversion rates were 31.2% for HBeAg and 9.4% for HBsAg. Hepatocellular carcinoma was diagnosed in 9.7% of patients, liver transplantation was performed in 9.7%, and overall mortality was 10.5%. Elevations of serum alanine aminotransferase (p = 0.0059) and viral load (p < 0.0001) were associated with progression to liver cirrhosis. High viral load was associated with progression to hepatocellular carcinoma (p < 0.0001). Significant risk factors associated with death were elevated alanine aminotransferase (p = 0.0039), liver cirrhosis (p < 0.0001), high viral load (p = 0.007), and hepatocellular carcinoma (p = 0.0008). HBeAg positive status was not associated with worse outcomes, and treatment may have been largely responsible. Conclusions: Elevations of viral load and serum alanine aminotransferase may select patients with worse prognosis, especially progression to cirrhosis and hepatocellular carcinoma, which were strongly association with death.

Análise retrospectiva da infecção crônica pelo vírus da hepatite B em 247 pacientes: fases evolutivas, resposta ao tratamento e fatores de pior prognóstico / Retrospective analysis of hepatitis B virus chronic infection in 247 patients clinical stages, response to treatment and poor prognostic factors

Introdução. A hepatite B crônica é uma importante causa de cirrose hepática e a história natural da doença tem várias fases clínicas que devem ser bem entendidas para se realizar o tratamento adequado. Objetivos. Descrever o comportamento clínico, a resposta ao tratamento e os fatores de pior prognóstico em 247 pacientes com infecção crônica pelo vírus da hepatite B. Métodos. Estudo retrospectivo observacional, realizado através da análise dos prontuários dos pacientes entre janeiro de 2000 e janeiro de 2015. Resultados. A maioria dos pacientes eram do gênero masculino (67,2%) e 74,1% eram HBeAg negativo. Cerca de 41% tinham cirrose hepática e 8,5% eram coinfectados pelo vírus da hepatite C. A negativação da carga viral em um ano com lamivudina, entecavir e tenofovir foi respectivamente de 56%, 75% e 75%; efeitos adversos foram mais comuns com tenofovir. A resistência virológica em cinco anos a lamivudina, adefovir e entecavir foi respectivamente de 57,5%, 51,8% e 1,9%. A taxa geral de soroconversão do HBeAg foi de 31,2% e do HBsAg foi de 9,7%. Carcinoma hepatocelular foi diagnosticado em 9,7%, transplante hepático foi realizado em 9,7% e a mortalidade geral foi de 10,5%. Elevações de alanina aminotransferase (p=0,0194) e carga viral (p<0,0001) foram associadas à evolução para cirrose hepática. Carga viral elevada foi associada à evolução para carcinoma hepatocelular (p=0,0019). Os fatores de risco significativos relacionados ao óbito foram elevação de alanina aminotransferase (p=0,0118), cirrose hepática (p<0,0001) e carcinoma hepatocelular (p=0,0008). Positividade para o HBeAg não foi associada a piores desfechos. Conclusões. Cirrose hepática e carcinoma hepatocelular foram associados a um pior prognóstico e novos estudos devem ser direcionados para prevenir estes fatores com a finalidade de diminuir o óbito relacionado a esse vírus. (AU)

Background. Chronic hepatitis B is a major cause of cirrhosis, and the natural history of the disease has several clinical stages that should be thoroughly understood for the implementation of proper treatment. Aim. To describe the clinical course, response to treatment and poor prognostic factors in 247 hepatitis B virus chronic infection patients. Methods. We carried out a retrospective and observational study, by analyzing the medical records of patients between January 2000 and January 2015. Results. Most patients were male (67.2%) and 74.1% were HBeAg negative. Approximately 41% had liver cirrhosis and 8.5% were hepatitis C virus coinfected. The viral load was negative in one year with lamivudine, entecavir and tenofovir in 56%, 75% and 75% of patients, respectively; adverse effects were more frequent with tenofovir. Virological resistance in five years for lamivudine, adefovir and entecavir was 57.5%, 51.8% and 1.9%, respectively. The overall rate of seroconversion was 31.2% for HBeAg and 9.7% for HBsAg. Hepatocellular carcinoma was diagnosed in 9.7% of patients, liver transplantation was performed in 9.7% and overall mortality was 10.5%. Elevations of serum alanine aminotransferase (p = 0.0194) and viral load (p <0.0001) were associated with progression to liver cirrhosis. High viral load was associated with progression to hepatocellular carcinoma (p = 0.0019). Significant risk factors associated with death were elevated alanine aminotransferase (p = 0.0118), liver cirrhosis (p <0.0001) and hepatocellular carcinoma (p = 0.0008). HBeAg positive state was not associated with worse outcomes. Conclusions. Liver cirrhosis and hepatocellular carcinoma were associated with a worse prognosis and further studies should concentrate on prevention of these factors in order to reduce mortality.(AU)

Strong correlation by ultrasonography of hepatomegaly and the presence of co-infection in HIV/HCV cirrhotic patients

OBJECTIVES: Progression of hepatic fibrosis is accelerated in patients co-infected with human immunodeficiency virus and hepatitis C virus compared to hepatitis C virus mono-infected patients. This study aimed to compare ultrasound features and selected clinical and biochemical variables between patients with human immunodeficiency virus/hepatitis C virus co-infection (n = 16) versus hepatitis C virus mono-infection (n = 16). METHODS: Each patient underwent abdominal ultrasound, and a specific evaluation was performed in order to detect findings consistent with chronic liver disease. Characterization of spleen size, liver structural pattern, diameter of the portal, spleen, and mesenteric veins was based on classical ultrasound parameters. Propensity score was used for control of selection bias and performed using binary logistic regression to generate a score for each patient. The Fisher and Mann-Whitney tests were used to evaluate categorical variables and continuous variables, respectively. RESULTS: On univariate analysis right hepatic lobe size was larger in human immunodeficiency virus/hepatitis C virus patients (157.06 ± 17.56 mm) compared to hepatitis C virus mono-infected patients (134.94 ± 16.95 mm) (p = 0.0011). The left hepatic lobe was also significantly larger in human immunodeficiency virus/hepatitis C virus patients Cirrhosis (115.88 ±22.69 mm) versus hepatitis C virus mono-infected patients (95.06 ±24.18 mm) (p= 0.0177). Also, there was a strong correlation between hepatomegaly and co-infection (p=0.005). CONCLUSION: Human immunodeficiency virus infection was the primary variable influencing liver enlargement in this population. Hepatomegaly on ultrasound was more common among cirrhotic human immunodeficiency virus/hepatitis C virus co-infected patients than among cirrhotic hepatitis C virus mono-infected patients. This aspect is very important in the management of human immunodeficiency virus/hepatitis C virus co-infected patients, because screening for hepatocellular carcinoma is necessary in this population.