Successful Treatment of Immune Thrombocytopenia as an Extrahepatic Manifestation in an HCV-Carrier Woman with Normal Liver Function Test Results

Case Report

J Hepat Res. 2014;1(2): 1006.

Successful Treatment of Immune Thrombocytopenia as an Extrahepatic Manifestation in an HCV-Carrier Woman with Normal Liver Function Test Results

Okazaki I1,2,3*, Ichiishi E2, Miyakawa Y4 and Sohara Y3,5

1Department of Internal Medicine, Sanno Hospital, International University of Helath and Welfare (IUHW), Japan

2Departments of Internal Medicine and

3Preventive Medical Center, IUHW Hospital, Japan

4Department of General Internal Medicine, Saitama Medical University, Japan

5Department of Chest Surgery, IUHW Hospital, Japan

*Corresponding author: Okazaki I, Internal Medicine, Sanno Hospital, International University of Health and Welfare, 8-10-16 Akasaka, Minato-ku, Tokyo 107-0052, Japan

Received: August 05, 2014; Accepted: August 13, 2014; Published: August 13, 2014

Abstract

The authors report a case of immune thrombocytopenia (ITP) as an extrahepatic manifestation in a hepatitis C virus (HCV)-carrier woman with normal liver function tests. The 46-year-old woman visited the Preventive Medical Center of International University of Health and Welfare (IUHW) Hospital in February 2011. She had no complaints and a conventional health check was conducted. The physical and laboratory examinations showed results within normal range except for iron-deficiency anemia and positive for HCV antibody (third generation). HCV-RNA (PCR) was 4.20 Log IU/ml, HCV genotype II and HCV core antibody 484.7. These findings suggested chronic infection with HCV, but there seemed to be no involvement of liver disease. Three months later, at the second visit, she showed thrombocytopenia. We believed the thrombocytopenia to be caused by chronic HCV infection and started anti-HCV viral therapy: interferon α2A (90&mug) injection weekly and ribavirin (600mg/day). Five months later the treatment was discontinued due to neutropenia even though GCSF injections were frequently administered. After treatment for two months, levels of HCV PCR copies were not detected, and the platelet count recovered to normal after six months. Since then three years have passed, HCV-PCR copies have shown non-detectable levels and the platelet count remains normal. There are numerous papers reporting that HCV causes ITP as an extrahepatic manifestation, but a case report of ITP caused by chronic HCV infection without liver disease has not been found. The present case report discusses the specificity of HCV infection on extrahepatic manifestation, and the treatment of ITP caused by chronic HCV infection

Keywords: Hepatitis c Virus; Extrahepatic Manifestations; Immune Thrombocytopenia; Interferon; Ribavirin

Abbreviations

GCSF: granulocyte-colony stimulating factor; HAV: hepatitis A virus; HBV: hepatitis B virus; HCV: hepatitis C virus; IFN: interferon; IFNα2a: interferon α2a; ITP: immune thrombocytopenia; PAIgG: Platelet-associated immunoglobulin G

Introduction

The authors examined a middle-aged HCV-carrier woman with no abnormal liver function test results who showed a decreased platelet count. Anti-viral therapy was used. Interferon (IFN) and ribavirin to render HCV-PCR copies negative and subsequently to recover the platelet count. This case was assumed to be secondary immune thrombocytopenia (ITP) as an extrahepatic manifestation of chronic HCV infection because the platelet-associated immunoglobulin G (PAIgG) was positive.

Worldwide, 145 million individuals have been estimated to be infected with HCV, equivalent to 2.2% of the world's population [1]. The prevalence of ITP among patients infected with HCV has been reported to be 10% to 36 % (total of 159 ITP/799 HCV patients; 20%) [2]. Moreover, the review [2] noted as follows: thrombocytopenia may be present even in the absence of clinically evident liver disease or splenomegaly and may be mistakenly diagnosed as primary ITP [3-5]. Although the latter part of this statement is correct and important for hematologists, the former part requires clarification. Although one literature was found (not available and not yet examined in detail) [6], any case without clinically evident liver disease was described in the cited papers [3,4]. The detailed information in these papers [3,4] showed the presence of chronic hepatitis C or HCV-related cirrhosis with or without splenomegaly. Another paper [5] reported immunological alterations in HCV-positive patients with lymph proliferative and connective tissue disorders. Therefore, the present authors decided to report this case to contribute to the body of information for hepatologists and hematologists as well as to assist in the treatment of ITP as an extrahepatic manifestation in chronic HCV infection.

ITP is usually a complication in chronic hepatitis C to HCVinfected cirrhosis patients [6], 20% as noted above. The present case showed no clinically evident liver disease, the size of the spleen was normal, and abdominal ultrasonography showed no abnormal findings in the liver. The precise clinical course of this case is presented here and the possible pathogenesis of ITP in this case is discussed. Moreover, the extrahepatic manifestations of hepatitis A virus (HAV), hepatitis B virus (HBV) and HCV are compared with those in the literature, and the treatment of ITP caused by chronic HCV infection is discussed.

Case Presentation

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A 46-year-old woman visited the Preventive Medical Center of International University of Health and Welfare (IUHW) Hospital in February 2011 for a health check. She had no complaints, but physical examination revealed anemia without purpura. Laboratory findings showed positive for HCV antibody (third generation) besides low hemoglobin content (9.0 g/dl) and low iron content (0.322 μ mol/l), as shown in Table 1. Other physical and clinical data (BMI 20.3, blood pressure 106/60, urinalysis, stool blood, blood chemical examination including liver function tests, lipid analysis, etc., gastro-fluorography, and abdominal ultrasonography) were normal. There was nothing out of the ordinary in her own or her family history. She did not smoke or consume alcohol.

Citation: Okazaki I, Ichiishi E, Miyakawa Y and Sohara Y. Successful Treatment of Immune Thrombocytopenia as an Extra Hepatic Manifestation in an HCV-Carrier Woman with Normal Liver Function Test Results. J Hepat Res. 2014;1(2): 1006. ISSN:2381-9057