Presentation: Relapse of Hepatitis C Virus-Associated Mixed Cryoglobulinemia Vasculitis in Patients with Sustained Viral Response (2007)

2016 Relapse of Hepatitis C Virus-Associated Mixed Cryoglobulinemia Vasculitis in Patients with Sustained Viral Response

Purpose: Hepatitis C virus (HCV) infection is the leading cause of Mixed Cryoglobulinemia (MC) vasculitis, a systemic autoimmune disorder. Anti-viral treatment has been shown to result in remission in the vasculitis provided that a sustained viral response (SVR) can be achieved. The aim of this study is to describe a group of patients who experienced a relapse in vasculitis manifestations despite achieving a SVR with anti-viral treatment.
Methods: Retrospective chart evaluation was performed in patients with HCV associated MC vasculitis that completed antiviral treatment, achieved a SVR (defined as serum HCV RNA negative 6 months after treatment withdrawal) but experienced a relapse of MC-vasculitis symptoms. Search for HCV RNA was performed by the most sensitive method, i.e. the transcription-mediated amplification method (TMA) in the serum and cryoprecipitate of the patients.
Results: Eight patients with HCV MC vasculitis relapse despite achieving a SVR have fulfilled the inclusion criteria. Relapse appeared early after the end of treatment (mean±SD, 2.5±3.5 months), and included mainly purpura (n=7) and arthralgia (n=5). It was associated with an increase in serum cryoglobulin levels compared with end of treatment levels (0.3±0.09g/l and 0.08±0.04g/l, respectively, p<0.01) and a decrease in C4 levels (figure1). In most patients the relapse was short lived and MC vasculitis manifestations either disappeared completely or were of lesser severity compared with pre-treatment levels. Cryoglobulin levels also decreased accompanied by C4 increase. Search for HCV RNA by TMA was negative in all tested patients (7/8), both in the serum as well as in the cryoprecipitate. In 3 patients MC vasculitis symptoms persisted associated with elevated cryoglobulin levels, two of whom were diagnosed with a B cell lymphoproliferative disorder (lymphoplasmacytic lymphoma), which may explain the severe relapse.
Conclusions: MC vasculitis relapse does occur in a minority of HCV infected patients despite SVR. In most cases, relapse is short-lived and may be related to the withdrawal of Interferon-alpha treatment. However, in patients with persistent MC vasculitis symptoms a different underlying condition should be considered, especially B cell lymphoproliferative disorders.

 D.A. Landau, None; D. Saadoun, None; P. Halfon, None; M. Martinot, None; E. Fois, None; J. Piette, None; P. Cacoub, None.