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1072 Crespi M, et al. , 2018; 17 (6): 1072-1077 CASE REPORT November-December, Vol. 17 No. 6, 2018: 1072-1077 The Official Journal of the Mexican Association of Hepatology, the Latin-American Association for Study of the Liver and the Canadian Association for the Study of the Liver Improvement in Waldenström’s Macroglobulinemia after Successful Treatment of HCV with Direct-acting Antivirals Mattia Crespi,* Maria Giulia Demarzo,* Matteo Brunacci,* Gaia Pellegatta,* Fabio Ferrando,** Alberto Ballestrero,** Federica Grillo,*** Vincenzo Savarino,* Edoardo G. Giannini* * Gastroenterology Unit, Ospedale Policlinico San Martino, IRCCS per l’Oncologia, University of Genoa, Genoa, Italy. ** Internal Medicine and Oncology Unit, Department of Internal Medicine, Ospedale Policlinico San Martino, IRCCS per l’Oncologia, University of Genoa, Genoa, Italy. *** Pathology Unit, Department of Surgical Sciences, Ospedale Policlinico San Martino, IRCCS per l’Oncologia, University of Genoa, Genoa, Italy. ABSTRACT Chronic hepatitis C (HCV) virus infection may be associated with several non-hepatic manifestations, mainly driven by chronic im- mune stimulation, such as mixed cryoglobulinemia and Non-Hodgkin’s Lymphoma. This association has been proved by several meta-analyses and some interventional studies demonstrating that antiviral treatment may be effective in inducing HCV-associated lymphoma regression. The recent advent of direct acting antivirals (DAAs) in the therapeutic armamentarium of HCV infection made possible treatment of patients with advanced liver disease. Here we report on a rare association of a cirrhotic patient with HCV and Waldenström’s Macroglobulinemia with severe cryoglobulinemia, who had already failed an interferon-based antiviral regimen, whose haematologic disease was ameliorated by HCV eradication following treatment with sofosbuvir and simeprevir with ribavirin, and where successful treatment was accompanied also by consistent improvement in liver function and parameters of portal hyperten- sion. Key words. Cirrhosis. Portal hypertension. Outcome. Haematology. BACKGROUND HCV infection has several non-hepatic manifestations, mainly driven by chronic immune stimulation, such as Hepatitis C virus (HCV) infects more than 184 million mixed cryoglobulinemia and Non-Hodgkin’s Lymphoma people worldwide, and sequelae of chronic infection such (NHL).7 This association has been proved by several as chronic hepatitis, cirrhosis, and hepatocellular carcino- meta-analyses and some interventional studies demon- ma represent a major public health problem.1 The recent strating that antiviral treatment with pegylated-IFN or development of direct-acting antiviral agents (DAAs) for DAAs, in monotherapy or in combination with ribavirin, the treatment of chronic HCV infection in adults-in par- is effective in inducing HCV-associated lymphoma re- ticular second generation DAA that made possible inter- gression.7-9 As a result, the antiviral treatment has been feron (IFN)-free therapy – has revolutionized the proposed as first line therapy in asymptomatic patients treatment of HCV infection allowing for safe treatment of with HCV- related indolent NHL who do not need im- patients with advanced disease with unprecedented high mediate conventional treatment. Despite a potential addi- rates of sustained virological response (SVR).2 It is pro- tive effect inherent to its immune-modulatory properties, jected that by 2030 chronic HCV infection should theoret- IFN treatment has a low SVR rate in patients with cirrho- ically be confined, but even after few years from the sis and is burdened by several side effects, being not rec- introduction of DAAs the landscape of patients with HCV ommended in patients with advanced disease; therefore, infection and advanced disease has dramatically changed, DAAs therapy is the treatment of choice in these patients with a chance of delisting patients due to improved liver due to a better profile of safety and efficacy. function, and a decline in listing for liver transplantation Among B-cell NHL, the main subtypes associated with and occurrence of hepatocellular carcinoma.3-6 Moreover, HCV are marginal zone lymphoma, diffuse large B-cell Manuscript received: October 18, 2017. Manuscript accepted: December 28, 2017. DOI:10.5604/01.3001.0012.2124 HCV clearance and outcome of Waldenström’s Macroglobulinemia. , 2018; 17 (6): 1072-1077 1073 lymphoma, and lymphoplasmacytic lymphoma.10 Walden- lithiasis, and steroid-induced diabetes. The patient was re- ström’s Macroglobulinemia (WM) is a lymphoplasma- ferred to our Unit from the Haemato-Oncology Unit of cytic lymphoma characterised by the production of the Internal Medicine Department where, in 2009, she was monoclonal IgM involving bone marrow, and there is evi- diagnosed with WM (monoclonal component: 36-43 g/L) dence for an association between HCV infection and WM, by bone marrow biopsy (Figure 1). The haematologic ma- with a 3-fold higher risk of this lymphoproliferative disor- lignancy was associated with mixed cryoglobulinemia der in HCV-positive subjects as compared to controls.10,11 (cryocrite: 89%) and vasculitis. At diagnosis, due to the Although the evidence for this association is nevertheless presence of renal damage, the patient underwent kidney debated and data on optimal treatment of patients affected biopsy with evidence of membranoproliferative glomeru- by WM with concurrent HCV infection are limited, there lonephritis. At the same time, the patient complained of are reports of antiviral treatment in these patients.12 At the symptoms compatible with peripheral neuropathy (sensi- same time, however, the downstream consequences of tive and motor deficit). A first cycle of rituximab was ad- clinical features of WM such as cryoglobulinemia-in- ministered in November 2009, with a mild clinical duced renal damage, as well as the side effects of drugs response (improvement of vasculitis-related peripheral used to treat the underlying haematologic malignancy (e.g., neuropathy) but with no monoclonal component reduc- steroids, anti-CD 20), may hamper successful antiviral tion. When the patient was referred to our Unit, clinical treatment. and biochemical work-up was compatible with compen- This case reports on a middle-aged lady with chronic sated cirrhosis without clinically relevant portal hyperten- HCV infection, cirrhosis, and WM. In this case, the course sion, and a 48-week course of antiviral treatment with of disease was worsened by severe renal damage due to pegylated-IFN α2a (135 µg/weekly) with low-dose ribavi- cryoglobulinemia that required rituximab and steroids rin (200 mg/daily) due to reduced glomerular filtration treatment; the patient was unsuccessfully treated with an rate, was started. Antiviral treatment, besides being bur- IFN-based therapy in the pre-DAAs era, and was later re- dened by the common side effects of IFN and ribavirin treated with DAAs obtaining SVR and showing, besides (anaemia, fatigue, flu-like symptoms) and despite erythro- improvement in liver function, also a dramatic improve- poietin support, led to a worsening of peripheral neurop- ment in clinical and biochemical manifestations of WM. athy (need for crutches) that greatly affected the patient’s quality of life. This notwithstanding, the patient was able CASE PRESENTATION to complete the whole course of antiviral treatment, showing negativity of serum HCV RNA during therapy, A 50-year-old Caucasian lady was referred to our Gas- but with reappearance of viraemia at the end of treatment troenterology Unit in 2010 for assessment of chronic HCV (relapse). In December 2012 the patient was admitted to infection (genotype 1b) and cirrhosis. hospital because of bilateral feet ischaemia, with instru- Medical history included hemicolectomy for congeni- mental evidence of severe peripheral vasoconstriction as tal megacolon at the age of 20, cholecystectomy for biliary the cause of symptoms, for which she was treated with in- Figure 1. Bone marrow biopsy showing focale intertrabecular infiltration of lymphoplasmacytic cells (yellow circle) with plasmocytoid features (see inset A) and expression of CD20 (see inset B). Haematoxylin and Eosin, x20 magnification, main figure; Haematoxylin and Eosin, x60 magnification, inset A; CD20, x60 magnification, inset B. 1074 Crespi M, et al. , 2018; 17 (6): 1072-1077 A. Monoclonal component (g/L). 70 DAA treatment 60 50 40 30 Rituximab treatment 20 10 Jul-11 Jul-12 Jul-13 Jul-14 Jul-15 Jul-16 Oct-11 Jan-12 Apr-12 Oct-12 Jan-13 Apr-13 Oct-13 Jan-14 Apr-14 Oct-14 Jan-15 Apr-15 Oct-15 Jan-16 Apr-16 Oct-16 Jan-17 Apr-17 B.B.P-IgM (g/L). 90 80 DAA treatment 70 60 50 40 30 Rituximab treatment 20 10 Jul-11 Jul-12 Jul-13 Jul-14 Jul-15 Jul-16 Oct-11 Jan-12 Apr-12 Oct-12 Jan-13 Apr-13 Oct-13 Jan-14 Apr-14 Oct-14 Jan-15 Apr-15 Oct-15 Jan-16 Apr-16 Oct-16 Jan-17 Apr-17 Figure 2. P-IgM (g/L). Monoclonal component (g/L). Modifications in monoclonal component (A) and plasmatic IgM (B) during the course of the disease. travenous iloprost and metilprednisolone. Moreover, due (nadir: 27.3 g/L, Figure 2A) and plasmatic IgM (41.5 g/L, to the absence of other therapeutic options for HCV infec- Figure 2B) that lingered on even after treatment cessation tion and the presence of symptoms, the patient underwent and during follow-up. Bence-Jones protein in urine be- three more cycles of rituximab until May 2015, although came negative. Moreover, we also observed consistently she experienced no significant haematologic and clinical satisfying haemoglobin levels despite
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