Severe immune thrombocytopenia after peg-interferonalpha2a, ribavirin and telaprevir treatment completion: a case report and systematic review of literature

Mild to moderate autoimmune thrombocytopenia(AITP) is a common finding in patients receiving interferonbased antiviral treatment, due to bone marrow suppression. Here we report the case of a patient with chronic genotype 1b hepatitis C virus(HCV) infection treated with pegylated-interferon alpha-2a, ribavirin and telaprevir for 24 wk; the patient developed severe AITP three weeks after treatment withdrawal. We performed a systematic literature search in order to review all published cases of AITP related to HCV antiviral treatment. To our knowledge, this is the second case of AITP observed after antiviral treatment withdrawal. In most published cases AITP occurred during treatment; in fact, among 24 cases of AITP related to interferonbased antiviral treatment, only one occurred after discontinuation. Early diagnosis of AITP is a key factor in order to achieve an early interferon discontinuation; in the era of new direct antiviral agents those patients have to be considered for interferon-free treatment regimens. Prompt prescription of immuno-suppressant treatment(i.e., corticosteroids, immunoglobulin infusion and even rituximab for unresponsive cases) leads to favourable prognosis in most of cases. Physicians using interferonbased treatments should be aware that AITP can occur both during and after treatment, specially in the new era of interferon-free antiviral treatment. Finally, in the case of suspected AITP, presence of anti-platelet antibodies should be checked not only during treatment but alsoafter discontinuation.

Long-term leukocyte natural α-interferon and ribavirin treatment in hepatitis C virus recurrence after liver transplantation

AIM:To evaluate the effect of long-term treatment with leukocyte natural-interferon(ln-α-IFN)plus ribavirin(RBV).METHODS:Forty-six patients with hepatitis C virus(HCV)recurrence received 3 MU three times a week of ln-α-IFN plus RBV for 1 mo;then,patients with good tolerability(n=30)were switched to daily IFN administration,while the remaining were treated with the same schedule.Patients have been treated for 12 mo after viral clearance while non-responders(NR)entered in the longterm treatment group.Liver biopsies were planned at baseline,1 year after sustained virological response(SVR)and at 36 mo after start of therapy in NR.MedCalc software package was used for statistical analysis.RESULTS:About 16.7%of genotype 1-4 and 70%of genotype 2-3 patients achieved SVR.Nine patients withdrew therapy because of non-tolerance or noncompliance.A significant improvement in serum biochemistry and histological activity was observed in all SVR patients and long-term treated;100%of patients with SVR achieved a histological response(fibrosis stabilization or improvement)with a significant reduction in mean staging value(from 2.1 to 1.0;P=0.0031);histological response was observed in 84%of long-term treated patients compared to 57%of drop-out.Six patients died during the entire study period(follow-up 40.6±7.7 mo);of them,5 presented with severe HCV recurrence on enrollment.Diabetes(OR=0.38,95%CI:0.08-0.59,P=0.01),leukopenia(OR=0.54,95%CI:0.03-0.57,P=0.03)and severe HCV recurrence(OR=0.51,95%CI:0.25-0.69,P=0.0003)were variables associated to survival.Long-term treatment was well tolerated;no patients developed rejection or autoimmune disease.CONCLUSION:Long-term treatment improves histology in SVR patients and slows disease progression also in NR,leading to a reduction in liver decompensation,graft failure and liver-related death.