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Author: G Friedman, S Mehta, E Lamoureux and AH Sherker, Division of Gastroenterology and Department of Pathology, SMBD-Jewish General Hospital, McGill University, Montreal, Quebec, Canada.

A 51 year old female with previously diagnosed transfusion- related chronic hepatitis C presented with complaints of hematochezia, bilateral sensori-motor peripheral neuropathy of her hands, palpable purpura and dependent petechiae. The AST was 1.5 times normal but the other liver enzymes were normal. The serum cryoglobulins and cryofibrinogen qualitative assays were positive. A liver biopsy revealed chronic active hepatitis with cirrhosis. Biopsy of her skin lesions revealed a leukocytoclastic vasculitis and colonoscopy showed ulcerations which on histology were consistent with vasculitic ulcers. Therapy with alpha-interferon at 3 million units thrice weekly was initiated for hepatitis C-related cryoglobulinemia.
The patient tolerated the interferon poorly with severe nausea and anorexia and was admitted to hospital with dehydration in the second week of therapy. Shortly after admission, the patient's peripheral neuropathy deteriorated to the point of functional quadriplegia. Aggressive therapy against cryoglobulinemia including plasmapheresis, intravenous immunoglobulins and high dose corticosteroids was attempted. Despite this, the patient suffered recurrent massive upper gastrointestinal bleeding secondary to gastric vasculitis and severe metabolic acidosis. Coma ensued and the patient eventually died from uncontrollable bleeding.

Based on several clinical trials, alpha-interferon is currently considered to be the first line treatment for hepatitis C-related cryoglobulinemia. This case demonstrates a severe exacerbation of cryoglobulinemia temporally related to the initiation of alpha- interferon therapy. In the future, caution should be exercised when treating patients with alpha-Interferon for cryoglobulinemia.

Source: American Association for the Study of Liver Diseases - 1996 Annual Meeting

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