Acute pericarditis due to pegylated interferon alpha therapy for chronic HCV hepatitis - Case report

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Acute pericarditis due to pegylated interferon alpha therapy for chronic HCV hepatitis - Case report

ISSN 1471-230XArticle type Case reportSubmission date 5 December 2010Acceptance date 31 March 2011Publication date 31 March 2011Article URL http://www.biomedcentral.com/1471-230X/11/30 Case reportAcute pericarditis due to pegylated interferon alpha therapy for chronic HCV hepatitis - Case reportCristina Popescu , Arama and Smaranda Gliga BMC Gastroenterology 2011, 11:30doi:10.1186/1471-230X-11-30Published: 31 March 2011 Abstract (provisional)BackgroundCardiotoxicity due to interferon therapy was reported only in small case series or case reports. The most frequent cardiac adverse effects related to interferon are arrhythmias and ischemic manifestations. The cardiomyopathy and pericarditis are rare but can be life threatening. The predisposing factors

for interferon cardiotoxicity were described only for ischemic manifestations and arrhythmias.Case presentationThe authors report a case of pericarditis due to alpha interferon therapy for chronic hepatitis C, in a young woman without previous cardiac pathology. The clinical manifestations started during the 7-th month of interferon treatment. The cessation of interferon was necessary. After interferon discontinuation the patient recovered, with complete resolution of pericarditis. The patient scored 9 points on the Naranjo ADR probability scale, indicating a very probable association between pericarditis and interferon administration. ConclusionIf a patient receiving interferon therapy complains of chest pain of sudden onset, a cardiac ultrasound should be performed in order to rule out pericarditis. We point out the possibility of an infrequent but severe adverse effect of interferon therapy. BACKGROUND

Pegylated interferon plus ribavirin represents the gold standard therapy for hepatitis C virus (HCV) but various side effects may occur, limiting its efficacy [1, 2]. Although some of theseadverse effects are rarely reported, their severity can be higher than expected, sometimes leadingto a life-threatening event. The diversity of the described adverse effects may increase becauseof the high number of patients who receive treatment for HCV hepatitis. Their monitoring andreporting is important in order to facilitate subsequent recognition of similar cases.We report a case of acute pericarditis without tamponade which was correlated with pegylatedinterferon alpha 2a treatment for chronic HCV hepatitis.CASE PRESENTATIONA 38-year-old white female, without previous cardiac pathology, was being monitored andtreated for chronic HCV hepatitis, genotype I virus. She was started on a combination

treatmentwith peginterferon alpha 2a (180μg weekly) and ribavirin (1000mg daily, according to her bodyweight). The patient had complete early virologic response (HCV-RNA was undetectable at 12weeks of treatment). In the first seven months of treatment no severe side effects (hematologic,endocrine, ophthalmic or autoimmune) were observed.In the 7th month of treatment the patient accused chest pain, dry cough, fatigue, dyspnea, withoutfever and she presented herself to the emergency room.On physical examination we found: tachypnea (22-24/min), tachycardia (96/min), a bloodpressure of 100/70 mmHg with pulmonary and abdominal examination within the normal limits.Cardiac examination revealed a third heart sound over the precordium as well as muffled cardiac sounds. The pulmonary X-ray was normal and the ECG showed no specific repolarisation abnormalities. Trans-thoracic cardiac ultrasonography revealed a

pericardial effusion withouttamponade. Laboratory data revealed: mild leukopenia, anemia, thrombocytopenia (which didn’tneed reduction of interferon or ribavirin doses), minor biological inflammatory syndrome (CRP– 17mg/l). The hepatic enzymes were normal, HCV-RNA was undetectable, serological tests forviruses and bacteria which could have explained the pericarditis were negative: ECHO,sackie, adenovirus, influenza virus, parainfluenza virus, EBV, CMV, HIV, Mycoplasmapneumoniae, Chlamydia pneumoniae, Rickettsia spp, Legionella pneumophila, Borreliaburgdorferii. Serological tests for viruses remained negative for the following 2 weeks.Quantiferon TB gold was negative. The patient didn’t receive antimycobacterial medication. TheASO titer was in the normal range. Autoimmune tests were performed, with negative antinuclearfactor, anti-DNA antibodies, p ANCA, c ANCA, anti-mitochondrial antibody,

anti-Roand anti-La antibodies and negative cryoglobulinemia. Thyroid function tests were normal, andanti tyreo-peroxidase antibodies were absent.The antiviral medication was stopped and the patient received ibuprofen. The symptomsdisappeared and the pericardial effusion resolved in 15 days.Because the patient was infected with genotype 1 virus and detection of HCV-RNA at 4 weeksof treatment was not performed (in order to confirm a rapid virological response), the antiviraltreatment was restarted only with pegylated interferon. After the first dose of interferonadministration symptoms reappeared. The echocardiography showed an increase of pericardialfluid (at 24 hours after interferon administration). The antiviral medication was stopped againwith rapid recovery. Six months after discontinuation of treatment, the HCV-RNA was undetectable (the patient hadsustained virologic response).The

correlation of pericarditis with interferon administration was appreciated, for the presentedcase using the Naranjo ADR probability scale, which summed up 9 points, indicating a veryprobable association (table 1) [3].DISCUSSIONInterferon plays an essential role in the mechanisms of defense against infections, beingproduced by a variety of cells. Until now two types of interferon have been identified: type I(alpha and beta interferon), which blocks the translation and viral replication and type II (gammainterferon), which initiates the synthesis of chemical substances with antiviral properties. [4] Ontop of the positive effects, the administration of interferon can be associated with manyunwanted adverse effects because of the destruction of uninfected cells. The prevalence of lifethreatening complications during the interferon treatment is less then 1%. The cardio toxicity ofinterferon has been even

rarely reported, only in small series of patients, and often just in isolatedcases. [5] Among the three types of interferon, the alpha interferon is the most cardio toxic,followed by beta and gamma interferon.The mechanism through which interferon is cardio toxic has not been clearly demonstrated[6, 7], but it is presumed that at least two factors are implicated: the deterioration of endothelialcells inducing the overlay of immune complexes at this level; and stimulation of TNF alpha, IL2, IL 6, IL 1 release, that influence the vasopressor response.The most common cardio toxic clinical effects of interferon are: arrhythmias- 58 %, acutecoronary syndrome- 21 %, cardiomiopathies-12 % and other manifestations - 9 % (includingpericarditis) [5]. There are no described predisposing factors for interferon cardio toxicity. Acute pericarditis is determined by a multitude of causes: infectious,

neoplastic, uremia, autoimmune, traumatic, drug induced. Concerning drug toxicity, there have been reported casesof acute pericarditis after the administration of: hydralazine, procainamide, izoniazid,phenylbutazone, dantrolene, doxorubicin, penicillin, these situations being extremely rare.Interferon is not cited by the ESC Guidelines on the Diagnosis and Management of PericardialDiseases [8] as one of the causes of drug induced pericarditis.Acute pericarditis, as a consequence of interferon treatment is extremely rare. So far, very fewcases of pericarditis related to administration of interferon have been reported; some of thesepatients received interferon for neoplastic diseases such as melanoma or acute leukemia [9, 10].The role of ribavirin in the pathogenesis of pericarditis could be considered. In our case, werestarted only interferon therapy (after two weeks of discontinuation), which concluded in

thereappearance of pericardial effusion.Six cases of pericarditis due to interferon alpha have been reported in patients with chronic HCVhepatitis. Three of these patients had an underlying pathology that could explain the pericarditis:Sikole et al. reported a case of pericarditis among hemodialysis patients receiving interferon forhepatitis C [11], Suarez A et al described a case of pericarditis in a patient with cryoglobulinemia[12], Boonen et al. reported a case of pericarditis during the treatment of chronic HCV hepatitisas part of a lupus-like syndrome, with clinical manifestations of auto-immune pathologies [13].Recently Kazuahi Nishio et al described a case of pericarditis related to pegylated interferontherapy for HCV hepatitis. This patient had positive anti-DNA and anti-ds DNA IgM antibodies[14]. The case of pericarditis reported by Gressens B et al in conjunction with theadministration of

interferon occurred four months after stopping the treatment [15]. We are reporting a very rare adverse effect of pegylated interferon treatment- acute toxic pericarditis, this being the second case observed in a patient with no underlying pathology,described in the medical literature. The first case was reported by Wisniewski B et al; pericarditisoccurred in this case after the first dose of interferon. [16]In summary, we report a patient without any history of cardiac disease who developedpericarditis after interferon treatment. Reappearance of symptoms when the antiviral treatmentwas restarted indicates a strong correlation between drug and adverse effects [3]. The effect ofthe virus itself is quite unlikely (undetectable HCV-RNA). The clinical and biological markers ofa possible associated autoimmune pathology were absent. We excluded a viral or bacterial(including tuberculosis) etiology of

pericarditis.CONCLUSIONSWe consider that in a patient receiving interferon, pericarditis must be evoked if the patientaccuses sudden chest pain. It is of most importance that a cardiac ultrasound should beperformed in a situation like this. http://www.biomedcentral.com/content/pdf/1471-230x-11-30.pdf

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