A Case of Guillain-Barre Syndrome (GBS) Associated with Peginterferon Alfa-2a and Weight Based Ribavirin for Chronic Hepatitis C (HCV)

Abstract

Purpose: Almost all patients treated with Peginterferon and ribavirin experience one or more adverse events during the course of therapy. However, significant neurological side effects are rare. A 55 year old Caucasian male was referred to us for treatment-naive chronic HCV infection. The laboratory findings showed AST 60 and ALT 62. HCV RNA viral load was 1,620,000 IU/ml and it was a genotype la infection. Liver biopsy revealed stage 3 bridging fibrosis with mild macro vesicular steatosis and severe inflammation. Patient was subsequently started on Peginterferon alfa-2a 180 mcg/ml per week and Ribavirin 1000 mg/day in divided doses. He was tolerating the treatment fairly well with a more than 2 log drop in HCV RNA at week 8. At that time, the patient went to a local hospital with the complaint of numbness of the face, facial asymmetry, difficulty eating and loss of taste. A brain MRI and carotid ultrasound were normal. Patient was diagnosed with Bell's Palsy, started on oral steroids and interferon was held. Next week, the patient noted gradual onset of progressive weakness of bilateral lower extremities and facial diplegia. Patient also started having back pain and neuropathic pain in bilateral lower extremities. All these symptoms progressed over a course of two weeks and patient became wheelchair bound. Examination revealed decreased deep tendon reflexes (DTRs) in bilateral upper extremities, absent DTRs at the knees bilaterally and decreased at the ankles. Patient was found to have 4/5 motor strength in both lower extremities and bilateral weakness involving both upper and lower facial muscles. Patient underwent an electromyography study (EMG) and cerebrospinal fluid (CSF) analysis by lumbar puncture. The EMG revealed uniformly increased latency with uniformly decreased amplitude and decreased velocity across all nerves tested. The CSF showed markedly elevated protein levels (405.8 mg/dl, normal 15.0-45.0 mg/dl) with a normal glucose and 3 leukocytes/μl. Based upon these findings, the patient was diagnosed with acute inflammatory demyelinating polyneuropathy (GBS) and started on Intravenous Immunoglulin (IVIG). Thereafter, patient was transferred to rehab and started improving. The neuropathic pain has improved significantly. Patient is able to walk short distances with a walker. As per knowledge, this is the first case of typical GBS reported with chronic HCV therapy. We think it is important for clinicians to keep this association in mind when prescribing Peginterferon alfa-2a and Ribavirin for HCV treatment. Close attention should be paid to any neurological symptoms developing during the course of treatment. Prompt referral to a neurologist is warranted if these symptoms develop.