Onset of Celiac Disease in a Patient Associated With Treatment of Chronic Hepatitis C Using Interferon-Based Triple Therapy

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Introduction: Patients treated with interferon-based therapies for chronic HCV may develop exacerbation of autoimmune disease. We present the first case in the literature of a patient who developed celiac disease (CD) as a result of triple therapy (interferon, ribavirin, and boceprevir) for chronic HCV. Case Report: A 53-year-old white female with past medical history of IV drug abuse, previously treated with interferon monotherapy for HCV genotype 3a, was referred by her PCP for abnormal LFTs. Laboratory data on initial visit was positive for HCV RNA of 4,515,392 IU/mL, HCV genotype 1a, with normal CBC and LFTs. Liver biopsy showed Metavir grade 2 inflammatory activity and stage 1 fibrosis. Treatment was initiated with a 4-week lead-in phase of pegylated interferon alfa 2a plus ribavirin, followed by triple therapy using boceprevir (BOC) for a total of 28 weeks. HCV viral load obtained at week 4, 8, 12, and 21 were <5 IU/mL. The patient achieved ETR and SVR at 6 months. Approximately 4 weeks after initiation of therapy, the patient developed loose, non-bloody bowel movements, which persisted even after completion of therapy associated with dyspnea on exertion, weight loss, and anemia. Initially attributed to interferon therapy, her anemia did not resolve after cessation of therapy. Serum anti-tissue transglutaminase IgA was 85 U/mL. She underwent an upper endoscopy and biopsies from first and second portions of the duodenum, which revealed mild villous blunting, mild crypt hyperplasia, and intraepithelial lymphocytes consistent with celiac disease. The patient was treated with a gluten-free diet. Her intestinal symptoms improved and the hemoglobin returned to normal. Conclusion: Chronic HCV patients treated with interferon alfa can develop celiac disease during or after therapy. Direct acting anti-viral agents may impact the risk. CD should be considered in patients who develop celiac disease-like symptoms while on treatment, or if anemia fails to return to baseline after cessation of interferon.