Reversal of Liver Cirrhosis in a Nonreponder with Chronic Hepatitis C

Abstract

Background: Chronic hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and hepatocellular carcinoma, thereby increasing the population in need of liver transplantation. The Use of interferon and ribavirin has reduced the morbidity and mortality of this disease. Case: A 49-year old African American female seen in clinic with elevated ALT 68 and AST 99(alanine and aspartate aminotransferases) on routine checkup. She quit alcohol and intravenous drug use 14 years ago. Vital signs and physical examination were unremarkable. Hepatitis profile was positive for only HCV, genotype was 2A. Complete blood count, electrolytes, Iron studies, thyroid function, amylase, lipase and alpha 1-antitrypsin were normal. Hepatic panel was normal except for elevated ALT and AST. Alpha feto protein and screening for autoimmune hepatitis were unremarkable. Pretreatment liver biopsy showed severe piecemeal and bridging necrosis (grade 3) and cirrhosis (stage 4). She received two 12month courses of Ribavirin and interferon alpha 2b with partial viral response without viral clearance. Five months after her last treatment viral count was 279,000 copies/ml. She received another 12month trial of Pegylated interferon alpha-2b and ribavirin with partial response after 12 months. Lowest viral count during treatment was 224,000copies/ml but the 6 months post treatment count was 700,000copies/ml. Repeat liver biopsy showed mild piecemeal necrosis (grade 1) and mild fibrosis (stage 1). Conclusion: The goal of treatment in Hepatitis C infection is to prevent complications. Infection is considered eradicated when there is sustained Virologic response (SVR), defined as absence of virus in serum by RNA testing 6months after 1 year of treatment. The primary benefit of treatment is histological, that is prevention of cirrhosis and hepatocellular carcinoma. Several studies have shown that there is histological advantage in treatment of nonresponders even in the absence of viral clearance. As seen in this case there was complete reversal of cirrhosis without eradication of the virus. Hopefully as more data becomes available there will be a stronger recommendation for treatment of nonresponders who can tolerate the medications.