S2657 A Common Hepatitis C Treatment With an Uncommon Finding: Abdominal Perforation After Initiation of Mavyret

Abstract

INTRODUCTION: Mavyret (glecaprevir/pibrentasvir) is a prescription medicine used to treat adults with chronic Hepatitis C Virus (HCV) typically over a course of 8–16 weeks. The mechanism of action involves inhibiting HCV NS3/4A and HCV NS5A proteases, both of which are essential for viral RNA replication. The most common severe gastrointestinal (GI) adverse effects reported include reactivation of Hepatitis B infection and in rare cases hepatic failure. We present a case of an adult female found to have an atypical GI adverse effect: a contained abdominal perforation seven days after the initiation of Mavyret. CASE DESCRIPTION/METHODS: A 60-year-old Caucasian female with past medical history of hypothyroidism and cholecystectomy was referred for Hepatitis C treatment in August 2018. She denied jaundice, edema, confusion or ascites. Labs revealed elevated AST/ALT to 118/106 IU/L, normal bilirubin, alkaline phosphatase and total protein. A hepatitis panel was positive for hepatitis C antibody and negative for hepatitis A and B. Additional labs revealed a positive RNA viral load, genotype 1b with FibroSURE fibrosis score of 0.84. An abdominal US showed no cirrhosis. A FibroScan showed cirrhosis with F4 disease. In April 2019, the patient began HCV treatment with Mavyret. One week later she developed severe, sharp abdominal pain localized to the lower abdomen. She presented to an outside emergency department and was admitted after an abdominal CT scan showed severe bowel wall thickening of a loop of the distal jejunum with associated pneumatosis and potential focal perforation. The Surgery team was consulted and recommended conservative management. Mavyret was discontinued and IV antibiotics were started. Within a few days she had marked improvement in abdominal pain and was discharged home to complete a seven day course of Ciprofloxacin/Flagyl. A repeat abdominal CT scan three weeks later showed a normal liver and no abnormal bowel wall thickening, obstruction or evidence of pneumatosis. DISCUSSION: This case identifies a female found to have abdominal pain early in the onset of taking Mavyret with an abdominal CT scan concerning for a contained perforation. No other cases of perforation have been reported with Mavyret use. Whether this was an actual adverse effect of Mavyret is remains uncertain; however this case documents a potentially new and life threatening side effect of Mavyret about which patients and providers should be aware.