Severe Systemic Lupus Erythematosus Induced by Antiviral Treatment for Hepatitis C

Abstract

Purpose: There have been only 9 reported cases in the medical literature of systemic lupus erythematosus (SLE) developing in patients receiving α-interferon treatment in hepatitis C. We report a case of a 43 year old man who had SLE develop after receiving pegylated α-interferon and ribavirin for chronic hepatitis C. Methods: He had previously been diagnosed with a non-specific inflammatory arthritis and was commenced on 15 mg prednisone daily with good symptom control. He was found to have an elevated HCV RNA viral load (>800,000 IU) genotype 3 a with elevated ALT. He was commenced on treatment with pegylated interferon α-2a at a dose of 180 micrograms per week and ribavirin 400 mg twice daily. His HCV RNA viral load became undetectable at 12 weeks with normalisation of liver enzymes. However 14 weeks into treatment he presented with a severe flare of arthritis and pleuritis. His interferon and ribavirin were ceased. 4 weeks after discontinuing antiviral treatment he was admitted to hospital with recurrent arthritis and pleuritis. Results: His hospital admission was prolonged and he displayed 8 features of the American College of Rheumatology (ACR) criteria for SLE – notably arthritis, pleuritis, florid discoid rash, anaemia and lymphopenia, oral and aphthous ulceration, glomerulonephritis, the development of high titres of ANA and anti-double stranded DNA antibodies after antiviral therapy. His hospital admission was complicated by life-threatening myopericarditis and vasculitis which necessitated admission to an intensive care unit. He was administered pulsed cyclophosphamide, methylprednisolone and intravenous gammaglobulin. Conclusion: He made a slow but complete recovery aided by rehabilitation. Unfortunately his HCV viral load is now detectable and there is evidence of a mild transaminitis consistent with a recurrent flare of hepatitis C viral replication. This case is notable for the clinical severity and nature of multi-organ lupus involvement arising from hepatitis C antiviral therapy.Table: Autoimmune serological progression and clinical events