Sexually transmitted reinfection with a new hepatitis C genotype during pegylated interferon and ribavirin therapy

Abstract

Hepatitis C (HCV) is an important cause of liver disease worldwide, and intravenous drug use (IVDU) is the most important risk factor in the western world. A minority of cases is sexually transmitted. Double or reinfections with a different HCV genotype are rare. Reinfection with different HCV strains has been reported in multitransfused thalassaemic children [1] and recently in one intravenous drug user during interferon treatment [2]. Reinfection during the most effective HCV treatment [3] has never been described. We report a case of a 30-year-old homosexual man who developed an acute HCV infection with a new strain during pegylated-interferon (PEG-IFN) and ribavirin treatment for his first acute HCV infection. In 2002, an asymptomatic homosexual HIV-1-positive patient with a CD4 cell count of 670 × 106 cells/l was referred to our outpatient clinic. From 1998 to 2004 he was treated for several sexually transmitted diseases (gonorrhoea, syphilis, rectal lymphogranuloma venereum). Blood examination showed normal liver enzymes and no HCV antibodies or HCV RNA. As the CD4 cell count decreased to 270 × 106 cells/l, treatment with zidovudin/lamivudine/nevirapine was started, with a good virological response. In October 2003 (Fig. 1, t = 5 months) an increase of aspartate aminotransferase (AST) was thought to be nevirapine related, and this drug was substituted by lopinavir/ritonavir. As the AST levels only decreased slightly, he mentioned participation in sex parties, during which he had unprotected receptive anal intercourse with many penises and fists (‘fist-fucking’), and one of the participants was HCV positive. HCV antibodies of the patient showed seroconversion between January and May 2003, with a HCV-RNA load up to 1.92 × 109 copies/ml of genotype 1. Treatment with PEG-IFN-α2a, 180 μg/week and ribavirin 1000 mg/day was started, and lamivudine/tenofovir/lopinavir/ritonavir was continued. HCV RNA was cleared after 12 weeks and AST levels normalized (Fig. 1). At month 13, still on PEG-IFN/ribavirin therapy, AST levels increased and HCV RNA became detectable. Genotyping by Inno-LIPA HCV reverse hybridisation assay (InnoGenetics, Belgium) showed genotype 2. The patient admitted he had participated in one more ‘fist-fucking’ party at month 11 in Berlin. The patient denied IVDU at any time.Fig. 1: Patient's data in time. Serum aspartate aminotransferase (AST) levels (▪), and CD4 cell counts (•), are plotted on the left Y axis, HIV RNA (▾), and hepatitis C virus (HCV) RNA (▴) are plotted on the right Y axis. The treatment time of highly active antiretroviral therapy (zidovudine/lamivudine/nevirapine) and the switch to lamivudine/tenofovir/lopinavir/ritonavir and the treatment period of pegylated interferon (PEG-IFN-α2a)/ribavirin are indicated with the time bars below the figure. LPV, Lopinavir; NVP, nevirapine; RBV, ribavirin; RTV, ritonavir; TDF, tenofovir; 3TC, lamivudine; ZDV, zidovudine. For the quantitative and qualitative HCV-RNA assay the lower limit of detection was 1000 resp. 200 copies/ml. Samples detectable with the qualitative assay, but less than 1000 copies/ml were plotted as 500 copies/ml.This is the first reported case of reinfection with HCV during intensive treatment with PEG-IFN and ribavirin, which suggests a failure of the prevention of HCV. This case questions the prophylactic use (before any sign of infection) of PEG-IFN after accidental HCV exposure. Furthermore, starting HCV treatment in patients who continue risky behaviour (IVDU and homosexual promiscuous behaviour such as fisting), is therefore questionable.