Chronic hepatitis C treatment and pseudo-tumor cerebri
A 45 year-old-male patient, known to have chronic hepatitis C, two years ago a decision was taken for his treatment by bcombined pegylated interferon and ribavirin.
His pretreatment assessment including the fundus examination showed no contraindications, so he received peginterferon alpha-2a (180 mcg once per week) and ribavirin (1000 mg daily in two divided doses). Apart from occurrence of little flu-like symptoms the treatment was going quite well. The patient was very happy when his PCR at the 12th week showed no viraemia, he also had normal other follow-up investigations.
His blood picture proceeded in an accepted manner, just normocytic normochromic anemia with the first two injections that corrected spontaneously, and sustained normal throughout the treatment course .At the 16th week he developed headache and gradual progressive diminution of vision, he sought ophthalmologic consultation that revealed bilateral papilledema and visual field loss, so was advised to do brain CT scan .
When I first saw him he was deeply frustrated with his mind hopelessly occupied with the strong possible etiology, the space occupying lesion. But his mood changed rapidly when I told him about the other possible etiology …Drug induced increased intracranial tension, pseudo-tumor cerebri, do you think this?
However brain CT scan and MRI showed no space occupying lesion, so the decision was taken to stop the treatment with administration of carbonic anhydrase inhibitor (Acetazolamide). Days later the symptoms started gradually to relieve and his follow-up ophthalmic examination showed progressive improvement as regard the degree of papilledema as well as the acuity and the field of vision.
Alpha interferon which are given as subcutaneous injections have been used since the late 1980s in the treatment of chronic hepatitis C. Refinement of their use, pegylation to make them long acting, and the addition of oral ribavirin to them has brought their rate of long term viral clearance, or sustained virological response, form less than 5% to approximately now more than 50% in patients who have never received treatment before.
Side effects of treatment however are essentially universal, dose reduction or discontinuation of interferon or ribavirin is another important step in side effect management, indicated immediately if severe side effects of therapy develop. Dose reduction should be done judiciously, particularly early in therapy as it has been shown to be associated with decreased rate of sustained virological response in some settings.
The most important reported side effects include the following:
-Constitutional: fatigue, fever, headache and myalgias.
-Gastrointestinal: nausea, anorexia and diarrhea.
-Psychiatric: insomnia, irritability and depression.
-Pulmonary: interstitial fibrosis.
-Dermatological: alopecia and skin rash.
-Hematological: anemia, neutropenia and thrombocytopenia.
-Other side effects: dyspnea, chest pain.
-Visual changes: are fairly uncommon but exact incidence is unknown, but the most commonly documented eye complaints are cotton wool spots and retinal hemorrhages but most interferon related retinopathy is asymptomatic and reversible.
-Thyroid dysfunction: hper- or hypo-thyroidism.
However, Benign increased intracranial tension (psudo-tumor cerebri), is a non-reported side effect.
Author:
Prof. Mohamed AL-Alfy, M.D., Internal medicine Department, Bab Al-Sheiria Hospital, Al Azhar University, Egypt
Conflict of interest:
No personal, financial nor academic conflict of interest stated by us.
Funding :
No sources of funding
References
1 GL Davis, LA Balart, ER Schiff, K Lindsay, HC Bodenheimer Jr, RP Perrillo, W Carey, IM Jacobson, J Payne, and JL Dienstag. Treatment of chronic hepatitis C with recombinant interferon alfa. A multicenter randomized, controlled trial. Hepatitis Interventional Therapy Group.N. Engl. J. Med., Nov 1989; 321:1501-6.
2 Michael P Manns, John G McHutchison, Stuart C Gordon, et al. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomized trial. The Lancet; 358: 958-965.
3 Fried MW, Shiffman ML, Reddy KR, et al.Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002; 347: 975-82.
4 Hauser P. Neuropsychiatric side effects of HCV therapy and their treatment: focus on IFN alpha-induced depression. Gastroenterol Clin North Am. 2004; 33: S35-50
5 Hadziyannis SJ, Sette H Jr, Morgan TR, Balan V, Diago M, Marcellin P, et al. Peginterferon-alpha2a and ribavirin combination therapy in chronic hepatitis C: a randomized study of treatment duration and ribavirin dose. Ann Intern Med. 2004;140(5):346-55.
