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Sexually transmitted reinfection with a new hepatitis C genotype during pegylated interferon and ribavirin therapy
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AIDS: Volume 19(6) 8 April 2005 p 639-640
den Hollander, Jan Ga,b; Rijnders, Bart Jc; van Doornum, Gerard JJd; van der Ende, Marchina Ec
aDepartment of Internal Medicine, Medical Centre Rijnmond Zuid, Rotterdam, the Netherlands
bDepartments of Medical Microbiology and Infectious Diseases
cInternal Medicine, Section of Infectious Diseases
dVirology, Erasmus MC, Rotterdam, the Netherlands.
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 A 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 A 106 cells/l, treatment with zidovudin/lamivudine/nevirapine was started, with a good virological response. In October 2003 ( 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 A 109 copies/ml of genotype 1. Treatment with PEG-IFN-Eo2a, 180 EÊg/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.
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.
References
1. Lai ME, Mazzoleni AP, Argiolu F, De Virgilis S, Balestrieri A, Purcell RH, et al. Hepatitis C virus in multiple episodes of acute hepatitis in polytransfused thalassaemic children. Lancet 1994; 343:388-390.
2. Asselah T, Vidaud D, Doloy A, Boyer N, Martinot M, Vidaud M, et al. Second infection with a different hepatitis C virus genotype in a intravenous drug user during interferon therapy. Gut 2003; 52:900-902.
3. Torriani FJ, Rodriguez-Torres M, Rockstroh JK, Lissen E, Gonzalez-Garcia J, Lazzarin A, et al. Peg-IFN alfa-2a plus ribavirin for chronic hepatitis C virus infection in HIV-infected patients. N Engl J Med 2004; 351:438-450.
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