1. Hematologic Disorders Related to HCV Infection and their managementBy
prof.Rashed Hasan

2. Extra-hepatic manifestations of HCV

3. Introduction: Mechanism:
They are included under extrahepatic manifestations (EHMs) of hepatitis C virus (HCV) infection .
Forty to 75% of patients with chronic HCV infection exhibit at least one clinical EHM .
Many of these extrahepatic manifestations of hepatitis C infection can be grouped into four types: blood disorders, autoimmune disorders, skin conditions and kidney disease.
Mechanism:
1-Direct infection of extrahepatic tissue cells (viral tropism) by HCV .
2-the majority of EHMs are thought to be secondary to immune-mediated mechanisms, infection results in upregulation of the humoral immune system in patients with chronic disease, which leads to increases in monoclonal and polyclonal autoantibodies via chronic antigenic stimulation . It has been postulated that anti-HCV-IgG and HCV lipoprotein complexes may act as B-cell superantigens inducing the synthesis of non-HCV reactive IgM with rheumatoid factor-like activity . These autoantibodies, in turn, form immune complexes, which circulate through the body and are deposited in small to medium blood vessels, resulting in complement activation and extrahepatic injury.
3-Lymphoproliferative effect of the virus
4-Autoimmune in nature.

4. The autoimmunity is due to:-
1-Auto antibodies production to the cellular components which leak from the persistent destruction of the infected cells. About 20% with hepatitis C patients are ANA positive .
2-The molecular mimicry between NS5A and NS core proteins of HCV and auto antigens .
3-Abnormality of lymphocytic cells :
HCV infection and proliferation within lymphocytes leads to functional alteration of lymphocyte and production of excessive auto- antibodies and cryoglobulins

7. 1- Peripheral blood cell disorders
1-ANEMIA
The influence of HCV infection on the peripheral blood cell count has not been well studied. A recent National Health and Nutrition Examination Survey of HCV-infected individuals in the United States showed that HCV antibody—positive subjects were more likely to have low neutrophil and platelet counts than were HCV-negative individuals, but there was no association between HCV status and anemia .
However, independent case studies have demonstrated that patients with chronic HCV infection can develop autoimmune hemolytic anemia in the absence of treatment with IFN-α .
In these HCV-infected patients, autoimmune hemolytic anemia was reversible with prednisolone therapy . In addition, fatigue, a major symptom of anemia, was recently reported to be the most common extrahepatic complication in HCV-infected patients, and, in one study, it was considered by almost one-half (48%) of all untreated HCV-infected patients to be the initial or worst symptom

8. Anemia of chronic disease (ACD) occurs in association with chronic infections and inflammatory or neoplastic diseases. ACD can be mild or severe (hemoglobin level of 7–12 g/dL) with normochromic/normocytic or normochromic/microcytic RBCs . An inflammatory response, manifesting as increases in levels of TNF-α and IL-1 (which inhibit erythropoiesis), is common among patients with ACD . Patients with HIV infection or cancer typically have bone marrow suppression, which results in ACD . Although it appears that individuals with chronic HCV monoinfection do not demonstrate ACD, it has been shown that HCV can replicate extrahepatically, specifically in the bone marrow —the physiologic site of erythropoiesis. Replication of HCV in the bone marrow may also contribute to the etiology of neutropenia and thrombocytopenia observed in HCV-infected patient.
Aplastic anemia:May occure several weeks or months following acute HCV infection.It is usually severe & irreversible.

9. 2-HCV related Thrombocytopenia
HCV antibodies were identified in 30% of patients with chronic idiopathic thrombocytopenia purpura .
Pathogenesis:Thrombocytopenia associated HCV may be present even in the absence of clinically evident liver disease or splenomegaly and may be wrongly diagnosed as ITP . The detection of HCV in platelet and megakaryocytes make HCV related thrombocytopenia is probable cause. High affinity binding of HCV to platelet membrane with subsequent binding of anti-HCV antibody might lead to phagocytosis of platelets . High rate of HCV RNA in HCV related-thrombocytopenia than non thrombocytopenic patients was detected.Furthermore, HCV may be causative factor for the production of platelate associated immunoglobulin G inducing thrombocytopenia in mechanism similar to idiopathic thrombocytopenia purpura (ITP)

11. Treatment:Classical therapeutic approaches such as corticosteroid, antiviral therapy and Intravenous immunoglobulin and splenectomy can be used. Disappearance of HCV RNA after IFN α associated with improvement of
thrombocytopenia. Caution is recommended
in thrombocytopenic patients treated with
PEG-IFN α and ribavirin when platelet count less
than 50,000/μl as significant aggravation of
thrombocytopenia may occur

12. Platelet count can be decrease from 30-50% in patient who administrates interferon or peginterferon, so reduction of the dose must be if the platelet counts reach /mm and discontinuation of the antiviral therapy if the counts reach /mm. Peg interferon alpha 2a can reduce the weekly dose from 180μg to 135 or even to 90μg, and peg interferon alpha 2b can reduce from 1.5μg/kg to 1μg/kg or even to 0.5μg/kg

13. 2-Human Recombinant Interleukin –11(Oprelvekin) :Oprelvekin promoting proliferation and maturation of megakerocytes which can be used to stimulate increasing number of platelet count at dose of 5 μg/kg/day S.C for 7 days initially and if necessary during antiviral therapy maintainance by taking 1-3 doses per week

14. 3-Elthrombopag:Active thrombopoietin receptor agonist (Elthrombopag) may be applied before and during antiviral therapy in HCV related thrombocytopenia at dose 30, 50 and 75mg lead to sustained increase of platelate count and it allows initiation and/or continuation of antiviral therapy. 4-Rituximab has promising therapeutic approach,especially in refractory cases or aggravating thrombocytopenia during the course of antiviral therapy

17. 2-Bleeding Disorders & Hepatitis C
“Bleeding disorders” is a general term for a wide range of medical problems that lead to poor blood clotting and continuous bleeding. Medical terms referring to bleeding disorders include coagulopathy, abnormal bleeding and clotting disorders.
A person with a bleeding disorder has a tendency to bleed longer. The disorders can result from defects in the blood vessels or from abnormalities in the blood itself.The abnormalities may be in blood clotting factors or in platelets. Unfortunately, the liver is intimately involved in the production of clotting factors and platelets; so having hepatitis C on top of a blood disorder is not a good thing.
As we all know,advanced liver disease can cause bleeding disorders as the liver becomes too diseased to manufacture clotting factors and hormones to make platelets

18. 3-Clotting Disorders and HCV
Thrombophilia:
It is the opposite of hemophilia. While people with hemophilia have an increased tendency to bleed, people with thrombophilia have an increased tendency to clot. Just as hemophilia is caused by an abnormality of a blood-clotting factor, some forms of thrombophilia are also caused by an abnormality or deficiency of a blood-clotting factor.
Chronic hepatitis C and treatment with interferon have often been associated with a procoagulant state, and may cause a protein C and S deficiency (natural anticoagulants synthesised in the liver). This deficiency has been known to cause mesenteric vein thrombosis, and can be fatal

19. Thrombotic Thrombocytopenic Purpura (TTP or Moschcowitz Syndrome):TPP is a rare disorder of the blood-coagulation system, causing extensive microscopic thromboses to form in small blood vessels throughout the body.
This disorder is associated with both hepatitis C and treatment with interferon and ribavirin. There are quite a few studies demonstrating that interferon treatment can trigger TTP, most probably as a result of heightened immune system response.
As for blood clotting disorders, hopefully with the advent of new direct-acting antiviral therapy and interferon-free combinations, the incidence of thrombophilia and TTP will be greatly reduced because these new treatments have a greater chance of curing HCV, thus getting rid of these associated conditions

20. 4-CRYOGLOBULINEMIA
Definition of Cryoglobulinemia: Cryoglobulinemia refers to the presence of one (monoclonal) or more (mixed or polyclonal) immunoglobulins in the serum, which reversibly precipitate in vitro at temperatures below normal body temperature (less than 37°C). These immunoglobulins dissolve again when reheating the serum. Cryoglobulins typically are composed of a mixture of immunoglobulins and complement components.
Mechanism of Disease: In HCV-related cryoglobulinemia, immune complexes that contain HCV particles igG-igM-RF antibody complex & complement deposit in the walls of capillaries, venules, or arterioles, causing small vessel inflammation. In patients who develop cryoglobulinemia, HCV causes chronic stimulation of lymphocytes, which is thought to induce B-cell clonal expansion and production of antibodies, including rheumatoid factor.

21. 1-The common hypothesis regarding HCV-related cryoglobulinemia is the chronic antigenic stimulation of the humoral immune system, which facilitates clonal B-lymphocyte expansion.
2-Other hypotheses:
-Chronic HCV infection of B cells and Bcl-2 activation (protoncogene). Bcl-2 (B-cell lymphoma 2), encoded in humans by the BCL2 gene, is the founding member of the Bcl-2 family of regulator proteins that regulate cell death (apoptosis), by either inducing (pro-apoptotic) it or inhibiting it (anti-apoptotic). Bcl-2 is specifically considered as an important anti-apoptotic protein and is thus classified as an oncogene which increase B cell survival by inhibiting apoptosis .
-Interaction of HCV E2 envelope protein with the cell surface glycoprotein CD81 that is present on B cells as well as on hepatocyte reduces the threshold for B-cell activation.
HCV-specific proteins also demonstrate molecular mimicry with auto antigens. NS5A and NS core proteins can simulate host auto antigens, possibly resulting in B-lymphocyte activation and auto antibody production which may allow cross-

24. Classification of Cryoglobulinemia: Cryoglobulinemia is classically grouped into three types according to the Brouet classification system.
Type 1 cryoglobulinemia consists of isolated monoclonal immunoglobulin IgM and most commonly occurs in association with lymphoproliferative disorders; type 1 cryoglobulinemia represents only 10 to 15% of cases of cryoglobulinemia.
Type 2 cryoglobulinemia consists of mixed immune complexes, typically monoclonal IgM and polyclonal IgG. This type of cryoglobulinemia most often develops in persons who have chronic viral infections, such as HCV, hepatitis B virus, and cytomegalovirus (CMV), but also occurs in persons with chronic inflammatory states, such as systemic lupus erythematosus, rheumatoid arthritis, and Sjögren's syndrome. Type 2 cryoglobulinemia is the most common type of cryoglobulinemia seen in HCV-infected patients.
Type 3 cryoglobulinemia consists of mixed immune complexes, typically formed by polyclonal IgM, and it represents 25 to 30% of cases of cryoglobulinemia.

25. Association between HCV and Mixed Cryoglobulinemia: Multiple reports have shown a close association of HCV and mixed cryoglobulinemia, most often type 2 cryoglobulinemia. With HCV-related mixed cryoglobulinemia, immune complexes comprised of immunoglobulin and HCV particles precipitate in many organs, including the skin, kidneys, and peripheral nerve fibers.
Investigators have postulated that expansion of rheumatoid factor activity and cryoprecipitability is responsible for the vasculitis. Most patients with mixed cryoglobulinemia have evidence of chronic HCV infection: studies have shown from 50 to 100% of patients with mixed cryoglobulinemia cases have HCV infection. Conversely, most HCV-infected patients do not have mixed cryoglobulinemia, with estimates ranging from 10 to 50% :

26. Clinical Syndromes Associated with Cryoglobulinemia: A variety of clinical syndromes can be associated with cryoglobulinemia. The most common manifestations of HCV-associated cryoglobulinemia, along with the prevalence of the condition in patients with HCV and cryoglobulins, are shown in the following list:
Mixed cryoglobulinemia vasculitis (4 to 40%). Cryoglobulinemic vasculitis is considered a systemic small vessel vasculitis. In this disorder, damage to the small vessels is thought to result from the deposition of immune complexes on the vessel wall followed by subsequent activation of the complement cascade. Fewer than 10% of patients with cryoglobulinemia develop cryoglobulinemic vasculitis. Diagnosis of Cryoglobulinemic Vasculitis: Specific criteria of cryoglobulinemic vasculitis have not yet been defined. The diagnosis is typically made from the combination of history, skin purpura, low complement levels, circulating cryoglobulins, and histology that shows small vessel inflammation with immune deposits found in the vascular wall.
Fatigue, arthralgia, myalgia (35 to 54%)
Renal disease (27 to 30%)
Palpable purpura (18 to 33%). Palpable purpura is evident in more than 90% of patients with mixed cryoglobulinemia, and is usually the first sign of cryoglobulinemia. The finding of palpable purpura in a patient with chronic hepatitis C should raise an immediate suspicion for cryoglobulinemic vasculitis.
Neuropathy (11 to 30%)
Sicca syndrome (10 to 25%).
The majority of HCV-infected patients with cryoglobulinemia have either no symptoms or nonspecific clinical manifestations. A triad of purpura, myalgia, and arthralgia (Meltzer’s triad) occurs in an estimated 30% of patients with HCV-related mixed cryoglobulinemia.

28. Correlation with Liver Disease:
MC tends to correlate with duration of HCV
infection and older age.
However, cryoglobulinemia in the serum of HCV patients has been associated with increased risk of advanced fibrosis, the severity of hepatic steatosis on liver biopsy and cirrhosis, irrespective of age or disease duration

29. Treatment of HCV-related Cryoglobulinemic Vasculitis
1-Interferon alfa: In patients with cryoglobulinemic vasculitis, experience with HCV treatment regimens that include interferon or peginterferon has shown that HCV RNA levels decrease to an undetectable range before cryoglobulin levels substantially decline. There is no evidence that patients with cryoglobulinemia have different SVR rates than patients without cryoglobulinemia. Low HCV RNA levels alone predict a favorable response of cryoglobulins to interferon monotherapy, but approximately 80% of these responders will relapse within 6 months after completion of interferon therapy.
The combination of peginterferon alfa with ribavirin enhances and improves the response. Use of interferon or peginterferon in this setting remains controversial since treatment may precipitate and aggravate neuropathies, induce renal failure, and delay ulcer healing. Insufficient data exist regarding the treatment of hepatitis C-related cryoglobulinemia using regimens that include or consist entirely of new direct acting antiviral agents. Interferon-free regimens would theoretically provide an advantage by avoiding the interferon-related complications associated with treatment of cryoglobulinemia.

30. Corticosteroids, Cytotoxic Agents, and Plasmapheresis: Some experts have used corticosteroids in combination with cytotoxic agents and plasmapheresis to treat rapidly progressive cryoglobulinemic vasculitis. Treatment with these agents should be administered by an expert (or in consultation with an expert) who has experience with treating this disorder.
Monoclonal Antibodies: B-cell clonal expansion is a key finding in mixed cryoglobulinemia. Rituximab (Rituxan), an anti-CD20 monoclonal antibody, modifies the dynamics of B cells by deleting expanded clones in cryoglobulinemic patients. This treatment may provide protection against factors potentially involved in the pathogenesis of malignant B-cell transformation. Patients with HCV infection may have increased HCV RNA levels detected after treatment with rituximab. A few studies have investigated the use of rituximab in combination with peginterferon and ribavirin and have shown an improvement in results when compared with peginterferon and ribavirin alone. Treatment with rituximab should be administered by an expert (or in consultation with an expert) who has experience with use of rituximab.

32. LAC-diet(low antigen content)
The rationale of the use of LAC-diet in the treatment of patients with mixed cryoglobulinemia is to reduce the input of food antigens to the mononuclear phagocytic system which is satured by large amounts of endogenous immune-complexes (chiefly the cryoglobulins).
The administration of the restricted diet (LAC-diet) for days every month should maintein the efficiency of mononuclear phagocytic system in the clearance of cryoglobulins.
The following foods must be avoided during the LAC-diet treatment:
dairy products
eggs
fish
meats (except turkey, rabbit, lamb)
legumes
alcohol
additives, preservatives
tomatoes

33. 5-Lymphoproliferative disorders (LPD) &HCV:
Lymphoproliferative disorders (LPDs) are neoplasms of the blood and encompass lymphoma, multiple myeloma, and leukemia.The associated lymphoma include Hodgkin & non- Hodgkin lymphoma(NHL).
NHL include diffuse large B-cell lymphoma, marginal zone lymphoma, lymphoplasmacytic lymphoma{Waldenström macroglobulinemia(WM)}, splenic lymphoma with villous lymphocytes, and extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue(MALT lymphoma).
Diffuse large B-cell lymphomas is aggressive lymphoma. Indolent lymphomas include: follicular lymphoma, small lymphocytic lymphoma, marginal zone lymphomas, splenic marginal zone lymphoma, primary nodal marginal zone lymphoma and extranodal marginal zone lymphoma of mucosa-associated tissue (MALT), and lymphoplasmacytic lymphoma. Indolent lymphomas are defined from a clinical point of view as scarcely symptomatic lymphomas, growing and spreading slowly.

34. Relationship: Chronic hepatitis C infection has been associated with the development of B-cell non-Hodgkin lymphoma, HCV RNA has been isolated in the gastric mucosa of patients with MALT lymphoma , raising the possibility that HCV may play a role in its pathogenesis as well as primary hepatic lymphoma. There is a high prevalence of HCV seropositivity (15%) in patients with B-cell lymphoproliferative disorders, especially B-cell non-Hodgkin lymphoma. Primary hepatic diffuse large B-cell lymphoma (DLBCL) is also associated with HCV. DLBCL may present on histology as large lymphoid cells with vacuolated nuclei in a diffuse infiltrating pattern intermingled with small lymphoid cells. The large cells typically stain positively for CD20, CD10, and CD25.
Low grade lymphomas are more frequently associated with HCV . The association between HCV and NHL is strongest in geographic areas with the highest prevalence of the viral infection.
Overall, marginal zone lymphoma appears to be the most frequently encountered low-grade B-cell lymphoma in HCV patients. HCV infection is documented in approximately 35% of patients with nongastric B-cell marginal zone lymphoma. Splenic marginal zone lymphoma, in particular has a high prevalence of HCV infection and is often associated with type II cryoglobulinemia

35. Other hematologic disorders in the course of HCV infection are gammopathies of uncertain significance (MGUS): usually they are gammopathies IgM/Kappa.MGUS are present in up to 11% patients with HCV infection without cryoglobulins. Some authors reported an association with HCV genotype 2a/c. These monoclonal gammopathies have to be monitorized in order to exclude the possibility of an evolution to multiple myeloma.
Waldenström macroglobulinemia(WM), one of the malignant monoclonal gammopathies, is a chronic, indolent, lymphoproliferative disorder. It is characterized by the presence of a high level of a macroglobulin (immunoglobulin M [IgM]), elevated serum viscosity, and the presence of a lymphoplasmacytic infiltrate in the bone marrow. A clonal disease of B lymphocytes, Waldenström macroglobulinemia is considered to be a lymphoplasmacytic lymphoma. No definite etiology exists for Waldenström macroglobulinemia. Environmental, familial, genetic, and viral factors have been reported. IgM monoclonal gammopathies of undetermined significance (MGUS) are considered a precursor of Waldenström macroglobulinemia. Hepatitis C, hepatitis G, and human herpesvirus 8 have been implicated, but as yet, no strong data support a causative link between these viruses and Waldenström macroglobulinemia.
Results from a few studies show that people who have the Hepatitis C virus may have an increased risk of Hodgkin’s lymphoma.

36. Pathogenesis: The mechanism may be due to long term HCV infection, resulting in clonal B cell expansion of immunoglobulin (cryoglobulin) secreting lymphocytes, also a combination of a mutation agents like factors (genetic, environmental, immunological) result in activation of oncogenes and resulting in NHL. Another possibility is the inhibition of apoptosis of HCV infected lymphocytes by over-expression of the bcl2, and a second mutation (myc oncogene) may lead to the development of lymphoma . This data suggest that the multi step lymphomagenetic cascade may have points of no-return, making LPD progressively independent from HCV infection . The pioneering work of Bishop and colleagues established that v-myc was the oncogene captured by the avian MC29 myelocytomatosis transforming virus
According to the currently more accepted pathogenetic model, the role of HCV infection in lymphomagenesis may be related to the chronic antigenic stimulation of B-cell immunologic response by the virus , similarly to the well-characterized induction of gastric MALT lymphoma development by Helicobacter pylori chronic infection . In a similar way, chronic HCV infection may possibly sustain a multistep evolution from type II mixed cryoglobulinemia to overt low-grade NHL and eventually to high-grade NHL . The most convincing argument in favour of a causative link between HCV and lymphoproliferation is represented by interventional studies demonstrating that in HCV-positive patients affected by indolent NHL eradication of HCV with antiviral treatment (AT) could directly induce lymphoma regression .
Moreover, the upcoming novel antiviral anti-HCV agents as boceprevir and telaprevir, whose addition to standard treatment has already demonstrated an increased rate of viral eradication also in more resistant genotypes (i.e., genotype 1b) , will possibly further improve the efficacy of this treatment for HCV-positive indolent NHL in the near future

38. Treatment and Prognosis:
Survival outcomes for patients with diffuse large B-cell lymphoma with HCV infection are worse than in patients without HCV infection. This may be due to hepatotoxicity of chemotherapy for the lymphoma. Limited data suggest that low-grade B-cell lymphomas might regress with HCV clearance induced by antiviral therapy with IFN ; however high-grade B cell malignancies still require systemic chemotherapy.
he use of rituximab in HCV-associated NHL, in monotherapy or in combination with antiviral treatment and/or chemotherapy, appears very promising, especially in the setting of low-grade NHL, where rituximab monotherapy has been proposed as first-line treatment.
Interestingly, Hainsworth et al showed that the use of rituximab in low-grade NHL with scheduled maintenance at 6-mo intervals produced high overall and complete response rates and a longer progression-free survival than has been reported with a standard 4-wk reatment

39. In patient with aggressive lymphoma, antiviral therapy must be delayed until the NHL is under control. Rituximab-based chemotherapy has become the first-line approach to treating aggressive B cell lymphomas.
Although hepatotoxicity has been reported at higher frequency in patients treated for HCV-related NHL, some of the data are hard to interpret because of the definitions for hepatotoxicity used.
Although there have been infrequent reports of HCV ‘flares’ during chemotherapy, most data suggest that HCV does not ‘reactivate’ like HBV and chemotherapy should be well tolerated in HCV-infected individuals without cirrhosis.
As antiviral therapy improves, it may even be possible to combine HCV treatment with treatment for NHL

40. Multiple myeloma (MM)
Itis a B-cell malignancy characterized by the proliferation of clonal plasma cells in the bone marrow. Clinically, it often presents with hypercalcemia, renal dysfunction, anemia, and bone disability.
. Extensive analysis revealed that the risk of developing MM was significantly increased among patients with HCV. Some results showed a prevalence of HCV of 32% in the myeloma patients compared with a prevalence of 9% in the control . Many people with monoclonal gammopathy of undetermined significance (MGUS) or solitary plasmacytoma will eventually develop multiple myeloma.
Regression of a case of Multiple Myeloma with antiviral treatment (Pegilated alpha-Interferon 180 μg/week and Ribavirin 1000 mg p.o./day)in a patient with chronic HCV infection(Panfillo et al 20013). The clear response obtained in this case suggests a possible role of chronic HCV infection in MM

42. Treatment for Multiple Myeloma
Multiple myeloma treatment depends on several factors, including the stage of the disease and the overall health and age of the patient. The goal of treatment is to reduce symptoms and prolong survival (called palliative treatment). Treatment for multiple myeloma may involve radiation therapy, chemotherapy and other medications (e.g., targeted therapy, corticosteroids), stem cell transplantation, and additional treatments.
Patients with early stage multiple myeloma (i.e., smoldering myeloma) or slow-growing (indolent) myeloma usually do not require treatment. Instead, these patients are closely monitored and receive regular testing (called watchful waiting.
Radiation therapy usually is administered once daily (e.g., 5 days per week) for several weeks. Treatment sessions usually last about 30 minutes.
Some patients with multiple myeloma receive chemotherapy prior to undergoing stem cell transplantation

43. Many thanks