Is peginterferon-alpha plus ribavirin therapy safe and effective for patients with chronic hepatitis C and ulcerative colitis? – a case report

Introduction: We report on a 55-year old man with chronic hepatitis C, who showed exacerbation of ulcerative colitis during peginterferon-alpha and ribavirin therapy.

Case: At the initiation of antiviral therapy, ulcerative colitis was in complete remission with 5-ASA monotherapy. In response to the treatment at week 12, HCV-PCR became negative and ALT and AST levels returned to the normal limit, ulcerative colitis showed neither clinical, nor laboratory activity. Continuation of this well tolerated therapy was planned until week 48 because of genotype I of HCV infection. At week 46, the patient was admitted to our department with a sudden onset of bloody diarrhea, abdominal pain and severe malnutrition. Local steroid therapy was initiated and the dose of antiviral therapy was reduced. 5-ASA therapy was combined with small dose of azathioprine. At this time PCR revealed some virological relapse of HCV (viraemia<100IU/ml) but normal ALT and AST was found. Antiviral therapy was stopped and parenteral prednisone therapy was initiated. After 4 weeks of parenteral steroid therapy and nasojejunal feeding, significant improvement was not observed, and severe psychotic episodes occurred. Parenteral antipsychotic therapy was started. With 6 weeks of steroid therapy, significant clinical improvement was not achieved proving a steroid refractory active ulcerative colitis. A limited control colonoscopy showed subacute ulcerative colitis with pseudopolyps and microulcers in the left side of the colon. Two days after the colonoscopy, sudden acute abdominal pain, meteorism and fever occurred. Clinical and radiological examinations indicated urgent surgery and left sided hemicolectomy with transversostomy was performed. After the operation patient is getting better now.

Discussion: The mechanism of action of interferon-alpha is probably complex, but the possible interaction of interferon-alpha with the cytokine cascade and immune system has to be considered. To answer the question, whether peginterferon-alpha is safe and effective in chronic hepatitis C with ulcerative colitis warrant further research and controlled clinical trials.