Objective To report a case of polyarteritis nodosa in HCV patient along with a number of extrahepatic manifestations with unique presentation and a novel approach to treatment.
Case Report A 53-year-old Caucasian male with a past medical history significant for chronic untreated hepatits C. The patient presented with abdominal pain with evidence of cholelithiasis on abdominal ultrasound but no biliary obstruction. He underwent an elective cholecystectomy; an intraoperative liver biopsy was also done, which showed steatosis but no evidence of cirrhosis. After a few days the patient presented with hypertensive encephalopathy resulting in left-sided weakness diagnosed as lacunar infarct on CT of the head. He had a new onset of very high blood pressure as he noted in home as well not responding to previous medication. After 1 month the patient presented again, with marked pedal edema and acute renal failure. Urinalysis showed new-onset nephrotic range protein urea, hematuria, and cryoglobulins, which was thought to be the cause of continuous deteriorating renal function. Meanwhile gall bladder biopsy showed medium-sized vessel inflammation consistent with polyarteritis nodosa. Liver enzymes were normal during all these presentations. This was a novel finding and could explain recent onset of very high blood pressure, cholecystitis, and stroke. A renal biopsy was done, which showed evidence of double glomerulonephritis with HCV-associated cryoglobulinemia nephropathy superimposed on diabetic glomerulosclerosis. Due to high suspicion for PAN, positive biopsy in gall bladder, new-onset labile hypertension, and stroke, immunosuppression with cyclophosphamide and prednisone was started. After 6 months of immunosuppressive treatment the patient's creatinine improved and treatment for viral hepatitis with interferon was initiated with astounding decrease in HCV RNA.
Conclusion Polyarteritis nodosa is a rarely reported extrahepatic manifestation of hepatitis C. PAN has been reported rarely in hepatitis C patients diagnosed on the basis of cutaneous rash. Our patient presented with cholecystitis, which has not been reported as presenting manifestation in hepatitis C patients with PAN. This complex situation was treated with a combination of immunosuppression and antivirals. This case also advocates for early hepatitis C treatment with normal liver enzymes. HCV patients also need a high suspicion for various extrahepatic manifestations that can present with otherwise indolent liver disease.
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