This is a 62-year-old woman with a history of chronic liver disease HCV genotype 1b, without previous personal complaints or varices in endoscopic follow-up.
Percutaneous liver biopsy was performed to estimate the degree of fibrosis.
Histological analysis revealed hepatitis with moderate inflammatory activity and moderate fibrosis (P3, L2, F2).
During follow-up visits, the patient developed a maculo-eritematous rash in the distal third of the lower limbs (LLL) with biopsy compatible with leukocytoclastic vasculitis.
At the same time, the patient developed paresthesia in both feet.
It was studied by performing neurophysiological and analytical study.
The first one showed the existence of signs of symmetrical involvement of motor fibers and connective tissue in the lower limbs, suggesting multiple mononeuritis.
The analyses looked at the following findings: haemoglobin 11.9 g/dl, MCV 85.3, INR 1.34, normal renal function, albumin 3.1 g/dl, total bilirubin 2.1 mg/dl, alkaline phosphatase ALT hepatitis C/dl 74
Therefore, the diagnosis of CG associated with HCV was made with cutaneous and neurological involvement in the form of leukocytoclastic vasculitis and multiple mononeuritis, respectively.
Prior to the beginning of treatment, the patient was admitted with a sudden onset of symptoms characterized by distal weakness of the RLL, dorsal foot pain and distal reticular ipsilateral leg involvement, as well as inability to experience livedbility of the lower limbs.
Neurological examination showed data of peroneal neuropathy which, given the patient's history, was placed in the context of multiple mononeuritis secondary to GC.
Due to significant motor impairment, it was decided to perform combined treatment with methylprednisolone (3 intravenous boluses of 250 mg followed by 1 mg/kg for one month with subsequent progressive decrease, 6 weekly sessions of plasmapheresis).
Forty-eight hours after admission, the patient developed progressive dyspnea secondary to a massive right pleural effusion due to the placement of a chest tube, with good subsequent evolution.
Fluid analysis showed data of transudate, echocardiography and chest CT showed no abnormalities, and abdominal ultrasound showed data of chronic liver disease, patency of mesenteric vessels, as well as portal hypertension.
The absence of cardiopulmonary disease, good response after diuretics and the presence of esophageal varices in control gastroscopy put the picture in relation to colitis associated with liver disease.
The discrepancy with the previous finding of grade 2 fibrosis in the liver biopsy could be due to the sampling error inherent to this procedure.
During admission, the study was completed by performing a cranial MRI that showed no significant changes and a new electromyography that located the lesion at the level of the right common peroneal nerve.
The analyses showed no significant alterations with respect to the previous ones, except for the presence of thrombopenia around 75,000/μl and mild proteinuria and microhematuria in the urine analysis without deterioration of the associated renal function.
The evolution during his stay in the plant was favorable with a partial improvement of motor symptoms, in addition to the practice resolution of livedo reticularis and negativization of cryoglobulins.
The day before discharge, the first infusion of RTX was administered without incidents.
The following 3 doses were administered on an outpatient basis and two months after admission, and almost one month after the administration of RTX, antiviral treatment was initiated with PEG interferon and ribavirin, which had to be discontinued at week 12.
The subsequent evolution in consultations with a follow-up period of 26 months has been favorable without GC relapse and with functional recovery of motor paresis.
As possible side effects associated with the administration of RTX, the patient presented two respiratory infections resolved with antibiotic treatment, as well as persistent hypogammaglobulinemia.
From the point of view of her liver disease, the patient requires diuretic treatment for proper control of herpetic infections.
It has a score of 7 points (grade B) in Child-Pugh classification, so after assessing pros and cons with the patient it was decided not to make a new attempt of antiviral treatment with protease inhibitors.
