Short communication Recurrent demyelinating myelitis associated with hepatitis C viral infection Amrit K. Grewal a , M. Beatriz Lopes b , Carl L. Berg c , Audrey K. Bennett b Vena ˆncio A.F. Alves d , Joel M. Trugman a, * a Department of Neurology, University of Virginia Health System, Charlottesville, PO Box 800394, Charlottesville, VA 22911, United States b Department of Pathology, University of Virginia Health System, Charlottesville, Virginia, United States c Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, Virginia, United States d Department of Pathology, Sao Paulo University School of Medicine and Immunohistochemistry Laboratory, Adolfo Lutz Institute, Sao Paulo, Brazil Received 25 September 2003; received in revised form 15 June 2004; accepted 16 June 2004 Available online 12 August 2004 Abstract We report a 46-year-old-man who developed recurrent myelitis associated with hepatitis C viral (HCV) infection. Spinal cord biopsy showed acute demyelination without evidence of vasculitis. Antibodies to HCV were present in the CSF; HCV RNA was not detected in the CSF. Neither HCVantigens nor RNA were detected in the spinal cord biopsy, whereas they were found in the liver biopsy. Evaluation for other infectious or autoimmune causes was unrevealing. These observations suggest that recurrent myelitis in this patient is etiologically related to HCV infection, possibly via an immune-mediated mechanism. This is the first report of pathologically proven myelitis associated with HCV infection and we suggest that HCV be considered in the differential diagnosis of the transverse myelitis syndrome. D 2004 Elsevier B.V. All rights reserved. Keywords: Hepatitis C virus; Myelitis; Demyelination; Immunohistochemistry 1. Introduction Hepatitis C virus (HCV), a single stranded RNA virus of the flaviviridae family, is a major cause of chronic liver disease, affecting approximately 2.7 million people in the United States [1]. Both peripheral and central nervous system (CNS) disorders have been described as complica- tions of HCV infection. In the peripheral nervous system, the evidence for association is strongest for vasculitic neuro- pathy with cryoglobulinemia [2–5]. In the CNS, ischemic and hemorrhagic stroke due to vasculitis is well documented [2,5]. Encephalomyelitis has been reported as a complication and myelitis has been described, but the association with HCV infection is not well established [5–7]. We report a patient with biopsy-proven, recurrent, demyelinating myelitis which occurred in association with HCV infection. Other infectious and autoimmune etiologies were excluded. This case suggests that HCV infection may cause recurrent myelitis. 2. Case report A 46-year-old man presented in February, 2002, with a 2-month history of malaise and fatigue. He had a history of drug abuse but denied intravenous drug use; he had recently been tattooed. A diagnosis of HCV infection was established with elevated serum transaminases and hepa- titis C viral load (Table 1). Liver biopsy performed in May 2002, showed chronic portal, periportal, and lobular hepatitis, consistent with hepatitis C, with moderate necroinflammatory (grade 3) and probable focal bridging fibrosis (probable focal stage 3) [8]. The exact time of onset and duration of HCV infection could not be determined. 0022-510X/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.jns.2004.06.013 * Corresponding author. Tel.: +1 434 924 8377; fax: +1 434 9821726. E-mail address: jmt2r@virginia.edu (J.M. Trugman). Journal of the Neurological Sciences 224 (2004) 101 – 106 www.elsevier.com/locate/jns