Bayupurnama and Taroeno-Hariadi, J Clin Case Rep 2012, 2:11 DOI: 10.4172/2165-7920.1000173 Volume 2 • Issue 11 • 1000173 J Clin Case Rep ISSN: 2165-7920 JCCR, an open access journal Open Access Case Report The Development of Cold-type Autoimmune Hemolytic Anemia during Peginterferon alfa-2a plus Ribavirin Treatment in Chronic Hepatitis C Patient: a Case Report Putut Bayupurnama 1 * and Kartika Widayati Taroeno-Hariadi 2 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito General Hospital, Yogyakarta, Indonesia 2 Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito General Hospital, Yogyakarta, Indonesia Abstract Peginterferon-alfa 2a or alfa 2b plus ribavirin is the treatment of choice in chronic hepatitis C. Severe adverse effects may compromise effcacy of this regiment. There are few reports of warm autoimmune hemolytic anemia following interferon-alfa or peginterferon-alfa2b plus ribavirin treatment. This present report discusses autoimmune hemolytic anemia which developed during peginterferon alfa-2a/ribavirin treatment and caused dose cessation. The anemia was improved with discontinuation of peginterferon-alfa 2a/ribavirin and adminstration of erythropoietin stimulating agent. *Corresponding author: Dr. Putut Bayupurnama, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito General Hospital, Yogyakarta, Indonesia, E-mail: pututby@yahoo.com Received June 28, 2012; Accepted July 17, 2012; Published July 19, 2012 Citation: Bayupurnama P, Taroeno-Hariadi KW (2012) The Development of Cold- type Autoimmune Hemolytic Anemia during Peginterferon alfa-2a plus Ribavirin Treatment in Chronic Hepatitis C Patient: a Case Report. J Clin Case Rep 2:173. doi:10.4172/2165-7920.1000173 Copyright: © 2012 Bayupurnama P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Chronic hepatitis C is still a serious health problem, with limited choice of treatment. Peg interferon based treatment combined with ribavirin is the treatment of choice. Te length of treatment and their responses are well predicted by their genotype. Genotype 2 and 3 have better response rate (70%) with shorter duration of combination treatment (24 weeks), while genotype 1 and 4 have poor response rate (about 45%) and need a longer treatment duration (48 weeks). Te non responder rate is still high in genotype 1 HCV infection [1]. Te side efects of interferon and ribavirin limit their treatment efcacy in some cases and severe side efect may urge to stop the treatment. We report a chronic hepatitis C patient who developed cold-type autoimmune hemolytic anemia during peginterferon (Peg- IFN) alfa-2a/ribavirin combination treatment. Case Description A male of 64 year-old sufered from chronic hepatitis C. His pre- treatment HCV-RNA PCR was 10 7 IU/mL, with genotype 1. He was planned to get combination treatment of peginterferon (Peg-IFN) alfa- 2a 180 mcg/week and 1000 mg of ribavirin/day for 48 weeks. On the early weeks of treatment the hemoglobin level tends to decrease from 10 g/dL to 8.9 g/dL. At week-7 of treatment hemoglobin continued to fall to 8.7 g/dL that led to reduction of ribavirin dose to 600 mg/day and peg-IFN alfa-2a 135 mcg/week. Patient also received 4000 IU erythropoietin stimulating agent subcutaneously twice weekly. Tis treatment approach did not help much and hemoglobin level continued to fall as low as 6.6 g/dL, at week-9. Ribavirin was then discontinued and patient only received peg-interferon 135 mcg/week along with erythropoietin 4000 IU twice a week. Te HCV-RNA PCR was undetected at week-12. Hemoglobin level raised to 8.2 g/dL at week-13. At week-21 he got accident and was hospitalized for fracture of his lower lef leg. His hemoglobin level was around 8 g/dL and packed red cell transfusion was given to reach 10 g/dL of hemoglobin level as preoperative requirement. Orthopaedic surgery was done successfully and ribavirin 200 mg/day was added along with peg-IFN alfa-2a 135 mcg at this time. Four days afer surgery his hemoglobin level decreased to 8.7 g/dL accompanied with decreased of platelet count to 124.000/ mm 3 . Packed red cells transfusion was planned but the results of direct and indirect Coomb’s test (direct antiglobulin test) were positive with consequence of transfusion cancelation. Reticulocyte count was 3 %. Indirect bilirubin was 2 mg/dL with peripheral blood smear showed destruction of erythrocyte cells. Serum LDH was slightly raised to 578 IU/L. Diagnosis of hemolytic anemia is made based on clinical and laboratory fndings. Te 135 mcg peg-IFN alfa-2a for week-24 was injected along with erythropoietin 10.000 IU per week while ribavirin was discontinued. Te hemoglobin and platelet level continued to decrease to 6.7 g/dL and 66.000 /mm 3 , respectively. Screening antibody in immunohematology test revealed that he had cold type-autoimmune hemolytic anaemia (cold type-AIHA). Peg-IFN alfa-2a and ribavirin were discontinued and he only received erythropoietin. Te HCV is still undetected at week-24 by HCV-RNA PCR examination even though the intensity of treatment dose was not reached. About three months later the haemoglobin level reached 12.6 g/dL and the patient was back to normal life without continuing of peg-IFN alfa-2a and ribavirin due to the probability of these two drugs or one of them induced the development of cold-type autoimmune haemolytic anemia(AIHA). He continued the erythropoetin treatment. Twenty four weeks post treatment the patient relapsed with HCV-RNA 1.24 x 10 6 IU/mL and he still use erythropoietin 10.000 UI three times a week to maintain the normal haemoglobin level. Discussion Tere is emerging evidence that hepatitis C virus may induce Journal of Clinical Case Reports J o u r n a l o f C li n i c a l C a s e R e p o r t s ISSN: 2165-7920