New-onset ascites as a manifestation of virologic relapse in patients with hepatitis C cirrhosis
A 61-year-old woman with CHC genotype 1, biopsy-proven cirrhosis, and previous nonresponse to three courses of interferon-based therapy was started on telaprevir-based therapy. Cirrhosis was well compensated, without evidence of ascites or hepatic encephalopathy. Upper endoscopy was negative for esophageal varices. Laboratory evaluation revealed albumin 2.7 g/dL, AST 132 U/L, ALT 81 U/L, alkaline phosphatase 394 U/L, total bilirubin 0.8 mg/dL, hemoglobin 13.3 g/dL, platelet count 156,000/μL, and HCV viral load 71,600 IU/mL.\nAfter initiation of telaprevir-based therapy, the patient achieved rapid virologic response. Side effects of therapy included anemia, requiring ribavirin dose reduction and erythropoietin therapy. Treatment was noteworthy for stable hypoalbuminemia, with albumin level 2.1 g/dL without edema or ascites. She completed 12 weeks of telaprevir-based therapy, but therapy was discontinued at treatment week 31 due to a severe facial rash requiring systemic steroids for 2 days. HCV viral load remained undetectable from treatment week four until the end of therapy. Laboratory evaluation at the end of therapy revealed albumin 2.1 g/dL, AST 64 U/L, ALT 32 U/L, alkaline phosphatase 347 U/L, total bilirubin 1.3 mg/dL, hemoglobin 10.8 g/dL, and platelet count 80,000/μL. Weight at the end of therapy was 122 lb.\nThe patient presented 1 month later with 8 lb weight gain (weight 130 lb) over 2 weeks, new ankle edema, and abdominal distention. Abdominal ultrasound showed moderate ascites. HCV viral load was undetectable, albumin 2.9 g/dL, AST 71 U/L, ALT 37 U/L, alkaline phosphatase 309 U/L, total bilirubin 1.5 mg/dL, BUN 13 mg/dL, and creatinine 0.7 mg/dL. The patient refused diagnostic paracentesis. An echocardiogram was obtained, which revealed normal left and right ventricular function, with no sign of pulmonary hypertension. Sodium-restricted diet and diuretics (spironolactone 50 mg, furosemide 20 mg daily) were started, with prompt resolution of edema and ascites. Three months after the end of therapy, HCV viral load was 203 IU/mL, and on repeat 69,900 IU/mL, confirming relapse. Albumin level was 2.6 g/dL, AST 91 U/L, ALT 55 U/L, alkaline phosphatase 348 U/L, total bilirubin 1.1 mg/dL, BUN 12 mg/dL, creatinine 0.6 mg/dL, hemoglobin 13.5 g/dL and platelet count 140,000/μL. Diuretics were tapered, then discontinued at posttreatment week 20 with continued control of ascites. Albumin level remained stable at 2.6 g/dL.