New-onset ascites as a manifestation of virologic relapse in patients with hepatitis C cirrhosis
A 53-year-old woman with CHC genotype 1, biopsy-proven cirrhosis, and previous partial response to polyethylene glycosylated (PEGylated) interferon and ribavirin was started on telaprevir-based therapy. Cirrhosis was well compensated, without ascites or edema before and during therapy. Pretreatment laboratory evaluation revealed albumin 4.4 g/dL, aspartate aminotransferase (AST) 115 U/L, alanine aminotransferase (ALT) 120 U/L, alkaline phosphatase 191 U/L, total bilirubin 1.1 mg/dL, hemoglobin 16.3 g/dL, platelet count 183,000/μL, and hepatitis C virus (HCV) viral load 3,210,000 IU/mL. Upper endoscopy was negative for varices. Therapy was complicated by anemia requiring ribavirin dose reduction and erythropoietin therapy and rash that resolved after discontinuation of telaprevir. Viral load was 110 IU/mL at treatment week three and undetectable at week eight. PEGylated interferon and ribavirin were discontinued after 48 weeks of therapy. HCV viral load remained undetectable from week eight until the end of therapy. Laboratory evaluation at week 45 revealed albumin 2.7 g/dL, AST 125 U/L, ALT 67 U/L, total bilirubin 1.3 mg/dL, hemoglobin 10.1 g/dL, and platelet count 49,000/μL. Weight at the end of therapy was 132 lb (60 kg). One month after discontinuation of therapy, the patient presented with 5 lb weight gain (weight 137 lb) and new-onset ascites. Evaluation revealed albumin 3.1 g/dL, AST 77 U/L, ALT 44 U/L, total bilirubin 0.8 mg/dL, blood urea nitrogen (BUN) 8 mg/dL, creatinine 0.7 mg/dL, hemoglobin 13.5 g/dL, platelet count 105,000/μL, and virologic relapse with HCV viral load of 228 IU/mL. Abdominal magnetic resonance imaging (MRI) revealed a cirrhotic morphology, abdominal ascites, and recanalization of the umbilical vein and left retroperitoneal varices consistent with portal hypertension. The patient refused diagnostic paracentesis. An echocardiogram was obtained, which revealed normal left ventricular systolic and diastolic functions and right ventricular systolic pressure, with no sign of pulmonary hypertension. Ascites rapidly responded to sodium-restricted diet and diuretic therapy (spironolactone 50 mg, furosemide 20 mg daily). Repeat laboratory evaluation after control of ascites revealed an albumin level of 3.9 g/dL. Repeat viral load 3 months after the end of therapy was 528,810 IU/mL. Repeat abdominal MRI 7 months after therapy cessation showed no ascites.