Chronic Hepatitis C Virus [HCV]-associated Cryoglobulinemia and its possible impact on the skin in Egyptian Patients

ABSTRACT

Chronic hepatitis C virus [HCV] infection may have extremely variable clinical consequences and is more than just a liver disease; it has been associated with numerous extra-hepatic manifestations [EHM]. According to various international studies Mixed Cryoglobulinemia [MC] was found to be the most common EHM, however its local prevalence in Egyptian HCV patients was not clearly studied. The aim of our study was to investigate the frequency of cryoglobulinaemia in sera of chronic HCV patients and their association with clinical symptoms especially, vasculitis. One hundred patients with chronic HCV infection attending the outpatient clinic of the National Hepatology and Tropical Medicine Research Institute were interviewed. Patients with decompensated liver disease, on interferon therapy, having end-stage renal disease or coexisting viral infection like hepatitis B surface antigen positive patients were all excluded from the research. All patients were subjected to general and dermatological examination for liver affection signs; Cryoglobulinemia related clinical manifestations and/or associated dermatoses. Cryoglobulins, CBC, LFT. AFP, ALP, KFT, ANA and RF were assessed. Overall 15% of 100 patients were positive for presence of cryoglobulins in their sera. We found a relatively high incidence of clinical symptoms commonly accompanying cryoglobulinemic cases in the form of Purpura, Arthralgia, Generalized weakness, Peripheral Neuropathy and Reynaud's phenomenon with prevalence of 26.67%, 46.67%, 53.33%, 40% and 6.67% respectively. Our data also demonstrated that 46.67% [7] of our 15 cryopositive patients had concomitant skin manifestations in the form of Pruritus 40% [6] and Vasculitis 26.67% [4] [P=0.004] which was significant in comparison with prevalence of vasculitis in all patients 4.7% [4 patients]. Generalized weakness and fatigue, which is the most prevalent symptoms related to Chronic Hepatitis C [CHC] patients whether positive or negative for Cryoglobulinemia, were present in 52% of all patients. Other associated dermatological diseases in all patients were Lichen Planus, Psoraiasis, Urticaria, Necrolytic Acral Erythema [NAE] and Vitiligo with prevalence of [1%], [1%], [5%], [1%] and [2%] respectively. The most common dermatological disease was pruritus 36% [36] of all patients and 40% [6] in cryopositive patients. Regarding liver condition there was no significant correlation between presence of cryoglobulins and biochemical parameters. However, we found a significant correlation between presence of Cryoglobulinemia and presence of ANA in sera of HCV patients with incidence of 40% in comparison to 4.7% in cryonegative patients respectively while there is no significant correlation as regard RF [40% in cryopositive and 55.3% in cryonegative patients]. Among all patients 10% [10] were ANA positive and 53% [53] were RF positive. We also found that 26.67% [4] of our cryopositive patients were associated with vasculitic skin lesions. For each patient a skin biopsy was taken from the lesional area and tissue [Insitu] PCR was done to detect the presence of HCV RNA within it. Biopsy results revealed that 3 biopsies were positive and 1 biopsy was negative for HCV RNA by tissue PCR. The prevalence of cryoglobulinaemia in Egypt may be lower than other areas. In HCV patient complaining from generalized weakness, arthralgia, purpuric skin lesions, peripheral neuropathy, Reynaud's phenomenon or renal troubles, serum cryoglobulins presence should be searched for