“Explosive” worsening of chronic hepatitis C-associated cryoglobulinemia vasculitis, as unmasking of lymphoma a case report.

Introduction and Objectives

Hepatitis C virus (HCV)- related lymphoproliferative disease from cryoglobulinemia to B-cell non-Hodgkin lymphoma (B-NHL) through cryoglobulinemic vasculitis (CryoVas). The CryoVas is difficult to diagnose; once diagnosed, we must rule out the HCV infection. We presented a patient with HCV and CryoVas, which presented a sudden “explosive” worsening, warning about the development of a B-NHL.

Materials and Patients

55-year-old male with HCV and CryoVas; what was the trigger for the diagnosis of HCV twenty years before? He received pegylated interferon and ribavirin without response. The virological, biochemical, and immunological characteristics are shown in Table 1. The flare of CryoVas appeared twice a year at most, limited to purpuric lesions on the legs, below the knees, arthralgia, and fatigue; was often triggered by infections, self-limiting throughout 2 to 3 weeks. The last flare started as usual but getting worse rapidly, spreading to the thighs, abdomen, chest, and upper extremities, plus fever, nocturnal diaphoresis, severe wasting, and inguinal, axillary lymph nodes. Lymph node biopsy shows diffuse large B-cell lymphoma (DLBCL)

Results

He received chemotherapy (CT), previously was re-treated with sofosbuvir/velpatasvir for 12 weeks. Five months after first-line treatment for DLBCL he presented an early relapse and received a second line of CT; at 3-year follow-up is in remission with no relapse of CryoVas, waiting for a bone marrow transplant.

Conclusions

Clinicians treating hepatitis C should be aware of the need to carry out immunological parameters at the basal evaluation, such as cryoglobulins, rheumatoid factor, C4 fraction, and even a flow cytometry in specific patients to the detection of leukemias and/or related lymphomas.

Ethical statement

The identity of the patients is protected. Consentment was obtained.

Declaration of interests

None

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Table 1.

Viral, biochemical and immunological parameters during the HCV infection, CryoVas and B-LNH.

Variable	2006 year (y)	Basal 2019 y	SVR12	Last follow up 2022y
Viral load, UI/mL (log)	13466 (4.13)	867277 (5.94)	ND	NR
Genotype	1b	1b	NR	NR
Hemoglobin g/dL	9.9	10.6	12.8	13
Total leukocytes K/µL	NR	8.6	7.6	9
Total lymphocytes K/µL	NR	2.3	1.5	1.9
Platelets	152	88	80	122
AST	40	79	20	21
ALT	83	108	20	29
GGT	38	66	33	NR
LDH	130	370	180	100
AFP	1	2	3	2
FIB4	1.16	4.76	3	0.49
APRI	0.75	2.57	0.71	1.86
Crioglobulins	NR	Positive	NR	Negative

SVR12: Sustained viral response at 12 weeks after treatment, AST, Aspartate aminotransferasec ALT, Alanine aminotransferase; GGT, gamma glutamyl transpeptidase; LDH, lactate dehydrogenase; AFP, alpha-fetoprotein; ND, No detected.