hepatitis c and tuberculosis
Tumelo Roestoff FCP(SA)
Fellow of Gastroenterology
Charlotte Maxeke Johannesburg Academic Hospital
is there a link between the two entities?
Epidemiology
>10%
2.5–10%
1–2.5%
WHO. Wkly Epidemiol Rec 2002; 77: 41
Impact of hepatitis C infection
on TB treatment
Definition of DIH (DILI)
1) normal liver chemistry before starting anti-tuberculosis treatment;
1) the patient was receiving INH, RMP or PZA alone or in combination
for at least 5 days before the development of abnormal liver
chemistry;
2) an increase in ALT and/or AST to ⩾3 times the upper limit of
normal (ULN) with symptoms, or an increase in ALT and/or AST to
⩾5 times the ULN without symptoms;
3) no other apparent cause for the elevation of liver chemistry, such
as excessive alcohol intake; and
1) removal of the medications re- sulted in a normalisation or at least
a 50% improve- ment of the abnormal liver chemistry.
“Co-infection with HBV was not associated with a
higher rate of hepatitis but was associated with
later onset (102 ± 68.7 vs. 37.0 ± 31.9 days, P =
0.01), higher peak alanine amino- transferase level
and slower recovery (55.5 ± 62.9 vs. 15.4 ± 10.8
days, P = 0.01).”
JY chien et al. Int J tuberc lung disease, 2010; 14(5): 616 - 621
AM J RESPIR CRIT CARE MED 1998;157:1871–1876.
• 6 patients relapsed with reintroduction of
TB treatment
• 2 were excluded because of HIV coinfection
• 4 patients consented to interferon alpha
2a therapy
– This allowed succesful re-introduction of TB
therapy and completion of treatment
– Variable response in terms of Hep C viral loads,
but no SVR attained in any of the patients
UNGO J.R et al, AM J RESPIR CRIT CARE MED 1998;157:1871–1876.
Impact of TB on Hepatitis C
therapy
UPTODATE
Pegylated Interferon alpha 2a and Ribavarin
Adverse reactions significant ( 1 – 10%)
Respiratory: Bronchitis (≥1% to ≤5%), epistaxis (≥1% to ≤5%), nasal congestion
(≥1% to ≤5%), nasopharyngitis (≥1% to ≤5%), pharyngolaryngeal pain (≥1% to
≤5%), rhinitis (≥1% to ≤5%), sinus congestion (≥1% to ≤5%), throat sore (≥1% to
≤5%), upper respiratory infection (≥1% to ≤5%), pneumonia (HIV-HCV
coinfection: ≥1% to ≤3%)
Warnings/Precautions
Disease related concerns:
Infectious disorders: Interferon therapy may cause or aggravate fatal or
life-threatening infectious disorders; discontinue if signs and symptoms
occur. Investigate the etiology of any persistent fever during therapy.
• Numbers are not overwhelming –
controversial as to whether treatment can
result in TB infection
• Mostly case reports
• One study looking at HepC and HIV coinfected population
• Adverse effects in treatment
Reactivation?
Scandinavian journal of infectious diseases; 2006
• 62yr old gentleman
• Developed cough and haemoptysis
7months into therapy with Pegylated
Interferon and Ribavarin
• CT chest suggestive and Montoux was
positive,
• bronchoscopy and sputum– both smear
positive and MTB was cultured
• CD4+ depletion to below 290 and abnormal
CD4+:CD8+ ratios
• Patient was smear positive for a total of 13
weeks on treatment
• Subsequent normalisation of CD4+ count with
TB treatment
J Formos Med Assoc 2009;108(9):746–750]
• 55yr old Taiwanese lady
• Type 2 Diabetes Mellitus
• HepC genotype 2a/2c
• Cirrhosis on liver biopsy
• Symptoms began 8 weeks in to therapy
with combination pegylated interferon
alpha 2a and Ribavarin
Complication of
therapy?
- controversial
n = 97
TB complicating Hep C
therapy in the HIV
population
Clinical Infectious Diseases 2009;48:e82–5
• Retrospective observational study
• 3 hospitals in Madrid Spain
• Interferon based therapy for HepC
between 1996 and 2007
• HIV and Hep C con-infected patients
Results:
• 570 patients
• 4 developed TB during therapy
Key points:
• All therapy was discontinued upon
diagnosis of TB
• Diagnosis was severely delayed
– Clinical features were attributed to the
side effects of therapy
conclusion
• Hepatitis C is a risk factor for TB DILI
• It appears to be responsible for cases
of reactivation of latent TB
– May influence clinical practice
• It does rarely complicate interferon
based HepC therapy in the low incidence
areas of the world
• ?treatment impact in high TB incidence
areas such as Sub-Saharan africa.
Thank you