Nasir Khokhar.
Bone marrow suppression in chronic hepatitis C.
Pak J Med Sci Jan ;17(4):251-3.

Summary: Various extrahepatic manifestations of chronic viral infections are known. Here are described four cases of chronic hepatitis C in which marrow suppression was found on initial diagnosis. The diagnosis was made with standard criteria of elevated ALT, with positive anti HCV and presence of HCV RNA. No anti viral treatment with Interferon or Ribavirin was possible in these cases. Only supportive treatment was feasible. All these patients died because of complications of chronic liver disease.

Case No. 1: A 60 years old female who had history of diabetes mellitus sand hypertension came with abdominal swelling, fatigue and weakness. There was no history of drug intake, alcoholism or surgery. Her physical examination showed blood pressure 150/90 mmHg. No ascites was noted. No hepato-splenomegaly was found. Her serum alanine aminotransferase (ALT) was 64 µ/l (Normal 0-40), her fasting blood sugar was 140 mg/dl (Normal 70-110), white blood cells (WBC) 1700/µl (Normal 4000-10000), platelet 45000/µl (Normal 150,000-400,000) and hemoglobin 11 g/dl (Normal 12-18). Anti HCV was positive and hepatitis C virus (HCV) RNA was detected in serum. Coombs test was negative. She had a bone marrow aspiration and biopsy, which showed pancytopenia consistent with marrow suppression. She was treated conservatively and symptomatically with diuretics when she developed ascites. She became progressively weak and her condition deteriorated over the next 6 months period. She was hospitalized with drowsiness due to hepatic encephalopathy. She died after gastro-intestinal hemorrhage.

Case No. 2: A 48 years old male presented with fatigue, vague abdominal discomfort and symptoms of indigestion. He had no previous history of drug intake, alcoholism or blood transfusion. His physical examination showed mild hepatomegaly. Spleen was not palpable and no ascites was noted. No definite stigmata of chronic liver disease were present. His ALT was 74 µ/l and anti HCV was positive. HCV RNA was detected in serum. WBC count was 1800 µ/l, hemoglobin 10.1 g/dl and platelet count 18000 µ/l. Coombs test was negative. Bone marrow examination could not be done due to risk of bleeding with low platelets. Patient was followed and supportive measures were provided. His condition deteriorated over the period of two years and he developed complications of chronic liver disease including ascites, hepatic encephalopathy, which lead to his death.

Case No. 3: A 50 years old female presented with history of fatigue, nausea, general weakness and bodyache. There was no history of drug or alcohol intake. The patient was in fair health and had no hepato-splenomegaly or ascites. She had an ALT of 84 µ/l and anti HCV was positive. Serum HCV RNA was positive. Her complete blood count (CBC) showed hemoglobin of 10 g/dl, WBC’s count 2100/µl and platelet 41000/µl. Coombs test was negative. Patient refused bone marrow aspiration. She developed progressive ascites and hepatorenal syndrome and eventually had gastro-intestinal hemorrhage. She died in intensive care unit.

Case No. 4: A 41 years old male had history of generalized bodyache and fatigue. He had no history of transfusion, surgeries, drug or alcohol intake. Physical examination showed mild hepatomegaly and no ascites. Spleen was not palpable. His ALT was 139 µ/l and anti HCV was positive. HCV RNA was detected in the serum. His WBC count was 2300/µl, platelet count 32000/µl and hemoglobin 9 g/dl. Coombs test and anti-nuclear antibodies were negative. His bone marrow examination showed pancytopenia consistent with marrow suppression. Patient could not be treated with anti viral agents and was given supportive treatment. He continued to developed progressive symptoms and developed complications of chronic liver disease and died about a year after the diagnosis.

PakMediNet -Pakistan's largest Database of Pakistani Medical Journals - http://www.pakmedinet.com