SP01 | TREATMENT WITH DAA OF HCV INFECTION WITH HIGH INTRAMEDULLARY VIRAL REPLICATION IN SUBJECT WITH SEVERE MEDULLARY APLASIA

Background: Bone marrow aplasia is a condition characterized by pancytopenia due to reduced or absent production of blood cells by the bone marrow. Acquired forms can be secondary to many factors including viral infections such as HCV. In these cases, hematopoietic stem cell dysfunction is immune-mediated. Anamnesis: Patient 42-year old male, diagnosed with Very severe medullary aplasia. Comorbidities: Diabetes mellitus on insulin treatment, secondary Polyglobulia (JAK-2 Negative), Arterial hypertension, Acute myocardial infarction with stent revascularization, mild CRF, Chronic HCV liver disease. Baseline HCV-RNA 28,000,000 IU/ml on marrow, Genotype 1a, Elastosonography with Fibroscan: kPa 14 (F4), Constant cytolysis (ALT >3 nv), no signs of portal hypertension Blood count: GR 2.20 106/uL; Hb 6 g/dL; GB 2,000 103/uL; N 100 103/uL; L 2100 103/uL; PLT 7,000 103/uL. Bone marrow aspirate: not assessable due to very poor cellularity; Bone marrow biopsy: cellularity <5%. Absent hematopoietic lines. Treatment: The patient underwent immunosuppressive first-line treatment with Antilymphocyte Serum (horse ATG) (3200 mg iv for 4 days) and Cyclosporine 150 mg daily, associated with prophylactic therapy for the prevention of infectious complications. Intense transfusion support was required. After infectious disease consultation, anti-HCV Interferon-free and Ribavirin-free therapy with oral drugs DAAs is proposed. The patient is offered therapy with Sofosbuvir+Velpatasvir (Epclusa) for 12 weeks. Virological checks were carried out on peripheral blood monthly along with bone marrow aspirate analysis. Results: The reassessment of the disease carried out by bone biopsy, two months after the end of treatment with Epclusa, revealed the patient’s complete hematologic response: variable cellularity of 30%, maturing granulopoiesis with increased precursors, erythropoiesis prevalent with increased precursors, megacaricytopoiesis consisting of rare elements. Also, after the start of the administration of Epclusa, the patient withdrew platelet and RBC transfusions. Conclusions: The eradication of HCV with antiviral therapy has defused the immune-mediated mechanisms responsible for the production reduction of central hematopoietic cells not targeted by viral infection with their consequent depletion in peripheral blood. The therapeutic success has brought a substantial benefit to the patient which is cured of HCV infection and of serious hematological disease.