Case Presentation: A 43-year-old man with past medical history of AIDS, Hepatitis C, alcohol use disorder (AUD), and cirrhosis presented with one week of severe abdominal pain and distension and pleuritic chest pain. He had been prescribed antiretroviral therapy (ART) for the past three years but was poorly adherent. Patient had stopped taking ART three months prior to presentation and refused treatment for Hepatitis C infection. His physical exam was notable for a distended abdomen with diffuse tenderness, guarding and rigidity. Labs were significant for CD4 count of 51 cells/mm3 (6%) and HIV RNA of 1700 copies/ml. HCV genotype done previously was genotype 3a. Although the HCV RNA had been over 2 million IU/mL prior to starting ART, it was undetectable on three occasions in the year prior to the current presentation and remained undetectable this admission. Imaging showed a large liver mass and extensive adenopathy, and a biopsy confirmed hepatocellular carcinoma (HCC). Due to advanced disease, the patient elected palliative goals of care and was discharged to inpatient hospice.
Discussion: The spontaneous resolution of chronic hepatitis C infection in HIV/HCV coinfected patients is a rare entity. The viral clearance has mainly been observed after the initiation of ART. Spontaneous resolution of chronic hepatitis C infection has been reported during pregnancy, liver transplantation, cessation of immunosuppression, and HBV superinfection. Our patient with HIV/HCV coinfection had spontaneously cleared HCV RNA two years after initiating ART, but later developed HCC. Although the mechanism behind the resolution of chronic hepatitis C is still unknown, immune reconstitution is the favored theory in the literature. Our patient had genotype 3a which is a favorable genotype for spontaneous resolution. IL28B testing was not done for our patient but IL28B CC polymorphism has been found to predispose to spontaneous resolution. Spontaneous resolution after the initiation of ART is rare but our case differs from most described in the literature in that our patient had documented poor adherence to ART with a low CD4 count and high HIV viral load at the time of clearance. In addition, the etiology of HCC in our patient is unclear but could have been due to his alcohol use disorder or due to cirrhosis caused by hepatitis C infection.
Conclusions: Spontaneous clearance of chronic hepatitis C infection has been seen in HIV/HCV coinfected patients after the initiation of ART. Although IL28B and genotype 3 have been found to predispose a patient to spontaneously clear chronic hepatitis C infection, further research is required to assess the clinical relevance and its impact on management of HIV/HCV coinfected patients.