Rev. Bras. Reumatol. vol.55 número2

rev bras reumatol.2015;55(2):181–184

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Case

report

Induction

of

cytoplasmic

pattern

in

the

form

of

“rods

and

rings”

through

the

treatment

of

hepatitis

C:

a

case

report

夽

Mariano

Felisberto

,

Alex

Sandro

Jorge

,

Rafael

Andrade

Menolli

,

Laísa

Vieira

Gnutzmann

_,

_Vanessa

_Nesi

a_{LaboratóriodeAnálisesClínicasdoHospitalUniversitáriodoOestedoParaná,Florianópolis,SC,Brazil}

b_{UniversidadeEstadualdoOestedoParaná(Unioeste),Florianópolis,SC,Brazil}

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Articlehistory: Received1April2013 Accepted28January2014

Availableonline27November2014

Keywords: HepatitisC Self-antibodies Rodsandrings Cytoplasmicpattern

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Femalepatient,complainingofweaknessandpaininhypogastric,wasadmittedtothe emergencydepartmentoftheUniversityHospitaloftheWestofParaná(HUOP).Duringthe interviewreportedtreatmentofchronicinfectionwithhepatitisCvirus(HCV)with pegin-terferonandribavirin.Amongthelaboratorytestsordered,thesearchforself-antibodies againstcellularantigens,traditionallyknownasantinuclearfactor,showedfluorescence shapedlikerodsand/orringsinthecytoplasmofcells.Thisstudyattemptstoclarifythe relationshipbetweenthispatternnotyetcompletelyunderstoodandtheclinicalpictureof thepatient.Thispatternischaracterizedby3–10␮mrodsorringswith2–5␮min

diame-terscatteredthroughoutthecytoplasmofthecell.Therefore,thisnewstandardhasbeen designatedas“rodsandrings”(RR).Theantigenictargetofthisreactionwasidentifiedas inosine-5′_{-monophosphatedehydrogenasetype2(IMPDH2)whichisakeyenzymeinthe} synthesisofpurinenucleotides.TheIMPDH2enzymeaggregatedormodifiedshapedRR inthosepatientstreatedwithribavirinmaybecomeantigenicandinduceanautoimmune response.Itispossiblethatinterferonalphastimulatestheoccurrenceofanti-RRreactivity apparentlyinducedbyribavirin.SofaritisnotknownwhythestandardRRinHEp2cells occursonlyinafractionofpatientswithHCV.Previousstudiespresentedinthispaperallow affirmingthattheseantibodiesassociatedwiththestandardRRarestronglyrelatedto hep-atitisC.Moreover,itcanbestatedthattheoccurrenceofanti-RRreactivityispromotedby combinationtherapywithinterferonandribavirin.

©2014ElsevierEditoraLtda.Allrightsreserved.

夽

StudyconductedatDiagnosticandTherapeuticSupportService(SADT),HospitalUniversitáriodoOestedoParaná(HUOP-Unioeste). ∗ _{Correspondingauthor.}

E-mail:marianofelisberto@hotmail.com(M.Felisberto). http://dx.doi.org/10.1016/j.rbre.2014.01.004

182

Induc¸ão

do

padrão

citoplasmático

em

forma

de

“bastões

e

anéis”

através

do

tratamento

da

hepatite

C

_:

_relato

_de

_caso

Palavras-chave: HepatiteC Autoanticorpos Bastõeseanéis Padrãocitoplasmático

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Paciente dosexofeminino,queixando-sede asteniae dorem hipogastro, foiadmitida nopronto-socorrodoHospitalUniversitáriodoOestedoParaná(HUOP).Durantea anam-neserelatoutratamentodeinfecc¸ãocrônicapelovírusdahepatiteC(VHC)cominteferon peguiladoeribavirina.Dentreosexameslaboratoriaissolicitados,apesquisade autoan-ticorposcontraantígenoscelulares(PAAC-HEp-2),conhecidotradicionalmentecomofator antinúcleo(FAN),apresentoufluorescênciaemformadebastõese/ouanéisnocitoplasma dascélulas.Essepadrãoécaracterizadoporbastõesde3-10␮meanéiscom2-5␮mde

diâmetroespalhadosatravésdocitoplasmadacélula.Portanto,essenovopadrãotemsido designadocomo“bastõeseanéis”(traduzidodoinglês:RodsandRings,RR).Oalvoantigênico dessareac¸ãofoiidentificadocomoinosina-5′_{-monofosfatodesidrogenasetipo2(IMPDH2)} queéumaenzimachavenasíntesedenucleotídeospúricos.AenzimaIMPDH2agregadaou modificadaemformadeRRnospacientestratadoscomribavirinapodetornar-seantigênica einduzirumarespostaautoimune.Épossívelqueointerferonalfaestimuleaocorrênciade reatividadeanti-RRaparentementeinduzidapelaribavirina.Atéomomentonãosesabepor queopadrãoRRemcélulasHEp-2ocorremapenasemumafrac¸ãodepacientesportadores doVHC.Osdadosapresentadosemtrabalhosanteriorespossibilitamafirmarqueesses anticorposassociadosaopadrãoRRestãofortementerelacionadoscomotratamentoda hepatiteC.Alémdisso,pode-seafirmarqueaocorrênciadereatividadeanti-RRépromovida pelaterapiacombinadacominterferonalfaeribavirina.

©2014ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Hepatitis C virus (HCV) is an RNA virus of the Flaviviri-dae family, genus Hepacivirus, with a high rate of hepatic replication.Thisisanenvelopedvirus,withasizebetween 30 and 40nm.1–3 _{HCV was originally isolated in a serum}

sample of an individual with non-A, non-B hepatitis in 1989byChoo et al.4 _{Sincethen,hepatitisC gained special}

relevanceamongthe causesofchronicliverdisease world-wide.In1992,thefirsttestforidentificationoftheantibody againstHCVwasdeveloped,providinggreatersafetyinblood transfusions.1,2

The HCV transmission occurs through contact with infectedblood duetopercutaneousexposure,bloodand/or blood products transfusion and transplants from infected donors. Although some patients with acute HCV infection have an immune system able of eliminating the virus, 55–58% of patients develop chronic infection, defined as the persistence of infection for no less than six months, with only 10–15% of cases reaching spontaneous healing. The hepatocellular injury, seen in chronic HCV infection, does not seem to be directly related to a viral cytopathic effect,beingrelatedtoimmunemediators,withnaturalkiller cellsand CD8+Tlymphocytes playingacentralrole inthe pathogenesis.1,2

The treatment of HCV infection aims to control the progressionofliverdiseasebyinhibitingviralreplication. Fur-thermore,thereductionininflammatoryactivitypreventsits progressiontocirrhosisandhepaticcarcinoma.The recom-mendedtherapyforchronicHCVinfectionisacombination ofaformulationofinterferonalphaandribavirin.3

Interferon is a cytokine which composes the innate responseofthehumanhost.Theadditionofone polyethyl-eneglycolmoleculetotheinterferonmoleculeprolongsthe action,increasestherateofabsorption,extendsthehalf-life andreducestheclearanceofinterferon.Ribavirinisa nucleo-sideanalogantiviralagentusedorally,withawidespectrum ofactionagainstviralpathogens.Ribavirinalsohastheeffect ofmodulatingthe immuneresponse.2,3 _{Morietal.recently}

demonstratedthatribavirinintherapeuticdosesinhibitsthe replication of HCV RNA, and proposed that this anti-HCV activity is mediated through the inhibition of inosine-5′ -monophosphatedehydrogenase(IMPDH).5

Case

report

Femalepatientcomplainingofastheniaandpainat hypogas-tricarea,admittedonOctober4,2011intheemergencyroom ofHospitalUniversitáriodoOestedoParaná(HUOP)inthecity ofCascavel-PR.Duringanamnesis,thepatientreported treat-mentofchronicinfectionwithhepatitisCviruswithpegylated interferonalphaandribavirin,startingonDecember7,2010 andconcludedonNovember1,2011.Duringthisperiodthe patient developed severe pancytopenia due to the adverse effectsofthemedication.

rev bras reumatol.2015;55(2):181–184

183

Fig.1–Rodsmeasuring3–10␮mandringswith2–5␮mof

diameter,scatteredacrossthecellcytoplasm.

thediagnosis ofautoimmunedisease,asearchfor autoan-tibodiesagainstcellularantigens(PAAC-HEp-2),traditionally knownasantinuclearantibodies(ANA),wasrequested, show-ingfluorescenceintheshapeofrodsand/orringsinthecell cytoplasm.

Thisdescriptionofaclinical caseaimstobringcurrent informationaboutthisfluorescencepatternfoundinHep-2 cells,notyetcompletelyunderstood,inanattemptto under-standitsrelationshipwiththeclinicalpictureofthepatient.

Discussion

Recently,anewcytoplasmicpatterninPAAC-HEp-2hasbeen reportedinpatientswithHCV.Thispatternischaracterized byrodswith3–10␮mandringswith2–5␮mindiameter,

scat-teredacrossthecellcytoplasm(Fig.1).Becauseofthat,this patternhasbeendesignatedas“rodsandrings”(RR).6

Seeligetal.,whendoingasearchforPAAC-HEp-2,detected theRRpatterninaserumsampleofapatient,andthe anti-genictargetofthisreactionwasidentifiedthroughsearchesin databasesasbeingIMPDHtype2,whichisakeyenzymeinthe synthesisofpuricnucleotides.7_{InthestudybyCarcamoetal.,}

cellculturestreatedwithribavirinshowedthatthisdrughas theabilitytoinducetheformationoftheRRpattern;onthe otherhand,ininvivotests25%ofHCVpositivepatientstreated withribavirinand interferonalphahad anti-RRantibodies, whilenoneoftheuntreatedsubjectsdevelopedthispattern.8

In mammals, there are two isoforms of this enzyme, IMPDH1 and IMPDH2. While IMPDH1 is constitutively expressed in normal cells, the expression and activity of IMPDH2are increasedinmalignantcells.8 _{Therefore,HEp-2}

cells,bybeingoriginatedfromhumanlaryngealcarcinoma, presentincreasedexpressionandactivityofIMDH2enzyme.

IMPDH2, aggregated or modified in the form of RR in thesepatients treatedwith inhibitorsof this enzymesuch asribavirin, maybecomeantigenicand inducean autoim-muneresponse.Itispossiblethatinterferonalphastimulates the occurrenceofanti-RR reactivityapparently induced by ribavirin.6–8

Keppekeetal.carriedoutalongitudinalstudyandanalyzed samples from 597 patients using indirect immunofluores-cence (IIF) technique in HEp-2 slides. The RR pattern was observed in 14.1% of 342 patients with HCV, and none of the117patientswithoutHCVshowedthispattern.Regarding treatment, anti-RR antibodies were present in 38% of 108 patients receiving interferon alpha and ribavirin, but nei-therofthe26patientsreceivingmonotherapywithinterferon alphaorribavirinnorthose166untreatedpatientspresented RR.

Inthisstudyweobservedthepresenceofantibodies anti-RRjustafterthebeginningoftreatment,withitsappearance startingwithinthefirstmonthin6%ofpatients;however,at sixmonthsmorethan47%ofthetestedsamplespresentedthe RRpattern.Anotherrelevantfactofthisstudywasthat,among anti-RR-positivepatients,77%didnotrespondtotreatment. Ontheotherhand,amonganti-RR-negativepatients,therate was64%.Thus,thispattern isnotrelatedtothesuccessof drugtherapy.8

WhenitcomestoRRpattern,thereisdiscrepancyinthe resultsobtainedinPAAC-HEp-2withIIFbyusingslidesfrom differentmanufacturers,andthisremainsanotcompletely resolvedissue,butthatmaystemfromdifferencesinculture conditions,sampleprocessing,orboth.7,8_{Thisdifficultywas}

alsofoundinourlaboratory,consideringthat,whenfacedwith thispattern,hithertounknown,itwasnecessarytoconfirmit withslidesofvarioustrademarks;butweobservedthe forma-tionofRRpatternonlyinoneofthecommercialslidesused, thuscreatingdoubtsabouttherelevanceofthepattern.Infact, inmostoftheHEp-2-positiveslides,serumsamplespositive fortheRRpatternproduceanon-specificspottedcytoplasmic pattern,orpresentnosignificantreaction.6

Theidentificationofanewautoantibodyassociatedwith agivenpathologymaycontributetotheunderstandingofits pathophysiologyandcanenrichthearsenalofdiagnostictests forthisdisease.6_{Itisthereforeimportantthatfurtherstudies}

areconducted,inordertounderstandtheclinicalsignificance ofthiscytoplasmicpattern.

Datapresentedinthisstudyrevealedthatantibodies asso-ciatedtoRRpatternarestronglyassociatedwiththetreatment of hepatitis C; that the occurrence of anti-RR reactivity is promotedbyacombinedtherapywithinterferonalphaand ribavirin;andthatitsfrequencyincreaseswiththeduration of treatment. However, the same was not observed when thesedrugsareusedseparately.Furthermore,previousstudies showed no relationship between this pattern and demo-graphicparameters,durationofdiagnosisofHCV,treatment responsepattern,HCVgenotypeorviralload.8

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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hepatitisC.NEnglJMed.2006;355:2444–51.

4.ChooQL,KuoG,AlterHJ,GitnickGL,RedekerAG,PurcellRH, etal.Anassayforcirculatingantibodiestoamajoretiologic virusofhumannon-A,non-Bhepatitis.Science.

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5.MoriK,IkedaM,AriumiY,DansakoH,WakitaT,KatoN. MechanismofactionofribavirininanovelhepatitisCvirus replicationcell.VirusRes.2011;157:61–70.

6.CarcamoWC,SatohM,KasaharaH,TeradaN,HamazakiT, ChanJY,etal.Inductionofcytoplasmicrodsandrings

structuresbyinhibitionoftheCTPandGTPsyntheticpathway inmammaliancell.PLoSONE.2011;6:1–12.

7.SeeligHP,AppelhansH,BauerO,BluthnerM,HartungK, SchranzD,etal.Autoantibodiesagainst

inosine-5′_{-monophosphatedehydrogenase2–characteristics}

andprevalenceinpatientswithHCV-infection.ClinLab. 2011;9:753–65.

8.KeppekeGD,NunesE,FerrazML,SilvaEA,GranatoC,ChanEK, etal.Longitudinalstudyofahumandrug-inducedmodelof autoantibodytocytoplasmicrods/ringsfollowingHCVtherapy withribavirinandinterferon-␣.PLOSONE.2012;7: