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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#58;</span></p><p class="elsevierStylePara">The prevalence of hepatitis C virus infection among patients on haemodialysis is estimated at 3&#37;-23&#37; in developed countries&#46; Some of the adverse effects described in treating patients on haemodialysis with interferon as a monotherapy include<span class="elsevierStyleSup">1</span>&#58; flu-like symptoms&#44; anaemia&#44; immunological graft intolerance&#44; depression&#44; leukopoenia&#44; confusion&#44; diarrhoea&#44; bone pain&#44; thyroid alterations&#44; thrombocytopenia&#44; and convulsions&#46; To a lesser degree&#44; there have also been descriptions in the medical literature of autoimmune diseases and neurological alterations in relation to this type of treatment in patients on haemodialysis&#46; Pegylated interferon improves drug absorption and extends the half-life of this medication&#46;</p><p class="elsevierStylePara">Here we describe the case of a 47-year old male on haemodialysis with no known allergies&#44; a history of smoking and social drinking&#44; and a previous addiction to parenteral drugs&#46; The patient suffered from stage 5 chronic kidney disease of an unknown origin&#46; The patient had received a transplant but had to return to haemodialysis after 8 years&#46; The patient also had arterial hypertension&#44; positive serology for hepatitis C virus &#40;HCV&#41;&#44; positive CRP &#40;genotype 3a&#41;&#44; positive cryoglobulins&#44; chronic gastritis&#44; bronchiectasis&#44; and had problems with his vascular access in the form of a permanent right jugular catheter&#46;</p><p class="elsevierStylePara">The patient had no alterations in transaminase levels or clotting factors&#44; and in the absence of ultrasound indications of portal hypertension&#44; we started him on treatment with alpha-2-a pegylated interferon as a monotherapy&#44; considering the patient to be a candidate for a second kidney transplant&#46; During the first three months of treatment&#44; the patient suffered only mild adverse side effects related to treatment&#44; in the form of mild thrombocytopenia and nausea &#40;table 1&#41;&#46;</p><p class="elsevierStylePara">After this initial period&#44; a series of complications began to arise&#58;</p><p class="elsevierStylePara">- Right basal pneumonia with haemoptysis&#44; pleural effusion&#44; and marked thrombocytopenia&#46; At this point we suspended treatment with interferon&#46;</p><p class="elsevierStylePara">- Epigastric pain with irradiation into the hypochondria and lumbar area that intensified during haemodialysis and that did not recede with analgesia&#44; prompting several incomplete haemodialysis sessions&#46;</p><p class="elsevierStylePara">- Deterioration in general state of health&#44; including weight loss&#44; anaemia despite increased doses of darbepoetin&#44; and weakness in the legs&#44; prompting hospitalisation&#46; We performed a gastroscopy&#44; observing antral and ectatic gastropathy with no signs of acute bleeding&#46; A computed axial tomography &#40;CAT scan&#41; of the chest detected a solid hilar tumour in the lower right quadrant that was producing a total obstruction of the bronchus in the right lower lobule&#46; We performed a bronchoscopy&#44; extracting the blood clot from the aforementioned location&#46; A bronchial swab and biopsy revealed negative test results&#46; We diagnosed the patient with hypothyroidism&#46;</p><p class="elsevierStylePara">- Diplopia&#44; inability to close the left eye&#44; and inability to walk&#44; three weeks after suspending interferon and in an outpatient setting&#46; A cranial CAT scan revealed no signs of acute damage&#44; but signs of vascular leukoencephalopathy were observed&#44; which were later confirmed by nuclear magnetic resonance &#40;NMR&#41;&#46; A CAT scan of the eye sockets revealed a symmetrical increase in the size of the extra-ocular muscles and the inferior&#44; medial&#44; and superior rectus muscles of both eyes&#44; suggesting thyroid orbitopathy&#46; The patient refused transferral to the neurology department&#46; After an initial neurological examination including electroneurography and NMR&#44; the diagnostic conclusion was that of peripheral nervous system involvement with symptoms of thick fibre sensory neuropathy &#40;deep sensitivity&#41;&#44; including paralysis of the left sixth cranial nerve&#44; in relation to treatment with interferon&#44; with spontaneous recovery 3 months after suspending treatment&#46;</p><p class="elsevierStylePara">We started treating the patient with hormone replacement therapy using levothyroxine&#46; We also considered administering corticosteroids to treat the 6<span class="elsevierStyleSup">th</span> cranial nerve paralysis&#44; as well as the possibility of an autoimmune component &#40;table 2&#41;&#46; However&#44; we decided against this strategy in order to avoid the potential for viral replication &#40;viral RNA had become negative after three months of treatment&#41; and in light of the clinical deterioration of the patient&#44; maintaining a conservative approach&#46; The patient&#8217;s symptoms progressively improved after treatment was suspended&#46;</p><p class="elsevierStylePara">Autoimmune and neurological involvement in patients on haemodialysis treated with pegylated interferon is an uncommon complication&#46;<span class="elsevierStyleSup">1-3</span> Measurements of auto-antibodies prior to treatment with interferon is a fundamental step for the differential diagnosis of autoimmune complications&#46; Some authors have described an increase in endogenous interferon-alpha during haemodialysis sessions in patients with positive HCV serology &#40;without treatment&#41;&#44; which could explain the decrease in viral load produced during treatment&#46;<span class="elsevierStyleSup">4</span> However&#44; this supposed increase in interferon could produce a paradoxical effect&#44; as in our case&#44; and activate the complement system&#44; which could in turn be related to the intra-dialytic lumbar pain&#46;</p><p class="elsevierStylePara">Paralysis of the 6<span class="elsevierStyleSup">th</span> cranial nerve is not a common occurrence in the context of thyroid orbitopathy&#46;<span class="elsevierStyleSup">5</span> In our case&#44; involvement of the peripheral nervous system and the normal aspect of the external extra-ocular rectus muscle leads us to believe that the peripheral nervous system involvement was the cause of the squinting&#46; Several cases have been published of patients not on haemodialysis who were treated with pegylated interferon and suffered paralysis of the 6<span class="elsevierStyleSup">th</span> cranial nerve&#46; The induction mechanism for the involvement of the 6<span class="elsevierStyleSup">th</span> cranial nerve stemming from treatment with interferon is still not understood&#46; The treatment option for many of these cases described was corticosteroids&#46;<span class="elsevierStyleSup">6-8</span></p><p class="elsevierStylePara">Our objective in presenting this case was not to alarm the medical community regarding the complications inherent to the treatment of patients on haemodialysis with interferon&#44; but rather to alert the readership as to the less common and late adverse effects that the nephrologist might be the first to notice&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors state that they have no potential conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11639&#95;108&#95;39924&#95;en&#95;t1&#46;18&#46;jpg" class="elsevierStyleCrossRefs"><img src="11639_108_39924_en_t1.18.jpg" alt="Laboratory analysis results"></img></a></p><p class="elsevierStylePara">Table 1&#46; Laboratory analysis results</p><p class="elsevierStylePara"><a href="grande&#47;11639&#95;108&#95;39925&#95;en&#95;t2&#46;18&#46;jpg" class="elsevierStyleCrossRefs"><img src="11639_108_39925_en_t2.18.jpg" alt="Autoimmune state following suspension of interferon"></img></a></p><p class="elsevierStylePara">Table 2&#46; Autoimmune state following suspension of interferon</p>"
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