Rituximab as second-line therapy after new direct antiviral agents in peripheral neuropathy Hepatitis C Virus related : always correct therapeutic approach?

Nowadays, Hepatitis C virus (HCV) infection remains a major public health problem in many countries (1). The cryoglobulinemic vasculitis HCV-related may involve small vessels of skin, kidney and peripheral nervous system. The treatment of peripheral neuropathy (PN) HCV related is based on corticosteroids, plasmapheresis, rituximab and new direct antiviral agents therapy (DAAs) (2). In May 2015, a male of 54-years old was referred to our Department for recurrent palpable purpura on legs, asthenia, arthralgias, sicca syndrome (dry mouth and eyes), paresthesias, burning and pain in all limbs. The clinical and laboratory parameters are reported in table 1. In peripheral blood, the cytometry detected monoclonal kB cells lymphocytes (MBL), CD20+, CD10-, CD38, CD23-, CD5+, CD22+, CD79b+, FMC7+, CD81+, CD200-. Computed tomography scan showed slight hepatomegaly, normal spleen, no lymphoadenophaties. The Electromyography (EMG) highlighted axonal motor-sensitive neuropathy to all limbs. From June to August 2015, therapy with sofosbuvir 400 mg/day, plus ribavirin 1000 mg/day started. After one month, HCV- RNA viremia was undetectable. At the end of therapy, clinical regression of purpura, asthenia and arthralgias were achieved. In August 2016 a complete immunological response has been reported (see table 2). However, in the peripheral blood MBL was still detectable and the EMG reported no remission of neuropathy.