易被忽视的血清HCV-RNA阴性丙型肝炎的诊治

目的研究血清HCV-RNA阴性慢性丙型肝炎（CHC）的诊断及治疗。方法2004-02／2008-02连续收治的血清HCV-RNA阴性CHC患者12例，平均年龄41．1岁。11例有创伤或手术史，10例血清抗．HCV检查阳性至少3次，另2例阴性（此前曾有过阳性）。血清ALT、AST持续或反复升高6mo以上。头5例肝穿活检见HCV-RNA，炎症活动度为Ⅱ度4例，Ⅲ度1例。排除其它肝病。所有患者均予干扰素α300万U，im，1次／2d；利巴韦林900mg／d，分次口服，前11例疗程48wk、最后1例24wk后随访。结果10例治疗48wk，1例治疗36wk自行停药，1例完成24wk治疗。所有患者血清ALT和AST均于4wk内降至正常。12例均有不同程度的干扰素副反应，均未影响治疗。治疗结束后随访10-48mo所有患者血清ALT和AST均正常，HCV-RNA及抗-HCV无变化。结论有创伤／手术史，血清抗-HCV阳性或以前曾有过阳性，HCV-RNA阴性、ALT、AST持续或反复异常超过6mo当考虑血清HCV-RNA阴性CHC诊断，排除其它肝病及／或肝组织检测到HCV-RNA时当诊断血清HCV-RNA阴性CHC并积极抗病毒治疗，对干扰素α和利巴韦林反应良好。

Diagnosis and treatment of chronic hepatitis C with serum HCV ribonucleic acid negative

Objective To study the diagnosis and the treatment of chronic hepatitis C （CHC） with serum HCV-RNA negative. Methods Twelve CHC patients aged 41.1 （range 31-56） years with serum HCV-RNA negative were consecutively collected and treated since 2 Feb, 2004.11 of them had injured history （pluck teeth, wound or operations） 2-10years from the injuries to this study. Serum tests for anti-HCV were positive at least three tests in 10 cases, and 2 had been previous positive. Serum ALT（104＋/-13.3U）, AST （65.4 ＋/-10.4U） were incessantly （7 eases） or repeatedly （5 cases） elevated for more than 6 months. Inflammatory activity degree of liver histopathology in first 5 cases with biopsy showed G Ⅱ in 4 cases and GⅢ in 1 case, and found HCV- RNA by immunohistochemistry in all these 5 cases. There were no evidences of other viral hepatitis, or immunological, alcoholic, metabolic, medicine-induced and steatohepatitis. Serum HCV-RNA negative CHC were diagnosed in all of 12 patients and anti-HCV treatment were carried out with interferon （IFN）-alpha-2b 300MU, intramuscularly, once/2d, combining with rihavirin 900 mg/d for 48wk in first 11cases,and 24wk in last 1 case. All patients were repeatedly tested for ALT, AST, HCV-RNA etc. during study and followed up regularly after treatment. Results 10 of 12 cases performed 48wk treatment,1 case ended the treatment after 36wk, another one performed 24 wk treatment. ALT and AST descended to normalization within 4 weeks in all patients. No abnormal events were found except common IFN adverse events. ALT and AST remained normal during followed 10-48 months, and HCV-RNA, anti-HCV remained unchanged. Conclusions A diagnosis of CHC with serum HCV-RNA negative would be considered when the patient who have injured history, serum anti-HCV positive （or previous positive） but HCV-RNA negative with incessantly or repeatedly elevated ALT, AST for more than 6 months, and the diagnosis would be decided when exclude other liver diseases or find HCV RNA in liver histology. Anti-HCV treatment would be actively carried out in spite of serum HCV-RNA negative and there is a better response to IFN and ribovirin.