Very late relapse of hepatitis C virus infection immediately after liver transplant

Late relapse of hepatitis C virus (HCV) infection is very rare in the era of modern direct-acting antiviral therapy. We report here the first case of a late relapse, after direct-acting antiviral therapy, occurring immediately after liver transplant (LT), with 93 weeks of sustained virologic response before LT. HCV RNA in serum and in liver biopsy was negative the day of LT, and relapse was diagnosed 11 days after LT. HCV NS5A sequencing was performed on samples before and after LT, with 99% of homology demonstrating a true late relapse rather than a reinfection. This late relapse could be explained by extrahepatic reservoirs of HCV and the high immunosuppressive therapy, including bolus of steroids, within the first days post LT. In conclusion, our case suggests that monitoring HCV RNA after LT could be recommended to detect and treat early relapse, even after a long virologic response.