A Case of Reactivation of Hepatitis B and Fulminant Hepatitis which developed 3 months following Chemotherapy Including Rituximab in a Patient with Lymphoma

Tae Won Lim; Hee Taek Oh; Seung Un Song; Hae Won Lee; Ji Yeon Kim; Seon Ja Park

doi:10.7180/kmj.2014.29.2.161

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Lim, Oh, Song, Lee, Kim, and Park: A Case of Reactivation of Hepatitis B and Fulminant Hepatitis which developed 3 months following Chemotherapy Including Rituximab in a Patient with Lymphoma

Case Report

Kosin Medical Journal 2014;29(2):161-168.

Published online: 18 December 2014

DOI: https://doi.org/10.7180/kmj.2014.29.2.161

A Case of Reactivation of Hepatitis B and Fulminant Hepatitis which developed 3 months following Chemotherapy Including Rituximab in a Patient with Lymphoma

Tae Won Lim¹, Hee Taek Oh^1,, Seung Un Song¹, Hae Won Lee¹, Ji Yeon Kim¹, Seon Ja Park¹

¹Department of Gastroenterology, Dae-Dong Hospital, Busan, Korea

Corresponding Author : Tae Won Lim, Department of Internal Medicine, Dae-Dong Hospital, 187, Chungyeldae-ro, Dongrae-gu, Busan, 607-711, Korea TEL: +82-51-550-9615 FAX: +82-51-553-7575 E-mail: twoni@hanmail.net

Received 27 December 201327 December 2013 Accepted 14 February 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Since Wands et al. reported for the first time in 1975 the reactivation of the hepatitis B virus in hematologic disease patients who had been receiving chemotherapy, the efficacy of chemotherapy and immunosuppressants has improved. As a result, the frequency of the reactivation of hepatitis B is increasing. Reported herein is a case of a non-Hodgkin lymphoma patient in her 70s who was suspected to have had HBsAg negative/anti-HBs negative occult HBV infection. The patient experienced fulminant hepatitis caused by the reactivation of hepatitis B, and died three months after the R-CHOP regimen was completed. In the HBsAg negative plus HBV DNA-negative case, there were few instances of viral activation of HBV. In this case, antiviral therapy was needed when the patient was confirmed to have become HBV DNA positive through regular monitoring, but its necessity is often overlooked, unlike the preemptive antiviral treatment in the HBsAg positive cases.

Keywords: Chemotherapy, Hepatitis B virus, Immunosuppression

REFERENCES

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Figure 1A Figure 1B

Figure 2

Figure 3

Table 1.

Serial of Immunologic findings

	8 month ago	HDU#1
HBsAg	Negative	Positive
anti-HBs	Negative	Negative
HBeAg		Negative
anti-HBe		Negative
IgM anti-HBc		Negative
IgG anti-HBc		Positive
HBV DNA (copies/mL)		4.8 × 10⁸
HAV Ab IgM		Negative
HAV Ab IgG		Positive
ami-HCV	Negative	Negative

HD; hospital day

Table 2.

Serial of blood chemistry.

	HD#1	HD#2	HD#5	HD#6	HD#7
AST (IU/L)	2461	2345	781	542	262
ALT (IU/L)	2329	2312	1116	895	496
Total bilirubin (mg/dL)	15.0		25.8	28.8	30.7
Direct bilirubin	9.09		11.8	13.5	15.1
gamma GTP (IU/L)	166		107		64
ALP (IU/L)	570		300	295	259
Total protein ig/dL)	5.5		5.7	5.6	5.5
Atbumin	2.9		3.4	32	3.3
PT (sec)	35.6		33.2	40.8	34.8
PT(%)	24		25	20	24
PTINR	3.198		2.85	3.46	2.98
Ammonia	54				269

HD: hospital day

Table 3.

Cases of HBV Reactivation after Treatment including Rituximab in Patients with Lymphoma and HBsAg negative.

Age/ Sex	HBV prior to treatment				HBV reactivation				Onset	Cone
Age/ Sex	HBs Ag	HBs Ab	HBc	DNA	HBs Ag	HBs Ab	HBc	DNA	Onset	Cone
71/F^¶			ND	ND	+	-	+	+	3	Exp
79/F⁸	-	+	+	ND	+	-	+	+	8	Exp
56/F¹³	-	+	+	ND	-	-	+	+	14	Rcc
69/M²³	-	+	ND	ND	+	-		+	7	Rec
59/M²⁴	-	+	+	ND	+	-	+	+	2	Exp
66/F²⁵	-	+	ND	ND	+	-	ND	+	2	Rec

^¶ This case. ND, not done. HBc, IgG anti-HBc. Onset, Onset months of reactivation after treatment with rituximab. Cone, Conclusion. Rec, Recovered. Exp, Expired.

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