Korean J Gastroenterol.  2010 Apr;55(4):266-269. 10.4166/kjg.2010.55.4.266.

Fulminant Hepatic Failure with Hepatitis B Virus Reactivation after Rituximab Treatment in a Patient with Resolved Hepatitis B

• Chung SM
• Sohn JH
• Kim TY
• Yoo KD
• Ahn YW
• Bae JH
• Jeon YC
• Choi JH

• KMID: 1792779
• DOI: http://doi.org/10.4166/kjg.2010.55.4.266

Abstract

It is well known that the reactivation of hepatitis B virus (HBV) may occur as an acute hepatitis after chemotherapy or immunosuppressive therapy. Although most of these cases have been reported in HBsAg-positive patients, there have been a few reports of HBV reactivation in HBsAg-negative patients. There have been concerns for the need to screen the reactivation as well as anti-viral prophylaxis in HBsAg-negative patients with possible HBV occult infection who are planning to undergo chemotherapy or immunosuppressive therapy. Rituximab, an anti-CD20 monoclonal antibody, is effective in the treatment of non-Hodgkin's lymphoma. However, rituximab can affect the immunity against HBV, consequently increasing viral replication. In fact, there have been reports of HBV reactivation after treatment with rituximab. Here, we report a case of HBV reactivation following rituximab plus systemic chemotherapy in diffuse large B cell lymphoma patient who was HBsAg negative, anti-HBs positive, and anti-HBc positive, ultimately leading to treatment-unresponsive fulminant hepatic failure.

Keyword

Hepatitis B; Reactivation; HBsAg; Rituximab; Lymphoma

MeSH Terms

Aged
Antibodies, Monoclonal/*therapeutic use
Antineoplastic Agents/*therapeutic use
Antiviral Agents/therapeutic use
DNA, Viral/analysis
Female
Guanine/analogs &derivatives/therapeutic use
Hepatitis B/*diagnosis/drug therapy
Hepatitis B virus/isolation &purification
Humans
Liver Failure, Acute/*diagnosis
Lymphoma, Large B-Cell, Diffuse/*drug therapy
Recurrence

Figure

• 

  Fig. 1. Serial changes of liver function test and viral status. RCHOP, rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone; HD, hosptial day.

Reference

1. Gupta S, Govindarajan S, Fong TL, Redeker AG. Spontane-ous reactivation in chronic hepatitis B: patterns and natural history. J Clin Gastroenterol. 1990; 12:562–568.

2. Conjeevaram HS, Lok AS. Occult hepatitis B virus infection: a hidden menace? Hepatology. 2001; 34:204–206.

3. Tsutsumi Y, Kanamori H, Mori A, et al. Reactivation of hepatitis B virus with rituximab. Expert Opin Drug Saf. 2005; 4:599–608.

4. Lok AS, McMahon BJ. Chronic hepatitis B. Hepatology. 2007; 45:507–539.

5. Kim EB, Kim DS, Park SJ, Park Y, Rho KH, Kim SJ. Hepatitis B virus reactivation in a surface antigen-negative and antibody-positive patient after rituximab plus CHOP chemotherapy. Cancer Res Treat. 2008; 40:36–38.

6. Lim SM, Jang JW, Kim BW, et al. Hepatitis B virus reactivation during chlorambucil and prednisolone treatment in an HBsAg-negative and anti-HBs-positive patient with B-cell chronic lymphocytic leukemia. Korean J Hepatol. 2008; 14:213–218.

7. Yeo W, Chan PK, Zhong S, et al. Frequency of hepatitis B virus reactivation in cancer patients undergoing cytotoxic chemotherapy: a prospective study of 626 patients with identi-fication of risk factors. J Med Virol. 2000; 62:299–307.

8. Hu KQ. Occult hepatitis B virus infection and its clinical implications. J Viral Hepat. 2002; 9:243–257.

9. Dervite I, Hober D, Morel P. Acute hepatitis B in a patient with antibodies to hepatitis B surface antigen who was receiving rituximab. N Engl J Med. 2001; 344:68–69.

10. Sera T, Hiasa Y, Michitaka K, et al. Anti-HBs-positive liver failure due to hepatitis B virus reactivation induced by rituximab. Intern Med. 2006; 45:721–724.

11. Yamagata M, Murohisa T, Tsuchida K, et al. Fulminant B hepatitis in a surface antigen and hepatitis B DNA-negative patient with diffuse large B-cell lymphoma after CHOP chemotherapy plus rituximab. Leuk Lymphoma. 2007; 48:431–433.

12. Tur-Kaspa R, Burk RD, Shaul Y, Shafritz DA. Hepatitis B virus DNA contains a glucocorticoid-responsive element. Proc Natl Acad Sci USA. 1986; 83:1627–1631.

13. Yeo W, Chan TC, Leung NW, et al. Hepatitis B virus reactivation in lymphoma patients with prior resolved hepatitis B undergoing anticancer therapy with or without rituximab. J Clin Oncol. 2009; 27:605–611.

14. Hui CK, Cheung WW, Zhang HY, et al. Kinetics and risk of de novo hepatitis B infection in HBsAg-negative patients undergoing cytotoxic chemotherapy. Gastroenterology. 2006; 131:59–68.

15. van der Kolk LE, Baars JW, Prins MH, van Oers MH. Rituximab treatment results in impaired secondary humoral immune responsiveness. Blood. 2002; 100:2257–2259.