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Case Report
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 Oh1, Seung Un Song1, Hae Won Lee1, Ji Yeon Kim1, Seon Ja Park1
Kosin Medical Journal 2014;29(2):161-168.
DOI: https://doi.org/10.7180/kmj.2014.29.2.161
Published online: December 18, 2014

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: December 27, 2013   • Accepted: February 14, 2014

Copyright © 2014 Kosin University School of Medicine Proceedings

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.

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  • 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
Figure 1A Figure 1B
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Figure 2
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Figure 3
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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
HBs Ag HBs Ab HBc DNA HBs Ag HBs Ab HBc DNA
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.

  • 1.Wands JR, Chura CM, Roll FJ, Maddrey WC. Serial studies of hepatitis-associated antigen and antibody in patients receiving antitumor chemotherapy for myeloproliferative and lymphoproliferative disorders. Gastroenterology 1975;68:105–12.ArticlePubMed
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        A Case of Reactivation of Hepatitis B and Fulminant Hepatitis which developed 3 months following Chemotherapy Including Rituximab in a Patient with Lymphoma
        Kosin Med J. 2014;29(2):161-168.   Published online December 18, 2014
        DOI: https://doi.org/10.7180/kmj.2014.29.2.161
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      A Case of Reactivation of Hepatitis B and Fulminant Hepatitis which developed 3 months following Chemotherapy Including Rituximab in a Patient with Lymphoma
      Image Image Image
      Figure 1A Figure 1B
      Figure 2
      Figure 3

      Figure 1A Figure 1B

      Figure 2

      Figure 3

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

      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

      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

      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
      HBs Ag HBs Ab HBc DNA HBs Ag HBs Ab HBc DNA
      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
      Table 1. Serial of Immunologic findings

      HD; hospital day

      Table 2. Serial of blood chemistry.

      HD: hospital day

      Table 3. Cases of HBV Reactivation after Treatment including Rituximab in Patients with Lymphoma and HBsAg negative.

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

      Table 1.

      Table 2.

      Table 3.

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