Reactions 1218 - 6 Sep 2008

SAntineoplastics

Hepatitis B reactivation: 2 case reportsTwo patients experienced reactivation of hepatitis B virus

(HBV) infection following treatment with the rituximab-containing antineoplastic regimen R-CHOP (rituximab,cyclophosphamide, doxorubicin, vincristine and prednisone/prednisolone* [dosages not stated]); patient 1 subsequentlydied.

Patient 1, a 68-year-old woman with large B-cell lymphoma,received six courses of R-CHOP. After 1 year, while inremission, she presented with a respiratory infection.Laboratory findings at this time showed an AST level of109 UI/L, an ALT level of 88 UI/L, a GGT level of 221 UI/L, abilirubin level of 0.9 mg/dL and a LDH level of 536 UI/L.Despite negative viral serology, she began receivinglamivudine. Her liver function tests worsened over thefollowing week reaching an AST level of 153 UI/L, an ALT levelof 97 UI/L, a GGT level of 815 UI/L, a bilirubin level of 14 mg/dLand a LDH level of 342 UI/L. Serology was HBsAg and HBeAgpositive, consistent with HBV reactivation. Her conditioncontinued to deteriorate with liver and renal dysfunctionleading to multiple organ failure and death.

Patient 2, a 53-year-old woman with follicular lymphoma,received three courses of R-CHOP. Nine months later, while incomplete remission, asymptomatic liver dysfunction wasnoted. She had an AST level of 177 UI/L, an ALT level of177 UI/L, a GGT level of 201 UI/L, a bilirubin level of 1.2 mg/dLand a LDH level of 495 UI/L. Despite serology showing onlyresolved HBV infection she received lamivudine. Later testsconfirmed reactivation of HBV (HBsAg and HBeAg positivewith a HBV-DNA level of 3120 pg/mL). After 7 months, shedeveloped pancreatitis which resolved following cessation oflamivudine. Treatment resumed with entecavir. Three monthslater she remained asymptomatic with a declining HBV-DNAlevel and a slight improvement in her liver function.

Author comment: "Rituximab induces profound anddurable B-cell depletion. This may account for the increasingincidence of HBV reactivation in HBsAg-negative patients."

* It is not specified whether the patients were receiving prednisone orprednisolone as part of R-CHOP

Garcia-Rodriguez MJ, et al. Late reactivation of resolved hepatitis B virusinfection: an increasing complication post rituximab-based regimens treatment?American Journal of Hematology 83: 673-675, No. 8, Aug 2008 -Spain 801117780

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