Fulminant Hepatic Failure due to Chemotherapy-Induced Hepatitis B Reactivation: Role of Rituximab

Zusammenfassung

Die Reaktivierung einer Hepatitis-B-Virus-Infektion während immunsuppressiver Therapien kann zu akutem Leberversagen führen, für welches es nur begrenzt Therapieoptionen gibt. In der vorliegenden Fallbeschreibung werden 2 Fälle präsentiert mit schwerer Hepatitis-B-Reaktivierung unter immunsuppressiver Therapie mit Rituximab bei B-Zell-Lymphom, die mit Leber- bzw. Leberzelltransplantation behandelt wurden. Vor Beginn der immunsuppressiven Therapie war die Leberfunktion normal und eine Hepatitis-B-Infektion unbekannt. Nach 4 bzw. 6 Zyklen Chemotherapie wurde erstmalig eine eingeschränkte Leberfunktion festgestellt und im Verlauf entwickelte sich bei beiden Patienten ein akutes Leberversagen trotz antiviraler Therapie mit Lamivudin oder Entecavir. Patient A wurde bei kompletter Remission des B-Zell-Lymphoms lebertransplantiert und überlebte bisher ohne Zeichen einer Hepatitis-B-Reaktivierung. Patient B erhielt 4 Zyklen einer Leberzell-Transplantation, überlebte allerdings nicht. Diese Fälle verdeutlichen die Relevanz von anti-HBc-Screeninguntersuchungen bei Patienten mit immunsuppressiver Therapie, insbesondere mit Rituximab. Eine prophylaktische antivirale Behandlung ist indiziert, da ein später Beginn der antiviralen Therapie ein Leberversagen häufig nicht mehr verhindern kann.

Abstract

Hepatitis B virus reactivation during immunosuppressive therapies can lead to liver failure with very limited treatment options available. We report here on two cases of severe hepatitis B reactivation during chemotherapy including rituximab for B cell lymphoma which were treated with liver or liver-cell transplantation. Liver function was normal and HBV infection was unknown in both patients before chemotherapy was started. Impaired liver function became apparent after 4 and 6 courses of chemotherapy, respectively, and both patients experienced fulminant hepatic failure despite antiviral treatment with lamivudine or entecavir. Patient A underwent liver transplantation after documentation of complete remission of the lymphoma and survived without any evidence for hepatitis B recurrence. Patient B received 4 courses of hepatocyte transplantation but did not survive. These cases underline the importance of anti-HBc screening in patients receiving immunosuppressive treatments in particular when rituximab is given. Pre-emptive antiviral treatments should be administered since delayed antiviral treatment is frequently unable to prevent liver failure.

Schlüsselwörter

Rituximab - Hepatitis B - immunsuppressiver Therapie - Transplantation

Key words

rituximab - immunosuppression - hepatitis B - transplantation

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