entecavir and Anti-Neutrophil-Cytoplasmic-Antibody-Associated-Vasculitis

Rituximab (RTX), a chimeric mouse anti-human CD20 monoclonal antibody, is indicated for the treatment of patients with non-Hodgkin's lymphoma, chronic lymphocytic leukemia, granulomatosis with polyangiitis and microscopic polyangiitis, and rheumatoid arthritis, but nowadays it is increasingly used for the treatment of many other immune-mediated disorders. Hepatitis B virus (HBV) reactivation in RTX-treated patients, eventually leading to fatal liver failure, has been reported more often among hepatitis B surface antigen (HBsAg)-positive patients (overt infection) than in HBsAg-negative, antibody to hepatitis B core antigen (anti-HBc) seropositive patients (resolved infection).. This paper reviews the safety of RTX in patients with overt or resolved HBV infection, providing recommendations for its safe use in such patients.. Prior to starting RTX treatment, all patients should be screened for HBV infection. While HBsAg-positive active carriers should receive long-term antiviral treatment with entecavir (ETV) or tenofovir, inactive carriers are candidates for universal prophylaxis with lamivudine, or ETV or tenofovir in selected cases, to prevent hepatitis reactivation. Conversely, for HBsAg-negative anti-HBc positive carriers, that is, those with resolved HBV infection, universal prophylaxis with lamivudine is recommended for those with onco-hematological diseases, whereas watchful monitoring of HBsAg/HBV DNA levels is advisable for all the other indications.

Topics: Adenine; Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis; Antibodies, Monoclonal, Murine-Derived; Antiviral Agents; Arthritis, Rheumatoid; Autoimmune Diseases; Carrier State; Disease Management; DNA, Viral; Guanine; Hepatitis B; Hepatitis B Surface Antigens; Hepatitis B virus; Humans; Leukemia, Lymphocytic, Chronic, B-Cell; Lymphoma, Non-Hodgkin; Lymphoproliferative Disorders; Organophosphonates; Rituximab; Tenofovir; Virus Activation

Transverse myelitis, subarachnoid hemorrhage, and nephropathy are established but rare complications of hepatitis B virus infection that can potentially be triggered by an antibody-mediated vasculitis as a result of a viral infection. The following is a case report detailing a patient presenting with all three of the above presentations who is cytoplasmic antineutrophil cytoplasmic antibody-positive and a chronic carrier of hepatitis B.. A 33-year-old Nepalese man presented to our hospital with headache, swelling of his body, paraplegia, and back pain that developed over a period of 10 days. Laboratory studies showed proteinuria and elevated levels of serum urea and creatinine. Viral serology was suggestive of chronic inactive hepatitis B carrier state. A computed tomography scan of his head revealed features suggestive of subarachnoid hemorrhage. Magnetic resonance imaging of his dorsal spine showed diffuse T2 high signal intensity within his spinal cord extending from second to 12th thoracic vertebral level which was suggestive of transverse myelitis. The origin of these symptoms was attributed to immune complex-mediated vasculitis after serum analysis for cytoplasmic antineutrophil cytoplasmic antibody came out positive. He was managed with steroids administered orally and intravenously and entecavir administered orally.. This case highlights the possibility of a hepatitis B virus-induced vasculitis as the cause of subarachnoid hemorrhage, transverse myelitis, and nephropathy.

Topics: Adult; Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis; Antibodies, Antineutrophil Cytoplasmic; Antiviral Agents; Back Pain; Edema; Guanine; Headache; Hepatitis B virus; Humans; Kidney; Magnetic Resonance Imaging; Male; Methylprednisolone; Myelitis, Transverse; Paraplegia; Subarachnoid Hemorrhage; Thoracic Vertebrae; Tomography, X-Ray Computed; Treatment Outcome