It is widely accepted that seroconversion of HBsAg to. HBsAb indicates clearance of hepatitis B virus. We describe a 50-year-old man with chronic myelocytic leu ...
Bone Marrow Transplantation, (2000) 25, 105–108 2000 Macmillan Publishers Ltd All rights reserved 0268–3369/00 $15.00 www.nature.com/bmt
Case report Fulminant hepatitis B following bone marrow transplantation in an HBsAg-negative, HBsAb-positive recipient; reactivation of dormant virus during the immunosuppressive period K Iwai1, M Tashima1, M Itoh1, T Okazaki1, K Yamamoto1, H Ohno1, H Marusawa2, Y Ueda2, T Nakamura2, T Chiba2 and T Uchiyama1 Departments of 1Hematology and Oncology, 2Hepatology and Gastroenterology, Clinical Sciences for Pathological Organs, Graduate School of Medicine, Kyoto University, Kyoto, Japan
Summary: It is widely accepted that seroconversion of HBsAg to HBsAb indicates clearance of hepatitis B virus. We describe a 50-year-old man with chronic myelocytic leukemia who developed lethal hepatitis B 22 months after allo-BMT. He had been negative for HBsAg and positive for HBsAb before BMT. Hepatitis B virus latently existing in the liver cells before BMT proliferated during the immunosuppressed period causing fatal hepatitis. Recipients with positive HBsAb should be considered to have the potential for active hepatitis B to emerge after BMT. Bone Marrow Transplantation (2000) 25, 105–108. Keywords: bone marrow transplantation; hepatitis B; HBsAg-negative
The risk of hepatitis B caused in patients positive for hepatitis B surface antigen (HBsAg) by reactivation of the virus after bone marrow transplantation (BMT) has been well recognized.1–3 However, hepatitis occurring in patients who had been positive for anti-hepatitis B surface antibody (HBsAb) before BMT is rarely reported.4–6 We report here lethal hepatic failure that developed in an immunosuppressed patient after allo-BMT due to reactivation of latent hepatitis B virus (HBV) despite having HBsAb and no virus DNA detected in the serum before transplantation. Methods EIA enzyme immunoassay kits AxSYM (Dinabot, Tokyo, Japan) were used for detection of HBsAg, HBsAb, antiHBV core antibody (HBcAb), HBV e antigen (HBeAg) and anti-HBV e antibody (HBeAb). Serum HBV was measured by the branched DNA probe method using commercial
Correspondence: K Iwai, Department of Hematology and Oncology, Clinical Sciences for Pathological Organs, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharamachi, Sakyo-ku, Kyoto, 606–8397, Japan Received 4 January 1999; accepted 3 August 1999
Quantiplex HBV-DNA (Chiron, Emeryville, CA, USA). All procedures were performed according to the manufacturer’s recommendations. Polymerase chain reaction (PCR) assays were performed as described previously.7 Case report A 50-year-old man consulted our hospital in April 1995 for leukocytosis that had been found on a regular checkup at his company and which was accompanied by abdominal fullness. He had splenomegaly 16 cm below the left costal margin and the peripheral blood showed a leukocytosis with basophilia. Bone marrow aspiration and biopsy revealed a hypercellular marrow with a very low G/E ratio and an increased percentage of blast cells, although the value remained under 30%, and myelofibrosis. The karyotype of all bone marrow cells examined was 46XY, t(9;22) (q34;q11). BCR-ABL fusion mRNA was also detected by the PCR method. He was diagnosed as having a chronic myelocytic leukemia in accelerated phase and was treated with hydroxyurea and interferon-␣. Because stable hematological remission was not obtained and his disease was considered to be very close to blast crisis, he underwent unrelated bone marrow transplantation from an HLA one locus mismatched 43-year-old female donor in April 1996. He was given buslfan 3.6 mg/kg over 4 days, cytarabin 50 mg/kg over 3 days, and cyclophosphamide 60 mg/kg over 3 days without total body irradiation as conditioning therapy. FK506 and short-term methotrexate were used for prophylaxis of acute GVHD. Engraftment was confirmed on day 13 by X-chromosomal examination (FISH). The level of serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and ␥-glutamyl transferase (␥-GTP) were elevated (first episode) 68 days after BMT, and at the same time a maculopapular skin eruption developed on the face, body and extremities. Skin biopsy findings were consistent with acute GVHD. Those eruptions disappeared with 60 mg of prednisone daily in addition to 5 mg of FK506 daily. Transaminase levels also decreased to within two times the normal range. Doses of immunosuppressants were gradually decreased to the minimum necessary to suppress GVHD because he had second-
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a
b
PSL FK506
ALT
γ - GTP
(IU/l)
(mg/dl)
MTX 10 mg
DHPG
T-BIL Iamivudine
CPA 100 mg
(mg/dl) PE
800
30
4000
Liver biopsy 600
3000 20
400
2000 10
200
1000
0 200
250
300
350
660
670
680
690
700
Days after BMT Figure 1 Clinical course of the second and third episodes. MTX ⫽ methotrexate; CPA ⫽ cyclophosphamide; PSL ⫽ prednisone; DHPG ⫽ ganciclovir; PE ⫽ plasma exchange.
ary diabetes mellitus possibly due to steroid therapy. However, a skin eruption and elevation of the liver enzyme levels were again observed. The ␥-GTP was especially elevated to over 4000 IU/l but the total bilirubin remained under 4.2 mg/dl (second episode, Figure 1a). Ulceration of the oral mucosa was noted. The patient was readmitted to our hospital in December 1997 for treatment of chronic GVHD and diabetes mellitus. At this time, evaluations including antigen and antibody for HBV did not suggest active viral hepatitis (Table 1). He was treated with an increased dose of both FK506 and corticosteroid for exacerbated chronic GVHD. Insulin was given to control the blood sugar level. The total bilirubin level returned to under 1.5 mg/dl, and the serum levels of ALT and ␥-GTP also decreased from ⬎931 IU/l at the peak to 82 IU/l, and from ⬎4000 IU/l at the peak to 527 IU/l, respectively (Figure 1a). Skin and oral GVHD also improved and stablised. Dose reduction of the immunosuppressive drugs was tried again. Five hundred and sixty days after BMT, the total bilirubin and other liver enzymes, Table 1
especially AST and ALT began to rise more markedly than had the previous elevation of ␥-GTP (third episode Figure 1b). Skin and oral GVHD symptoms did not appear to worsen. At this time, reversed seroconversion for HBV was observed. The serum HBV surface and e antigen changed from negative to positive, while HBsAb, HBcAb and HBeAb changed from positive to negative. The amount of serum HBV DNA was over 5700 mEq/ml, which had not been detected before transplantation even by the PCR method (Table 1). The HBV had a mutation in the precore region. Histopathology of a liver specimen obtained by needle biopsy revealed acute hepatitis with small lymphocyte infiltration (Figure 2). HBsAg and HBcAg were detected in almost all hepatocytes by immunochemical examination (Figures 3, 4). There had been no history of blood product transfusion since the second episode. These results suggested that the third episode was proscribed by proliferation of HBV that existed before transplantation. Although the quantity of serum virus DNA decreased dramatically after administration of ganciclovir and lamivud-
Serological profile of HBV markers
Days after BMT
HBsAg HBsAb HBcAb HBeAg HBeAb HBV-DNA
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⫺361
309 (2nd episode)
659 (3rd episode)
686
702
0.7 (⫺) 41.0 (⫹) 97.0 (⫹) 0.7 (⫺) 90.1 (⫹) ⬍0.7 mEq/ml
1.0 (⫺) 8.0 (⫹) 97.0 (⫹)
69.7 (⫹) 0.0 (⫺) 39.4 (⫺) 3.0 (⫹) 5.5 (⫺) ⬎5700
90.0 (⫹) 0.0 (⫺) 27.9 (⫺) 2.2 (⫹) 5.3 (⫺) 1100
183.9 (⫹) 0.0 (⫺) 65.4 (⫹) 1.3 (⫺) 3.2 (⫺) 2.4
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Figure 2 Histological examination of needle liver biopsy. HE staining. Ballooned and necrotic hepatocytes and little lymphocytic infiltration of the portal area were seen.
Figure 5 Postmortem examination of the liver. Azan stain demonstrating massive necrosis of the hepatocytes and increased fibrosis. Cholestasis was also seen.
Discussion
Figure 3 Immunohistochemical examination of the sample. HBsAg staining. Almost all hepatocytes were positive for HBsAg.
Figure 4 HBcAg staining. Almost all hepatocytes were also positive for HBcAg.
ine (Figure 1b), he died of hepatic failure and disseminated aspergillosis 702 days after transplantation. Postmortem examination confirmed acute hepatitis with massive necrosis of the hepatocytes, and systemic aspergillosis.
The patient described above was positive for HBsAb, HBeAb and HBcAb, but negative for HBsAg and HBeAg, and HBV DNA in the serum was not detectable by a sensitive PCR assay before transplantation. Such data are routinely accepted as indicating that hepatitis has resolved and that the patient no longer has HBV. However, patients who have undergone live liver transplantation from HBcAb positive donors have recently been reported to become highly positive for HBsAg, and HBV has been detected in the liver of HBcAb positive healthy donors.7 Another report of HBV DNA being detectable in the hepatocytes after clearance of HBsAg from serum is given in Ref. 8. The patient in this case also had the virus existing latently or replicating in the liver cells. This was thought to be the source of severe hepatitis after BMT because the donor and blood products were all negative for HBsAg, although it could not completely be excluded that a new exogenous virus may have infected the recipient since HBV negativity of the donor’s bone marrow was not confirmed. Exacerbation of HBV-induced hepatitis or development of active hepatitis in recipients positive for HBsAg after BMT is well known.1–3 In these cases, hepatitis has occasionally progressed to the fulminant stage and it is thought that this was induced by reactivation of HBV in the recipient’s liver cells. The virus begins to proliferate during immunosuppression after BMT and then active hepatitis develops depending on the recovery of the immune response when doses of immunosuppressant are reduced or discontinued. The same mechanism may have been in operation in the case reported here. The recipient’s prior immunity was reduced after BMT, while the immune function deriving from the donor cells was still suppressed because of immunosuppressive agents. During this period, the dormant virus proliferated and infected the majority of the liver cells. The actual risk of reverse seroconversion of HBV markers after BMT has recently been reported to be relatively high, whereas there are only a few cases reported in the literature of patients who were negative for HBsAg before BMT developing hepatitis following BMT.4,6,7 Additionally, only one of these reported case progressed to Bone Marrow Transplantation
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a fatal outcome. From 1 to 2% of healthy individuals are carriers of HBsAg in Japan.9 Moreover, the number of people who are positive for HBsAb is approximately 30%.9 For this reason, our case indicates that the potential risk of active and fulminant hepatitis should not be underestimated. There are some procedures which may prevent or treat this type of hepatitis.10 It is better to choose a vaccinated donor. Donors positive for HBsAg or HBsAb should be tested for HBV DNA by PCR not only on serum but also blood cells and liver cells. More important is recognition of the risk that latent HBV infection may lead to fulminant hepatitis in a recipient positive for HBsAb. Therefore, molecular examination of liver cells biopsied before transplantation to detect HBV and whether this is the wild or mutant type can be useful because it is important to determine the possibility of HBV reactivation in order to prevent severe hepatitis. In the post-transplant period, early detection of HBV DNA in blood is required and suppression of its proliferation. HB specific immunoglobulin infusions may be effective.7,11 When active hepatitis does occur, ganciclovir or lamivudine may be effective.12 Lamivudine inhibits the reverse transcriptase step in HBV replication.13 These drugs were, in fact, able to decrease viral DNA in the serum of our patient instead of allowing mutation of the precore region, which often contributes to resistance to treatment with agents including lamivudine.14 However, in our case, early treatment before massive liver damage had occurred may have prevented liver failure.
Acknowledgements We would like to thank Dr Y Morishima, Dr H Sao and Dr K Kitaori for their BMT procedure.
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References 14 1 McIvor C, Morton J, Bryant A et al. Fatal reactivation of precore mutant hepatitis B virus associated with fibrosing choles-
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tatic hepatitis after bone marrow transplantation. Ann Int Med 1994; 121: 274–275. Pariente A, Goudeau A, Dubois F et al. Fulminant hepatitis due to reactivation of chronic hepatitis B virus infection after allogeneic bone marrow transplantation. Diges Dis Sci 1988; 33: 1185–1191. Caselitz M, Hein R, Maschek H et al. Hepatitis B associated liver failure following bone marrow transplantation. J Hepatol 1997; 27: 572–577. Webster A, Brenner MK, Prentice HG, Griffiths PD. Fatal hepatitis B reactivation after autologous bone marrow transplantation. Bone Marrow Transplant 1989; 4: 207–208. Martin BA, Rowe JM, Kouides PA et al. Hepatitis B reactivation following allogeneic bone marrow transplantation: case report and review of the literature. Bone Marrow Transplant 1995; 15: 145–148. Dhe´din N, Douvin C, Kuentz M et al. Reverse seroconversion of hepatitis B after allogeneic bone marrow transplantation. Transplantation 1998; 66: 616–619. Uemoto S, Sugiyama K, Marusawa H et al. Transmission of hepatitis B virus core antibody-positive donors in living related liver transplants. Transplantation 1998; 65: 494–499. Mason A, Xu L, Guo L et al. Molecular basis for persistent hepatitis B virus infection in the liver after clearance of serum hepatitis B surface antigen. Hepatology 1998; 27: 1736–1742. Brown P. The seroepidemiology of hepatitis A and B in the Asia-Pacific region. Asia Pac J Public Health 1987; 1: 62–78 Strasser S, McDonald B. Hepatitis viruses and hematopoietic cell transplantation: a guide to patient and donor management. Blood 1999; 93: 1127–1136. Tchervenkov J, Barkun J, Forbes C et al. Recurrence-free long-term survival after liver transplantation for hepatitis B using interferon-alpha pretransplant and hepatitis B immune globulin posttransplant. Ann Surg 1997; 226: 356–369. Mertens T, Kock J, Hampl W et al. Reactivated fulminant hepatitis B virus replication after bone marrow transplantation: clinical course and possible treatment with ganciclovir. J Hepatol 1996; 25: 968–971. Doong L, Tsai H, Schinazi F et al. Inhibition of the replication of hepatitis B virus in vitro by 2⬘-3⬘-dideoxy-3⬘-thiacytidine and related analogues. Proc Natl Acad Sci USA 1991; 88: 8495–8499. Bartholomew M, Jansen R, Jeffers L et al. Hepatitis-B-virus resistance to lamivudine given for recurrent infection after orthotopic liver transplantation. Lancet 1997; 349: 20–22.
