51 Not surprisingly, patients with occult infection appear to be at higher risk for HBV reactivation than HBcAb positive/HBV DNA negative patients.37 The true incidence of chemotherapy-induced reactivation selleck compound of hepatitis B in these patients is uncertain. Lok and colleagues performed
a prospective study of HBV reactivation in 100 Chinese patients who received chemotherapy for lymphoma. Fifty-one of these patients had evidence of previous hepatitis B exposure (HBcAb positive with or without HBsAb). Following chemotherapy, reactivation hepatitis occurred in 4%, none of whom died, compared to 48% in patients who were HBsAg positive at the time of chemotherapy, in whom the mortality reached 8%.17 More recently, in a retrospective analysis of 319 HBcAb positive/HBsAg negative patients receiving chemotherapy for lymphoma, reactivation of hepatitis B occurred in just over 1%. However in the 74 patients in this study who received chemotherapy in combination with rituximab, the reactivation rate was 2.7%.56 There are now a number of case reports of fatal reactive hepatitis in HBcAb-positive patients who received rituximab-containing chemotherapy for lymphoma.42,46,57–59 In the setting of allogenic hematopoietic stem cell transplantation seroreversion is far check details more common than following standard chemotherapy; it occurs in 40% at 2 years and 70% of patients at 5 years post-transplantation.60
With find more prolonged follow-up, the rate of seroreversion in one case series approached 100%.61 Patients with graft-versus
host disease appear more likely to undergo seroreversion and represent a particularly high-risk group.62 It has been proposed that a drop in HBsAb titer can identify patients at risk of seroreversion and who are likely to benefit from antiviral prophylaxis.60,63 However, this approach is not applicable to HBsAb-negative and HBcAb positive patients and remains untested in other patient populations. Reactivation has also been described in HBcAb positive/HBsAg negative patients following organ transplantation,64 although the relative risk of reactivation is low and routine anti-viral therapy is generally not used in this patient group.65 The most important first step in avoiding the serious morbidity associated with HBV reactivation is to identify patients at risk before they undergo chemotherapy. Clearly, in areas of high HBV endemicity all patients should be screened for HBsAg and HBcAb prior to immunosuppressive chemotherapy. There are many immunosuppressive therapies that carry a low risk of HBV reactivation, and are so widely used to make routine HBV screening in low risk populations impractical. These include short courses of corticosteroids alone, and widely used immunosuppressant medications such as methotrexate and azathioprine when used as monotherapy.