Fatal Fulminant Hepatitis from Rituximab-induced Hepatitis B Reactivation in a Patient with Follicular Lymphoma: A Case Report and a Brief Review of Literature

Abstract

The objective of our study was to recognize hepatitis B reactivation as a complication of rituximab chemotherapy and to realize the importance of screening for prior Hepatitis B virus (HBV) exposure in all patients with hematologic malignancies who will receive rituximab as part of their therapy. Rituximab is a monoclonal antibody targeting CD 20 receptors on the membrane of B cells. In this case report, we described a 79-year-old man who presented to our department with nausea, fatigue, and jaundice. Two months ago, he had received the last dose of the chemotherapy regimen containing rituximab for follicular B cell lymphoma. Ultrasound and computed tomography (CT) scan of abdomen did not show any focal lesions. Liver function tests showed worsening hepatic failure and viral serology demonstrated active HBV infection. Antiviral therapy with entecavir and tenofovir disoproxil fumarate failed to improve his symptoms, and he died of fulminant hepatic failure. Rituximab targets CD 20 receptors positive B cells. It can destroy both cancerous and normal B cells. A decline in immune function can activate occult HBV infection. Prior to initiation of rituximab therapy, screening should be conducted in all cases for HBV associated serological markers. Patients with active or occult HBV infection must be started on appropriate antiviral therapy to prevent any severe outcomes with rituximab-containing regimens.

Burden, Outcome, and Comorbidities of Extrahepatic Manifestations in Hepatitis B Virus Infections

“…Because HBV-associated vasculitic neuropathy occurs commonly with a mixed cryoglobulinemia presentation, the preferred treatment includes entecavir for antiviral therapy, started concomitantly with glucocorticoids and rituximab, regardless of HBe and HBV DNA status [ 96 , 97 ]. An exception to rituximab use is the patient in an active hepatitis flare since this situation can have fatal consequences [ 98 ].…”

Peripheral B Cell Deficiency and Predisposition to Viral Infections: The Paradigm of Immune Deficiencies

“…Rituximab has now been used in clinical practice for more than 20 years and its role as an independent risk-factor for the development of viral infections is well documented (34,71). Cases of viral reactivation are reported in the literature (Table 1), most commonly by hepatitis B virus (34,(144)(145)(146), VZV (disseminated or cutaneous infection) (33,34,71,115) and CMV (meningoencephalitis (107, 108), pneumonitis (109,110), colitis (111)). JC virus-induced PML (57,58), BK virusassociated nephropathy/viremia (71), severe warts (123), adenovirus-induced fulminant hepatitis (63), and HSV-induced encephalitis (94), keratitis (95) and tracheitis (96) have also been reported.…”

Human hepatitis viruses-associated cutaneous and systemic vasculitis

“…Considering the risk of viral reactivation in patients with positive HBs or an occult infection with negative HBs and positive anti-HBc, prophylaxis with NAs should be initiated before the rituximab treatment[ 70 , 124 , 129 ]. Because of a potentially fatal complication, its use should be avoided during an active flare of HBV infection[ 70 , 130 ]. Prescription of this biologic as a second-line agent can be considered in patients with severe disease refractory to NA therapy[ 70 , 123 ].…”