DDSEP® 8 Quick Quiz

March 2020 - Question 1

Publish date: February 28, 2020

Q1. A 45-year-old man has recently been diagnosed with leukemia. The chemotherapeutic regimen will include rituximab and high-dose steroids. He is a former IV drug user but has been sober for 20 years. His lab work is as follows: ALT 25 U/L, HAV total antibody positive, HBs antibody positive, HBs antigen negative, HBc total positive, HCV antibody positive, HCV RNA undetected.

Which of the following is true?

The patient is at risk of HCV reactivation because of prior exposure.

The patient should receive prophylaxis against HBV reverse seroconversion through his chemotherapy.

The patient should receive prophylaxis against HBV reverse seroconversion through his chemotherapy and for 12-18 months afterwards.

The HBV reactivation is not a concern in this patient.

A watchful waiting approach is reasonable with q 3 month monitoring of the ALT and HBV DNA.

Correct answer: C

Rationale

This patient has been exposed to HBV in the past and has cleared the virus. The HBVcore total Ab is indicative of prior exposure while the HBV surface Ab is detectable and gives immunity against reinfection under most routine clinical scenarios. Patients who have been exposed to HBV still have HBV ccc DNA within their hepatocytes that is dormant, but under extreme combined B and T cell immunosuppression, the patients are at risk for reverse seroconversion where they can lose HBV surface Ab and manifest HBV surface antigen and present as an acute HBV infection. Prophylaxis is required during therapy and for at least 12-18 months after therapy due to the long-lasting effects of anti-B cell monoclonal antibodies like rituximab. Reactivation of HCV in HCV Ab–positive, RNA-negative patients has not been reported.

Reference

1. Pauly MP, Tucker LY, Szpakowski JL, et al. Incidence of hepatitis B virus reactivation and hepatotoxicity in patients receiving long-term treatment with tumor necrosis factor antagonists. Clin Gastroenterol Hepatol. 2018 Apr 24. doi: 10.1016/j. cgh.2018.04.033.

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