REACTIVATION OF HEPATITIS B IN A PATIENT WITH UNTREATED CHRONIC LYMPHOCYTIC LEUKEMIA

Abstract

Objective Introduction: The natural course of hepatitis B virus (HBV) infection is determined by the interaction between viral replication and the host's immune response. HBV persists in the body of all infected patients, even those with evidence of serological recovery. Therefore, individuals with a history of HBV infection receiving immunosuppressive therapy are at risk for HBV reactivation. HBV reactivation can result in increased serum aminotransferase levels, fulminant liver failure, and/or death. HBV reactivation has been described in patients receiving chemotherapy for various hematological and solid tumors. We present our patient with a diagnosis of chronic lymphocytic leukemia (CLL) who was spontaneously reactivated during follow-up without treatment. Case report: A female patient, who had been followed up with the diagnosis of chronic lymphocytic leukemia for 13 years without treatment, presented in August 2022 with complaints of loss of appetite, weight loss, and jaundice in the eye. It was learned in her history that she had not received chemotherapy or radiotherapy before, had no known disease, and did not use any medication. On physical examination, sclera icteric, multiple lymph nodes with a size of 1 cm in the cervical region and splenomegaly were detected.The patient's Rai stage 2, CLL-IPI score of 3, 17p(-), mutation in the IGHV gene was detected. Detection of leukocyte count 157,000/mm3, lymphocyte count 149.660/mm3, hemoglobin 13.5 g/dL, platelet count 117.000/mm3, alanine aminotransferase (ALT) 2045 U/L, aspartate aminotransferase (AST) 2252 U/L, total bilirubin 10.72 mg/dL, direct bilirubin 9.62 mg/dL, protrombin time 18.7 sec, active partial thromboplastin time 30 sec. While IgG was normal, IgA and M were low. HBsAg positive, anti-HBs negative, anti-HBc IgM negative, anti-HBcIgG positive, HBV-DNA 28,000,000 IU/mL were determined to explain liver dysfunction. One year ago, HBsAg was negative, anti-HBs negative, anti-HBc-IgM negative, while anti-HBc-IgG was positive. The patient was accepted as HBV reactivation and tenofovir disoproxil was started. In the first month of treatment, AST-ALT and bilirubin values returned to normal limits. In the 3rd month of the treatment, HBsAg and HBV-DNA became negative and anti-HBs became positive. The patient was followed up without treatment for CLL. Long-term use of tenofovir disoproxil was planned, despite the possibility of spontaneous HBV reactivation again. Methodology detected: Detection of leukocyte count 157,000/mm3, lymphocyte count 149.660/mm3, hemoglobin 13.5 g/dL, platelet count 117.000/mm3, alanine aminotransferase (ALT) 2045 U/L, aspartate aminotransferase (AST) 2252 U/L, total bilirubin 10.72 mg/dL, direct bilirubin 9.62 mg/dL, protrombin time 18.7 sec, active partial thromboplastin time 30 sec. While IgG was normal, IgA and M were low. HBsAg positive, anti-HBs negative, anti-HBc IgM negative, anti-HBcIgG positive, HBV-DNA 28,000,000 IU/mL were determined to explain liver dysfunction. One year ago, HBsAg was negative, anti-HBs negative, anti-HBc-IgM negative, while anti-HBc-IgG was positive. The patient was accepted as HBV reactivation and tenofovir disoproxil was started. In the first month of treatment, AST-ALT and bilirubin values returned to normal limits. In the 3rd month of the treatment, HBsAg and HBV-DNA became negative and anti-HBs became positive. The patient was followed up without treatment for CLL. Long-term use of tenofovir disoproxil was planned, despite the possibility of spontaneous HBV reactivation again. Results: determined to explain liver dysfunction. One year ago, HBsAg was negative, anti-HBs negative, anti-HBc-IgM negative, while anti-HBc-IgG was positive. The patient was accepted as HBV reactivation and tenofovir disoproxil was started. In the first month of treatment, AST-ALT and bilirubin values returned to normal limits. In the 3rd month of the treatment, HBsAg and HBV-DNA became negative and anti-HBs became positive. The patient was followed up without treatment for CLL. Long-term use of tenofovir disoproxil was planned, despite the possibility of spontaneous HBV reactivation again Conclusion: tenofovir disoproxil was planned, despite the possibility of spontaneous HBV reactivation again. Discussion: HBsAg positive individuals are at greater risk for HBV reactivation compared to HBsAg negative individuals. It has been reported that HBV reactivation rate is up to 70% in HBsAg-positive individuals receiving standard chemotherapy.For those with cured infection (defined as HBsAg-negative, anti-HBc-positive, HBV DNA-negative), reactivation ranged from 0.3% to 9.0%.