Reactivation of Hepatitis B Virus Infection 66 months after Rituximab Therapy For Chronic Lymphocytic Leukemia, Emphasis on Interplay between Infection, Drugs and Disease Biology

Hepatitis B virus (HBV) reactivation (HBVr) in patients receiving immunosuppression is an evolving topic. American Gastroenterology Association (AGA) have reported a guideline for the management of patients with certain HBV status who will undergo immunosuppression with regard to patient’s HBV status as well as the category and duration of immunosuppression. Here we are presenting a case with CLL who have received rituxmab with bendamustine 66 months before, developing HBVr with an emphasis on the discussion pathophysiological process of the disease itself, not just the treatment course. 59 years old male patient diagnosed with CLL and chronic asymptomatic HBV infection received 3 lines of treatment under viral prophylaxis in 13 years. 66 months after the last treatment with rituximab, HBV reactivation developed and treated with dual antiviral therapy. During this period a decrease in lymphocyte count was observed concurrent with transaminase elevation. As the reactivation was controlled, lymphocyte counts increased back to pre-flare levels. While the patient had impaired antibody related immune response since monoclonal B cells are nonfunctional, an attempt to improve T cell related response may be resulted with both to the clearance of lymphocytes (as they were decreased) and the immune reaction of necroinflammation in the hepatocytes were triggered.