Severe Acute Hepatitis B in HBV-Vaccinated Partner of a Patient with Multiple Myeloma Treated with Cyclophosphamide, Bortezomib, and Dexamethasone and Autologous Stem Cell Transplant

Abstract

Hepatitis B reactivation can occur with various forms of immunosuppression. Cyclophosphamide, Bortezomib, and Dexamethasone (CYBOR-D) chemotherapy is commonly used for the treatment of multiple myeloma and has not been noted in guidelines to be causative in HBV reactivation. Indeed, current guidelines do not recommend providing antiviral prophylaxis to patients with prior HBV infection. We present a case of HBV reactivation as a result of CYBOR-D and autologous stem cell transplant which is complicated by the patient's partner who developed acute hepatitis B. Our case highlights the need to review the role of antiviral prophylaxis for patients undergoing treatment of multiple myeloma and also the role of ensuring immunity for close contacts of these patients who may also be at risk.

Injury pattern recognition to discriminate competing causes of liver injury

“…Hepatitis B virus reactivation occurred 4‐24 months after bortezomib was started. Four patients had evidence of prior resolved infection with positive HBsAb seroreversion during their disease course . The reactivation in two of the cases was identified early due to close HBV DNA monitoring and immediate start of antiviral therapy at occurrence of HBV DNA positivity prevented hepatitis .…”

“…The reactivation in two of the cases was identified early due to close HBV DNA monitoring and immediate start of antiviral therapy at occurrence of HBV DNA positivity prevented hepatitis . The third patient had evidence of mild reactivation about 6 months after Autologous stem cell transplant (ASCT), and 10 months after bortezomib therapy that was only identified in hindsight and spontaneously resolved . A fourth patient was not started on antiviral therapy until clinically evident HBV reactivation occurred resulting in that patient's death .…”

“…HBsAb seroreversion during their disease course. [11][12][13][14] The reactivation in two of the cases was identified early due to close HBV DNA monitoring and immediate start of antiviral therapy at occurrence of HBV DNA positivity prevented hepatitis. 11,13 The third patient had evidence of mild reactivation about 6 months after Autologous stem cell transplant (ASCT), and 10 months after bortezomib therapy that was only identified in hindsight and spontaneously resolved.…”

“…11,13 The third patient had evidence of mild reactivation about 6 months after Autologous stem cell transplant (ASCT), and 10 months after bortezomib therapy that was only identified in hindsight and spontaneously resolved. 12 A fourth patient was not started on antiviral therapy until clinically evident HBV reactivation occurred resulting in that patient's death. 14…”

Reactivation of Hepatitis B Virus in Patients with Multiple Myeloma

“…Retrospective reports summarizing HBV reactivation in MM patients, including case reports, included a total of 125 cases [8,22,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68] (Table 4 and Table 5). All 16 cases with HBV reactivation through 2010 underwent HSCT [56,57,58,59,60,61].…”