Practice Lesson of the Week

Fatal reactivation of hepatitis B after chemotherapy for lymphoma

BMJ 2008; 337 doi: (Published 01 July 2008) Cite this as: BMJ 2008;337:a423
  1. Richard Dillon, senior house officer1,
  2. Gideon M Hirschfield, clinical lecturer2,
  3. Michael E D Allison, consultant2,
  4. Kanchan P Rege, consultant1
  1. 1Department of Haematology, Hinchingbrooke Hospital, Huntingdon
  2. 2Department of Hepatology, Addenbrooke’s Hospital, Cambridge CB2 2QQ
  1. Correspondence to: G M Hirschfield gideon.hirschfield{at}
  • Accepted 18 July 2007

Routine screening for hepatitis B in patients receiving chemotherapy or immunotherapy will save lives

One third of the world’s population has evidence of previous infection with the hepatitis B virus (hepatitis B core antibodies), and 350 million people have chronic infection (hepatitis B surface antigen).1 Global migration will change the prevalence of disease in the UK; currently 200 000 people are chronically infected, and around 1500 acute and 8000 chronic new infections are diagnosed annually ( Although intravenous drug users and homosexual men are at notable risk, most cases are in people coming from high prevalence areas, where vertical transmission is common.2

Patients receiving chemotherapy or immunomodulatory drugs who have been exposed to hepatitis B virus are at risk of viral reactivation.3 4 5 In this context, and particularly when steroids are included in the treatment protocol, it is thought that immune mechanisms keeping viral replication under control are suppressed, allowing unchecked viraemia. This occurs in a large proportion of patients who have been infected with hepatitis B virus, and it can be fatal. However, screening for hepatitis B virus before starting immunosuppressive treatments or chemotherapy is not done throughout the United Kingdom.

We present a case of fatal hepatitis B virus reactivation in a young woman treated for lymphoma. With predictions of a rising prevalence of hepatitis B virus in the UK, clinicians prescribing chemotherapy or immunosuppressive treatments (including biological agents such as rituximab) should adopt strategies for screening for hepatitis B and give prophylaxis where required to prevent similar occurrences.

Case report

A 21 year old woman originally from West Africa presented to hospital with a two month history of pleuritic chest pain and weight loss, having previously been fit and well. Chest x ray confirmed a large anterior mediastinal mass and associated left sided pleural effusion. After …

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