Hepatitis B associated liver failure following bone marrow transplantation

Background: Several cases have been reported showing clearance of HBsAg in chronic hepatitis B carriers due to adoptive transfer of immunity by an hepatitis B immunised bone marrow. Case Report: We report on a 27-year-old man with chronic myelocytic leukemia and asymptomatic chronic hepatitis B who received allogeneic bone marrow transplantation (BMT). The donor was his HLA identical brother with natural immunity against hepatitis B. Before BMT the donor had received an additional dose of recombinant hepatitis B vaccine. Twenty days after BMT alanine aminotransferase levels increased and graft versus host disease of the skin was observed. Elevation of liver enzymes was initially attributed to graft versus host disease of the liver and the patient received high doses of steroids in addition to standard immunosuppression. Alanine aminotransferase levels increased up to a maximum on day 52 while the HBV DNA level peaked on day 38 after BMT. A liver biopsy showed reactivation of hepatitis B and treatment with steroids was tapered down. Although alanine aminotransferase and HBV DNA levels decreased, liver function deteriorated. The patient died 130 days after BMT due to liver failure. Conclusion: This report indicates that disturbance of the balance between HBV replication and immune control after BMT may result in fatal reactivation of hepatitis B. Careful monitoring, including HBV DNA level and early liver biopsy, of patients with chronic hepatitis B undergoing BMT as well as determination of the HBV immune status of the BMT donor is suggested and necessary.