Correspondence

Lamivudine in the Treatment of Polyarteritis Nodosa Associated with Acute Hepatitis B

N Engl J Med 2001; 344:1645-1646May 24, 2001

Article

To the Editor:

There is no consensus on the optimal treatment of polyarteritis nodosa associated with hepatitis B virus (HBV) infection. The potential risk of accelerating viral replication complicates the use of corticosteroids and cytotoxic agents. Benefit from the combined use of plasmapheresis, corticosteroids, and antiviral agents has been reported previously.1 We describe a patient with HBV-associated polyarteritis nodosa who was treated with this approach.

A 39-year-old woman was transferred to our hospital in December 1999 for the treatment of vasculitis. In September 1999, she had presented with a diffuse pruritic rash, polyarticular symmetric arthritis, abdominal pain, and constitutional symptoms. Because the results of her liver-function tests were abnormal (Table 1Table 1Results of Laboratory Tests.), she underwent cholecystectomy for suspected acute cholecystitis. Histopathological examination of the gallbladder revealed vasculitis involving medium-sized arteries that was consistent with the presence of polyarteritis nodosa. The patient was treated with oral prednisone (1 mg per kilogram of body weight) until left footdrop developed, and she was then transferred to our hospital.

On admission to our hospital, the patient had decreased sensation in the distal parts of her lower extremities and left footdrop. Findings on laboratory examinations were consistent with the presence of acute HBV infection (Table 1). Electromyography revealed mononeuritis multiplex in the lower extremities. The patient began to receive plasmapheresis three times per week, 100 mg of lamivudine per day, and prednisone, which was slowly tapered. In February 2000, she had a transient elevation in her liver aminotransferase levels (Table 1), consistent with the occurrence of hepatitis B early antigen seroconversion.2 Since her condition was clinically stable, the frequency of plasmapheresis was decreased, and it was then discontinued four weeks later. From February 2000 to September 2000, she continued to receive low-dose prednisone (<10 mg per day, which was tapered). Treatment with lamivudine (100 mg per day) was continued, and in October 2000 the patient's HBV infection was serologically resolved while her condition was clinically stable (Table 1).

Lamivudine has been shown in a randomized, prospective study to be effective for the treatment of chronic HBV infection,3 and a case report suggests it may also be effective for acute HBV infection.4 In our patient, who had life-threatening vasculitis associated with acute HBV infection, corticosteroids and plasmapheresis were used to control the acute manifestations of the vasculitis. Lamivudine, a nucleoside analogue, was used to suppress viral replication and the integration of viral DNA into the hepatocytes. With the use of this regimen and without any cytotoxic drugs, the patient had no further complications of vasculitis. In addition, effective immunity against HBV developed and the viral infection was cleared. The use of antiviral agents for the treatment of vasculitis associated with HBV infection warrants further study.

Samardeep Gupta, M.D.
Cyrus Piraka, M.D.
Michele Jaffe, M.D.
University of Michigan, Ann Arbor, MI 48109-0358

4 References

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   Full Text | Web of Science | Medline

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   Reshef R, Sbeit W, Tur-Kaspa R. Lamivudine in the treatment of acute hepatitis B. N Engl J Med 2000;343:1123-1124
   Full Text | Web of Science | Medline

Citing Articles (6)

Citing Articles

1. 1

   Helen S. Te. (2010) Treatment of Acute Hepatitis B with Nucleoside and/or Nucleotide Analogues. Current Hepatitis Reports 9:2, 119-123
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2. 2

   Dragan Delic, Zorica Nesic, Milica Prostran, Ivan Boricic, Neda Svirtlih. (2009) Treatment of subacute hepatitis B with lamivudine: A pilot study in Serbia. Vojnosanitetski pregled 66:3, 199-202
   CrossRef

3. 3

   Necati Çakir, Ömer Nuri Pamuk, Hasan Ümit, Kenan Midilli. (2006) Successful Treatment with Adefovir of One Patient Whose Cryoglobulinemic Vasculitis Relapsed under Lamivudine Therapy and Who was Diagnosed to Have HBV Virologic Breakthrough with YMDD Mutations. Internal Medicine 45:21, 1213-1215
   CrossRef

4. 4

   S. Nahon, Y. Bouhnik. (2004) Vascularites, collagénoses et tube digestif. EMC - Chirurgie 1:5, 573-581
   CrossRef

5. 5

   Veslav Stecevic, Martin M. Pevzner, Stuart C. Gordon. (2003) Successful Treatment of Hepatitis B-Associated Vasculitis With Lamivudine. Journal of Clinical Gastroenterology 36:5, 451
   CrossRef

6. 6

   Raymond M Johnson, Giorgio Barbarini, Giuseppe Barbaro. (2003) Kawasaki-like syndromes and other vasculitic syndromes in HIV-infected patients. AIDS 17, S77-S82
   CrossRef