Hepatitis B associated fulminant polyarteritis nodosa: successful treatment with pulse cyclophosphamide, prednisolone and lamivudine following emergency surgery.
For hepatitis B virus associated polyarteritis nodosa, alpha interferon and plasma exchanges have been proposed to be the first-line treatment. We report a case of hepatitis B surface antigen (HBsAg)-positive fulminant polyarteritis nodosa with predominant gastrointestinal involvement who showed good response to pulse cyclophosphamide, prednisolone, and lamivudine therapy. The patient, a 22-year-old man, presented with a short history of epigastric pain. Initial upper gastrointestinal endoscopy revealed gastritis and duodenal erosions. His pain did not respond to H2-receptor antagonists. He had slightly impaired liver function tests, and was HBsAg and hepatitis B e antigen (HBeAg) positive. Around 3 weeks after initial presentation, he developed massive gastrointestinal haemorrhage requiring resuscitation and emergency laparotomy. Microscopic examination of the resection specimens revealed necrotizing vasculitis of small and medium-sized arteries in the submucosa compatible with polyarteritis nodosa. The patient was treated with pulse cyclophosphamide and prednisolone, with lamivudine being added when he showed an acute rise in liver enzymes. He subsequently developed HBeAg seroconversion, and remained well 18 months after cessation of all immunosuppressives. We believe that the efficacy of pulse cyclophosphamide, prednisolone, and lamivudine in the treatment of hepatitis B virus associated polyarteritis nodosa, especially in comparison with interferon and plasma exchanges, deserves further evaluation.
Lau
Chik Fai
CF
Department of Medicine, Kwong Wah Hospital, Hong Kong, China. dcflau@netvigator.com
Hui
Pak Kwan
PK
Chan
Wai Man
WM
Fung
Tang Tat
TT
Tung
Yau Man
YM
Loo
Ching Kong
CK
Yip
Wai Chun
WC
Lam
Kwong Ming
KM
D000328:Adult; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D003520:Cyclophosphamide / Q000008:administration & dosage / Q000627:therapeutic use*; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000601:surgery; D006509:Hepatitis B / Q000150:complications*; D006514:Hepatitis B Surface Antigens / Q000032:analysis; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D019259:Lamivudine / Q000627:therapeutic use*; D008297:Male; D010488:Polyarteritis Nodosa / Q000188:drug therapy* / Q000209:etiology; D011239:Prednisolone / Q000627:therapeutic use*; D020551:Pulse Therapy, Drug; D018894:Reverse Transcriptase Inhibitors / Q000627:therapeutic use*
D000893:Anti-Inflammatory Agents; D006514:Hepatitis B Surface Antigens; D007166:Immunosuppressive Agents; D018894:Reverse Transcriptase Inhibitors; D019259:Lamivudine; D003520:Cyclophosphamide; D011239:Prednisolone