title: Fatal acute liver failure due to reactivation of hepatitis B following treatment with fludarabine/cyclophosphamide/rituximab for low grade non-Hodgkin's lymphoma.
abstract: BACKGROUND
  Reactivation of chronic hepatitis B in HBsAg carriers is a well known complication of chemo?therapy. The clinical spectrum ranges from asymptomatic hepatitis to fatal hepatic failure. Although it impairs the prognosis of cancer treatment, it may be overlooked due to other possible causes of liver damage.
  
  
  METHODS
  The patient presented with acute liver failure after 6 cycles of rituximab, fludarabine, and cyclophosphamide for low grade non-hodgkin's lymphoma. Differential diagnoses were chemotherapy-induced liver failure, autoimmune hepatitis, phenprocoumon-induced liver failure and infiltration of the liver by lymphoma. Finally, reactivation of hepatitis B with a fibrosing cholestatic pattern was identified.
  
  
  CONCLUSIONS
  This case reminds clinicians that patients receiving high-intensive chemotherapy or immunosuppressive therapy should be screened for HBsAg. HbsAg positive patients should obtain prophylactic antiviral therapy with lamivudine or another substance active against HBV.
authors.affiliation: Department of Internal Medicine I, University Hospital of Bonn, Germany. j-c.wasmuth@uni-bonn.de
authors.forename: J-C
authors.initials: JC
authors.lastname: Wasmuth
authors.forename: H-P
authors.initials: HP
authors.lastname: Fischer
authors.forename: T
authors.initials: T
authors.lastname: Sauerbruch
authors.forename: F L
authors.initials: FL
authors.lastname: Dumoulin
mesh_terms: D000911:Antibodies, Monoclonal / Q000009:adverse effects*; D058846:Antibodies, Monoclonal, Murine-Derived; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects; D003520:Cyclophosphamide / Q000009:adverse effects*; D003937:Diagnosis, Differential; D017809:Fatal Outcome; D019694:Hepatitis B, Chronic / Q000150:complications* / Q000175:diagnosis / Q000473:pathology; D006801:Humans; D008099:Liver / Q000473:pathology; D017114:Liver Failure, Acute / Q000209:etiology* / Q000473:pathology; D008228:Lymphoma, Non-Hodgkin / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D000069283:Rituximab; D014740:Vidarabine / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D000069283:Rituximab; D003520:Cyclophosphamide; D014740:Vidarabine; C024352:fludarabine