title: Case report: passive transfer of hepatitis B antibodies from intravenous immunoglobulin.
abstract: BACKGROUND
  Prior to initiating immunosuppressive therapy in the treatment of autoimmune inflammatory conditions, it is a requirement to screen for certain viral serology, including hepatitis B (HBV). A positive result may indicate the need for antiviral therapy, or contraindicate immunosuppression all together. An accurate interpretation of serological markers is therefore imperative in order to treat patients appropriately. We present a case of passive anti-HBV antibody transfer following intravenous immunoglobulin (IVIg) infusion, in which misinterpretation of serology results almost led to inappropriate treatment with antiviral therapy and the withholding of immunosuppressive agents. This phenomenon has been previously reported, but awareness remains limited.
  
  
  METHODS
  A 50 year old Caucasian gentleman with a history of allogeneic haematopoietic stem cell transplant for transformed follicular lymphoma was admitted to hospital with recurrent respiratory tract infections. Investigation found him to be hypogammaglobulinaemic, and he was thus given 1 g/kg of intravenous immunoglobulin. The patient also disclosed a 3-week history of painful, swollen joints, leading to a diagnosis of seronegative inflammatory polyarthritis. Prior to initiating long term immunosuppression, viral screening found hepatitis B serology suggestive of past infection, with positive results for both anti-HBc and anti-HBs antibody, but negative HBV DNA. In response, prednisolone was weaned and the local hepatology team recommended commencement of lamivudine. Having been unable to identify a source of infection, the case was reported to the local blood centre, who tested a remaining vial from the same batch of IVIg and found it to be anti-HBc and anti-HBs positive. Fortunately the blood products were identified and tested prior to the patient initiating HBV treatment, and the effect of a delay in starting disease-modifying therapy was inconsequential in light of an excellent response to first-line therapies.
  
  
  CONCLUSIONS
  Misinterpretation of serology results following IVIg infusion may lead to significant patient harm, including unnecessary antiviral administration, the withholding of treatments, and psychosocial damage. This is especially pertinent at a time when we have an ever increasing number of patients being treated with IVIg for a wide array of immune-mediated disease. Passive antibody transfer should be considered wherever unexpected serological changes are identified.
authors.affiliation: Flat 19, 3 St Pancras Way, London NW1 0PB, UK. simonjmparker@gmail.com.
authors.forename: Simon
authors.initials: S
authors.lastname: Parker
authors.forename: Eliza
authors.initials: E
authors.lastname: Gil
authors.forename: Patricia
authors.initials: P
authors.lastname: Hewitt
authors.forename: Katherine
authors.initials: K
authors.lastname: Ward
authors.forename: Yasmin
authors.initials: Y
authors.lastname: Reyal
authors.forename: Sasha
authors.initials: S
authors.lastname: Wilson
authors.forename: Jessica
authors.initials: J
authors.lastname: Manson
mesh_terms: D000998:Antiviral Agents / Q000627:therapeutic use; D018380:Hematopoietic Stem Cell Transplantation; D006509:Hepatitis B / Q000175:diagnosis*; D006510:Hepatitis B Antibodies / Q000097:blood*; D006512:Hepatitis B Core Antigens / Q000276:immunology*; D006514:Hepatitis B Surface Antigens / Q000097:blood; D006515:Hepatitis B virus; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000009:adverse effects* / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D019259:Lamivudine / Q000627:therapeutic use; D008224:Lymphoma, Follicular / Q000276:immunology / Q000628:therapy; D008297:Male; D019300:Medical Errors; D008875:Middle Aged; D012698:Serologic Tests
chemical_list: D000998:Antiviral Agents; D006510:Hepatitis B Antibodies; D006512:Hepatitis B Core Antigens; D006514:Hepatitis B Surface Antigens; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D019259:Lamivudine