Takuya Sawabe, MD, PhD; Takeshi Uenotsuchi, MD; Shinichi Imafuku, MD; Hiroshi Kohno, MD; Junichi Arima, MD, PhD; Takahiko Horiuchi, MD, PhD
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Sawabe T, Uenotsuchi T, Imafuku S, Kohno H, Arima J, Horiuchi T. Remission of Hepatitis B Virus-Related Vasculitis with Lamivudine. Ann Intern Med. 2004;140:672-673. doi: 10.7326/0003-4819-140-8-200404200-00035
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Published: Ann Intern Med. 2004;140(8):672-673.
TO THE EDITOR:
Background: Lamivudine is a nucleoside analogue approved for treating chronic hepatitis B (1, 2), and one case report has suggested that it may also be effective for treating vasculitis associated with hepatitis B virus (HBV) infection (3). We describe a patient whose cryoglobulinemic vasculitis associated with HBV infection was ameliorated after additional administration of lamivudine.
Case Report: A 48-year-old woman was admitted to our hospital with skin ulcers on 9 September 2000. She had had polyneuropathy in 1985. On admission, she had multiple skin ulcers on her feet, fever, and decreased sensation in the distal extremities. Urinalysis showed no abnormal findings. Hematologic examination showed mild anemia (hemoglobin level, 105 g/L). Serum chemistry studies, including aminotransferase levels, showed no marked aberrations. Immunologic data indicated elevated levels of C-reactive protein (44.1 mg/L), IgG (24.6 g/L), and immune complex (33.9 µg/mL). The patient's serum was positive for rheumatoid factor, antinuclear antibody, and cryoglobulin and negative for antineutrophil cytoplasmic antibody. Virologic results were positive for hepatitis B surface antigen and hepatitis B e antibody and negative for hepatitis B surface antibody and hepatitis B e antigen. Results of tests for HBV DNA were negative. On the basis of these findings, cryoglobulinemic vasculitis in an HBV carrier was diagnosed. Alprostadil alfadex, 120 µg/d, was administered to increase blood supply to the ulcers, and oral prednisolone, 1 mg/kg of body weight per day, was also administered. Cryoglobulin disappeared from the serum, and most skin ulcers healed. However, ulcers on the right third and fourth toes worsened, necessitating amputation. After amputation, the skin around the surgical wound became necrotic, and a large ulcer formed. Cryoglobulin reappeared in the patient's serum as the prednisolone dose was tapered, leading to worsening of the foot ulcer. In February 2001, the patient's aminotransferase levels became elevated, and serologic results were positive for hepatitis B e antigen and negative for hepatitis B e antibody. The level of serum HBV DNA also increased. Exacerbation of chronic hepatitis B was diagnosed, and lamivudine, 100 mg/d, was started. Aminotransferase levels decreased to within the normal range, and tests for serum HBV DNA yielded negative results. The serum cryoglobulin level also diminished again. Levels of complement components rose, and levels of serum immune complex, which had not been normalized by prednisolone alone, decreased to within the normal limits. Consistent with these findings, the persistent skin ulcer rapidly improved after administration of lamivudine. The Figure summarizes the patient's clinical course.
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