P2566 - Hepatitis B Virus Reactivation on Tenofovir Alafenamide During Immunosuppressive Therapy

Award: Presidential Poster Award

Michelle Jones-Pauley, DO, MS, Ramon Minjares, MD, Tamneet Basra, MD, David W. Victor, MD, Sudha Kodali, MD, MPH
Houston Methodist Hospital, Houston, TX

Introduction: Hepatitis B Virus (HBV) reactivation in patients on prophylactic nucleos(t)ide analog (NA) treatment is rare. This is a case of a patient with chronic HBV infection and hepatocellular carcinoma (HCC) on treatment with tenofovir alafenamide (TAF) who presented with reactivation.

Case Description/Methods: The patient is a 59 year old man with chronic HBV, cirrhosis, multifocal HCC who received multimodal therapy, including trial therapy, admitted for further evaluation of fever. He was noted to have elevated liver enzymes and presence of HBV DNA in serum despite prophylaxis with TAF. The patient was started on TAF after initial diagnosis of HBV in 2019 and reported compliance. He was diagnosed with HCC in 2020 with completion of multiple locoregional therapies and multiple systemic chemotherapy regimens, most recently the CATCH trial regimen: cyclophosphamide/fludarabine lymphodepletion followed by glypican-3-targeting chimeric antigen receptor (CAR)-T cells two weeks prior to admission. Physical exam was without focal abnormalities. Pertinent labs showed: aspartate aminotransferase (AST) 4166 U/L, alanine aminotransferase (ALT) 657 U/L, alkaline phosphatase (AP) 138 U/L, total bilirubin (TB) 3.5 mg/dL, white blood cells 0.37 x10⁹/L, HBV PCR 749 IU/mL. Contrast-enhanced MRI Abdomen showed a cirrhotic liver with numerous enhancing lesions, compatible with multifocal HCC and areas of necrosis consistent with prior successful treatment. Hepatitis D virus antibody was negative, alpha fetoprotein 274 ng/mL (decreased from 611 ng/mL); TAF resistance panel was not performed as the viral titer was too low at the time of collection. Repeat HBV PCR 7 days later was 21,627 IU/mL. The patient was started on entecavir in addition to TAF. Repeat HBV PCR 7 days later decreased to 661 IU/mL and further decreased 10 days later to 209 IU/mL. His liver enzymes continue to improve.

Discussion: HBV reactivation is not uncommon in patients on chemotherapy or immunosuppressive medications. However, it is very rare for HBV reactivation to occur in patients on prophylaxis with TAF. There are a few case reports of patients post-CAR-T cell therapy for lymphoma experiencing reactivation of HBV despite prophylaxis with entecavir. There are no published cases of HBV reactivation on TAF. This case further illustrates the necessity for close monitoring of liver enzymes and HBV serology on CAR-T cell therapy and also the advantage of dual NA therapy in the event of reactivation.



Disclosures:


Michelle Jones-Pauley, DO, MS, Ramon Minjares, MD, Tamneet Basra, MD, David W. Victor, MD, Sudha Kodali, MD, MPH. P2566 - Hepatitis B Virus Reactivation on Tenofovir Alafenamide During Immunosuppressive Therapy, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.