Case presentation

A 68-year-old man was transferred to a hospital for hepatocellular carcinoma.

History

The patient had pain in upper right part of his belly. He mentioned loss of appetite and feeling of fullness because of which his body weight had reduced. He was diagnosed with hepatitis B virus (HBV)-related cirrhosis 1 year back. He was prescribed entecavir 0.5 mg/day orally for positive serum HBV deoxyribonucleic acid (DNA). The therapy helped in achieving complete virologic response (< 1,000 copies/ml). However, administration of entecavir had to be discontinued 3 months later because of an allergy rash.

Examination

Tenderness in abdomen, especially in the upper right quadrant.

Signs of jaundice were evident.

Investigations

Serum HBVDNA level: 3.5 × 104 copies/ml

Diagnosis

Hepatocellular carcinoma

Management

The patient was started on oral lamivudine 100 mg daily. He was advised liver transplantation. The surgery was performed successfully a month later when the serum HBVDNA had already turned to be negative. After transplantation, he was given lamivudine and hepatitis immunoglobulin (HBIG) intramuscularly injection to keep the HBIG titer above 100 IU/ml.

No clinical complications were reported at a follow up visit after 4 years. Although both HBsAg and HBVDNA were negative, it was not easy to maintain the targeted HBIG titer. Therefore, there was a high probability of HBV recurrence. Lamivudine was then replaced by entecavir 0.5 mg/day, with no rash as a side effect. However, HBsAg was detectable after 2 months and HBIG was discontinued. One month later, HBVDNA was 8.83 × 103 copies/ml. The genetic sequencing revealed the rtM204I mutation. Then, adefovir was added which helped in reducing HBVDNA to less than 500 copies/ml 6 months later. The condition of the patient remained stable till 1 year. Subsequently, serum HBVDNA became positive and liver function worsened. He was then administered tenofovir 300 mg/day instead of adefovir as a rescue therapy. One month after this treatment, his serum HBVDNA level became undetectable. Moreover, recovery in his liver function was also seen. Thus, tenofovir seems to be a suitable agent for treating recurrence of hepatitis B virus in a liver transplant recipient with several nucleo(s/t)ide treatment failures.