Hepatitis-B reactivation during treatment with tumor necrosis factor-α blocker adalimumab in a patient with psoriasis arthritis

Hepatitis-B reactivation during treatment with tumor necrosis factor-alpha blocker adalimumab in a patient with psoriasis arthritis. History and admission findings: A 66-year-old man with acute fever, myalgia, arthralgia, restricted movement and neck stiffness was admitted to our emergency unit. Three weeks earlier treatment with adalimumab, a tumor necrosis factor(TNF)-alpha an-tagonist was started by the patient's dermatologist because of a psoriasis vulgaris with associated psoriasis arthritis. All previous laboratory tests where without pathological findings. Investigations: The imaging procedures showed no pathological findings. Transaminase and CRP levels were markedly elevated. Hepatitis serology revealed reactivation of a chronic hepatitis B infection, while a combined viral and toxic hepatitis was detected by liver biopsy. Treatment and course: On the day of admittance acute neurological symptoms developed including muscular cramps and dyskinesia. Hypotonia and tachyarrhythmia were treated with parenteral infusions and digitoxin. Reactivation of a chronic hepatitis B infection with subfulminant liver failure was diagnosed, caused by immunosuppressive therapy with adalimumab. The patient was transferred to be treated with the antiviral drug entecavir. Conclusion: The exclusion of acute and/or chronic hepatitis before using TNF-alpha antagonists is recommended but in daily routine often ignored. The presented case demonstrates the risk of reactivating a chronic hepatitis B during therapy with a TNFalpha antagonist.