Hepatitis B and rheumatic disease 4/5 (1)

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Chronic viral infection (Hepatitis B virus: HBV) of the liver. Transmitted via blood, sperm or vaginal fluid. Hepatitis B is not a classic "Opportunistic infection"But important to consider before starting treatment with immunosuppressive drugs against rheumatic disease. Chronic Hepatitis B infection occurs when viruses (HBsAg) are detected in the body over 6 months or longer (reference: The Norwegian Public Health Institute, 2015).

Hepatitis B occurs most frequently in Asia and Africa. About 1 / 3 of the world's population is infected with Hepatitis B. After a needlestick of infected blood, the 10-30% disease is transmitted.

  • A latent (sleeping) Hepatitis B infection may flare if rheumatic disease is treated with drugs that cause significantly reduced immune systems, such as biological drugs (Reference: The Nard F, 2015)


About 30% does not notice symptoms

  • Acute sickness: Influenza-like symptoms with fatigue, liver inflammation (elevated "liver enzymes" in blood samples of 30%), nausea and vomiting. Most (90%) recover during 4 months
  • Chronic Illness: Among 3 - 5% of those infected, the disease becomes chronic. Gradually, approx. 15% liver damage (liver fibrosis, cirrhosis). After many years, liver cancer (Hepatocellular cancer) diagnosed in some cases. Chronic hepatitis B infection is the cause of approx. 50% of liver cancer cases
  • Rheumatic symptoms (please see the next section)

Rheumatic symptoms of Hepatitis B

Antibody against Hepatitis B in blood samples

  • HBsAs (Antibody to Hepatitis B) is a marker for undergone disease. The antibody is also detected in subjects vaccinated against Hepatitis B
    • Vaccinated persons: HBsAg (antigen) and HBc are normal / negative. Normal liver enzyme (ALT, AST, G-Gt)
  • Anti HBc antibody occurs throughout the course of hepatitis B. Anti HBc antibody indicates that the person has been in contact with the hepatitis B virus sometime. The infection may have passed. (Not to be confused with HBc-antigens which is located intracellularly (inside the cells) and do not appear in blood serum)
  • HBsAg (antigen) can be detected in the blood when the infection is active and requires treatment
  • Anti-HBe-antigens The blood is associated with disease activity and infectivity
  • However, in the case of "negative (or no) antibodies" in the blood, latent virus infection may persist in liver cells. In case of immunosuppression (with drugs), Hepatitis B may be reactivated and disease may occur. If suspected earlier infection, HBV DNA may be tested by PCR technique before any anti-rheumatic treatment with rituximab or others Biological drugs or others immunosuppressive drugs

Interpretation of antibody tests by Hepatitis B

  • Never infected: HBsAg / HBsAs / HBc
  • Vaccinated: HBsAg / HBsAs + / HBc
  • Previously undergone infection with low disease risk: HBsAg / HBsAs + / HBc + (Follow up ALAT and HBV DNA)
  • Previously undergone infection with moderate disease risk: HBsAg / HBsAs / HBc + (measure HBV DNA)
  • Chronic infection: HBsAg +/ HBsAs / HBc + (Treatment Indication)

Almost all infections with Hepatitis B remain latent (viruses remain in the cells). By Biological treatment 20-50% will receive reactivation, especially after rituximab. Check all current blood tests for hepatitis B before treatment begins.

Prevent infection

Vaccine if increased risk is expected

Medical examination with blood samples

  • Hepatitis B antibody (HBsAs, HBc)
  • Hepatitis Bs antigen (HBsAg)
  • By positive findings


PEGylert interferon and other antiviral agents, but many are non-responders.


Opportunistic infections, BINDEVEVSSYKDOMMER.no

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