Resolution of acute hepatitis B-associated aplastic anaemia with antiviral therapy

Abstract

A previously healthy 44-year-old woman presented with 3 days of worsening petechial rash, epistaxis and fatigue. Admission labs revealed pancytopenia, low reticulocyte index and elevated liver enzymes. Bone marrow biopsy demonstrated a profoundly hypocellular bone marrow without dysplasia and additional testing demonstrated an acute hepatitis B infection. In the context of an acute hepatitis B infection, elevated liver enzymes and aplastic anaemia, our patient was diagnosed with severe hepatitis-associated aplastic anaemia due to an acute hepatitis B infection. She was initiated on antiviral therapy with tenofovir and briefly received immunosuppressive therapy with a robust sustained improvement in her blood counts. Acute hepatitis B-associated aplastic anaemia is an exceptionally rare presentation of aplastic anaemia. We present acute hepatitis B-associated aplastic anaemia that resolved with antiviral therapy, which to our knowledge is the second such case reported in the literature and the first using tenofovir.

Keywords: haematology (drugs and medicines); hepatitis (sexual health); hepatitis and other gi infections; hepatitis b; malignant and benign haematology.

Figure 1

Peripheral blood smear, Wright’s stain, 20×. The peripheral blood shows normocytic, normochromic anaemia. The neutrophils do not exhibit nuclear dysplastic features. The platelets are decreased in number.

Figure 2

Bone marrow aspirate smear, Wright’s stain. The aspirate smear shows a hypocellular particle of marrow with rare maturing marrow elements (original magnification 10×). The majority of aspirate was composed of mature neutrophils and lymphocytes with rare maturing erythroids or megakaryocytes seen (inset, original magnification 20×).

Figure 3

Bone marrow core biopsy, H&E. The megakaryocytes, erythroids and myeloid lineages are decreased to virtually absent on the core biopsy (original magnification 20×) The bone marrow cellularity is approximately 5% cellular which is hypocellular for age in this patient (inset, original magnification 2×).

Figure 4

(A) Time course of AST, ALT and medical therapy from the date of admission. (B) Time course of WBC, ANC and medical therapy from the date of admission. (C) Time course of haemoglobin, platelet count and medical therapy from the date of admission. ALT, alanine transaminase; ANC, absolute neutrophil count; AST, aspartate transaminase; ATG, antithymocyte globulin; CSA, cyclosporin; WBC, white blood cell.