He was diagnosed with CML with initial presentation of leukocytosis and thrombocytosis. He started to receive IM 400 mg once daily after bone marrow biopsy and find more info cytogenetic study. The pretreatment liver panel were ALT = 26 U/L, total bilirubin = 1.1 mg/dL, albumin = 4.8 g/dL and prothrombin time = 12.6 s. Complete cytogenetic response (CCyR, < 1% Bcr-Abl/Abl ratio according to the IS) was achieved 7 mo after IM treatment. However, jaundice and anorexia developed 53 mo after IM treatment. Laboratory studies revealed an increased AST level of 110 U/L and an increased ALT level of 374 U/L (Figure (Figure1B).1B). Total bilirubin level was 2.74 mg/dL. HBsAg and HBeAg were positive. HBV DNA was positive at a concentration of 12 165 714 IU/mL.
Results for hepatitis A IgM antibody, hepatitis C antibody, HSV, EBV, CMV, ANA were within normal limits. Liver ultrasonography showed no biliary tract dilatation. Entecavir 0.5 mg once daily was prescribed under the consideration of HBV reactivation. IM was not discontinued. After 1-mo treatment with entecavir, his ALT level fell to 41 IU/L, as demonstrated in Figure Figure1B.1B. HBV DNA level was 10 IU/mL 12 mo after entecavir administration. Status of CMR was achieved on April, 2011. The clinical course of this patient is summarized in Figure Figure1B1B. Case 3 A 50-year-old woman was referred to our institution on November 2009 for evaluation of leukocytosis, anemia, and thrombocytopenia. She was a HBV carrier. A diagnosis of CML was made based on the findings of proliferation of myeloid lineage cells and presence of Ph+ in bone marrow biopsy.
IM 400 mg daily was used after diagnosis of CML. The pretreatment liver panel were ALT = 23 U/L, total bilirubin = 0.4 mg/dL, albumin = 4.1 g/dL and prothrombin time = 11 s. Because Bcr-Abl/Abl ratio was not significantly reduced 12 mo later with IM, treatment regimen was shifted to nilotinib 400 mg twice daily. However, 3 mo after treatment with nilotinib, the patient experienced tea-colored urine and easy fatigue. The patient denied usage of acetaminophen or herbs. Laboratory studies revealed an increased AST level of 346 U/L and an increased ALT level of 592 U/L (Figure (Figure1C).1C). Total-bilirubin level was 2.54 mg/dL. Coagulation profiles were normal. HBsAg was positive, whereas HBeAg was negative. Results for hepatitis A, hepatitis C, HSV, EBV, and CMV were negative.
HBV DNA was positive at a concentration of 27 120 705 IU/mL. Liver ultrasonography showed normal results. Because HBV reactivation was considered, entecavir 0.5 mg once daily was prescribed. Nilotinib was not discontinued. After 2-mo treatment with entecavir, ALT level fell to 92 IU/L, as demonstrated in Figure Figure1C.1C. HBV DNA was at a lower level of Brefeldin_A 18 IU/mL 6 mo after treatment with entecavir. Status of MMR was achieved 6 mo after entecavir treatment.