Isolated HBsAg positivity in a Mexican patient with newly diagnosed lupus nephritis

Abstract Introduction: Hepatitis B surface antigen (HBsAg) is usually regarded as a marker of hepatitis B virus (HBV) infection. The concurrence of lupus nephritis (LN) and HBsAg-positivity is a challenge for the clinician, since immunosuppressant use may be associated with an increase in viral replication and an exacerbation of liver disease. Case presentation: Here, we describe the case of a 30-year-old Mexican woman with newly diagnosed focal proliferative LN who also tested repeatedly positive for HBsAg by chemiluminescent microparticle immunoassay (CMIA). She had no clinical features of hepatitis and her liver function tests were within normal limits. Her abdominal ultrasound was also normal. While waiting for further results, she was started on lamivudine (100 mg daily). However, total HBV core antibody test was negative. Owing to the infrequency of this serological pattern, an in vitro polymerase chain reaction (PCR) assay was performed and HBV was not detected. Overall, we interpreted these results as a false-positive screening. Methylprednisolone pulse therapy was subsequently given (1 g daily for three doses) without hepatic repercussion, neither clinically nor biochemically. Conclusions: Isolated HBsAg positivity may result from multiple causes, one of which is crossreactivity. To the best of our knowledge, this is the first report of a false-positive reading using CMIA technique in an active lupus patient. It is reasonable to stress that lupus patients with a positive screening for HBV should undergo a confirmatory assay (such as genomic detection), since this diagnosis may have important therapeutic implications. � 2016 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier. B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/

Severe gastrointestinal involvement in adult-onset Henoch–Schönlein purpura associated with clarithromycin-resistant Helicobacter pylori infection

Background: Henoch–Schönlein purpura (HSP) is an uncommon vasculitis in adults. Gastrointestinal involvement is part of the classical tetrad and can present as bleeding. Helicobacter pylori infection in the setting of HSP has been reported a few times in the literature and may be involved in the pathogenesis of this disease as a triggering agent. Case report: A 48-year-old man presented to the emergency department with 9 days of acute symmetric additive polyarthritis, 2 days of palpable purpura involving lower limbs, recent-onset intense mesogastric pain and hematochezia. H. pylori was detected in gastric tissue and triple therapy (clarithromycin, amoxicillin and omeprazole) was started. Gastrointestinal bleeding and other symptoms stopped 24 h after steroid initiation and he was later discharged on prednisone (1 mg/kg) and azathioprine (100 mg/day). Shortly after discharge he was readmitted with hematochezia and clarithromycin-resistant H. pylori infection was suspected. Bleeding stopped following reinstitution of corticosteroids and a second-line scheme (levofloxacin, amoxicillin and omeprazole) was introduced. Corticosteroids were gradually tapered and he remained on azathioprine. Nine months later he was doing fine. The pertinent literature is briefly discussed, highlighting the previous cases of concurrent diagnosis in adult patients. Conclusion: To the best of our knowledge, this is the first report describing resistance to clarithromycin-containing triple therapy in a H. pylori-infected adult patient with HSP. Gastrointestinal bleeding remains one of the most feared manifestations of HSP. These patients may benefit from H. pylori screening, as this might positively affect their prognosis. Further studies in adults are nevertheless needed to clarify this association and its therapeutic impact