Immune-mediated diseases wherein
immune complex-mediated injury is predominant;
plasma exchange remains a therapeutic option for
vasculitis. Hepatitis B virus-associated
polyarteritis nodosa (HBV-PAN) wherein
immunosuppressants can be contraindicated,
plasma exchanges have a proven role when combined with
antiviral therapy.
Plasma exchange by hastening the clearance of
immune complexes is beneficial in acute organ dysfunction. A 25-year-old male presented with complaints of generalized weakness, tingling
numbness and weakness of extremities,
joint pain,
weight loss, and rashes over arms and legs for 2 months.
Hepatitis B workup showed high viral loads of HBV (34 million IU/ml) and
hepatitis e antigen positivity (1129.06 U/ml). Cardiac workup showed elevated cardiac
enzymes and decreased ejection fraction (40%-45%). The finding of contrast-enhanced computed tomography (CECT) chest and abdomen with CT angiogram abdomen was steady with medium vessel
vasculitis. A diagnosis of
vasculitis with probable etiology of HBV-related PAN with
mononeuritis multiplex and
myocarditis was made. He was treated with
steroids,
tablet tenofovir, and 12 sessions of
plasma exchanges. On average, 2078 ml of plasma was exchanged during each session with 4%
albumin as a replacement fluid using central femoral line dialysis
catheter as vascular access on automated cell separator Optia ®Spectra (Terumo BCT, Lakewood, Co). He was discharged with the resolution of symptoms, including
myocarditis and increase in power strength and still in follow-up. The present index case indicates that
antiviral combined with
plasma exchange after short-term
corticosteroids is an effective
therapy for HBV-PAN. TPE can be used as adjuvant
therapy along with
antiviral therapy in a
rare disease like HBV-related PAN.