Hepatology: hepatitis B reactivation with chemotherapy: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Hepatology: hepatitis B reactivation with chemotherapy

Sample item

A 60-year-old woman with newly diagnosed diffuse large B-cell lymphoma is about to start rituximab-containing chemotherapy. Screening shows HBsAg negative, total anti-HBc positive and anti-HBs negative. What is the most appropriate management?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

C. Start entecavir or tenofovir before chemotherapy and continue for at least 12 months after it ends

Anti-CD20 therapy carries a high risk (above 10%) of hepatitis B reactivation even in HBsAg-negative, anti-HBc-positive patients, because covalently closed circular DNA persists in hepatocytes. Prophylaxis with a high-barrier nucleos(t)ide analogue should start before treatment and continue for at least 12 months after it ends. Reactivation can cause fulminant hepatitis.

Option by option

  • A. Start peginterferon alfa to clear the virus before chemotherapy

    Peginterferon is immunostimulatory, poorly tolerated with chemotherapy and not used for prophylaxis.

  • B. Proceed with chemotherapy and check liver enzymes only if she becomes symptomatic

    Waiting for symptoms allows severe hepatitis or liver failure to develop before treatment is given.

  • C. Start entecavir or tenofovir before chemotherapy and continue for at least 12 months after it ends (correct)

    Correct. Antiviral prophylaxis prevents reactivation in a high-risk setting.

  • D. Give a three-dose hepatitis B vaccine course and start chemotherapy immediately

    Vaccination will not generate a protective response during profound immunosuppression and gives no time-efficient protection.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is C, Start entecavir or tenofovir before chemotherapy and continue for at least 12 months after it ends. Anti-CD20 therapy carries a high risk (above 10%) of hepatitis B reactivation even in HBsAg-negative, anti-HBc-positive patients, because covalently closed circular DNA persists in hepatocytes.

Why is "Start peginterferon alfa to clear the virus before chemotherapy" not the answer?

Peginterferon is immunostimulatory, poorly tolerated with chemotherapy and not used for prophylaxis.

Why is "Proceed with chemotherapy and check liver enzymes only if she becomes…" not the answer?

Waiting for symptoms allows severe hepatitis or liver failure to develop before treatment is given.

Why is "Give a three-dose hepatitis B vaccine course and start chemotherapy i…" not the answer?

Vaccination will not generate a protective response during profound immunosuppression and gives no time-efficient protection.

What concept does this question test?

It tests Hepatology: hepatitis B reactivation with chemotherapy in General Medicine. Prophylaxis with a high-barrier nucleos(t)ide analogue should start before treatment and continue for at least 12 months after it ends. Reactivation can cause fulminant hepatitis.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Hepatology: hepatitis B reactivation with chemotherapy?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.