A 51-year-old Cantonese-speaking female with a history of stage 3 breast cancer had been receiving neoadjuvant chemotherapy. Of note, the oncology service had checked her liver function tests prior to chemotherapy, and they were found to be normal. Hepatitis serologies were not checked prior to administration of chemotherapy. Well into receipt of her chemotherapy, the patient complained of fever, rash, and bone pain and was subsequently admitted to the general medicine service. Admitting labs were notable for a mild transaminitis, but repeat testing of liver function tests was not performed during this hospitalization nor were hepatitis serologies checked. Cultures of blood and urine were negative, and her symptoms were attributed to pegfilgrastim (fever, bone pain) and paclitaxel (rash). Two days later, the patient presented with abdominal pain and AST of 9986 U/L, ALT 4366 U/L, and an INR of 2.3. Shortly thereafter, she became encephalopathic, requiring endotracheal intubation. Subsequent review of her outside records revealed chronic hepatitis B, diagnosed 15 years earlier, with surface antigen positivity. The patient had no knowledge of her hepatitis B diagnosis. The patient was started on entecavir for her reactivation of hepatitis B and transferred to a liver transplant center. Luckily, she has made a complete recovery from her liver failure and is receiving chronic therapy for her hepatitis B, along with treatment for her breast cancer.
Analysis of the case revealed that the oncology department lacked a standard practice to check hepatitis serologies on patients prior to initiation of chemotherapy. Moreover, the admitting team erred by not considering the possibility of hepatitis as the cause of the patient's fever, rash, and transaminitis.
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