Bedani P L, Bergami M, Cavazzini P L, Strumia R, Morelli M C, Stabellini G, Gilli P
Division of Nephrology, Sant'Anna Hospital, Ferrara, Italy.
J Nephrol. 2001 Sep-Oct;14(5):428-30.
Cutaneous periarteritis nodosa (PAN) is a clinical feature characterized by chronic, benign course; its pathogenesis is unknown. In patients submitted to renal transplantation cutaneous PAN is a rare complication. We report a case of cutaneous PAN associated with the reappearance of hepatitis B antigen 16 years after kidney transplantation. A 44-year-old man underwent successful renal transplantation in June 1980. In December 1996 he presented multiple painful erythematous subcutaneous nodules on both legs. Skin lesion biopsy showed the presence of cutaneous PAN. Six months later laboratory data demonstrated the presence of HbsAg. HBeAg, HBcAb and detectable HBV-DNA serum by polymerase-chain-reaction (PCR) assay. Anti-HBs and anti-HBe proved negative. In July 1998 the laboratory tests showed an important increase of HBV-DNA (5.1 billion by Branched DNA), and so lamivudine (100 mg/day) was introduced. HBV-DNA became undetectable by PCR after 3 months of therapy. Seven months later a new skin biopsy was performed. The typical signs of PAN were no longer evident. As HBV infecion was demonstrated six months after the clinical appearance of the PAN, in a patient who was believed to be immune to the virus, it is possible that, in the early stages, the hepatitis B antigen title was methodologically indeterminable, but sufficient to form circulating immune complexes responsible for vasculitis primer. Lamivudine therapy resulted efficacious in favouring the regression of cutaneous PAN, but its long-term efficacy requires further evaluation as regards potential selection of drug resistant hepatitis B virus (HBV) mutants during treatment.
皮肤型结节性多动脉炎（PAN）是一种具有慢性、良性病程特点的临床特征；其发病机制尚不清楚。在接受肾移植的患者中，皮肤型PAN是一种罕见的并发症。我们报告一例肾移植16年后出现乙肝抗原重现并伴有皮肤型PAN的病例。一名44岁男性于1980年6月成功接受肾移植。1996年12月，他双下肢出现多个疼痛性红斑皮下结节。皮肤病变活检显示存在皮肤型PAN。6个月后实验室数据显示存在乙肝表面抗原（HbsAg）、乙肝e抗原（HBeAg）、乙肝核心抗体（HBcAb），并通过聚合酶链反应（PCR）检测到血清中有乙肝病毒DNA（HBV-DNA）。乙肝表面抗体（Anti-HBs）和乙肝e抗体（Anti-HBe）检测为阴性。1998年7月，实验室检查显示HBV-DNA显著升高（分支DNA法检测为51亿），因此开始使用拉米夫定（100毫克/天）。治疗3个月后，PCR检测不到HBV-DNA。7个月后再次进行皮肤活检。PAN的典型体征不再明显。由于在PAN临床表现出现6个月后证实存在乙肝感染，而该患者之前被认为对病毒免疫，所以在早期阶段，乙肝抗原滴度可能在方法学上无法确定，但足以形成负责血管炎引发的循环免疫复合物。拉米夫定治疗有利于皮肤型PAN的消退，但就治疗期间潜在的耐药乙肝病毒（HBV）突变体选择而言，其长期疗效需要进一步评估。
