Guillevin L, Merrouche Y, Gayraud M, Jarrousse B, Royer I, Léon A, Baudelot J
Service de Médecine interne, Hôpital Avicenne, Université Paris XIII, Bobigny.
Presse Med. 1988 Sep 10;17(30):1522-6.
The treatment and prognosis of periarteritis nodosa associated with hepatitis B virus were reconsidered from a series of 13 patients representing 32.5 per cent of the 40 patients with periarteritis nodosa admitted during the same period. HBs and HBe antigens were present in every case, and hepatitis B virus replication was demonstrated by the finding of viral DNA in serum. One patient had anti-HBc IgM's. Five patients were treated with corticosteroids, cyclophosphamide and occasional plasma exchanges. All were cured or achieved complete remission. Eight patients were treated with plasma exchanges and vidarabine, either as first-line therapy (3 cases) or after failure of corticosteroids and/or immunosuppressants (5 cases). This treatment was clinically effective in 5/8 cases, including 3 with seroconversion. The 2 patients in whom the combined treatment failed were given corticosteroids; one of them also had plasma exchanges. The 8th patient died after a few days of treatment. Eleven of the 13 patients are still alive and either cured or in complete remission. Two patients who developed severe chronic hepatitis after steroids were discontinued received vidarabine alone: arrest of viral replication was obtained in both cases, with emergence of an anti-HBe (but not anti-HBs) antibody. The overall positive virological response rate to vidarabine alone or combined with plasma exchanges was 50 per cent. When vidarabine was prescribed as treatment of acute periarteritis nodosa (the 2 cases where it was used for chronic hepatitis being excluded), this response rate was 37.5 per cent. This, in patients with periarteritis nodosa associated with hepatitis B virus immunosuppressive drugs should be withdrawn and replaced by plasma exchanges and antiviral agents. This would be the first-line treatment to be replaced by corticosteroid therapy if it fails.
对13例结节性多动脉炎合并乙型肝炎病毒感染的患者进行了重新评估，这些患者占同期收治的40例结节性多动脉炎患者的32.5%。所有病例均检测到乙肝表面抗原（HBs）和乙肝e抗原（HBe），血清中检测到病毒DNA证实乙肝病毒复制。1例患者抗乙肝核心抗体IgM阳性。5例患者接受了皮质类固醇、环磷酰胺治疗，偶尔进行血浆置换。所有患者均治愈或完全缓解。8例患者接受了血浆置换和阿糖腺苷治疗，其中3例作为一线治疗，5例在皮质类固醇和/或免疫抑制剂治疗失败后使用。该治疗在8例中有5例临床有效，其中3例发生血清学转换。联合治疗失败的2例患者接受了皮质类固醇治疗，其中1例还进行了血浆置换。第8例患者在治疗几天后死亡。13例患者中有11例仍存活，已治愈或完全缓解。2例在停用类固醇后发生严重慢性肝炎的患者单独接受了阿糖腺苷治疗：2例均实现了病毒复制停止，并出现了抗HBe（但无抗HBs）抗体。单独使用阿糖腺苷或联合血浆置换的总体病毒学阳性反应率为50%。当阿糖腺苷用于治疗急性结节性多动脉炎（排除用于慢性肝炎的2例）时，该反应率为37.5%。因此，对于结节性多动脉炎合并乙型肝炎病毒感染的患者，应停用免疫抑制药物，代之以血浆置换和抗病毒药物。如果该治疗失败，应采用皮质类固醇治疗作为一线治疗。
