Faculty Development Case of the Month: April 2021

Please view the April 2021 Case of the Month below:

Submitted by:
Lesley Miller, MD, FACP
Professor of Medicine, Medical Director, Grady Liver Clinic
Division of General Internal Medicine, Department of Medicine
Emory University School of Medicine

STORY AND CASE

A 28 yo woman presented as a new patient to the Grady Liver Clinic. She was referred from a substance use disorder treatment program for treatment of chronic hepatitis C virus infection (HCV). She reported being diagnosed with HCV three years prior and had been using IV heroin for the past 10 years. She denied any other HCV risk factors including blood transfusions or unregulated tattoos or piercings. At the time of her visit she had been in a recovery program on methadone for five months and was using IV methamphetamine daily. She used occasional alcohol and marijuana and smoked half a pack of cigarettes daily. She had a history of bipolar disorder and PTSD and no other medical problems. She took no medications other than methadone. Review of systems revealed RUQ abdominal pain but no jaundice, increased abdominal girth or leg swelling. She reported chronic memory loss, intermittent numbness in her hands and feet, and depression and anxiety. Her vital signs were as follows: Blood pressure 92/54, heart rate 68, respiratory rate 18, temperature 97.1 F and SpO2 100% on room air. Her BMI was 20. She appeared well and her exam was significant only for RUQ abdominal tenderness. There were no viral hepatitis test results available so testing was performed for hepatitis A, B and C, chemistry, CBC and INR. Results showed an ALT of 34, AST of 34, bilirubin total of 0.4 and direct of 0.1, albumin of 4.3, platelet count of 180,000 and INR of 1.0. HIV was negative. HCV antibody was positive with an HCV RNA of 4 million copies. HAV antibody was negative. HBV surface antigen was positive, HBV core antibody was negative and HBV surface antibody was negative.

What is the diagnosis?

ANSWER AND EXPLANATION

The patient’s hepatitis B serology revealed early acute hepatitis B (HBV) infection superimposed on chronic hepatitis C infection. This is explained by the presence of HBV surface antigen without presence of HBV core antibody, which develops subsequent to surface antigen but early on in the infection. The absence of both significant symptoms and elevated liver enzymes is also consistent with very early infection. The patient was brought back for repeat testing one month later which revealed an ALT of 620, AST of 743 and unchanged bilirubin, albumin, platelets and INR. At that time, the HBV surface antigen remained positive, HBV core IgM Ab was positive, and HBV surface antibody remained negative. The HBV e antigen was reactive with an HBV DNA level of 782,741,123. Three months later, ALT was 181 and AST was 145, HBV e antigen was negative, HBV e antibody was positive and HBV surface antigen persisted. Finally, seven months after her initial visit, liver enzymes normalized, HBV surface antigen was negative, HBV core antibody remained positive and HBV surface antibody was positive. HBV DNA was undetectable. The patient had cleared her acute HBV infection and we proceeded with treatment of her HCV which was ultimately cured.

FINAL DIAGNOSIS?

Early acute hepatitis B infection superimposed on chronic hepatitis C infection

DISCUSSION

This case is unusual in that early acute HBV infection was detected incidentally on routine laboratory testing during work up for HCV treatment. The patient had minimal symptoms; in fact, only 5-40% of patients with acute HBV report symptoms. Having caught the infection so early, it was possible for us to follow the patient’s labs sequentially and observe clearance of the virus over several months. The vast majority (75% or more) of people with acute HCV clear the infection. We were concerned about the delay in HCV treatment that the acute HBV infection caused, and worried that we might miss a window for HCV treatment in a patient with ongoing substance use and multiple life stressors. However, the patient continued to follow up throughout her HBV infection and for subsequent HCV treatment and cure. HBV and HAV are vaccine preventable infections, and all persons with chronic HCV as well as those who inject drugs have indications for vaccination, meaning this patient had a missed opportunity for vaccination and disease prevention.

CITATIONS

• https://www.cdc.gov/hepatitis/hbv/vaccadults.htmacute
• Terrault, N.A., Lok, A.S., McMahon, B.J., Chang, K.‐M., Hwang, J.P., Jonas, M.M., Brown, R.S., Jr., Bzowej, N.H. and Wong, J.B. (2018), Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology, 67: 1560-1599. https://doi.org/10.1002/hep.29800
• Mantzoukis K, Rodríguez-Perálvarez M, Buzzetti E, Thorburn D, Davidson BR, Tsochatzis E, Gurusamy KS. Pharmacological interventions for acute hepatitis B infection. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD011645. DOI: 10.1002/14651858.CD011645.pub2.

Acknowledgements:

We acknowledge the patient presented here for her courage and eagerness to share her story in the hopes of helping others.