Coexistence of Intrahepatic Cholestasis of Pregnancy Accompanied by Hepatitis B Flare in a Pregnant Woman and the Subsequent Development of Postpartum Thyroiditis and HBS Antigen Loss: A Case Report

Abstract

A 23-year-old pregnant woman was admitted to our hospital due to pruritus and right upper quadrant pain. Her abdominal ultrasound revealed hepatomegaly and the fetal ultrasonography was normal. Her HBS antigen was positive and HBe antigen was negative. HBV-DNA level was 350,000 copies/ml. Coincidental hepatobiliary diseases in pregnancy were ruled out. The patient received a diagnosis of HBe antigen negative hepatitis B and tenofovir disoproxil 245 mg/day was prescribed. At a follow-up visit one month later, she reported no improvement in her pruritus. The levels of liver transaminases were near-normal and HBV DNA was zero. However, her biochemistry revealed raised alkaline phosphatase and gamma glutamyl transferase levels. Her consecutively calculated fasting serum bile acid levels were too high. A diagnosis of severe intrahepatic cholestasis of pregnancy associated with hepatitis B infection was made and a treatment of ursodeoxycholic acid 1000 mg/day was prescribed while she continued to take tenofovir disoproxil. She had a normal delivery and there were no adverse outcomes for the fetus. Several weeks later, she was readmitted with tremor and nervousness. Her TSH level was low and CRP level was high. The rest of the laboratory findings were normal and an ultrasonography of thyroid showed paranchymal heterogenity. The aggregate of findings was consistent with postpartum thyroiditis. Finally, L-thyroxine was initiated on a daily basis. Interestingly, at the week of 96, loss of Hepatitis B surface antigen was detected during tenofovir treatment. J Med Cases. 2012;3(4):240-242 doi: https://doi.org/10.4021/jmc594w