Immunosuppression and Prophylactic Antiviral Therapy in a Patient with Crohnʼs Disease Flare and Hepatitis B Infection

Abstract

Crohn's disease patients with co-morbid Hepatitis B infection present a challenging therapeutic dilemma during IBD exacerbations because immunosuppressive therapies such as prednisone and biologics may cause a flare of their hepatitis. Several studies have previously shown that using antiviral prophylaxis with drugs such as tenofovir, entecavir, or adefovir in patients with Crohn's and Hepatitis B is frequently efficacious in preventing Hepatitis B viral load escalations during immunosuppression periods. Resistance patterns have suggested that tenofovir and entecavir may serve as superior antiviral prophylaxis medications. Studies have also shown that prophylaxis with antiviral medications should be started early (either at the start of immunosuppression or prior to immunosuppression) rather than waiting for hepatitis B reactivation to occur. A 40-year-old African American female with a past medical history of Crohn's disease presented to our gastroenterology clinic after being lost to follow-up for many years. She was first diagnosed with Crohn's disease in 1991; the extent of her disease was unknown at this time but she had been taking mesalamine 800 mg three times daily for years. Upon presentation, she complained of diffuse abdominal pain and 5-6 watery bowel movements per day for the past several weeks. She was afebrile with a normal heart rate and blood pressure. Her abdomen was diffusely tender to palpation throughout, with voluntary guarding and no rebound tenderness. She was transferred to the emergency department and admitted to the internal medicine service. Labs were significant for an elevated C-reactive protein of 14.39 mg/dL (normal range <0.9 mg/dL), normal white blood cell count and hemoglobin of 11.7 mg/dL. A Hepatitis panel revealed positive Hepatitis B surface antigen, negative Hepatitis B E antigen, plus a HBV DNA qualitative PCR 2542 IU/mL (log 3.4). A flexible sigmoidoscopy revealed diffuse inflammation, pseudopolyps and a narrowed stricture at 20 cm that was able to be traversed (see images). Biopsies were consistent with Crohn's disease. The patient was started on both intravenous steroids as well as tenofovir for her Hepatitis B infection. The patient is currently being treated on a steroid taper without hepatitis viral load flare, liver enzyme elevations, or abdominal symptoms. The surgery team was consulted early on to discuss possible need for surgical intervention and the potential role of biologics to prevent future structuring disease. The patient has achieved dramatic symptomatic improvement on tenofovir and prednisone with resolution of her loose bowel movements and debilitating abdominal pain. Through the use of tenofovir prophylaxis, we were able to prevent worsening of her Hepatitis B infection and alleviate her family and primary internal medicine team's concern that steroid immunosuppression therapy may fuel a Hepatitis B fire storm in her liver leading to hepatic complications. This case report supports the limited literature that prophylactic antiviral therapy can control Hepatitis B viral flares in patients being treated with steroids for a Crohn's Disease flare. Our plan based on the literature review is to continue tenofovir therapy with any future biologic or immunosuppressive treatment regimens.