Reactivation of Chronic Hepatitis B Leading to Fulminant Hepatic Failure in an Immunosuppressed Patient

Abstract

The dangers of immunosuppression in patients that are known to be hepatitis B surface antigen positive have been described in the literature. It is proposed that steroids increase the rate of viral replication leading to an increased risk of reactivation. We report a case of fulimant hepatic failure (FHF) secondary to reactivation of hepatitis B in an immunosuppressed patient. A 50 year old male with a history of meningioma status post resection two months prior treated with high dose steroids for cerebral edema presented with progressively worsening bilaterally lower extremity edema that was refractory to escalating doses of oral diuretics. He also noted worsening right upper quadrant pain and jaundice. He denied any risk factors for viral hepatitis including sexually activity, IV drug abuse or travel to endemic areas. His medications included dexamethasone 4mg four times a day. His exam was significant severe lower extremity pitting edema, sclera icterus, right upper quadrant tenderness and ascites. Initial lab values revealed an AST of 328 IU/L, ALT of 732 IU/L, Total Bilirubin of 9.9 mg/dL, PTT of 31.8 seconds and INR of 2.1. Upon admission, his initial hepatitis panel was HepBsAg +, HepBeAg + and HepBeAb -. His HBV viral load was 2 billion. His anti-HCV and HDV DNA PCR were both negative. The patient quickly developed signs of hepatic encephalopathy and was started on lactulose and lamivudine. He was evaluated for liver transplant, but rejected because of his recent brain surgery with associated intracranial swelling. The patient's condition worsened and he expired 4 weeks later of hepatorenal syndrome and respiratory failure. This case demonstrates a known danger of the immunosuppression in patients with chronic latent hepatitis B. For our patient, the etiology of his FHF was thought to be due to the high dose steroids that the patient was prescribed for cerebral edema. Unfortunately, our patient was unaware of his hepatitis B status and gave no risk factors on initial history. This is a common issue and should be taken into account by healthcare providers. Knowledge about this potential risk is especially timely given the increased use of long term immunosuppressive therapies by a variety of specialties. Awareness of this potentially fatal complication will lead to increased screening of patients for HBV prior to initiating immunosuppressive treatment.