S2604 Acute Severe Cholestatic Hepatitis B Infection in an Immune-Competent Patient

Abstract

INTRODUCTION: Acute severe cholestatic hepatitis B is uncommon and usually reported in organ transplant recipients. We report a unique case of acute HBV infection with severe cholestasis in an immune-competent patient whose symptoms were initially felt to be secondary to complications from choledocholithiasis. CASE DESCRIPTION/METHODS: A 67-year-old female presented with right upper quadrant (RUQ) pain, vomiting, fatigue & jaundice for 2 weeks. She had a new sexual partner with unknown hepatitis status. The patient had no history of alcohol, drug use or new medications. RUQ tenderness & scleral icterus were noted on exam. Labs showed AST-629u/l (Normal[N]: 10–40 u/l), ALT-497u/l (N: 12–78 u/l), ALP-294u/l (N: 33–138 u/l), T. Bili-8.4mg/dl (N: 0.0–1.5 mg/dl), D. Bili-7.5mg/dl (N: 0.0 −1.5mg/dl), INR-1. On ultrasound of the abdomen cholelithiasis with gall bladder wall thickening with normal biliary ducts was noted. Endoscopic ultrasound revealed a 2.5 mm filling defect without shadowing in distal common bile duct (CBD) & Endoscopic retrograde pancreatic duodenoscopy showed a small filling defect in mid CBD and a distal CBD stricture about 1–2 cm in length. Biopsy of CBD stricture showed inflammation. A plastic biliary stent was deployed with good drainage. Her liver tests did not improve, and additional investigations performed were positive for Hepatitis B surface antigen (HbsAg), core antibody Total (Anti HBc Total) & core IgM, Hepatitis e antigen (HBeAg). She was negative for Hepatitis B e antibody (HBeAb) and Hepatitis B surface antibody (HBsAb). HBV PCR was 765,000,000 IU/ml. She was discharged with a follow up scheduled in liver clinic, but was readmitted 2 weeks later with worsening fatigue & liver tests. A liver biopsy showed active hepatitis without evidence of bridging fibrosis or cirrhosis & positive HBV staining. Anti-viral therapy with Tenofovir was initiated with improvement in symptoms. DISCUSSION: Although several case reports describe severe cholestasis with HBV post-liver transplantation, it has rarely been described in immunocompetent patients. Our patient's presentation was initially concerning for biliary obstruction. Despite biliary drainage patient's symptoms worsened, & further investigations revealed acute HBV infection with high replication which was confirmed by biopsy. Prompt therapy with antivirals improved the clinical course. Given these findings one should have high index of suspicion to evaluate for HBV infection in unusual presentation with cholestasis.Figure 1.: Immunohistochemical stain highlights Hepatitis B surface antigen within the cytoplasm of hepatocytes (200X magnification).Figure 2.: Hepatic parenchyma with dense mixed acute and chronic inflammation throughout the hepatic lobule and intermixed ceroid-laden macrophages removing dead hepatocytes (100x magnification).Figure 3.: Hepatic parenchyma with dense mixed acute and chronic inflammation throughout the hepatic lobule and intermixed ceroid-laden macrophages removing dead hepatocytes (200 X magnification).