The First Case Report of Hepatitis B Virus (HBV) Reactivation in an Inactive Carrier of Chronic HBV After the Initiation of Treatment for Tuberculosis

Abstract

Introduction: The HBV is a DNA virus that causes inflammation of the liver whether the infection is acute or chronic. After the initial phase of acute infection with HBV, resolution occurs in about 15% of patients, while chronic HBV infection is seen in about 85% of patients. Despite serological recovery, HBV DNA persists in the hepatocyte through integration into the host genome; therefore clinicians need to be aware of the risk of HBV reactivation in patients receiving chemotherapy and other immunosuppressive medications. Case Presentation: A 32-year-old female with a history of chronic HBV in the inactive carrier state and tuberculous lymphadenitis presented to the emergency department with generalized weakness, nausea, vomiting and jaundice for two weeks. She had recently been started on Ethambutol, Levofloxacin and Capreomycin by her private medical doctor for tuberculosis treatment. She denied use of any other medications or herbal supplements. She denied alcohol or illicit drug use. Her family history was unremarkable for liver disease. Physical examination was notable for scleral icterus but otherwise unremarkable. HIV test was negative. Her hepatic function tests returned as follows; aspartate transaminase 1397 U/L, alanine transaminase 1234 U/L, gamma-glutamyl transpeptidase 107 IU/L, total bilirubin 2.3 mg/dL, and direct bilirubin 0.6 mg/dL. Liver enzymes were normal four months prior to admission. Due to concern for drug-induced liver injury her anti-tuberculosis medications were discontinued. An abdominal ultrasound revealed mild increased liver echogenicity. Hepatitis C Virus antibody was non-reactive. HBsAg was reactive, anti-HBs was non-reactive, and anti-HBc was reactive and IgM anti-HBc nonreactive. HBV DNA level was greater than 1,000,000,000 IU/mLconsistent with a diagnosis of reactivation of HBV. The patient was started on tenofovir 300 mg PO daily. Ultimately the patient was discharged home. Follow up one month later revealed normalizing liver enzymes and an HBV DNA level of 471 IU/mL. Conclusion: Reactivation of HBV after starting chemotherapy or immunosuppressive medications is well described. Our case report is the first to describe HBV reactivation after starting anti-tuberculosis medications. Screening for HBV infection should be considered prior to initiating anti-tuberculosis therapy due to concern for reactivation of HBV, which can be severe and potentially fatal.