DRUG INDUCED HBV REACTIVATION LEADING T
O FULMINANT HEPATIC FAILURE:
A CASE REPORT ON ACUTE ON CHRONIC LIVER FAILURE
GCA Carpio, M.D.1 MC Quiambao, M.D.2 JD Sollano, M.D.1
1Section of Gastroenterology, Department of Medicine, University of Santo Tomas Hospital 2Department of Medicine, University of Santo Tomas Hospital
Significance: Chronic hepatitis B ranges from asymptomatic carriers, to reactivation and fulminant hepatic failure. Several factors have been proven to predispose to disease progression, one of which is significant exposure to immunosuppressive therapy such as corticosteroids and azathioprine. This report aims to discuss the course of hepatitis B infection, and its reactivation in a patient given immunosuppressive agents.
Clinical Presentation: Patient is a 54 year-old female initially presenting with jaundice. 3 months prior, patient was diagnosed with IgA nephropathy and was started on steroids and azathioprine. 2 weeks into treatment, she developed jaundice, with elevated liver enzymes (AST 244 U/L ALT 190 U/L). She was admitted for further work-up. During the course, the patient remained jaundiced, with occasional abdominal pain, generalized weakness and anorexia.
Management: Laboratories showed increasing levels of bilirubin and liver enzymes (SGOT 1593 U/L SGPT 1518 U/L) with worsening coagulopathy (INR 1.9 to up to 9). Workup included HBV DNA with a value of 170,000,000. She was started on entecavir 0.5mg/tab 1 tab OD. Due to development of progressive alteration in sensorium, with episodes of hemodynamic instability, tenofovir and encephalopathy regimen were started. However, on the 6th hospital day, despite adequate hydration, vasopressor support and initiation of broad spectrum antibiotics, the patient developed bleeding, hypotension and unresponsiveness leading to her demise.
Conclusion: Hepatitis B reactivation is a life-threatening and detrimental consequence of steroid and immunosuppressive exposure in HBV infected individuals. Screening, prompt recognition, diagnosis and pre-treatment prophylaxis are vital in preventing fulminant hepatic failure in patients with HBV.