Case Report: A Middle-aged Male Presenting with Chronic Hepatitis B
Emory University
Author Note:
This paper represents my own work in accordance with the School and University regulations.
Abstract
Introduction
Hepatitis B virus (HBV) infection is a global public health problem, which is the leading cause of liver cirrhosis and subsequent liver cancer. It is transmitted through bodily fluids and blood. Chronic hepatitis B infection is distinguished from the acute HBV infection by having persistent hepatitis B surface antigen (HBsAg) for a period exceeding six months. Chronic HBV infection is incurable but the available treatment can prolong survival.
Case presentation
In this case report, a 51-year-old male patient is presented who was diagnosed with chronic HBV infection. The patient had a history of travelling in high HBV prevalence regions and body tattooing. The HBsAg and anti-HBc tested positive and liver blood tests were not in the normal ranges. His viral load was above 2000 IU/L. He was managed using oral antiviral medication (entecavir) and within six months the viral load had gone down while blood test measurements had normalised, but the HBsAg persisted.
Conclusion
Treatment is needed for chronic HBV patients with high viral loads and signs of liver malfunction with the aim of slowing the progression towards cirrhosis or liver cancer and prolonging survival. Nonetheless, it until now remains and challenge to completely cure chronic HBV and thus the best strategy is to target prevention.
Key words: Hepatitis B, chronic HBV infection, HBsAg, treatment
Introduction
Hepatitis B is categorised as one of the major global public health problems. It is estimated that over 200 million people globally live with chronic hepatitis B (WHO, 2019). The US is considered a low prevalence region with a prevalence rate of below 2% (Hyun Kim & Ray Kim, 2018). According to the World Health Organisation (WHO), hepatitis B is responsible for over 800,000 deaths annually mostly due to hepatocellular carcinoma (HCC) and cirrhosis. Hepatitis B virus (HBV) is spread through contact of blood and body fluids such as seminal, vaginal, menstrual and saliva. In the areas of high prevalence, mother to child transmission is the most common. In most cases, the chronic infection is associated with HBV infection that happens before five years of age. Among healthy adults who acquire the infection as adults, those the chance of developing chronic illness is less than 5% (WHO, 2019). Men who have sex with men, heterosexual individuals who have sex with sex workers and/or with several partners have a higher risk of contracting hepatitis B infection. Reuse or sharing of syringes and needles among injectable drug users, through tattooing, body piercing, surgical procedures and any other practice involving use of sharp objects that have contact with infected blood also lead to the transmission of the virus. Furthermore, people with compromised immune systems either due to chronic infections such as HIV or from taking immune-suppressing medications are more vulnerable to HBV infection.
Hepatitis B presents with similar clinical symptoms as other strains of hepatitis, thus, laboratory tests are used for confirmation and distinguishing chronic and acute infection. Using laboratory diagnosis HBV infection presents with hepatitis B surface antigen HBsAg and immunoglobulin M (IgM) (Song & Kim, 2016). In the early stages, the infected individuals also have the hepatitis B e antigen (HBeAg), which indicates high virus replication rate (McMahon et al., 2014). In short, HBV infection diagnosis involves tests for hepatitis B surface antigen (HBsAg), antibody (anti-HBs), and hepatitis B core antibody (anti-HBc). The acute hepatitis B shows symptoms within one to four months and it resolves within a few weeks or month. When anti-HBs and anti-HBc are present concurrently, a patient is considered to have had a past HBV infection (Song & Kim, 2016). Moreover, one is considered to be suffering from chronic HBV infection if the HBsAg persists for at least six months (WHO, 2019). Chronic HBV infection is mostly asymptomatic and can linger for years without showing clinical signs. However, later in life, it can progress to cause liver cirrhosis or cancer of the liver (WHO, 2019). The possible mechanism of HBV persistence and the pathogenesis to the development of cirrhosis and hepatocellular carcinoma are described by Chisari, Isogawa & Wieland (2010). Nonetheless, it is approximated that 30% of those with chronic HBV infection will develop cirrhosis or liver cancer (WHO, 2019). Chronic HBV infection is managed using antiretroviral agents that suppress the virus.
Case presentation
The patient is a 51-year-old male Singaporean immigrant with a family history of divorce and two children. It was his twentieth year since migrating to the US but the patient reported regularly travelling to Singapore. At the time of admission, the patient was living alone. The patient endorsed no history of injectable drugs use or having an HBV infected mother. The patient had a large tattoo on his back and declined to comment on whether he has had multiple sex partners.
During admission, the patient presented with general body weakness, fever, jaundice, and loss of appetite, and dark urine lasting for the past seven days. According to his medical history, he had experienced similar symptoms 18 months previously at which point he was diagnosed with acute HBV infection. The patient reports symptoms resolving but states he never received follow-up care.
The patient was tested for HBsAg, which was found to be positive. In addition, the anti-HBc test result was positive indicating the patient was not immune to the HBV and had past HBV infection. Liver studies that were done included alanine aminotransferase (ALT), Complete blood count (CBC), and liver function tests (LFTs). The ALT was 75 IU/L, the CBC results were: white blood cell count (WBC) 5000, platelet 130,000, and haematocrit 45. LFT results: Total Bilirubin 2.0 mg/dL, and Albumin 2.5 g/dL. Viral load was also tested which was found to be 2100 IU/L. The ALT of 75 IU/L indicated that the patient was at the moderate risk of liver injury since the normal upper limit for men is 35 IU/L. The CBC and LFTs results had also slightly deviated from the normal ranges indicating a likelihood of liver malfunction. Liver biopsy was then done, which indicated minor liver injury.
| Test | Patient readings | Normal ranges |
| ALT | 75 IU/L | Upper limit 35IU/L |
| CBC
WBC- Platelets – Hematocrit- |
5000 130, 000 45 |
5000-10,000/mm3 140, 000- 400,000/mm3 40.7 – 50 % |
| LFTs
Total bilirubin Albumin |
2.0 mg/dL 2.5 g/dL |
0.1 – 1.2
3.5 – 5.0 |
| Viral load | 2100 IU/L | <2000 |
Table 1: Lab results of the patient on admission
The patient was started on oral antiretroviral treatment with entecavir. The patient was followed up for six months during which laboratory studies and viral load were monitored. In the sixth month, the HB viral load was significantly reduced and there was no evidence of further hepatic dysfunction. However, HBsAg was still positive.
Discussion
Hepatitis B infection is common among people from high prevalence regions or who have come into contact with persons from those regions. Eastern Asia is one such region (WHO, 2019) and thus the patient coming from Singapore, he could have already contracted the virus. In addition, the tattooing could have been the source of his infection as it been indicated that tattooing is one of the risk factors for HBV infection as people may be using objects that are already contaminated with the virus. On the other hand, concerning chronic HBV infection, though it is not common among those who get infected when they are already adults it can never be overlooked as is can progress to liver cirrhosis and liver cancer.
Chronic HBV infection is diagnosed by the identification of persistent HBsAg, which can be alongside HBeAg or not. In acute HBV infection, the anti-HBc diminishes within a period of six months (Schillie et al., 2018). However, in a patient with a resolved HBV infection or chronic HBV anti-HBc continues being detected. Therefore, one criterion of diagnosing chronic HBV is the presence of anti-HBc alongside HBsAg past six months since the first infection was detected (Song & Kim, 2016). Moreover, to understand the virus replication activity, viral load is measured using HBV DNA. Detection of the HBV DNA is highest during the early phases of HBV infection but it is relatively low in chronic infection (Song & Kim, 2016). Higher viral load is associated with an accelerated progression of the disease and heightened hepatocellular carcinoma incidence (Song & Kim, 2016). The viral load test is important in determining patients requiring antiviral treatment and in monitoring the progression of treatment (McMahon et al., 2014). The viral load exceeding 2000 IU/L is considered to be high but it must be in addition to other parameters such as high ALT and persistent HBsAg that treatment is required. Hence, the patient, in this case, met the treatment criteria since his viral load was 2100 IU/L plus other measures were relatively high.
Chronic HBV infection is managed using oral anti-viral medications that act by suppressing the virus thus slowing the advancement of cirrhosis, lowering the HCC incidence and improving long-term survival. Currently, there are two types of antiviral agents for HBV that have been approved, nucleos(t)ide analogs (NAs) and Pegylated interferon (Peg-IFN) for the treatment of chronic hepatitis B infection (Osiowy, Coffin & Andonov, 2016). Examples of NAs include entecavir and tenofovir. NAs have been shown to be well-tolerated; however, many patients require extended therapy as there is a risk of relapsing with the treatment termination (Tseng & Kao, 2017). Nevertheless, NAs continue to be the most popular medications in the management of chronic HBV infection. Notwithstanding, HBV remains incurable as research is ongoing to find treatments that can lead to a cure. According to Chahal et al (2018), the most cost-effective way of controlling chronic HBV infection is by combining screening, vaccination, and treatment strategy among high-risk populations.. Early screening and vaccination could have prevented him from developing chronic HBV.
Conclusion
Chronic hepatitis B infection presents with persistent HBsAg. Moreover, until now, there is no cure for chronic HBV but it can be managed using oral medications. Treatment is initiated for HBV patients with high viral loads and signs of liver malfunction with the aim of slowing the progression towards cirrhosis or HCC and prolonging survival. To that point, the best way of controlling HBV infection is by applying preventive measures such routine vaccination of all infants, screening for the HBV among all at-risk groups, vaccinating them accordingly, avoiding risky practices such sharing of needles/syringes, and having unprotected sex with individuals of unknown HBV status.
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