Marilia Campos, MD, Andrew Henn, MD, Ahmad Malli, MD
Hennepin County Medical Center, Minneapolis, MN
Patients with chronic HBV/HIV coinfection are at high risk of HBV chronicity and reactivation. Here we present a case of a patient who presented with acute liver failure secondary to hep B reactivation after adjustment of his HIV medication regimen.
Case Description/Methods: A 56 year old male with HIV/HBV coinfection with undetectable viral loads was evaluated in the ED for new onset nausea and jaundice. Examination was significant for jaundice in the absence of any encephalopathy or other stigmata of chronic liver disease. Blood tests revealed INR 3, ALK-P 210, ALT 2186, AST 2934 and Bili T/D 25.6/17, platelet count 197K, Cr 1.98, and CD4 count 394. Liver US showed normal hepatic echotexture with patent vasculature. Serologic evaluation showed undetectable HIV viral load, negative Hep C PCR, positive HepBsAg, and highly positive hepatitis B DNA ( >1 billion copies). About 5 months prior to this acute presentation, he was switched from (Cobicistat, Elvitegravir, Emtricitabine, and Tenofovir) to another regimen that doesn’t include hepatitis B coverage (Atazanavir, Cobicistat , Rilpivirine, and Abacavir) due to concerns about Tenofovir contributing to his unexplained CKD. He was started on dual therapy with tenofovir and entecavir and was transferred to a nearby liver transplant center. His passed away after a short complicated hospital stay with acute liver failure and colonic pneumatosis.
Our patient presented with acute fulminant liver failure after a brief period of inadvertent Hep B treatment interruption. Medical treatment was not helpful despite attempts at combination therapy with Tenfovovir and Entecavir (in contrast to Tenofovir monotherapy) despite the scarcity of data in this specific situation.
There are case reports that demonstrated clinical improvement especially early treatment in the course; however progression to hepatic failure, liver transplantation, and death has also been widely reported despite therapy. This case serves as a reminder to all medical providers about the complexity of concomitant chronic HBV and HIV coinfection. Any medication regimen change in this patient population needs a multidisciplinary team based approach between HIV specialists and Hepatologists.
Citation: Marilia Campos, MD, Andrew Henn, MD, Ahmad Malli, MD. P0760 - A CASE OF HEPATITIS B REACTIVATION RESULTING IN FULMINANT HEPATIC FAILURE. Program No. P0760. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.