Co occurrence of Hepatitis B Virus Infection and Autoimmune Hepatitis with Marked Hepatitis B Virus Replication Following Treatment of Autoimmune Hepatitis

Abstract

Background: Children have different natural history of Hepatitis B virus (HBV) infection. They commonly develop asymptomatic chronic carrier state which is less frequently seen in adults. We describe a rare case of acute on chronic liver failure (ACLF) in the course of concurrent autoimmune hepatitis (AIH) and HBV infection and replication of HBV following the treatment for autoimmune hepatitis. Case Report: A 15 year old male child presented with jaundice and altered sensorium. Physical examination showed hepatosplenomegaly. The liver function tests were markedly altered. Serology was positive for anti liver kidney microsomal antibody (LKM), hepatitis B surface antigen (HBsAg) and immunoglobulin M (IgM) anti hepatitis B core antigen (HBc Ag). Liver biopsy showed chronic hepatitis with features of acute exacerbation. Patient was started on treatment with azathioprine and prednisolone for AIH following which clinical and biochmemical improvement was noted. After two years of continued treatment a repeat biopsy performed showed fairly reduced histological activity, but marked replication of the HBV (immunohistochemistry for HBsAg and anti HBcAg showed diffuse cytoplasmic and nuclear positivity respectively). These findings suggest viral replication although the patient was clinically stable. At six months follow-up after the second biopsy and cessation of azathioprine and prednisolone, there were raised liver enzymes and viral load, hence the patient was started on antiviral drug Entecavir to which there was good response and the patient is presently doing well. Conclusion: We describethe rare co occurrence of HBV infection and AIH with marked HBV replication following the treatment for AIH

Keywords

• Acute on chronic liver failure
• Hepatitis B virus
• Autoimmune hepatitis
• Liver biopsy