Hepatitis B Virus Reactivation Superimposed Hepatitis A Co-Infection Leading to Acute on Chronic Liver Failure:  A Case Report and Literature Review

Satria Agung Maulana Fahmi; Tamara Audrey Kadarusman; Rusdiyana Ekawati

Authors

Satria Agung Maulana Fahmi
Tamara Audrey Kadarusman
Rusdiyana Ekawati

Keywords:

Acute on Chronic Liver Failure, Hepatitis B, Reactivation, Hepatitis A, co-infection

Abstract

Acute-on-chronic liver failure (ACLF) is a severe condition with an incidence rate of 5.7 cases per 1,000 person-years. A primary trigger for ACLF is hepatitis B reactivation, which is responsible for 40-60% of cases. Co-infection with hepatitis A can also contribute to its occurrence.This study presents the case of a 58-year-old male patient with a history of hepatitis B virus (HBV)-related cirrhosis, presenting with symptoms including confusion, disorientation, worsening jaundice, abdominal discomfort, nausea, vomiting, loss of appetite, malaise, muscle pain, and fever. Despite regular treatment for HBV, the patient’s condition deteriorated over 14 days. He had no history of hypertension, diabetes, autoimmune diseases, alcohol consumption, or smoking. On examination, the patient exhibited grade 2 hepatic encephalopathy, severe jaundice, ascites, and lower limb edema. Laboratory results revealed elevated liver enzymes, increased bilirubin levels, and decreased albumin. Subsequent testing confirmed acute hepatitis A infection and a significant hepatitis B viral load.The report highlights that reactivation of Chronic Hepatitis B, accompanied by co-infection with hepatitis A, played a critical role in inducing inflammation and worsening the ACLF condition.

References

Sarin SK, Choudhury A, Sharma MK, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update. Hepatol Int. 2019 Jul 1;13(4):353–90.

Vinay Kumar BR, Sarin SK. Acute-on-chronic liver failure: Terminology, mechanisms and management. Vol. 29. Clinical and Molecular Hepatology. Korean Association for the Study of the Liver; 2023. p. 670–89.

Luo J, Li J, Li P, et al. Acute-on-chronic liver failure: far to go—a review. Vol. 27. Critical Care. BioMed Central Ltd; 2023.

Moreau R, Gao B, Papp M, Bañares R, Kamath PS. Acute-on-chronic liver failure: A distinct clinical syndrome. J Hepatol. 2021 Jul;75:S27–35.

Zhu Y, Li H, Wang X, et al. Hepatitis B virus reactivation increased the risk of developing hepatic failure and mortality in cirrhosis with acute exacerbation. Front Microbiol. 2022 Jul 7;13.

Lashkarbolouk N, Khodabakhshi B, Mazandarani M. Acute Hepatitis A and Hepatitis B coinfection in a young female: A case report and literature review. Case Rep Infect Dis. 2023 Jun 3;2023:1–4.

Kanda T, Sasaki R, Masuzaki R, et al. Co-occurrence of hepatitis A infection and chronic liver disease. Vol. 21. International Journal of Molecular Sciences. MDPI AG. 2020;1–18.

Zaccherini G, Weiss E, Moreau R. Acute-on-chronic liver failure: Definitions, pathophysiology and principles of treatment. Vol. 3. JHEP Reports. Elsevier B.V.; 2021.

Bajaj JS, O’Leary JG, Lai JC, et al. Acute-on-chronic liver failure clinical guidelines. American Journal of Gastroenterology. 2022 Feb 1;117(2):225–52.

Adetunji B, Alare K, Afolabi S, Olajire A, Adegboye O. Acute on chronic hepatic failure due to hepatitis B infection: A case report. Vol. 5. Case Report Medical Journal of Viral Hepatitis (MJVH) Medical Journal of Viral Hepatitis (MJVH). 2021.

Mahmud N, Kaplan DE, Taddei TH, Goldberg DS. Incidence and mortality of acute-on-chronic liver failure using two definitions in patients with compensated cirrhosis. Hepatology. 2019 May 1;69(5):2150–63.

Garg P, Madan K. Acute-on-chronic liver failure due to hepatitis B. Frontiers in Gastroenterology. 2023 Mar 9;2.

Wu T, Li J, Shao L, et al. Development of diagnostic criteria and a prognostic score for hepatitis B virus-related acute-on-chronic liver failure. Gut. 2018;67(12):2181–91.

Shi Y, Yang Y, Hu Y, et al. Acute-on-chronic liver failure precipitated by hepatic injury is distinct from that precipitated by extrahepatic insults. 2015.

Moreau R, Tonon M, Krag A, et al. EASL clinical practice guidelines on acute-on-chronic liver failure. J Hepatol. 2023 Aug;79(2):461–91.

Cahyono SB, Rasari N, Bayupurnama P, Maduseno S, Nurdjanah S. Reactivation and flare of chronic Hepatitis B: Natural history, diagnosis, therapy, and prevention. The Journal of Internal Medicine, Acta Interna. 2014;4.

Lok ASF, McMahon BJ. Chronic hepatitis B. Hepatology. 2007;45:507–39.

Liang J, Liu L, Cao Y, et al. Hepatitis B-related acute-on-chronic liver failure induced by hepatotropic viral insult is associated with worse prognosis than that induced by non-viral insult. BMC Infect Dis. 2021 Dec 1;21(1).

Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018 Apr 1;67(4):1560–99.

Arroyo V, Moreau R, Jalan R. Acute-on-chronic liver failure. In: Longo DL, editor. New England Journal of Medicine [Internet]. 2020;382(22):2137–45. Available from: http://www.nejm.org/doi/10.1056/NEJMra1914900

Bernardi M, Angeli P, Claria J, et al. Albumin in decompensated cirrhosis: New concepts and perspectives. Gut. BMJ Publishing Group. 2020;69:1127–38.

Emenena I, Emenena B, Kweki AG, et al. Model for end stage liver disease (MELD) score: A tool for prognosis and prediction of mortality in patients with decompensated liver cirrhosis. Cureus. 2023 May 20.

Arroyo V, Moreau R, Jalan R, Ginès P. Acute-on-chronic liver failure: A new syndrome that will re-classify cirrhosis. Journal of Hepatology. 2015;62: S131–43.

Bernal W, Hyyrylainen A, Gera A, et al. Lessons from look-back in acute liver failure? A single centre experience of 3300 patients. J Hepatol. 2013 Jul;59(1):74–80.