A 95-year old gentleman developed fatal icteric flare of chronic hepatitis B despite lamivudine treatment. This article highlights the atypical presentations of chronic hepatitis B in elderly patient and the need to consider this possibility for acute fulminant hepatitis in endemic areas.published_or_final_versio

Chan, HLY

Leung, WK

Wong, WS

World Journal of Gastroenterology

PubMed

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Title Icteric flare of chronic hepatitis B in a 95-year old patientAuthor(s) Wong, WS; Leung, WK; Chan, HLYCitation World Journal Of Gastroenterology, 2003, v. 9 n. 12, p. 2876-2877Issued Date 2003URL http://hdl.handle.net/10722/162750Rights Creative Commons: Attribution 3.0 Hong Kong LicenseP.O.Box 2345, Beijing 100023,China                                                                                                                                                                 World J Gastroenterol  2003;9(12):2876-2877Fax: +86-10-85381893                                                                                                                                                                                                                                 World Journal of GastroenterologyE-mail: wjg@wjgnet.com     www.wjgnet.com                                                                                                                                   Copyright © 2003 by The WJG Press ISSN 1007-9327• CASE REPORT •Icteric flare of chronic hepatitis B in a 95-year old patientWS Wong, Wai Keung Leung, Henry L Y ChanWS Wong, Wai Keung Leung, Henry L Y Chan, Department ofMedicine and Therapeutics, the Prince of Wales Hospital, Hong KongSAR, The Chinese University of Hong KongCorrespondence to: Dr W K Leung, Department of Medicine andTherapeutics, 9/F, the Prince of Wales Hospital, 30-32 Ngan ShingRoad, Shatin, N.T., Hong Kong.  wkleung@cuhk.edu.hkTelephone: +852-2632-3140    Fax: +852-2637-3852Received: 2003-08-28    Accepted: 2003-10-23AbstractA 95-year old gentleman developed fatal icteric flare ofchronic hepatitis B despite lamivudine treatment. This articlehighlights the atypical presentations of chronic hepatitis Bin elderly patient and the need to consider this possibilityfor acute fulminant hepatitis in endemic areas.Wong WS, Leung WK, Chan HLY. Icteric flare of chronichepatitis B in a 95-year old patient. World J Gastroenterol2003; 9(12): 2876-2877http://www.wjgnet.com/1007-9327/9/2876.aspCASE REPORTA 95-year old gentleman was admitted in July 2003 fordecreased appetite and reduced mobility. He enjoyed good pasthealth and had no history of hepatitis or jaundice. Two weeksprior to admission, family members noted that he becamedrowsier and refused food. He was living at home with familyand had no history of percutaneous exposure before admission.He had never had tattooing, blood transfusion, casual sex orillicit drug use. There was no traveling history for more thantwenty years. The patient was not on any medication or herbs.       On admission, the patient was barely arousable. He couldonly answer simple questions. He was in deep jaundice anddehydrated. There was no stigma of chronic liver disease.Abdominal examination did not reveal any tenderness,organomegaly or ascites. Flapping tremor could not bedemonstrated because the patient was in grade 3 hepaticencephalopathy.       Blood test results were compatible with the picture of severehepatitis. The serum bilirubin level was 188 mmol/l, alkalinephosphatase was 76 IU/l (normal 40-100 IU/l), and alanineaminotransferase was 825 IU/l (normal <58 IU/l). Theprothrombin time was prolonged at 18.1 seconds. Platelet countwas 86×109/l. Renal function was normal. Urgent ultrasoundscan showed normal liver echotexture and normal size spleen.The biliary trees were normal. There was no gallstone.       His hepatitis B surface antigen (HBsAg) was positive, IgManti-hepatitis B core antigen (anti-HBc) was equivocal,hepatitis B e-antigen was negative, and antibodies to hepatitisB e-antigen (anti-HBe) was positive. Hepatitis B virus DNAwas 97.9×106 copies/ml by TaqMan real-time polymerasechain reaction[1]. The serology tests for hepatitis A, C, D and Eviruses were negative.      Lamivudine 100 mg daily was commenced on the fourthday of admission, and supportive treatment with vitamin K,lactulose and intravenous fluids replacement were prescribed.While the level of alanine aminotransferase was on decreasingtrend, serum bilirubin and prothrombin time graduallyincreased (Figure 1). He developed progressive liver failurewith worsening hepatic encephalopathy and eventuallysuccumbed sixteen days after admission.Figure 1  Serial blood results of the patient with acute flare ofchronic hepatitis B. The serum bilirubin, alanine aminotrans-ferase and prothrombin time are shown.DISCUSSIONThis case illustrates an unusual presentation of severe hepatitisB virus infection at an advanced age. Although liver biopsyhas not been performed, other causes of acute hepatitis havebeen excluded by negative drug history and negative serologytests for other hepatitis viruses. The absence of risky percutaneousexposure renders the possibility of acute hepatitis B veryunlikely. As a majority of chronic hepatitis B patients areasymptomatic and most people in Hong Kong do not haveregular health check-up, it is most likely that this patient wassuffering from chronic hepatitis B with HBsAg first discoveredto be positive at this presentation. Equivocal IgM anti-HBctest is not diagnostic of acute hepatitis B but could also bedetected in severe reactivation of chronic hepatitis B[2].     According to most prospective series, reactivation ofchronic hepatitis B typically occurred at around the secondand third decades[3-5]. Once a patient develops HBeAgseroconversion to anti-HBe, the durability reaches eightypercent. Patients often have quiescent disease afterwards, andthe risks of complications, such as hepatocellular carcinomaand liver cirrhosis, are considerably reduced. Our patientprobably has achieved sustained HBeAg seroconversion anddisease remission several decades before this admission as hehad negative HBeAg and no sign of liver cirrhosis at the ageof 95. Reactivation of chronic hepatitis B causing jaundiceand liver failure at this advanced age is uncommon. This caseillustrates the importance to consider chronic hepatitis B as acause of liver function derangement in endemic areas suchas Asia.      Icteric reactivation of chronic hepatitis B carries a poorprognosis even with lamivudine treatment. In a series of 46Bilirubin (umol/l)/ALT (IU/I)1 2 3 4 5  6  7  8 9 10  11 12 13  14  15 161 0009008007006005004003002001000BilirubinALTProthrombin timeProthrombin time (s)4035302520151050Admission dayspatients with severe reactivation of chronic hepatitis B withjaundice a quarter of patients died or required livertransplantation[6]. When both independent predictors of liver-related mortality including thrombocytopenia (platelet countbelow 143×109/l) and hyperbilirubinemia (serum bilirubingreater than 172 mmol/l) are present, as in our case, the mortalityrate is up to 69.2 %.      In conclusion, despite atypical presentation and atypicalage group, chronic hepatitis B should be considered in casesof acute fulminant hepatitis in endemic areas.REFERENCES1 Chan HLY, Chui AKK, Lau WY, Chan FKL, Wong ML, TseCH, Rao ARN, Wong J, Sung JJY. Factors associated with viralbreakthrough in lamivudine monoprophylaxis of hepatitis Bvirus recurrence after liver transplantation. J Med Virol 2002;68: 182-1872 Maruyama T, Schodel F, Iino S. Distinguishing between acuteand symptomatic chronic hepatitis B virus infection. Gastroenter-ology 1994; 106: 1006-10153 McMahon BJ, Holck P, Bulkow L, Snowball M. Serologic andclinical outcomes of 1536 Alaska natives chronically infected withhepatitis B virus. Ann Intern Med 2001; 135: 759-7684 Lok AS, Lai CL, Wu PC, Leung EK, Lam TS. Spontaneous hepa-titis B e antigen to antibody seroconversion and reversion inChinese patients with chronic hepatitis B virus infection. Gastro-enterology 1987; 92: 1839-18435 Liaw YF, Chu CM, Lin DY, Sheen IS, Yang CY, Huang MJ. Age-specific prevalence and significance of hepatitis B e antigen andantibody in chronic hepatitis B virus infection in Taiwan: a com-parison among asymptomatic carriers, chronic hepatitis, livercirrhosis, and hepatocellular carcinoma. J Med Virol 1984; 13:385-3916 Chan HL, Tsang SW, Hui Y, Leung NW, Chan FK, Sung JJ. Therole of lamivudine and predictors of mortality in severe flare-upof chronic hepatitis B with jaundice. J Viral Hepat 2002; 9: 424-428Edited by Wang XLWong WS et al. Icteric flare of chronic hepatitis B in a 95-year old patient          2877

Icteric flare of chronic hepatitis B in a 95-year old patient

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Icteric flare of chronic hepatitis B in a 95-year old patient

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