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Hepatic failure due to fibrosing cholestatic hepatitis in a patient with pre-surface mutant hepatitis B virus and mixed connective tissue disease treated with prednisolone and chloroquine
Journal of Clinical Virology 31 (2004) 53–57
Hepatic failure due to fibrosing cholestatic hepatitis in a patient with pre-surface mutant hepatitis B virus and mixed connective tissue disease treated with prednisolone and chloroquine Simon A. Zanati a , Stephen A. Locarnini c , John P. Dowling b , Peter W. Angus d , Francis J. Dudley a , Stuart K. Roberts a,∗ a
d
Department of Gastroenterology and Hepatology, The Alfred Hospital, Commercial Road, Prahran, Vic. 3181, Australia b Department of Pathology, The Alfred Hospital, Prahran, Vic., Australia c Victorian Infectious Diseases Reference Laboratory, North Melbourne, Vic., Australia Department of Gastroenterology and Hepatology, The Austin and Repatriation Medical Centre, Austin Campus, Heidelberg, Vic., Australia Received in revised form 13 February 2004; accepted 16 February 2004
Abstract Fibrosing cholestatic hepatitis (FCH) is a severe variant of hepatitis B infection that has until recently been described almost exclusively in the setting of organ transplantation and HIV infection. This case report describes a patient with pre-surface (pre-S) mutant hepatitis B virus (HBV) infection who developed a fatal form of FCH after high dose prednisolone for mixed connective tissue disease (MCTD). The role of corticosteroids and pre-S viral mutation in the pathogenesis of the disease is discussed, and the importance of early diagnosis is emphasised. This report alerts the physician to the need for close monitoring of LFTs and HBV DNA of hepatitis B carriers during immunosuppressive therapy regardless of the indication. As in the transplantation setting, viral DNA levels should be kept to undetectable if viral replication or recurrence is to be prevented. © 2004 Elsevier B.V. All rights reserved. Keywords: Fibrosing cholestatic hepatitis; Hepatitis B pre-S mutant; Prednisolone; Chloroquine
1. Introduction Fibrosing cholestatic hepatitis (FCH) is an uncommon variant of chronic hepatitis B virus (HBV) infection that is characterised clinically by the onset of rapidly progressive liver failure, and histologically by the presence of intense cholestasis, peri-portal fibrosis and modest inflammatory cell infiltrate (Davies et al., 1991). Until recently, FCH has been described almost exclusively in heavily immunosuppressed organ transplant recipients (Davies et al., 1991; Hawkins et al., 1996; Lam et al., 1996; McIvor et al., 1994; McMillan et al., 1996; Trautwein et al., 1996) and subjects with HIV and hepatitis B co-infection (Fang et al., 1993). The condition is associated with very high levels of HBV replication and little evidence of immune-mediated hepatocellular injury. This has lead to the suggestion that liver injury in FCH ∗ Corresponding author. Tel.: +61-3-9276-3375; fax: +61-3-9276-2194. E-mail address: [email protected] (S.K. Roberts).
1386-6532/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.jcv.2004.02.013
is mediated via the direct viral cytopathic effects of HBV antigen over-expression in hepatocytes (Davies et al., 1991; Lau et al., 1992a). Infection with mutant strains of hepatitis B including those involving the pre-core and pre-surface (pre-S) regions of the HBV genome appears to increase the risk of developing liver failure (Hawkins et al., 1996; Lam et al., 1996; Liang et al., 1991; McIvor et al., 1994; McMillan et al., 1996; Trautwein et al., 1996). We report a patient with pre-surface mutant HBV infection who developed FCH following treatment of mixed connective tissue disease (MCTD) with prednisolone and chloroquine.
2. Case report A 29-year-old Chinese woman with chronic hepatitis B was diagnosed with MCTD in 1996 when she developed Raynaud’s phenomenon, arthritis, fevers, and pleurisy associated with anti-Ro and anti-RNP antibodies. She was well on maintenance prednisolone 5 mg per day and
54
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
hydroxychloroquine therapy until October 1999, when she presented with fever and headaches. Aseptic meningitis was diagnosed after MRI of brain was normal and lumbar puncture revealed an elevated CSF protein and lymphocytosis, but no acid-fast bacilli or cryptococci. She responded to intravenous hydrocortisone and was discharged on prednisolone 30 mg bd. Of note, LFTs were normal apart from a GGT of 94 U/l (normal <43 U/l). In December 1999, she had ongoing headaches so hydroxychloroquine was replaced by chloroquine 250 mg per day and prednisolone reduced to 50 mg per day. One month later, she was well so the dose of prednisolone was slowly reduced by 5 mg per week. Her LFTs were unchanged. Two weeks later, she presented with 1 week of nausea, vomiting, right upper quadrant pain, and jaundice. LFTs were now abnormal with serum bilirubin 96 mol/l, ALT 225 U/l, alkaline phosphatase 206 g/l, GGT 597 U/l, and albumin 34 g/l. Hepatitis B surface antigen (HBsAg) remained positive while viral serology for hepatitis A, C, and D, and HIV, and PCR testing for CMV, HSV, and VZV were all negative. Abdominal CT scan revealed gallbladder wall oedema but normal calibre intra- and extra-hepatic bile ducts and no gallstones. Over the following week, she developed progressive liver failure with increasing jaundice, ascites, coagulopathy, and renal impairment (creatinine 0.15 mmol/l) (Fig. 1). Because of worsening abdominal pain, on day 6 an emergency laparotomy was performed.
60
At surgery, the liver appeared pale and firm, but the gallbladder and biliary ductal system were both normal. Liver histology demonstrated preserved architecture but florid cholestasis with prominent bile duct proliferation, feathery degeneration and swelling of hepatocytes, a mixed neutrophilic and lymphocytic cellular infiltrate, and marked fibrous expansion of portal tracts (Fig. 2A). Orcein staining for HBsAg was negative. Post-operatively, she was transferred to intensive care and commenced on intravenous broad-spectrum antibiotics and hydrocortisone 100 mg tds. However, no focus of sepsis could be identified on full-septic work-up that included multiple sets of blood cultures. Worsening liver function necessitated transfer to a liver transplant unit on day 10 where she developed multi-organ failure requiring inotropes, ventilatory support, and hemofiltration (Fig. 1). HBV studies performed on admission confirmed high level viral replication with HBV DNA positive in a titre of >5.6 × 108 copies/ml. HBeAg was also detected. Immunoperoxidase staining of the original biopsy specimen revealed that while few hepatocytes were positive for HBsAg, most (over 70%) stained strongly for core antigen (HBcAg) with uniform cytoplasmic but minimal nuclear staining (Fig. 2B). Following review of the biopsy, FCH was diagnosed and treatment commenced with lamivudine 50 mg per day. However, her condition deteriorated and she died on day 13. An autopsy was not performed.
60
50
40 Prednisolone (mg/d) Chloroquine 250 mg/d
500 Bilirubin (mmol/L) ALP (U/L) 400
Serum level
ALT (U/L) 300
200
100
0
-100 -42 -14
0
5
10
13
Days Fig. 1. Hepatologic course in relation to immunosuppressive therapy including serum ALT, ALP and total bilirubin (bili) plotted over time. The time course of immunosuppressive drug therapy is shown above the graph.
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
HBV DNA extracted from the patient’s serum was amplified by PCR for direct sequencing. Sequencing of the surface envelope gene of the viral DNA revealed genotype B and that a mixed HBV population was present. One viral population contained an ∼300 bp deletion within the pre-S1
55
domain. Sequence analysis of the area encompassing this deletion indicated that the entire S promoter region was missing. The 324 bp deletion began approximately 60 bp after the pre-S1 start codon and ended approximately 60 bp before the pre-S2 start as shown in Fig. 3. The second
Fig. 2. Light photomicrographs of liver sections stained with H&E (A) and immuno-peroxidase (B and C). Note the prominent bile duct proliferation (arrows), bile plug (BP) and moderate mixed inflammatory cell infiltrates (arrowheads) within portal tracts (PT), and hepatocyte ballooning. Dashed line represents boundary between PT and lobule (A). Hepatocytes show minimal staining for surface antigen (B), but intense uniform cytoplasmic staining for core antigen (C) (original magnification 160×).
56
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
Fig. 2. (Continued ).
Fig. 3. HBV surface gene and the overlapping polymerase region. The 324 bp deletion, indicated by the shaded area, removes the entire S promoter region within the pre-S1 gene from amino acid 20 through to amino acid 119, and amino acids 1–9 of the pre-S2 gene. This deletion also removes part of the spacer region within the polymerase gene.
viral population was of the wild type containing a normal S-promoter region.
3. Discussion To our knowledge, this is the first case of a death due to immunosuppression-induced FCH to be reported outside the setting of transplantation. The patient developed rapidly progressive liver failure after commencing high-dose prednisolone and chloroquine. Hepatitis B-related FCH was
diagnosed based on the clinical course, biochemical findings, and the demonstration of active HBV replication, abundant HBV in hepatocytes, and characteristic histologic features (Davies et al., 1991). Both diagnosis and treatment were delayed and this may have adversely affected the patient’s outcome. The initial interpretation of liver histopathology was influenced by the virtual absence of HBsAg staining in hepatocytes and mixed inflammatory cell infiltrate, that in the context of the patient’s abdominal pain, suggested that acute suppurative cholangitis or intra-abdominal sepsis were possible. Indeed, cholangiography, measurement of serum HBV
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
DNA and liver staining for HBcAg were required before the diagnosis of FCH was made and lamivudine commenced. This emphasises that severe cholestatic hepatitis is part of the histologic spectrum of FCH (Davies et al., 1991) and that both surface and core antigen expression in liver and serum HBV DNA should be measured when severe HBV reactivation is suspected. Immunosuppression is likely to have played a key role in the development of severe liver disease in this case. The picture was not consistent with a severe flare of chronic hepatitis B due to withdrawal of immunosuppression (Flowers et al., 1990), since the disease developed while the patient was receiving high-dose prednisolone, ALT levels were only modestly elevated and the typical histological findings were absent. Prednisolone may potentiate HBV replication and markedly enhance intracellular HBV antigen expression in hepatocytes (Davies et al., 1991; Lau et al., 1992b) acting via the glucocorticoid-responsive element on the HBV genome (Tur-Kaspa et al., 1986). There is also evidence that chloroquine may reduce lysis of infected hepatocytes possibly by interfering with the normal cellular processing of viral antigens in the liver (Kouroumalis and Koskinas, 1986). Hence, both drugs may have contributed to the marked accumulation of HBV antigen in the liver and the development of FCH. The weak reactivity of HBsAg was almost certainly due to the presence of the pre-S mutant HBV as the dominant virus. Pre-S mutants often co-exist with wild-type HBV but in contrast to pre-core mutants, they are rarely reported to cause FCH (Bock et al., 1997; Melegari et al., 1994). Nevertheless, pre-S mutants can cause viral retention within hepatocytes, particularly mutants with deletions in the pre-S1 region that affect the S promoter. These viruses are capable of replication but have defective secretion of viral particles including surface protein (Bock et al., 1997; Kouroumalis and Koskinas, 1986; Melegari et al., 1994; Xu and Yen, 1996). Thus, pre-S1 mutant infection may have contributed to hepatic injury in this case through the cellular accumulation of viral replicative intermediates. However, functional in vitro assays are required to precisely define the role of pre-S mutants in the pathogenesis of FCH (Bock et al., 1997). In conclusion, this report of fatal HBV infection with FCH in a non-transplant patient on high-dose prednisolone illustrates the need for close monitoring of LFTs and HBV DNA of hepatitis B carriers during immunosuppressive therapy regardless of the indication. As in the transplantation setting, viral DNA levels should be kept to undetectable if viral replication or recurrence is to be prevented (McCaughan et al., 1999), and this is best achieved by combination antiviral chemotherapy (Shaw and Locarnini, 2000).
57
References Bock CT, Tillmann HL, Maschek HJ, Manns MP, Trautwein C. A preS mutation isolated from a patient with chronic hepatitis B infection leads to virus retention and misassembly. Gastroenterology 1997;113:1976– 82. Davies SE, Portmann BC, O’Grady JG, Aldis PM, Chaggar K, Alexander GJ, Williams R. Hepatic histological findings after transplantation for chronic hepatitis B virus infection, including a unique pattern of fibrosing cholestatic hepatitis. Hepatology 1991;13:150–7. Fang JW, Wright TL, Lau JY. Fibrosing cholestatic hepatitis in patient with HIV and hepatitis B [letter]. Lancet 1993;342:1175. Flowers M, Heathcote J, Wanless I, Sherman M, Reynolds W, Cameron R, Levy G, et al. Fulminant hepatitis as a consequence of reactivation of hepatitis B virus infection after discontinuation of low-dose methotrexate therapy. Ann Intern Med 1990;112:381–2. Hawkins AE, Gilson RJ, Gilbert N, Wreghitt TG, Gray JJ, Ahlers-de Boer I, Tedder RS, et al. Hepatitis B virus surface mutations associated with infection after liver transplantation. J Hepatol 1996;24:8–14. Kouroumalis EA, Koskinas J. Treatment of chronic active hepatitis B (CAH B) with chloroquine: a preliminary report. Ann Acad Med Singapore 1986;15:149–52. Lam P, Wachs M, Somberg K, Vincenti F, Lake J, Ferrell L. Fibrosing cholestatic hepatitis in renal transplant recipients. Transplantation 1996;61:378–81. Lau JY, Bain VG, Davies SE, O’Grady JG, Alberti A, Alexander GJ, et al. High-level expression of hepatitis B viral antigens in fibrosing cholestatic hepatitis. Gastroenterology 1992a;102:956–62. Lau JY, Bain VG, Smith HM, Alexander GJ, Williams R. Modulation of hepatitis B viral antigen expression by immunosuppressive drugs in primary hepatocyte culture. Transplantation 1992b;53:894–8. Liang TJ, Hasegawa K, Rimon N, Wands JR, Ben-Porath E. A hepatitis B virus mutant associated with an epidemic of fulminant hepatitis [see comments]. N Engl J Med 1991;324:1705–9. McCaughan GW, Spencer J, Koorey D, Bowden S, Bartholomeusz A, Littlejohn M, et al. Lamivudine therapy in patients undergoing liver transplantation for hepatitis B virus precore mutant-associated infection: high resistance rates in treatment of recurrence but universal prevention if used as prophylaxis with very low dose hepatitis B immune globulin. Liver Transpl Surg 1999;5:512–9. McIvor C, Morton J, Bryant A, Cooksley WG, Durrant S, Walker N. Fatal reactivation of precore mutant hepatitis B virus associated with fibrosing cholestatic hepatitis after bone marrow transplantation. Ann Intern Med 1994;121:274–5. McMillan JS, Bowden DS, Angus PW, McCaughan GW, Locarnini SA. Mutations in the hepatitis B virus precore/core gene promoter in patients with severe recurrent disease following liver transplantation. Hepatology 1996;24:1371–8. Melegari M, Bruno S, Wands JR. Properties of hepatitis B virus pre-S1 deletion mutants. Virology 1994;199:292–300. Shaw T, Locarnini S. Combination chemotherapy for hepatitis B virus: the final solution? Hepatology 2000;32:430–2. Trautwein C, Schrem H, Tillmann HL, Kubicka S, Walker D, Boker KH, et al. Hepatitis B virus mutations in the pre-S genome before and after liver transplantation. Hepatology 1996;24:482–8. Tur-Kaspa R, Burk RD, Shaul Y, Shafritz DA. Hepatitis B virus DNA contains a glucocorticoid-responsive element. Proc Natl Acad Sci USA 1986;83:1627–31. Xu Z, Yen TS. Intracellular retention of surface protein by a hepatitis B virus mutant that releases virion particles. J Virol 1996;70:133–40.
Hepatic failure due to fibrosing cholestatic hepatitis in a patient with pre-surface mutant hepatitis B virus and mixed connective tissue disease treated with prednisolone and chloroquine Simon A. Zanati a , Stephen A. Locarnini c , John P. Dowling b , Peter W. Angus d , Francis J. Dudley a , Stuart K. Roberts a,∗ a
d
Department of Gastroenterology and Hepatology, The Alfred Hospital, Commercial Road, Prahran, Vic. 3181, Australia b Department of Pathology, The Alfred Hospital, Prahran, Vic., Australia c Victorian Infectious Diseases Reference Laboratory, North Melbourne, Vic., Australia Department of Gastroenterology and Hepatology, The Austin and Repatriation Medical Centre, Austin Campus, Heidelberg, Vic., Australia Received in revised form 13 February 2004; accepted 16 February 2004
Abstract Fibrosing cholestatic hepatitis (FCH) is a severe variant of hepatitis B infection that has until recently been described almost exclusively in the setting of organ transplantation and HIV infection. This case report describes a patient with pre-surface (pre-S) mutant hepatitis B virus (HBV) infection who developed a fatal form of FCH after high dose prednisolone for mixed connective tissue disease (MCTD). The role of corticosteroids and pre-S viral mutation in the pathogenesis of the disease is discussed, and the importance of early diagnosis is emphasised. This report alerts the physician to the need for close monitoring of LFTs and HBV DNA of hepatitis B carriers during immunosuppressive therapy regardless of the indication. As in the transplantation setting, viral DNA levels should be kept to undetectable if viral replication or recurrence is to be prevented. © 2004 Elsevier B.V. All rights reserved. Keywords: Fibrosing cholestatic hepatitis; Hepatitis B pre-S mutant; Prednisolone; Chloroquine
1. Introduction Fibrosing cholestatic hepatitis (FCH) is an uncommon variant of chronic hepatitis B virus (HBV) infection that is characterised clinically by the onset of rapidly progressive liver failure, and histologically by the presence of intense cholestasis, peri-portal fibrosis and modest inflammatory cell infiltrate (Davies et al., 1991). Until recently, FCH has been described almost exclusively in heavily immunosuppressed organ transplant recipients (Davies et al., 1991; Hawkins et al., 1996; Lam et al., 1996; McIvor et al., 1994; McMillan et al., 1996; Trautwein et al., 1996) and subjects with HIV and hepatitis B co-infection (Fang et al., 1993). The condition is associated with very high levels of HBV replication and little evidence of immune-mediated hepatocellular injury. This has lead to the suggestion that liver injury in FCH ∗ Corresponding author. Tel.: +61-3-9276-3375; fax: +61-3-9276-2194. E-mail address: [email protected] (S.K. Roberts).
1386-6532/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.jcv.2004.02.013
is mediated via the direct viral cytopathic effects of HBV antigen over-expression in hepatocytes (Davies et al., 1991; Lau et al., 1992a). Infection with mutant strains of hepatitis B including those involving the pre-core and pre-surface (pre-S) regions of the HBV genome appears to increase the risk of developing liver failure (Hawkins et al., 1996; Lam et al., 1996; Liang et al., 1991; McIvor et al., 1994; McMillan et al., 1996; Trautwein et al., 1996). We report a patient with pre-surface mutant HBV infection who developed FCH following treatment of mixed connective tissue disease (MCTD) with prednisolone and chloroquine.
2. Case report A 29-year-old Chinese woman with chronic hepatitis B was diagnosed with MCTD in 1996 when she developed Raynaud’s phenomenon, arthritis, fevers, and pleurisy associated with anti-Ro and anti-RNP antibodies. She was well on maintenance prednisolone 5 mg per day and
54
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
hydroxychloroquine therapy until October 1999, when she presented with fever and headaches. Aseptic meningitis was diagnosed after MRI of brain was normal and lumbar puncture revealed an elevated CSF protein and lymphocytosis, but no acid-fast bacilli or cryptococci. She responded to intravenous hydrocortisone and was discharged on prednisolone 30 mg bd. Of note, LFTs were normal apart from a GGT of 94 U/l (normal <43 U/l). In December 1999, she had ongoing headaches so hydroxychloroquine was replaced by chloroquine 250 mg per day and prednisolone reduced to 50 mg per day. One month later, she was well so the dose of prednisolone was slowly reduced by 5 mg per week. Her LFTs were unchanged. Two weeks later, she presented with 1 week of nausea, vomiting, right upper quadrant pain, and jaundice. LFTs were now abnormal with serum bilirubin 96 mol/l, ALT 225 U/l, alkaline phosphatase 206 g/l, GGT 597 U/l, and albumin 34 g/l. Hepatitis B surface antigen (HBsAg) remained positive while viral serology for hepatitis A, C, and D, and HIV, and PCR testing for CMV, HSV, and VZV were all negative. Abdominal CT scan revealed gallbladder wall oedema but normal calibre intra- and extra-hepatic bile ducts and no gallstones. Over the following week, she developed progressive liver failure with increasing jaundice, ascites, coagulopathy, and renal impairment (creatinine 0.15 mmol/l) (Fig. 1). Because of worsening abdominal pain, on day 6 an emergency laparotomy was performed.
60
At surgery, the liver appeared pale and firm, but the gallbladder and biliary ductal system were both normal. Liver histology demonstrated preserved architecture but florid cholestasis with prominent bile duct proliferation, feathery degeneration and swelling of hepatocytes, a mixed neutrophilic and lymphocytic cellular infiltrate, and marked fibrous expansion of portal tracts (Fig. 2A). Orcein staining for HBsAg was negative. Post-operatively, she was transferred to intensive care and commenced on intravenous broad-spectrum antibiotics and hydrocortisone 100 mg tds. However, no focus of sepsis could be identified on full-septic work-up that included multiple sets of blood cultures. Worsening liver function necessitated transfer to a liver transplant unit on day 10 where she developed multi-organ failure requiring inotropes, ventilatory support, and hemofiltration (Fig. 1). HBV studies performed on admission confirmed high level viral replication with HBV DNA positive in a titre of >5.6 × 108 copies/ml. HBeAg was also detected. Immunoperoxidase staining of the original biopsy specimen revealed that while few hepatocytes were positive for HBsAg, most (over 70%) stained strongly for core antigen (HBcAg) with uniform cytoplasmic but minimal nuclear staining (Fig. 2B). Following review of the biopsy, FCH was diagnosed and treatment commenced with lamivudine 50 mg per day. However, her condition deteriorated and she died on day 13. An autopsy was not performed.
60
50
40 Prednisolone (mg/d) Chloroquine 250 mg/d
500 Bilirubin (mmol/L) ALP (U/L) 400
Serum level
ALT (U/L) 300
200
100
0
-100 -42 -14
0
5
10
13
Days Fig. 1. Hepatologic course in relation to immunosuppressive therapy including serum ALT, ALP and total bilirubin (bili) plotted over time. The time course of immunosuppressive drug therapy is shown above the graph.
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
HBV DNA extracted from the patient’s serum was amplified by PCR for direct sequencing. Sequencing of the surface envelope gene of the viral DNA revealed genotype B and that a mixed HBV population was present. One viral population contained an ∼300 bp deletion within the pre-S1
55
domain. Sequence analysis of the area encompassing this deletion indicated that the entire S promoter region was missing. The 324 bp deletion began approximately 60 bp after the pre-S1 start codon and ended approximately 60 bp before the pre-S2 start as shown in Fig. 3. The second
Fig. 2. Light photomicrographs of liver sections stained with H&E (A) and immuno-peroxidase (B and C). Note the prominent bile duct proliferation (arrows), bile plug (BP) and moderate mixed inflammatory cell infiltrates (arrowheads) within portal tracts (PT), and hepatocyte ballooning. Dashed line represents boundary between PT and lobule (A). Hepatocytes show minimal staining for surface antigen (B), but intense uniform cytoplasmic staining for core antigen (C) (original magnification 160×).
56
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
Fig. 2. (Continued ).
Fig. 3. HBV surface gene and the overlapping polymerase region. The 324 bp deletion, indicated by the shaded area, removes the entire S promoter region within the pre-S1 gene from amino acid 20 through to amino acid 119, and amino acids 1–9 of the pre-S2 gene. This deletion also removes part of the spacer region within the polymerase gene.
viral population was of the wild type containing a normal S-promoter region.
3. Discussion To our knowledge, this is the first case of a death due to immunosuppression-induced FCH to be reported outside the setting of transplantation. The patient developed rapidly progressive liver failure after commencing high-dose prednisolone and chloroquine. Hepatitis B-related FCH was
diagnosed based on the clinical course, biochemical findings, and the demonstration of active HBV replication, abundant HBV in hepatocytes, and characteristic histologic features (Davies et al., 1991). Both diagnosis and treatment were delayed and this may have adversely affected the patient’s outcome. The initial interpretation of liver histopathology was influenced by the virtual absence of HBsAg staining in hepatocytes and mixed inflammatory cell infiltrate, that in the context of the patient’s abdominal pain, suggested that acute suppurative cholangitis or intra-abdominal sepsis were possible. Indeed, cholangiography, measurement of serum HBV
S.A. Zanati et al. / Journal of Clinical Virology 31 (2004) 53–57
DNA and liver staining for HBcAg were required before the diagnosis of FCH was made and lamivudine commenced. This emphasises that severe cholestatic hepatitis is part of the histologic spectrum of FCH (Davies et al., 1991) and that both surface and core antigen expression in liver and serum HBV DNA should be measured when severe HBV reactivation is suspected. Immunosuppression is likely to have played a key role in the development of severe liver disease in this case. The picture was not consistent with a severe flare of chronic hepatitis B due to withdrawal of immunosuppression (Flowers et al., 1990), since the disease developed while the patient was receiving high-dose prednisolone, ALT levels were only modestly elevated and the typical histological findings were absent. Prednisolone may potentiate HBV replication and markedly enhance intracellular HBV antigen expression in hepatocytes (Davies et al., 1991; Lau et al., 1992b) acting via the glucocorticoid-responsive element on the HBV genome (Tur-Kaspa et al., 1986). There is also evidence that chloroquine may reduce lysis of infected hepatocytes possibly by interfering with the normal cellular processing of viral antigens in the liver (Kouroumalis and Koskinas, 1986). Hence, both drugs may have contributed to the marked accumulation of HBV antigen in the liver and the development of FCH. The weak reactivity of HBsAg was almost certainly due to the presence of the pre-S mutant HBV as the dominant virus. Pre-S mutants often co-exist with wild-type HBV but in contrast to pre-core mutants, they are rarely reported to cause FCH (Bock et al., 1997; Melegari et al., 1994). Nevertheless, pre-S mutants can cause viral retention within hepatocytes, particularly mutants with deletions in the pre-S1 region that affect the S promoter. These viruses are capable of replication but have defective secretion of viral particles including surface protein (Bock et al., 1997; Kouroumalis and Koskinas, 1986; Melegari et al., 1994; Xu and Yen, 1996). Thus, pre-S1 mutant infection may have contributed to hepatic injury in this case through the cellular accumulation of viral replicative intermediates. However, functional in vitro assays are required to precisely define the role of pre-S mutants in the pathogenesis of FCH (Bock et al., 1997). In conclusion, this report of fatal HBV infection with FCH in a non-transplant patient on high-dose prednisolone illustrates the need for close monitoring of LFTs and HBV DNA of hepatitis B carriers during immunosuppressive therapy regardless of the indication. As in the transplantation setting, viral DNA levels should be kept to undetectable if viral replication or recurrence is to be prevented (McCaughan et al., 1999), and this is best achieved by combination antiviral chemotherapy (Shaw and Locarnini, 2000).
57
References Bock CT, Tillmann HL, Maschek HJ, Manns MP, Trautwein C. A preS mutation isolated from a patient with chronic hepatitis B infection leads to virus retention and misassembly. Gastroenterology 1997;113:1976– 82. Davies SE, Portmann BC, O’Grady JG, Aldis PM, Chaggar K, Alexander GJ, Williams R. Hepatic histological findings after transplantation for chronic hepatitis B virus infection, including a unique pattern of fibrosing cholestatic hepatitis. Hepatology 1991;13:150–7. Fang JW, Wright TL, Lau JY. Fibrosing cholestatic hepatitis in patient with HIV and hepatitis B [letter]. Lancet 1993;342:1175. Flowers M, Heathcote J, Wanless I, Sherman M, Reynolds W, Cameron R, Levy G, et al. Fulminant hepatitis as a consequence of reactivation of hepatitis B virus infection after discontinuation of low-dose methotrexate therapy. Ann Intern Med 1990;112:381–2. Hawkins AE, Gilson RJ, Gilbert N, Wreghitt TG, Gray JJ, Ahlers-de Boer I, Tedder RS, et al. Hepatitis B virus surface mutations associated with infection after liver transplantation. J Hepatol 1996;24:8–14. Kouroumalis EA, Koskinas J. Treatment of chronic active hepatitis B (CAH B) with chloroquine: a preliminary report. Ann Acad Med Singapore 1986;15:149–52. Lam P, Wachs M, Somberg K, Vincenti F, Lake J, Ferrell L. Fibrosing cholestatic hepatitis in renal transplant recipients. Transplantation 1996;61:378–81. Lau JY, Bain VG, Davies SE, O’Grady JG, Alberti A, Alexander GJ, et al. High-level expression of hepatitis B viral antigens in fibrosing cholestatic hepatitis. Gastroenterology 1992a;102:956–62. Lau JY, Bain VG, Smith HM, Alexander GJ, Williams R. Modulation of hepatitis B viral antigen expression by immunosuppressive drugs in primary hepatocyte culture. Transplantation 1992b;53:894–8. Liang TJ, Hasegawa K, Rimon N, Wands JR, Ben-Porath E. A hepatitis B virus mutant associated with an epidemic of fulminant hepatitis [see comments]. N Engl J Med 1991;324:1705–9. McCaughan GW, Spencer J, Koorey D, Bowden S, Bartholomeusz A, Littlejohn M, et al. Lamivudine therapy in patients undergoing liver transplantation for hepatitis B virus precore mutant-associated infection: high resistance rates in treatment of recurrence but universal prevention if used as prophylaxis with very low dose hepatitis B immune globulin. Liver Transpl Surg 1999;5:512–9. McIvor C, Morton J, Bryant A, Cooksley WG, Durrant S, Walker N. Fatal reactivation of precore mutant hepatitis B virus associated with fibrosing cholestatic hepatitis after bone marrow transplantation. Ann Intern Med 1994;121:274–5. McMillan JS, Bowden DS, Angus PW, McCaughan GW, Locarnini SA. Mutations in the hepatitis B virus precore/core gene promoter in patients with severe recurrent disease following liver transplantation. Hepatology 1996;24:1371–8. Melegari M, Bruno S, Wands JR. Properties of hepatitis B virus pre-S1 deletion mutants. Virology 1994;199:292–300. Shaw T, Locarnini S. Combination chemotherapy for hepatitis B virus: the final solution? Hepatology 2000;32:430–2. Trautwein C, Schrem H, Tillmann HL, Kubicka S, Walker D, Boker KH, et al. Hepatitis B virus mutations in the pre-S genome before and after liver transplantation. Hepatology 1996;24:482–8. Tur-Kaspa R, Burk RD, Shaul Y, Shafritz DA. Hepatitis B virus DNA contains a glucocorticoid-responsive element. Proc Natl Acad Sci USA 1986;83:1627–31. Xu Z, Yen TS. Intracellular retention of surface protein by a hepatitis B virus mutant that releases virion particles. J Virol 1996;70:133–40.