Ask the Professor: Hepatitis B and C Clinical Vignettes

1. Ask the Professor:Hepatitis B and C Clinical Vignettes The Oregon Gut Club October 2nd, 2011

2. Case 1 • 66 year old male with history of NIDDM and obesity. Seen by PCP for 1 month fatigue • No history of liver disease or risk factors for viral hepatitis • Laboratory studies: Tot Bil = 1.1 HAV negative AlkPhos = 130 HBsAgreactive AST = 228 HCV negative ALT = 601 INR = 1.2 plt = 92

3. Case 1 - continued • Additional Labs HBcAbIgMreactive HBeAgreactive HBeAb negative HBV DNA >170,000,000 IU/mL • Abdominal Ultrasound Liver mildly enlarged with diffuse increased echogenicity. Spleen is normal.

4. Case 1 - continued • Wait and watch or treat? • After initial consultation with Gastroenterology the patient was seen by cardiology and underwent a coronary angiogram which showed obstructive 3 vessel coronary artery disease. CABG recommended.

5. Case 2 • 32 year old male from Ghana referred to gastroenterology for hepatitis B • No history of jaundice, encephalopathy, or ascites • Risk factors for chronic viral hepatitis • Country of birth • Blood transfusion at 12 years old • Negative family history for chronic HBV • No history of IVDU

6. Case 2 - continued • Laboratory studies: • Tbil = 0.5 • AlkPhos = 60 • AST = 41 • ALT = 43 • INR = 1.3 • Plt = 172 • Abdominal US • Normal liver and spleen. No ascites. • HBV DNA 153 million IU/mL • HBeAgreactive

7. Case 2 - Continued • What Next? • Liver Biopsy • Chronic hepatitis grade 1 stage 2

8. Case 3 • 30 year old Vietnamese female in second trimester of pregnancy • Referred to GI by her obstetrician for positive hepatitis B surface antigen • Presumed vertical transmission based on family history • No history of jaundice, ascites, encephalopathy, or GIB

9. Case 3 - continued • Laboratory Studies • Tbil = 0.2 • AlkPhos = 43 Liver Biopsy 1 year prior • AST = 23 Grade 1 Stage 1 • ALT = 33 • Plt = 220 • INR = 1.0 • HBV DNA 89,000 IU/mL • HBeAgpositive

10. Case 4 – second opinion • 32 year old Chinese femalewith a history of chronic HBV diagnosed after emigrating to the United states. • Presumed vertical transmission • No history of liver ascites/encephalopathy/GIB • Referred to GI in 2006 • ALT = 195 AST =99 • HBeAgpositive • HBV DNA 19,400,000 IU/mL Genotype C

11. Case 4 - Continued • Several months later was found to be HBeAg negative and HBeAbpositive. • Started on Entecavir due to rising transaminases • Liver tests normalized and HBV became undetectable within 6 months. • Labs have remained normal for 2 years. • Most recent studies • HBsAgpositive, HBeAb positive, HBV DNA neg, ALT =16

12. Case 4 - continued • Next step? • Wait for surface antigen loss or stop Entacavir?

13. Case 5 • 63 year male with Chronic HCV, genotype 1, diagnosed in 2004 • No history of ascites, encephalopathy, or GIB • Liver biopsy 3/3/04 showed grade 1, stage 1 disease • Developed acute renal failure with nephrotic range proteinuria and anasarca in 2011. Kidney biopsy showed glomerular changes suggestive of possible membranoproliferative glomerulonephritis • Started on plasmapheresis and sent to GI for possible HCV treatment

14. Case 5 - continued • Pertinent laboratory studies • HCV PCR 1,710,000 IU/mL • Tbil = 0.2 • AlkPhos = 62 • ALT = 18 C3 = 67 L • AST = 20 C4 = 27 RF = <10 • Plt = 204 Cryoglobulin = neg • INR = 1.1 • Creat = 2.0

15. Case 6 • 35 year female with history of heavy alcohol use, depression with active suicidal ideation, and chronic HCV genotype 1. • Biopsy in 2010: Grade 2 Stage 3 disease. • Therapy deferred in 2010 due to poor social support, mental illness, and ongoing alcohol use. • Now sober for 1 year and returns to clinic to discuss the “new” hepatitis C medications.