Ask the Professor: Hepatitis B and C Clinical Vignettes

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

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 Alk Phos = 130 HBsAg reactive AST = 228 HCV negative ALT = 601 INR = 1.2 plt = 92

3. Case 1 - continued Additional Labs HBcAb IgM reactive HBeAg reactive 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 Alk Phos = 60 AST = 41 ALT = 43 INR = 1.3 Plt = 172 Abdominal US Normal liver and spleen. No ascites.

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 Alk Phos = 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 HBeAg positive

10. Case 4 – second opinion 32 year old Chinese female with 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 HBeAg positive HBV DNA 19,400,000 IU/mL Genotype C

11. Case 4 - Continued Several months later was found to be HBeAg negative and HBeAb positive. 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 HBsAg positive, 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 Alk Phos = 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.