Protracted Severe Acute Hepatitis B on a Patient with Hyperthyroidism

Abstract

Acute hepatitis B is a self-limiting infection, but severe cases resulting in liver failure and death have been reported in 1% of acute hepatitis B cases. Severe acute hepatitis B is diagnosed when one of the following criteria is present:  international normalized ratio (INR) >1.5, severe jaundice (total bilirubin >3 mg/dL), or encephalopathy. Severe acute hepatitis B is considered prolonged if it lasts >4 weeks. Hyperthyroidism may lead to liver cell disruption or cholestasis injury. Severe acute hepatitis B associated hyperthyroidism is a case that is very rare.

We report a 37-year-old woman with severe acute hepatitis B with protracted jaundice and thyrotoxicosis. Total bilirubin levels persisted >20 mg/dL during eight weeks of treatment despite liver enzymes falling after two weeks of treatment. The patient also had a relapse of hyperthyroidism which had been on remission phase for ten years.  The patient was treated with antiviral combination of tenofovir and entecavir to prevent deterioration to liver failure. Methimazole and propranolol were given to manage the patient's hyperthyroid symptoms.

The association of hepatitis B with thyrotoxicosis and persistent jaundice is debatable, as is the extrahepatic manifestation of hepatitis B which trigger the relapse of hyperthyroidism. Combination management of two antivirals should be considered in protracted severe acute hepatitis to prevent liver failure.

zenodo Doi: https://zenodo.org/records/14541011

Keywords:

Antivirus, Acute Hepatitis B, Hyperthyroidism

References

Wang CY, Zhao P, Liu WW. Acute liver failure caused by severe acute hepatitis B: a case series from a multi-center investigation. Annals of clinical microbiology and antimicrobials. 2014 Jun;13:23.

H Muljono D. Epidemiology of Hepatitis B and C in Republic of Indonesia. Euroasian journal of hepato-gastroenterology. 2017;7(1):55–9.

Rimšelienė G, Nilsen Ø, Kløvstad H, Blystad H, Aavitsland P. Epidemiology of acute and chronic hepatitis B virus infection in Norway, 1992-2009. BMC infectious diseases. 2011 May;11:153.

Hyun Kim B, Ray Kim W. Epidemiology of Hepatitis B Virus Infection in the United States. Clinical liver disease. 2018 Jul;12(1):1–4.

Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology (Baltimore, Md). 2018 Apr;67(4):1560–99.

Yim HJ, Kim JH, Park JY, Yoon EL, Park H, Kwon JH, et al. KASL clinical practice guidelines for management of chronic hepatitis B. Clinical and molecular hepatology. 2019 Jun;25(2):93–159.

Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26(10):1343–421.

Malik R, Hodgson H. The relationship between the thyroid gland and the liver. QJM: monthly journal of the Association of Physicians. 2002 Sep;95(9):559–69.

Cui W, Deng B, Wang W, Liu P. Graves’ hyperthyroidism accompanied with acute hepatitis B virus infection: an extrahepatic manifestation? Virology journal. 2016 May;13:80.

Yim HJ, Kim JH, Park JY, Yoon EL, Park H, Kwon JH, et al. Comparison of clinical practice guidelines for the management of chronic hepatitis B: When to start, when to change, and when to stop. Clinical and molecular hepatology. 2020 Oct;26(4):411–29.

Lampertico P, Agarwal K, Berg T, Buti M, Janssen HLA, Papatheodoridis G, et al. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. Journal of hepatology. 2017 Aug;67(2):370–98.

Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HLY, Chen CJ, et al. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatology international. 2016 Jan;10(1):1–98.

Menzo S, Minosse C, Vincenti D, Vincenzi L, Iacomi F, Zaccaro P, et al. Long-Term Follow-Up of Acute Hepatitis B: New Insights in Its Natural History and Implications for Antiviral Treatment. Genes. 2018 Jun;9(6).

Maya P, Augustine P, Mathew PG, Francis J V, Chettupuzha AP, Mukkada RJ, et al. Entecavir + tenofovir combination improved survivial in acute severe hepatitis B. Journal of Clinical and Experimental Hepatology. 2013 Mar 1;3(1):S56.

Bockmann JH, Dandri M, Lüth S, Pannicke N, Lohse AW. Combined glucocorticoid and antiviral therapy of hepatitis B virus-related liver failure. World journal of gastroenterology. 2015 Feb;21(7):2214–9.

Li X, Yang J, Jin S, Dai Y, Fan Y, Fan X, et al. Mechanistic examination of methimazole-induced hepatotoxicity in patients with Grave’s disease: a metabolomic approach. Archives of toxicology. 2020 Jan;94(1):231–44.

Teschke R, Zhu Y, Jing J. Herb-induced Liver Injury in Asia and Current Role of RUCAM for Causality Assessment in 11,160 Published Cases. Journal of clinical and translational hepatology. 2020 Jun;8(2):200–14.

Kappus MR, Sterling RK. Extrahepatic manifestations of acute hepatitis B virus infection. Gastroenterology & hepatology. 2013 Feb;9(2):123–6.

Yoffe B, Burns DK, Bhatt HS, Combes B. Extrahepatic hepatitis B virus DNA sequences in patients with acute hepatitis B infection. Hepatology (Baltimore, Md). 1990 Aug;12(2):187–92.

Pastore F, Martocchia A, Stefanelli M, Prunas P, Giordano S, Toussan L, et al. Hepatitis C virus infection and thyroid autoimmune disorders: A model of interactions between the host and the environment. World journal of hepatology. 2016 Jan;8(2):83–91.