Chronic viral hepatitis type B and chronic delta Chapter 2 Viral Hepatitis 1 Chronic viral hepatitis type B and chronic delta Case 2.5

Clinical Presentation 2 Viral Hepatitis 2 Clinical Presentation A 51-year-old man became lethargic several months prior to admission, with right upper quadrant pain, dark urine, and pale stools subsequently developing. He also noted a rash on his upper chest, but denied arthralgias at that time. He had numerous episodes of gingival bleeding over the past few weeks associated with brushing his teeth. He denied anorexia, nausea, vomiting, jaundice, or weight loss.

Clinical Presentation 2 Viral Hepatitis 3 Clinical Presentation There was a history of IV drug abuse, but no history of foreign travel, tattoos, or known hepatitis exposure. He had a partial nephrectomy many years ago and was transfused at that time. He also had a drinking history of about two drinks per day for many years. On physical exam the liver was firm and palpable four fingerbreadths below the right costal margin. Splenomegaly, palmar erythema, and spider telangiectasia were present.

Laboratory Values Course in Hospital AST: 213 ALT: 141 Alk Phos: 144 Viral Hepatitis 4 Laboratory Values AST: 213 ALT: 141 Alk Phos: 144 Total Bilirubin/Direct: 1.1/0.4 Total Protein: 8.7 Albumin: 3.2 Serologies: HBsAg, anti-HBe, anti-delta IgG: Positive Anti-HAV IgG and IgM, HBeAg: Negative Course in Hospital He was assessed as having chronic hepatitis B with coexisting chronic delta virus infection and a liver biopsy was performed.

2 Viral Hepatitis 5 Pathology Portal fibrosis with bridging was present without regenerative nodule formation (trichrome) (a). The portal tracts exhibited a moderate predominantly lymphocytic infiltrate with periportal interface inflammatory activity (b). Figure 2.5(a) Figure 2.5(b)

2 Viral Hepatitis 6 Pathology The parenchyma exhibited diffuse necroinflammatory change, the inflammatory cells chiefly lymphocytes (c) Occasional hepatocytes contained eosinophilic round inclusions (“ground glass” cells) representing HBsAg particles (arrows) (d). Figure 2.5(c) Figure 2.5(d)

2 Viral Hepatitis 7 Diagnosis Chronic viral hepatitis type B and chronic delta infection, with portal bridging fibrosis and moderate necroinflammatory activity

2 Viral Hepatitis 8 Comment The delta virus is a defective putative RNA virus (virion) that requires co-infection with the HBV virus for virion synthesis and release. The prevalence parallels that of HBV; however, the overall incidence has significantly declined during the past two decade in Europe and the United States, although chronic infection is still more prevalent in southern and eastern Europe, the Amazon region, the Middle East, and in tropical and subtropical Africa.

2 Viral Hepatitis 9 Comment Acute infection may follow a fulminant course much more often than acute HBV alone; additionally chronic delta with coexisting chronic HBV usually shows more periportal and lobular necroinflammatory change and will progress more quickly to cirrhosis than in chronic HBV without delta infection. The delta agent can be seen within the liver cell nuclei by positive immunoperoxidase staining for the delta antigen in both acute and chronic infection. The present case is an example of active chronic delta virus infection (positive delta IgG antibody); also usually the HBV viral replication is hindered in delta infection, manifested in this case by HBeAg negative but anti-HBe positive (with active HBV replication the reverse serologies are seen).