Acute Viral Hepatitis-B in a COVID-19 Patient with Respiratory Failure
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LETTER TO THE EDITOR
VOLUME: 14 ISSUE: 1
P: 3 - 3
January 2025

Acute Viral Hepatitis-B in a COVID-19 Patient with Respiratory Failure

Mediterr J Infect Microb Antimicrob 2025;14(1):3-3
1. Aksaray Training and Research Hospital Clinic of Infectious Diseases and Clinical Microbiology, Aksaray, Türkiye
No information available.
No information available
Received Date: 27.09.2024
Accepted Date: 24.12.2024
Online Date: 19.11.2024
Publish Date: 03.02.2025
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Dear Editor,

Coronavirus Disease of 2019 (COVID-19) is caused by a novel coronavirus, named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). COVID-19 is typically characterized by the presentation of the symptoms of viral pneumonia such as fever, fatigue, dry cough, anosmia, and headache, which may progress to respiratory failure[1]. It causes systemic disease by inducing changes in circulating lymphocytes and the immune system[2]. In addition to the respiratory symptoms, gastrointestinal symptoms such as vomiting, diarrhea, abdominal pain, and elevated liver enzyme and/or bilirubin levels have been reported in association with COVID-19[3]. The frequency of elevated liver enzymes in hospitalized COVID-19 patients, primarily elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and slightly elevated bilirubin, ranges from 14% to 53%[2]. This elevation may be the result of any liver damage occurring during a disease and its treatment or it may occur due to primary liver diseases[4]. We have reported herein a case of COVID-19 with hepatitis-B (HB) virus (HBV) coinfection presenting as an acute symptom.

A 57 year-old woman with a history of diabetes mellitus, asthma, and coronary artery disease, was admitted applied the to emergency department with complaints of nausea, vomiting, dry cough, and fever for 3-4 days. The patient was febrile (38.2 °C),
conscious, and displayed orientation cooperation. Her physical examination revealed the following: Glasgow Coma Scale 15, blood pressure 135/84 mm/Hg, heart rate 107/min, respiratory rate 23/min, and oxygen saturation 88% in room air. She also displayed bilateral rales on respiratory examination. Her thorax tomography revealed widespread infiltration.

The initial blood work showed remarkably elevated liver function. Pertinent laboratory findings are presented in Table 1.

In the emergency department, the nasopharyngeal swab was taken and her COVID-19 polymerase chain reaction test result was found positive. Then, she was hospitalized and subjected to symptomatic treatment for SARS-CoV-2. Detailed examinations of her liver function tests were planned in light of previously negative hepatitis serology and no familial hepatitis history. Apart from her recent dental treatment, she had no history of consuming alcohol, drug abuse, or unprotected sexual intercourse. Her serological tests were negative for human immunodeficiency virus, hepatitis A, and hepatitis C. Further liver examination revealed positive HB surface antigen, positive HB core antibody (Ab) immunoglobulin M, positive HBe Ag, and negative HBe antibody (Ab). Her HB-DNA viral load was 171,400,000 IU/mL, confirming the diagnosis of an acute HBV infection. The liver ultrasound did not show any anomalies but showed an echogenic liver without cirrhosis, common bile duct obstruction, or gallstones.

In the initial days of hospitalization, a reduction in liver function was observed with symptomatic treatment while the bilirubin levels increased. The relation between liver function tests and bilirubin level is presented in Figure 1.

After the 5th day, the patient’s respiratory complaints increased and her oxygen saturation started to decrease to 65% in the room air. At this stage, high doses of steroids and immunoplasma had to be supplemented in the treatment for COVID-19. Meanwhile, tenofovir disoproxil fumarate was started for viral HB. After 4 weeks of follow-up, her respiratory symptoms gradually began to improve and the patient’s liver function tests also reached the normal level. As the patient’s respiratory symptoms started to improve, the steroid dosage was gradually tapered and then discontinued and the patient was discharged from the hospital. After 15 days of discharge, in her polyclinic follow-up examination, her HB surface antigen became negative and her HB surface Ab value was (21.34 mIU/mL) positive. Four months later, this value reached over 1,000 mIU/mL. Her antiviral treatment was also discontinued after 1 year of the HB surface Ab positive result.

COVID-19 caused a pandemic that affected a wide area across the world. Symptomatic SARS-CoV-2 infections are mostly mild to moderate, and not severe. The most common serious manifestation is pneumonia. Chest radiographs are usually normal in the early stages of this disease. At 10–12 days after the onset of symptoms, lung infiltration may increase and the disease may worsen[5]. Our patient showed a tolerable oxygen saturation with oxygen support on room air when she was first admitted to the hospital. In the following days of follow-up, her respiratory complaints increased in line with the course of COVID-19 and her oxygen saturation level began to decrease, as such, high-dose corticosteroids and immune plasma treatment were initiated as supportive treatment.

Elevated liver enzymes are common in COVID-19, as seen in 18.2% of nonsevere cases and up to 39.4% in severe cases[6]. Liver damage in COVID-19 patients may be attributed to the viral infection as well as drug hepatotoxicity. In addition, immune-mediated inflammation and pneumonia-associated hypoxia may contribute to liver injury. Liver disease including chronic-acute viral hepatitis, non-alcohol fatty liver disease, and alcohol-related liver disease represents a major disease burden globally. Although liver enzyme elevation due to COVID-19 is common, its coincidence with acute viral HB is rare. Such rare cases have been reported earlier, and most of these cases were exacerbations of the underlying viral hepatitis disease. Previously, there have been reports of cases showing serological compatibility with acute viral hepatitis but with generally fulminant unknown hepatitis serology[7, 8]. Our patient’s HB profile showed no history of hepatitis, suggesting an early acute HB infection[9] (Table 1).
Treatment for acute HBV is mainly supportive. HBV infection recover clinically and virologically without antiviral therapy in more than 95% of adults. Only patients with severe acute HB, characterized by coagulopathy, and protracted course or signs of acute liver failure should be treated with nucleoside analogs. Past data support the use of tenofovir disoproxil fumarate, entecavir, or lamivudine for such cases[10]. In the present case, as we opted for immunosuppressive treatment for respiratory failure and because the patient’s bilirubin levels tended to increase during this period, we planned oral antiviral treatment to prevent liver failure. In the follow-up of our clinically recovered patient, anti HB seroconversion was detected after treatment.

In conclusion, serological tests should be conducted in each patient showing high liver enzymes and the coexistence of the two diseases simultaneously. Such cases should be managed by considering the progression of each disease and the appropriate treatment options.

Footnotes

Authorship Contributions

Design: S.S.Y., F.K.B., Data Collection or Processing: S.S.Y., F.K.B., Analysis or Interpretation: S.S.Y., F.K.B., Literature Search: S.S.Y., F.K.B., Writing: S.S.Y., F.K.B.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.

References

1
Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, Tai Y, Bai C, Wang G, Xia P, Dong J, Zhao J, Wang F. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020;8:420-42.
2
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China. Lancet. 2020;395:497-506.
3
Cheung KS, Hung IF, Chan PP, Lung KC, Tso E, Liu R, Ng YY, Chu MY, Chung TW, Tam AR, Yip CC, Leung KH, Fung AY, Zhang RR, Lin Y, Cheng HM, Zhang AJ, To KK, Chan KH, Yuen KY, Leung WK. Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from the Hong Kong cohort and systematic review and meta-analysis. Gastroenterology. 2020:1-15.
4
Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections. Liver Int. 2020:14435.
5
Wong HYF, Lam HYS, Fong AH, Leung ST, Chin TWY, Lo CSY, Lui MM, Lee JCY, Chiu KW, Chung T, Hui JYY, Tam HH, Wu TC, Ng MY. Frequency and distribution of chest radiographic findings in COVID-19 positive patients. Radiology. 2020:1-11.
6
Zhang C, Shi L, Wang FS. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol. 2020:428-30.
7
Elrazi A, Ziglam H, Kohla S, Ali M, Ahmed A, Al-Mulla M, Lamloum M. A case of fulminant liver failure in a 24-year-old man with coinfection with hepatitis B virus and SARS-CoV-2. Am J Case Rep. 2020:e925932.
8
Akerele IO, Nnabuchi CV, Oreh AC. Coronavirus disease (COVID-19) and acute non-icteric hepatitis: A case report from Asokoro, Nigeria. J Family Community Med. 2021;28:59-62.
9
Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, Kowdley KV, Lim JK, Martin P, Bzowej NH, Wong JB. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 Hepatitis B Guidance. Clin Liver Dis (Hoboken). 2018:33-34.
10
European Association for the Study of the Liver (EASL). Clinical practice guidelines on the management of hepatitis B virus infection. J Hepatol. 2017:370-398.