HBV Cases

Case 1

• Mr. M.D.
• 18 y.o.
• Consult Nov. 2017
• History of jaundice in May 2017 ; HBsAg +
• P/E: normal
 Case 1 (con’t)

• LFTs:
• ALT: 46.5 IU/L
• AST: 37.9 IU/L
• Serologies:
• HBsAg + HBcAb + HBsAb –
• HBeAg + HBeAb –
• HCV Ab –
• PICT- NR
 Case 1 (con’t)

• Viral load : 6,466,962 IU/mL= 6.8 log/mL

• CBC : normal
• αFP: 10.18 IU/mL(0-5.8)
• Liver US: Normal

• What will you do? Treat or not?

 Case 1 (con’t)

• Observation
• Control in February 2018
• ALT: 505.4 IU/l
• AST: 246.1 IU/L
• VL: 112,119,093 IU/L = 8.05log

• ALT in Nov 2016: 62 IU/L

• What is the diagnosis?

• Chronic hepatitis-B ( HbeAg +)
 Case 1 (con’t)

• Treat
• Which treatment?
Tenofovir? ETV?
• For Which endpoint?
• Hbe-Ag and HBs-Ag Clearance
 Case 1 (con’t)

• Tenofovir DF 300mg OD
• Control 3 mo later
• ALT: 44.8 IU/L
• AST: 46.9 IU/L
 Case 2

• Mrs J. G.
• 26 y.o
• Screened HBsAg+ at ANC
• Pregnant of 7 mo
• No complaint
• P/E : Pregnant
 Case 2( cont’d)

• Lab tests :
• HBeAg -
• HBeAb –
• HBcAb +
• HBsAb –
• ALT = 68 IU/L
• VL = 6.4 log10
• Liver Ultrasound: normal
 Case 2 (cont’d)

• Acute Vs chronic infection?

• Is she eligible for long term drug therapy ?
 Case 2 (cont’d)

• Considering the risk of vertical transmission!!! What do you do?

• Oral drug: Tenofovir
• Vaccine at birth (< 24h)
• HB Immunoglobulin at birth
• How do Monitor mother status after delivery?
• When to stop TDF?
• HBsAg clearing and HBsAb seroconversion
 Case 2 (cont’d)

• Come back 2yrs later:

• Pregnant of 28wks
• She reports treatment stop after delivery
• P/E: normal
• US : normal
• Lab: AST= 26, ALT= 19
• HBV VL= 186,000
• HBeAg: -, antiHBeAb+
 Case 2 (cont’d)

• What will you do?

 Case 3

• Mr A.G
• 32 y.o
• Admitted for upper GIT bleeding
• P/E : Mild jaundice, ascities, LL pitting oedema
• Lab tests:
• HBsAg +, HCVAb –, PIHCT –ve
• HBeAg -, HBeAb +, HBcAb +

• Further work up ?
 Case 3 (cont’d)

• Lab tests:
• ALT: 36 IU( <32)
• AST: 45 IU( < 31)
• Tot. Bil: 28 μmol/L(NR 5-17)
• Albumine: 32g/L
• INR: 1.5
• Platelets: 99,000/ μL
• VL: 4.6log/mL
• Gastroscopy : oesophageal varices-G-2
• Abdominal US: liver with irregular margin, ascites
• Diagnosis?
• Decompensated liver cirrhosis HBV
 Case 3 (cont’d)

• Management?
• Treat ascites: diuretics – aldactone and furosemide
• Treat portal HTN
• Treat HBV
HBV/HCV Cases
 Case 1

• Mrs U.L.
• 63 y.o.
• Consults for liver disease: abdominal distension since 3 mo.
• With lab tests: HBsAg+, anti-HCVAb-
• P/E: huge ascites, LL pitting oedema, wasted
 Case 1 (cont’d)

• Lab tests:
• AST: 72 ( < 31)
• ALT: 56 ( < 32)
• Albumin: 26g/L
• Platelets: 102000
• AFP: 3.6(<5.0)
• Creatinine: 88mcmol/L
• HBV VL: ??(can’t afford)
• US abd: coarse echotexture, irregular margin
• Upper GI endoscopy: OV grade 2
 Case 1 (cont’d)

• What will you do?

 Case 1 (cont’d)

• Treat:
• TDF: 300mg OD
• Diuretics – aldactone and furosemide
• Propanolol: 40mg OD
 Case 1 FU

• 3 mo later:
• No abd distention, no LL oedema, no more wasted
• Lab:
• AST: 41
• ALT: 36
• Albumin: 35g/L
• Platelet: 123
• INR: 1.2
 Case 1 FU

• 6 mo later:
• AST: 86 (<31)
• ALT: 65 (<32)
• Albumin: 39
• Platelets: 120
• INR: 1.08
• US: no ascites, liver cirrhosis features. No focal lesion
 Case 1 FU

• What will you do?

 Case 1 FU

• Check for other causes of elevated liver enzymes

• Repeat tests:
• HBs Ag: + (Elisa)
• AntiHCV Ab: +(Elisa)
• HCV VL: 56878 IU/mL
 Case 1 FU

• How will you treat?

• Sofosbuvir + velp 12 weeks ?
• Sofosbuvir + Ledipasvir 12 weeks ?
• Sofosbuvir + Ledipasvir 12 weeks + Riba ?
• Sofosbuvir + Ledipasvir 24 weeks ?
• Sofosbuvir + Daclatasvir 12 weeks?
• Sofosbuvir + Daclatasvir 12 weeks + Riba?
• Sofosbuvir + Daclatasvir 24 weeks?
Discussion/Questions