P2872 - Acute Hepatitis C Infection Mimicking Fibrosing Cholestatic Hepatitis in an Immunocompetent Patient

Matthew A. Heckroth, MD¹, Michael Eiswerth, DO¹, Mohamed Eisa, MD¹, Ashutosh Barve, MD, PhD^2
1University of Louisville, Louisville, KY; ²University of Louisville School of Medicine, Louisville, KY

Introduction: Hepatitis C infection is one of the most common causes of chronic liver disease worldwide. Although most patients with acute HCV are asymptomatic, some may present with malaise, abdominal pain and jaundice. Post-transplant and other immunocompromised patients with HCV may develop a severe form of hepatitis known as Fibrosing Cholestatic Hepatitis (FCH). Acute cholestatic hepatitis is rarely seen in immunocompetent patients with HCV and biopsy may be required for diagnosis.

Case Description/Methods: A 28-year-old male with history of drug use presented with jaundice, abdominal pain and nausea. Labs revealed hyperbilirubinemia, elevated transaminases, a positive HCV antibody and HCV viral load of 1.2 million. He was readmitted twice with worsening jaundice and hyperbilirubinemia, but transaminases and HCV viral load improved. Biopsy showed normal liver architecture without fibrosis, moderate inflammatory cell infiltrates in the portal tracts and bile ducts and canalicular/hepatocellular cholestasis consistent with acute cholestatic hepatitis. As viral load became undetectable without signs of acute liver failure he was treated symptomatically and discharged with outpatient follow up.

Discussion: Nearly 70% of acute HCV cases are asymptomatic and diagnosed in the chronic phase. When symptoms are evident, they often resemble other forms of acute hepatitides with jaundice, abdominal pain and malaise. Acute cholestatic hepatitis is rare in immunocompetent patients with acute HCV. Acute cholestatic hepatitis is a pattern of liver injury that combines hepatocellular injury, cholestasis and varying degrees of inflammation and is commonly associated with drug-induced liver injury and certain infections. In immunocompromised patients with HCV, however, cholestatic liver injury is commonly seen as FCH.

FCH is a rapidly progressive form of liver injury often seen in immunosuppressed patients with HBV or HCV. It is characterized by jaundice, a cholestatic pattern of liver injury and high viral titers. Diagnosis is made with biopsy showing bridging fibrosis, pericellular and sinusoidal fibrosis, hepatocyte ballooning, bile ductular reaction and cholestasis. Our case highlights an immunocompetent patient with HCV which clinically mimicked FCH but was ruled out with biopsy. Literature regarding this topic is limited. May et al. hypothesized that the use of IV drugs may augment the tendency to a more cholestatic pattern of liver injury due to the direct toxic effect of the drug preparations on the liver.

	2/21/2020	3/17/2020	4/8/2020
Total Bilirubin	9.7	17.1	29.8
Alkaline Phosphatase	172	196	244
Aspartate Aminotransferase	1759	866	152
Alanine Aminotransferase	2541	927	187
HCV Viral Load	1,220,724	254,000	< 15
INR	1.1	1.1	1.7
Platelet Count	214	181	361

Table: Two Month Lab Values Trend


Disclosures:
Matthew Heckroth indicated no relevant financial relationships.
Michael Eiswerth indicated no relevant financial relationships.
Mohamed Eisa indicated no relevant financial relationships.
Ashutosh Barve indicated no relevant financial relationships.


Matthew A. Heckroth, MD¹, Michael Eiswerth, DO¹, Mohamed Eisa, MD¹, Ashutosh Barve, MD, PhD². P2872 - Acute Hepatitis C Infection Mimicking Fibrosing Cholestatic Hepatitis in an Immunocompetent Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.