809 - An unusual case of hepatitis B reactivation in the setting of long-term corticosteroid use

Case Diagnosis: CVA
 

Case Description: A 45-year-old male with history of hyperlipidemia and tobacco use presented with left-sided vision loss for 6 months and found to have sellar/suprasellar mass. Patient underwent right frontotemporal craniotomy with orbitotomy for subtotal tumor resection. In the postoperative setting, the patient developed panhypopituitarism, and was initiated on desmopressin, levothyroxine, and low-dose hydrocortisone 30 mg daily.
Upon admission to acute inpatient rehabilitation day 1 (AIRD1), liver function tests (LFT) revealed mildly elevated ALT 79, normal AST 26, mildly elevated ALP 146 (Figure 1). Repeat liver function testing on AIRD10 showed similar values. LFTs increased to ALT 367, AST 157, ALP 176 AIRD13. Hepatitis workup obtained AIRD13 was significant for positive hepatitis B surface antigen, positive core and envelope antibodies, hepatitis B DNA viral load (850,000), indicative of hepatitis B flare in the setting of recent corticosteroid use for panhypopituitarism. Patient was subsequently initiated on tenofovir.

Discussions: Patients receiving immunosuppressive therapy are at risk for HBV reactivation and flare, which can lead to fulminant hepatic failure or death.¹ Current guidelines suggest screening for evidence of HBV infection in adults who will receive immunosuppressive therapy. For patients receiving glucocorticoids alone, screening is recommended for patients who will receive doses of prednisone >20 mg/day for at least 4 weeks. Our patient was treated with low-dose hydrocortisone equivalent to 7.5 mg of prednisone/day. For low-risk patients, frequent monitoring is recommended so that HBV reactivation can be detected early in its course and appropriate therapy can be initiated. In acute inpatient rehabilitation, patients may be monitored and treated accordingly. Further studies are needed to evaluate the efficacy of HBV screening and prophylaxis in low-risk patients.²

Conclusions: Contrary to current guidance, very low-dose corticosteroid can cause hepatitis B reactivation. High index suspicion for this complication should be maintained.