An unusual case of HBV reactivation in a patient with cholangitis and choledocho-lithiasis undergone to ERCP. A case report

Evelise Frazzetto¹, Stefano Malaguarnera², Rossella Caruso³, Emanuele Bertino¹, Mariangela Malaguarnera², Antonio Pesce⁴, Antonio Zanghì⁴, Stefano Puleo⁴, Alessia Laneri¹, Gaetano Bertino¹

¹Hepatology Unit, A.O.U. Policlinico-Vittorio Emanuele, Department of Clinical and Experimental Medicine, University of Catania, Catania - Italy - ²Research Centre "The Great Senescence", Cannizzaro Hospital, University of Catania, Catania, Italy - ³Academic Unit of Internal Medicine, School of Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Cannizzaro Hospital, Catania, Italy - ⁴General Surgery Unit, A.O.U.  Policlinico-Vittorio Emanuele, Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy

Introduction: In the landscape of presentation of HBV infection, it is possible to identify patients with Hepatitis B “e” Antigen-positive chronic hepatitis B infection without liver disease (previously called “asymptomatic chronic carrier”), and in the natural history of this condition an Hepatitis B Virus reactivation is possible. In literature it has been shown that reactivation often occurs during conditions of immunosuppression or chemotherapy, although in recent years case reports of Hepatitis B Virus reactivation are emerging in chronic coinfected patients after therapy with Direct Acting Antivirals.

Materials and methods: We describe a clinical case of Hepatitis B Virus HBV reactivation not ordinarily secondary to immunosuppression or chemotherapy, but realistically secondary to choledocholithiasis. It has been supposed an atypical reactivation of HBV, and therefore an antiviral treatment with entecavir has been promptly initiated. 

Results: At 24 weeks and one year after the antiviral treatment, the patient showed a normalization of all liver function tests and an undetectable HBV DNA with Polymerase Chain Reaction test.

Conclusion: In case of liver dysfunction in a patient with an history of HBV infection, we suggest to firstly suspect and test a viral reactivation and then, if the reactivation is confirmed, to start the antiviral therapy as early as possible. It would be also desirable to evaluate the extension of the pre-treatment protocols with 3rd generation Nucleos-(t)ide analogues even in the case of important septic episodes, major surgery and invasive procedures.