Mount Sinai Beth Israel Medical Center New York, NY, United States
Gres Karim, MD1, Michelle Shah, DO1, Sanjana Luther, MD2, Huifang Zhou, MD3, Ilan Weisberg, MD, MSc2 1Mount Sinai Beth Israel Medical Center, New York, NY; 2Mount Sinai Morningside and Mount Sinai West/Mount Sinai Beth Israel Medical Center, New York, NY; 3Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY
Introduction: Viral suppression and transaminase normalization are goals of antiviral therapy in chronic Hepatitis B. Transaminase elevations are typically representative of medication nonadherence, or less commonly, viral resistance. Achievement of viral suppression with persistent transaminase elevation should prompt exclusion of other etiologies. Frequently, extrahepatic causes of transaminase elevation are not evaluated, leading to an invasive workup, including liver biopsy. Here we report a case of persistently elevated liver tests in a patient with an adequately suppressed HBV viral load found to be secondary to vigorous exercise.
Case Description/Methods: A 36-year-old man with chronic hepatitis b virus (HBV) infection, e antigen-negative with an undetectable viral load presented with persistently elevated liver tests in the absence of alcohol or other hepatotoxins. Current medications included Descovy for pre-exposure prophylaxis and HBV. He reported a vigorous exercise routine with sleep disruption and increased stress. Physical exam was unremarkable for jaundice, icterus, abdominal pain, or features of portal hypertension (HTN). Laboratory results displayed an ALT/AST of 50/61 with normal ALP, bilirubin, and INR. Viral serologic workup including HBV viral load and delta virus were unrevealing. MRI showed nodularity of the liver with patent vasculature and no features of portal HTN. Elastography indicated an absence of steatosis or advanced fibrosis. Given this incongruence, no evidence of portal hypertension or advanced fibrosis on laboratory evaluation and physical exam, further evaluation including liver biopsy was obtained. Creatine phosphokinase (CPK) was elevated to 1001 U/L, suggestive of rhabdomyolysis. Liver biopsy was consistent with his previous diagnosis of chronic inactive HBV with stage 1 fibrosis. There was no inflammation, thus active hepatitis was excluded.
Discussion: Elevations in transaminases are frequently associated with liver pathology but are nonspecific. Frequently, ALT levels above 800 U/L are inconsistent with an isolated muscle injury, leading to an extensive liver disease investigation. Although our patient’s ALT was minimally elevated, it persisted while on adequate viral suppression thus prompting further investigation with liver biopsy. This case illustrates that transaminase elevation may require investigating an etiology beyond the liver, including history and laboratory evaluation such as CPK levels, before pursuing more invasive methods.
Figure: Figure 1: Liver Biopsy. H&E stain demonstrating preserved hepatic architecture, portal fibrosis, and many glycogenated nuclei. There are centrilobular hepatocytes with ground-glass cytoplasm. There is no portal or lobular inflammation, and no steatosis.
Gres Karim indicated no relevant financial relationships.
Michelle Shah indicated no relevant financial relationships.
Sanjana Luther indicated no relevant financial relationships.
Huifang Zhou indicated no relevant financial relationships.
Ilan Weisberg indicated no relevant financial relationships.
Gres Karim, MD1, Michelle Shah, DO1, Sanjana Luther, MD2, Huifang Zhou, MD3, Ilan Weisberg, MD, MSc2. P0820 - Hepatitis or Not? Beyond the Liver, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.