Acute-on-chronic Liver Failure (ACLF) in a Patient With Nonalcoholic Steatohepatitis (NASH) Exacerbated by Hepatitis B Infection Following Tattooing: A Case Report

Background Tattoo-acquired hepatitis B virus (HBV) infection is an under-recognized source of acute hepatic insult. Tattooing has emerged as a non-traditional yet significant source of HBV transmission, particularly when done from unregularized parlors. HBV can serve as an acute insult precipitating acute-on-chronic liver failure (ACLF) in patients with underlying chronic liver disease, such as nonalcoholic steatohepatitis (NASH). ACLF refers to a reversible clinical syndrome having high short-term mortality, characterized by acute hepatic insult leading to liver decompensation in patients with underlying chronic liver disease. 1 The condition can be precipitated by various acute events, including viral infections. This case report describes a rare instance of tattoo-acquired hepatitis B infection precipitating ACLF in a patient with asymptomatic undiagnosed NASH. Case Presentation A 34-year-old male, with a body mass index of 24.4 kg/m² and no significant medical history, presented with jaundice, nausea, vomiting, and fever after undergoing a tattoo procedure a few weeks prior. Liver function tests revealed elevated transaminases, high bilirubin levels, and prolonged prothrombin time. Hepatitis B surface antigen (HBsAg) was positive, while tests for other hepatitis viruses, including hepatitis A, C, and E, were negative. Imaging and liver biopsy indicated underlying NASH with fibrosis but no cirrhosis. The patient was treated with antivirals, antibiotics, and diuretics, showing significant improvement by the time of discharge. Conclusion Tattoo-related HBV infection can precipitate ACLF in individuals with silent chronic liver disease. This case underscores the importance of public awareness, regulation of tattooing practices, and vigilance for NASH, even in non-obese individuals.