S5797 Beyond HELLP: Uncovering Acute Hepatitis B in a Case of Presumed Preeclampsia-Related Liver Injury

Introduction: Hepatitis B (HBV) affects 254 million people globally, with 1.2 million new infections each year. In the United States, incidence is lower due to vaccination and public health initiatives. Acute hepatitis B, defined by hepatitis B surface antigen positivity for under 6 months, can present with fever, chills, malaise, abdominal pain, and jaundice. If present in a pregnant patient, signs of HBV can mimic HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a life-threatening third-trimester condition. Herein, we present a case of a pregnant patient who was initially diagnosed with HELLP, however, later discovered that it was likely acute HBV causing her symptoms. Case Description/Methods: A 26-year-old healthy woman, 25 weeks pregnant, presented to the emergency department with sudden-onset severe headache, subjective fevers, and rigors. She reported mild gastroenteritis symptoms after eating spoiled vegetables earlier in the week, which resolved within a day. Labs showed alanine aminotransferase (ALT) 515, aspartate aminotransferase (AST) 862, bilirubin 0.4, alkaline phosphatase 70, international normalized ratio 1.3, and platelets 98—all normal 3 months earlier. Within 8 hours, her labs worsened: ALT 2419 AST 4822, bilirubin 3.3, international normalized ratio rose to 1.9, and she developed new proteinuria. She remained alert, afebrile, normotensive, and not encephalopathic. Liver ultrasound with doppler was unremarkable. Despite confounding features like fever and normal blood pressure, she met diagnostic criteria for HELLP. Fetal decelerations prompted emergent C-section. Her condition improved post-delivery. Two days later, admission labs returned, revealing acute hepatitis B. Her husband, unaware of his chronic HBV, was likely the source. She declined antiviral therapy. At 3-month follow-up, her liver enzymes had normalized, consistent with resolved infection. Discussion: This case highlights the diagnostic overlap between acute hepatitis B and HELLP, especially with delayed lab results. Her initial flu-like symptoms were likely the prodromal phase of the infection. Although the liver is the main target, HBV can affect bone marrow and kidneys—explaining thrombocytopenia and proteinuria. She had tested negative for HBV 3 months prior but was not vaccinated, despite susceptibility. Early vaccination or timely HBV identification could have altered management.