S5694 A Case of Biopsy Proven Relapsing Hepatitis A Infection

Introduction: Hepatitis A virus (HAV) is one of the most common causes of hepatitis in the world. It is highly endemic in developing areas with contaminated water implicated in outbreaks. Common presentation in the U.S. follows travel to an endemic area. Clinical presentation includes symptoms of acute hepatitis. Course is typically self-limited with clinical/biochemical resolution by 6 months. Fulminant liver failure is very rare (<1% of cases) and associated with pre-existing liver disease/advanced age. Relapsing HAV is atypical (10% of cases). We present a biopsy-proven case of relapsing HAV. Case Description/Methods: A 52-year-old man presented with abdominal discomfort following a recent trip to Mexico. Exam was unremarkable. Workup included aminotransferase elevation (2,000s-3,000s), hyperbilirubinemia (3.5) and marked hepatomegaly. HAV IgM was positive. MRCP for concurrent obstruction was negative. Autoimmune workup (antinuclear antibody and anti-smooth muscle) was negative. Patient endorsed alcohol consumption (10 drinks per week) and otherwise had no liver disease risk factors. Symptoms/liver tests improved. He did not go into acute liver failure and was discharged for outpatient monitoring. Elevated liver tests continued to resolve at one month with aminotransferase improvement (100s-200s) and hyperbilirubinemia resolved. In spite of avoidance of alcohol/supplements, levels worsened at the 2 month mark, prompting further evaluation. Liver biopsy noted moderate lobular hepatitis, suspected secondary to relapsing HAV. Patient remained clinically asymptomatic, and he had remission 6 months out from his initial diagnosis. Discussion: Although severity of HAV relapse is low, it is an important differential to consider for a patient with persistent/recurrent elevated liver tests. Relapse timeline is 2-3 months from initial presentation. Clinical course is typically mild and may be isolated to biochemical relapse. Multiple relapses are exceedingly rare. Persistent viremia/HAV shedding are detectable during recurrence. If severe relapse is present (hyperbilirubinemia/pruritis), a short course of corticosteroids may be considered. In our case, asymptomatic relapse occurred 2 months after initial. Recurrent aminotransferase elevation was milder. Case was managed conservatively. Our case highlights the importance of including relapsing HAV in a differential and utilizing biopsy as a diagnostic tool. It also highlights the importance of continued monitoring until full resolution is reached.