A Chronic Hepatitis B Patient with

HBeAg Negative ( A Reactivation

Phase )

Ratih Rachmanyati Pasah

Ummi Maimunah

Department of Internal Medicine

Airlangga University School of Medicine
Dr. Soetomo General Hospital

1
 INTRODUCTION
Chronic Hepatitis B is a viral infection
with two form of HBeAg ( Positive and
negative )
Chronic Hepatitis B with HBeAg
negative have highest incidence in Asia
Pacific (36% cases have been reported)
Reactivation of Chronic Hepatitis B
need HBV DNA test for diagnosis

2
 CASE REPORT

Mr D, 26 yo, live in Surabaya, Moslem,

Javaneese, a worker in expedition company
Admitted at Emergency Department of dr.Soetomo
hospital on June,13th,2007
Chief complaint:
jaundice of the eyes

3
Anamnesis ANAMNESIS

• Jaundice of the eyes since 5 days before

admission. There is no icteric in the body
• Nausea since one week before admission.
There is no vomitting.
• The appetitte and body weight is decreasing
• Fatigue and general weakness
• Febris especially in afternoon and night
• History of past illness : There are history alcohol
consumption since 5 years, free sex 2 years
ago, and having tatto since 7 years ago
4
Physical examination

anemia (-), jaundice(+),no

cyanosis, no dyspnea. No increase
in JVP

GCS 3-4-6
BP 120/80 HR was 84 bpm, RR
20x/M, t 36,5

Chest no abnormalities.
Abdomen was not distended, ascites -
, collateral -, spider nevi -, ginekomasti
-

The extremities was warm, liver palm -

edema -
Laboratory Results June 13th 2009
• Hb : 14,0 g/dl
• Leukocyte : 7550 /mm3
• Thrombocyte : 202000 /mm3
• HCT : 40 %
• Random Blood Sugar : 124 mg/dl
• AST : 1932 U/L
• ALT : 1440 U/L
• BUN : 7,7 mg/dl
• SK : 0,7 mg/dl
• Total bilirubun : 19,79 mg/dl
• Direct bilirubin : 16,24 mg/dl
• Albumin : 3,5 g/dl
• Globulin : 4,3 g/dl
• Natrium : 136,2 meq/l
• Kalium : 3,6 meq/l
• URINE :
• Biilirubin : +3
• Urobilin : +3
• Lekosit : 0-1 /lp
• Eritrosit : 0-1 /lp
• Epitel : 0-1 /lp
• Protein :-
Chest X Ray
 Pulmo : Normal
 Cor : Normal
Conclusion : Normal limit
Abdominal Ultrasonography
Liver : enlargement, sharp edge, echoparenchym
Spleen : Splenomegaly
Gall Bladder : thickening of the gall bladder wall
Pancreas, Left and Right Kidney : WNL
Conclusion : Parenchymatous hepatitis
 Diagnosis :
S. Hepatitis virus akut

Diagnosis :
- Ig M anti HAV, HBsAg, Ig M anti HBc, anti HCV
- Profil lipid, Faal hemostasis
- Tes HIV 3 method (VCT)
- Endoscopy

Treatment :
Bed rest
TKTP diet 2100 kalori/hari
Infus PZ:RD5= 1:2 / 24 hours
Inj. Omeprazole 2x1 ampul i.v
Multivitamin 3x1 tablet.
8
Progress Note
Day 1 Day 3 Day 10

Consciouss
VS stable Consciouss
SGOT 1897 U/L; SGPT 1389 U/L; vs stable
Consciouss SGOT 896 U/L;
bilirubin total 24.52 mg/dl;
GCS 456 bilirubin direk 15,13 mg/dl SGPT 666 U/L;
VS stable bilirubin total 20,61
Ig M anti HAV negative, HBsAg mg/dl; bilirubin direk
Dx : continued positif, Ig M anti HBc negative,
anti HCV negative. HIV 3 method : 14,97 mg/dl
Tx :continued non reaktif HBeAg negatif, Anti
Endoscopy is normal HBe positif
Fibrous Scan :
Dx : S.chronic hepatitis B with Stiffness 67,8 Kpa
reactivation Dx : S.chronic
Pdx : HBeAg,HBV DNA,Anti hepatitis B with
HBE,liver biopsy,fibrous scan HBeAg negative
(reactivation phase)
Ptx : Lamivudine 1x100mg p.o., Pdx : -
other continued Ptx: contunued
Progress Note
Day 17 Day 20 Day 22

Consciouss
Consciouss
VS stabil VS stabil
SGOT 139 U/L; SGPT 65 U/L;
SGOT 107 U/L; bilirubin total 19,90 mg/dl;
SGPT 87 U/L; bilirubin direk 12,92 mg/dl
bilirubin total 20,43 HBV DNA 3,35 x 105 IU/ml (19,50
mg/dl; bilirubin x 105 kopi/ml)
direk 13,38 mg/dl Dx : chronic hepatitis B with
Dx : S.chronic HBeAg negative ( reactivation Discharged
hepatitis B with phase )
reactivation Pdx : -
Pdx : - Ptx: contunued
Ptx: contunued
11
Characteristic of chronic hepatitis B (Liaw YF, 2009)

Karakteristik Imunotolerans Imunoklirens HBsAg inaktif Reaktivasi

Usia <20-25 20-40 >35-40 >35-40

HBeAg Positif Positif Negatif Negatif

HBV-DNA (IU/ml) >2 x 106-7 >2 x 104-5 <2 x 103 >2 x 103-4

ALT Normal Meningkat/flare Normal Meningkat/flare

Nekroinflamasi Tidak Sedang/berat Tidak ada/minimal Sedang/berat

ada/minimal

Skor fibrosis (Ishak) 0-1 2-6 0-6 2-6

Precore/core Tipe Wild Tipe Tipe mutant>wild Tipe mutant>>wild

wild>mutant

Sirosis Jarang 2-4%/tahun Jarang 2-3%/tahun

HBsAg Tidak ada Tidak ada 1-2%/tahun Tidak ada

serokonversi
• There are replication of HBV and mutation of precore/core of
HBV in patient Chronic hepatitis B with HBeAg negative (
reactivation phase )
• The reactivation of Chronic Hepatitis B with HBeAg negative is
spontaneously and the pathophisiology remains unknown.
• If there are a lot of reactivation so the patient can have liver
cirrhosis or hepatoseluler carcinoma
• The prognosis of these patient is very bad
• Lamivudine is the best choice for treatment of chronic hepatitis
B with HBeAg negative ( reactivation phase )
• Lamivudine is anti virus that able to reduce the replication of
HBV and also could reduce the value of ALT and HBV DNA
• The goal treatment of long term antivirus for this patient is to
reduce the clinical sign and also to avoiding the risk of liver
cirrhosis and hepatoseluler carcinoma
14