Syed Bilal Shah

Background/Aim: Hepatitis D virus (HDV) infection is the most severe form of viral hepatitis but is under-recognized. We evaluated HDV screening frequency and clinical characteristics of HDV-positive patients in our liver center in the United States. Method: Patients with chronic hepatitis B (CHB) evaluated between January 2021 and December 2023 were included. For those tested anti-HDV(+), HDV RNA was performed and clinical data were recorded. Results: Among 1,337 (M=716, F=621) CHB patients, 93.3% were foreign-born. The cohort included 74.9% Asians, 12.3% Blacks, 9.1% Whites and 1.3% Hispanics. HDV screening significantly increased after 2011 reflecting an increase in HDV awareness. Patients aged 18-40 years had the highest screening rate of 58%. Overall, 13 (1.95%) were tested HDV positive and 11 were repeatedly HDV RNA(+). PWID was noted in 5 of 11. Despite low HBV DNA levels, all had ≥stage 2 fibrosis, and 7 had advanced stage 3-4 disease. After a median follow-up of 8.75 years, 8 (73%) developed hepatic decompensation and 4 had hepatocellular carcinoma. Conclusion: HDV screening reached 51.3% among our predominantly foreign-born CHB patients. The high prevalence of advanced fibrosis at diagnosis underscores the importance of HDV screening. Early diagnosis and effective therapy are urgently needed for this challenging disease.

Patients with chronic hepatitis B often require prolonged nucleos(t)ide analogue since functional cure is rarely achieved. Medication nonadherence can trigger life-threatening hepatitis B virus (HBV) reactivation. We report a 58-year-old Asian man with HBeAg-negative chronic hepatitis B and cirrhosis. After 10 years of entecavir therapy, he achieved undetectable HBV DNA and fibrosis regression, but quantitative hepatitis B surface antigen remained >1200 IU/mL. He self-discontinued medication and presented with severe hepatitis reactivation. Liver condition gradually improved on restarting nucleos(t)ide analogue. This case highlights that medication cessation with a high hepatitis B surface antigen titer can precipitate severe hepatitis and liver failure, even after long-term HBV DNA suppression.