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13 March 2023 : Case report  USA

[In Press] Acute Immune Reconstitution Inflammatory Syndrome-HBV Flare in an HIV/HBV Coinfected Patient After Antiretroviral Therapy Initiation: Case Report and Literature Review

Unknown etiology, Challenging differential diagnosis

Iqra Arshad1AEF, Mukti Gandhi1EF, Marcia Gossai1EF, Addi Feinstein2EF

DOI: 10.12659/AJCR.939210

Am J Case Rep In Press; DOI: 10.12659/AJCR.939210  

Available online: 2023-03-13, In Press, Corrected Proof

Publication in the "In-Press" formula aims at speeding up the public availability of the pending manuscript while waiting for the final publication. The assigned DOI number is active and citable. The availability of the article in the Medline, PubMed and PMC databases as well as Web of Science will be obtained after the final publication according to the journal schedule


Immune reconstitution inflammatory syndrome (IRIS) is a well-recognized complication after antiretroviral therapy (ART) initiation among patients with HIV. Acute HBV flares after starting antiretroviral therapy have been reported in 20% to 25% of coinfected patients, among whom only 1% to 5% develop clinical hepatitis. Liver biopsy and serological evaluation help in diagnosis.
A 24-year-old man with history of HIV diagnosed in 2018 developed severe IRIS-related HBV flare after initiation of ART. He was taking ART since 2018 until his immigration to the United States in 2021. He came to establish care and was started on bictegravir/emtricitabine/tenofovir alafenamide (BIC/F/TAF). Three weeks later, he presented to the Emergency Department with polyarthralgia and loose stools; transaminases showed an increasing trend on follow-up. He was admitted for closer monitoring. Workup was remarkable for reactive HBsAg, HBeAg, and HBcIgM antibodies, with HBV viral load of 295 304 copies/mL. Abdominal imaging was unremarkable. ART was switched to rilpivirine/emtricitabine/tenofovir alafenamide (RPV/FTC/TAF), considering the hypothetical risk of hepatotoxicity from BIC/F/TAF. Despite therapy, transaminases were up-trending. He underwent computerized tomography-guided liver biopsy, showing moderate to severe acute hepatitis, compatible with IRIS. He received steroids, and ART was continued. Transaminases resolved, HBV load reduced significantly, HIV load became undetectable at 9 weeks, and he developed HBeAb (seroconversion) at 4 months after initiating ART.
Our case highlights the importance of early recognition and management of IRIS-HBV flares after initiation of ART among coinfected patients. Liver biopsy is indicated for definitive diagnosis. ART directed against both viruses should be continued.

Keywords: Antiretroviral Therapy, Highly Active; Hepatitis B e Antigens; HIV; Iris


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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923