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Abstract
Hepatitis A is a self-limiting infection caused by the hepatitis A virus (HAV), transmitted predominantly by the faecal–oral route including some sexual practices. Outbreaks are commonly reported in the men who have sex with men (population. Previous exposure is thought to provide life-long immunity against subsequent infections with the development of an HAV IgG response. This paper reports a case of acute Hepatitis A infection, despite evidence of a previously positive Hepatitis A IgG results in an HIV-positive individual.
- hepatitis a
- vaccination
- HIV
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Background
Hepatitis A is a self-limiting infection caused by the hepatitis A virus (HAV), which is transmitted predominantly by the faecal–oral route, but also through sexual exposure (eg, Rimming, use of sex toys).1 Recent outbreaks have been reported in the men who have sex with men (MSM) population worldwide.2 Vaccination with two doses of HAV vaccine, or previous infection, which is usually asymptomatic in childhood, is thought to provide life-long immunity against subsequent infection. Testing for the presence of HAV IgG is recommended to determine immunity where a clear infection or vaccination history is not revealed.
Presentation
A 55-year-old Eastern European, HIV-positive MSM patient, presented to clinic with a 2-week history of fevers, poor appetite, nausea and increasing jaundice. He reported unprotected oral and protected active anal intercourse with casual male partners in saunas, with a recent encounter 3 weeks prior to his presentation. He also travelled to Hungary for a 3-day trip 2 weeks prior to his presentation where he had further unprotected oral and protected anal intercourse with casual male partners. He denied any use of sex toys or rimming. He denied further sexual activity since returning to the UK.
Medical history included well-controlled HIV infection, diagnosed 2 years prior. Latest CD4 was 470/uL (21.66%), with an undetectable viral load on Truvada and Raltegravir. He also had right hip osteoarthritis and a history of treated secondary syphilis.
The patient’s history did not suggest a drug-induced, toxin-induced or alcohol-induced liver injury.
On examination he was jaundiced, with no evidence of abdominal organomegaly or chronic liver disease.
Investigations
His liver function was deranged with a conjugated hyperbilirubinaemia, elevated liver enzymes, with normal full blood counts, renal, coagulation and inflammatory markers (summarised in table 1). HAV IgM and IgG antibodies were positive with detectable plasma HAV RNA, and genotyping showed it was related to a current MSM-related outbreak. An autoimmune screen was negative, there was no evidence of active Hepatitis C or E, and he had natural immunity to Hepatitis B (table 1). Syphilis rapid plasma region titres did not reveal evidence of active syphilis.
Evolution of liver function tests and Hepatitis A serology over time
Baseline Hepatitis A IgG was detected at the time of HIV diagnosis, in the absence of a vaccination history, this suggested natural immunity. Retrospective analysis on this baseline sample revealed a borderline result (table 1) and a negative result on a stored sample taken 6 months prior to presentation.
An ultrasound scan of his liver showed a 14 mm haemangioma in the left lobe, but otherwise unremarkable examination of the rest of the upper abdominal organs.
Management
He improved clinically and biochemically with resolution of his jaundice with conservative management. Public Health England was notified of the acute Hepatitis A infection, and partner notification was discussed.
Discussion
There have been no reported cases for a new episode of acute Hepatitis A with previously documented HAV IgG serology, despite reports of reinfection of infectious hepatitis in animal models, prior to serological testing availability3 and reports of clinical relapses of the disease shortly after the initial presentation.4
Possible explanations include: (1) the patient may have had an incomplete vaccination course, resulting in loss of IgG response over time; however, there was no recall of prior hepatitis or travel vaccinations either from patient’s history or GP records; (2) the initial detectable HAV serology may have been a false positive due to assay performance, sample contamination or mislabelling. However, current laboratory practice and accreditation of assays make such cases exceptionally rare events.
The current British HIV Association guidelines, European AIDS Clinical Society and US Advisory Committee on Immunisation Practices guidelines all recommend vaccinating HIV-positive individuals with risk exposure or relevant medical comorbidities.5–7 The immune response to the HAV vaccine may be impaired in HIV-positive individuals, as demonstrated by lower seroconversion rates and shorter duration of protection after vaccination.8 In immunocompetent hosts, including patients with well-controlled HIV, immune memory to HAV may be present despite the absence of detectable antibodies9 10; however, the presence of neutralising antibodies should indicate immunity.
In conclusion, in HIV-positive individuals identified at risk of HAV infections (eg, outbreak settings, contact of confirmed cases), clinicians should discuss and test for Hepatitis A IgM even in the presence of detectable Hepatitis A IgG results.
Key messages
Acute Hepatitis A infections may occur despite previous positive hepatitis A virus (HAV) IgG serology in HIV-positive patients.
In HIV-positive patients, clinicians should be cautious of assuming sustained HAV immunity from a single detectable serology result particularly in outbreak settings and in individuals with identified risks such as being a contact of a confirmed case of HAV.
Footnotes
Contributors All the authors equally contributed to the manuscript draft.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.