KYAMC Journal Vol. 14, No.

03, October 2023

Case Report
Viral Hepatitis: HBV-HCV Co-infection
Syed Minhaj Uddin Ahmed1, Quazi Manjurul Haque2, Kazi Shihab Uddin3, Md Zulfikar Ali4.

Abstract
Co-infection with HBV and HCV is a complex clinical existence which estimated prevalence is reported 0.7% to 16% worldwide.
HCV superinfection is very common due to viral replication in HCV is more dominant over HBV. Most of the clinical studies
reported that disease progression is faster in HBV and HCV co-infected patients in compare to those with mono-infection.
Therefore, early diagnosis and proper treatment is important for withholding the disease progression. Here a case of 45 years old
male with fever, anorexia, vomiting and mucus mixed stool. HBsAg and anti-HCV are positive. USG of whole abdomen suggesting
chronic liver disease with chronic kidney disease. Endoscopy of upper GIT revealed grade III esophageal varices. There are no
established guidelines for treatment of HBV-HCV co-infection. Only symptomatic treatment was given.

Key words: Hepatitis B virus, Hepatitis C virus, Co-infection, Esophageal varices

Date of received: 15.05.2023

Date of acceptance: 25.09.2023

DOI: https://doi.org/10.3329/kyamcj.v14i03.68704 KYAMC Journal. 2023; 14(03): 178-180.

Introduction
Hepatitis B (HBV) and Hepatis C (HCV) virus infection northern part of Bangladesh owing to the passage of stool mixed
account for the leading cause of death globally. World Health with mucus 7-8 times per day for 3 days. He also complained of
Organization estimates that approximately more than 250 fever, anorexia, nausea and vomiting for same duration. On the
million and 170 million people are infected with HBV and HCV day of hospital admission, he was reported marked jaundice
respectively.1 In Bangladesh the prevalence of HBV is 5.4% in with respiratory distress. The patient’s drug history, he had had
general population. On the other hand, there is limited data some herbal medicine for few days. The patient having a history
about the prevalence HCV that is estimated approximately of staying abroad as an expatriate for 18 years.
0.84%.2 The mode of transmission of these two viruses are On admission to the hospital, the patient was alert, with a blood
treatment from quacks by reusing of unsterilized syringes and pressure of 110/80 mm Hg, a pulse rate of 95 bpm, a body
other implements, shaving and hair trimming in barber shops, temperature of 98°F and SPO2 92%. The bilateral palpebral
body piercing, vaccination against small pox, cholera, dental conjunctiva was significantly jaundiced. Mild leg edema was
procedure, intravenous infusion and drug abusers etc.2 Because present and bowel sound was normal. There was mild upper
of the shared modes of transmission coinfection with two abdominal tenderness and splenomegaly. Other physical
viruses is common. HBV-HCV coinfection is more complex examinations revealed normal. He was initially diagnosed with
compare to mono-infection with HBV or HCV alone. The exact acute viral hepatitis.
prevalence of HBV and HCV coinfection is unknown but is
reported to be between 0.7% and 16% in high endemic region To determine the cause of acute hepatitis, viral antibodies, and
and among people at high risk for parenteral infection.3-5 hepatitis B surface antigen were tested. HBsAg and anti-HCV
HCV-HBV coinfection may also occur by superinfection. HCV were positive. The relevant laboratory tests on admission to the
superinfection is more common whereas HBV superinfection is hospital showed the following: ESR 37 mm in 1st hour; hemo-
rare.6-7 globin 12 g/dL; total white blood cells, 7.51×109/L with
evidence of lymphocytopenia (14%); platelets, 110×109/L;
Case Presentation prothrombin time with INR (International normalized ratio)
20.10 sec; 1.66. Serum albumin 25.88 g/L. Liver enzyme ALT
A 45-year-old male, taxi driver was admitted to Khwaja Yunus
level was elevated 458 U/L; but alkaline phosphatase was 81
Ali Medical College Hospital, a tertiary-level hospital in the

1. Assistant Professor, Department of Biochemistry, Khwaja Yunus Ali Medical College and Hospital, Enayetpur, Sirajgang, Bangladesh.
2. Professor, Department of Microbiology, Khwaja Yunus Ali Medical College and Hospital, Enayetpur, Sirajgang, Bangladesh.
3. Associate Professor, Department of Medicine, Khwaja Yunus Ali Medical College and Hospital, Enayetpur, Sirajgang, Bangladesh.
4. Professor, Department of Medicine, Khwaja Yunus Ali Medical College and Hospital, Enayetpur, Sirajgang, Bangladesh.

Corresponding author: Syed Minhaj Uddin Ahmed, Assistant Professor, Department of Biochemistry, Khwaja Yunus Ali Medical College
and Hospital, Enayetpur, Sirajgang, Bangladesh. Cell: +8801711978360, E-mail: drminhajtopu@gmail.com

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U/L; total bilirubin was 672.69 μmol/L; serum creatine level prevalence of one virus over the other.8 Diagnosis of acute
was 267.37μmol/L; serum electrolytes revealed hyponatremia hepatitis is difficult due to most cases are asymptomatic. Others
(serum sodium 129 mmol/L). Ultrasonography of whole have only nonspecific symptoms like fever, fatigue, myalgia
abdomen showed chronic liver disease (there was no biliary
and anorexia may misdiagnosed acute hepatitis as a common
obstructions or mass lesions in the liver) with mild ascites,
Acute kidney injury (AKI) on chronic kidney disease (CKD), cold. When the symptoms persist more than 10 days following
bilateral renal cortical cysts and mild splenomegaly. Endoscopy jaundice acute hepatitis should be considered and liver enzymes
of upper gastrointestinal tract (GIT) revealed esophageal should be estimated. Jaundice is the most specific liver related
varices grade III with congestive gastropathy (Figure: 1) symptom and around 50% to 84% symptomatic patients having
Hence the final diagnosis was chronic liver disease caused by the jaundice. If the liver enzymes are elevated the cause of
hepatitis B and C virus associated with CKD and esophageal
hepatitis should be determined.9
varices.The patient received only symptomatic treatment. The
patient’s symptoms subsided gradually, and he was discharged
from the hospital.

Figure 1: Endoscopy of the upper GIT showing (A and B) elongated dilated veins in the middle and lower 3rd of the esophagus
and (C and D) multiple submucosal hemorrhagic lesions with mosaic in appearance in the fundus and body of the stomach.

Discussion Several studies have shown that HBV-HCV co-infection is a

The global prevalence of HBV and HCV coinfection has been factor which prone to the progression of the liver fibrosis and
reported 0.7% to 16% worldwide and likely to be underestimat- the increased incidence of cirrhosis. Moreover, the coinfection
ed while the disease outcomes are more severe in comparison with these two infections may be associated with the develop-
to patients with single hepatitis virus infection. Coinfection is ment of liver cancer,10 and the risk of development of liver
frequently observed in population with high-risk parenterally cancer is greatly higher in HBsAg/HCV positive cirrhotic
acquired infections. Unfortunately, patients with HBV-HCV patient than individuals infected with HCV or HBV alone. HCV
coinfection have heterogenous clinical manifestations. Either has been associated with microalbuminuria. This viral infection
there could be HCV predominance or HBV predominance. It may have higher risk and development of CKD within short
indicates that acquisition time of each infection is crucial for the time. Studies revealed that HCV infection is associated up to

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2.2-folds higher mortality, rapid progression of CKD to end 5. Gaeta GB, Stornaiuolo G, Precone DF, et al. Epidemiologi-
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Our patient developed chronic hepatitis with CKD and esopha-
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