Prelude

A 25-year-old woman walked into the clinic with a decade-long history of unexplained fatigue, brain fog, and joint pain—all dismissed as "stress" or "malaria." Her family’s hidden burden of hepatitis B and a puzzling mix of lab results unveiled a tale of occult infection and metabolic liver disease. This case highlights the importance of digging deeper when routine tests fail to explain chronic symptoms.

Case Study: The Mystery of Fatigue, Family Secrets, and a Silent Liver Infection

Introduction

A 25-year-old woman presented with a decade-long history of unexplained fatigue, brain fog, and joint pain—all dismissed as "stress" or "malaria." Her family’s hidden burden of hepatitis B and a puzzling mix of lab results unveiled a tale of occult infection and metabolic liver disease. This case highlights the importance of digging deeper when routine tests fail to explain chronic symptoms.

Case Presentation

• Patient: 25-year-old female
• Chief Complaint: Chronic fatigue, cognitive slowing, and arthralgia.
• History:
  • Symptoms ongoing for 10 years, worsening in the last year.
  • Family history: Mother and brother hepatitis B surface antigen (HBsAg)-positive.
  • Repeated negative malaria/typhoid tests; initial HBsAg screening negative.
• Physical Exam:
  • Vitals: BMI 29.4 (overweight), BP 125/65 mmHg, no fever.
  • HEENT: Slight pallor, no jaundice.
  • Abdomen: Mild hepatomegaly (palpable 2 cm below costal margin), no tenderness.
  • MSK: No synovitis, but generalized joint stiffness.
• Laboratory Findings:
  • Liver Enzymes: AST 41 U/L, ALT 39 U/L, GGT 68 U/L (elevated).
  • Hepatitis Workup:
    • HBsAg: Negative
    • Anti-HBc IgG: Positive
    • Hepatitis C antibody: Negative
    • HBV DNA PCR: 2,100 IU/mL (detectable).
  • Metabolic Panel: Normal renal function, fasting glucose 110 mg/dL (impaired).
  • Hematology: Hb 12 g/dL (low-normal), MCV 88 fL, ferritin 45 ng/mL (low).
  • Imaging: Liver ultrasound: Steatosis (grade 2), hepatomegaly; no cirrhosis.

Key Findings Driving the Case

• Occult Hepatitis B: HBsAg-negative but HBV DNA-positive (2,100 IU/mL) + anti-HBc IgG-positive → Confirms occult infection.
• NAFLD: Ultrasound shows grade 2 steatosis and hepatomegaly.
• Iron Deficiency: Low ferritin (45 ng/mL) + mild pallor → Contributing to fatigue.

Discussion

This case underscores the challenges of diagnosing occult hepatitis B virus (OBI) and its coexistence with non-alcoholic fatty liver disease (NAFLD). OBI, though silent, can contribute to chronic liver injury, especially when combined with NAFLD. Early intervention is critical to prevent progression to cirrhosis or hepatocellular carcinoma.

Management Options

• Occult Hepatitis B:
  • Antiviral Therapy: Tenofovir disoproxil fumarate (TDF) or entecavir to suppress viral replication.
  • Liver Fibrosis Assessment: FibroScan to stage fibrosis.
• NAFLD:
  • Lifestyle Modifications: Weight loss (5–10% of body weight), Mediterranean diet, exercise.
  • Pharmacotherapy: Vitamin E (800 IU/day) or pioglitazone for insulin resistance.
• Iron Deficiency: Oral iron supplementation + dietary iron.
• Monitoring: Regular liver enzymes, HBV DNA, glucose, and ultrasound.

Public Health Advice

• Hepatitis B Awareness: Screen family members of HBV carriers; vaccinate unvaccinated contacts.
• NAFLD Prevention: Promote healthy lifestyles to combat obesity and metabolic syndrome.
• Safe Practices: Avoid sharing razors/toothbrushes; use condoms to reduce HBV transmission.
• Healthcare Provider Education: Consider OBI in patients with unexplained liver enzyme elevations.

Conclusion

This case illustrates the importance of integrating family history, advanced diagnostics, and holistic management for patients with overlapping metabolic and infectious liver diseases. Early intervention with antivirals, lifestyle changes, and iron repletion offers a pathway to improved outcomes. Public health efforts must focus on screening high-risk families and addressing modifiable risk factors for liver disease.

Disclaimer & Credit: All medical articles including ours, are informative and provide population trends not specific to individuals which can be very different. Always seek personalized medical advice from your doctor for individual healthcare decisions.

Posted March 15, 2025