Autoimmune Hepatitis Induced by Hepatitis Delta Virus: A Conundrum

Area of Science:

• Hepatology
• Virology
• Immunology

Background:

• Hepatitis delta virus (HDV) infection is associated with autoimmune features.
• Clinical autoimmune hepatitis (AIH) is rarely reported in HDV infection, often in the context of peginterferon treatment.

Purpose of the Study:

• To present a challenging case of autoimmune-like hepatitis potentially induced by chronic HDV infection.
• To highlight the importance of high suspicion for HDV in cases of refractory AIH.
• To discuss the potential role of HDV suppression in managing autoimmune liver disease.

Main Methods:

• Case report of a 46-year-old woman with AIH-like symptoms, chronic hepatitis B, and positive anti-HDV antibody.
• Diagnostic work-up included serology, viral load testing (HDV RNA), liver histology, and treatment trials (tenofovir, prednisolone, azathioprine, acyclovir, mycophenolate mofetil).

Main Results:

• Initial presentation consistent with AIH type 1, with negative HDV RNA.
• HDV RNA became positive (genotype 5) during a later hepatitis flare, after immunosuppressive therapy was modified.
• Patient refused bulevirtide therapy, a treatment shown to reverse autoimmune liver disease by suppressing HDV.

Conclusions:

• This case underscores the diagnostic challenge of HDV-induced autoimmune-like hepatitis.
• Early identification of HDV is critical to prevent potentially harmful escalation of immunosuppression.
• Bulevirtide offers a potential therapeutic strategy for HDV-associated autoimmune liver disease, as suggested by recent findings and this patient's case.