title: Virological pattern of hepatitis B infection in an HIV-positive man with fatal fulminant hepatitis B: a case report.
abstract: BACKGROUND
  There seem to be no published data concerning the clinical impact of populations of hepatitis B virus (HBV) in the hepatic and extrahepatic compartments of HIV-infected people with severe acute hepatitis.
  
  
  METHODS
  A 26-year-old Caucasian man presenting to our hospital with clinical symptoms suggesting acute hepatitis was found to have an acute hepatitis B profile upon admission. He developed fatal fulminant hepatitis and was found to be heavily immunocompromised due to HIV-1 infection. He had a high plasma HBV and HIV load, and analysis of the partial pre-S1/pre-S2 domain showed the presence of mixed infection with D and F genotypes. Analysis of the point mutations within this region revealed the presence of HBV strains with amino acid substitutions at the immunodominant epitopes involved in B or T cell recognition. A homogeneous population of a pre-core mutant strain harbouring the A1896G and A1899G affecting HBeAg expression was invariably found in the liver tissue, plasma and peripheral blood mononuclear cells despite active HBeAg secretion; it was the dominant strain in the liver only, and was characterised by the presence of two point mutations in the direct repeat 1 domain involved in HBV replication activity. Taken together, these mutations are indicative of a highly replicative virus capable of evading immune responses.
  
  
  CONCLUSIONS
  This case report provides clinical evidence of a possible association between the rapid spread of highly replicative escape mutants and the development of fulminant hepatitis in a heavily immunocompromised patient. Virological surveillance of severe acute hepatitis B may be important in establishing an early treatment strategy involving antiviral drugs capable of preventing liver failure, especially in individuals for whom liver transplantation is not accepted as a standard indication.
authors: Infectious Diseases Department, San Raffaele, Scientific Institute, Via Stamira d'Ancona, Milano 20127, Italy.
authors: Sabrina
authors: S
authors: Bagaglio
authors: Luca
authors: L
authors: Albarello
authors: Priscilla
authors: P
authors: Biswas
authors: Caterina
authors: C
authors: Uberti-Foppa
authors: Claudio
authors: C
authors: Fortis
authors: Giulia
authors: G
authors: Morsica