Hepatitis and cholestasis
Abnormal liver biochemistry and/or hepatomegaly are common clinical problems although frank jaundice is uncommon. With the multiple therapies being used in treatment and prophylaxis, a drug-induced hepatitis must always be considered in a patient with AIDS and abnormal liver function tests.
The differential diagnosis is wide and may involve the use of serology, abdominal ultrasound, ERCP, and liver biopsy. These latter two diagnostic procedures are clearly invasive and would not be indicated unless treatment of opportunistic infection, malignancy or biliary strictures was contemplated. In the absence of dilatated bile ducts on ultrasound, liver biopsy usually shows a granulomatous hepatitis caused by atypical mycobacteria.AIDS sclerosing cholangitis presents with right upper quadrant pain, accompanied by a raised alkaline phosphatase. Abdominal ultrasound is abnormal in the majority of patients with biliary tract dilatation. ERCP may demonstrate papillary stenosis, dilatation of the common bile duct and dilatations and strictures with “beading” of the intrahepatic ducts. The disease is commonly associated with cryptosporidiosis, microsporidiosis, or cytomegalovirus infection. Endoscopic sphincterotomy may give pain relief in a proportion of patients with papillary stenosis. Liver function tests do not usually improve, and as it is a late-stage manifestation, the prognosis is poor, with most patients dying from some other HIV-related complication within six months of diagnosis.
HIV infection may alter the natural history of hepatitis B infection in a number of ways. The response rate to hepatitis B vaccination is lower in HIV-infected recipients. Immunodeficiency may favour the establishment of chronic infection following acute infection and HBV replication is increased with a reduction in the rate of spontaneous loss of HBe antigen. Interferon therapy would appear to be less effective in chronic HBV/HIV dual infection. The immune restoration following the initiation of antiretroviral therapy may lead to a hepatitis “flare” in chronic HBV carriers.
Hepatitis C virus infection is found primarily in intravenous drug users, although it may also be sexually transmitted. HIV can modify the natural history of HCV infection and patients with HIV/HCV dual infection tend to have more aggressive liver disease.