Elevated Carbohydrate Antigen 19-9 Levels in Acute Viral Hepatitis

Abstract

Increased serum levels of carbohydrate antigen 19-9 (CA 19-9) are associated with pancreatic cancer and various other gastrointestinal malignancies. Elevated CA 19-9 levels have also been reported in various nonneoplastic liver diseases. We report a rare case of a 63-year-old male who presents with elevated CA 19-9 levels during an acute bout of hepatitis B, which normalized after spontaneous resolution of the infection.

Keywords: Acute Hepatitis B; CA 19-9; Pancreatic Obiliary Malignancies

Introduction

Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker that is used to diagnose and prognosticate pancreatic obiliary malignancies. While elevated CA 19-9 levels are associated with malignancy, they can also indicate benign conditions, such as acute cholangitis, severe steatosis, autoimmune hepatitis, chronic alcoholic hepatitis, and hepatic cirrhosis [1,2]. Additionally, elevated CA 19-9 levels may be seen in chronic viral hepatitis, most often found in patients with chronic hepatitis C. Statistically significant correlations were observed between the serum CA 19-9 concentration and the following hepatic liver tests: aspartate aminotransferase, alkaline phosphatase and bilirubin [3].

In 1998, Collazos et al reported one case of elevated CA 19-9 levels in a patient with acute hepatitis B in Spain [4]. In 2020, on retrospective review of 6,899 South Korean cases of elevated CA 19-9 levels (≥80 U/mL), Kim et al reported 3 cases in which acute hepatitis B was identified as the likely source [5]. Presently, to the best of our knowledge, there have not been any cases of elevated CA 19-9 levels in the setting of acute hepatitis B in the United States. Here, we present the case of a patient with an elevated CA 19-9 level during an acute bout of hepatitis B, which normalized after spontaneous resolution of the infection.

Case Presentation

A 63-year-old male with a history of acid reflux, Barrett’s esophagus, and irritable bowel syndrome presented to the clinic with mild fatigue. One month prior, the patient began to experience fatigue, weight loss and poor appetite. Three weeks after appearance of his symptoms, the patient noted the onset of jaundice, which gradually improved several days before presentation. The patient denied any abdominal pain and physical exam revealed bilateral sclera icterus and markedly jaundiced skin. At the time, laboratory data was significant for total bilirubin of 18.38 mg/dL, Aspartate Aminotransferase (AST) of 439 U/L, and Alanine Aminotransferase (ALT) of 728 U/L. Laboratory data was also significant for CA 19-9 levels of 104 U/mL. Blood tests were significant for hepatitis B surface antigen (HBsAg) and hepatitis core IgM (IgM anti-HBc), consistent with an acute bout of hepatitis B.

Computed Tomography (CT) of the abdomen and pelvis without contrast did not reveal any hepatic or biliary pathology. Abdominal and pelvic ultrasound showed no evidence of a gross calculus or biliary dilatation but revealed an irregularly shaped gallbladder that was under distended, limiting its evaluation.

The patient’s acute hepatitis B resolved spontaneously, and his CA 19-9 level eventually normalized to 22 U/mL. Table 1 illustrates the clinical course of the infection with corresponding lab values and serological markers.

  

    
 
    
Reference    range 
    
Acute    HBV infection 
    
Window    period 
    
Recovery 
  
  

    
October 25
    
November 13
    
November 27
    
January 2
    
February    12 
  
  

    
Total    Bilirubin (mg/dL)
    
0.20    - 1.50
    
18.38*
    
8.33*
    

    

    
0.72
  
  

    
AST(U/L)
    
3    - 50
    
439*
    
464*
    
33
    

    
20
  
  

    
ALT    (U/L)
    
3    - 60
    
728*
    
542*
    
42
    

    
16
  
  

    
CA19-9    (U/mL)
    
0    - 37
    
104*
    
130*
    
63*
    
28
    
22
  
  

    
HBsAg
    
N/A
    
+
    
+
    
–
    
–
    
–
  
  

    
IgM anti-HBc
    
+
    

    

    
+
    
+
  
  

    
anti-HBs
    

    
–
    
–
    
–
    
+
  
  

    
HBV DNA (copies/mL)
    
1,451,810
    
79,103
    
 
    
+
    
–
      
(as of 04/16)
  
  

    
*Indicates abnormal value. 
  

Table 1: Clinical course of acute hepatitis B with associated liver function tests, CA19-9 levels, and hepatitis serological markers.