Abstract
Background: Acute exacerbation of chronic hepatitis B virus occurs as either a flare of HBV in immune clearance phase or as a reactivation of HBV in patients with inactive or resolved HBV infection. In rare situations, HBV causes systemic autoimmunity that improves with antiviral therapy. However, in certain patients, puritan forms of autoimmune hepatitis develop independent of HBV that requires immunosuppressive therapy. Report: We present the case of a religious nun, who presented with suspected reactivation of HBV leading to jaundice and grade 2 hepatic encephalopathy not responding to 3 weeks of antiviral therapy with fluctuating jaundice and elevated transaminases. A timely liver biopsy based on a strong clinical suspicion led to a final diagnosis. We also briefly discuss the importance of liver biopsy in this scenario. Conclusion: We present the case of a patient who was incidentally detected to have HBV infection during work up of a flare of AIH. Treating physicians must be astute in analysing blood tests in the light of clinical symptoms and signs for comprehensive diagnosis of multiple insults that could occur in the liver.

Key words: chronic hepatitis B, reactivation of hepatitis B, HBV infection, autoimmune hepatitis, tenofovir, antivirals