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Q. I have a case of a 40 year old Asian male with hx of chronic HBV, who was on lamivudine and tenofovir in the past. He has been HBV DNA negative for last 3 years while he remained off the antiretoviral meds and being only followed up by 6 monthly HCC screening and HBV DNA. He was recently found to have cirrhosis by CT scan findings (no clinical decompensation) and presence of esophageal varices, grade 1 at EGD. Other than current followup and yearly variceal screening, is there any other specific thoughts in the further management of this patient?
A. This is an unusual situation in that the patient appears to have developed cirrhosis despite antiviral therapy of hepatitis B and despite having undetectable HBV DNA levels for several years. If ALT levels had been elevated (ALT levels were not provided), I would consider evaluating the patient for other causes of liver disease such as autoimmune hepatitis, metabolic diseases (alpha-1-antitrypsin deficiency, hemochromatosis, Wilson disease), hepatitis C and biliary disease (eg, primary sclerosing cholangitis, PSC). I would also consider doing a liver biopsy to confirm the presence of cirrhosis as an ultrasound may not be reliable in this regard. A liver biopsy would also assist in assessing other causes of liver disease in this patient.
—Adrian M. Di Bisceglie, MD, FACP
Q: A baby that has been born of an HBV carrier (HBsAg positive, Anti-HBs negative, HBeAg negative, Anti-HBe positive), shows the following markers when she is 15 months old: HBsAg(-), Anti-HBs(-), Anti-HBc IgM(-), Anti-HBc(+), HBeAg(-) and Anti-HBeAg(-). That is, it is a case with isolated Anti-HBc. She has no other symptoms, except that ALT is 53. How can we interpret these results? May she be recovering from an acute HBV?
A: It is recommended that infants born to mothers with hepatitis B receive both hepatitis B immune globulin (HBIG) and the first of three doses of hepatitis B vaccine shortly after birth. This approach appears to protect most infants and only about 5% become infected with HBV, particularly if the mother is seropositive for HBeAg and has high serum levels of HBV DNA. It is further recommended that infants be tested for hepatitis B at 12 months of age. The usual test done at this time is HBsAg.
The case described is somewhat unusual for a few reasons. Firstly, the infant is seronegative for anti-HBs, which would be unusual particularly if she received HBIG and a full course of vaccine as recommended. It would also be unusual to order all of these tests as described. If the infant were recovering from acute HBV infection as was suggested by the reader, it is likely that IgM anti-HBc would still be detectable but it is negative in this infant. So there are only three possible explanations for the serological findings in this infant: 1) the child may have been infected with HBV and recovered without making anti-HBs, 2) the child may be chronically infected at a very low level with HBV, hence anti-HBs has not appeared or 3) this may be a false positive anti-HBc.
My approach to this case would be to: 1) repeat serological testing (in particular HBsAg, anti-HBs and anti-HBc with a sensitive test for HBV DNA to check for the presence of low level HBV infection and measurement of serum aminotransferases to check for disease activity, and 2) if HBsAg and anti-HBs remain negative, I would repeat the course of three doses of vaccination.
It may be that the answer only becomes clear with time, but at this stage I would not be too concerned about the child's condition.
— Adrian M. Di Bisceglie, MD, FACP