A 32-year-old man comes to the office due to a week of nausea and generalized fatigue. He has no chronic medical problems and recently donated blood. He does not use alcohol or illicit drugs but smokes marijuana occasionally. The patient has been sexually active with multiple partners and does not use condoms consistently.
Blood pressure is 122/76 mm Hg and pulse is 78/min. BMI is 35 kg/m². There is mild scleral icterus with no jaundice. The lymph nodes are not enlarged. Chest examination is unremarkable. The liver and spleen cannot be palpated due to obesity. Neurological examination shows no focal deficits.
Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old man comes to the office due to a week of nausea and generalized fatigue. He has no chronic medical problems and recently donated blood. He does not use alcohol or illicit drugs but smokes marijuana occasionally. The patient has been sexually active with multiple partners and does not use condoms consistently.
Blood pressure is 122/76 mm Hg and pulse is 78/min. BMI is 35 kg/m². There is mild scleral icterus with no jaundice. The lymph nodes are not enlarged. Chest examination is unremarkable. The liver and spleen cannot be palpated due to obesity. Neurological examination shows no focal deficits.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9854_4656_853d_81a77ef64cc4_MD0002_00 Acute hepatitis B virus (HBV) infection is characterized by positive hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), IgM hepatitis B core antibody (anti-HBc/HBcAb), and detectable HBV DNA. It often remains subclinical, manifesting as an asymptomatic transaminase elevation, but approximately 30% of patients have nausea, fatigue, jaundice, and/or abdominal pain. Fulminant hepatic failure can occur (<1%), but the vast majority (>95%) of adult patients clinically improve and clear the infection with only supportive care. For patients with acute HBV infection, antiviral treatment (eg, tenofovir, entecavir) should be considered only in those with a severe (eg, INR >1.5) or prolonged (eg, >4 weeks of symptoms with significant jaundice and bilirubin >3 mg/dL) course or with acute liver failure (to reduce posttransplant reinfection risk). Although this patient with acute HBV infection has bilirubin >3 mg/dL, he has not had >4 weeks of symptoms and has no other indications (eg, liver failure, hepatic encephalopathy) for treament (Choice D). Chronic HBV develops following acute infection in up to 5% of adults; it is defined by persistent HBsAg for >6 months and can be active or inactive. Chronic inactive HBV is characterized by a negative HBeAg, normal alanine aminotransferase (ALT), and <2,000 IU/L HBV DNA and does not require treatment. Patients with active chronic HBV (elevated HBV DNA, ALT >2x normal, and HBeAg positive) can be considered for antiviral treatment, as can the subset of patients with occult chronic HBV infection (negative HBeAg but elevated HBV DNA). This patient with 1 week of symptoms has acute, not chronic, HBV infection. (Choice A) HBV immune globulin and vaccination should be considered in patients who have a potential exposure to HBV (eg, needlestick) and no evidence of HBV immunity, but they do not have a role in those who already have evidence of active infection. (Choice B) Sofosbuvir and velpatasvir are polymerase inhibitors used in combination for the treatment of chronic hepatitis C virus (HCV) infection. These drugs are not used for HBV and, in fact, may worsen HBV infection when given to patients with HCV and HBV co-infection who are not on HBV antiviral therapy. (Choice E) Liver biopsy can be considered for patients with chronic HBV infection to assist in treatment decisions, but it does not have a role in acute infection. Educational objective: Serology in acute hepatitis B virus infection typically demonstrates hepatitis B surface antigen (HBsAg), hepatitis B e antigen, IgM hepatitis B core antibody, and elevated viral DNA. Most adult patients will improve clinically and clear the infection with only supportive care and do not require antiviral therapy. A small minority will develop chronic infection evidenced by persistence of HBsAg for >6 months. __________ References: Hepatitis B: the virus and disease. (http://www.ncbi.nlm.nih.gov/pubmed/19399811) Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance (http://www.ncbi.nlm.nih.gov/pubmed/29405329)

A 32-Year-Old Man Comes to the Office Due to a Week