A 40-year-old man comes to the clinic after having an abnormal laboratory evaluation during a blood donation program. He had hepatitis B serologies as follows: The patient has the same results on repeat testing at the office. He is concerned that he has a serious liver disease that needs to be treated. What is the next best step in management of this patient?

Question

A 40-year-old man comes to the clinic after having an abnormal laboratory evaluation during a blood donation program.  He had hepatitis B serologies as follows:  The patient has the same results on repeat testing at the office.  He is concerned that he has a serious liver disease that needs to be treated.  What is the next best step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has an isolated elevation of anti-HBc, or total core antibody (includes IgM and IgG). This occurs in about 1% of blood donors in low prevalence areas such as the United States but in 10%-20% of donors in endemic areas. There are only 3 situations in which isolated anti-HBc may be seen: During the "window period" of acute hepatitis B virus (HBV) infection when HBsAg has fallen but anti-HBs has not yet risen. Patients may be symptomatic with a history of recent exposure but about 70% have subclinical hepatitis. IgM anti-HBc is typically positive and liver enzymes are elevated. Years after recovery from acute HBV infection once anti-HBs has waned off. Liver enzymes are normal and IgM anti-HBc is usually negative. After many years of chronic HBV infection when HBsAg has fallen to an undetectable level. Patients may have evidence of chronic liver disease and HBV DNA is detectable. IgM anti-HBc is typically negative. Once a patient with isolated anti-HBc has been identified, HBV serology (eg, anti-HBc, HBsAg, anti-HBs, anti-HBe) should initially be repeated to ensure that it is not a false positive result. If there are no changes in the results, IgM anti-HBc should be measured to determine if the infection is recent (as in the "window period" of acute hepatitis B). Liver function tests should also be performed, as an elevation in transaminase levels suggests an active infection. If liver enzymes are abnormal with negative IgM anti-HBc, or if there is evidence of chronic liver disease, HBV DNA should be obtained to evaluate for chronic HBV infection (Choice E). (Choice B) HBcAg should never be detected in the serum as it is present in infected hepatocytes only. (Choice C) An ultrasound would be appropriate for characterizing changes in the liver parenchyma and biopsy planning after a serologic diagnosis is made. (Choice D) HBV vaccination should not cause a rise in anti-HBc as the vaccine contains only the surface component. It should cause an isolated rise in the anti-HBs. Educational objective: Patients with an isolated elevation of anti-HBc should have hepatitis B serologies repeated to rule out a false positive result, followed by measurement of IgM anti-HBc and liver function tests to determine the acuity of infection. IgM anti-HBc may be the only diagnostic marker for acute HBV infection during the "window period." References: Hepatitis B: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/20387772) Hepatitis B virus infection. (http://www.ncbi.nlm.nih.gov/pubmed/24954675)

A 40-Year-Old Man Comes to the Clinic After Having an Abnormal