A 34-year-old woman comes to the office due to malaise and jaundice. The patient was in good health until about 4 weeks ago, when she developed joint pain, fatigue, and a pruritic rash over her trunk and extremities. The joint pain and rash resolved about a week ago, but the fatigue has persisted. Two days ago, the patient noticed some yellowish discoloration of the whites of her eyes and began to experience decreased appetite. However, she has been able to eat and drink without difficulty. Medical history includes irritable bowel syndrome and allergic rhinitis. Medications include docusate and intranasal fluticasone. She does not use any other over-the-counter medications. Immunization history is unknown. She is sexually active with 2 male partners and uses condoms inconsistently. The patient drinks on social occasions and does not use tobacco or illicit drugs. Temperature is 36.7 C (98 F) , blood pressure is 110/64 mm Hg, and pulse is 68/min. BMI is 25 kg/m². Physical examination is notable for moist mucous membranes, scleral icterus, and normal jugular venous pressure. Heart and lung sounds are normal. Abdominal examination reveals a palpable liver edge approximately 2 cm below the costal margin without tenderness. Bowel sounds are normoactive. The extremities are warm and without edema. The joints are nontender and without erythema. Neurologic examination is normal with no asterixis. The remainder of the physical examination is unremarkable. Laboratory results are as follows:
Shortly after the initial visit, the patient's hepatitis B viral DNA level is found to be 300,000 IU/mL. She has returned to the clinic multiple times over the past several weeks since her initial illness. Today's visit is 6 weeks after her initial presentation. The patient's anorexia, fatigue, and jaundice have resolved. Laboratory results are as follows:
What is the most appropriate means of treating this patient's condition?

Question

A 34-year-old woman comes to the office due to malaise and jaundice. The patient was in good health until about 4 weeks ago, when she developed joint pain, fatigue, and a pruritic rash over her trunk and extremities. The joint pain and rash resolved about a week ago, but the fatigue has persisted. Two days ago, the patient noticed some yellowish discoloration of the whites of her eyes and began to experience decreased appetite. However, she has been able to eat and drink without difficulty. Medical history includes irritable bowel syndrome and allergic rhinitis. Medications include docusate and intranasal fluticasone. She does not use any other over-the-counter medications. Immunization history is unknown. She is sexually active with 2 male partners and uses condoms inconsistently. The patient drinks on social occasions and does not use tobacco or illicit drugs. Temperature is 36.7 C (98 F) , blood pressure is 110/64 mm Hg, and pulse is 68/min. BMI is 25 kg/m². Physical examination is notable for moist mucous membranes, scleral icterus, and normal jugular venous pressure. Heart and lung sounds are normal. Abdominal examination reveals a palpable liver edge approximately 2 cm below the costal margin without tenderness. Bowel sounds are normoactive. The extremities are warm and without edema. The joints are nontender and without erythema. Neurologic examination is normal with no asterixis. The remainder of the physical examination is unremarkable. Laboratory results are as follows:

Shortly after the initial visit, the patient's hepatitis B viral DNA level is found to be 300,000 IU/mL. She has returned to the clinic multiple times over the past several weeks since her initial illness. Today's visit is 6 weeks after her initial presentation. The patient's anorexia, fatigue, and jaundice have resolved. Laboratory results are as follows:

What is the most appropriate means of treating this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf9b_9ef8_8f63_3fa971329792_MD0005_00 As patients recover from acute hepatitis B virus (HBV) infection, there is normally a steady drop in both aminotransferase and HBV DNA levels. Aminotransferase levels typically normalize within 2-8 weeks. Patients who do not clear hepatitis B surface antigen after 6 months are diagnosed with progression to chronic HBV infection. In addition, some patients may develop complications such as acute liver failure or coagulopathy during the initial phase of infection. Consequently, patients should be monitored regularly to evaluate for the development of chronic HBV infection or hepatic decompensation. Symptom resolution is variable and partially depends on severity of initial presentation. Patients with a milder onset may recover completely within days, whereas those with a more severe presentation (eg, bilirubin >10 mg/dL) may report fatigue and nausea for months following acute infection. (Choice A) Hepatitis B vaccine and hepatitis B immune globulin are usually administered as postexposure prophylaxis to health care workers exposed to contaminated blood or other body fluids. These vaccines should be given as soon as possible (ideally within 12-24 hours of exposure) for maximal efficacy. However, these interventions are not helpful in established HBV infection. (Choice B) Antiviral therapy has not been demonstrated to significantly change the course of acute HBV infection, but it may be considered for patients who have acute liver failure, immunosuppression, concomitant hepatitis C or D, or preexisting liver disease. (Choice C) Identification of the viral genotype is helpful in patients who develop chronic HBV infection, especially if the patient wishes to consider interferon therapy (improved outcomes with genotype A), but it is not necessary in acute infection. (Choice D) Liver biopsy is unnecessary in this patient with acute HBV infection and whose clinical course is following an expected pattern. However, if the patient progresses to chronic HBV infection, a liver biopsy may be considered to evaluate for fibrosis. Educational objective: As patients recover from acute hepatitis B virus (HBV) infection, there is normally a steady drop in both aminotransferase and HBV DNA levels and clearance of hepatitis B surface antigen within 6 months. References: Management of acute hepatitis B and reactivation of hepatitis B. (http://www.ncbi.nlm.nih.gov/pubmed/23286861)

A 34-Year-Old Woman Comes to the Office Due to Malaise