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:
The patient voices concern about her prognosis. Which of the following is the approximate likelihood she will develop chronic hepatitis B?

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:

The patient voices concern about her prognosis. Which of the following is the approximate likelihood she will develop chronic hepatitis B?

Quizplus · Accepted Answer

Explanation: The risk of developing symptoms in acute hepatitis B virus (HBV) infection progressively increases with age due to enhanced immune response to the virus. As a consequence, the risk of progression from acute to chronic HBV infection decreases with age. The progression rate for perinatally acquired infection is 90% due to increased immune tolerance (Choice E). Patients infected at age 1-5 have a 20%-50% progression rate to chronic HBV infection, but for adults the progression rate is under 5% (Choice C). (Choice A) Of the major hepatitides, hepatitis A is not known to cause chronic infection, although a small subset of patients may have a relapse within the first several months after the initial illness. (Choice D) Hepatitis C has a much higher risk of progression to chronic infection (approximately 75%-85%). The acute phase is often mild or asymptomatic, and patients are typically diagnosed by serology in later stages of the illness. Similar to HBV infection, the severity of acute symptoms in hepatitis C infection is inversely proportional to the risk of chronic infection. Educational objective: The risk of developing chronic hepatitis after acute hepatitis B virus (HBV) infection is dependent on age. Fewer than 5% of adults with acute HBV infection will go on to develop chronic HBV infection. References: Natural history of hepatitis B virus infection: an update for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/17673066)

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