MKSAP Quiz: Management of HBV infection

This month's quiz asks readers to determine the most appropriate next step in management of a 29-year-old woman with hepatitis B virus (HBV) infection and normal liver enzyme levels.

A 29-year-old woman is evaluated during a new-patient appointment. She was diagnosed with hepatitis B virus (HBV) infection 10 years ago; her mother had HBV infection, and it was presumed that the patient acquired the infection at birth. She reports feeling well. Her medical history is otherwise unremarkable and she takes no medication.

On physical examination, vital signs are normal, as is the remainder of the examination.

Laboratory studies are positive for hepatitis B surface antigen and positive for hepatitis B e antigen. The serum HBV DNA level is 20,000,000 IU/mL. Alanine aminotransferase and aspartate aminotransferase levels are within normal limits.

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

A. Entecavir
B. Hepatic ultrasonography
C. Pegylated interferon
D. Repeat liver chemistry tests in 6 months
E. Tenofovir

Reveal the Answer

MKSAP Answer and Critique

The correct answer is D. Repeat liver chemistry tests in 6 months. This content is available to MKSAP 18 subscribers as Question 2 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.

Repeat liver chemistry testing in 6 months is the most appropriate next step in the management of this patient. The patient has hepatitis B virus (HBV) infection in the immune-tolerant phase, which can be determined by the likely vertical transmission and the patient's young age, positive hepatitis B e antigen (HBeAg), high viral load, and normal aminotransferase levels. Therefore, the patient only requires serial monitoring of aminotransferase levels. There are four typical phases of HBV infection: (1) immune tolerant, (2) immune active, (3) immune control (inactive), and (4) reactivation. Not all patients go through each phase. Patients with infection in the immune-tolerant phase do not have significant hepatic inflammation and have no fibrosis, and, therefore, do not require treatment. However, infection can progress to the immune-active, HBeAg-positive phase, in which hepatic inflammation, elevated aminotransferase levels, and fibrosis develop, underscoring the need for surveillance of aminotransferase levels.

Patients with HBV infection in the immune-active, HBeAg-positive and reactivation, HBeAg-negative phases require treatment if the alanine aminotransferase level is elevated. Antiviral therapy is also required for patients who present with acute liver failure, all patients with cirrhosis, and patients undergoing treatment with certain immunosuppressive or chemotherapy regimens. None of these scenarios apply to this patient, so she does not require antiviral treatment such as tenofovir, entecavir, or pegylated interferon.

Patients with HBV infection are at increased risk for hepatocellular carcinoma, even in the absence of cirrhosis. Patients from Southeast Asia should undergo hepatocellular carcinoma surveillance with ultrasonography starting at age 40 years for men and at age 50 years for women, and patients from sub-Saharan Africa should begin at age 20 years. Other indications include persistent inflammatory activity (defined as an elevated alanine aminotransferase level and HBV DNA levels greater than 10,000 IU/mL for at least a few years) and a family history of hepatocellular carcinoma. The preferred surveillance strategy is liver ultrasonography with or without α-fetoprotein measurement. This patient is not yet old enough to warrant hepatocellular carcinoma surveillance, so hepatic ultrasonography is not indicated.

Key Point

  • Patients with hepatitis B infection in the immune-tolerant phase require serial monitoring of aminotransferase levels.