From the Guidelines
When both HBs antibody and HBs antigen are positive, this represents an unusual serological pattern that requires further investigation, likely indicating a chronic hepatitis B infection with the beginning of immune clearance or a false positive result for one of the tests. This pattern could indicate several possibilities: a resolving acute hepatitis B infection where both markers are transiently present, a chronic hepatitis B infection with the beginning of immune clearance, or a false positive result for one of the tests. According to the most recent guidelines 1, I recommend immediate consultation with a hepatologist or infectious disease specialist for proper evaluation. Additional testing is necessary, including HBe antigen, HBe antibody, HBc antibody (both IgM and total), and hepatitis B viral DNA quantification to clarify your infection status, as suggested by the guidelines 2. Liver function tests should also be performed to assess for any liver damage. While awaiting specialist consultation, avoid alcohol consumption and medications that could stress the liver. Do not start any hepatitis B treatments without proper medical guidance. This serological pattern is uncommon because typically HBs antibody indicates immunity and should not coexist with HBs antigen, which indicates active infection. The presence of both markers suggests either a transitional phase in the infection or a testing anomaly that needs clinical correlation. Some key points to consider in the management of this condition include:
- The risk of HBV reactivation in patients with past HBV infection, particularly those undergoing anticancer therapies associated with an established high risk of HBV reactivation 3
- The importance of antiviral prophylactic therapy for patients with chronic HBV receiving any systemic anticancer therapy 1
- The need for careful monitoring of patients with past HBV undergoing anticancer therapies that are not clearly associated with a high risk of HBV reactivation 1
From the Research
Hepatitis B Surface Antigen and Antibody Coexistence
- The coexistence of Hepatitis B surface antigen (HBsAg) and Hepatitis B surface antibody (anti-HBs) has been reported in several studies 4, 5, 6, 7, 8.
- This phenomenon can occur due to various factors, including mutations in the viral genome, immune status, and genetic factors of the host 4.
- The coexistence of HBsAg and anti-HBs can also be detected due to the use of novel HBsAg assays with higher sensitivity and ability to detect mutations or immune complexes 4.
Clinical Implications
- The presence of both HBsAg and anti-HBs does not necessarily indicate recovery or immunity from Hepatitis B virus (HBV) infection 5, 6.
- In fact, HBsAg and anti-HBs coexistence has been associated with progressive liver diseases, including hepatocellular carcinoma 4.
- The frequency of HBsAg and anti-HBs coexistence is higher in patients with chronic active hepatitis than in those with acute hepatitis or asymptomatic carrier state 7, 8.
Serological Characteristics
- The coexistence of HBsAg and anti-HBs can be heterotypic, meaning that the HBsAg and anti-HBs are directed against different subdeterminants of the surface antigen 7, 8.
- The presence of heterotypic markers is not associated with specific risk factors or delta-infection, but is associated with evidence of viral replication and features of active inflammation 7.
- The antibody pattern in sera from patients with HBsAg and anti-HBs coexistence can be complex, and may not provide natural immunization against HBV infection 5, 8.