What follow-up lab tests and imaging studies are recommended for a patient with positive Hepatitis B core antibody (hepBcAb) and Hepatitis B surface antibody (hepBsAb)?

Follow-up Testing for Patients with Positive HBcAb and HBsAb

For patients with positive hepatitis B core antibody (HBcAb) and hepatitis B surface antibody (HBsAb), HBV DNA testing is recommended to rule out occult HBV infection, along with liver function tests to assess for any liver damage. 1

Initial Laboratory Evaluation

• HBV DNA quantification: Essential to rule out occult HBV infection, which can occur in 1-20% of anti-HBc positive individuals 1
• Liver function tests:
  • Complete blood count with platelets
  • AST/ALT (hepatic panel)
  • Alkaline phosphatase
  • Gamma-glutamyl transpeptidase
  • Bilirubin
  • Albumin
  • Prothrombin time 2, 1
• HBeAg/anti-HBe testing: To further characterize the infection status 2, 1
• Tests for coinfections:
  • Anti-HCV
  • Anti-HDV (particularly in patients from endemic regions or with history of injection drug use)
  • Anti-HIV (in those at risk) 2, 1
• Hepatitis A immunity (anti-HAV): Coinfection with HAV in HBV carriers increases mortality risk 5.6-29 fold 2

Interpretation of Results

The pattern of positive HBcAb and positive HBsAb typically indicates resolved past HBV infection with immunity 1. However, several important considerations exist:

1. Occult HBV infection: Despite this serologic pattern, low-level viral replication may still occur, especially in immunocompromised patients 1

2. Risk assessment: If HBV DNA is detected, more intensive monitoring is required, and referral to a hepatologist should be considered 1

3. Immunosuppression risk: Patients with this serologic pattern who will undergo immunosuppressive therapy (especially with anti-CD20 antibodies) may require prophylactic antiviral therapy to prevent HBV reactivation 1, 3

Imaging Studies

• Baseline ultrasound: Recommended to assess for signs of cirrhosis and exclude focal lesions in the liver 4

• HCC screening: Consider screening for hepatocellular carcinoma in relevant populations:

  • Alpha-fetoprotein (AFP) at baseline
  • Ultrasound for high-risk patients 2

Follow-up Recommendations

• ALT monitoring: Check ALT every 6-12 months if initially normal 2

• If ALT becomes elevated (>1-2 × ULN):

  • Check serum HBV DNA level
  • Exclude other causes of liver disease
  • Consider liver biopsy if ALT remains borderline or mildly elevated on serial tests 2

• Hepatology consultation: Strongly recommended for patients requiring immunosuppressive therapy 1

Special Considerations

• Immunosuppression: Patients with positive HBcAb who will undergo immunosuppressive therapy require close monitoring and possibly prophylactic antiviral therapy 1, 3

• Household and sexual contacts: Should be screened for HBV (HBsAg and anti-HBs) and vaccinated if negative 1

• Hepatitis A vaccination: Should be administered if patient is not immune to HAV 2, 1

Common Pitfalls

1. Assuming complete immunity: The presence of both HBcAb and HBsAb does not guarantee complete protection against HBV reactivation in immunosuppressed patients

2. Missing occult infection: Failing to test for HBV DNA could miss occult HBV infection

3. Neglecting coinfection screening: Not testing for HDV, HCV, or HIV coinfection in at-risk patients

4. Overlooking hepatitis A immunity: Forgetting to check HAV immunity status and vaccinate if needed

The combination of positive HBcAb and HBsAb generally indicates resolved past infection with immunity, but careful evaluation and monitoring are still necessary, particularly before immunosuppressive therapy or in the presence of abnormal liver function tests.