What is the management for a patient with positive Hepatitis B surface antigen (HBsAg) and negative Hepatitis B surface antibody (anti-HBs) and negative Hepatitis B core antibody (anti-HBc)?

Management of Positive HBsAg with Negative Anti-HBs and Anti-HBc

A patient with positive HBsAg, negative anti-HBs, and negative anti-HBc requires immediate referral to a hepatologist for evaluation of early acute hepatitis B infection and initiation of appropriate monitoring and potential antiviral therapy.

Interpretation of Serologic Profile

This unusual serologic pattern suggests one of the following scenarios:

• Early acute HBV infection: The most likely explanation is that this represents very early acute hepatitis B infection before the development of anti-HBc 1
• False positive HBsAg: Laboratory error or cross-reactivity in the assay
• Immunosuppression: Severely immunocompromised patients may not mount an antibody response

Initial Management Steps

1. Confirm the serologic results

   • Repeat HBsAg testing to rule out false positive
   • Add HBeAg/anti-HBe testing
   • Order HBV DNA quantification to assess viral replication 1
   • Consider IgM anti-HBc to specifically detect acute infection 2, 3

2. Liver function assessment

   • Complete blood count
   • Liver enzymes (AST/ALT)
   • Bilirubin, albumin, prothrombin time
   • Consider liver imaging (ultrasound) 1

3. Additional testing

   • Screen for coinfections (HAV, HCV, HDV, HIV) 1
   • Check HAV immunity status for vaccination purposes 1

Follow-up and Monitoring

• Short-term monitoring: Repeat serologic testing in 2-4 weeks to detect seroconversion to anti-HBc
• Liver function tests: Monitor every 2-4 weeks initially
• HBV DNA levels: Follow to assess viral replication 1

Treatment Considerations

Treatment decisions should be based on:

1. Disease phase determination:

   • If HBV DNA is high with elevated ALT: Consider antiviral therapy
   • If HBV DNA is low with normal ALT: Monitor closely 1

2. Antiviral therapy:

   • First-line options include entecavir, tenofovir disoproxil fumarate, or tenofovir alafenamide 4
   • These agents have high barriers to resistance and are preferred over lamivudine 1

Special Considerations

Immunosuppression Risk

• If the patient requires immunosuppressive therapy or chemotherapy, prophylactic antiviral therapy is mandatory regardless of HBV DNA levels 1, 4
• Antiviral prophylaxis should begin before immunosuppression or at least 7 days prior to treatment 1
• Continue antiviral therapy for at least 6-12 months after completing immunosuppressive therapy (12+ months for rituximab-containing regimens) 1, 4

Prevention of Transmission

• Counsel patient on preventing transmission:

  • Avoid sharing personal items (razors, toothbrushes)
  • Practice safe sex
  • Cover open wounds
  • Inform sexual partners and household contacts 4

• Vaccinate susceptible close contacts 4

Pitfalls to Avoid

1. Misinterpreting as chronic infection: This pattern likely represents early acute infection rather than chronic HBV infection

2. Delayed referral: Early specialist consultation is crucial for proper management

3. Inadequate monitoring: Close follow-up is essential to detect seroconversion and disease progression

4. Overlooking immunosuppression risk: Any planned immunosuppressive therapy requires immediate antiviral prophylaxis 1, 4

5. Missing coinfections: Always screen for other viral hepatitis infections that may complicate management 1

This unusual serologic pattern requires careful evaluation and close monitoring. The primary goal is to determine if this represents early acute infection and to prevent progression to chronic hepatitis B, which carries significant risks for cirrhosis and hepatocellular carcinoma.