Interpretation and Management of Positive HBV Core Antibody with Negative Surface Antigen and Positive Surface Antibody
A serologic pattern showing positive hepatitis B core antibody (anti-HBc), negative hepatitis B surface antigen (HBsAg), and positive hepatitis B surface antibody (anti-HBs) represents resolved past hepatitis B virus (HBV) infection with immunity, and no specific treatment is required for this serological profile. 1
Interpretation of Serological Pattern
This specific serological pattern indicates:
- Resolved past HBV infection with immunity: The presence of anti-HBc indicates previous exposure to HBV, while the presence of anti-HBs (>10 IU/mL) indicates protective immunity 2, 1
- Not currently infectious: The absence of HBsAg means the patient is not currently infected with HBV 2
- Natural immunity: This pattern distinguishes from vaccine-induced immunity, which would show positive anti-HBs but negative anti-HBc 2
Clinical Implications
Risk Assessment
- Low risk for liver disease progression: Patients with this serological pattern generally have no ongoing liver damage related to HBV 2
- Potential for reactivation: Under certain circumstances, particularly with immunosuppression, HBV can reactivate even in patients with resolved infection 2, 1
- Not infectious to others: These individuals are not considered infectious under normal circumstances 2
Monitoring Recommendations
For immunocompetent individuals:
- No specific HBV monitoring is required
- No antiviral therapy is needed
- Standard health maintenance with routine liver function tests as appropriate for age and risk factors
For patients requiring immunosuppression:
Risk stratification based on immunosuppressive regimen 1:
- High risk (>10%): B-cell depleting agents (e.g., rituximab), anthracycline derivatives
- Moderate risk (1-10%): TNF-α inhibitors, tyrosine kinase inhibitors
- Low risk (<1%): Traditional immunosuppressants, low-dose corticosteroids
Management based on risk 2, 1:
- High-risk scenarios: Prophylactic antiviral therapy (entecavir or tenofovir preferred)
- Moderate-risk scenarios: Consider prophylaxis or close monitoring
- Low-risk scenarios: Monitoring of liver function tests every 3 months
Special Considerations
Occult HBV Infection
In rare cases, this serological pattern may represent occult HBV infection, where HBV DNA is present at very low levels despite negative HBsAg 2. Consider HBV DNA testing if:
- Patient has unexplained elevated liver enzymes
- Patient requires immunosuppressive therapy
- Patient has HIV co-infection
False Positive Results
Isolated anti-HBc positivity (without anti-HBs) can sometimes be a false positive result 3, 4. However, with positive anti-HBs, this is less likely to be a false positive and more likely represents true past infection.
Vaccination Considerations
- No HBV vaccination is needed as the patient already has immunity 2
- Consider hepatitis A vaccination if the patient is not immune, as coinfection with hepatitis A in those with prior HBV infection can increase morbidity and mortality 2, 1
Patient Counseling
Patients should be advised:
- They have recovered from a past HBV infection
- They are immune to future HBV infection
- They are not infectious to others
- They should inform healthcare providers of their HBV status before immunosuppressive therapy
- They should avoid alcohol and other hepatotoxic substances to maintain liver health 2
Common Pitfalls to Avoid
- Misinterpreting as active infection: This pattern represents resolved infection, not active disease
- Unnecessary treatment: Antiviral therapy is not indicated for this serological pattern in immunocompetent individuals
- Failing to consider reactivation risk: Always assess for potential immunosuppression that could lead to reactivation
- Confusing with vaccine immunity: Vaccine-induced immunity shows positive anti-HBs but negative anti-HBc 2
- Overlooking potential for occult HBV: In certain clinical scenarios, consider testing for HBV DNA despite negative HBsAg
This serological pattern is generally reassuring and indicates successful immune control of past HBV infection, requiring no specific intervention in most cases.