How to manage a previously unvaccinated adult or adolescent patient with resolved acute Hepatitis B (HBV) infection, who presented with fever and jaundice, and later became non-reactive for Hepatitis B after a few weeks?

Management of Resolved Acute Hepatitis B Infection

For a previously unvaccinated adult or adolescent who presented with acute hepatitis B (fever, jaundice, HBsAg-positive) and subsequently became non-reactive after a few weeks, no specific antiviral treatment is needed—this represents spontaneous resolution, which occurs in over 95% of immunocompetent adults. 1, 2, 3

Confirm True Resolution

Verify complete serologic resolution with the following tests:

• Confirm HBsAg negativity on repeat testing at least 6 months after initial presentation to definitively establish resolution rather than chronic infection 1
• Check for anti-HBs (antibody to hepatitis B surface antigen) to confirm immunity from resolved infection 1
• Measure anti-HBc (antibody to hepatitis B core antigen) which should be positive, indicating past infection 1, 4
• Ensure ALT/AST normalization to confirm resolution of hepatic inflammation 1, 5

The median time to HBsAg clearance is approximately 27 weeks, and anti-HBs appearance occurs around 41 weeks, so only an estimated 36% clear HBsAg by the traditional 6-month mark 6. This means your patient's "few weeks" timeline for becoming non-reactive is unusually rapid and warrants careful confirmation that this represents true HBsAg clearance rather than a false-negative test or fluctuating levels.

Post-Resolution Management

Once resolution is confirmed, the following steps are essential:

Vaccination Considerations

• No hepatitis B vaccination is needed if anti-HBs is positive (≥10 mIU/mL), as the patient now has natural immunity 7, 8
• If anti-HBs is negative or low despite HBsAg clearance, consider vaccination to boost immunity 8

Contact Management and Prevention

• Identify and test all sexual partners, household contacts, and needle-sharing contacts for HBsAg, anti-HBc, and anti-HBs 1
• Vaccinate all susceptible contacts immediately after drawing blood for testing—do not wait for results 1
• Contacts who are HBsAg-negative and anti-HBc-negative should receive the complete three-dose hepatitis B vaccine series 1

Long-Term Monitoring

Patients with resolved HBV infection require minimal but important follow-up:

• Annual ALT monitoring for at least 1-2 years to ensure sustained biochemical remission 1
• Counsel about reactivation risk if future immunosuppression is planned (chemotherapy, biologics, high-dose corticosteroids) 1
• If immunosuppression becomes necessary, check HBV DNA and consider prophylactic antiviral therapy even in HBsAg-negative patients with anti-HBc positivity, as occult HBV can reactivate 1

Hepatitis A Vaccination

• Vaccinate against hepatitis A with two doses 6-18 months apart, as superinfection with HAV in someone with any history of liver disease can cause severe hepatic injury 2, 8

Critical Pitfalls to Avoid

Do not assume resolution based on a single negative HBsAg test. Acute hepatitis B can have fluctuating viral loads, and some patients may have transient HBsAg negativity before developing chronic infection 1. The 6-month confirmation test is mandatory.

Do not miss occult hepatitis B. Even after HBsAg clearance, HBV DNA can persist in the liver at low levels 1. While this rarely causes clinical problems in immunocompetent hosts, it poses significant reactivation risk with immunosuppression 1.

Do not forget to screen and vaccinate contacts. Sexual and household contacts have substantial exposure risk and should be managed proactively rather than waiting for them to develop symptoms 1.

Do not overlook the need for hepatitis A vaccination. Even though the acute hepatitis B has resolved, this patient had documented liver inflammation and remains at higher risk for severe outcomes if exposed to HAV 2, 8.

Special Consideration: Unusually Rapid Clearance

The described timeline of "a few weeks" for HBsAg clearance is atypically fast compared to the usual 27-week median 6. Consider these possibilities:

• Laboratory error or false-positive initial test - repeat HBsAg and add IgM anti-HBc to confirm true acute infection 1, 4
• Transient seronegativity - HBsAg may fluctuate before true clearance 1
• Misdiagnosis - ensure other causes of acute hepatitis with jaundice were excluded 2

Repeat complete serologic testing (HBsAg, anti-HBs, anti-HBc, ALT) at 3 months and 6 months to definitively confirm resolution rather than relying on early negative results 1.