What are the recommendations for a 19-year-old female with a confirmed positive hepatitis B surface antigen (HBsAg) test result, leukocytosis, and a history of 4 lifetime sexual partners?

Management of Confirmed Hepatitis B Infection in a 19-Year-Old Female

This patient requires immediate confirmatory testing to distinguish acute from chronic HBV infection, comprehensive serologic evaluation including anti-HBc IgM and HBV DNA, referral to a hepatologist or infectious disease specialist experienced in hepatitis B management, and urgent contact tracing with vaccination of all sexual and household contacts. 1

Immediate Confirmatory Testing

• Retest HBsAg to verify chronic infection status, as persistence of HBsAg for ≥6 months confirms chronic HBV infection 1, 2
• Order IgM anti-HBc to distinguish acute infection (IgM positive) from chronic infection (IgM negative or low-level positive) 1, 3
• The leukocytosis with neutrophilia (10.4) and lymphocytosis (4.4) may represent acute infection or concurrent illness and warrants correlation with clinical symptoms 2

Complete Serologic and Virologic Panel

Obtain the following tests immediately 1, 3:

• HBV DNA quantitative level - essential for assessing viral replication and infectivity
• HBeAg and anti-HBe - determines phase of infection and degree of infectivity
• Liver function tests (ALT, AST, bilirubin, albumin, prothrombin time) - assess hepatic injury
• Complete hepatitis panel: Anti-HAV IgG (consider HAV vaccination if negative), anti-HCV, and anti-HCV antibody 1
• HIV testing - mandatory given sexual transmission risk and potential for coinfection 1
• Complete STI screening including syphilis, gonorrhea, and chlamydia given her history of 4 lifetime partners 1

Mandatory Specialist Referral

• Refer immediately to hepatology or infectious disease specialist experienced in chronic hepatitis B management for treatment decisions and monitoring 1
• Referral should not be delayed while awaiting complete test results 1

Contact Tracing and Vaccination (Critical Public Health Intervention)

All 4 sexual partners plus household contacts must be identified, tested, and vaccinated immediately 1:

• Test contacts for HBsAg, anti-HBc, and anti-HBs to determine infection status and immunity 1
• Administer first dose of hepatitis B vaccine immediately after drawing blood for serologic testing - do not wait for results 1
• Susceptible contacts (negative for all markers) should complete the 3-dose vaccine series on schedule 1
• Contacts found to be HBsAg-positive require their own medical evaluation and management 1
• Report this case to your state/local health department as required by law 1

Patient Counseling on Transmission Prevention

Provide specific instructions 1:

• Sexual transmission: Use latex condoms with all partners until partners are vaccinated and demonstrate immunity (anti-HBs ≥10 mIU/mL) 1
• Never donate blood, plasma, organs, tissue, or semen 1, 4
• Do not share toothbrushes, razors, or any items that could contact blood 1
• Cover all cuts and skin lesions to prevent spread through infectious secretions 1
• Avoid or limit alcohol consumption as it accelerates liver disease progression 1, 3
• Inform all healthcare and dental providers of HBsAg status before procedures 1

Additional Risk Assessment

Given her age and sexual history 1:

• Assess for injection drug use history (even remote or single use) - this is a critical risk factor often underreported 1, 5
• Screen for other high-risk behaviors including tattoos, piercings, or occupational exposures 1, 5
• Evaluate for pregnancy or pregnancy plans - this is essential as perinatal transmission prevention requires specific protocols 1

Monitoring and Follow-Up

• If HBsAg remains positive on repeat testing, schedule serial ALT/AST monitoring every 3-6 months 1, 2
• HBV DNA levels guide treatment decisions and predict disease progression 2, 6
• Patients with chronic HBV require lifelong HCC surveillance with ultrasound ±AFP every 6 months once treatment decisions are made 2

Common Pitfalls to Avoid

• Do not delay contact vaccination while waiting for complete serologic results - the first vaccine dose should be given immediately 1
• Do not assume isolated HBsAg positivity means chronic infection without confirmatory testing including IgM anti-HBc 3, 2
• Do not fail to test for HIV and other STIs - coinfections significantly alter management 1
• Do not overlook pregnancy testing in women of childbearing age, as this fundamentally changes management priorities 1