What is the management for a patient with acute hepatitis B infection, presenting with jaundice and a normal ultrasound, who had Hepatitis B surface antigen (HBsAg) reactivity that became non-reactive after 2 months?

Management of Acute Hepatitis B with Spontaneous Resolution

This clinical scenario represents acute hepatitis B infection that has spontaneously resolved, as evidenced by HBsAg clearance within 2 months—no antiviral therapy is indicated, but close monitoring and contact management are essential. 1

Serologic Interpretation

The patient's clinical course is consistent with acute hepatitis B that has successfully resolved:

• Initial presentation (HBsAg positive + jaundice + normal ultrasound) indicates acute hepatitis B infection 2, 1
• HBsAg clearance at 2 months represents spontaneous resolution, which occurs in 90-95% of immunocompetent adults with acute HBV infection 3
• The normal ultrasound excludes biliary obstruction, cirrhosis, or other structural liver pathology 2

Required Follow-Up Serologic Testing

Complete the serologic profile immediately to confirm resolution and document immunity:

• Anti-HBs (antibody to HBsAg): Should be positive, indicating protective immunity 2, 1
• Total anti-HBc (IgG + IgM): Should be positive and will persist lifelong as a marker of past infection 2, 4
• IgM anti-HBc: May still be detectable if tested within 6 months of acute infection, but should be declining 1, 4
• ALT/AST levels: Should be normalizing or normalized 1

The expected serologic pattern for resolved infection is: HBsAg negative + anti-HBs positive + total anti-HBc positive 2, 5

Acute Management (No Antiviral Therapy Required)

Supportive care only is the mainstay of management for acute hepatitis B:

• No specific antiviral treatment is indicated for uncomplicated acute hepatitis B 1
• Antiviral therapy is reserved only for patients developing acute liver failure (approximately 1% of cases), which this patient clearly did not develop given the spontaneous HBsAg clearance 1
• Monitor for complete biochemical resolution with ALT/AST normalization 1

Critical Monitoring Timeline

Follow-up testing at 6 months post-onset to confirm complete resolution:

• Repeat HBsAg to confirm persistent negativity 2
• Confirm anti-HBs remains positive (≥10 mIU/mL indicates protective immunity) 2
• Verify ALT/AST normalization 1
• IgM anti-HBc should be undetectable or very low by this time 1, 4

This 6-month timepoint is critical because persistence of HBsAg beyond 6 months would define chronic infection, which did not occur in this case 2

Contact Management and Prevention

Screen and vaccinate all close contacts immediately:

• Test all household and sexual contacts for HBsAg and anti-HBs 1, 5
• Vaccinate all seronegative contacts with the complete hepatitis B vaccine series 2, 1
• HBV can survive on environmental surfaces for at least 1 week, requiring proper infection control measures 5

Hepatitis A Vaccination

Vaccinate against hepatitis A if anti-HAV antibody is negative:

• Hepatitis A coinfection in patients with any history of HBV infection increases mortality risk 5.6-29 fold 5
• Administer 2 doses of hepatitis A vaccine at baseline and 6-12 months 2

Long-Term Considerations

No ongoing HBV-specific monitoring is required after confirmed resolution, but counsel the patient on:

• Alcohol abstinence: Even limited alcohol consumption can worsen outcomes in patients with any history of HBV infection 5
• Future immunosuppression risk: If the patient ever requires chemotherapy, immunosuppressive therapy, or biologic agents (especially anti-CD20 antibodies like rituximab), they are at risk for HBV reactivation (3-45% depending on regimen) and will need prophylactic antiviral therapy 2, 5, 6
• HCC surveillance is NOT indicated in this patient because HBsAg clearance occurred before any cirrhosis could develop 5

Key Pitfalls to Avoid

• Do not confuse this with chronic hepatitis B reactivation: Chronic HBV patients can have acute exacerbations (CHB-AE) that mimic acute hepatitis B, but they remain HBsAg positive beyond 6 months 3
• Do not assume immunity without confirming anti-HBs: Approximately 5% of patients do not develop protective anti-HBs after natural infection and may need vaccination 2
• Do not overlook occult hepatitis B: In rare cases, HBV DNA can persist despite HBsAg clearance, particularly in immunocompromised patients 2, 4