What is the management and prognosis for a patient with HBsAb positive, HBcAb positive, HBeAg non-reactive, anti-HBe reactive, and IgM anti-HBc non-reactive serology?

Resolved Hepatitis B Infection with Immunity

This serologic pattern (HBsAb+, HBcAb+, HBeAg-, anti-HBe+, IgM anti-HBc-) indicates resolved past hepatitis B infection with immunity—no antiviral treatment is required, but you must assess for risk of reactivation if immunosuppression is planned. 1, 2, 3

Interpretation of Your Serologic Profile

Your patient has the classic pattern of past HBV infection with recovery and immunity:

• HBsAb positive = Protective antibodies present 1
• HBcAb positive = Evidence of prior natural infection (not vaccination) 4, 2
• HBeAg non-reactive + anti-HBe reactive = Low viral replication state 4
• IgM anti-HBc non-reactive = Not acute infection; this is resolved/past infection 5, 6

This differs from vaccine-derived immunity (which would be HBsAb+ but HBcAb-). 1

Immediate Diagnostic Workup Required

Essential Testing Now

• HBV DNA by PCR to confirm viral clearance—3-5.5% of patients with this pattern have detectable HBV DNA indicating occult infection 2, 3
• ALT and AST to assess for ongoing liver inflammation 2, 3
• HBsAg should be confirmed negative (though your pattern suggests this) 4, 2

Additional Screening

• Hepatitis C antibody and RNA to rule out coinfection that accelerates liver disease 3
• Hepatitis A IgG if patient is under 50 years old—vaccination recommended if negative 4, 3
• HIV testing if any risk factors present 3

Management Based on HBV DNA Results

If HBV DNA is Negative (Expected Scenario)

• No antiviral therapy needed 2, 3
• Monitor liver function tests periodically 2
• Patient is not infectious and has protective immunity 1

If HBV DNA is Positive (Occult Infection)

• Refer to hepatology immediately for evaluation of chronic hepatitis B 3
• Consider liver biopsy if ALT persistently elevated 2
• Initiate antiviral therapy if HBV DNA >2,000 IU/mL with elevated ALT or significant fibrosis 3

Critical Reactivation Risk Assessment

This is the most important clinical consideration for this serologic pattern.

If Immunosuppression is Planned

Even with negative HBV DNA, covalently closed circular DNA remains in the liver and can reactivate with immunosuppression. 4

High-risk scenarios requiring prophylactic antiviral therapy:

• Anti-CD20 therapy (rituximab) = 25% reactivation risk 4
• Stem cell transplantation = High risk 4
• Hematologic malignancies = High risk 4
• Multiple immunomodulators for prolonged periods 4

Management for high-risk immunosuppression:

• Start entecavir, tenofovir disoproxil fumarate, or tenofovir alafenamide 2 weeks before immunosuppression 4
• Continue for at least 12 months after completion of anticancer therapy 4
• For anti-CD20 therapy, continue even longer as reactivation risk extends to nearly 2 years post-therapy 4
• Test for HIV before starting these antivirals (they have anti-HIV properties) 4

Lower-risk scenarios (monitoring approach acceptable):

• Inflammatory bowel disease with standard immunomodulators = Reactivation extremely rare 4
• Corticosteroids alone = Lower risk 4
• Monitor AST/ALT routinely and check HBV DNA if elevation occurs 4

Risk Stratification by Anti-HBs Status

Patients with negative anti-HBs have 3.51 times higher risk of reactivation (HR 3.51,95% CI 1.37-8.98) compared to anti-HBs-positive patients. 4

Your patient is anti-HBs positive, placing them in the lower-risk category for reactivation, but prophylaxis is still indicated for high-risk immunosuppression regimens. 4

Contact Screening and Prevention

• Screen all household and sexual contacts for HBsAg and anti-HBs 3
• Vaccinate all seronegative contacts immediately with standard 3-dose series 3
• Hepatitis A vaccination recommended for this patient to prevent additional liver injury 4, 3

Common Pitfalls to Avoid

• Do not assume immunity means zero reactivation risk—occult HBV can reactivate with potent immunosuppression even when HBV DNA is undetectable 4, 2
• Do not delay antiviral prophylaxis until after immunosuppression starts—begin 2 weeks prior 4
• Do not stop antivirals too early after immunosuppression—continue minimum 12 months, longer for anti-CD20 therapy 4
• Do not skip HBV DNA testing—a small percentage will have occult infection requiring different management 2, 3