How should I manage a young adult male with acute hepatitis B infection (HBsAg positive, anti‑HBs negative, anti‑HBc total positive) and resolved hepatitis C (anti‑HCV positive, HCV RNA undetectable) who is HIV negative?

Management of Acute Hepatitis B with Resolved Hepatitis C

Confirm the Diagnosis

This patient has acute hepatitis B infection (not chronic) based on the serologic pattern, and requires close monitoring rather than immediate antiviral therapy. 1

The serologic profile indicates:

• Acute HBV infection: HBsAg positive, anti-HBs negative, anti-HBc positive (likely IgM anti-HBc positive if tested, which confirms acute infection) 1
• Resolved HCV infection: Anti-HCV positive with undetectable HCV RNA indicates past infection that has cleared 1

Critical next step: Order IgM anti-HBc immediately to definitively confirm acute versus chronic HBV infection, as this is the single most important distinguishing marker 1, 2

Initial Management Approach

For Acute Hepatitis B (>95% self-resolve in immunocompetent adults)

Supportive care is the primary management strategy, as >95% of immunocompetent adults will spontaneously clear acute HBV infection without antiviral therapy. 1

• Monitor liver function tests (ALT/AST, bilirubin, albumin, prothrombin time/INR) weekly initially 1
• Repeat HBsAg, anti-HBs, and HBV DNA every 3-6 months to document clearance 1
• Antiviral therapy (entecavir or tenofovir) is reserved only for:
  • Fulminant hepatitis with coagulopathy (INR >1.5) or encephalopathy 1
  • Severe protracted hepatitis with bilirubin >10 mg/dL or INR >1.5 persisting beyond 4 weeks 1
  • Immunocompromised status 1

Monitor for Chronicity

If HBsAg remains positive beyond 6 months, the patient has progressed to chronic HBV infection and requires different management. 1

• Repeat HBsAg testing at 3 months and 6 months post-presentation 1
• If chronic infection develops (HBsAg positive >6 months), perform comprehensive evaluation including HBeAg/anti-HBe, quantitative HBV DNA, and assessment of liver fibrosis 1, 3

Address the Resolved HCV

No HCV-specific treatment is needed since HCV RNA is undetectable, indicating spontaneous viral clearance or successful prior treatment. 1

• Document this as resolved HCV infection 1
• No further HCV monitoring required unless immunosuppression occurs 1

Screen for Other Hepatotropic Viruses

Test for hepatitis A immunity (IgG anti-HAV) and vaccinate if negative, as acute HAV superinfection in patients with underlying liver disease carries increased risk of fulminant hepatic failure. 1

• HAV vaccination is specifically recommended for all patients with chronic liver disease or viral hepatitis 1, 4
• If anti-HAV IgG is negative, administer HAV vaccine series 1

Critical Pitfalls to Avoid

Do not start antiviral therapy reflexively in acute HBV infection - this is a common error, as the vast majority of immunocompetent adults will clear the infection spontaneously, and unnecessary treatment exposes patients to medication costs and potential side effects 1

Do not assume chronicity without 6 months of HBsAg positivity - acute and chronic HBV require fundamentally different management approaches 1

Do not overlook the need for IgM anti-HBc testing - this single test definitively distinguishes acute from chronic infection and guides all subsequent management decisions 1, 2

Follow-Up Protocol

If Acute Infection Resolves (Expected in >95% of Cases)

• HBsAg will become negative 1
• Anti-HBs will develop (typically within 3-4 months of HBsAg clearance) 1
• Anti-HBc will persist for life 1
• No further HBV-specific monitoring needed once anti-HBs appears 1

If Progression to Chronic Infection Occurs (<5% Risk)

• Continue HBsAg positive beyond 6 months 1
• Requires lifelong monitoring with ALT every 3-6 months, HBV DNA quantification, and HCC surveillance 1, 3
• Treatment decisions based on HBeAg status, HBV DNA level (>20,000 IU/mL for HBeAg-positive or >2,000 IU/mL for HBeAg-negative), ALT elevation, and degree of fibrosis 1, 3