Hepatitis B

Question: A 22 year old Chinese female presents to you for evaluation of her hepatitis B virus.  Her AST is 41 and ALT is 44, both over the upper limit of normal (40).  Surface antigen is positive, surface antibody negative, core antibody is positive, e antigen is positive, e antibody is negative.  Hepatitis B DNA (viral load) is 3,000 IU/mL.  All other causes of LFT abnormalities have been excluded.  What do you recommend?

A. begin lamivudine

B. begin entecavir

C. send her for liver biopsy and treat if advanced fibrosis is present

D. repeat LFT and viral load in 3 months

Answer: Understanding the indications for HBV treatment is part of the “bread and butter” of hepatology.  This young female has a wild-type HBV infection (in contrast to a mutant strain, where the e antigen is negative and e antibody is positive).

Treatment in wild-type cases is indicated when ALT is above the upper limit of normal and HBV DNA is > 20,000 IU/mL.  She only meets one of these criteria.  If she were older, and at higher risk for more advanced disease, a liver biopsy should be considered; treatment could be initiated if fibrosis is moderate or advanced, or if inflammatory activity is high.

However, she is very young and therefore repeating blood tests in 3 months is appropriate.  Viral loads and ALT levels tend to fluctuate over time; in 3 months she may meet treatment criteria or have all normal values.  Sometimes, treatment decisions should not be made after just one set of blood tests!

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