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A 27-year-old woman without pertinent medical history presented with elevated transaminase levels and a positive hepatitis B surface antigen (HBsAg) test result. Hepatitis B surface antibody (anti-HBs) testing was initially performed 11 months after hepatitis B virus (HBV) vaccination to assess immunologic response before beginning nursing school. Because of elevated liver enzymes and lack of anti-HBs following vaccination, further serologic testing was performed (Table).
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D. The patient has chronic HBV infection.
HBsAg enzyme immunoassay is the first serologic marker to appear in serum at 1 to 10 weeks after infection with HBV and 2 to 8 weeks before the onset of clinical symptoms of hepatitis B.1,2 After acute infection, HBsAg typically disappears 1 to 3 months after symptom onset.1,2 Persistence of HBsAg for more than 6 months, consistent with chronic HBV, is the primary indicator of risk for developing chronic liver disease and hepatocellular carcinoma later in life.1 Thus, HBsAg can assist with diagnosing both acute and chronic hepatitis B.1,2 A negative HBsAg test result rules out acute hepatitis B infection, except during the “window period,” which is the time typically between 100 and 160 days after symptom onset when HBsAg disappears and before anti-HBs appear.1,2 During this time, the total and IgM hepatitis B core antibodies (anti-HBc) are the only serologic markers present.1,2 In the setting of chronic hepatitis B, the absence of HBsAg can occur in the setting of variants in the surface S gene (S-escape variants), evading detection by HBsAg assays and consistent with occult chronic hepatitis B.1,3,4 The prevalence of occult chronic hepatitis B is approximately 0.11% in highly endemic areas.5
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Maroun M. Sfeir, MD, MPH, MS, Department of Pathology and Laboratory Medicine, Clinical Microbiology Laboratories, University of Connecticut Health Center, Farmington, CT 06053 (firstname.lastname@example.org).
Published Online: November 19, 2021. doi:10.1001/jama.2021.19803
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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