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Clinical Case 8
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Objectives:

  • Generate a differential diagnosis for patients with abnormal liver enzymes
  • Identify patients at risk for hepatitis B
  • Use the various hepatitis B antigens and antibodies to determine a patient's infection status
  • Describe the route of transmission of hepatitis B



1

A 24-year-old woman comes to your office complaining of fatigue for the past month. Despite getting 8-9 hours of sleep each night, she becomes easily fatigued and often has to "push" herself to get through her work. She has also had a poor appetite and has lost about 3 pounds over this period. She reports that she was told that she had "hepatitis" when she was about 10 years old but does not recall what type. She is otherwise healthy and takes no medications.

The patient is from China and is a graduate student in engineering. She is single and uses neither tobacco nor alcohol. She has no history or percutaneous exposures or blood transfusion. She is not aware of any liver disease in her family except for a grandfather who died of "liver cancer." Physical examination reveals a thin, tired-appearing woman. The liver edge is palpable 2 cm below the right costal margin and is slightly tender. There are no ascites, splenomegaly, or cutaneous stigmata of chronic liver disease. Laboratory studies are remarkable for mild anemia (hemoglobin 9.1 g/dL). Liver tests reveal elevated aminotransferases (ALT 289 IU/L, AST 158 IU/L), albumin 3.2 g/dL, total bilirubin 1.5 mg/dL (normal 0.2-1.0 mg/dL).

Diagnostic possibilities at this point include:
A)Hepatitis A.
B)Hepatitis B.
C)Hepatitis C.
D)Autoimmune hepatitis.
E)All of the above.
2

Appropriate laboratory studies at this point include which of the following?
A)Quantitative HCV PCR.
B)HBsAg (hepatitis B surface antigen).
C)Anti-hepatitis A antibodies (IgG and IgM).
D)B and C.
E)A, B, and C.
3

The patient's results show a positive HBsAg, positive total anti-HAV with no IgM detected, and negative anti-HCV antibody. You phone her to discuss these results, but her roommate tells you that the patient had to return to China unexpectedly because her mother had suddenly become ill.

Four months later, she returns for a follow-up visit. She tells you that she took an herbal medicine while she was back in China and has been feeling much better recently. Her HBsAg remains positive, but her liver enzymes, albumin, and total bilirubin are now completely normal.

Appropriate actions at this time include:
A)Treatment with interferon-alpha 5 million units daily for 16 weeks.
B)Order hepatitis Be antigen, anti-HBe, and HBV DNA level.
C)Begin periodic screening for hepatocellular carcinoma with ultrasound and alpha-fetoprotein (AFP).
D)A and C.
E)B and C.
4

The patient returns to discuss the results of her tests. Laboratory results show that she is negative for HBeAg and is anti-HBe+. Her HBV DNA is undetectable using an unamplified assay. AFP is within limits and abdominal ultrasound is unremarkable. She continues to feel well. She also tells you that she will be getting married in 2 months. She asks you what can be done to prevent her fiancé and future children from becoming infected with HBV.

All of the following are accurate responses to her question EXCEPT:
A)No special precautions need to be taken because she has undetectable HBV and is therefore not infectious.
B)If her fiancé has not been immunized against HBV, he should be tested and vaccinated if not immune.
C)If her fiancé is not immune to HBV, they should use barrier contraceptives (e.g., condoms) until he has completed his HBV vaccination series.
D)She should cover any open cuts or scratches with a bandage and clean up any blood spills with bleach.
E)Administration of hepatitis B immune globulin (HBIG) and HBV vaccination begun immediately after birth is 95% effective in preventing perinatal transmission of HBV.







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