Hepatitis B

A 35-year-old man presents with a one-week history of new onset fatigue, nausea, as well as reporting his urine looks like, quote, ice tea. He also reports, feel like someone kicked me right underneath my ribs on the right. He denies recent travel, contact with individuals with similar signs and symptoms, and reports a new sex partner for the past six months, stating, quote, we sometimes use condoms. 

In considering the diagnosis of acute hepatitis B, which of the following laboratory profiles would be noted?

A. Hep B surface antigen positive, anti-HBs negative, or Hep B surface antibody. ALT markedly elevated at 1390. AST similarly elevated at 1100. Total bilirubin markedly elevated at 4.8

B. Hep B surface antigen positive, anti-HBs, HBS- or Hep B surface antibody ALT modestly elevated at 68 as is AST total bilirubin .9 within normal limits

C. Hep B surface antigen negative, anti-HBS- or Hep B surface antibody, ALT 24, AST 22 and a total bilirubin of 0.6

D. Hep B surface antigen negative, anti-HPS negative, ALT 150, AST 140, total bilirubin 0.7 within normal limits

---

YouTube: https://www.youtube.com/watch?v=gIaXKQMAino&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=126

Visit fhea.com to learn more!

Transcript

Host: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 35-year-old man presents with a one-week history of new onset fatigue, nausea, as well as reporting his urine looks like, quote, iced tea. He also reports, "I feel like someone kicked me right underneath my ribs on the right." He denies recent travel, contact with individuals with similar signs and symptoms, and reports a new sex partner for the past six months, stating, quote, "We sometimes use condoms." And considering the diagnosis of acute hepatitis B, which of the following laboratory profiles would be noted?

Option A. Hep B surface antigen positive, anti-HBs negative, or Hep B surface antibody. ALT markedly elevated at 1390. AST similarly elevated at 1100. Total bilirubin markedly elevated at 4.8
Option B. Hep B surface antigen positive, anti-HBs, HBS- or Hep B surface antibody, ALT modestly elevated at 68 as is AST, total bilirubin 0.9 within normal limits
Option C. Hep B surface antigen negative, anti-HBS- or Hep B surface antibody, ALT 24, AST 22 and a total bilirubin of 0.6
Option D. Hep B surface antigen negative, anti-HPS negative, ALT 150, AST 140, total bilirubin 0.7 within normal limits.

The correct answer here is Option A. Hep B surface antigen positive, anti-HBs negative, ALT 1390, AST 1100, total bilirubin 4.8.

Where should we start with this question? First, determine what kind of a question it is. Given we're provided with a diagnosis that we're to look at here, we're then being asked to find the data that would support this diagnosis. Uh, this could be viewed as either an assessment question, where more information is being added to what was previously given, or it might be part of a diagnosis question. You could really see on the boards how questions could fit, if you will, technically in one or more category.

A bit of background information. Hepatitis is a general term for liver inflammation, whereas a number of viruses can invade the liver and cause infection. There are hepatitis-specific viral agents. In North America, these viruses are largely as follows: the hepatitis A virus, referred to as HAV, causing acute hepatitis A—remember, there's no such thing as chronic hep A. Hepatitis B virus, referred to as HBV, resulting in acute or chronic hepatitis B. The hepatitis C virus, referred to as HCV, resulting in acute or chronic hepatitis C, and the hep D virus, which is actually fairly uncommon, referred to as HDV, resulting in acute hepatitis D.
And just as an aside, the only way a person will get sick with the hep D virus is if they acquired it while they also had the hep B virus on board. In some parts of the world, there are other hepatic-specific viruses found, with hepatitis E being fairly common outside of North America.

Hepatitis B obviously is the focus of the question, and it's caused by a small double-strand DNA virus that contains an inner core protein of hepatitis B core antigen and an outer surface of hep B surface antigen. Hep B virus is usually transmitted through the exchange of blood and body fluids and is commonly transmitted via sexual activity. This is, out of all the hepatitis-specific viruses, the one best concentrated in sexual fluids. You'll note in the story of the question, the stem of the question, that he has a new sex partner for the past six months, and they usually but not consistently use condoms.

Injection drug use, particularly with needle sharing, also poses a very significant HBV risk. This is, of course, a vaccine-preventable disease with a highly effective immunization usually provided during childhood. And in this question, no vaccine history is mentioned. So, I know I'm reading it, and I'm going, "Yeah, but what about the vaccine history?" What I have to do is move on; it's not mentioned. So, we have to figure out what's going on in the absence of that vaccine history.
What is the clinical presentation of acute hepatitis B? Well, in this patient, the clinical presentation is much like we're seeing here. Symptoms include malaise, myalgia, fatigue, nausea, anorexia, sensitivity to certain smells—particularly tobacco smoke is often reported. The right upper quadrant abdominal tenderness is almost universal. And don't think gallbladder attack, think more like what this patient is saying: I feel like somebody kicked me under my ribs. It's a dull ache. It can be really rather uncomfortable, but it's pretty constant, and it's not sharp like gallbladder pain is usually described as.

On abdominal exam, the liver is mildly tender, no rebound, and hepatomegaly will be noted in about 50%. Jaundice is not a universal finding and will usually occur about one week after more general onset of symptoms. Clay-colored stools are sometimes reported. Dark colored urine—my urine looks like CocaCola, iced tea, Guinness, Malta, a common beverage like a soft drink in the Caribbean—I think you get the idea. The urine is typically very dark brown.

And why is the urine dark brown? It's loaded with bilirubin, because the liver's excretion function is not working the way it should. Bilirubin levels go up, and the body tries to offload as best as it can bilirubin via the urine.

The duration of the acute hepatitis B illness is generally about two to three weeks. The organism has an incubation time of about sixty to ninety days. A key point to keep in mind with this patient—he mentions not being around individuals with similar symptoms, and that's actually a fairly common report in hep B infection due to the long incubation time.

There are few areas of laboratory diagnosis that I am asked more about when I'm helping people get ready for the NP boards. Now, this is one of the things—full disclosure—am I giving you a litany of every single darn marker for hepatitis B? No, I'm not. And I'm not going to apologize for it. But what I'm doing is I'm going to provide you enough to get you through the boards and to help you with the initial diagnosis of a person with the clinical scenario presented here.

I'll go through these different lab markers as I cover the answers. So back to the question. A 35-year-old man presents with a one-week history of new onset fatigue, nausea, as well as reporting his urine looks like, quote, iced tea, close quote. He also reports that I feel like somebody kicked me right underneath my ribs on the right. He denies recent travel, contact with individuals with similar signs and symptoms, and reports a new sex partner for the past 6 months stating we usually use condoms.

In considering the diagnosis of acute hepatitis B, which of the following laboratory profiles would be noted? A, hep B surface antigen positive, anti-HBs negative, markedly elevated ALT at 1390, AST at 1100, similarly markedly elevated, total bilirubin also quite high at 4.8. This is, of course, the correct answer.

As I said earlier, not every single hep B lab marker that is available is being reported here, but it's enough to get you started. And one of the key points I want you to walk away from this is as follows: the hep B surface antigen is a surrogate marker for the hep B virus. It's only found in the body when there's hep B virus on board. One way to remember this is the AG in surface antigen stands for always growing. Well, of course, it doesn't, but that's one way to remember it. So, the virus would be always growing if you have AG on board. In addition, he's anti-HBs negative—sometimes this is called hep B surface antibody. Anti-HBs is a marker for immunity against hepatitis B. It makes sense; you can't have the virus on board at the same time as being immune to the virus.

However, when we look at him, his ALT is markedly elevated, more than twenty times the upper limits of normal; AST similarly elevated. This is an indication of very significant hepatocellular injury. So remember, ALT goes up when a bunch of liver cells have been busted open. That's what causes the rise, because where is most of the ALT held? In the liver, within the hepatocytes. And just one more marker: ALT, the only place in the human body there is ALT is the liver. Therefore, if the ALT is up, you have to look and say, okay, there's something going on in the liver.

What's going on there? Okay, AST is found a couple of other places in the body besides the liver. You'll also note his bilirubin is elevated, and that's consistent with the comment that his urine looks like iced tea. As I mentioned earlier, his body is trying to throw off that extra bilirubin and part of it will go out in the urine. And as I mentioned before, it doesn't say he's jaundiced, but not everybody with hepatitis B does report jaundice.

Option B: Hep B surface antigen positive, anti-HBs negative, modestly elevated ALT and AST at 68, respectively, total bilirubin is normal. This is incorrect. Now, the labs start off similar to our patient with acute hepatitis B, don't they? And yeah, this patient definitely has a hep B virus on board, because the person has hep surface antigen on board. However, the lab values—they're not normal. ALT's upper limits of normal for most labs is around forty, this ALT is sixty-eight. So you know there are extra busted up liver cells in circulation.

So, we see the person has a hep virus on board but normal bilirubin and only a minor bump in the hepatic enzymes. This is the clinical scenario of the person with chronic hepatitis B. These folks in the day-to-day are without acute signs and symptoms of liver disease—like in our patient example for the question, he doesn't feel good. Person with chronic hepatitis B, absolutely fine in the day-to-day.
And how common is chronic hepatitis B? It's about one in twenty adults who contract the hep B virus will develop chronic hepatitis B. About one in twenty adults who contract the hepatitis B virus will go on to develop chronic hepatitis B. What happens to the other nineteen? They develop permanent immunity to the hep B virus. But I just want to remind you, again—people with acute hepatitis B are sick, like out of work sick for two weeks, three weeks. I've seen people be just down for the count for a month.

I remember one of the last patients I saw with acute hepatitis B was an otherwise well younger woman who had turned down hep B vaccine in the past, long story, contracted hep B from her new sex partner who did not know he had chronic hepatitis B, and she was out of work for a full month. She was out of work in a job where she had no sick time, no paid sick time, so it was a tremendous financial hit for her. Thankfully, she did not go on to develop chronic hepatitis B.

But here's one of the other parts: about 90% of infants born to hep B surface antigen positive persons in the United States will develop chronic hepatitis B infection, and about one quarter of those will eventually die from chronic liver disease. At the same time, about 50% of all infants who develop chronic hepatitis B were born to moms who are hep B surface antigen negative and likely picked up the hep B virus from a household member or other close contact. It doesn't need to be sexual contact. It could be a person who's walking around with chronic HBV, doesn't realize they've got it, they've got an abrasion on their hand, they bathe the baby, the baby's got a little skin irritation. This is a durable virus that transmits very, very easily, and that's one of the reasons why children are recommended to be immunized against hepatitis B in life.

Okay, Option C: Anti-HBs negative, anti-HBs positive, ALT and AST both within normal limits at 24 and 22, respectively, and normal total bilirubin at 0.6. This is also, of course, incorrect, because this person doesn't have the hep B virus on board, shown by the lack of hep surface antigen, but also has the anti-HBs on board telling us this person is immune to the hep B virus. On top of that, the hepatic enzymes are normal. So is the bilirubin. This person will never acquire hepatitis B because the surface antibody is highly protective against that virus.
Option D: obviously not correct, because we've already hit the correct answer. Hep surface antigen negative, anti-HBs negative, ALT 150, AST 140, so both, like three-plus times upper limits of normal, total bilirubin is normal. This person has no hepatitis B markers, either the hep B surface antigen or the anti-HBs. So there's no acute hep B virus on board, but not showing any protection against hepatitis B. And you might say, well, compared to the enzymes in the patient in question, Option A, where the results were literally in the thousands, these hepatic enzymes are not that elevated. Remember, folks, we get paid to worry. That's our job. We get paid to be concerned about an abnormal finding like this. This is a worrisome situation where the hepatic enzymes are elevated, and this person is not protected against hepatitis B.

What could this be? It could be fatty liver disease. It could be drug-induced liver toxicity. We don't have any patient history. We can't make heads or tails out of this. It's hard to say. But what I will say is this person does have some kind of liver disease, and we need to start investigating further.

But what this person should be offered today is hepatitis-specific immunization against hep A and against hep B, because any type of liver disease—if they get an infectious disease on top of it, like hep A or hep B—it can be absolutely a devastating disease.

Key takeaway: The NP boards are testing you on your walking around information, or what any person prepared as an entry-level practitioner should have at hand without looking up. Getting into the finer points of hep B diagnosis, such as e antigen, core antigen, and the like—wonderful, very helpful—but that goes under the category of your look-up information, which most clinicians, unless they practice exclusively in GI or hepatology, will need to do.