Home Forums Discussions General Discussion Hep B e Ag

Hi everyone,

For all you smart guys and gals out there, please help me make sense of this:

51-year-old RN, received three hepatitis B immunizations in approximately 1995. Patient has been having fibromyalgia like symptoms, minimal if any objective joint findings, as well as depression, sent her to a rheumatologist. He did a mega workup, including hepatitis tests. Here's what came back:

Normal liver function tests, AST 17, ALT 13
Normal sed rate and CRP

Hep B e Antigen REACTIVE
Hep B S Ag nonreactive
Hep B S Ab nonreactive
Hep B Core Ab nonreactive
Hep B Core IgM Ab nonreactive
Hep B e Ab nonreactive

Thinking this was a lab error, I repeated the tests, which were repeated eight days later. The results were the same.

I have had virtually no experience with hepatitis B since residency, many many moons ago. I can't understand how, based on usually published charts, e antigen could be the only positive test.

I'm going to send her to gastroenterologist, but I'd like some insight as to just what's going on.

Thank you!

Gene

Could it be that she is unable to mount an antibody response and has acute HBV, and have you checked the HBV DNA? But one would think her LFT's would be elevated. Let us know what you find out.

Fibromyalgia patients often have some borderline test results, cause they have so many tests done.

Get GI and psych evaluations to get some peace of mind and treat her for fibromyalgia. The biggest problem is usually patients not getting adequately aggressive care for their depression since it is more acceptable to have a fibromyalgia label. Usually only psychiatrists are comfortable mixing multiple meds for this. Beware bipolar.

Very very true.

But that does not change the fact that e antigen positivity usually indicates a high viral load, which would be potentially infectious, which would not be good for an RN!

Thanks.

Gene

Likely a false + e antigen, no S antigen, do a viral DNA load suspect will be neg

I actually printed that order this morning!

Gene

Didn't notice this until just now. I agree with Koby. If the DNA is negative, you are done.
Please give us follow-up.

Hi everyone,

This

"HBV DNA PCR8369 Status: RESULTED Priority: ROUTINE
Date Collected: 04/05/2013 08:45a
HEPA B- IU <20 NORMAL <20 IU/mL
Not Detected

HEPA B- COPIES <116 NORMAL <116
INFCE Result Units: copies/mL
Not Detected
Please note:
Due to character limitations of some clients' LIS
systems, viral load values greater than 10 million are
reported using scientific exponential notation.
For example a result of 10 Million (10,000,000) is
reported as 10.0E6 IU/mL or copies/mL. If your LIS
will accept the number of characters required for
viral loads greater than 10 million, please contact
your local service representative to have this
reporting convention changed.
The method used in this test is Real-Time PCR of
the pre-core region of the circular HBV genome.
This test was performed using the COBAS(R) AmpliPrep/
COBAS(R) TaqMan(R) HBV Test, v2.0 (Roche Molecular
Systems, Inc.)"

is the result. So it looks like the e Ag was a false positive.

On a somewhat related note, this episode has me thinking about hepatitis B. Regarding immunization, my understanding is, for all practical purposes, you get three shots and then forget it. The literature seems to say that detectable titers will disappear about seven or eight years after the immunizations. But, except for the specific instance of a needlestick, I don't see any specific recommendations for routine testing/reimmunization/booster/etc.

I'm thinking of myself, it has been about 26 years since I received hepatitis B immunizations. I'm in a fairly low risk setting, office practice only.

Any thoughts?

Thanks. Gene.

This is from up to date--

Healthcare workers ? Vaccination programs of health care workers have met with the most success. Continued education and enforcement of OSHA guidelines is necessary to ensure that this group is adequately protected. In November 2011, CDC published the updated recommendations of the Advisory Committee on Immunization Practices (ACIP). Among the recommendations were [43]:

Healthcare practitioners and trainees and certain high-risk populations should undergo prevaccination serologic testing for previous infection, regardless of vaccination status.
Trainees should have their vaccination series completed before they have contact with a patient's blood.
Post-vaccination testing and documentation should be performed for all healthcare practitioners at high risk for occupational percutaneous or mucosal exposure to blood or body fluids. The results of the tests are to determine the need for revaccination and post-exposure prophylaxis. For healthcare practitioners with low risks for percutaneous or mucosal exposure to body fluids, post-vaccination testing is not cost-effective. However, these individuals must be informed to seek immediate medical attention upon exposure.
Healthcare practitioners with an anti-HBs concentration of less than 10mIU/mL should receive another three appropriately scheduled doses of the vaccine with serological testing performed one to two months after the third dose.
Individuals with an anti-HBs level less than 10 mIU/mL after the second series should be tested for HBsAg and anti-HBc. Those who are not infected and who had not responded to the vaccine are considered susceptible to HBV infection and must be counseled about prevention and transmission of hepatitis B. These individuals, upon known or likely exposure, should receive HBIG.
Individuals who are HBsAg positive should be counseled about prevention of transmission of hepatitis B to others. Those who perform exposure-prone procedures must seek counsel from a review committee regarding procedures they can perform safely. Individuals who are anti-HBc positive and HBsAg negative require no vaccination or treatment.

Hi jimmie,

Thanks for posting this.

Correct me if I'm wrong, but it looks like this is specifically addressing the period of time after the initial hepatitis B immunization, especially for nonresponders.

I'm wondering if there's anything to address people of unknown initial responder status, who are now several decades out from their immunizations.

Thanks. Gene.

This I think addresses your question (I hope)--also from up to date--

In the US, a booster dose is not recommended for adults with normal immune status [76]. Nevertheless, the loss of an anamnestic response and the possible loss of immunity against hepatitis B after primary vaccination as described above suggest that these individuals may be at risk of acquiring hepatitis B infection. However, the magnitude of risk has not been well defined. As an example, in a study on 493 Alaskan Natives, a protective effect of anti-HBs was demonstrated in 87 percent of individuals 22 years after vaccination [77]. Of the remaining 13 percent, none developed acute HBV.

However, there is currently only weak evidence supporting the recommendations for booster vaccination. An ongoing study will help determine the durability of HBV vaccination and provide further insight on the utility of HBV booster vaccination [78].

In high-risk individuals (eg, healthcare workers), periodic testing for anti-HBs levels and the administration of a booster vaccine, when appropriate, may be required to maintain immunity. However, more data regarding the actual risk of acquiring hepatitis B infection among individuals who completed a course of vaccination as an infant or child are needed before recommendations on booster dose administration can be formulated.

hi jimmie, (reminds me of e e cummings every time i type your name in small letters),

Thanks for going above and beyond to post that!

But the conclusion still seems to be "We don't know."

Thanks.

Gene

Brushing up for the boards so selfishly I wanted to know to avoid any surprises with any of the hep B questions in 2weeks.

But thanks for the great post, as I learned quite a bit with this thread!!!

I'll second that, one of the few boards that I visit that I usually learn something every time I drop in.

I wish we actually had more clinical discussion on here. Perhaps a separate thread to discuss patient or intellectual issues.

Hi Chris,

That's a great idea! I'll send Bert a PM about it.

I actually have been a little hesitant to do much posting about clinical matters, because this is primarily an Amazing Charts/practice management board. But there are times it's very very beneficial to get someone else's input on a case, and other times when it's good to be able to share something unusual.

A separate, primarily clinical, forum would let those of us with such interests discuss them, and let people who are just interested in the Amazing Charts/practice management aspect skip them.

Thanks.

Gene

If folks are able to weed through UK kitchen ads, skipping clinical discussions that were not of interest should be trivial.

Actually, I have been thinking of that for a long time.