Dear Editor:
Given the following tests
results, should a patient have a liver biopsy: HBsAg positive, HBeAg negative, normal
liver enzymes levels and 5000 copies/ml of HBV DNA detected by a PCR test? Concerning
the HBV DNA PCR test, was it at all necessary? If so, what would be the cutoff
for the number of HBV DNA copies detected which mandates further investigation?
SD
Dear SD:
The pattern
of tests point to your patient being an inactive HBsAg carrier. The three phases of HBV infection as defined at a
recent NIH conference are:
1.
Immune
Tolerant Phase - HBsAg (+), HBeAg
(+), anti-HBe (-), HBV DNA > log 5, ALT persistently normal;
2.
Immunoactive
Phase (also called Chronic Hepatitis
B) - Same as above, except HBeAg may be (+) (wild type infection) or (-)
(precore or core promoter infection), and ALT is persistently or intermittently
elevated;
3.
Inactive HBsAg
Carrier - HBsAg (+), HBeAg (-),
anti-HBe (+), HBV DNA< log 4 (often log 2-3 or undetectable), and ALT normal
(or occasionally just slightly elevated).
There is no reason for a
liver biopsy. Your patient should be followed every 6 months with a liver
function panel to be sure the ALT remains normal, and undergo hepatoma
screening with ultrasound and AFP every 6t months if age >30 to 40 years
(there are different recommendations based on age).