Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 25-year-old man is evaluated in follow-up after recently testing positive for hepatitis B surface antigen. He underwent testing as part of the immigration process from Somalia. Two other siblings also have hepatitis B virus (HBV) infection.

On physical examination, he is a young, healthy-appearing man. Vital signs are normal. No jaundice is noted, and the abdominal examination is unremarkable.

Laboratory studies:

Alanine aminotransferase	Normal
Aspartate aminotransferase	Normal
α-Fetoprotein	Normal
Hepatitis B surface antigen	Positive
Hepatitis B e antibody	Positive
Hepatitis B e antigen	Negative
HBV DNA	896 IU/mL

Ultrasound of the upper abdomen is normal.

Which of the following is the most appropriate management?

A. Administration of hepatitis B vaccine
B. Administration of pegylated interferon
C. Administration of tenofovir
D. α-Fetoprotein measurement every 12 months
E. Ultrasound imaging of the liver every 6 months

MKSAP Answer and Critique

The correct answer is E. Ultrasound imaging of the liver every 6 months.

The most appropriate management is ultrasound imaging of the liver every 6 months. This patient from Africa has evidence of chronic hepatitis B virus (HBV) infection. In approximately 50% of untreated patients with chronic HBV infection in the United States, HBV will contribute to the cause of death (from hepatocellular carcinoma [HCC] or other complications of end-stage liver disease, such as cirrhosis). HCC surveillance is advised in African patients over the age of 20 years with chronic HBV infection. Screening and surveillance for HCC consist of cross-sectional imaging with ultrasound, CT, or MRI. Ultrasound is the most widely available and least expensive imaging modality and is preferred. For patients with normal imaging at diagnosis, the recommended interval for surveillance imaging is 6 months.

Serum α-fetoprotein measurement does not have sufficient diagnostic accuracy alone to be a valuable tool for early detection. The combination of ultrasonography and α-fetoprotein measurement increases cancer detection rates, but this comes at the expense of increased false-positive findings. Other indications for HCC surveillance in patients with chronic HBV infection are 1) patients with cirrhosis, 2) Asian men older than 40 years, 3) Asian women older than 50 years, 4) patients with a family history of HCC, and 5) patients with persistent hepatocellular inflammation (defined as elevated alanine aminotransferase [ALT] level and HBV DNA level greater than 10,000 IU/mL).

This patient has already been infected with HBV, so vaccination at this point will not be effective.

This patient’s HBV infection is in the inactive carrier/immune control state, as evidenced by his normal ALT level and HBV DNA level below 10,000 IU/mL. Treatment with antiviral agents such as pegylated interferon or tenofovir is not necessary for patients in the inactive carrier state. However, surveillance for HCC is still indicated.

Key Point

• Screening and surveillance for hepatocellular carcinoma consist of cross-sectional imaging with ultrasound, CT, or MRI.

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