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ESSENTIALS OF DIAGNOSIS

  • Prodrome of anorexia, nausea, vomiting, malaise, aversion to smoking.

  • Fever, enlarged and tender liver, jaundice.

  • Normal to low white blood cell count; markedly elevated aminotransferases early in the course.

  • Liver biopsy shows hepatocellular necrosis and mononuclear infiltrate but is rarely indicated.

GENERAL CONSIDERATIONS

Hepatitis B virus (HBV) is a 42-nm hepadnavirus with a partially double-stranded DNA genome, inner core protein (hepatitis B core antigen, HBcAg), and outer surface coat (hepatitis B surface antigen, HBsAg). There are 10 different genotypes (A–J), which may influence the course of infection and responsiveness to antiviral therapy. The sodium-taurocholate cotransporting polypeptide, NTCP, is thought to be the cellular receptor of HBV on hepatocytes. HBV is usually transmitted by inoculation of infected blood or blood products or by sexual contact and is present in saliva, semen, and vaginal secretions. HBsAg-positive mothers may transmit HBV at delivery; the risk of chronic infection in the infant is as high as 90%.

Since 1990, the incidence of HBV infection in the United States has decreased from 8.5 to 1.5 cases per 100,000 population. The prevalence is 0.27% in persons aged 6 or older. Because of universal vaccination since 1992, exposure to HBV is now very low among persons aged 18 or younger. HBV is prevalent in men who have sex with men and in people who inject drugs (about 7% of HIV-infected persons are coinfected with HBV), but the greatest number of cases result from heterosexual transmission. Other groups at risk include patients and staff at hemodialysis centers, physicians, dentists, nurses, and personnel working in clinical and pathology laboratories and blood banks. Half of all patients with acute hepatitis B in the United States have previously been incarcerated or treated for a sexually transmitted disease. The risk of HBV infection from a blood transfusion in the United States is no higher than 1 in 350,000 units transfused. Screening for HBV infection is recommended for high-risk groups by the US Preventive Services Task Force.

The incubation period of hepatitis B is 6 weeks to 6 months (average 12–14 weeks). The onset of hepatitis B is more insidious, and the aminotransferase levels are higher on average than in HAV infection. Acute liver failure occurs in less than 1%, with a mortality rate of up to 60%. Following acute hepatitis B, HBV infection persists in 1–2% of immunocompetent adults, but in a higher percentage of children and immunocompromised adults. There are as many as 2.2 million persons (including an estimated 1.32 million foreign-born persons from endemic areas) with chronic hepatitis B in the United States and 248 million worldwide. Compared with the general population, the prevalence of chronic HBV infection is increased 2- to 3-fold in non-Hispanic blacks and 10-fold in Asians. Persons with chronic hepatitis B, particularly when HBV infection is acquired early in life and viral replication persists, are at substantial risk for cirrhosis and hepatocellular carcinoma (up to 25–40%); men ...

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