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For further information, see CMDT Part 16-03: Acute Hepatitis B

Key Features

Essentials of Diagnosis

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

  • Fever, tender hepatomegaly, jaundice

  • Markedly elevated serum aminotransferases early in the course

  • Normal to low white blood cell count

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

General Considerations

  • Hepatitis B virus (HBV) contains an inner core protein (hepatitis B core antigen, HBcAg) and outer surface coat (hepatitis B surface antigen, HBsAg)

  • The incubation period is 6 weeks to 6 months (average 3 months)

  • The onset of HBV is more insidious and the aminotransferase levels higher on average than in hepatitis A virus (HAV) infection

  • 10 genotypes of HBV (A–J) have been identified


  • Incidence has decreased from 8.5 to 1.5 cases per 100,000 population since the 1990s

  • HBV is usually transmitted by

    • Infected blood or blood products

    • Sexual contact

  • It is also present in saliva, semen, and vaginal secretions

  • About 7% of HIV-infected persons are coinfected with HBV

  • HBsAg-positive mothers may transmit HBV to the neonate at delivery

  • The risk of chronic infection in the infant approaches 90% if the mother is HBeAg positive

  • HBV is prevalent in men who have sex with men and injection drug users, but most cases result from heterosexual transmission

  • Other groups at high risk include

    • Patients and staff at hemodialysis centers

    • Physicians, dentists, and nurses

    • Personnel working in clinical and pathology laboratories and blood banks

  • 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

Clinical Findings

Symptoms and Signs

  • Onset may be abrupt or insidious

  • Malaise, myalgia, arthralgia, fatigability, upper respiratory symptoms, anorexia, and a distaste for smoking

  • Nausea and vomiting, diarrhea or constipation

  • Low-grade fever is generally present; serum sickness may occur

  • Abdominal pain is usually mild and constant in the right upper quadrant or epigastrium

  • Defervescence and a fall in pulse rate coincide with the onset of jaundice

  • Jaundice occurs after 5–10 days but may appear at the same time as the initial symptoms; in many patients, it never develops

  • Often worsening of the prodromal symptoms, followed by progressive clinical improvement

  • Stools may be acholic

  • The acute illness usually subsides over 2–3 weeks

  • In most patients, there is complete clinical and laboratory recovery by 16 weeks

  • In 5–10% of cases, the course may be more protracted, but acute liver failure develops in < 1%

  • Hepatitis B may become chronic

Differential Diagnosis

  • Acute and chronic hepatitis ACDE

  • The TT virus (TTV) is found in up to 7.5% of blood donors and is ...

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