Keywords: Hepatitis B Virus; Hepatocellular Carcinoma; West Africa; Viral Load; Liver Enzymes; High-Risk Group; Monitoring; Antiviral.

Abbreviations: HB Core Ab: Hepatitis B core antibodies;

HBs A: Hepatitis B surface Antigen; HBVL: Hepatitis B Viral Load; ALT: Alanine Transaminase; INR: The international normalized ratio; AFP: Alpha Fetoprotein;  HB Core Ab: Hepatitis B core antibodies; AST: Aspartate Aminotransferase; Bil: Bilirubin Level; ALP: Alkaline Phosphatase; SGGT: Gamma Glutamyl Transferase; HCV Ab: Hepatitis C Virus Antibodies; HIV: Human Immunodeficiency Virus; S: serum; TL: total; OTC: Over The Counter; LFT: Liver Function Test; BBV: Blood Borne Viruses, HCC: Hepatocellular Carcinoma.

Case Presentation

SM is a 31-year-old male originally from Central-West Africa, who migrated to Australia 5 years ago. He is married and lives with his wife and three children, all of whom were born in Australia and are up-to-date vaccinated according to age. However, his wife has no history of immunization in adult life. The patient is a disability support worker, with no history suggesting needlestick injury incidents or Blood blood-borne disease (BBD). He was asymptomatic, with no significant past medical history, regular medications, smoking history nor history of alcohol consumption. There was no family history of HBV or cancer within firstdegree family members, though his mother’s sister has a history of hepatitis B. Clinical examination demonstrated no signs of chronic liver disease, his Body Mass Index (BMI) was 24, and there was no abnormality detected on abdominal examination. SM was diagnosed with HBV (Table 1) after a follow-up on abnormal Liver Function Tests (LFT) - with minimally elevated Alanine Transaminase Test (ALT)-on initial blood check that led to an opportunistic screen, confirming Chronic HBV infection status [4] (Table 2) and negative results for HCV and HIV (Table 3).   

Initial HBV screening blood analysis results revealed the following:

• Positive HB core Ab
• Positive surface Ag (HBsAg)
• negative eAg (HBeAg)
• F/U analyses confirmed a low viral load of 471 IU/mL  (Table 5)
• ALT 46, INR 1, Platelet count of 156 x109/L, AFP 2.5. 

Upon further assessment, an elastogram was performed for liver fibro-scan, which highlighted low-to-nil liver scarring (score < 6 kilopascal).   

Screenshots are depicted below, reflecting the patient’s initial results:

Table 1: Hepatitis Serology

Hepatitis B Interpretation: Hepatitis B surface antigen coEnfirmed Positive. Consistent with chronic Hepatitis B virus infection.

Table 2: SE-Chemistry. MULTIPLE BIOCHEMICAL ANALYSIS – Serum

Requested: 26/03/2022;  Collected: 28/03/2022;  Reported: 29/03/2022

Table 3: HIV & HCV Serology

Table 4: SE Hepatitis Virtual

Requested:26/03/2022; Collected: 28/03/2022; Reported: 30/03/2022

Table 5: Se-Hep B Viral Load.

Requested: 26/03/2022; Collected: 28/03/2022; Reported: 01/04/2022

Testing performed on Roche^™ COBAS^® 6800. The range of qualifications was 10 IU/mL to 1,000,000,000 IU/mL (Log 1.0 to Log 9.0) with a lower limit of detec6on at 3.5 IU/mL. 

Discussion

The patient was initially reluctant to accept HBV positive, having no h/o sexually transmitted condition/blood transfusion with no family history of HBV or personal history of bloodborne diseases, therefore he requested a repeat of investigations in the following month, which only confirmed the initial results but rather helped in building stronger rapport and facilitating further better care and management. After reviewing the results and performing a thorough discussion with the patient, he was highly willing to further manage his condition and to involve his family as well (wife and children) in screening. The ALT level remained unchanged during patient management and initial follow-up tests, at 46 U/L, being slightly abnormal. Nonetheless, this could be attributed to other factors, including fatty liver, use of OTC medications, among other probable causes. Therefore, after careful physical examination revealed nonsignificant findings, a plan was agreed upon to repeat LFT and lipids profile analyses, together with arrangements for HCC screening that were set for the 6-month follow-up session.

 Even though the patient was highly motivated to commence oral treatment, being aware of his high-risk demographic group for HCC among chronic active hepatitis patients, a management plan was agreed upon for monitoring only, with no oral treatment to be initiated at this stage. Moreover, arrangements were placed to vaccinate his wife, as her initial screening results demonstrated a negative status for HBV, with no adequate immunity. 

Results

A 6-month follow-up revealed an optimal outcome with improvement in ALT level to within normal range, with hepatic ultrasound scan demonstrating no change or abnormality, while patient AFP level remained within the normal range. The patient was happy to continue follow-up sessions, given his high-risk group category for HCC (being from West Africa), with preventive measures being undertaken at home, combined with supportive tools and educational materials provided-including further clarification regarding possible routes of HBV acquisition and common myths tackled and explained (e.g. HBV is not transmitted through casual contact, sharing of meals, water etc). 

References

1. https://www.who.int/health-topics/hepatitis#tab=tab_1 
2. Kedar Mukthinuthalapati VVP, Sewram V, Ndlovu N, Kimani S, Abdelaziz AO, Chiao EY, Abou-Alfa GK. Hepatocellular Carcinoma in Sub-Saharan Africa. JCO Glob Oncol. 2021 May;7:756-766.
3. Shimakawa Y, Lemoine M, Njai HF, Bottomley C, Ndow G, Goldin RD, Jatta A, Jeng-Barry A, Wegmuller R, Moore SE, Baldeh I, Taal M, D’Alessandro U, Whittle H, Njie R, Thursz M, Mendy M. Natural history of chronic HBV infection in West Africa: a longitudinal populationbased study from The Gambia. Gut. 2016 Dec;65(12):2007-2016.
4. Dusheiko G, Agarwal K, Maini MK (2023) New Approaches to Chronic Hepatitis B, N Engl J Med. 388:1148.