1. Presented by Robert Kruse, MD, PhD and reviewed by Heba Mostafa, MBBCh, PhD

 

A middle aged patient born in a country with high hepatitis B endemicity presents to the emergency department with recent vomiting of bright red blood. The patient’s blood pressure was 90/60 and Hgb was 4.2, and two units of RBC were promptly transfused. Upper GI endoscopy reveals bleeding esophageal varices, which were ligated with bands to stop bleeding. Right upper quadrant abdominal ultrasound demonstrated imaging consistent with cirrhosis. The patient reported some recent mental fogginess and a lactulose was administered after ammonia levels were found to be elevated.

Patient reports a medical history of hepatitis B virus infection, first diagnosed at a young age. The patient’s mother had limited prenatal care before giving birth. The patient reports being previously treated with interferon, but states there was no response to therapy. The patient was eventually lost to follow up without routine medical care, and does not endorse being on any other medications since then. The patient then immigrated to the United States. The patient denies any history of drinking alcohol or smoking, and did not have direct interaction with any agricultural crops.

The patient’s HBV testing is summarized in the table below. Interestingly, the patient’s HBV DNA levels were below the limit of detection in spite of not being on any reverse transcriptase inhibitor drugs, which suppress viral replication under the limit of detection.

Question: Which of the following is the most likely explanation for the patient’s HBV testing and explains the overall clinical scenario?