Acute hepatitis B US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Acute hepatitis B. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Acute hepatitis B US Medical PG Question 1: A 29-year-old man comes to the physician for a routine health maintenance examination. He feels well. He works as a nurse at a local hospital in the city. Three days ago, he had a needlestick injury from a patient whose serology is positive for hepatitis B. He completed the 3-dose regimen of the hepatitis B vaccine 2 years ago. His other immunizations are up-to-date. He appears healthy. Physical examination shows no abnormalities. He is concerned about his risk of being infected with hepatitis B following his needlestick injury. Serum studies show negative results for hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis C antibody. Which of the following is the most appropriate next step in management?
- A. Revaccinate with 3-dose regimen of hepatitis B vaccine
- B. Revaccinate with two doses of hepatitis B vaccine
- C. Administer hepatitis B immunoglobulin
- D. Administer hepatitis B immunoglobulin and 3-dose regimen of hepatitis B vaccine (Correct Answer)
- E. Administer hepatitis B immunoglobulin and single dose hepatitis B vaccine
Acute hepatitis B Explanation: ***Administer hepatitis B immunoglobulin and 3-dose regimen of hepatitis B vaccine***
- This patient had prior vaccination but current serology shows **negative HBsAb**, indicating **non-response** to the vaccine (failure to develop protective antibodies).
- Given exposure to a hepatitis B positive patient, immediate post-exposure prophylaxis with **HBIG** is crucial for passive immunity and immediate protection.
- A **complete 3-dose revaccination series** should be initiated simultaneously, as per **CDC/ACIP guidelines** for vaccine non-responders with occupational exposure [1].
- This provides both immediate passive protection (HBIG) and attempts to establish active immunity through revaccination [1].
*Revaccinate with 3-dose regimen of hepatitis B vaccine*
- While revaccination is necessary due to the non-response, starting a 3-dose regimen alone without **HBIG** would leave the patient vulnerable during the initial period before vaccine response develops.
- After high-risk exposure in a non-responder, both passive (HBIG) and active (vaccine) immunity are required.
*Revaccinate with two doses of hepatitis B vaccine*
- A 2-dose regimen is insufficient; the standard revaccination schedule for non-responders is **3 doses** at 0, 1, and 6 months [1].
- Additionally, this option lacks **HBIG** for immediate protection after the high-risk exposure.
*Administer hepatitis B immunoglobulin*
- **HBIG** alone provides immediate passive immunity, which is crucial given the recent exposure and the patient's non-immune status.
- However, offering only HBIG without initiating active immunization (vaccine series) would leave the patient unprotected once the passive immunity wanes (approximately 3-6 months).
- This approach fails to address the need for long-term protection through revaccination.
*Administer hepatitis B immunoglobulin and single dose hepatitis B vaccine*
- While HBIG is appropriate for immediate protection, giving only a **single dose** of vaccine is inadequate.
- Standard post-exposure management for vaccine non-responders requires initiating a **complete 3-dose revaccination series**, not just one dose [1].
- A single dose would not provide adequate long-term protection for this non-responder.
Acute hepatitis B US Medical PG Question 2: Two months after giving birth to a boy, a 27-year-old woman comes to the physician with her infant for a well-child examination. She was not seen by a physician during her pregnancy. Physical examination of the mother and the boy shows no abnormalities. Laboratory studies show elevated titers of hepatitis B surface antigen in both the mother and the boy. Which of the following statements regarding the infant's condition is most accurate?
- A. Hepatitis B e antigen titer is likely undetectable
- B. Chronic infection is unlikely
- C. Lifetime risk of hepatocellular carcinoma is low
- D. Significant elevation of transaminases is not expected (Correct Answer)
- E. The viral replication rate is low
Acute hepatitis B Explanation: **Significant elevation of transaminases is not expected**
- Infants infected with HBV vertically are often **immunologically tolerant** to the virus, leading to low or normal levels of **alanine aminotransferase (ALT)** and **aspartate aminotransferase (AST)** despite high viral loads.
- This **immune tolerance** means their immune system does not actively attack infected hepatocytes, preventing inflammation and liver damage in the early stages.
*Hepatitis B e antigen titer is likely undetectable*
- In infants with **vertical transmission** of HBV, especially when not treated, the **HBeAg titer** is typically **HIGH** and detectable, indicating active viral replication.
- A detectable HBeAg in this scenario signifies a **highly infectious state** and is a marker of high viral load.
*Chronic infection is unlikely*
- Perinatal transmission of HBV has a very high — 70-90% — likelihood of leading to **chronic HBV infection** if the infant is not properly immunized at birth.
- The presence of **HBsAg in both mother and child** and lack of prenatal care strongly suggest chronic infection in the infant.
*Lifetime risk of hepatocellular carcinoma is low*
- Infants who acquire HBV perinatally and develop **chronic infection** have a significantly **increased lifetime risk** of developing **cirrhosis** and **hepatocellular carcinoma (HCC)**.
- The immune tolerance and persistent viral replication in early life contribute to long-term liver disease progression.
*The viral replication rate is low*
- In infants with vertically transmitted HBV who are in the **immune-tolerant phase**, the **viral replication rate is high**, often characterized by very high HBV DNA levels.
- This high replication without significant immune response is why they are often asymptomatic but highly infectious.
Acute hepatitis B US Medical PG Question 3: A 28-year-old man presents to the office with complaints of malaise, anorexia, and vomiting for the past 2 weeks. He also says that his urine is dark. The past medical history is unremarkable. The temperature is 36.8°C (98.2°F), the pulse is 72/min, the blood pressure is 118/63 mm Hg, and the respiratory rate is 15/min. The physical examination reveals a slightly enlarged, tender liver. No edema or spider angiomata are noted. Laboratory testing showed the following:
HBsAg Positive
IgM anti-HBc < 1:1,000
Anti-HBs Negative
HBeAg Positive
Anti-HBe Negative
HBV DNA 2.65 × 10⁹ IU/L
Alpha-fetoprotein 125 ng/mL
What is the most likely cause of this patient's condition?
- A. Acute HBV infection
- B. Passive immunity
- C. Acute resolving infection
- D. Resolved HBV infection (innate immunity)
- E. Acute exacerbation of chronic HBV infection (Correct Answer)
Acute hepatitis B Explanation: ***Acute exacerbation of chronic HBV infection***
- The combination of **HBsAg positive** (indicating extant infection) and **IgM anti-HBc < 1:1,000** (a low titer consistent with chronic infection, not acute) points towards a pre-existing chronic hepatitis B infection.
- The elevated **HBV DNA (2.65 × 109 IU/L)**, along with clinical symptoms like malaise, anorexia, vomiting, dark urine, and a tender liver, suggests an **acute exacerbation** of this chronic condition.
*Acute HBV infection*
- An acute HBV infection would typically present with a **high titer of IgM anti-HBc** and often **HBeAg positive** initially, but this patient's low IgM anti-HBc titer rules out a new acute infection.
- While symptoms align with acute hepatitis, the serology (low IgM anti-HBc) is not characteristic of primary acute infection.
*Passive immunity*
- Passive immunity would be characterized by the presence of **Anti-HBs without HBsAg**, which is not seen here.
- This scenario usually occurs after receiving hepatitis B immunoglobulin or transplacental transfer of antibodies.
*Acute resolving infection*
- A resolving acute infection would typically show a **decrease in HBsAg** and the **presence of Anti-HBs**, neither of which are observed in this patient.
- The **high viral load (HBV DNA)** and persistent HBsAg also contradict a resolving infection.
*Resolved HBV infection (innate immunity)*
- A resolved HBV infection is defined by the **absence of HBsAg** and the **presence of Anti-HBs**, along with anti-HBc.
- This patient still has **HBsAg present** and **Anti-HBs negative**, ruling out a resolved infection.
Acute hepatitis B US Medical PG Question 4: A 27-year-old woman who recently emigrated from Brazil comes to the physician because of fever, fatigue, decreased appetite, and mild abdominal discomfort. She has not seen a physician in several years and her immunization status is unknown. She drinks 2 alcoholic beverages on the weekends and does not use illicit drugs. She is sexually active with several male partners and uses condoms inconsistently. Her temperature is 38°C (99.8°F). Physical examination shows right upper quadrant tenderness and scleral icterus. Serology confirms acute infection with a virus that has partially double-stranded, circular DNA. Which of the following is most likely involved in the replication cycle of this virus?
- A. Adhesion of virus to host ICAM-1 receptor
- B. Cleavage of gp160 to form envelope glycoprotein
- C. Bacterial translation of viral DNA
- D. Transcription of viral DNA to RNA in the cytoplasm
- E. Reverse transcription of viral RNA to DNA (Correct Answer)
Acute hepatitis B Explanation: ***Reverse transcription of viral RNA to DNA***
- The description of a virus with **partially double-stranded, circular DNA** that causes acute infection with fever, fatigue, and **scleral icterus** points to **Hepatitis B virus (HBV)**.
- HBV is a **hepadnavirus** with a unique replication strategy: despite being a DNA virus, it replicates through an **RNA intermediate** (pregenomic RNA).
- The virus uses **reverse transcriptase** to synthesize DNA from this RNA template within the nucleocapsid—making it the only DNA virus that uses reverse transcription in its replication cycle.
*Adhesion of virus to host ICAM-1 receptor*
- The **intercellular adhesion molecule 1 (ICAM-1) receptor** is primarily used by viruses like **rhinovirus** for entry into host cells, which is not characteristic of HBV.
- HBV primarily uses the **sodium taurocholate co-transporting polypeptide (NTCP)** as its entry receptor on hepatocytes.
*Cleavage of gp160 to form envelope glycoprotein*
- **gp160** is a precursor protein of the **HIV envelope glycoprotein**, which is cleaved into gp120 and gp41, essential for HIV entry.
- This process is specific to **retroviruses** like HIV and is not involved in HBV replication.
*Bacterial translation of viral DNA*
- Viruses, including HBV, replicate within **eukaryotic host cells** and utilize the host cell's machinery for replication, transcription, and translation.
- **Bacterial translation** is irrelevant to viral replication in human hosts.
*Transcription of viral DNA to RNA in the cytoplasm*
- While transcription of viral DNA to RNA does occur in HBV, it primarily takes place in the **nucleus** of the host hepatocyte, not the cytoplasm.
- The resulting pregenomic RNA is then exported to the cytoplasm for **reverse transcription** within newly assembled nucleocapsids.
Acute hepatitis B US Medical PG Question 5: A 3255-g (7-lb) female newborn is delivered at term. Pregnancy and delivery were uncomplicated. On the day of her birth, she is given a routine childhood vaccine that contains a noninfectious glycoprotein. This vaccine will most likely help prevent infection by which of the following pathogens?
- A. Bordetella pertussis
- B. Rotavirus
- C. Poliovirus
- D. Haemophilus influenzae type b
- E. Hepatitis B virus (Correct Answer)
Acute hepatitis B Explanation: ***Hepatitis B virus***
- The **Hepatitis B vaccine** is routinely given at birth and contains a **noninfectious glycoprotein** (HBsAg) that elicits an immune response.
- This vaccine is crucial for preventing mother-to-child transmission and provides long-term protection against **Hepatitis B infection**.
*Bordetella pertussis*
- The vaccine for **Bordetella pertussis** (whooping cough) is part of the DTaP vaccine and is typically given at 2 months of age, not at birth.
- The DTaP vaccine usually contains **inactivated toxins** or acellular components, not solely a glycoprotein.
*Rotavirus*
- The **Rotavirus vaccine** is an **oral live-attenuated vaccine** administered in two or three doses, with the first dose typically given at 2 months of age.
- It does not contain a noninfectious glycoprotein.
*Poliovirus*
- The **Poliovirus vaccine** (IPV) is an **inactivated vaccine** given at 2 months of age, and the **oral poliovirus vaccine (OPV)** is a live-attenuated vaccine.
- Neither is routinely given at birth, nor described as a noninfectious glycoprotein.
*Haemophilus influenzae type b*
- The **Haemophilus influenzae type b (Hib) vaccine** is a polysaccharide-protein conjugate vaccine, first administered at 2 months of age.
- While it contains a protein component, it is not typically given at birth.
Acute hepatitis B US Medical PG Question 6: A scientist is studying the replication sequences of a number of different viruses. He observes that one particular virus he is studying creates a single stranded DNA from an RNA template during its replication sequence. Which of the following viruses is he most likely observing?
- A. Hepatitis C virus
- B. Norovirus
- C. Hepatitis B virus (Correct Answer)
- D. HSV-1
- E. Hepatitis A virus
Acute hepatitis B Explanation: ***Hepatitis B virus***
- This virus is a **DNA virus** that replicates via an **RNA intermediate**, using a **reverse transcriptase** enzyme to synthesize DNA from an RNA template.
- Its replication cycle involves creating a pre-genomic RNA from its DNA genome, which is then reverse-transcribed into **partially double-stranded DNA** for packaging into new virions.
*Hepatitis C virus*
- This is an **RNA virus** that replicates entirely within the cytoplasm and does not utilize a DNA intermediate or reverse transcriptase.
- Its replication involves the synthesis of a **negative-sense RNA strand** from the positive-sense genomic RNA, which then serves as a template for new positive-sense RNA genomes.
*Norovirus*
- This is a **positive-sense, single-stranded RNA virus** that replicates in the cytoplasm of host cells.
- It uses an **RNA-dependent RNA polymerase** to synthesize new RNA genomes directly from an RNA template, without a DNA intermediate.
*HSV-1*
- **Herpes Simplex Virus type 1 (HSV-1)** is a **double-stranded DNA virus** that replicates in the nucleus of infected cells.
- Its replication pathway involves **DNA-dependent DNA polymerase** to replicate its genome and does not involve an RNA to DNA transcription step.
*Hepatitis A virus*
- This is a **positive-sense, single-stranded RNA virus** that belongs to the **Picornaviridae family**.
- Like other RNA viruses, it replicates its genome via an **RNA-dependent RNA polymerase**, directly creating new RNA copies from an RNA template without a reverse transcription step.
Acute hepatitis B US Medical PG Question 7: A 52-year-old female presents to her primary care physician for medical evaluation prior to an elective hip replacement surgery. She has hypertension and diabetes, both of which are well controlled on oral medications. She also admits to occasional use of recreational injection drugs so a panel of serologies are obtained. Based on the results, the patient is found to have had a previous infection with hepatitis B from which she has fully recovered. Which of the following is a characteristic of the immunoglobulin subtype that most likely binds to hepatitis B core antigen in this patient?
- A. It exists as a dimer
- B. It is only activated by multivalent immunogens
- C. It exists as a pentamer
- D. It activates mast cells
- E. It exists as a monomer (Correct Answer)
Acute hepatitis B Explanation: ***It exists as a monomer***
- In a recovered hepatitis B infection, **anti-HBc IgG** antibodies are prominent, indicating past exposure and immunity.
- **IgG** is the most abundant immunoglobulin in serum and exists primarily as a **monomer**, providing long-term immunity.
*It exists as a dimer*
- This characteristic primarily describes **secretory IgA**, which is found in mucosal secretions like tears, saliva, and breast milk.
- While IgA can be involved in host defense, it's not the primary antibody subtype associated with sustained immunity after hepatitis B recovery, nor does it typically target the **core antigen** in this context.
*It is only activated by multivalent immunogens*
- This statement is more characteristic of **IgM**, which often requires multiple binding sites to activate complement efficiently due to its pentameric structure.
- **IgG** can bind to both univalent and multivalent antigens and is effective in neutralizing pathogens and activating other immune responses.
*It exists as a pentamer*
- This describes **IgM**, which is typically the first antibody produced during a primary immune response and is found on the surface of B cells.
- In a recovered infection, IgM would have largely subsided, replaced by **IgG**.
*It activates mast cells*
- This is a hallmark function of **IgE**, which binds to receptors on mast cells and basophils, triggering the release of histamine and other mediators in allergic reactions.
- **IgG** has different effector functions, such as opsonization, neutralization, and complement activation.
Acute hepatitis B US Medical PG Question 8: A 33-year-old female comes to her primary care physician with complaints of fatigue and nausea. She has also noticed that her skin tone is darker than it used to be. On exam, the physician notes that the woman appears to be jaundiced and obtains liver enzymes which demonstrate an elevated AST and ALT. Further testing subsequently confirms the diagnosis of hepatitis B (HBV). The woman is extremely concerned about transmitting this disease to her loved ones and ask how HBV is transmitted. By which of the following routes can HBV be spread? (I) blood, (II) sexual contact, (III) maternal-fetal, and/or (IV) breast milk?
- A. II, III
- B. I, II, III, IV
- C. I, II, III (Correct Answer)
- D. I, III, IV
- E. I only
Acute hepatitis B Explanation: ***I, II, III***
- **Hepatitis B virus (HBV)** is primarily transmitted through contact with infected **blood** or other bloody body fluids (e.g., semen, vaginal secretions), making routes I (blood) and II (sexual contact) major modes of transmission.
- **Maternal-fetal transmission** (route III) can occur during childbirth, especially if the mother has high viral loads, although *in utero* transmission is rare.
*II, III*
- This option is incorrect because it omits **blood transmission (I)**, which is a major route for HBV spread through shared needles, transfusions, or open wounds.
- While sexual and maternal-fetal transmissions are significant, they do not account for all primary modes of spread.
*I, II, III, IV*
- This option is incorrect because while routes I, II, and III are valid, **breast milk (IV)** is generally *not* considered a significant route for HBV transmission.
- Studies have shown a very low, if any, risk of HBV transmission through breast milk, and breastfeeding is typically safe for HBV-positive mothers, especially if the infant is vaccinated.
*I, III, IV*
- This option is incorrect because it includes **breast milk (IV)**, which is not a clinically significant route of transmission, and it excludes **sexual contact (II)**, a very common mode of HBV spread.
- Many HBV infections are acquired through unprotected sexual intercourse with an infected partner.
*I only*
- This option is incorrect as it severely underrepresents the various transmission routes of HBV, omitting **sexual contact (II)** and **maternal-fetal transmission (III)**.
- While blood transmission is critical, HBV is also frequently spread through other bodily fluids and from mother to child.
Acute hepatitis B US Medical PG Question 9: A 52-year-old male patient with chronic alcoholism presents to an ambulatory medical clinic, where the hepatologist elects to perform comprehensive hepatitis B screening, in addition to several other screening and preventative measures. Given the following choices, which serologic marker, if positive, would indicate the patient’s immunity to the hepatitis B virus?
- A. HBeAb
- B. HBeAg
- C. HBsAb (Correct Answer)
- D. HBsAg
- E. HBcAb
Acute hepatitis B Explanation: ***HBsAb***
- A positive **HBsAb** (Hepatitis B surface antibody) indicates immunity to hepatitis B virus, either from successful **vaccination** or **recovery from past infection**.
- This antibody provides **protective immunity** against future HBV infection and is the definitive marker of immunity.
*HBeAb*
- **HBeAb** (Hepatitis B e antibody) indicates **seroconversion** from HBeAg during chronic HBV infection, suggesting lower viral replication.
- It does **not confer immunity** against the virus itself and only reflects a phase of chronic infection.
*HBeAg*
- **HBeAg** (Hepatitis B e antigen) indicates **active viral replication** with high infectivity during ongoing hepatitis B infection.
- Its presence signifies a **replicative phase** of infection and increased risk of transmission to others.
*HBsAg*
- **HBsAg** (Hepatitis B surface antigen) indicates **active hepatitis B infection**, whether acute or chronic.
- This antigen is the **first serologic marker** to appear following exposure and confirms presence of the virus.
*HBcAb*
- **HBcAb** (Hepatitis B core antibody) indicates **previous or current exposure** to hepatitis B virus.
- It does **not differentiate** between acute, chronic, or resolved infection and does not confer protective immunity.
Acute hepatitis B US Medical PG Question 10: A 32-year-old woman comes to the emergency department for a 2-week history of right upper quadrant abdominal pain. She has also been feeling tired and nauseous for the past 5 weeks. She has a history of depression and suicidal ideation. She is a social worker for an international charity foundation. She used intravenous illicit drugs in the past but quit 4 months ago. Her only medication is sertraline. Her temperature is 37.8°C (100.0°F), pulse is 100/min, and blood pressure is 128/76 mm Hg. She is alert and oriented. Scleral icterus is present. Abdominal examination shows tenderness to palpation in the right upper quadrant. The liver edge is palpated 3 cm below the right costal margin. There is no rebound tenderness or guarding. The abdomen is non-distended and the fluid wave test is negative. She is able to extend her arms with wrists in full extension and hold them steady without flapping. Laboratory studies show:
Hemoglobin 13.8 g/dL
Leukocytes 13,700/mm3
Platelets 165,000/mm3
Prothrombin time 14 seconds
Partial thromboplastin time 35 seconds
Serum:
Total bilirubin 4.8 mg/dL
Direct bilirubin 1.3 mg/dL
Aspartate aminotransferase 1852 U/L
Alanine aminotransferase 2497 U/L
Urea nitrogen 21 mg/dL
Creatinine 1.2 mg/dL
Hepatitis A IgM antibody Negative
Hepatitis B surface antigen Negative
Hepatitis B surface antibody Negative
Hepatitis B core IgM antibody Positive
Hepatitis C antibody Positive
Hepatitis C RNA Negative
Urine beta-hCG Negative
Which of the following is the most appropriate next step in management?
- A. Supportive therapy (Correct Answer)
- B. Vaccination against Hepatitis B
- C. Ribavirin and interferon
- D. Tenofovir
- E. Pegylated interferon-alpha
Acute hepatitis B Explanation: ***Supportive therapy***
- The patient has **acute hepatitis B** based on positive **hepatitis B core IgM antibody** and highly elevated **ALT** and **AST** (>2000 U/L).
- The serological pattern (**HBsAg negative, HBcore IgM positive, HBsAb negative**) represents the **"window period"** of acute hepatitis B, occurring when HBsAg has cleared but HBsAb has not yet developed.
- Acute hepatitis B in **immunocompetent adults** is typically **self-limiting** (>95% clearance rate), making **supportive care** the appropriate management.
- No signs of **hepatic encephalopathy** (no asterixis), **coagulopathy** (PT normal), or **fulminant hepatic failure** are present, so antiviral therapy is not indicated.
- While she has **Hepatitis C antibody positive**, the **Hepatitis C RNA is negative**, indicating **resolved past infection** (likely from prior IV drug use) and not the cause of her current acute hepatitis.
*Vaccination against Hepatitis B*
- **Vaccination is contraindicated** during active/acute hepatitis B infection, as evidenced by positive **Hepatitis B core IgM antibody**.
- Vaccination is for **prevention**, not treatment, of existing infection.
*Ribavirin and interferon*
- This combination therapy was historically used for **chronic hepatitis C infection**, which this patient does not have (negative HCV RNA indicates resolved infection).
- It is **not indicated for acute hepatitis B** treatment.
*Tenofovir*
- **Tenofovir** is an antiviral agent used to treat **chronic hepatitis B** or **severe/fulminant acute hepatitis B** with signs of liver failure.
- Given the patient's **immunocompetent status**, absence of hepatic decompensation, and the typically **self-limiting nature of acute HBV** in adults, antiviral therapy is **not indicated**.
- Treatment would only be considered if signs of **fulminant hepatic failure** develop (encephalopathy, severe coagulopathy, rapidly rising bilirubin).
*Pegylated interferon-alpha*
- **Pegylated interferon-alpha** is used in some cases of **chronic hepatitis B and C**, but it is **not indicated for acute hepatitis B** in immunocompetent adults.
- The infection is expected to resolve spontaneously with supportive care in >95% of immunocompetent adults.
- Side effects are significant, and its use is reserved for chronic cases, not acute self-limiting presentations.
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