Chronic hepatitis B phases US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Chronic hepatitis B phases. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Chronic hepatitis B phases US Medical PG Question 1: A 35-year-old male anesthesiologist presents to the occupational health clinic after a needlestick exposure while obtaining an arterial line in a patient with cirrhosis. In addition to a standard bloodborne pathogen laboratory panel sent for all needlestick exposures at his hospital, additional hepatitis panels are ordered upon the patient's request. The patient's results are shown below:
HIV 4th generation Ag/Ab: Negative/Negative
Hepatitis B surface antigen (HBsAg): Negative
Hepatitis C antibody: Negative
Anti-hepatitis B surface antibody (HBsAb): Positive
Anti-hepatitis B core IgM antibody (HBc IgM): Negative
Anti-hepatitis B core IgG antibody (HBc IgG): Positive
What is the most likely explanation of the results above?
- A. Window period
- B. Chronic infection
- C. Acute infection
- D. Immune due to infection (Correct Answer)
- E. Immune due to vaccination
Chronic hepatitis B phases Explanation: ***Immune due to infection***
- The presence of **anti-HBc IgG** along with **anti-HBsAb** in the absence of **HBsAg** indicates past resolution of HBV infection.
- This combination confers **natural immunity** following a prior exposure, distinguishing it from vaccine-induced immunity (which would lack anti-HBc IgG).
*Window period*
- This period is characterized by the absence of **HBsAg** and **anti-HBsAb**, with the only positive marker being **anti-HBc IgM**.
- The patient's results show positive **anti-HBsAb** and **anti-HBc IgG**, which rule out a window period.
*Chronic infection*
- Chronic infection is defined by the persistence of **HBsAg** for more than six months.
- The patient's **HBsAg is negative**, therefore excluding chronic infection.
*Acute infection*
- Acute infection would be evidenced by the presence of **HBsAg** and often **anti-HBc IgM**.
- Both **HBsAg** and **anti-HBc IgM** are negative in this patient, ruling out acute infection.
*Immune due to vaccination*
- Vaccination leads to the development of **anti-HBsAb** but does not produce **anti-HBc antibodies**.
- The presence of **anti-HBc IgG** in this patient indicates exposure to the complete virus, not just vaccination.
Chronic hepatitis B phases US Medical PG Question 2: A 26-year-old woman who is a medical student is undergoing evaluation after sticking herself with a needle while drawing blood from a patient. The patient’s medical history is unknown. A blood sample from the medical student is drawn and processed, and the results are presented below:
Anti-HAV IgM negative
Anti-HAV IgG positive
HBsAg negative
HBeAg negative
Anti-HBs negative
Anti-HBc IgG negative
Anti-HBc IgM negative
Anti-HBe negative
Anti-HCV negative
What is true about the student’s laboratory findings?
- A. She has not been vaccinated against the hepatitis B virus. (Correct Answer)
- B. She recovered from a hepatitis B virus infection.
- C. She is infected with the hepatitis D virus.
- D. She can transmit the hepatitis A virus.
- E. She is an asymptomatic carrier of the hepatitis B virus.
Chronic hepatitis B phases Explanation: ***She has not been vaccinated against the hepatitis B virus.***
- A **negative Anti-HBs** indicates a lack of protective antibodies developed either through vaccination or past infection.
- A **negative Anti-HBc IgG** and **IgM** further confirms no prior exposure to the hepatitis B core antigen, which would be present with natural infection.
*She recovered from a hepatitis B virus infection.*
- Recovery from HBV infection would typically show **positive Anti-HBs** and **positive Anti-HBc IgG**, neither of which are present here.
- The absence of **Anti-HBc antibodies** rules out past natural infection, whether resolved or chronic.
*She is infected with the hepatitis D virus.*
- Hepatitis D virus (HDV) infection only occurs in the presence of an active **Hepatitis B virus (HBV) infection**.
- The student's **HBsAg negative** status indicates no active HBV infection, thereby ruling out HDV.
*She can transmit the hepatitis A virus.*
- **Anti-HAV IgG positive** indicates prior exposure to HAV or vaccination, leading to immunity.
- **Anti-HAV IgM negative** suggests no acute HAV infection, meaning she is not currently infectious.
*She is an asymptomatic carrier of the hepatitis B virus.*
- An asymptomatic carrier of HBV would have **positive HBsAg** and likely **positive Anti-HBc IgG**, but both are negative in this case.
- The absence of **HBsAg** definitively rules out an active carrier state.
Chronic hepatitis B phases US Medical PG Question 3: 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)
Chronic hepatitis B phases 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.
Chronic hepatitis B phases US Medical PG Question 4: 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
Chronic hepatitis B phases 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.
Chronic hepatitis B phases US Medical PG Question 5: 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
Chronic hepatitis B phases 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.
Chronic hepatitis B phases US Medical PG Question 6: 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)
Chronic hepatitis B phases 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.
Chronic hepatitis B phases US Medical PG Question 7: 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
Chronic hepatitis B phases 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.
Chronic hepatitis B phases US Medical PG Question 8: A 44-year-old woman presents to the emergency department with jaundice and diffuse abdominal pain. She denies any previous medical problems and says she does not take any medications, drugs, or supplements. Her temperature is 97.6°F (36.4°C), blood pressure is 133/87 mmHg, pulse is 86/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for sclera which are icteric and there is tenderness to palpation over the right upper quadrant. Laboratory studies are ordered as seen below.
Hepatitis B surface antigen: Positive
Hepatitis B surface antibody: Negative
Hepatitis B core antibody IgM: Negative
Hepatitis B core antibody IgG: Positive
Hepatitis B E antigen: Positive
Hepatitis B E antibody (anti-HBe): Negative
Which of the following is the most likely diagnosis?
- A. Chronic hepatitis B infection (Correct Answer)
- B. Hepatitis B vaccination
- C. Acute hepatitis B infection
- D. Resolved hepatitis B infection
- E. No hepatitis B vaccination or infection
Chronic hepatitis B phases Explanation: ### ***Chronic hepatitis B infection***
- The presence of **Hepatitis B surface antigen (HBsAg) positive** combined with **Hepatitis B core antibody IgG (anti-HBc IgG) positive** indicates infection that has persisted beyond 6 months.
- **Hepatitis B core antibody IgM (anti-HBc IgM) negative** rules out acute infection, as IgM antibodies appear early in acute hepatitis B.
- **Hepatitis B e antigen (HBeAg) positive** indicates active viral replication and high infectivity, consistent with HBeAg-positive chronic hepatitis B.
- The clinical presentation with jaundice and RUQ pain suggests an acute flare of chronic hepatitis B infection.
### *Hepatitis B vaccination*
- Successful hepatitis B vaccination produces **anti-HBs positive** with **HBsAg negative** and **anti-HBc negative**.
- This patient has **HBsAg positive** and **anti-HBc IgG positive**, indicating actual infection rather than vaccine-induced immunity.
### *Acute hepatitis B infection*
- Acute hepatitis B is characterized by **HBsAg positive** with **anti-HBc IgM positive** (IgM appears first in acute infection).
- This patient has **anti-HBc IgM negative** and **anti-HBc IgG positive**, indicating the infection occurred more than 6 months ago, consistent with chronic rather than acute infection.
### *Resolved hepatitis B infection*
- Resolved infection shows **HBsAg negative**, **anti-HBs positive**, and **anti-HBc IgG positive**.
- This patient's **HBsAg positive** status directly indicates ongoing infection, not resolution.
### *No hepatitis B vaccination or infection*
- Complete absence of exposure would show **HBsAg negative**, **anti-HBs negative**, and **anti-HBc negative** (all markers negative).
- This patient has multiple positive markers including **HBsAg** and **anti-HBc IgG**, confirming hepatitis B infection.
Chronic hepatitis B phases US Medical PG Question 9: A 47-year-old woman comes to the physician because of a 3-week history of generalized fatigue, mild fever, abdominal pain, and nausea. She attended the state fair over a month ago, where she tried a number of regional foods, and wonders if it might have been caused by something she ate. She has also noticed darkening of her urine, which she attributes to not drinking enough water recently. She has type 2 diabetes mellitus. She drinks 1–2 beers daily. She works as nursing assistant in a rehabilitation facility. Current medications include glyburide, sitagliptin, and a multivitamin. She appears tired. Her temperature is 38.1°C (100.6°F), pulse is 99/min, and blood pressure is 110/74 mm Hg. Examination shows mild scleral icterus. The liver is palpated 2–3 cm below the right costal margin and is tender. Laboratory studies show:
Hemoglobin 10.6 g/dL
Leukocyte count 11600/mm3
Platelet count 221,000/mm3
Serum
Urea nitrogen 26 mg/dL
Glucose 122 mg/dL
Creatinine 1.3 mg/dL
Bilirubin 3.6 mg/dL
Total 3.6 mg/dL
Direct 2.4 mg/dL
Alkaline phosphatase 72 U/L
AST 488 U/L
ALT 798 U/L
Hepatitis A IgG antibody (HAV-IgG) positive
Hepatitis B surface antigen (HBsAg) positive
Hepatitis B core IgG antibody (anti-HBc) positive
Hepatitis B envelope antigen (HBeAg) positive
Hepatitis C antibody (anti-HCV) negative
Which of the following is the most likely diagnosis?
- A. Acute hepatitis B infection
- B. Resolved acute hepatitis B infection
- C. Active chronic hepatitis B infection (Correct Answer)
- D. Alcoholic hepatitis
- E. Inactive chronic hepatitis B infection
Chronic hepatitis B phases Explanation: ***Active chronic hepatitis B infection***
- The presence of **HBsAg positive**, **anti-HBc IgG positive** (not IgM), and **HBeAg positive** indicates chronic hepatitis B infection with active viral replication.
- The key distinguishing feature is **anti-HBc IgG** rather than anti-HBc IgM. In acute hepatitis B, **anti-HBc IgM** would be positive, whereas **anti-HBc IgG** indicates infection that occurred more than 6 months ago (chronic infection).
- The **HBeAg positivity** indicates active viral replication and high infectivity, making this an "active" chronic infection rather than an inactive carrier state.
- The markedly elevated **AST (488 U/L)** and **ALT (798 U/L)** levels indicate significant hepatocellular damage with active inflammation.
- Clinical features of **scleral icterus**, **dark urine** (conjugated hyperbilirubinemia), **fever**, **fatigue**, and **abdominal pain** are consistent with active hepatitis.
*Acute hepatitis B infection*
- This is ruled out by the presence of **anti-HBc IgG** rather than **anti-HBc IgM**.
- In acute hepatitis B infection, **anti-HBc IgM** (the IgM class antibody to core antigen) would be positive, indicating recent infection.
- The presence of IgG class antibody indicates the infection occurred more than 6 months ago, establishing chronicity.
*Resolved acute hepatitis B infection*
- In resolved infection, **HBsAg** would be negative, and **anti-HBs** (Hepatitis B surface antibody) would be positive, indicating immunity.
- This patient is **HBsAg positive**, ruling out resolved infection.
- Resolved infection would not cause the current hepatocellular injury.
*Alcoholic hepatitis*
- Although the patient drinks 1-2 beers daily (modest consumption), the **AST:ALT ratio** (488:798 = 0.61) is less than 2:1.
- In alcoholic hepatitis, the AST:ALT ratio is typically **>2:1** due to alcohol-induced pyridoxine deficiency affecting ALT more than AST.
- The specific **viral serology markers** (positive HBsAg, HBeAg, and anti-HBc IgG) definitively establish hepatitis B as the cause of liver inflammation.
*Inactive chronic hepatitis B infection*
- In inactive chronic hepatitis B (also called inactive carrier state), **HBsAg** would be positive, but **HBeAg** would be negative with positive **anti-HBe** antibody.
- **ALT levels** are typically normal or minimally elevated (<40-50 U/L) in inactive carriers, not markedly elevated as in this case (ALT 798 U/L).
- The positive **HBeAg** and significantly elevated transaminases indicate active viral replication and inflammation, not an inactive state.
Chronic hepatitis B phases 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
Chronic hepatitis B phases 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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