# Situation: A 29-year-old woman has a pre-employment medical examination at a private manufacturing company. Her hepatitis B surface antigen (HBsAg) test is positive. Her alanine aminotransferase (ALT) level is normal, she has no symptoms, and she recalls no past illness with jaundice. The occupational health nurse counsels her. Further tests are done. Her results are: HBsAg: positive IgM antibody to hepatitis B core antigen (IgM anti-HBc): negative Total antibody to hepatitis B core antigen (anti-HBc): positive Antibody to hepatitis B surface antigen (anti-HBs): negative How should the nurse classify her hepatitis B status?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629716  
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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 29-year-old woman has a pre-employment medical examination at a private manufacturing company. Her hepatitis B surface antigen (HBsAg) test is positive. Her alanine aminotransferase (ALT) level is normal, she has no symptoms, and she recalls no past illness with jaundice. The occupational health nurse counsels her.

Further tests are done. Her results are:
HBsAg: positive
IgM antibody to hepatitis B core antigen (IgM anti-HBc): negative
Total antibody to hepatitis B core antigen (anti-HBc): positive
Antibody to hepatitis B surface antigen (anti-HBs): negative
How should the nurse classify her hepatitis B status?

## 보기

1. Chronic hepatitis B infection **✔ 정답**
2. Acute hepatitis B infection
3. Resolved infection with immunity
4. Early infection before antibodies form

**정답: 1**

## 해설

A positive HBsAg means the virus is present now. A positive total anti-HBc with a negative IgM anti-HBc shows that the infection is not recent, so the pattern is chronic infection (confirmed when HBsAg persists for more than 6 months). A resolved infection would show a negative HBsAg with a positive anti-HBs, and a normal ALT with no symptoms does not exclude chronic infection.

## 심화 해설

Interpreting the serologic pattern

The combination of a positive HBsAg, a positive total anti-HBc, and a negative IgM anti-HBc indicates that hepatitis B virus is currently present and that the infection is not in its early, acute phase. Because IgM anti-HBc is the marker that rises during recent infection and then disappears, its absence points away from acute hepatitis B. The presence of total anti-HBc confirms that the immune system has encountered the virus, while the persistently positive HBsAg shows that viral surface antigen is still being produced. This pattern is classified as chronic hepatitis B infection [1][3].

Key point! Chronic infection is confirmed when HBsAg remains positive for more than 6 months. In this patient, the negative IgM anti-HBc already suggests the infection is not recent, so the chronic classification is appropriate even before a full 6-month follow-up is documented [4].

Why the other options do not fit

A resolved infection with immunity would show a negative HBsAg and a positive anti-HBs. Here the anti-HBs is negative, meaning the patient has not cleared the surface antigen and has not developed protective surface antibody. An acute infection would typically show a positive IgM anti-HBc, which is absent in this case. Early infection before antibodies form would not yet show a positive total anti-HBc, so that option is also excluded [1][3].

Clinical significance of normal ALT and no symptoms

A normal alanine aminotransferase (ALT) level and the absence of jaundice or other symptoms do not rule out chronic hepatitis B. Many individuals with chronic HBV infection are asymptomatic and have normal or only mildly elevated liver enzymes, especially in the immune-tolerant or inactive carrier phases. The infection can still progress to cirrhosis or hepatocellular carcinoma over time, so ongoing monitoring is required [4].

Watch out! Do not interpret a normal ALT as evidence of resolved infection. The serologic markers, not symptoms or transaminase levels alone, define the phase of hepatitis B infection.

How the markers fit together

| Marker | Result in this patient | Interpretation |
| --- | --- | --- |
| HBsAg | Positive | Virus is present; ongoing infection |
| IgM anti-HBc | Negative | Infection is not acute or recent |
| Total anti-HBc | Positive | Past or ongoing exposure to HBV |
| Anti-HBs | Negative | No protective surface antibody; virus not cleared |

The negative IgM anti-HBc is the key discriminator between acute and chronic infection. In acute hepatitis B, IgM anti-HBc appears early and is positive. In chronic infection, the IgM class antibody is typically negative while total anti-HBc remains positive because the immune system has been exposed to the core antigen over a prolonged period [1][3].

Implications for nursing care and follow-up

The occupational health nurse should explain that the positive HBsAg means the patient is potentially infectious to others through blood and body fluid exposure. Counseling should include the need for regular follow-up, typically every 6 months, with liver function tests and, when indicated, HBV DNA measurement. Patients with chronic HBV also require periodic liver ultrasound for hepatocellular carcinoma surveillance if they meet high-risk criteria [4].

The serologic pattern of positive HBsAg, positive total anti-HBc, negative IgM anti-HBc, and negative anti-HBs is the classic profile of chronic hepatitis B infection, regardless of normal ALT or absence of symptoms.References (research sources)

- [1][Diagnosis of chronic hepatitis B infection].Research articleStene-Johansen K, Barlinn R (2013) · DOI: 10.4045/tidsskr.12.1206

- [3]Hepatitis B Virus: From Diagnosis to Treatment.Research articleGuvenir M, Arikan A (2020) · DOI: 10.33073/pjm-2020-044

- [4]The management of chronic hepatitis B infection.Research articleMatthews GV, Nelson MR (2001) · DOI: 10.1258/0956462011923273

## 임상 시나리오

Hepatitis B Serology InterpretationClassifying infection status in occupational health screening
Positive HBsAg indicates the virus is present now. A positive total anti-HBc with negative IgM anti-HBc shows the infection is not recent, classifying the patient as having chronic hepatitis B infection.

Chronic infection is confirmed when HBsAg remains positive for more than 6 months. A negative IgM anti-HBc already suggests a non-recent infection, so chronic classification is appropriate even before full follow-up documentation.

CautionA normal ALT and absence of symptoms do not exclude chronic infection. Resolved immunity requires negative HBsAg and positive anti-HBs; acute infection would show positive IgM anti-HBc.

## 핵심 개념

- **HBsAg** — Hepatitis B surface antigen; a positive result indicates current hepatitis B virus infection.
- **IgM anti-HBc** — IgM antibody to hepatitis B core antigen; a marker of recent or acute infection, typically absent in chronic infection.
- **Total anti-HBc** — Total antibody to hepatitis B core antigen; indicates past or ongoing infection, not immunity from vaccination.
- **anti-HBs** — Antibody to hepatitis B surface antigen; a positive result indicates recovery and immunity or vaccination.
- **Chronic hepatitis B** — Persistent hepatitis B infection defined by HBsAg positivity for more than 6 months.

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