A 47-year-old asymptomatic woman has tested positive for hepatitis delta antigen (HDAg) (confirmed on repeat testing) and hepatitis Be antigen (HBeAg). The following test results are negative: hepatitis Be antibody, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody, hepatitis B core antibody (both immunoglobulin M and immunoglobulin G). Hepatitis B viral (HBV) DNA is undetectable. She is negative for hepatitis C. Liver function tests are normal. Does she have hepatitis B?
—Karl Kaplan, MD, Van Nuys, Calif.

Hepatitis D occurs as an acute co-infection with hepatitis B or as superinfection in hepatitis B carriers; HBsAg is essential in either case. In an acute hepatitis D infection, HBV could be suppressed. Chronic hepatitis D is characterized by high titers of hepatitis D antibody (HDAb) but undetectable HDAg (sequestered by excessive HDAb) and persistently elevated hepatitis D viral RNA. I recommend rechecking the HBeAg, HBsAg, and HBV DNA in a reference lab to ensure the results are accurate. If those determinations are truly negative, then this patient does not have hepatitis B (and hence not D) infection, especially since her liver function tests are normal. For additional information, see J Hepatol. 2003;39 Suppl 1:S212-S219.
—Ramsey Cheung, MD, associate professor of medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, Calif. (117-23)

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