Occult HBV/reactivation?

I’m a little confused about the occult HBV and hope experts could shred some light.

About decade ago, I was accidentally tested very high ALT during routine exam (no symptoms), and HBsAg-, antiHBs+, antiHBc+. I was told I could have an acute HBV but already got natural immunity, just liver was still recovering. My husband then also got the HBV tests (same as mine except his ALT was normal). One month later, my liver function returned normal. Over the years, liver functions never tested abnormal again during routine checkups for both us, and hepatitis panel results remained the same, also HBV DNA not reactivated. We have no idea how we contracted the virus since we don’t have any risks through sexual or blood (we never had sex with anyone else except each other).

Not until recently, my husband had a few days’ abdomen upset with low fever but fully recovered, we thought it was just stomach flu. He happened to have an annual checkup one week later and surprisedly found high liver function (ALT>1000). He’s healthy otherwise and didn’t take any medications. He was then tested for all the possible viral/autoimmune, as well as ultrasound/MRI, everything showed negative. However, Fibroscan did show almost 10 kPa abnormal. Referred to GI and hepatologist and repeated all the tests but couldn’t find any possible cause. One month later, his liver function slowly returned to normal and remained normal ever since. So he was told he had an episode of acute hepatitis with unknown reason.

Fast forwarding another two months after liver functions returned normal, he saw another hepatologist for second opinion and the doctor didn’t trust previous Fibroscan results and retested himself, this time showed 5 kPa normal. This time the new doctor tested something different including HBV DNA (results <10, Not Detected), also a HBsAg number 0.4 (not sure what’s the units), antiHBs number>1000. All other tests repeated are still the same including HBsAg-, antiHBs+, antiHBc+ and normal liver function. So still couldn’t find out what happened and everything is normal now.

I was wondering, could it be occult HBV/reactivation? Note that during the acute phase (elevated ALT&AST), no doctors ever suspected HBV reactivation, so HBV DNA was not tested, but did tested for HBsAg-, antiHBs+, antiHBc+. By researching literature, I saw occult HBV is defined as HBsAg negative or positive, and/or HBV DNA negative or positive. So HBV DNA could be detected intermittently but not always. Could it be his HBV DNA was indeed positive at acute phase and then return undetected after the flare? Note that if he delayed the annual exam for one month, such acute hepatitis would never be detected and all his blood tests showed normal ever since.

Thanks in advance!

Edit:sorry that I took another look at all the tests results and find HBV DNA was indeed tested once during the time of elevated ALT/AST (Not Detected). I missed it and made a mistake in the original post. Now I’m really not sure, seems unlikely HBV reactivation then?

Hi @jjj,
Those are all great questions and thanks for sharing your experiences. Hepatitis B is a very complex disease and at times throw curve balls our way. Here is my layman’s view from the test results: (1). There is no evidence that your husband have hepatitis B (HBsAg-) and (2). he has antibodies against hepatitis B (antiHBs+). 3) There is no evidence of HBV DNA (not detected) as well. Regarding the high increase in either AST or ALT, these enzymes are not only made in the liver. There are other organs in the body such as the heart, pancreas etc and our muscle tissues produces them as well. They get released into the bloodstream when there is some sort of muscle damage. When someone starts heavy weight lifting or vigorous exercise regiment if they get tested they will see their numbers go up due to any muscle damage from this new lifestyle changes. Did you or your husband do anything different or new during the periods of the spikes in ALT? Is it possible that maybe you both contracted hepatitis A? Which is caused from drinking water or eating food that is contaminated with the virus. It can also cause liver enzymes elevation. If nothing changed during that time, my view will be to let the doctor look at other organs and muscle tissues as it is possible the liver is not the cause (that is if the condition still persist).

Other experts will chime in as soon as one is available. I hope you both do not have to go through this stress and ordeal again. Best, Bansah1.

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Hi, @Bansah1 :

Thanks for your kind response! The weird thing is his lifestyle didn’t change, no heavy exercise/lift, no muscle damage, etc. He did test for A, C, even D, E, as well as some other viral diseases that could possibly cause elevated ALT/AST, all negative. Autoimmune marks/antibodies all negative. Following repeated tests are all negative. Imaging on liver, pancreas, and other organs are all negative, no bile duct dilation, no gallstones (some gallbladder sludge, though). So that’s why I started wondering if HBV reactivation could be remotely possible…At one point autoimmune was suspected but repeated blood tests didn’t show any indications. Passing stone was also once suspected but imaging didn’t show abnormalities, bilirubin only slightly elevated (1.2) and ALT/AST didn’t decrease rapidly like passing stones. The whole time he felt healthy without symptoms other than a few days’ abdomen upset. His liver functions all returned to normal after one month, and now there’s no single trace of abnormal tests. The acute hepatitis episode remains a mystery… If he didn’t do that annual checkup at that time, the episode won’t even be caught. The only thing I can think of liver problem was accidental finding of a resolved HBV many years ago…

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Hi all,

I don’t see anything in this medical history consistent with HBV having suddenly activated from an occult state to a high level of replication followed by complete resolution to HBV undetectable without leaving any immunological markers. This is more likely a case of severe acute hepatitis from something else.

Lots of other viruses can infect the liver beyond just the classics (ie, HAV, HBV, HCV, HDV, and HEV), and they would have been unlikely to be tested for in this case. For example, Yellow Fever Virus is transmitted by mosquitos in tropical areas and causes hepatitis as part of its disease spectrum.

Also, a chemical toxicity is possible, but I’m not a physician and cannot comment on that much beyond noting that acetaminophen (ie, tylenol) overdoses are easy to get inadvertently as acetaminophen is in a lot of over-the-counter medications. This is the leading cause of acute liver failure in the USA.

Unfortunately, this is likely to remain a mystery. Hopefully it will not reoccur.

I wish you the best.



Hi, @john.tavis

Thanks for your insights! Yes, unfortunately doctors couldn’t find a cause other than an acute hepatitis diagnosis. He didn’t test for yellow fever virus, because we are not in this virus region and it was winter so no mosquitos. We didn’t travel so just low risk lifestyle and mostly ate together but I didn’t have the problem. Tylenol could cause liver damage but he didn’t take any medications including pain relievers. We asked the hepatologists if they were aware of any virus (cause acute hepatitis) circled around around the area but they didn’t notice any.

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