Name _____________________
Date _________________
Case Study One
A 42-year-old single white male went to his physician with complaints of fatigue, abdominal pain and loss of
appetite.
Past medical history:
·He had no history of hepatitis A vaccination or hepatitis B vaccination.
·He reported one male sex contact in the recent past.
Physical examination:
·the whites of his eyes were yellow
·liver was slightly enlarged and tender to palpation.
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Viral hepatitis was suspected, and hepatitis testing was ordered.
1. For the diagnosis of acute viral hepatitis, what serologic tests would be the most appropriate to order?
a. IgM anti-HAV, IgM anti-HBc, HBsAg, and anti-HCV
b. HBsAg and RIBA
c. IgM anti-HAV and IgM anti-HBc
The patient returned in one week for a follow-up visit.
The serologic results were as follows:
IgM anti-HAV - negative
IgM anti-HBc – positive
HBsAg – positive
anti-HCV – negative
2. Based on the serologic results above, what is the diagnosis?
a. Acute hepatitis A and acute hepatitis B
b. Acute hepatitis B
c. Acute hepatitis C
3. Identify the public health actions that should be taken in response to this case.
One The case of acute hepatitis B should be reported to the local health department.
Two The patient should be advised to inform his sex and household contacts that they might have been
exposed to HBV and that they should see a health care professional for medical evaluation.
Three The patient should be tested for total anti-HAV to determine if he is a candidate for hepatitis A
vaccination.
1. 1 and 3
2. 3
3. 1, 2 and 3
The patient notified the person with whom he had sex within the past four months (He had no sexual contact
within the last four weeks). The sexual contact then sought medical advice.
The contact had sex with the patient several times about three to four months ago. He had no signs or
symptoms of viral hepatitis. He had no history of having received hepatitis A or hepatitis B vaccine.
4.
What serologic tests should be done before vaccination of this sex contact?
One Total anti-HAV
Two Total anti-HBc
Three anti-HCV
a. 1 and 2
b. 2
c. 1, 2 and 3
Serologic results for the sexual contact were as follows:
Total anti-HBc – positive
Total anti-HAV – negative
5. Based on the serologic results, what further advice should be given to this patient?
One Get vaccinated against hepatitis A
Two Get vaccinated against hepatitis B
Three Get additional hepatitis B testing
Four Get tested for hepatitis C
a. 1, 2, 3 and 4
b. 1, 2 and 3
c. 1 and 3
Additional HBV test results for the sex contact were as follows:
HBsAg – positive
6. What does this serologic result indicate, and how should the patient be managed?
a. The patient is likely to have chronic HBV infection.
b. The patient should tell his sex and household contacts.
c. The patient should be evaluated for chronic liver disease
d. The case should be reported to the health department.
e. All of the above.
Case Study Two
Patient Information:
A 27-year-old African American female presented to the emergency room with a five day history of malaise, fatigue,
low-grade fever and nausea. Yesterday, she noted that her urine was very dark and her stools were very light in color. She
also complained of joint pain. Her liver was noted to be enlarged on physical exam and the whites of her eyes were
yellow. She had a history of three sex partners in the past few months, denied illegal drug use and otherwise was in good
health.
1. What viral hepatitis serologic tests would be appropriate to order? Please label the following groupings as A, B and C
and indicate the correct choice by letter or highlighting the group.
 HBsAg
 IgM anti-HBc
 IgM anti-HAV
 Anti-HCV



Total anti-HBc
Total anti-HAV
Anti-HCV


IgM anti-HBc
IgM anti-HAV
The results of the serologic tests were as follows:
HBsAg - positive
IgM anti-HBc - positive
IgM anti-HAV - negative
Anti-HCV – negative
2. Based on the serologic results, what is the patient's diagnosis? Please label the following bulleted groupings as A, B
C and D and indicate the correct choice by letter or highlighting the group.



Acute hepatitis A,
Acute hepatitis B, and
Acute hepatitis C

Acute hepatitis B

Acute hepatitis A
3. What else should the physician do?
a. Report the case of acute hepatitis B to the health department.
b. Counsel the patient that any sex contacts within the past six months are at risk of infection and should be told to
contact their health care provider for follow-up.
c. Counsel the patient about the importance of using methods (e.g., condoms) to prevent transmission of HBV to
sexual partners.
d. All of the above
Case Study Three
Patient Information:
A 32 year old white female has been an injection drug user for many years. She is now pregnant and is seeing
her obstetrician for her first prenatal visit. She has no history of hepatitis A or hepatitis B vaccination.
1. What viral hepatitis serologic tests would be appropriate to order? Please label the following bulleted groupings
as A, B and C and indicate the correct choice by letter or highlighting the group.



IgM anti-HBc
IgM anti-HAV
Anti-HCV

HBsAg only




HBsAg
Total anti-HBc
Total anti-HAV
Anti-HCV
The results of serologic testing were as follows:
HBsAg - negative
Total anti-HBc - positive
Total anti-HAV - negative
Anti-HCV - positive by enzyme immunoassay;
confirmatory test pending
2. Does the patient have chronic HBV infection?
a. Yes
b. No
3. Should the patient be evaluated for chronic liver disease?
a. Yes
b. No
The results of serologic testing were as follows:
HBsAg - negative
Total anti-HBc - positive
Total anti-HAV - negative
Anti-HCV – positive
4. Should the patient be considered for vaccination against hepatitis A?
a. Yes
b. No
5. Should the patient be vaccinated against hepatitis B?
a. Yes
b. No
The results of serologic testing were as follows:
HBsAg - negative
Total anti-HBc - positive
Total anti-HAV - negative
Anti-HCV - positive
(RIBA was performed and was positive)
6. Should her positive anti-HCV test result be reported to the state health department?
a. Yes
b. No
Case Study Four
Patient Information:
A 35 year-old Asian woman became ill with nausea, vomiting and abdominal pain. She also had "cola-colored"
urine for several days. She had been in Mexico approximately one month ago and had not had hepatitis A
vaccine or immune globulin prior to travel. On physical examination, she had icteric sclera and the right upper
quadrant of her abdomen was painful when palpated. The physician suspects acute viral hepatitis.
1. What serologic test(s) for acute viral hepatitis would be the most appropriate to order? Please label the
following bulleted groupings as A, B and C and indicate the correct choice by letter or highlighting the group.

IgM anti-HBc




IgM anti-HAV
IgM anti-HBc
HBsAg
Anti-HCV

IgM anti-HAV
The results of serologic testing were as follows:
HBsAg - negative
IgM anti-HBc - negative
IgM anti-HAV - positive
Anti-HCV - negative
2. Based upon these serologic results what is the diagnosis for the patient?
a. Acute hepatitis A
b. Acute hepatitis B
c. Acute hepatitis C
3. Should the patient’s household and sex contacts within the past two weeks be contacted for immune
globulin prophylaxis?
a. Yes
b. No
4. Should this case of acute hepatitis A should be reported to the health department?
a. Yes
b. No
5. What could she have done before her trip to Mexico to prevent HAV infection?
a. Get hepatitis A vaccine
b. Get immune globulin
c. Either of the above
Case Study Five
Patient Information:
A 44 year-old African American woman became ill with nausea, vomiting, and abdominal pain. She had been
on a trip to India about six weeks prior to the onset of her symptoms. Her physician noted that she was
jaundiced and the right upper quadrant of her abdomen was painful when palpated. The physician suspects
acute viral hepatitis.
The results of the serologic tests were as follows:
HBsAg - negative
IgM anti-HBc - negative
IgM anti-HAV - negative
Anti-HCV - negative
ALT - 2000 (upper limit of normal = 45)
1. Considering her travel history and the results of the blood tests, what other type of viral hepatitis should be
considered?
a. Hepatitis A
b. Hepatitis G
c. Hepatitis E
Case Study Six
Patient Information:
A 40-year-old white male with history of injection drug use for many years presented to the emergency room
with severe abdominal pain, jaundice, and mental confusion. Physical exam revealed "track" marks on both
arms.
1. What viral hepatitis serologic tests would be appropriate to order? Please label the following bulleted groupings
as A, B and C and indicate the correct choice by letter or highlighting the group.




HBsAg
IgM anti-HBc
IgM anti-HAV
anti-HCV



Total anti-HBc
Total anti-HAV
Anti-HCV


IgM anti-HBc
IgM anti-HAV
The results of the viral hepatitis testing were as follows:
HBsAg - positive
IgM anti-HBc - positive
IgM anti-HAV - negative
Anti-HCV - positive by enzyme immunoassay
HCV RNA – positive
2. Based upon the serologic results, what is the diagnosis for this patient?
a. Acute hepatitis B and HCV infection
b. HCV infection only
c. Acute hepatitis A
The results of the viral hepatitis testing were as follows:
IgM anti-HAV - negative
IgM anti- HBc - positive
Anti-HCV - positive
HCV RNA – positive
3. Considering the severity of his symptoms and his history of injection drug use, what other hepatitis tests
should be ordered?
a. Total anti-HDV
b. Total anti-HAV
c. All of the above
Results of further testing were as follows:
Total anti-HDV - positive
Total anti-HAV – positive
4. What do these results indicate?
a. Coinfection with HBV and HDV
b. History of HAV infection in the past
c. All of the above
His condition improved and he was discharged from the hospital. The discharge diagnosis was HBV-HDV
coinfection and chronic HCV infection. He had a follow-up visit with his physician 8 months after hospital
discharge. Results of hepatitis diagnostic testing done at this visit were as follows:
HBsAg - negative
Anti-HBs - 500 mIU/mL
HCV RNA - positive
Total anti-HDV – negative
5. What do these results indicate?
a. Resolved HBV/HDV coinfection
b. Immune to future HBV/HDV infections
c. HCV infection
d. All of the above
6. What should the physician recommend for the patient regarding his HCV status?
a. Nothing more needs to be done
b. Consult with or refer to a specialist in the management of chronic liver disease
Case Study Seven
Patient Information:
A 25 year old Asian male had been feeling very tired, was jaundiced and had vague "flu-like" symptoms. He
went to see his primary care physician who did a history and physical and ordered blood tests that included
serology for acute viral hepatitis.
1. What serologic test(s) for acute viral hepatitis would be the most appropriate to order? Please label the
following bulleted groupings as A, B and C and indicate the correct choice by letter or highlighting the group.

IgM anti-HBc




IgM anti-HAV
IgM anti-HBc
HBsAg
anti-HCV

IgM anti-HAV
Test results were as follows:
HBsAg - negative
IgM anti-HBc - negative
IgM anti-HAV - negative
Anti-HCV - positive by enzyme immunoassay (EIA)
- positive by recombinant immunoblot assay (RIBA)
ALT - 1500 IU (upper limit of normal - 45 IU).
2. What is the diagnosis for this patient?
a. Acute hepatitis C
b. Chronic hepatitis C
c. Acute hepatitis B
3. What further management does this patient need?
a. Interview to identify risk factors for infection
b. Counseling about how to reduce risk of transmitting HCV to others
c. Follow-up to determine outcome of the infection and possible need for treatment
d. All of the above
Case Study Eight
Patient Information:
A 43-year-old registered nurse was hired to work in the emergency room at a large tertiary care center. She was
given the 3-dose hepatitis B vaccine series followed by postvaccination testing two months after the last dose
for antibody to hepatitis B surface antigen (anti-HBs). Her anti-HBs concentration was 5 mIU/mL.
1. What does the anti-HBs result (5 mIU/mL) indicate?
a. She is protected from HBV infection
b. She is infected with the hepatitis B virus
c. She is not protected from HBV infection
2. What should be done next?
a. She should be revaccinated with a 3-dose hepatitis B vaccine series
b. Nothing more should be done
c. She should have the postvaccination testing
d. Repeated
She was revaccinated. Her postvaccination anti-HBs test result was 150 mIU/mL. She is now protected from
HBV infection. The result was placed in her occupational health record.
Six years later, she had a needlestick. The source patient was HBsAg positive and anti-HCV positive.
3. What needs to be done to protect her from HBV infection?
a. She should have a booster dose of vaccine
b. No postexposure prophylaxis is recommended
c. She should be tested for hepatitis B surface antigen
4. What needs to be done for the exposure to blood from an anti-HCV positive source patient?
a. Nothing should be done
b. Test only for ALT
c. Baseline testing for anti-HCV and ALT
5. Should immune globulin be given?
a. Yes
b. No
Baseline testing for anti-HCV was negative.
6. What additional follow-up should be done regarding her exposure to HCV-positive blood?
a. Provide follow-up testing for anti-HCV at 4-6 months after the needlestick
b. Provide counseling to refrain from blood donation until follow-up testing is done
c. Provide counseling to follow recommended infection control practices at work
d. All of the above
She was very relieved to find that her follow-up anti-HCV test was negative and her ALT level was within
normal limits. After this experience, she developed an in-service program for her hospital on safe use and
disposal of needles and other sharp instruments.