High Viral Load Despite Negative e Antigen in Hepatitis B Patients

e antigen negative

Hello, Doctor.
I have hepatitis B.
Previously, my liver inflammation caused my AST and ALT levels to exceed a thousand, with a viral load of over a million and positive e-antigen.
An ultrasound showed a 0.6 cm nodule.
After taking Baraclude, my e-antigen turned negative and I developed e-antibodies.
I was in the consolidation phase for one year, and my viral load decreased to 25 copies.
After taking medication for 27 months, I stopped, and six months later, I first experienced abnormal jaundice.
The doctor prescribed medication to reduce jaundice, which I took for nearly three months, but my AST and ALT levels rose above 100.
The doctor then prescribed liver support medication, which I also took for nearly three months, but my levels did not decrease.
After blood tests, my liver function and AST/ALT levels remained around 100, e-antigen was negative, but my viral load surged from 25 to over 90 million.
Why is my viral load high despite being e-antigen negative? Is this a sign of liver cancer? I'm feeling quite anxious.
Thank you!

Ayu, 40~49 year old female. Ask Date: 2018/01/26

Dr. Chen Shidian reply Gastroenterology and Hepatology

Hello, some patients with hepatitis B virus may undergo mutations to evade the immune system and relieve pressure, leading to the disappearance of the e-antigen, which allows the virus to continue replicating and causing liver inflammation.
It is recommended that antiviral medication be used; please discuss treatment options with your attending physician.
Changhua Hospital cares about your health.
Chen Shih-Dian

Reply Date: 2018/01/26

More Info

Understanding the complexities of Hepatitis B, particularly in cases where patients exhibit high viral loads despite negative e-antigen (HBeAg), is crucial for both patients and healthcare providers. Your situation, characterized by a history of high liver enzymes (GOT and GPT) and fluctuating viral loads, raises several important points regarding the nature of Hepatitis B virus (HBV) infection and its management.

Firstly, the presence of high viral loads in the context of negative HBeAg can be attributed to several factors. In chronic Hepatitis B infection, the virus can undergo mutations that may alter the expression of certain antigens. The e-antigen is typically associated with active viral replication and high infectivity. When HBeAg is negative, it often indicates a lower level of viral replication; however, this is not always the case. Mutations in the HBV genome, particularly in the precore or core promoter regions, can lead to the production of viral particles that do not express HBeAg, yet the virus can still replicate at high levels. This phenomenon is often referred to as "e-antigen negative chronic Hepatitis B" and can be associated with more aggressive liver disease.

Your concern about the implications of a high viral load, especially after a history of liver inflammation and elevated liver enzymes, is valid. Elevated HBV DNA levels, particularly in the millions, can indeed increase the risk of liver complications, including cirrhosis and hepatocellular carcinoma (HCC). The risk of HCC is particularly pronounced in patients with chronic Hepatitis B, especially those with high viral loads, elevated liver enzymes, and underlying liver damage. Regular monitoring through ultrasound and serum alpha-fetoprotein (AFP) levels is essential for early detection of liver cancer.

In your case, the significant increase in viral load after stopping antiviral therapy raises concerns. While some patients can achieve sustained virologic response and maintain low or undetectable viral loads after discontinuing treatment, others may experience a rebound in viral replication. This rebound can be due to the reactivation of the virus, especially if there was incomplete suppression during treatment or if the virus has developed resistance to the antiviral medications used.

Given your situation, it is crucial to re-evaluate your treatment plan with your healthcare provider. Options may include resuming antiviral therapy, possibly with a different agent such as tenofovir or entecavir, which are effective against HBV and have a high barrier to resistance. Additionally, your healthcare provider may consider performing a liver biopsy or non-invasive liver stiffness tests to assess the degree of liver damage and fibrosis, which can guide treatment decisions.

In summary, the presence of high viral loads despite negative HBeAg is a complex issue that requires careful monitoring and management. It is essential to maintain regular follow-ups with your healthcare provider, adhere to prescribed treatments, and undergo routine screenings for liver cancer. Understanding the dynamics of your Hepatitis B infection will empower you to make informed decisions about your health and treatment options.

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