Sarah is a 45-year-old woman, who has been experiencing abdominal pain in the right upper quadrant, loss of appetite, fatigue, and general body aches with a mild fever. Her symptoms started about two weeks ago.  She also noticed yellowish discoloration of her eyes, skin, and dark urine.  She reported that she got a blood transfusion a 4 months ago when she underwent a splenectomy due to a vehicle accident. She did not take any medications lately and did not have any significant illness before. On examination:

• Height: 164 cm, Weight: 74 kg, BMI: 27.6
• BP: 123/83 mmHg, Heart rate: 96/min, Respiratory rate: 16/min, Temperature: 37.7°C, O₂ SAT: 98%
• Yellow discoloration of sclera and skin.
• The liver is slightly enlarged and tender on palpation. Scar of previous splenectomy.

Which of the hepatitis viruses could have been transmitted by the blood transfusion Sarah received after her accident?

• Blood analysis:
  • CBC:
    • RBCs: 3.9 x 10¹²/ L, Hemoglobin: 133 g/L, Hematocrit: 0.39,
    • MCV: 97 fL, MCH: 30 pg, RDW: 11.9%, Reticulocytes: 0.9%, ESR: 15 mm/hour,
    • WBC: 12.3 x 10⁹/l, (Neutrophils: 7.0 x 10⁹/L, Lymphocytes: 6.3 x 10⁹/L, Basophils: 0.08. x 10⁹/L, Eosinophils: 0.33 x 10⁹/L, Monocytes: 0.6 x 10⁹/L),
    • Platelet counts: 395 x 10⁹/L
  • Na: 138 mmol/L, K: 3.9 mmol/L,
  • Glucose: 6.1 mmol/L, Creatinine: 77.2 umol/L, Uric Acid: 285 mmol/L
  • Triglycerides: 1.8 mmol/L, Cholesterol: 4.3 mmol/L, LDL: 2.2 mmol/L, HDL: 1.2 mmol/L
  • Total bilirubin: 169 umol/L, conjugated bilirubin: 140 umol/L
  • AST: 273 U/L, ALT: 408 U/L, ALP: 223 IU/L, GGT: 112 IU/L, 5'-NT: 36 IU/L, Albumin: 40.21 g/L, LDH: 212 U/L
  • INR: 1.3, Prothrombin time: 15 sec
  • B₁: 6.4 umol/L, Folic acid: 4.31 nmol/ml
• Virus Serology:

Diagnostic marker	Result
HBsAg	Positive
HBsAb	Negative
HBcAb IgM	Positive
HBV DNA	Positive
HBeAg	Positive
HBeAb	Negative
HAV IgG	Negative
Anti-HCV	Negative
HDV Ag and Anti-HDV	Negative
EBV, VCA, CMV	Negative

• Stool analysis: color: slightly pale, urobilin: +
• Urine analysis: color: dark, pH: 6.3, specific gravity: 1020, osmolarity: 661 mmol/kg; glucose, ketones: negative, bilirubin: ++, urobilinogen: +, bile salts: negative, WBCs and RBCs: 6-8 and 0/HPF, squamous epithelial cells: 2-4/HPF, casts, bacteria, yeast: negative.

Notice the hyperbilirubinemia and the elevated liver enzymes in Sarah’s laboratory investigation. Based on the viral serology results, what is your diagnosis?

All the followings are true statements about the HBsAg, EXCEPT:

1. The HBsAg is located in the surface or outer capsule of the hepatitis B virus.
2. HBsAg can be detected in the serum even before the onset of clinical symptoms.
3. The peak level of the HBsAg indicates the end of the acute phase of the infection.
4. Ongoing presence of the HBsAg indicates carrier state.
5. Individuals, who have been vaccinated against Hepatitis B do not have the HBsAg in their serum.

What is the best explanation of the hyperbilirubinemia in this patient?

1. It is mostly unconjugated and caused by excessive red blood cell injury.
2. It is mostly conjugated and caused by extrahepatic biliary obstruction.
3. Both conjugated and unconjugated bilirubin are elevated caused by hepatocellular damage.
4. Both conjugated and unconjugated bilirubin are elevated caused by centrilobular necrosis in the hepatic lobule.

Which of the following viral serology result would be consistent with a complete recovery from hepatitis B virus infection?

1. HBsAg +, HBsAb +, HBcAb +, HBeAb +
2. HBsAg -, HBsAb +, HBcAb +, HBeAg -
3. HBsAg +, HBsAb -, HBcAb -, HBeAg +
4. HBsAg -, HBsAb +, HBcAb -, HBeAb -