Hepatitis B virus surface antigen reactivity in the absence of antibodies to core antigen:: An atypical serological pattern having diverse significance

BACKGROUND. Reactivity for hepatitis B virus (HBV) surface antigen (HBsAg) in samples lacking antibody to the HBV core antigen (anti-HBc) may be due to either non-specific reactions or sample contamination, but it can also reflect other situations that may present clinical relevance. In Spain, the frequency described for this atypical pattern of HBV markers ranged from 0.05 to 1.3% in different series, so that it can be considered as moderately frequent. METHODS. Confirmatory assays for HBsAg and tests for detecting total and IgM anti-HBc, HBV "e" antigen and viral DNA were performed on serum samples taken from 96 patients who showed reactivity for HBAg in absence of total anti-HBc on routine studies. These samples were collected between January, 2001 and May, 2002 and were sent for study from different Spanish laboratories. Follow-up samples were also studied from selected cases. RESULTS. Presence of HBsAg was excluded in 70 cases (72.9%) and total anti-HBc was detected in two additional patients, so that the original results were confirmed in 24 patients (25.0%). After further investigations, two early phases of the window period of the acute HBV infection were identified, as well as a further case of chronic HBV carriage in absence of antibody response. A single case could be confirmed as due to a contamination of the aliquot of sample studied. The pattern of HBV markers and its evolution on the follow-up were the characteristic of the phenomenon known as "hepatitis B virus type 2 infection" in eight patients. No conclusions could be drawn from the remainder 12 cases, since no follow-up samples were available for study. CONCLUSIONS. Besides most cases respond to non-specific reactions or reflect situations of low clinical relevance, the reactivity for HBsAg in samples lacking anti-HBc should be taken into consideration and routinely investigated, since this atypical pattern can also reflect unusual, but clinically relevant facts of the HBV infection that must be noticed.