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40대 이후에도 E항원 양성, 높은 DNA 수치를 보이는 B형 간염 보균자 - 동대문구 답십리, 용답동, 우리안애 우리안愛 내과

40대 후반 남자

21년 10월 초진, 당시에는 간암검진 초음파만 시행함

; 추적시에 혈액검사도 필요함을 안내함

​

22년 상반기 간암 검진은 ***검진센터에서 받았다고 하며

하반기 간암 검진 위해 내원

​

기존에 얘기한 바 이번에는 혈액 평가도 같이 하는 것으로 상의하여 시행함

초음파는 만성 간질환 환자에서 보이는 거친 모습 (coarse parenchyma) 에 지방간 동반

소장 장간막이 간 앞으로 밀려 올라와 있고 대장도 올라와 있어 우측 간의 음창이 좋지 않으나 늑간 관찰로 커버함


혈액결과, 간수치 상승은 없으며

D1860003 AST(GOT) 31 ​M : < 40 U/L-

D1850003 ALT(GPT) 25​ M: < 41 U/L-

D1890003 γ- GTP 76H M : 10-71 U/L-

혈소판 감소는 없다.

D0002073 Platelet 316​ 130-400 ×(10)3/μL-


아직 E 항원, HBeAg 양성이며

D7020013 HBc Ab, Total Positive (7.72)​ Negative < 1.00 Index-

D7022003 HBe Ag Positive (1547.24)​ Negative < 1.00 Index-

D7024003 HBe Ab Negative (46.46) ​Negative > 1.00 Index-

D7015003 HBs Ag Positive(1796.39) ​Negative < 1.00 Index-

D7018003 HBs Ab Negative(0.00) ​Negative < 10.00 IU/L-

그와 같이 하여 바이러스 갯수, DNA titer는 높다. immune tolerant phase (면역 관용기) 의 모습이다.

D704403C HBV DNA 정량(real-timePCR)** ​< 10 IU/mL-​IU/mL 3.37 x 10(7)​​-​

copies/mL1.96 x 10(8)​​-

간암 표지자는 정상

(D2420) AFP (공단) 4.10 ​≤ 7.00 ng/mL

​ 40대 이후에도 E항원 양성에 높은 titer의 바이러스 입자를 가지고 있어 높은 위험에 대한 간암 검진이 필요함을 설명하였다. ​ ​ Approximately 90% of HBsAg carriers who acquire HBV in early life remain HBeAg positive at age 15–20 years, whereas HBeAg positivity decreases with increasing age and is <10% in patients older than 40 years. 40세 이상에서 HBeAg양성은 10% 미만으로 감소한다 ​ The cumulative HCC risk from age 30 to 70 years has been estimated to be 87% for those who were persistently seropositive for both HBsAg and HBeAg, 12% for those with persistent seropositivity for HBsAg only, and 1% for those who were seronegative for both HBsAg and HBeAg. 지속적으로 S항원, E항원이 둘다 양성인 경우 암 발생율은 87%에 해당한다. E항원 음전 되어 S항원만 양성인 경우 12%, S항원도 음전되면 1% ​ Clinical remission of liver disease and a sustained inactive state are observed in the majority of patients (67–85%) who underwent HBeAg seroconversion, particularly among those in whom HBeAg seroconversion occurred before the age of 30 years and who maintain low or PCR-undetectable HBV-DNA levels. Sustained disease remission after HBeAg seroconversion is associated with a regression of fibrosis upon liver biopsy. Hui and colleagues evaluated the histology of liver samples from 128 HBeAg positive, treatment-naive Chinese patients who had undergone serial liver biopsies after HBeAg seroconversion. When disease remission was defined as HBeAg seroconversion and HBV-DNA level of <104 copies/ml (2 × 103 IU/ml), the regression of fibrosis was higher in patients with sustained disease remission (38.5%) than in those without remission (19.1%; P < 0.00005). Multivariate analysis revealed that sustained disease remission (relative risk [RR] = 3.00; 95% confidence interval [CI] = 1.29–7.01; P = 0.01) and 20–29 years of age at initial liver biopsy (RR = 2.94; 95% CI = 1.01–8.62; P = 0.04) were independently associated with the regression of fibrosis. Furthermore, the rate of fibrosis progression was slower in patients with sustained disease remission than in patients who remained HBeAg positive (median = 0 fibrosis units/year; range = −2.00 to −0.70 fibrosis units/year versus median = 0.51 fibrosis units/year; range = 0 to +2.03 fibrosis units/year; P = 0.02). On the basis of these data, the authors concluded that HBeAg seroconversion was associated with a slower progression of disease and regression of fibrosis. Furthermore, among persons in such sustained inactive state, spontaneous HBsAg seroconversion to anti-HBs may occur at a rate of 1–2% per year. HBsAg seroclearance confers excellent prognosis and is a state closest to a “cure” if there is no pre-existing cirrhosis or hepatitis C virus superinfection. However, active hepatitis may relapse because of the reactivation of wild-type HBV associated with the reappearance of serum HBeAg (HBeAg seroreversion), or HBV with precore or basal core promoter mutations that abolish or downregulate the translation of HBeAg (HBeAg-negative hepatitis) E항원이 음전되더라도 재확성화되거나 혹은 precore 변이에 의해 E항원의 전사 없이 활동성 간염이 재발할 수 있다 . In cohort studies involving adult CHB patients from Taiwan who had undergone spontaneous HBeAg seroconversion, the estimated annual incidence of hepatitis relapse was 2.2–3.3%. E항원 음전 후 재발 확률 In one of these studies involving 283 patients with CHB who were followed for a median period of 8.6 years after HBeAg seroconversion, 4.2% had HBeAg reversion and 24% developed HBeAg-negative hepatitis with detectable HBV-DNA; most patients relapsed during the first 10 years after HBeAg seroconversion. The cumulative probability of developing HBeAg-negative hepatitis following spontaneous HBeAg seroconversion was 14, 18, and 22% at 3, 5, and 10 years of follow-up, respectively. A lower annual rate of CHB relapse was reported in a recent prospective long-term follow-up study involving 1,241 incidentally identified asymptomatic, adult, inactive HBsAg carriers, for whom the date of HBeAg seroconversion was unknown and they conceivably represent later phase after HBeAg seroconversion . During a mean follow-up period of 12.3 years, the annual rate of hepatitis relapse was only 1.5% and was significantly lower in those younger than 30 years at entry. In this patient cohort, the cumulative risk of CHB relapse was also higher during the first 5- to 10-year follow-up period and decreased thereafter, becoming negligible after 20 years of follow-up. Overall, male gender, genotype C HBV infection, and delayed HBeAg seroconversion were found to be predictive factors for the reactivation of hepatitis B following HBeAg seroconversion. Since the immune mechanism of HBeAg-negative hepatitis is similar to that of HBeAg-positive hepatitis, this phase with reactivation may be viewed as a variant of immune clearance phase. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748370/


HBsAg, HBeAg 모두 음성, 음전된 환자에서의 간암, 1%의 확률


DNA에 따른 간암 누적 발생율


E항원 음성, 10^5 이상의 DNA titer 에서 간경화



동대문구 답십리 우리안애, 우리안愛 내과, 건강검진 클리닉 내과 전문의 전병연



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