Inactive carrier versus e-antigen negative CHB

[jb4j96]

Good morning,

I was hoping that the community might be able to give me some additional knowledge regarding my condition.  I'm 34 years old, Korean (I was adopted, I never knew my birth mother nor did I have any medical records when I came to the USA in 1975 as an infant), and was diagnosed in March 2010 with chronic HBV.  I have been extremely healthy my entire life as an endurance athlete, and was only diagnosed because I donated blood for the first time.  This entire series of events from then until now has been very difficult emotionally.  Initially, through test results that I'll share below, I was diagnosed as an inactive carrier.  However, at my first 6 month check up my viral DNA count has increased significantly which makes me believe that I have a mutated strain of HBV.  I do not know this for sure as I have never been tested for this or for my genotype.  Below are my test results and following that are some questions I have, any insight you could offer is very much appreciated.

Initial test results - these were the first I ever received in March 2010:
HBV Viral DNA - 2502 IU/ML
HBV DNA Copies/ML - 14562

My gastroenterologist then ordered a second confirmatory test with a liver function panel in April 2010, these are the results:
AST - 29
ALT - 23
HBV Viral DNA - 2502 IU/ML
HBV DNA Copies/ML - 14562
I tested as e-antigen negative, e-antigen antibody positive
I also had a liver biopsy in May 2010 that revealed a grade of 0-1 with stage 0 fibrosis, so that was good.  Diagnosis then was that I was an inactive carrier.

Now, on October 1, 2010, I had a 6 month follow up, those results are:
AST - 29
ALT - 25
HBV Viral DNA - 28355 IU/ML
HBV DNA Copies/ML - 165026

So I had large increase in my viral load.  My doctor wants to retest in Dec 2010, if there is no improvement she wants to start me on oral anti-virals.  So my questions are:

1. Do inactive carriers' DNA levels fluctuate?  How much and how often?
2. Seeing as though I've had a fairly dramatic increase from April 2010 to Oct 2010 does this indicate that in fact I am not an inactive carrier?
3. If #2 is true, then that would automatically mean I have a mutant strain that can replicate despite my e-antigen negative status.

This is all very scary to me.  One other thing that I should add which might sound strange, but for the past month (Sept 2010 to Oct 2010) I have gotten several very painful subaceous acne-like cysts below the surface of my skin.  I have never gotten these before, but I have gotten very minor acne in the past (like one pimple at a time very few and far between) when my immune system was depressed, as in right before I got a cold, for example.  Is it possible that my immune system has been under attack or trying to react to the replication of the virus and hence cannot as adequately control other things in my body (like these acne cysts)?  These are now gone and I have had no other symptoms.  Just a thought, maybe it's completely not related at all.  

Please add your input to my questions or relate your own experience and wisdom, HBV has caught me totally by surprise, it's been very disconcerting especially in light of recent developments.

[cajim]

Can feel your dilemma.  It is a personal decision that each of us has to make.  Many of us take the conventional way and a few of us take the unconventional way.  As long as we share, we may help the newcomers.

[ono8ono]

watch this webcast about eantigen negative HBV. Viral load tend to change from time to time.

http://www.chronicliverdisease.org/webcasts/topics/Mgmt_of_HBV_HBeAg_Negaitive_Patients/tsai/webcast/

[stef2011]

as long as fibrosis stays below grade 2 i'll wait, even if alt gets to 30-40 range, there are many interesting treatments ready in a short time:
tenofovir with 4.5 fold more potent with no toxicity (lowered tnf and better intracellular absoprtion)
interferon lambda, no more sides like old interferons dure to improved action only in infected liver cels and not all body

the combination of both tenofovir and interferon lambda or telbivudine and interferon lamda will probably lead to hbv eradication in many cases, we know that 24weeks of normal interferon plus telbivudine made about 2log hbsag decrease (most cronic carriers have 3 logs) but there was myophathy sides on some so trial was stopped

so i'd definitely wait for interferon lambda news and then i'd not wait for the combo trials and go directly with this combo

[jb4j96]

The frustrating thing here is that I only have a very small slice of results here being newly diagnosed.  It's feasible I suppose that I could literally have been in the "state" I'm in for years now - going up and down.  However, there's no way of knowing.  Obviously, we know I sero-converted at some point, but how long ago, is not known.  So I could have been living with these fluctuating levels for quite some time (I did have a liver test done in 2003 for life insurance, my ALT was very slightly high then - I didn't think anything of it and neither did my insurance company, I qualified in the premium category).  

On one hand, I'd rather monitor because I don't want to be tethered to anti-virals for my entire life, I'm only 34.  On the other hand, I'd rather not play games with my liver.  Given that my liver functions are normal, which means damage is minimal (I think), should I monitor?  I feel like I need the advice of real people with this condition because I feel as though doctors, rightly or wrongly, simply follow their treatment rubric without deeply investigating each unique case.  Literally, my gastroenterologist was almost too casual in her response to my latest test result, as in - no big deal, we'll put you on oral anti-virals.  Well, I know she sees tons of patients, but it's a big deal to me.  However, she did say that if the viral load comes back down then we wouldn't go the anti-viral route and just continue to monitor.  I feel like the treatment playbook is so limited.  

[cajim]

1. Do inactive carriers' DNA levels fluctuate?  How much and how often?

--When HBVDNA fluctuates, the category of "inactive carrier" no longer fits.  Varies with what you eat, how you live and of course the HBV.

2. Seeing as though I've had a fairly dramatic increase from April 2010 to Oct 2010 does this indicate that in fact I am not an inactive carrier?

--Right.

3. If #2 is true, then that would automatically mean I have a mutant strain that can replicate despite my e-antigen negative status.

--Yes.

Given you have normal liver functions, no symptoms and very good liver biopsy result, some people will choose to monitor only, but the 2007 guideline which all Western doctors follow would recommend antiviral or IFN treatments.  You have a decision here.