A 40-YEAR-OLD New York man presented with complaints of fatigue. Five years previously he had an episode of acute hepatitis B from which he recovered symptomatically. In followup, however, he had persistently elevated serum alanine aminotransferase levels and hepatitis B surface antigen (HBsAg). A year previously he had a recurrence of symptoms of hepatitis with jaundice, anorexia, and malaise, after which he had persistent fatigue and intermittent abdominal discomfort.His medical history was unremarkable. He was born in Germany of Italian heritage. He was a sexually active, male homosexual but denied drug abuse, alcoholism, blood transfusions, and medications. Physical examination revealed mild hepatosplenomegaly, lymphadenopathy, and spider angiomata over the upper part of the chest. Laboratory test results included serum bilirubin level, 17 μmol/L; alanine aminotransferase level, 269 U/L (normal, <45 U/L); alkaline phosphatase level, 77 IU/L (normal, <115 IU/L); albumin level, 33 g/L (normal, 38 to 50 g/L);
Hoofnagle JH. Type D (Delta) Hepatitis. JAMA. 1989;261(9):1321–1325. doi:10.1001/jama.1989.03420090085036
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