Murat Afyon

The Brazilian Journal of Infectious Diseases

Afyon, Murat

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braz j infect dis 2 0 1 6;2  0(3):318–319
www.elsev i er .com/ locate /b j id
The Brazilian Journal of
INFECTIOUS  DISEASES
Letter to the EditorWhat  are the  causes  and  outcomes  of the
-H
r
1
2
3
http://dx.doi.org/10.1111/jvh.12492 [Epub ahead of print].
4.  Colson P, Borentain P, Motte A, et al. Clinical and virologicalcoexistence of  HBsAg  and  anti
Dear Editor,
We  read with great interest the article by Ding et al.,1 “Muta-
tions in the S gene and in the overlapping reverse transcriptase
region in chronic hepatitis B Chinese patients with coexis-
tence of HBsAg and anti-HBs”. We  would like to specify some
additional issues related to the coexistence of HBsAg and anti-
HBs in a summary.
The rate of simultaneous HBsAg and anti-HBs serological
proﬁle ranged from 2.93% to 36% in different patient groups.1–4
Also, it has been recently reported that the prevalence progres-
sively increased with age from 40 to 70 years old.3
As mentioned in the article, the mechanism underlying
the concurrent detection of HBsAg and anti-HBs remains
unclear.1,2 It is a fact that there is a relation between this
special serological proﬁle and mutations in S gene region,
particularly in the ‘a’ determinant. However, as a result
of some studies including this article, while no mutation
has been described in some patients with coexistence of
HBsAg and anti-HBs, some mutations which may be asso-
ciated with this serological pattern have been detected in
patients with only HBsAg positivity in the absence of anti-
HBs.1,3,4 Hereby, coexistence of HBsAg and anti-HBs may
result from not only mutations but also from some other
causes.
Aside from mutations in S gene region, the presence of
heterologous subtype-speciﬁc antibodies, superinfection with
a new (second) hepatitis B virus (HBV) strain, occult HBV
reactivation and false positivity for anti-HBs are the other fac-
tors considered to be associated with this serological pattern.2
Diversity in the ‘a’ determinant between strains of the ﬁrst
and second infections in patients with superinfection and
natural HBV sequence variations in patients with heterolo-
gous subtype coinfection may be the mechanisms underlying
the proﬁle.2,5 False positivity for anti-HBs may be caused by
glycoproteins such as pili fractions isolated from Neiserria gon-
orrhoeae and Escherichia coli.2
Clinical outcomes of this serological proﬁle are also con-
troversial. Although it has been reported that there was no
signiﬁcant difference with HBeAg positivity rate and HBV
deoxyribonucleic acid (DNA) concentration between the twoBs?
groups (anti-HBs negative or positive) in the article, both
of them have been reported to be signiﬁcantly higher in
patients with coexistence of HBsAg and anti-HBs in another
recent study.1,3 Hence, the authors stated that the concur-
rent detection of HBsAg and anti-HBs may be associated with
an increased risk of adverse clinical outcome.3 Additionally,
while some studies suggested that coexistence of HBsAg and
anti-HBs can be associated with poor prognosis, advanced
ﬁbrosis, cirrhosis, or hepatocellular carcinoma, there are also
studies showing no relation between this proﬁle and severity
of liver disease.1–4 However, transmission via HBV mutants
not affected by vaccine induced anti-HBs and misdiagnosis
in screening depending on the use of only anti-HBs can be
other clinical problems due to the coexistence of HBsAg and
anti-HBs.4
Conﬂicts  of  interest
The author declares no conﬂicts of interest.
 e  f  e  r  e  n  c  e  s
. Ding F, Miao XL, Li YX, Dai JF, Yu HG. Mutations in the S gene
and in the overlapping reverse transcriptase region in chronic
hepatitis B Chinese patients with coexistence of HBsAg and
anti-HBs. Braz J Infect Dis. 2015,
http://dx.doi.org/10.1016/j.bjid.2015.08.014.
pii:S1413-8670(15)00193-2. [Epub ahead of print].
.  Pondé RA. The underlying mechanisms for the simultaneous
HBsAg and anti-HBs serological proﬁle. Eur J Clin Microbiol
Infect Dis. 2011;30:1325–40,
http://dx.doi.org/10.1007/s10096-011-1240-z.
.  Pu Z, Li D, Wang A, et al. Epidemiological characteristics of the
carriers with coexistence of HBsAg and anti-HBs based on a
community cohort study. J Viral Hepat. 2015,signiﬁcance of the co-existence of HBsAg and anti-HBs
antibodies in hepatitis B chronic carriers. Virology.
2007;367:30–40.
 2 0 1 
5
M
t
Nb r a z j i n f e c t d i s .
. Zhang JM, Xu Y, Wang XY, et al. Coexistence of hepatitis B
surface antigen (HBsAg) and heterologous subtype-speciﬁc
antibodies to HBsAg among patients with chronic hepatitis B
virus infection. Clin Infect Dis. 2007;44:1161–9.
urat  AfyonGülhane Military Medical Academy Haydarpas¸a  Teaching Hospi-
al, Primary Care Inspection, Clinic of Family Health Center and the
aval Academy, Tuzla/Istanbul, Turkey6;2 0(3):318–319 319
E-mail addresses: muratafyon2002@yahoo.com,
muratafyon79@gmail.com
Received 11 January 2016
Accepted 25 January 2016
Available online 30 March 2016
1413-8670/© 2016 Elsevier Editora Ltda. This is an open
access article under the CC BY-NC-ND license. (http://
creativecommons.org/licenses/by-nc-nd/4.0/)
http://dx.doi.org/10.1016/j.bjid.2016.01.009


What are the causes and outcomes of the coexistence of HBsAg and anti-HBs? 

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What are the causes and outcomes of the coexistence of HBsAg and anti-HBs?

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What are the causes and outcomes of the coexistence of HBsAg and anti-HBs?

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