A 40-year-old man known to be HBsAg positive for several years develops acute icteric illness with marked transaminase elevation. Serology shows IgM antibody to hepatitis D virus positive and IgM anti-HBc negative. Which statement best describes this situation?

• A HDV co-infection, usually mild and self-limiting
• B HDV superinfection which never leads to chronicity
• C Reactivation of hepatitis B alone, HDV being a passenger finding
• D HDV superinfection, carrying a high risk of fulminant hepatitis and progression to chronic infection ✓

Explanation

Hepatitis B virus is defective and requires HBsAg for its envelope, so it infects only HBsAg-positive persons. When it enters an established chronic HBsAg carrier, this is superinfection, which is more severe than co-infection, carries a high rate of fulminant hepatitis and frequently becomes chronic. Co-infection implies simultaneous acute HBV and is signalled by IgM anti-HBc positivity, which is absent here, and it is typically self-limiting.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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