NIH Public Access

Author Manuscript
Hepatology. Author manuscript; available in PMC 2010 January 20.
Published in final edited form as:
NIH-PA Author Manuscript

Hepatology. 2009 May ; 49(5 Suppl): S13–S21. doi:10.1002/hep.22881.

Hepatitis B: The Virus and Disease

T. Jake Liang
Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
National Institutes of Health (NIH), Bethesda, MD

Abstract
Hepatitis B virus (HBV) infects more than 300 million people worldwide and is a common cause of
liver disease and liver cancer. HBV, a member of the Hepadnaviridae family, is a small DNA virus
with unusual features similar to retroviruses. HBV replicates through an RNA intermediate and can
integrate into the host genome. The unique features of the HBV replication cycle confer a distinct
ability of the virus to persist in infected cells. Virological and serological assays have been developed
for diagnosis of various forms of HBV-associated disease and for treatment of chronic hepatitis B
NIH-PA Author Manuscript

infection. HBV infection leads to a wide spectrum of liver disease ranging from acute (including
fulminant hepatic failure) to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Acute HBV
infection can be either asymptomatic or present with symptomatic acute hepatitis. Most adults
infected with the virus recover, but 5%–10% are unable to clear the virus and become chronically
infected. Many chronically infected persons have mild liver disease with little or no long-term
morbidity or mortality. Other individuals with chronic HBV infection develop active disease, which
can progress to cirrhosis and liver cancer. These patients require careful monitoring and warrant
therapeutic intervention. Extrahepatic manifestations of HBV infection are rare but can be difficult
to diagnose and manage. The challenges in the area of HBV-associated disease are the lack of
knowledge in predicting outcome and progression of HBV infection and an unmet need to understand
the molecular, cellular, immunological, and genetic basis of various disease manifestations
associated with HBV infection.

Virology
The hepatitis B virus (HBV) is a small DNA virus with unusual features similar to retroviruses.
1,2 It is a prototype virus of the Hepadnaviridae family. Related viruses are found in
woodchucks, ground squirrels, tree squirrels, Peking ducks, and herons. Based on sequence
NIH-PA Author Manuscript

comparison, HBV is classified into eight genotypes, A to H. Each genotype has a distinct
geographic distribution. Three types of viral particles are visualized in infectious serum by
electron microscopy. Two of the viral particles are smaller spherical structures with a diameter
of 20 nm and filaments of variable lengths with a width of 22 nm (Fig. 1). The spheres and
filaments are composed of hepatitis B surface antigen (HBsAg) and host-derived lipids without
viral nucleic acids and are therefore noninfectious.3 The infectious HBV virion (Dane particle)
has a spherical, double-shelled structure 42 nm in diameter, consisting of a lipid envelope
containing HBsAg that surrounds an inner nucleocapsid composed of hepatitis B core antigen
(HBcAg) complexed with virally encoded polymerase and the viral DNA genome. The genome
of HBV is a partially double-stranded circular DNA of about 3.2 kilobase (kb) pairs. The viral
polymerase is covalently attached to the 5′ end of the minus strand.4

The viral genome encodes four overlapping open reading frames (ORFs: S, C, P, and X) (Fig.
2A).1,2 The S ORF encodes the viral surface envelope proteins, the HBsAg, and can be

Potential conflict of interest: Nothing to report.

 Liang Page 2

structurally and functionally divided into the pre-S1, pre-S2, and S regions. The core or C gene
has the precore and core regions. Multiple in-frame translation initiation codons are a feature
of the S and C genes, which give rise to related but functionally distinct proteins. The C ORF
NIH-PA Author Manuscript

encodes either the viral nucleocapsid HBcAg or hepatitis B e antigen (HBeAg) depending on
whether translation is initiated from the core or precore regions, respectively (Fig. 2B). The
core protein has the intrinsic property to self-assemble into a capsid-like structure and contains
a highly basic cluster of amino acids at its C-terminus with RNA-binding activity.5 The precore
ORF codes for a signal peptide that directs the translation product to the endoplasmic reticulum,
where the protein is further processed to form the secreted HBeAg. The function of HBeAg
remains largely undefined, although it has been implicated as an immune tolerogen, whose
function is to promote persistent infection.6 The polymerase (pol) is a large protein (about 800
amino acids) encoded by the P ORF and is functionally divided into three domains: the terminal
protein domain, which is involved in encapsidation and initiation of minus-strand synthesis;
the reverse transcriptase (RT) domain, which catalyzes genome synthesis; and the ribonuclease
H domain, which degrades pregenomic RNA and facilitates replication. The HBV X ORF
encodes a 16.5-kd protein (HBxAg) with multiple functions, including signal transduction,
transcriptional activation, DNA repair, and inhibition of protein degradation.7–10 The
mechanism of this activity and the biologic function of HBxAg in the viral life-cycle remain
largely unknown. However, it is well established that HBxAg is necessary for productive HBV
infection in vivo and may contribute to the oncogenic potential of HBV.
NIH-PA Author Manuscript

Other functionally important elements within the HBV genome include two direct repeats (DR1
and DR2) in the 5′ ends of the plus strand, which are required for strand-specific DNA synthesis
during replication.11 Two enhancer elements, designated as En1 and En2, confer liver-specific
expression of viral gene products.12 A glucocorticoid-responsive element (GRE) sequence
within the S domain,13 a polyadenylation signal within the core gene, and a posttranscriptional
regulatory element overlapping En1 and part of HBxAg ORF have also been described.14

The HBV replication pathway has been studied in great detail and is summarized in Fig. 3. The
initial phase of HBV infection involves the attachment of mature virions to host cell
membranes, likely involving the pre-S domain of the surface protein.15 Various cellular factors
have been proposed to be the viral receptors, but only carboxypeptidase D has been shown to
play an essential role in viral entry for the duck HBV.16 Mechanisms of viral disassembly and
intracellular transport of the viral genome into the nucleus are not well understood and probably
involve modification of the nucleocapsid core protein.17 After entry of the viral genome into
the nucleus, the single-stranded gap region in the viral genome is repaired by the viral pol
protein, and the viral DNA is circularized to the covalently closed circular (cccDNA) form.
18 This form of HBV DNA serves as the template for transcription of several species of genomic
and sub-genomic RNAs and is the stable component of the replication cycle that is relatively
NIH-PA Author Manuscript

resistant to antiviral action and immune clearance (Fig. 2B).

The transcripts from the cccDNA are unspliced, polyadenylated, and possess a 5′ cap structure.
The 3.5-kb genomic transcripts consist of two species with different 5′ ends: the pregenomic
and the precore RNAs. The pregenomic RNA (pgRNA) serves as the template for reverse
transcription and the messenger RNA for core and polymerase; the precore RNA directs the
translation of the precore gene product. The polymerase translation is initiated at the pol start
codon of the pgRNA, probably as a result of a ribosomal scanning mechanism.19 The large
HBsAg (L-HBsAg) protein is translated from the 2.4-kb subgenomic RNA, the middle (M-
HBsAg) and small HBsAg (S-HBsAg) proteins from the various forms of 2.1-kb RNAs, and
the HBxAg protein from the 0.7-kb RNA.

The S-HBsAg is the major S gene product and the L and M proteins are the minor species.
Each surface protein has a glycosylation site in the S domain. Additional modifications of the

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 3

L and M proteins occur at the pre-S2 domain with an N-linked oligosaccharide and a myristic
acid at the amino-terminal glycine residue of the pre-S1 domain.20 The distribution of the three
envelope glycoproteins varies among the types of viral particles, with little or no L and M
NIH-PA Author Manuscript

protein in the 20-nm particles but relatively more L protein in the Dane particles.

Replication of HBV begins with encapsidation of the genome. The packaging signal is a cis-
acting element referred to as epsilon, which contains a stem-loop structure.21 The terminal
protein of the pol interacts with the epsilon and in concert with the core protein forms the
nucleocapsid. After encapsidation, the pol mediates the reverse transcription of the pgRNA to
minus-strand DNA and subsequent positive-strand synthesis. The circular form of the DNA is
completed through several complicated steps of strand transfer.22 The nucleocapsid then
interacts with the envelope proteins in the endoplasmic reticulum to assemble into mature
virions, which are then secreted into the extra-cellular milieu.

Diagnosis and Serology

HBV infection leads to a wide spectrum of liver disease ranging from acute hepatitis (including
fulminant hepatic failure) to chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC).
2 The diagnosis of HBV infection and its associated disease is based on a constellation of
clinical, biochemical, histological, and serologic findings. A number of viral antigens and their
respective antibodies can be detected in serum after infection with HBV, and proper
NIH-PA Author Manuscript

interpretation of the results is essential for the correct diagnosis of the various clinical forms
of HBV infection (Table 1).

The typical course of acute hepatitis B is shown in Fig. 4A. HBV DNA followed shortly
afterward by HBsAg and HBeAg are the first viral markers detected in serum.23 HBsAg may
be detected as early as 1–2 weeks or as late as 11–12 weeks after exposure, and its persistence
is a marker of chronicity. HBeAg correlates with the presence of high levels of HBV replication
and infectivity.24 Within a few weeks of appearance of viral markers, serum alanine and
aspartate aminotransferase (ALT, AST) levels begin to rise and jaundice may appear. HBeAg
is usually cleared early, at the peak of clinical illness, whereas HBsAg and HBV DNA usually
persist in the serum for the duration of clinical symptoms and are cleared with recovery.
Antibodies to the HBV proteins arise in different patterns during acute hepatitis B. Antibody
to HBcAg (anti-HBc) generally appears shortly before onset of clinical illness, the initial
antibody being mostly immunoglobulin M (IgM) class, which then declines in titer as levels
of IgG anti-HBc arise. Antibody to HBeAg (anti-HBe) usually appears shortly after clearance
of HBeAg, often at the peak of clinical illness. Thus, loss of HBeAg and appearance of anti-
HBe is a favorable serological marker during acute hepatitis B, indicating the initiation of
recovery. Antibody to HBsAg arises late during infection, usually during recovery or
NIH-PA Author Manuscript

convalescence after clearance of HB-sAg. Anti-HBs persists after recovery, being the antibody
associated with immunity against HBV. However, between 10% and 15% of patients who
recover from hepatitis B do not develop detectable anti-HBs and have anti-HBc alone as a
marker of previous infection. For this reason, anti-HBc testing is the most reliable means of
assessing previous infection with HBV, whereas anti-HBs testing is used to assess immunity
and response to HBV vaccine.25

Patients who develop chronic hepatitis B (Fig. 4B) have a similar initial pattern of serological
markers with appearance of HBV DNA, HBsAg, HBeAg, and anti-HBc. In these persons,
however, viral replication persists and HBsAg, HBeAg, and HBV DNA continue to be
detectable in serum, often in high titers. The subsequent course of chronic hepatitis B is quite
variable. Most persons remain HBsAg-positive for years if not for life and have some degree
of chronic liver injury (chronic hepatitis) that can lead to significant fibrosis and cirrhosis.
Persons with chronic HBV infection are also at high risk to ultimately develop HCC.

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 4

The diagnosis of acute hepatitis B is reliably made by the finding of IgM anti-HBc in serum,
particularly in a patient with HBsAg and signs, symptoms, or laboratory features of acute
hepatitis. Nevertheless, in some instances, HBsAg is cleared rapidly from the serum, and IgM
NIH-PA Author Manuscript

anti-HBc is the only marker detectable when the patient presents with hepatitis. Testing for
anti-HBc (total) and anti-HBs are not useful in diagnosis, and testing for HBeAg and anti-HBe
should be reserved for persons who test positive for HBsAg. The finding of HBsAg without
IgM anti-HBc suggests the presence of chronic hepatitis B, but this diagnosis generally also
rests upon finding of persistence of HBsAg for at least 6 months.23,26 HBV DNA testing can
also be helpful in the assessment of level of viral replication and possibly helpful in assessing
prognosis and need for antiviral therapy. Assays for HBV DNA level have improved
substantially over the years.27 The current real-time polymerase chain reaction–based assay
(TaqMan) has a lower limit of detection of 5–10 HBV DNA copies/mL and can accurately
quantify a wide range of levels (Fig. 5). With this degree of sensitivity, HBV DNA can be
detected early during the course of infection, arising before the appearance of other serological
markers, such as HBsAg or anti-HBc. As a consequence, testing for HBV DNA has emerged
as a primary approach in the diagnosis and management of HBV infection. HBV DNA testing
has now become routinely used in blood product screening (nucleic acid testing)28 and
monitoring of patients with HBV during treatment.29 Persistently high levels of HBV DNA
following resolution of hepatitis may be indicative of a failure to control the infection and an
evolution into chronic infection.
NIH-PA Author Manuscript

Acute Hepatitis B
About two-thirds of patients with acute HBV infection have a mild, asymptomatic and
subclinical illness that usually goes undetected.30 Approximately one-third of adults with acute
HBV infection develop clinical symptoms and signs of hepatitis, which range fom mild
constitutional symptoms of fatigue and nausea, to more marked symptoms and jaundice, and
rarely to acute liver failure. The clinical incubation period of acute hepatitis B averages 2–3
months and can range from 1–6 months after exposure, the length of the incubation period
correlating, to some extent, with the level of virus exposure.31 The incubation period is
followed by a short preicteric or prodromal period of constitutional symptoms such as fever,
fatigue, anorexia, nausea, and body aches. During this phase, serum ALT levels rise and high
levels of HBsAg and HBV DNA are detectable. The preicteric phase lasts a few days to as long
as a week and is followed by onset of jaundice or dark urine. The icteric phase of hepatitis B
lasts for a variable period averaging 1–2 weeks, during which viral levels decrease. In
convalescence, jaundice resolves but constitutional symptoms may last for weeks or even
months. During this phase, HBsAg is cleared followed by the disappearance of detectable HBV
DNA from serum.
NIH-PA Author Manuscript

Acute liver failure occurs in approximately 1% of patients with acute hepatitis B and jaundice.
32 The onset of fulminant hepatitis is typically marked by the sudden appearance of fever,
abdominal pain, vomiting, and jaundice, followed by disorientation, confusion, and coma.
HBsAg and HBV DNA levels generally fall rapidly as liver failure develops, and some patients
are HBsAg-negative by the time of onset of hepatic coma. Patients with acute liver failure due
to hepatitis B require careful management and monitoring and should be referred rapidly to a
tertiary medical center with the availability of liver transplantation.33

Chronic Hepatitis B
Chronic hepatitis B has a variable and dynamic course. Early during infection, HBeAg, HBsAg,
and HBV DNA are usually present in high titers, and there are mild to moderate elevations in
serum aminotransferase levels (Fig. 4B). With time, however, the disease activity can resolve
either with persistence of high levels of HBeAg and HBV DNA (the “immune tolerance phase”)

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 5

or with loss of HBeAg and fall of HBV DNA to low or undetectable levels (“inactive carrier
state”). Other patients continue to have chronic hepatitis B, although some lose HBeAg and
develop anti-HBe (HBeAg-negative chronic hepatitis B). The course and natural history of
NIH-PA Author Manuscript

hepatitis B are discussed in detail elsewhere in these proceedings.34

The overall prognosis of patients with chronic hepatitis is directly related to the severity of
disease. For those with severe chronic hepatitis and cirrhosis, the 5-year survival rate is about
50%.35–37 Among patients with evidence of chronic hepatitis (elevated ALT and inflammation
and/or fibrosis on liver biopsy), many are asymptomatic or have nonspecific symptoms, such
as fatigue and mild right upper quadrant discomfort. Patients with more severe disease or
cirrhosis may have significant constitutional symptoms, jaundice, and peripheral stigmata of
end-stage liver disease including spider angiomata, palmar erythema, splenomegaly,
gynecomastia, and fetor hepaticus. Ascites, peripheral edema, encephalopathy, and
gastrointestinal bleeding are seen in patients with more advanced cirrhosis. ALT and AST are
often elevated but may not correlate well with severity of liver disease. Bilirubin, prothrombin
time, and albumin often become abnormal with progressive disease. Decreasing platelet count
is often a poor prognostic sign.

Patients with chronic hepatitis may develop acute exacerbations with markedly elevated serum
ALT. This scenario is more frequently described in those with HBeAg-negative chronic
hepatitis B.6 To distinguish between acute hepatitis B and chronic hepatitis B with a flare, anti-
NIH-PA Author Manuscript

HBc IgM is a useful marker, as described in the previous section. However anti-HBc of the
IgM class can be detected occasionally in patients with chronic hepatitis B with exacerbation.
Alpha-fetoprotein (AFP), used as a marker for HCC, is often elevated in parallel with ALT
during acute exacerbation.38 However, it is unlikely to exceed 400 ng/mL. In patients with
AFP much greater than this level, development of HCC should be suspected.39

An estimated one-third of persons with chronic HBV infection will ultimately develop a long-
term consequence of the disease, such as cirrhosis, end-stage liver disease, or HCC. The
determinants of outcome of chronic hepatitis B appear to be both viral (HBV DNA levels, HBV
genotype, some HBV mutation patterns) and host-specific (age, gender, genetic background,
immune status).

Extrahepatic Manifestations of Hepatitis B

Extrahepatic manifestations of hepatitis B are present in 1–10% of HBV-infected patients and
include serum-sickness–like syndrome, acute necrotizing vasculitis (polyarteritis nodosa),
membranous glomerulonephritis, and papular acrodermatitis of childhood (Gianotti-Crosti
syndrome).40,41 Although the pathogenesis of these disorders is unclear, immune complex–
mediated injury related to high level of HBV antigenemia is thought to be the cause.
NIH-PA Author Manuscript

The serum-sickness–like syndrome occurs in the setting of acute hepatitis B, often preceding
the onset of jaundice.42 The clinical features are fever, skin rash, and polyarteritis. The
symptoms often subside shortly after the onset of jaundice, but can persist throughout the
duration of acute hepatitis B. The course of this syndrome often parallels the duration and level
of HBV viremia: rapid clearance of the virus leads to rapid resolution of the illness. This
disorder resembles experimental serum sickness, in which immune complexes activate the
complement pathways leading to complement-mediated injury. Patients with this syndrome
have low complement levels and high-level circulating immune complexes containing HBV
antigens and complement components.

About 30%–50% of patients with acute necrotizing vasculitis (polyarteritis nodosa) are HBV
carriers.41,43 This entity is more commonly seen in patients with recent exposure to HBV.
Immune-mediated vascular injury can involve large, medium, and small vessels. Early clinical

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 6

features are marked constitutional symptoms, high fever, anemia, and leukocytosis.
Multisystem involvement is common, including arthritis, renal disease (proteinuria and
hematuria), heart disease (pericarditis and congestive heart failure), hypertension,
NIH-PA Author Manuscript

gastrointestinal disease (acute abdominal pain and bleeding), skin involvement (vasculitic
lesions), and neurological disorders (mononeuritis multiplex and central nervous system
abnormalities). The disease is highly variable and has a mortality rate of 30% within 5 years
if not treated.

HBV-associated nephropathy has been described in adults but is more common in children.
44,45 Membranous glomerulonephritis is the most common form. Liver disease may be mild
or absent in many of these patients. This disorder is frequently observed in countries with high
prevalence of HBV infection. About 30%–60% of children with this disorder experience
spontaneous remission, especially with HBeAg seroconversion. However, about 30% of adults
with this condition can progress to renal failure with as many as 10% requiring dialysis or renal
transplant.46

Papular acrodermatitis (Gianotti-Crosti syndrome) is a distinct skin manifestation of acute

HBV infection in childhood.47 Skin lesions are maculopapular, erythematous, and nonpruritic,
and involve the face and extremities. The syndrome lasts about 15–20 days and can either
precede or follow the onset of jaundice in acute hepatitis B. Generalized lymphadenopathy and
hepatomegaly have been described.
NIH-PA Author Manuscript

Other immune-mediated hematological disorders, such as essential mixed cryoglobulinemia

and aplastic anemia have been described as part of the extrahepatic manifestations of HBV
infection, but their association is not as well-defined; therefore, they probably should not be
considered etiologically linked to HBV.

Occult or Latent HBV Infection

Other atypical HBV infections include seronegative occult or latent HBV infections. This
heterogeneous group consists of patients who are HBsAg-negative who are either seronegative
for all HBV markers or positive for anti-HBc and/or anti-HBs.48–52 Many of these patients are
positive for HBV DNA by polymerase chain reaction either in the liver or serum or both. Some
of these patients have underlying liver disease, suggestive of ongoing hepatocellular injury
from persistent HBV infection. Studies in animal models have demonstrated long-term
persistence of viral genomes in the serum and/or liver of animals that have biochemical and
serologic evidence of viral clearance and recovery from infection.49,53 The important question
is whether this observation represents ongoing viral replication and therefore clinically
significant infection in terms of liver disease and transmission. Existing evidence supports the
notion that it indeed indicates low-level viral replication, capable of transmission.49,54 Studies
NIH-PA Author Manuscript

in liver transplantation revealed transmission of HBV infection to recipients if the donors

carried the anti-HBc marker.55 In addition, reactivation of HBV infection in patients with
serologic evidence of recovery undergoing immunosuppression or chemotherapy has been
reported.56–59 These observations, together with the immunologic studies described above,
provide compelling evidence that one may not be able to completely eliminate HBV infection.
Patients with serologic evidence of recovery probably have low-level viral replication that is
effectively controlled by an active immune response. The possibility that these occult infections
are caused by HBV mutants has been proposed. Although mutations have been reported in
various regions of the viral genome,60–63 definitive evidence in support of a pathogenic role
of these mutants is lacking. Furthermore, whether liver disease can indeed result from these
occult HBV infections is controversial. At present, there are no convincing studies in support
of a causal relationship. Therefore, these occult HBV infections, other than the special
situations described above, may not be clinically important.

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 7

Important Questions and Needs for Future Research

1. How does HBV establish productive infection in vivo and what is the host response
NIH-PA Author Manuscript

early during the infection? Despite well-described information on the clinical

manifestations and natural history of acute HBV infection, detailed knowledge of the
virus-host interaction during this stage remains poorly defined. Advances in this area
would offer a better understanding of the pathogenesis of HBV infection and its
associated disease.
2. What is the immunologic basis of chronic infection and hepatocellular injury? There
have been great strides in understanding the virology and immune response of HBV
infection, but the molecular mechanisms whereby the host fails to clear the virus and
develops chronic infection remain largely unknown. In addition, the adaptive
evolution of virus under host immune pressure remains to be elucidated. Finally, the
pathogenesis of various extra-hepatic manifestations associated with HBV infection
is poorly understood. Further research in these areas is crucial not only in better
understanding the natural history and disease progression but also in improving
treatment for chronic hepatitis B.
3. What is the genetic basis of the diverse clinical manifestations and disease outcomes
of HBV infection? With the recent advances in genetic and genomic medicine, there
are increasing opportunities to elucidate the genetic basis for variations in expression
NIH-PA Author Manuscript

and susceptibility to HBV-associated diseases. Genome-wide association studies and

other genomic technological advances would provide crucial information to identify
useful genetic markers for disease outcome, clinical manifestations, and treatment
response of HBV-associated disease.

Acknowledgments
Supported by the NIDDK Intramural Research Program, NIH.

Abbreviations
AFP alpha-fetoprotein
ALT alanine aminotransferase
anti-HBc antibody to HBcAg
anti-HBe antibody to HBeAg
anti-HBs antibody to HBsAg
NIH-PA Author Manuscript

AST aspartate aminotransferase

cccDNA covalently closed circular DNA
DR direct repeats
HBsAg hepatitis B surface antigen
HBeAg hepatitis B e antigen
HBcAg hepatitis B core antigen
HBV hepatitis B virus
HBxAg hepatitis B x protein
HCC hepatocellular carcinoma
IgM immunoglobulin M

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 8

kb kilobase
NIH-PA Author Manuscript

L-HBsAg large HBsAg

M-HBsAg middle HBsAg
ORF open reading frame
pgRNA pregenomic RNA
pol HBV DNA polymerase
RT reverse transcriptase
S-HBsAg small HBsAg

References
1. Ganem, D.; Schneider, RJ. Hepadnaviridae and their replication. In: Knipe, DM.; Howley, PM.; Griffin,
DE.; Martin, MA.; Lamb, RA.; Roizman, B., et al., editors. Fields Virology. Vol. 4. Philadelphia, PA:
Lippincott-Raven Publishers; 2001.
2. Hollinger, FB.; Liang, TJ. Hepatitis B virus. In: Knipe, DM.; Howley, PM.; Griffin, DE.; Lamb, RA.;
Martin, MA.; Roizman, B., et al., editors. Fields Virology. Vol. 4. Philadelphia, PA: Lippincott-Raven
Publishers; 2001. p. 2971-3036.
NIH-PA Author Manuscript

3. Gavilanes F, Gonzales-Ros A, Peterson D. Structure of hepatitis B surface antigen: characterization

of the lipid components and their association with the viral proteins. J Biol Chem 1982;257:7770–
7777. [PubMed: 7085648]
4. Gerlich W, Robinson WS. Hepatitis B virus contains protein attached to the 5′ end of its complete
strand. Cell 1980;21:801–811. [PubMed: 7438207]
5. Hatton T, Zhou S, Standring DN. RNA- and DNA-binding activities in hepatitis B virus capsid protein:
a model for their roles in viral replication. J Virol 1992;66:5232–5241. [PubMed: 1501273]
6. Milich D, Liang TJ. Exploring the biological basis of hepatitis B e antigen in hepatitis B virus infection.
Hepatology 2003;38:1075–1086. [PubMed: 14578844]
7. Zhang Z, Torii N, Hu Z, Jacob J, Liang TJ. X-deficient woodchuck hepatitis virus mutants behave like
attenuated viruses and induce protective immunity in vivo. J Clin Invest 2001;108:1523–1531.
[PubMed: 11714744]
8. Cross JC, Wen P, Rutter W. Transactivation by hepatitis B virus X protein is promiscuous and
dependent on mitogen-activated cellular serine/threonine kinases. Proc Natl Acad Sci U S A
1993;90:8078–8082. [PubMed: 8367466]
9. Hu Z, Zhang Z, Kim JW, Huang Y, Liang TJ. Altered proteolysis and global gene expression in hepatitis
B virus X transgenic mouse liver. J Virol 2006;80:1405–1413. [PubMed: 16415018]
10. Bouchard MJ, Schneider RJ. The enigmatic X gene of hepatitis B virus. J Virol 2004;78:12725–
NIH-PA Author Manuscript

12734. [PubMed: 15542625]

11. Seeger C, Ganem D, Varmus HE. Genetic and biochemical evidence for the hepatitis B virus
replication strategy. Science 1986;232:477–485. [PubMed: 3961490]
12. Yee J. A liver-specific enhancer in the core promoter region of human hepatitis B virus. Science
1989;246:658–670. [PubMed: 2554495]
13. Tur-Kaspa R, Burk R, Shaul Y, Shafritz D. Hepatitis B virus DNA contains a glucocortcoid response
element. Proc Natl Acad Sci U S A 1986;83:1627–1631. [PubMed: 3006059]
14. Huang J, Liang TJ. A novel hepatitis B virus (HBV) genetic element with Rev response element-like
properties that is essential for expression of HBV gene products. Mol Cell Biol 1993;13:7476–7486.
[PubMed: 8246965]
15. Klingmuller U, Schaller H. Hepadnavirus infection requires interaction between the viral pre-S
domain and a specific hepatocellular receptor. J Virol 1993;67:7414–7422. [PubMed: 8230462]

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 9

16. Breiner KM, Urban S, Schaller H. Carboxypeptidase D (gp180), a Golgi-resident protein, functions
in the attachment and entry of avian hepatitis B viruses. J Virol 1998;72:8098–8104. [PubMed:
9733850]
NIH-PA Author Manuscript

17. Kang HY, Lee S, Park SG, Yu J, Kim Y, Jung G. Phosphorylation of hepatitis B virus Cp at Ser87
facilitates core assembly. Biochem J 2006;398:311–317. [PubMed: 16740137]
18. Kock J, Schilicht H-J. Analysis of the earliest steps of hepadnavirus replication genome repair after
infectious entry into hepatocytes does not depend on viral polymerase activity. J Virol 1993;67:4867–
4874. [PubMed: 8331730]
19. Jean-Jean O, Weimer T, de Recondo AM, Will H, Rossignol JM. Internal entry of ribosomes and
ribosomal scanning involved in hepatitis B virus P gene expression. J Virol 1989;63:5451–5454.
[PubMed: 2585611]
20. Persing DH, Varmus HE, Ganem D. The preS1 protein of hepatitis B virus is acylated at its amino
terminus with myristic acid. J Virol 1987;61:1672–1677. [PubMed: 3573147]
21. Pollack J, Ganem D. An RNA stem-loop structure directs hepatitis B virus genomic RNA
encapsidation. J Virol 1993;67:3254–3263. [PubMed: 7684464]
22. Will H, Reiser W, Weimer T, Pfaff E, Buscher M, Sprengel R, et al. Replication strategy of human
hepatitis B virus. J Virol 1987;61:904–911. [PubMed: 3806799]
23. Krugman S, Overby LR, Mushahwar IK, Ling CM, Frosner GG, Deinhardt F. Viral hepatitis, type
B. Studies on natural history and prevention re-examined. N Engl J Med 1979;300:101–106.
[PubMed: 758598]
24. Liang TJ, Ghany M. Hepatitis B e antigen–the dangerous endgame of hepatitis B. N Engl J Med
NIH-PA Author Manuscript

2002;347:208–210. [PubMed: 12124411]

25. Tabor E, Hoofnagle JH, Barker LF, Pineda-Tamondong G, Nath N, Smallwood LA, et al. Antibody
to hepatitis B core antigen in blood donors with a history of hepatitis. Transfusion 1981;21:366–371.
[PubMed: 7233523]
26. Perrillo RP, Chau KH, Overby LR, Decker RH. Anti-hepatitis B core immunoglobulin M in the
serologic evaluation of hepatitis B virus infection and simultaneous infection with type B, delta agent,
and non-A, non-B viruses. Gastroenterology 1983;85:163–167. [PubMed: 6406288]
27. Pawlotsky JM, Dusheiko G, Hatzakis A, Lau D, Lau G, Liang TJ, et al. Virologic monitoring of
hepatitis B virus therapy in clinical trials and practice: recommendations for a standardized approach.
Gastroenterology 2008;134:405–415. [PubMed: 18242209]
28. Kuhns MC, Busch MP. New strategies for blood donor screening for hepatitis B virus: nucleic acid
testing versus immunoassay methods. Mol Diagn Ther 2006;10:77–91. [PubMed: 16669606]
29. Loomba R, Liang TJ. Treatment of chronic hepatitis B. Antivir Ther 2007;12(Suppl 3):H33–H41.
[PubMed: 18284181]
30. McMahon BJ, Alward WL, Hall DB, Heyward WL, Bender TR, Francis DP, et al. Acute hepatitis B
virus infection: relation of age to the clinical expression of disease and subsequent development of
the carrier state. J Infect Dis 1985;151:599–603. [PubMed: 3973412]
31. Barker LF, Murray R. Relationship of virus dose to incubation time of clinical hepatitis and time of
NIH-PA Author Manuscript

appearance of hepatitis–associated antigen. Am J Med Sci 1972;263:27–33. [PubMed: 5057849]

32. Berk PD, Popper H. Fulminant hepatic failure. Am J Gastroenterol 1978;69:349–400. [PubMed:
685949]
33. Hoofnagle JH, Carithers RL Jr, Shapiro C, Ascher N. Fulminant hepatic failure: summary of a
workshop. Hepatology 1995;21:240–252. [PubMed: 7806160]
34. McMahon. The natural history of chronic hepaatitis B virus infection. Hepatology 2009;49
(suppl):S45–S55. [PubMed: 19399792]
35. Weissberg JI, Andres LL, Smith CI, Weick S, Nichols JE, Garcia G, et al. Survival in chronic hepatitis
B. An analysis of 379 patients. Ann Intern Med 1984;101:613–616. [PubMed: 6486592]
36. Liaw YF, Tai DI, Chu CM, Chen TJ. The development of cirrhosis in patients with chronic type B
hepatitis: a prospective study. Hepatology 1988;8:493–496. [PubMed: 3371868]
37. de Jongh FE, Janssen HL, de Man RA, Hop WC, Schalm SW, van Blankenstein M. Survival and
prognostic indicators in hepatitis B surface antigen-positive cirrhosis of the liver. Gastroenterology
1992;103:1630–1635. [PubMed: 1426884]

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 10

38. Lok AS, Lai CL. Alpha-fetoprotein monitoring in Chinese patients with chronic hepatitis B virus
infection: role in the early detection of hepatocellular carcinoma. Hepatology 1989;9:110–115.
[PubMed: 2461890]
NIH-PA Author Manuscript

39. Spangenberg HC, Thimme R, Blum HE. Serum markers of hepatocellular carcinoma. Semin Liver
Dis 2006;26:385–390. [PubMed: 17051452]
40. Dienstag JL. Hepatitis B as an immune complex disease. Semin Liver Dis 1981;1:45–57. [PubMed:
6126007]
41. Trepo C, Guillevin L. Polyarteritis nodosa and extrahepatic manifestations of HBV infection: the case
against autoimmune intervention in pathogenesis. J Autoimmun 2001;16:269–274. [PubMed:
11334492]
42. Alpert E, Isselbacher KJ, Schur PH. The pathogenesis of arthritis associated with viral hepatitis.
Complement-component studies. N Engl J Med 1971;285:185–189. [PubMed: 4996611]
43. Gocke DJ, Hsu K, Morgan C, Bombardieri S, Lockshin M, Christian CL. Association between
polyarteritis and Australia antigen. Lancet 1970;2:1149–1153. [PubMed: 4098431]
44. Lai KN, Li PK, Lui SF, Au TC, Tam JS, Tong KL, et al. Membranous nephropathy related to hepatitis
B virus in adults. N Engl J Med 1991;324:1457–1463. [PubMed: 2023605]
45. Takekoshi Y, Tanaka M, Shida N, Satake Y, Saheki Y, Matsumoto S. Strong association between
membranous nephropathy and hepatitis-B surface antigenaemia in Japanese children. Lancet
1978;2:1065–1068. [PubMed: 82085]
46. Lai KN, Lai FM. Clinical features and the natural course of hepatitis B virus-related glomerulopathy
in adults. Kidney Int Suppl 1991;35:S40–S45. [PubMed: 1770709]
NIH-PA Author Manuscript

47. Ishimaru Y, Ishimaru H, Toda G, Baba K, Mayumi M. An epidemic of infantile papular acrodermatitis
(Gianotti’s disease) in Japan associated with hepatitis-B surface antigen subtype ayw. Lancet
1976;1:707–709. [PubMed: 56530]
48. Liang TJ, Baruch Y, Ben-Porath E, Enat R, Bassan L, Brown NV, et al. Hepatitis B virus infection
in patients with idiopathic liver disease. Hepatology 1991;13:1044–1051. [PubMed: 2050320]
49. Liang TJ, Blum HE, Wands JR. Characterization and biological properties of a hepatitis B isolated
from a patient without HBV serologic markers. HEPATOLOGY 1990;12:204–212. [PubMed:
2167867]
50. Paterlini P, Gerken G, Nakajima E, Terre S, D’Errico A, Grigioni W, et al. Polymerase chain reaction
to detect hepatitis B virus DNA and RNA sequences in primary liver cancers from patients negative
for hepatitis B surface antigen. N Engl J Med 1990;323:80–85. [PubMed: 2359427]
51. Rehermann B, Ferrari C, Pasquinelli C, Chisari FV. The hepatitis B virus persists for decades after
patients’ recovery from acute viral hepatitis despite active maintenance of a cytotoxic T-lymphocyte
response. Nat Med 1996;2:1104–1108. [PubMed: 8837608]
52. Yotsuyanagi H, Yasuda K, Iino S, Moriya K, Shintani Y, Fujie H, et al. Persistent viremia after
recovery from self-limited acute hepatitis B. Hepatology 1998;27:1377–1382. [PubMed: 9581694]
53. Korba BE, Cote PJ, Wells FV, Baldwin B, Popper H, Purcell RH, et al. Natural history of woodchuck
hepatitis virus infections during the course of experimental viral infection: molecular virologic
NIH-PA Author Manuscript

features of the liver and lymphoid tissues. J Virol 1989;63:1360–1370. [PubMed: 2915383]
54. Thiers V, Nakajima E, Kremsdorf D, Mack D, Schellekens H, Driss F, et al. Transmission of hepatitis
B from hepatitis-B-seronegative subjects. Lancet 1988;2:1273–1276. [PubMed: 2904005]
55. Dickson RC, Everhart JE, Lake JR, Wei Y, Seaberg EC, Wiesner RH, et al. Transmission of hepatitis
B by transplantation of livers from donors positive for antibody to hepatitis B core antigen. The
National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database.
Gastroenterology 1997;113:1668–1674. [PubMed: 9352871]
56. Blanpain C, Knoop C, Delforge ML, Antoine M, Peny MO, Liesnard C, et al. Reactivation of hepatitis
B after transplantation in patients with pre-existing anti-hepatitis B surface antigen antibodies: report
on three cases and review of the literature. Transplantation 1998;66:883–886. [PubMed: 9798698]
57. Lok AS, Liang RH, Chiu EK, Wong KL, Chan TK, Todd D. Reactivation of hepatitis B virus
replication in patients receiving cytotoxic therapy. Report of a prospective study. Gastroenterology
1991;100:182–188. [PubMed: 1983820]

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 11

58. Hui CK, Cheung WW, Zhang HY, Au WY, Yueng YH, Leung AY, et al. Kinetics and risk of de novo
hepatitis B infection in HBsAg-negative patients undergoing cytotoxic chemotherapy.
Gastroenterology 2006;131:59–68. [PubMed: 16831590]
NIH-PA Author Manuscript

59. Loomba R, Rowley A, Wesley R, Liang TJ, Hoofnagle JH, Pucino F, et al. Systematic review: the
effect of preventive lamivudine on hepatitis B reactivation during chemotherapy. Ann Intern Med
2008;148:519–528. [PubMed: 18378948]
60. Blum HE, Galun E, Liang TJ, von Weizsacker F, Wands JR. Naturally occurring missense mutation
in the polymerase gene terminating hepatitis B virus replication. J Virol 1991;65:1836–1842.
[PubMed: 2002544]
61. Hou J, Karayiannis P, Waters J, Luo K, Liang C, Thomas HC. A unique insertion in the S gene of
surface antigen–negative hepatitis B virus Chinese carriers. Hepatology 1995;21:273–278. [PubMed:
7843693]
62. Kato J, Hasegawa K, Torii N, Yamauchi K, Hayashi N. A molecular analysis of viral persistence in
surface antigen-negative chronic hepatitis B. Hepatology 1996;23:389–395. [PubMed: 8617416]
63. Yamamoto K, Horikita M, Tsuda F, Itoh K, Akahane Y, Yotsumoto S, et al. Naturally occurring
escape mutants of hepatitis B virus with various mutations in the S gene in carriers seropositive for
antibody to hepatitis B surface antigen. J Virol 1994;68:2671–2676. [PubMed: 8139044]
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 12
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Fig. 1.
Electron micrograph of circulating forms of HBV particles in the blood is shown at the top and
a schematic drawing of Dane particle, the infectious HBV particle, is shown at the bottom with
various structural features.

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 13
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Fig. 2.
The HBV genome. (A) The genomic organization, RNA transcripts and gene products are
shown with several key regulatory elements. (B) The transcription start sites of various HBV
transcripts and the proteins they encode (see text for details).

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 14
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Fig. 3.
The replication cycle of HBV (see text for details).
NIH-PA Author Manuscript

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 15
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Fig. 4.
The clinical course and serologic profiles of (A) acute and (B) chronic hepatitis B.

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 16
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Fig. 5.
The detection limits and dynamic ranges of assays for HBV DNA.
NIH-PA Author Manuscript

Hepatology. Author manuscript; available in PMC 2010 January 20.

 Liang Page 17

Table 1
Hepatitis B Virus Serological and Virological Markers
NIH-PA Author Manuscript

HBsAg HBV infection, both acute and chronic

HBeAg High-level HBV replication and infectivity; marker for
treatment response
HBV DNA Level of HBV replication; primary virologic marker for
treatment response
Anti-HBc (IgM) Acute HBV infection; could be seen in flare of chronic
hepatitis B
Anti-HBc (IgG) Recovered or chronic HBV infection
Anti-HBs Recovered HBV infection or marker of HBV vaccination;
immunity to HBV infection (titer can be measured to assess
vaccine efficacy)
Anti-HBe Low-level HBV replication and infectivity; marker for
treatment response
Anti-HBc (IgG) and anti-HBs Past HBV infection; could lose anti-HBs
Anti-HBc (IgG) and HBsAg Chronic HBV infection
Anti-HBc (IgG) and/or anti-HBs and HBV DNA Latent or occult HBV infection
(PCR)
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Hepatology. Author manuscript; available in PMC 2010 January 20.