Serum albumin and globulin are usually within normal levels Decreased albumin or increased globulin levels should suggest an acute flare of chronic liver disease Serum ceruloplasmin levels should be drawn in all patients older than years who have suspected hepatitis to evaluate for Wilson disease Figure 91.3 demonstrates the sequence of clinical, biochemical, and serologic events in typical HAV and HBV infection The serodiagnosis of acute hepatitis is best approached by first testing for anti-HAV IgM, HB surface antigen, HB e antigen, HB serum DNA (quantitative), anti-HB core Ab, anti-HCV, hepatitis C serum PCR (quantitative), anti-CMV, and EBV serology The finding of serum IgM anti-HAV is diagnostic of acute HAV infection because the antibody is present at the time of clinical symptoms A positive HB surface antigen suggests the diagnosis of HBV in a symptomatic patient A positive HB e antigen or anti-HB core Ab is helpful in the rare patient who rapidly clears HB surface antigen from the serum It is also important to note that in long-term HB surface antigen carriers who have HDV superinfection, the suppression of HBV replication may lead to a transient absence of HBV markers in the serum; unless HDV markers in the serum are sought, the diagnosis may be missed Anti-HCV does not appear in the patient’s circulation until to months after the onset of acute illness, and in rare cases, detectable levels may not be demonstrated for up to year Thus, unless the acute presentation is actually a flare of chronic HCV, serodiagnosis of an HCV infection (Hep C PCR) will await long-term follow-up FIGURE 91.3 Serologic changes in hepatitis A HAAg, hepatitis-associated antigen; HAV, hepatitis A virus