What is the indicator for chronic hepatitis in a patient with positive HCV (Hepatitis C Virus) antibody and elevated HCV RNA levels?

Chronic Hepatitis C is the Indicator in This Patient

The correct answer is C - HCV (Hepatitis C Virus) is the indicator for chronic hepatitis in this patient, confirmed by the presence of both positive HCV antibody and detectable HCV RNA at 2 million IU/ml. 1

Diagnostic Interpretation

HCV Status - Active Chronic Infection

• Chronic hepatitis C is definitively diagnosed by the simultaneous presence of positive anti-HCV antibodies AND detectable HCV RNA, which this patient has. 1
• The HCV RNA level of 2 million IU/ml confirms active viral replication and chronic infection (not just past exposure). 1
• The diagnosis can be confidently made after 4-6 months of infection, as spontaneous viral clearance beyond this timepoint is extremely rare. 1

HBV Status - Past Infection with Immunity

• HBsAg negative indicates no active hepatitis B infection. 1
• HBsAb positive indicates either past resolved infection or vaccination-induced immunity - this is protective, not indicative of chronic disease. 1

HAV Status - Past Infection Only

• HAV IgG positive indicates past exposure with immunity - hepatitis A does not cause chronic hepatitis. 1
• Hepatitis A virus never establishes chronic infection; it only causes acute, self-limited disease. 1

HDV Status - Cannot Exist Without HBV

• Hepatitis D virus (delta agent) is a defective virus that requires HBV surface antigen to replicate. 1
• Since this patient is HBsAg negative, HDV infection is impossible. 1

Clinical Significance of This Patient's HCV

High Viral Load Implications

• The HCV RNA level of 2 million IU/ml places this patient above the threshold that historically predicted treatment outcomes. 2
• Approximately 34% of chronic hepatitis C patients have HCV RNA >2 million IU/ml. 2
• The history of blood transfusion years ago is the likely transmission source, as transfusion-related HCV was common before 1992 screening. 3

Risk of Disease Progression

• Approximately 85% of acute HCV infections progress to chronic infection, and this patient clearly has chronic disease. 4
• An estimated 20-30% of chronic hepatitis C patients develop cirrhosis, though progression is typically slow and insidious. 4, 1
• Once cirrhosis develops, patients face risk of hepatocellular carcinoma at rates of 1-7% per year. 1

Common Pitfalls to Avoid

• Do not confuse positive HCV antibody alone with active infection - HCV antibodies persist after viral clearance (spontaneous or treatment-induced) and do not distinguish current from past infection. 1, 5
• Do not assume normal aminotransferases exclude significant liver disease - chronic hepatitis C is often asymptomatic with minimal or intermittent ALT elevations, yet underlying cirrhosis may be present. 4, 3
• Do not overlook the need for HCV RNA confirmation - approximately 20-25% of anti-HCV positive individuals have cleared the virus and are HCV RNA negative. 5, 6

Next Steps for This Patient

Immediate Evaluation Required

• Liver function tests (ALT, AST, alkaline phosphatase, bilirubin, albumin, INR) to assess hepatic synthetic function. 7
• Complete blood count to evaluate for cytopenias suggesting advanced liver disease. 7
• HCV genotype determination to guide treatment selection. 1, 7
• Fibrosis assessment using non-invasive methods (FIB-4 score, APRI, or transient elastography) or liver biopsy if being considered for treatment. 7, 6
• Abdominal ultrasound to screen for hepatocellular carcinoma and evaluate for cirrhosis. 7

Treatment Considerations

• Direct-acting antiviral (DAA) therapy is the standard of care with sustained virological response rates >95%. 7
• The goal of therapy is HCV eradication to prevent progression to cirrhosis, hepatocellular carcinoma, and death. 1
• Treatment regimen selection depends on HCV genotype, presence/absence of cirrhosis, and prior treatment history. 7