Chronic Hepatitis C
This patient has chronic hepatitis C (Answer C). The presence of both positive HCV antibody and detectable HCV RNA at 1.5 million IU/mL definitively establishes active, ongoing HCV infection with viral replication 1.
Diagnostic Interpretation
The combination of positive anti-HCV antibodies AND detectable HCV RNA confirms chronic hepatitis C infection. According to the American Association for the Study of Liver Diseases, chronic hepatitis C is definitively diagnosed by the simultaneous presence of these two markers 1. The high HCV RNA level (1.5 million IU/mL) confirms active viral replication, not merely past exposure 1.
Why Not the Other Options?
Hepatitis A (Option A): The positive Hepatitis A IgG indicates past exposure with immunity; hepatitis A never causes chronic hepatitis as it is an acute, self-limited infection 2.
Hepatitis B (Option B): The negative HBsAg excludes active hepatitis B infection 3. The positive HBcAb indicates either past resolved HBV infection or, less commonly, vaccination-induced immunity, but does not indicate current chronic hepatitis B 1.
Hepatitis D (Option D): Hepatitis D virus requires active hepatitis B infection (HBsAg positive) to replicate, which this patient does not have 2.
Understanding the Serologic Profile
The positive HBcAb in this patient represents resolved prior HBV infection, not active disease. This is a critical distinction—HBcAb positivity with HBsAg negativity indicates past exposure to hepatitis B that has cleared, leaving behind immunologic memory 1, 4.
Chronic HCV infection is characterized by detection of HCV RNA persisting beyond 6 months after initial infection. The European Association for the Study of the Liver notes that spontaneous viral clearance beyond 4-6 months is extremely rare, making the diagnosis of chronic infection confident after this timepoint 3, 2.
Clinical Significance and Next Steps
This patient requires comprehensive evaluation for disease severity and treatment planning. The American Association for the Study of Liver Diseases recommends:
- Liver function tests and complete blood count 1
- HCV genotype determination 1
- Fibrosis assessment (either non-invasive or liver biopsy) 1
- Abdominal ultrasound for hepatocellular carcinoma surveillance if cirrhosis is present 1
Direct-acting antiviral therapy should be initiated to prevent disease progression. Modern DAA regimens achieve sustained virological response rates exceeding 95%, preventing progression to cirrhosis, hepatocellular carcinoma, and death 1, 2.
Important Monitoring Consideration
This patient requires HBV reactivation monitoring during HCV treatment. The FDA mandates testing all patients for evidence of current or prior HBV infection (HBsAg and anti-HBc) before initiating HCV treatment 4. In patients with serologic evidence of HBV infection (like this patient with positive HBcAb), clinical and laboratory monitoring for hepatitis flare or HBV reactivation is required during and after HCV treatment 4. Cases of HBV reactivation have been reported in patients with resolved HBV infection (HBsAg negative, anti-HBc positive) receiving HCV direct-acting antivirals, with some resulting in fulminant hepatitis, hepatic failure, and death 4.
Common Pitfalls to Avoid
Do not confuse positive HCV antibody alone with active infection—HCV antibodies persist after viral clearance, so HCV RNA testing is essential to confirm active infection 3, 1.
Do not assume normal aminotransferases exclude significant liver disease—chronic hepatitis C is often asymptomatic with minimal or intermittent ALT elevations 1, 2.
Do not overlook the risk of HBV reactivation in patients with positive HBcAb receiving HCV treatment, as this can lead to severe complications 4.