What is the chronicity status of a patient with a history of multiple blood transfusions, mild elevation of liver enzymes, positive Hepatitis C virus (HCV) antibodies, a significant viral load, and negative tests for Hepatitis B surface antigen (HbsAg), Hepatitis B surface antibody (HbsAb), Hepatitis A virus immunoglobulin M (HAV IgM), and Hepatitis B core antibody, but positive for Hepatitis B core antibody immunoglobulin G (IgG)?

Chronic Hepatitis C Infection Status

This patient has chronic hepatitis C infection, confirmed by the presence of positive HCV antibodies and a high viral load (HCV RNA PCR 1.5 million), with evidence of past resolved hepatitis B infection (HBcAb IgG positive, HBsAg negative, HBsAb negative). 1, 2

Hepatitis C Chronicity Assessment

The diagnosis of chronic hepatitis C is definitively established when HCV RNA remains detectable beyond 6 months after initial infection. 1 In this patient:

• Positive HCV antibodies (anti-HCV) indicate exposure to HCV 1
• Detectable HCV RNA at 1.5 million copies confirms active, ongoing viral replication 1
• The combination of positive anti-HCV and positive HCV RNA establishes chronic infection 1
• The history of multiple blood transfusions represents a classic risk factor for HCV transmission, particularly if transfusions occurred before widespread blood screening 1, 2

Approximately 75-85% of individuals infected with HCV develop chronic infection, and this patient clearly falls into that majority. 3, 4 The high viral load of 1.5 million copies indicates active viral replication and ongoing infectivity. 1

Hepatitis B Serologic Pattern Interpretation

The hepatitis B serologic profile requires careful interpretation:

• HBsAg negative rules out chronic hepatitis B infection 2
• HBsAb negative indicates absence of protective immunity from vaccination or complete recovery 2
• HBcAb IgG positive indicates past exposure to hepatitis B virus 5, 6, 2
• HBcAb IgM negative (referred to as "negative Core" in the question) rules out acute hepatitis B infection 5, 6

This serologic pattern (HBsAg negative, HBsAb negative, HBcAb IgG positive) represents past HBV infection with incomplete serologic recovery—the patient cleared HBsAg but has not yet developed anti-HBs antibodies, a pattern sometimes called "anti-HBc alone" or isolated core antibody. 2 This is distinct from chronic HBV infection and does not affect the HCV chronicity status.

Clinical Implications and Disease Activity

The mild elevation of liver enzymes (ALT/AST) in the context of detectable HCV RNA indicates active chronic hepatitis C with ongoing hepatocellular injury. 1 Key considerations:

• Chronic HCV infection leads to progressive liver disease in approximately one-third of patients over 20-30 years 3
• Post-transfusion hepatitis C has historically been associated with more aggressive disease progression, with studies showing 40% developing chronic active hepatitis and 10-20% developing cirrhosis within 5 years 1
• The presence of detectable HCV RNA with elevated liver enzymes confirms this is chronic hepatitis C (active disease), not merely chronic HCV infection (inactive carrier state) 1

Critical Management Points

This patient requires immediate HCV genotyping and quantitative viral load assessment to guide antiviral therapy decisions. 1 Additional considerations:

• The goal of therapy is viral eradication (sustained virological response) to prevent progression to cirrhosis, hepatocellular carcinoma, and liver-related death 1
• Patients with chronic HCV and elevated liver enzymes should be considered for antiviral treatment regardless of fibrosis stage 1
• Non-invasive fibrosis assessment (elastography or serum markers) should be performed to stage liver disease 1
• The patient remains highly infectious due to active viremia and should receive counseling on transmission prevention 1

Common Pitfalls to Avoid

• Do not confuse positive HCV antibodies alone with chronic infection—HCV RNA testing is mandatory to distinguish active infection from resolved infection 1, 2
• Do not delay treatment based on mild enzyme elevations—even patients with minimal ALT elevation can have significant fibrosis and benefit from treatment 1
• Do not misinterpret the isolated HBcAb IgG positivity as indicating chronic HBV coinfection—this patient has resolved HBV, not active HBV 2
• Do not assume the transfusion history alone determines chronicity—the combination of positive antibodies and detectable RNA for a presumed duration exceeding 6 months establishes chronicity 1