What is the diagnosis for a patient with a history of blood transfusions 10 years ago, who is asymptomatic, has normal liver enzymes (aspartate aminotransferase (AST) and alkaline phosphatase (ALP)), and has laboratory results showing hepatitis B surface antigen (HbsAg) positive, hepatitis B virus (HBV) immunoglobulin G (IgG) positive, HBV immunoglobulin M (IgM) negative, and hepatitis B virus e-antigen (HBeAg) positive, but negative for anti-HBe antibodies?

Chronic Hepatitis B Infection (Chronic Active Phase)

This patient has chronic hepatitis B infection in the immune active phase (HBeAg-positive chronic hepatitis B), not an inactive carrier state, acute infection, or past infection. 1, 2

Serologic Pattern Analysis

The key to this diagnosis lies in understanding the complete serologic profile:

• HBsAg positive for >6 months (given 10-year history from transfusion) confirms chronic HBV infection, not acute disease 3, 1
• HBV IgM negative definitively rules out acute infection, as IgM anti-HBc appears at symptom onset in acute hepatitis B and persists for approximately 6 months 3, 4
• HBV IgG positive (anti-HBc total) indicates chronic or past infection and persists for life 3
• HBeAg positive with anti-HBe antibody negative is the critical distinguishing feature indicating active viral replication and high infectivity 3, 1

Why Each Answer Choice is Correct or Incorrect

Choice A (Acute Infection) - INCORRECT

• Acute infection requires positive IgM anti-HBc, which this patient lacks 3, 4
• The 10-year history from blood transfusion and persistent HBsAg positivity indicate chronicity, not acute disease 3, 1

Choice B (Chronic Inactive Infection) - INCORRECT

• Inactive carrier state is defined by: HBeAg negative, anti-HBe positive, HBV DNA <2,000 IU/mL, and persistently normal ALT 3, 2
• This patient has the opposite serologic pattern: HBeAg positive and anti-HBe negative, indicating active viral replication 1, 2
• The presence of HBeAg positivity with absent anti-HBe antibodies indicates active viral replication and high infectivity, not an inactive state 1

Choice C (Immunization) - INCORRECT

• Vaccine-derived immunity shows anti-HBs positive with anti-HBc negative 3
• This patient is HBsAg positive (indicating active infection) and anti-HBc positive (indicating natural infection, not vaccination) 3

Choice D (Past Chronic Infection) - INCORRECT

• Recovery from HBV infection shows HBsAg negative, anti-HBs positive, and anti-HBc positive 3
• This patient remains HBsAg positive, confirming ongoing chronic infection 3, 1

Clinical Phase Classification

This patient is in Phase 1 (immune tolerant) or early Phase 2 (immune active) of chronic HBV infection, characterized by: 1

• HBeAg positive status indicating high viral replication
• Normal or minimally elevated ALT despite ongoing viral replication
• High infectivity due to elevated HBV DNA levels (presumed, requires quantification)

Critical Clinical Caveats

Normal liver enzymes do NOT indicate inactive disease or benign prognosis in this patient: 1, 2

• Normal ALT/AST is consistent with the immune tolerant phase where minimal hepatocellular damage occurs despite high viral replication 1
• The asymptomatic presentation with normal liver enzymes does not exclude significant ongoing viral replication or future disease progression 1
• Patients in this phase remain highly contagious and at risk for progression to cirrhosis and hepatocellular carcinoma 1

Mandatory Next Steps

HBV DNA quantification is essential to confirm the phase of chronic infection and determine treatment eligibility: 2

• HBeAg-positive patients typically have HBV DNA >20,000 IU/mL (>10^5 copies/mL) 3, 5
• Serial ALT monitoring every 3-4 months is required to detect disease progression 1, 2
• Hepatocellular carcinoma surveillance with ultrasound and alpha-fetoprotein is mandatory regardless of normal enzymes 3, 2