Chronic Hepatitis from Blood Transfusion Before Age 12 with HBV Antibodies Positive
Direct Answer
Hepatitis C (HCV) is the most likely cause of chronic hepatitis in this patient, despite the presence of HBV antibodies. 1
Clinical Reasoning
Why Hepatitis C is the Answer
- Blood transfusion before age 12 is a classic risk factor for HCV transmission, particularly before widespread screening of blood products began in the 1990s 1
- Hepatitis C causes chronic infection in 75-85% of infected individuals, making it notorious for chronicity 1
- The presence of HBV antibodies (anti-HBs and anti-HBc IgG) with negative HBsAg indicates resolved past HBV infection with natural immunity, NOT chronic HBV infection 1
Serologic Pattern Interpretation
- HBsAg negative rules out chronic hepatitis B, as HBsAg persistence for >6 months is required to define chronic HBV infection 2, 1
- Anti-HBs positive indicates immunity to hepatitis B from either resolved past infection or vaccination 1
- The combination of HBsAg negative, anti-HBs positive, and anti-HBc positive represents past HBV infection with recovery, not chronic infection 1
- This serologic profile (resolved HBV) does NOT explain the current chronic hepatitis symptoms 1
Historical Context of Transfusion-Associated Hepatitis
- Screening blood donors for HBsAg became mandatory in 1972, significantly reducing post-transfusion hepatitis B to 0.3%-0.9% per recipient by the mid-1970s 3
- Anti-HCV testing of blood donations began voluntarily in 1990, meaning transfusions before this period carried substantial HCV transmission risk 3
- Approximately 50% of patients with post-transfusion hepatitis C develop biochemical evidence of chronic liver disease when followed for at least 12 months 3
Critical Diagnostic Next Steps
- Anti-HCV antibody testing is mandatory to confirm hepatitis C exposure 1
- HCV RNA testing is essential because anti-HCV antibodies (IgG) do NOT distinguish between resolved and chronic HCV infection—only HCV RNA confirms active chronic infection 1
- Liver function tests including ALT, AST, bilirubin, albumin, and prothrombin time should be obtained to assess extent of liver disease 3
Important Clinical Caveats
- Many patients with chronic hepatitis C are asymptomatic for years, even those with documented cirrhosis, making the diagnosis easily missed 3
- Within 5 years of transfusion-associated chronic hepatitis C, ≥40% have chronic active hepatitis and 10-20% have cirrhosis on biopsy, despite minimal clinical manifestations 3
- The patient may have had dual exposure to both HBV and HCV from the transfusion, with HBV resolving spontaneously (as evidenced by the antibody pattern) while HCV persisted chronically 3