Recurrence of hepatitis B and delta hepatitis after orthotopic liver transplantation

The clinical course of 10 liver transplant recipients who had hepatitis B virus (HBV) and five recipients with HBV and D (delta) infection before transplantation is described. Six patients who underwent eight transplants died. The estimated one and two year survival rates in patients with HBV only before transplantation were 74% and 67% respectively. The estimated one and two year survival in patients with HBV and HDV infection beforehand was 100%. Graft infection by HBV occurred in 8 of 10 patients infected with HBV only; and in 4 of 5 patients with previous HBV and HDV infection. There was a widely variable time from transplantation to the appearance of HBV markers in liver or serum, ranging from 6-331 days. Hepatitis D antigen (HDAg) appeared in three grafts very rapidly after transplantation at 4, 8, and 37 days respectively. Graft infection by HBV was accompanied by significant liver injury in six allografts in five recipients. In particular, there was a striking morphological appearance in five infected livers in which the hepatocytes became progressively enlarged and distorted as they accumulated huge amounts of hepatitis B surface and core antigens (HBsAg, HBcAg). These features were accompanied by pericellular fibrosis and cholestasis but little associated inflammation. This syndrome carried a poor prognosis. A gradual progression to cirrhosis occurred in one additional liver. Finally, recurrent HBV infection was a principal or a contributing factor in all deaths. The presence of HBcAg and inflammation in he native liver increased the risk of HBV induced tissue damaged in the graft whereas HDV infection in the host liver seemed to reduce the risk of significant HBV induced tissue damage in the allograft. These data suggest that post transplant HBV infection is accompanied by a variety of changes in the liver allograft, some of which are unique to the transplanted liver and may result in impaired allograft function.

Fear of dying and HIV infection vs hepatitis B infection

Accidental exposure to the blood of hepatitis B patients produced less fear than does accidental exposure today to the human immunodeficiency virus (HIV), even though both have an approximately equal overall risk of death (approximately 1%). Subjects responding to hypothetical insect-exposure and disease-exposure scenarios chose to avoid the HIV-type risk of 1% chance of exposure/100% chance of death. Fear of certain death seems to account for the greater concern about exposure to HIV than to Hepatitis B.

What is the dentist's occupational risk of becoming infected with hepatitis B or the human immunodeficiency virus?

Surveys have shown that dentists are reluctant to treat persons infected with the human immunodeficiency virus (HIV). However, dentists are much more willing to treat patients with infectious hepatitis B virus (HBV). This study shows that the annual cumulative risk of infection from routine treatment of patients whose seropositivity is undisclosed is 57 times greater from HBV than from HIV, and that the risk of dying from HBV infection is 1.7 times greater than the risk of HIV infection, for which mortality is almost certain.

Hepatitis B virus reinfection after orthotopic liver transplantation. Serological and clinical implications

The implications of hepatitis B virus (HBV) reinfection after liver transplantation were studied in 29 patients followed for 1.7-15 years. Of 20 patients with HBV infection alone, nine were HBeAg and HBV DNA seronegative and 11 had evidence of HBV replication as measured by HBeAg or HBV DNA seropositivity. Nine patients had co-existing HBV and delta virus (HDV) infection. Five patients became HBsAg seronegative after transplantation (four immediately and one after an hepatitic episode). Of the 20 patients with HBV infection alone, 17 had evidence of viral replication after transplantation with markedly increased HBV DNA levels. Five patients with HDV infection had HBV DNA in serum, but in significantly lower amounts than in those with HBV infection alone. Twenty-five episodes of graft dysfunction attributed to recurrent HBV infection occurred in 19 patients (65.5%). Thirteen episodes (in 12 patients) were self-resolving acute hepatitic illnesses. Six patients had a rapidly progressive illness leading to graft loss within 6 weeks, with the distinctive histological features termed fibrosing cholestatic hepatitis (FCH). Liver function tests in these patients showed markedly abnormal serum bilirubin and prothrombin times, but only modest increases in serum transaminase levels. An additional six patients lost their graft as a consequence of HBV recurrence through various pathogenetic mechanisms including possible (but unproven) FCH, chronic active hepatitis or late-onset hepatic failure. Co-existing HDV infection appeared to confer some medium-term protection from graft loss.

Characteristics and outcome of acute infection with hepatitis B virus in children with cancer

After an outbreak of hepatitis B virus (HBV) infection in a unit of pediatric oncology, the clinical outcome and HBV markers were followed in 1 child with chronic and 10 children with acute HBV infection for 12 months. Four children had acute hepatitis with jaundice whereas 7 of the infections were subclinical. Ten children had antecedent malignancies and 1 had aplastic anemia. Four patients died of causes unrelated to the hepatitis after periods of 2, 4, 8 and 10 months. All 3 children who were not immunosuppressed at the time of contracting the HBV infection quickly turned negative for hepatitis B surface antigen (HBsAg), whereas only 2 of 8 patients who were immunosuppressed by chemotherapy eventually became HBsAg-negative. The latter 8 patients were also hepatitis B e antigen (HBeAg)-positive. Two of them quickly cleared HBeAg, but 6 remained HBeAg-positive throughout the follow-up. In 6 of 9 patients HBsAg was also detected in saliva. These results suggest that children who are receiving anticancer chemotherapy have an increased risk of remaining HBeAg-positive and secreting HBsAg and possibly HBV in their saliva, which makes them particularly infective.

Prognostic significance of pre-S2 antigen and antibody in fulminant hepatitis B. Evidence for heterogeneous serological responses

Serial sera were collected prospectively and from early on in the clinical course of ten patients with fulminant hepatitis B. These were analysed for HBV DNA (dot-blot technique), HBsAg, HBeAg, pre-S2-Ag and their respective antibodies. Two patterns emerged in nine of the patients. The first and well-recognised pattern of rapid clearance of antigens and appearance of antibodies was seen in four patients, all of whom survived. The second pattern seen in five patients was one of persistence of HBsAg and pre-S2 antigen and failure to detect antibodies but only one patient survived. The first pattern may reflect a more rapid cessation of virus replication and this may favour liver cell regeneration and recovery. In contrast, the second pattern may indicate continuing virus replication and liver cell damage which could contribute to the high mortality in some patients with fulminant hepatitis B.

Morbidity and mortality from chronic hepatitis B virus infection in family members of patients with malignant and nonmalignant hepatitis B virus-related chronic liver diseases

Three-hundred forty-one HBsAg-positive family members of 152 patients with chronic hepatitis B virus infection (47 asymptomatic carriers, 59 with chronic hepatitis, 17 with cirrhosis and 29 with hepatocellular carcinoma) were prospectively studied to determine the morbidity and mortality from chronic hepatitis B virus infection in the family members of patients with malignant and nonmalignant hepatitis B virus-related chronic liver diseases. Most of the family members had no history of acute hepatitis, were asymptomatic and were unaware of their carrier status. However, 5.3% had stigmata of chronic liver disease, 6% had serum ALT levels that exceeded two times the upper limit of normal and 78% of those who had biopsies had chronic hepatitis with or without cirrhosis. During a follow-up period of 12 to 90 mo (median = 39 mo), 3% had symptoms of chronic liver disease; 24% had transient, recurrent or persistent elevation in serum ALT levels, 1.4% had cirrhosis and 1% had hepatocellular carcinoma. Neither hepatocellular carcinoma in the index patient nor a previous history of hepatocellular carcinoma in the family was associated with an increase in the morbidity and mortality from chronic hepatitis B virus infection in the HBsAg-positive family members.

Passive immunoprophylaxis after liver transplantation in HBsAg-positive patients

110 HBsAg-positive patients underwent orthotopic liver transplantation and received long-term anti-hepatitis B virus (HBV) passive immunoprophylaxis with anti-HBs immunoglobulin. During a mean follow-up period of 20 months, all patients became HBsAg negative after transplantation but circulating HBsAg reappeared in 25 (22.7%). Overall 1-year survival was 83.6% and overall 2 year actuarial recurrence of HBsAg was 29% (59% after posthepatitis B cirrhosis, 13% after posthepatitis B-delta cirrhosis, and 0% after fulminant hepatitis B). Patients with HBV cirrhosis who were HBV-DNA positive had a much greater risk of HBsAg recurrence than patients who were HBV-DNA negative (96% vs 29% at 2 years). Reappearance of HBsAg was associated with evidence of HBV replication and abnormal histological findings in the graft. Long-term passive anti-HBV immunoprophylaxis significantly reduced HBV reinfection and improved survival in patients without evidence of active HBV replication before orthotopic liver transplantation.

[Possible long-term prognosis in epidemiologically significant virus infections]

The long-range prognosis of viral diseases must be assessed differently according to their geographical occurrence. The genetic disposition, environmental factors and additional infectious diseases play a decisive part here. Vaccinations are the most important measures in the prevention of these infections. The spectrum of possible chemotherapeutic intervention for viral infectious diseases is very small, which usually makes specific treatment impossible. The most important infective viruses epidemiologically, which lead to persistent complications, are discussed in detail as follows: influenza virus, measles virus, human T-cell leukaemia virus, human immuno-deficiency virus, hepatitis B and C virus. In a discussion conclusions are drawn from the virologist's point of view for a possible long-range prognosis, which depends on the one hand on the infective agent and on the other on individual reactivity. The last chapter talks about insurance medical aspects of the most important infective viruses, which have already been discussed virologically. Some scientific developments are shown which could be future solutions of problems in diagnosis and prognosis. Such new developments could help insurance medical officers to important decision parameters for long-range prognosis, which are still largely missing at present.

Aetiology and prognosis of fulminant viral hepatitis in Japan: a multicentre study. The Study Group of Fulminant Hepatitis

In 236 patients with fulminant viral hepatitis (FVH), type B (FBH) was most common (47.5%), followed by non-A non-B hepatitis (FNANB, 44.9%) and hepatitis type A (FAH, 7.6%). The survival rate was significantly higher in the FAH group than in the FBH and FNANB groups (61.1, 36.6 and 18.9% respectively), and was significantly higher in the FBH group than in the FNANB group. In spite of screening for hepatitis B virus (HBV), FBH was prevalent (27 of 41) in post-transfusion cases; this phenomenon is discussed in relation to a recently revealed mutation of HBV. Within a month after the onset of hepatitis symptoms all cases in the FAH, 93% in the FBH and 79% in the FNANB group, developed encephalopathy. When the duration of illness before the onset of encephalopathy was more than 10 days (a subacute form), the survival rate was significantly lower than when encephalopathy developed in less than 11 days (an acute form). This difference could be accounted for by the difference in the relative frequency of aetiological viruses in the two forms and the higher survival rate in the acute, than the subacute, form in the FNANB group.

Treatment with interferon of chronic hepatitis B associated with antibody to hepatitis B e antigen

Persistence of HBV replication (serum HBV-DNA and intrahepatic HBcAg) and markers of HBV-induced (IgM anti-HBc positive) liver disease in anti-HBe-positive patients characterize a peculiar form of chronic hepatitis B. This form of hepatitis B prevails in the Mediterranean Basin, Middle and Far East and is associated with the infection of an HBV variant that lacks the capacity to produce HBeAg. We analysed the results of interferon treatment of 90 patients with chronic anti-HBe-positive hepatitis included in four randomized controlled trials. Interferon inhibited viral replication to undetectable levels and ALT normalized in about 70% of patients. However, the effect was transient in the majority of cases and hepatitis B relapsed in 41 to 90% of patients. A discrepancy in the rate of relapses could be explained by a significant difference in patients populations with a higher prevalence of cirrhotic patients in studies with poorer response. Therefore, in advanced anti-HBe-positive chronic hepatitis B, interferon shows a lower efficacy than in HBeAg-positive patients. The earlier treatment starts, the more efficacious is the response to interferon. Future clinical trials should focus on higher doses for longer periods, repeated courses or on combination therapy with nucleoside analogs or immuno-stimulant drugs.

Fulminant hepatitis in children: report of 12 cases

Twelve cases of childhood fulminant hepatitis seen over a 4-year period are described. Six had hepatitis A, five hepatitis B and one non-A non-B hepatitis. Encephalopathy, the cardinal feature of fulminant hepatitis, was usually evident within 2 weeks of onset of illness, and the median duration of illness in fatal cases was 19 days. Deep jaundice, prolongation of the prothrombin time and raised serum ammonia were invariable. Eight children died and the four survivors were critically ill before recovering. Acute viral hepatitis is generally a benign illness in childhood. Although infrequently recorded, fulminant hepatitis may, however, ensue and is associated with a high mortality.

[Hepatitis B and risk in insurance medicine]

Hepatitis B is one of the best-researched infectious diseases, both as regards the structure of the virus and in terms of diagnostic possibilities for identifying its stages, tracing its course and, perhaps most importantly, prognosing its development. Even though the range of test methods and supplementary analyses available is extensive and complex, it is nevertheless well worthwhile applying them selectively, as they allow the risk to be defined with relatively good accuracy. Of particular importance is the ability to distinguish between acute and chronic courses and, within the chronic course, between chronic persistent and chronic active hepatitis. Another major benefit is the possibility of predicting in good time malignant degeneration in the form of hepatocellular carcinoma. Though by contrast with South-East Asia and especially Central Africa, where the Hepatitis B morbidity rate can attain 80 to 90 per cent in some regions, the proportion of the population affected in Central Europe is relatively low (a figure of 5 per cent is quoted for West Germany), this disease is of particular significance because of its concentration among certain professional and risk groups and because a not inconsiderable proportion of policyholders are recruited from these groups.

Spontaneous reactivation in chronic hepatitis B: patterns and natural history

We identified spontaneous reactivation of hepatitis B virus (HBV) retrospectively by utilizing serum alanine aminotransferase and HBV DNA in 19 men (79% homosexual), with an estimated annual incidence of 7.3%. In 11 patients, spontaneous reactivation occurred as a single episode and in eight patients, reactivation was recurrent, with two to five episodes each. The mean serum alanine aminotransferase level was elevated over 10-fold at the peak of reactivation. Serum anti-HBc IgM was detected during 73% of the reactivation episodes. Actuarial analysis revealed that reactivation was long lasting with 45% and nearly 20% of episodes continued after 6 and 24 months, respectively. The course of 24 chronic HBV carriers with a negative serum HBV DNA test and normal alanine aminotransferase levels at initial appearance was unremarkable. We could not identify clinical features predictive of reactivation or its resolution. Severe reactivation hepatitis occurred in three patients (10%), with two deaths (6%). None of the patients lost HBsAg. Spontaneous reactivation in chronic hepatitis B can appear variably, persist long term, recur, and be fatal. Therefore, accurate classification of chronic HBV infection requires prolonged observation, and spontaneous reactivation should be considered a variable in therapeutic trials for chronic hepatitis B.

Hepatitis B and delta viruses in fulminant hepatitis

From June 1985 to 1989, we studied 39 cases with fulminant viral hepatitis. These included 32 cases due to hepatitis B, of whom 27 died. Twenty of the 32 cases were positive for delta antibody, and all of them died. Four cases who died were negative for IgM anti-HAV, HBsAg and IgM anti-HBc and were classified as NANB. Thus, a total of 31 patients died. Hepatitis B and delta virus infection were the major risk factors for fulminant hepatitis and eventual death.

Hepatitis B-related sequelae. Prospective study in 1400 hepatitis B surface antigen-positive Alaska native carriers

A total 1400 hepatitis B surface antigen-positive Alaska natives, 824 men and 576 women of all ages, were followed up prospectively over a period of 7815 carrier years for the development of sequelae related to chronic hepatitis B virus infection. During the observation period, 20 cases of hepatocellular carcinoma, 14 cases of chronic active hepatitis, 8 cases of cirrhosis, and 1 case of glomerulonephritis developed in this cohort. The annual incidence of hepatocellular carcinoma was 387 per 100,000 for men and 63 per 100,000 for women. The incidence of chronic active hepatitis and cirrhosis was 193 and 107 per 100,000 in men and 158 and 95 per 100,000 in women, respectively. No cases of either essential mixed cryoglobulinemia or necrotizing vasculitis were seen. Sixty of the hepatitis B surface antigen-positive carriers died, with 13 (21.7%) of the deaths due to hepatocellular carcinoma. The leading cause of death in this group was malignant neoplasms compared with accidents in the general Alaska native population.

National surveillance of dialysis-associated diseases in the United States, 1988

To determine trends in a variety of dialysis-associated diseases and practices, the Centers for Disease Control surveyed 1,734 chronic hemodialysis centers in the United States in 1988 in conjunction with the annual facility survey performed by the Health Care Financing Administration. The response rate to a mailed questionnaire was 91%. These 1,586 centers represented 107,804 patients and 28,501 staff members. Over the last 13 years, the incidence of hepatitis B virus (HBV) infection decreased from 3.0 to 0.2% among patients and from 2.6 to 0.1% among staff members. Over the same time, the prevalence of HBsAg-positivity declined from 7.8 to 1.5% among patients and from 0.9 to 0.3% among staff members. Hepatitis B vaccine was given by 90% of the centers. By the end of 1988, 17% of susceptible patients and 53% of susceptible staff members had received all three doses of hepatitis B vaccine. From 1982 to 1988, as a result of receiving vaccine, the prevalence of antibody to HBsAg increased from 12 to 20% among patients and from 18 to 54% among staff. The incidence of non-A, non-B hepatitis in 1988 was reported to be 1.0% among patients and 0.1% among staff members. Fifteen percent of the centers reported pyrogenic reactions in the absence of septicemia among their patients and 45% reported septicemia. The reported incidence of dialysis dementia among hemodialysis patients was 0.2%, with a case fatality rate of 25%. In 1988, 67% of centers reported that they reused disposable dialyzers; these centers treated 72% of the dialysis patient population. Among centers that reused disposable dialyzers, the average number of reuses ranged from 2 to 50 (mean, 11) and the maximum number of times a disposable dialyzer was reused ranged from 3 to 131 (mean, 28). Chemical germicides used for reprocessing dialyzers included formaldehyde; Renalin, a peracetic acid-hydrogen peroxide-based germicide; and glutaraldehyde-based germicides. Reuse of disposable dialyzers was not associated with any increased risk of acquiring HBV infection among either patients or staff. However, pyrogenic reactions occurring in clusters were more frequently reported in centers that reused conventional dialyzer membranes compared with centers that did not. This increased risk was only associated with centers that reused these dialyzers in a manual reprocessing system, a result consistent with those obtained in 1986 and 1987. Eighteen percent of centers reported treating at least some of their patients by high flux dialysis.(ABSTRACT TRUNCATED AT 400 WORDS)

Results of sclerotherapy in 100 patients comparison of the outcome between schistosomiasis and hepatitis B

One hundred patients received sclerotherapy for acutely bleeding esophageal varices. Seventy per cent of these patients had chronic liver disease due to schistosomiasis or hepatitis B. The remaining 30% had chronic liver disease of other etiology, including alcohol in 2%. Our study shows a favorable outcome of sclerotherapy in the schistosomal group during a mean follow-up period of 39 months. Esophageal varices were completely sclerosed in 53.3% of schistosoma patients, in 37.5% of hepatitis B, and in 42.3% of other groups. The rebleeding rate was 11.1% in schistosomiasis, 43.8% in hepatitis B and 33.3% in other groups. The overall mortality rate was 4.4% in the schistosomal group, 50.0% in the hepatitis B, and 40% in other groups. Rebleeding from gastric varices occurred in 17 patients, 13 of whom died, including 11 who were operated on for bleeding gastric varices and died following surgery.

Fatal reactivation of chronic hepatitis B virus infection following withdrawal of chemotherapy in lymphoma patients

Four Chinese patients with non-Hodgkin's lymphoma and asymptomatic chronic hepatitis B infection developed fulminant hepatitis three to four weeks after two to five courses of chemotherapy. One was initially positive for hepatitis B e antigen and three were positive for antibody to HBeAg. They had normal initial serum aminotransferase levels. In all four patients, the hepatic illness appeared to be caused by reactivation of hepatitis B virus replication as evidenced by the appearance of HBV DNA in serum at the onset of hepatitis, seroreversion from anti-HBe to HBeAg positivity, and the absence of other incriminating drugs or viral markers. All died within three weeks after the onset of jaundice. Serum HBV DNA level dropped to undetectable level as the hepatitis progressed. We postulate that potent cytotoxic therapy reactivated HBV replication and permitted widespread infection of hepatocytes. Upon withdrawal of chemotherapy, the immunologic rebound resulted in rapid destruction of infected hepatocytes and massive liver necrosis. Several methods for the prevention of such hepatic reactivation are discussed.

A common-source outbreak of fulminant hepatitis B in a hospital

A nosocomial outbreak of fulminant hepatitis B infection at a medical center in Haifa, Israel, between 7 and 26 June 1986, involved five patients who had been hospitalized previously in the medical ward in late April and early May (first generation). This outbreak had an unusual clinical course, with fulminant hepatic failure associated with acute renal failure from acute glomerulonephritis, leading to death within a few days. The onset dates of hepatitis were tightly clustered temporally and incubation periods were short. Extensive laboratory and epidemiologic evaluation showed that the probable common-source vehicle of transmission was a multiple-dose vial of heparin and normal saline flush solution that may have been contaminated by blood of a known HBsAg carrier, who was positive for anti-HBe, hospitalized at the same time. A sixth patient died in August 1986 (second generation), after his initial admission in June that coincided with the terminal hospitalizations of three first-generation patients. Those patients had marked coagulopathies, and transmission to the sixth patient most probably occurred through environmental contamination by patients or through cross-contamination between patients through staff. The unusually high mortality rate (5 of 6) in this outbreak has not been definitely explained.