Correlation of serum HCV RNA and alanine aminotransferase levels in chronic hepatitis C patients during treatment with ribavirin

To evaluate the effect of ribavirin on serum hepatitis C virus (HCV) RNA and alanine aminotransferase (ALT) levels, 22 patients with chronic HCV infection were treated with oral ribavirin 1200 mg daily in three divided doses for 4 weeks. At the end of 4 weeks treatment, the serum ALT decreased in all but one patient and became normal in three individuals. The mean pretreatment serum ALT was reduced significantly from 193 +/- 45 i.u./L to 95 +/- 16 i.u./L after 4 weeks therapy (P = 0.009). However, 8 weeks after cessation of treatment, the serum ALT rose to a mean value of 154 +/- 21 i.u./L. The mean pretreatment serum HCV RNA was not significantly decreased at the end of 4 weeks treatment (7.0 x 10(5) vs. 4.1 x 10(5) copies/mL, P > 0.05). However, serum HCV RNA levels were decreased in 12 and increased in 10 patients at the end of 4 weeks therapy. Eight weeks after cessation of therapy, the serum HCV RNA of 22 patients rose to a mean value of 4.9 +/- 10(5) copies/mL. Six patients who continued to have elevated serum ALT and positive HCV RNA after the initial 4 weeks treatment received oral ribavirin at the same dosage for an additional 24 weeks. The serum ALT again decreased in all six patients during therapy, but rose to pretreatment values by 8 weeks after cessation of the treatment. In addition, no significant changes were noted in the mean serum HCV RNA levels during and after 24 weeks of ribavirin therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Nucleotide sequence analysis of the precore region in patients with spontaneous reactivation of chronic hepatitis B

The role of HBV precore mutations in the spontaneous reactivation of chronic hepatitis B (CHB) is currently unknown. We studied 10 patients with CHB; five were HBeAg+ (group I) and five were anti-HBe+ (group II). All 10 had spontaneous reactivation of CHB as defined by the appearance of clinical symptoms along with an increase of serum ALT activity at least 5X above baseline values, in the absence of any other known causes of liver disease or CHB reactivation. The precore (87 nt) and proximal core (81 nt) regions were sequenced after PCR amplification. From each patient three serum samples studied: one 3-12 months before, one during, and one six months after reactivation. Prior to reactivation, none of the group I patients harbored an HBV strain having a mutation that prevented HBeAg synthesis; however, 2/5 developed such a mutation during reactivation (G to A transition at nt 1896). Among the group II patients, three harbored an HBeAg defective mutant both before and during reactivation; after six months, two of these three patients were HBV DNA negative in serum by PCR. Several other sequence polymorphisms, some of which changed the predicted amino acid sequence, were either present initially or developed during reactivation. In conclusion, in this small group of CHB patients who were HBeAg+ spontaneous reactivation was accompanied in some cases by a shift to an HBeAg defective mutant, while in patients who were anti-HBe+, such mutations were frequently present prior to reactivation. In patients already harboring precore defective mutants, spontaneous reactivation may precede an attenuation of viral replication.

Hepatitis B virus infection in Asian Americans

This article summarizes studies on hepatitis B in the Asian American population and includes prevalence rates among different Asian subgroups, routes of transmission, and sequelae of both perinatal and childhood-acquired hepatitis B virus infection. Rationale for use of hepatitis B immune globulin and hepatitis B vaccine for Asian infants and vaccine for children and seronegative adults is discussed also. Chronic hepatitis B, cirrhosis, and primary hepatocellular carcinoma in adults and screening for early detection of liver cancer are reviewed.

Naturally occurring hepatitis B virus mutants with deletions in the core promoter region

A novel class of hepatitis B virus mutants in patients with chronic hepatitis B is described. The predicted effect of the mutations is to disrupt the X open reading frame. The location of the genetic alterations within the putative precore promoter also suggests that they may ameliorate precore transcription, which would provide an alternate mechanism for HBeAg(-) escape variation. Definitive conclusions regarding the effects of these mutations must await additional in vitro and in vivo studies.

Evidence for hepatitis C viral infection in patients with primary hepatocellular carcinoma

In testing for antibodies to the hepatitis C virus (anti-HCV) in 112 patients with primary hepatocellular carcinoma, 10 of 33 white patients (30%) and 15 of 79 Asian patients (19%) had a positive response to the antibody. The antibody profile to individual hepatitis C viral antigens and the presence of circulating hepatitis C viral RNA were determined in the 25 patients. The anti-HCV antibodies most frequently detected were toward the antigens from the core (C22) and NS3 regions. Serum hepatitis C viral RNA was present in 17 of the 25 patients (68%), and these patients tended to have serum levels of alanine and aspartate aminotransferases higher than those patients without viremia (136 +/- 22 U per liter versus 64 +/- 11 U per liter and 161 +/- 26 U per liter versus 79 +/- 14 U per liter, respectively, both P < .05). Of the 15 Asian patients with hepatocellular carcinoma and anti-HCV, 4 (27%) had coexisting hepatitis B surface antigen (HBsAg) and 13 (87%) had antibodies to either hepatitis B core or surface antigen. Of the 10 white patients with anti-HCV, however, only 1 (10%) had hepatitis B virus antibodies (P < .01). Among 4 Asian patients with coexisting anti-HCV and HBsAg, 1 was found to have serum hepatitis B viral DNA and the other 3 had hepatitis C viral RNA. A history of blood transfusion was obtained from 12 of the 25 patients with anti-HCV (48%); 20 (80%) had coexisting cirrhosis. Our findings support the hypothesis that hepatitis C virus is an important etiologic agent in the development of primary hepatocellular carcinoma in both white and Asian patients in the United States.

Risk factors for hepatitis C virus infection among health care personnel in a community hospital

OBJECTIVE

To determine the prevalence of and risk factors for antibody to the hepatitis C virus in hospital employees.

METHODS

Retrospective testing of serum samples obtained from 1677 hospital employees during a prehepatitis B vaccination program in a private teaching community hospital.

RESULTS

Twenty-three employees (1.4%) were found to have antibody to hepatitis C virus. The prevalence of antibody to hepatitis C virus was higher in blacks (3.4%) than in whites (1.1%, p = 0.03) and Hispanics (2.6%, p = 0.88). In a logistic regression model, factors significantly associated with antibody to hepatitis C virus seropositivity included antibody to hepatitis B core antigen (p = 0.002), a history of blood transfusion (p = 0.03), and needlestick injuries (p = 0.04).

CONCLUSION

Although the prevalence of antibody to hepatitis C virus in health care workers was not high, needlestick injuries were associated with an increased risk for acquiring hepatitis C virus infection.

Hepatitis A vaccination

The safety and immunogenicity of an inactivated hepatitis A virus vaccine were assessed in 101 healthy adults. Seronegative persons with normal serum aminotransferase levels were grouped according to age: Group 1 (n = 24) and group 3 (n = 22) were between 18 and 40 years of age, and group 2 (n = 25) and group 4 (n = 30) were older than 40 years. Groups 1 and 2 received vaccine on a 0-, 1-, and 2-month schedule (schedule A), and groups 3 and 4 received the vaccine on a 0-, 1-, and 12-month schedule (schedule B). Of the 101 vaccinated subjects, 98 (97%) seroconverted with antibody titers to hepatitis A virus of > or = 20 IU per liter after the first dose, and all subjects seroconverted after the second dose. The geometric mean titers a month after the third vaccine dose were significantly greater (P < .03) on both schedules for younger subjects (schedule A, 1,743 IU per liter, and schedule B, 7,882 IU per liter) than for older subjects (schedule A, 826 IU per liter, and schedule B, 4,279 IU per liter). Also, the differences in geometric mean titers a month after the third dose were significantly greater (P < .001) for subjects in both age groups on schedule B (group 3, 7,882 IU per liter, and group 4, 4,279 IU per liter) than for those on schedule A (group 1, 1,743 IU per liter, and group 2, 826 IU per liter). The hepatitis A virus was well tolerated, with mild discomfort at the injection site being the main side effect. This vaccine is both safe and highly immunogenic.

Nonviral risk factors for hepatocellular carcinoma in a low-risk population, the non-Asians of Los Angeles County, California

We conducted interviews on 74 patients with histologically confirmed hepatocellular carcinoma. These patients, aged 18-74 years, were black or white residents of Los Angeles County. We also interviewed 162 population control subjects who were comparable to the case patients by age, sex, and race. Cigarette smoking was a significant risk factor for hepatocellular carcinoma [relative risk (RR) = 2.1; 95% confidence limits (CL) = 1.1, 4.0]; the effects were similar in men and in women. Heavy alcohol consumption was another risk factor for hepatocellular carcinoma in men; men who consumed 80 g or more of ethanol per day had an RR of 4.7 (95% CL = 1.4, 15.4) relative to those who had never drunk alcohol on a weekly basis. The level of alcohol intake was relatively low in women, and no significant effect on risk of hepatocellular carcinoma was observed. Use of oral contraceptives was significantly related to risk of hepatocellular carcinoma in women (RR = 3.0; 95% CL = 1.0, 8.8); those who were exposed for more than 5 years exhibited a 5.5-fold increased risk (95% CL = 1.2, 24.8). The effects of these three risk factors on hepatocellular carcinoma development were independent of each other and independent of serologically determined viral hepatitis. Our data suggest that cigarette smoking, alcohol consumption, and use of oral contraceptives are major risk factors for hepatocellular carcinoma among non-Asian residents of Los Angeles County. We also observed a significant association between a history of diabetes and hepatocellular carcinoma (RR = 3.3; 95% CL = 1.5, 7.2), especially among those who had received insulin treatment (RR = 18.5; 95% CL = 2.2, 156.0). This association may have etiological significance.

A randomised double-blind placebo-controlled trial of prednisolone therapy in HBeAg and HBV DNA positive Chinese patients with chronic active hepatitis B

Forty-one hepatitis B e antigen (HBeAg) and hepatitis B virus (HBV) DNA positive Chinese patients with chronic active hepatitis B were randomized to receive either prednisolone or placebo oral for 8 weeks. The prednisolone group received 60 mg daily for 2 weeks, 40 mg for 2 weeks, 20 mg for 2 weeks, 10 mg for 1 week and 5 mg for 1 week. In 18 patients receiving prednisolone, serum HBV DNA levels rose during the course of therapy, but dropped abruptly within 1 month of cessation of treatment. Conversely, their serum alanine aminotransferase (ALT) levels decreased during high doses of prednisolone therapy, and then became transiently elevated during the period of withdrawal of prednisolone. At 1 year from initial treatment, the serum HBV DNA and ALT levels were similar between the groups of patients treated with prednisolone or placebo. In the prednisolone treated group, 66.7% of patients became HBV DNA negative, 50% became HBeAg negative, and 33.3% seroconverted to antibody to HBeAg (anti-HBe). In the placebo treated group, 60.9% of patients became HBV DNA negative, 60.9% became HBeAg negative, and 56.5% seroconverted to anti-HBe. Hepatic decompensation was not noted in any of the prednisolone-treated patients. Thus, the effects of the withdrawal prednisolone therapy on serum ALT and HBV DNA levels was temporary, and no differences in serum viral markers or biochemical parameters of liver inflammation between these two groups were noted at the 1 year follow-up period.

Prevalence of hepatitis B and C viral markers in black and white patients with hepatocellular carcinoma in the United States

The recent cloning of the genome of a non-A, non-B hepatitis agent, designated the hepatitis C virus (HCV), has led to the development of an immunoassay for circulating HCV antibodies (anti-HCV). We used this immunoassay to investigate the possible association between HCV infection and hepatocellular carcinoma in black and white residents of Los Angeles County, California. Serum samples from 51 patients (12 black and 39 white) in Los Angeles County with hepatocellular carcinoma and 128 control subjects (1 black and 127 white) were tested for the presence of anti-HCV. In addition, samples were tested for hepatitis B surface antigen (HBsAg), antibodies to the hepatitis B core antigen (anti-HBc), and antibodies to HBsAg (anti-HBs). Our results indicate that the presence of anti-HCV was a significant risk factor for hepatocellular carcinoma; the relative risk was 10.5 (95% confidence limits = 3.5, 31.3). Hepatocellular carcinoma risk was also significantly related to the presence of one or more of the hepatitis B virus (HBV) markers, primarily HBsAg and anti-HBc, and the relative risk was 7.0 (95% confidence limits = 3.1, 16.1). HCV and HBV independently contributed to hepatocellular carcinoma development. Significantly increased risk of hepatocellular carcinoma was demonstrated in individuals with HCV (relative risk = 4.8) or HBV (relative risk = 4.4) serologic markers alone. A synergistic effect on risk was observed when both hepatitis B and C viral markers were present in peripheral blood (10 cases vs. no controls). We estimate that approximately 47% of hepatocellular carcinoma occurring in black and white residents of Los Angeles County could be attributed to prior HCV and/or HBV infections: 9% were related to HCV alone, 20% to HBV alone, and 18% to occurrence of both HCV and HBV infections.

Hepatitis B vaccination of neonates and children

Perinatal transmission of the hepatitis B virus (HBV) occurs in a high percentage of infants born to mothers who are acutely infected with the virus at the time of delivery or who are chronic carriers of the hepatitis B surface antigen (HBsAg). The majority of infants who acquire the virus during the perinatal period and become HBV carriers have no clinical symptoms. However, there are reports of acute and fulminant hepatitis and even primary liver cancer occurring in a few HBsAg-positive infants. Immunoprophylaxis given to infants born to HBsAg-positive mothers at birth with a combination of hepatitis B immunoglobulin and hepatitis B vaccine is the most effective means of preventing the chronic HBV carrier state and its potential complications. In a multicenter trial in the United States, 85 to 90 percent of the children of HBsAg-positive mothers remained HBsAg-negative when treated with this combination regimen. Studies conducted outside the United States have yielded similar results. Other investigations indicate that the hepatitis B vaccine alone may be of value in preventing perinatal transmission of HBV in developing countries that are unable to afford hepatitis B immunoglobulin.

Relationship between cell membrane potential and natural killer cell cytolysis in human hepatocellular carcinoma cells

One of the body's natural defense mechanisms against tumor cells is lysis of the invading cell by cytotoxic T-cells and natural killer (NK) cells. Five human hepatocellular carcinoma cell lines were found to have different sensitivities to killing by peripheral blood monocytes in a 51Cr release assay. This killing was demonstrated to be due to NK cell lysis. Electrical recording measurements of the membrane potentials of these five cell lines showed different values for each line, all below values reported for normal hepatocytes. Correlation between mean cell membrane potential, and sensitivity to NK lysis, revealed an inverse relationship. In this study we demonstrate that the lower the mean membrane potential of a human hepatocellular carcinoma cell line, the more sensitive it is to NK cell cytolysis. Cell surface positive potential did not correlate with NK cytolysis and only a weak correlation was found between cell membrane negative potential and cell surface positive potential between cell lines.

Hepatitis B virus, aflatoxins, and hepatocellular carcinoma in southern Guangxi, China

We examined the roles of the hepatitis B virus and aflatoxin B1 in the development of primary hepatocellular carcinoma (PHC) in a cohort of 7917 men aged 25 to 64 yr old in southern Guangxi, China, where the incidence of PHC is among the highest in the world. After accumulating 30,188 man-yr of observation, 149 deaths were observed, 76 (51%) of which were due to PHC. Ninety-one% (69 of 76) of PHC deaths were hepatitis B surface antigen (HBsAg) positive at enrollment into the study in contrast to 23% of all members of the cohort (RR = 38.6). Three of the four patients who died of liver cirrhosis also were HBsAg positive at enrollment. There was no association between HBsAg positivity state and other causes of death. Within the cohort, there was a 3.5-fold difference in PHC mortality by place of residence. When estimated aflatoxin B1 levels in the subpopulations were plotted against the corresponding mortality rates of PHC, a positive and almost perfectly linear relationship was observed. On the other hand, no significant association was observed when the prevalence of HBsAg positivity in the subpopulations was compared with their corresponding rates of PHC mortality.

Lack of response to recombinant hepatitis B vaccine in nonresponders to the plasma vaccine

Yeast recombinant hepatitis B vaccine was administered to 25 nonresponders to the plasma-derived hepatitis B vaccine. After three 10-micrograms doses, nine subjects (36%) produced levels of antibodies to hepatitis B surface antigen (anti-HBs) of less than 2.1 sample ratio units (SRU) (nonresponders), and five (20%) developed anti-HBs of 2.1 to 9.9 SRU (hyporesponders); anti-HBs levels of 10 SRU or greater were detected at least once in 11 vaccinees (44%), but by the sixth and 12th months after the last vaccination, only three and one of these "responders," respectively, still maintained anti-HBs values of 10 SRU or greater. In these 25 subjects HLA subtyping showed a high prevalence of DR7, B8, and the combinations of DR3 and DR7 and DR4 and DR7. Our findings indicate that the yeast recombinant hepatitis B vaccine was not effective in eliciting a sustained anti-HBs response in nonresponders to the plasma hepatitis B vaccine.

Is anti-HBc IgM a useful clinical test in patients with HBsAg-positive chronic hepatitis or primary hepatocellular carcinoma?

Seventy HBsAg-positive patients, including 24 with primary hepatocellular carcinoma, 34 with chronic active hepatitis, 12 with chronic persistent hepatitis and 30 asymptomatic healthy hepatitis B virus carriers were tested for anti-HBc IgM using the Corzyme-M test. Anti-HBc IgM was detected in 50% of the primary hepatocellular carcinoma patients, 26.5% of the chronic active hepatitis patients, 25% of the chronic persistent hepatitis patients, but in none of the healthy hepatitis B virus carriers. There was no correlation between the presence of anti-HBc IgM and HBeAg, hepatitis B virus DNA, ALT or alpha-fetoprotein levels in either the chronic active hepatitis or chronic persistent hepatitis patients. However, a significantly higher positive rate of anti-HBc IgM was noted in the HBeAg-positive or HBV DNA-positive primary hepatocellular carcinoma patients than in those with negative markers of viral replication, but no correlation was noted between the presence of anti-HBc IgM and serum ALT or alpha-fetoprotein levels in these primary hepatocellular carcinoma patients. Also, no differences in positivity for HBeAg, HBV DNA or levels of serum ALT were noted when patients with high titers of anti-HBc IgM were compared to those with low titers. Thus, anti-HBc IgM cannot distinguish between HBsAg-positive patients with chronic active hepatitis, chronic persistent hepatitis or primary hepatocellular carcinoma, does not correlate with serum ALT or alpha-fetoprotein levels and is only associated with markers for viral replication in primary hepatocellular carcinoma patients. Based on this, anti-HBc IgM appears to have a limited usefulness for diagnosis of either chronic hepatitis B or primary hepatocellular carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

A cost comparison analysis for screening and vaccination of hospital personnel with high- and low-prevalence hepatitis B virus antibodies in California

We compared the cost of antibody screening and the projected cost for hepatitis B vaccination of antibody-negative individuals at hospitals with "high prevalence" and "low prevalence" rates for hepatitis B virus antibodies among their employees. The use of hepatitis B core antibody for screening and subsequent hepatitis B vaccination of antibody-negative personnel was most cost-effective for hospitals considered to have high prevalence for hepatitis B virus antibodies among its staff, although use of hepatitis B surface antibody in this setting only increased costs by 1.4%. In a hospital with low prevalence for hepatitis B virus antibodies among its staff, use of hepatitis B surface antibody and subsequent vaccination of antibody-negative individuals was the most cost-effective approach, while use of hepatitis B core antibody for the above purposes would have increased costs by 3.4%. The use of both hepatitis B surface antibody and core antibody in either setting followed by immunization was least economical, as costs were increased by 13% and 13.5% respectively. We concluded that hepatitis B core antibody should be used for screening in hospitals with high prevalence for hepatitis B virus antibodies among employees while hepatitis B surface antibody be used for screening in hospitals with low prevalence for hepatitis B virus antibodies among employees. A prediction of high and low prevalence for hepatitis B virus antibodies in hospital personnel may be made by knowledge of the distribution in ethnicity of staff.

Primary hepatocellular carcinoma following perinatal transmission of hepatitis B

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The application of flow cytometry in the study of natural killer cell cytotoxicity

A flow cytometric assay was developed to detect the cytotoxic function of natural killer (NK) cells. This procedure employed a single fluorochrome and forward angle light scatter to differentiate dead cells from live cells. When results obtained by flow cytometry were compared with 51Cr release assay, this assay showed high specificity and sensitivity. When propidium iodide was used to stain target cells killed by NK cells, we found that NK cell cytotoxicity was not cell cycle specific.

Characteristics of a cell line (Tong/HCC) established from a human hepatocellular carcinoma

A continuous adherent cell line was established from a hepatocellular carcinoma of an HBsAg-positive Italian male. This cell line, designated Tong/HCC, has been grown in a hormone-supplemented medium for more than 18 months. The cell line secretes HBsAg, alpha-fetoprotein, albumin and alpha 1-antitrypsin. alpha-Fetoprotein production is enhanced by the addition of hydrocortisone and appears to be glucocorticoid concentration-dependent. The concentrates of the supernatant from the cell cultures and cell lysates were negative when tested for HBeAg. The cell culture medium was negative for hepatitis B virus DNA when tested by dot-blot hybridization. However, hepatitis B virus DNA was found to be integrated in the chromosomal DNA by Southern blot analysis. At least five different integration sites were identified, and no free hepatitis B virus DNA was observed. The modal chromosome number was 64, and a translocation on Chromosome 15 was consistently noted. HLA typing revealed sites for A3, Aw24, Bw34 and Cw1.

Intrahepatic, nucleocapsid antigen-specific T cells in chronic active hepatitis B

Hepatitis B core antigen (HBcAg)-specific T cell lines were established from hepatic lymphomononuclear cells derived from five patients with chronic active hepatitis B. No hepatitis B virus envelope antigen-specific cell lines were established. Proliferation in response to recombinant and native HBcAg, but not to native hepatitis B surface antigen containing the pre-S(2) region, confirmed the specificity of the five T cell lines. All cell lines represented mixed populations of CD4+ and CD8+ T cells. The CD4+ subset provided antigen-specific help to autologous B cells with respect to anti-HBc production and to CD8+ cells with regard to HBcAg-induced proliferation and suppressor activity. The CD8+ subset contained suppressor cells that selectively inhibited the proliferative response of autologous HBcAg-specific CD4+ cells without inhibiting CD4+ cells of unrelated specificity (tetanus toxoid). Moreover, the CD8+ cells were also capable of suppressing HBcAg-stimulated antibody to HBcAg production without showing inhibition of total immunoglobulin production stimulated by pokeweed mitogen. The cytotoxic potential of the T cell lines was established in a lectin-dependent cytotoxicity system; natural killer cytotoxicity was completely absent. Our data suggest that the lesional T cells present at the site of hepatocellular injury in chronic active hepatitis B are primarily HBcAg-specific lymphocytes of the helper and suppressor/cytotoxic phenotypes and that both are functionally competent.

Intrahepatic, nucleocapsid antigen-specific T cells in chronic active hepatitis B

Hepatitis B core antigen (HBcAg)-specific T cell lines were established from hepatic lymphomononuclear cells derived from five patients with chronic active hepatitis B. No hepatitis B virus envelope antigen-specific cell lines were established. Proliferation in response to recombinant and native HBcAg, but not to native hepatitis B surface antigen containing the pre-S(2) region, confirmed the specificity of the five T cell lines. All cell lines represented mixed populations of CD4+ and CD8+ T cells. The CD4+ subset provided antigen-specific help to autologous B cells with respect to anti-HBc production and to CD8+ cells with regard to HBcAg-induced proliferation and suppressor activity. The CD8+ subset contained suppressor cells that selectively inhibited the proliferative response of autologous HBcAg-specific CD4+ cells without inhibiting CD4+ cells of unrelated specificity (tetanus toxoid). Moreover, the CD8+ cells were also capable of suppressing HBcAg-stimulated antibody to HBcAg production without showing inhibition of total immunoglobulin production stimulated by pokeweed mitogen. The cytotoxic potential of the T cell lines was established in a lectin-dependent cytotoxicity system; natural killer cytotoxicity was completely absent. Our data suggest that the lesional T cells present at the site of hepatocellular injury in chronic active hepatitis B are primarily HBcAg-specific lymphocytes of the helper and suppressor/cytotoxic phenotypes and that both are functionally competent.

Pulmonary involvement in primary biliary cirrhosis

Four patients with primary biliary cirrhosis (PBC) and Sjogren's syndrome presented with pulmonary disease manifested by fever, cough, and dyspnea. One patient had obstructive lung disease secondary to an autoimmune process documented by immunofluorescent staining of lung parenchyma. The other three patients had interstitial lung disease, pulmonary nodules, and multiple granulomas of the lung, respectively. Primary biliary cirrhosis is a complex autoimmune syndrome involving a disorder of the secretory immune system and its epithelial end organs. These four cases suggest that, in addition to biliary, lacrimal, intestinal, renal tubular, and salivary epithelium, lung tissue also is a possible site for autoimmune involvement in PBC.

Spontaneous reactivation of hepatitis B in Chinese patients with HBsAg-positive chronic active hepatitis

Eleven patients of Chinese origin experienced spontaneous reactivation of chronic active hepatitis B. Eight HBsAg-positive patients were followed for an average of 15 months prior to, while three others presented during reactivation. Fatigue, hepatomegaly and jaundice were frequent findings. Elevation of both serum ALT (average = 1,212 units per liter) and hepatitis B virus DNA levels were noted in all patients, and reactivation lasted an average of 4.4 months. During resolution, clinical symptoms abated, serum ALT levels reverted toward normal, and in nine patients, the hepatitis B virus DNA values became undetectable. All patients lacked evidence for acute hepatitis A, Epstein-Barr Virus, cytomegalovirus or hepatitis delta virus infection. Histologic findings of liver tissue from eight patients showed piecemeal necrosis and fibrosis. Within the parenchyma, varying degrees of hepatocytolysis with cuffing, perivenular necrosis and acidophilic bodies were noted. Ground-glass cells and regenerative changes also were observed. Cirrhosis was not present in any of the liver biopsies. These findings suggest that spontaneous reactivation of hepatitis B occurs in heterosexual patients with chronic active hepatitis B and contributes to chronic inflammation and to the progression of their liver disease.

Yeast-recombinant hepatitis B vaccine. Efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission

A yeast-recombinant hepatitis B vaccine was licensed recently by the Food and Drug Administration and is now available. To assess the efficacy of the yeast-recombinant vaccine, we administered the vaccine in combination with hepatitis B immune globulin to high-risk newborns. If infants whose mothers were positive for both hepatitis B surface antigen and the e antigen receive no immunoprophylaxis, 70% to 90% become infected with the virus, and almost all become chronic carriers. Among infants in this study who received hepatitis B immune globulin at birth and three 5-micrograms doses of yeast-recombinant hepatitis B vaccine, only 4.8% became chronic carriers, a better than 90% level of protection and a rate that is comparable with that seen with immune globulin and plasma-derived hepatitis B vaccine. These data suggest that, in this high-risk setting, the yeast-recombinant vaccine is as effective as the plasma-derived vaccine in preventing hepatitis B virus infection and the chronic carrier state.

Persistence of serum hepatitis B virus deoxyribonucleic acid in hepatitis B surface antigen-positive patients with chronic persistent hepatitis treated with prednisone

The effect of a short course of prednisone therapy was evaluated in 8 patients with liver biopsy-verified chronic persistent hepatitis B. In 6 of the 8 (75%) patients, an abrupt fall in serum alanine aminotransferase levels after the initiation of prednisone was noted, and in 4 patients, there was an increase in serum alanine aminotransferase values after prednisone was discontinued. However, the serum levels of hepatitis B virus deoxyribonucleic acid were consistently greater than or equal to 200 pg before, during, and after the course of treatment in 7 of the 8 (87.5%) patients. All patients were initially hepatitis B e antigen-positive and remained so during the study period. These findings indicate that, unlike some patients with chronic active hepatitis B, immunosuppression with prednisone had no effect in altering hepatitis B viral replication in patients with chronic persistent hepatitis.

A hepatitis B vaccination program in a community teaching hospital

Prior to offering the hepatitis B (HB) vaccine, a prescreen for hepatitis B virus (HBV) antibodies was conducted in a 565 bed hospital in Pasadena, California. Antibodies to the hepatitis B virus were detected in 14.5% of 1,745 employees tested. There was a significantly higher prevalence in those with a previous history of hepatitis, blood transfusions, exposure to needlesticks, number of years in the same occupation, and in the same hospital work area. Employees of Asian extraction (33.3%) and blacks (23.1%) had a higher prevalence of antibodies to the hepatitis B virus than Hispanics (13.7%) and whites (10.2%). Anti-HBs was detected in 92.6% of 865 employees who received three doses of the hepatitis B vaccine. Only 28.6% of nonresponders receiving a fourth dose of hepatitis B vaccine produced anti-HBs. The nonresponders to the HB vaccine were older (average age 64.9 years) when compared to the responders (average age 37.5 years), and more males failed to produce anti-HBs after vaccination than females. Hepatitis B vaccination of the majority of individuals with either "low level" anti-HBs alone or anti-HBc alone did not elicit an anamnestic response after one dose of vaccine, implying that these "low level" antibodies are nonspecific and do not represent antiviral antibodies. Adverse reactions to the hepatitis B vaccine were minor and included a flu-like syndrome, sore arm, and rash and swelling at the injection site. The reasons for nonparticipation were obtained from 179 individuals, and the main issue was concern about safety of the hepatitis B vaccine.

Vibrio vulnificus infection after raw oyster ingestion in a patient with liver disease and acquired immune deficiency syndrome-related complex

Sepsis, peritonitis, and gastroenteritis developed in a 45-yr-old homosexual man 1 day after ingestion of raw oysters. The patient had chronic active hepatitis and cirrhosis with hepatitis B virus and delta-infection. He also had persistent generalized lymphadenopathy associated with HTLV-III antibody positivity. Vibrio vulnificus was isolated from the patient's blood and peritoneal fluid as well as from the same batch of oysters at the restaurant where the patient had visited. To our knowledge, this is the first report relating direct microbiologic and clinical evidence that the infection is acquired through the gastrointestinal tract by consuming raw seafood containing the pathogen. This is also the first reported case of peritonitis associated with sepsis and gastroenteritis from this organism. Patients with liver disease and other immunocompromised states should be warned about such life-threatening infections and complications associated with the consumption of raw oysters or other undercooked seafoods.

Correlation between hepatic hepatitis B core antigen and serum hepatitis B virus-DNA levels in patients with chronic hepatitis B virus infections in Taiwan

Paired liver biopsy specimens and serum samples from 76 patients with chronic hepatitis B virus (HBV) infection were taken for staining of hepatitis B core antigen (HBcAg) by immunoperoxidase and testing of HBV-DNA by a spot hybridization technique, respectively. Thirty-two tissue specimens showed positive staining for HBcAg in their hepatocytes. The two patients with diffuse HBcAg expression in liver tissue also had high serum concentrations of HBV-DNA (greater than 10 pg/10 microL). Among 30 patients with focal HBcAg distribution, 28 patients (93.3%) had measurable levels of serum HBV-DNA and 17 patients (60.7%) had high levels of serum HBV-DNA. Of 44 patients without hepatic HBcAg expression, only 12 patients (27.3%) had detectable serum HBV-DNA, and most patients (93.1% [11/12]) had low concentrations (less than 10 pg/10 microL). Nineteen patients had superimposed hepatitis D virus infection, and, of these, three patients (15.8%) had detectable serum HBV-DNA in low concentrations, while one of the three patients had stainable HBcAg in his hepatocytes with focal distribution. Two of the three patients with hepatitis A virus superinfection who had focal HBcAg expression in their liver tissue had serum HBV-DNA levels that were high during the acute phase of hepatitis A virus infection, and in one patient his serum HBV-DNA levels further increased from 10 pg/10 microL to 40 pg/10 microL during the recovery phase. Thus, measurement of serum HBV-DNA levels in patients with chronic HBV infection correlated well with their hepatic HBcAg expression, and both represent the precise status of HBV replication.

Primary hepatocellular carcinoma and hepatitis B infection during childhood

Twenty pediatric patients with primary hepatocellular carcinoma in Taiwan were tested for HBsAg, and all were found to be positive. The youngest case was 8 months of age, five cases occurred between 9 and 10 years of age, and 14 cases occurred between 11 and 16 years of age. The serum alpha-fetoprotein was elevated in all 20 primary hepatocellular carcinoma patients, and the average survival of these cases after diagnosis was 4.7 months. Seventy per cent of the mothers of the pediatric primary hepatocellular carcinoma cases and 52.9% of their siblings who were tested also were positive for HBsAg. In addition, two families had clustering of primary hepatocellular carcinoma cases. The occurrence of primary hepatoceullar carcinoma in the pediatric age group suggests the need for close follow-up of young HBsAg-positive carriers. Also, prevention of perinatal transmission of hepatitis B virus by immunoprophylaxis will significantly decrease both the hepatitis B virus carrier rate and the incidence of primary hepatocellular carcinoma in the asian population.

A pilot study on the effects of prednisone withdrawal on serum hepatitis B virus DNA and HBeAg in chronic active hepatitis B

We investigated the efficacy of a short course of prednisone therapy in 20 patients with histologic evidence of chronic active hepatitis B. Sixteen of 20 prednisone-treated patients who were initially serum hepatitis B virus DNA-positive had a transient elevation of their serum ALT activity on withdrawal of prednisone. Subsequently, 14 of these 16 patients (87.5%) became persistently negative for serum hepatitis B virus DNA, and 10 also lost their HBeAg. In addition, there was a significant fall in serum ALT levels and HBsAg titers up to 12 months of follow-up in the prednisone-treated group. Five of 20 (25%) prednisone-treated patients experienced a transient episode of hepatic decompensation coinciding with the peak of enzyme elevation. To contrast, only 3 of 15 (20%) initially hepatitis B virus DNA-positive matched untreated patients followed during the same time period became negative for serum hepatitis B virus DNA, and no significant changes in serum ALT values or HBsAg titers were noted over the 12-month study period. Thus, patients with chronic active hepatitis B appear to be responsive to immunologic manipulation with prednisone as indicated by a pronounced rebound immune response and clearance of hepatitis B virus DNA with improvement in liver disease activity.

Prevention of maternal-infant hepatitis B virus transmission by immunization: the role of serum hepatitis B virus DNA

Sera from 108 HBsAg carrier mothers at delivery and their respective offspring at birth and at 6 months of age were examined for hepatitis B virus DNA by the dot-blot hybridization technique. Hepatitis B virus DNA was detected in 83% of 88 carrier mothers who were HBeAg positive, and in 10% of 20 carrier mothers who were HBeAg negative. All five infants born to HBeAg-positive carrier mothers with hepatitis B virus DNA levels over 80 pg per 10 microliters of serum were infected by hepatitis B virus, in spite of receiving hepatitis B immunization. All 17 infants without hepatitis B immunization who were born to HBeAg and hepatitis B virus DNA-positive carrier mothers developed hepatitis B virus infection. Of 56 infants born to HBeAg and hepatitis B virus DNA-positive carrier mothers and who had received hepatitis B immunization, a higher hepatitis B virus infection rate was found in a group of infants whose sera hepatitis B virus DNA were positive (15/16, 93.8%) than in infants whose sera were negative (17/40, 42.5%) at birth (p less than 0.0005). These data suggest that the assay for hepatitis B virus DNA in sera of HBsAg carrier mothers at delivery or their infants at birth will predict the efficacy of hepatitis B immunization for prevention of maternal-infant hepatitis B virus transmission.

Histologic and clinicopathologic features of Chinese patients with HBsAg-positive chronic active hepatitis

Needle biopsies of both the right and left lobes of the liver were performed during peritoneoscopy in 20 male patients with chronic active hepatitis B in Taiwan. Microscopic study of these biopsy specimens led to the recognition of three groups: 1) five patients in whom the lobular architecture was easily recognizable but in whom necrosis and early intralobular fibrosis were present, along with severe chronic inflammation of the portal tracts; 2) seven patients in whom the livers were characterized by early septal formation and a good regenerative response, but few recognizable lobules with normal architecture; and 3) eight patients in whom the disease had progressed to severe fibrosis with septal formation and tiny pseudolobules, indicative of early cirrhosis. The left lobe was the more severely damaged in 16 of the 20 patients.

Impaired antibody synthesis in patients with chronic hepatitis B infection

In vitro synthesis of the anti-HBc, anti-HBs and polyclonal IgG and IgM classes of antibodies were determined from supernatants of peripheral blood mono-nuclear cells cultured in the presence of pokeweed mitogen. Thirty-seven patients with chronic hepatitis B and 10 healthy control subjects whose sera were positive for anti-HBs formed the study group. Twenty-four of 37 patients showed histologic evidence of chronic active hepatitis B while the remaining 13 patients had chronic persistent hepatitis B. Lymphocytes from chronic persistent hepatitis B, chronic active hepatitis B and healthy controls secreted similar levels of IgM. However, IgG synthesis was markedly impaired (p less than 0.002) in the chronic persistent hepatitis B group as compared with healthy controls or chronic active hepatitis B patients. In vitro anti-HBc production and serum anti-HBc titers correlated directly with hepatocellular inflammation and inversely with serum hepatitis B virus DNA. Anti-HBc synthesis was significantly higher in chronic active hepatitis B patients who exhibited a more pronounced hepatocellular damage when compared to chronic persistent hepatitis B patients who had little or no liver cell injury.

Alterations in the immune response of nonresponders to the hepatitis B vaccine

The phenotypic characteristics of peripheral blood lymphocytes (PBLs) from responders and nonresponders to hepatitis B (HB) vaccine and their response to pokeweed mitogen (PWM) stimulation in vitro were compared. The nonresponders had significantly higher absolute numbers and percentages of T11+, HNK-1+, and T8+ lymphocytes. Also, after PWM stimulation, PBLs from HB-vaccine nonresponders had impaired IgG and IgM production and failed to produce antibodies to HB surface antigen in vitro. These findings suggest that healthy individuals who fail to produce such antibodies have a higher population of suppressor lymphocytes that alters their normal immune response to HB vaccination.

Liver involvement in sickle cell disease

In an effort to clarify the features of hepatic dysfunction in sickle cell disease, we obtained serial tests of liver function in 100 consecutive patients with sickle cell anemia and in 30 consecutive patients with hemoglobinopathy SC during a five-year period. There were 32 patients with chronic abnormalities in tests of liver function. These abnormal tests were explained by a variety of lesions in 30 cases, and the liver disease remained unexplained in only 2 patients who declined liver biopsy. The diagnoses in these 30 patients included hepatitis, chronic passive congestion, common duct obstruction, alcoholic liver disease, pregnancy, collagen-vascular disease, and sarcoidosis. Evidence for hepatitis B infection was present in 19 of those with sickle cell anemia and in 6 of those with hemoglobinopathy SC. The bilirubin levels in sickle cell anemia appeared to have a trimodal distribution, with six patients exhibiting markedly elevated levels of indirect bilirubin suggesting a difference in bilirubin metabolism. There was no evidence of liver disease in 72 patients with sickle cell anemia, nor in 24 patients with hemoglobinopathy SC, as these patients exhibited only mild elevation of their serum indirect bilirubin levels owing to chronic hemolysis. Intrasinusoidal sickling and Kupffer cell erythrophagocytosis were nearly universal findings at liver biopsy, irrespective of the clinical disorder, and were not related to the degree of liver test abnormalities. Liver and biliary tract dysfunction in sickle cell disease have been attributed to anoxia secondary to sinusoidal obstruction by sickled erythrocytes and Kupffer cell erythrophagocytosis. However, some causes of liver disease in sickle cell patients can be explained by clinical disorders other than the hemoglobinopathy alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between peripheral lymphocyte subsets and antibody to hepatitis B surface antigen response in hepatitis B vaccine recipients

Peripheral lymphocyte subsets of 14 heterosexual recipients of hepatitis B vaccine were measured by indirect immunofluorescence using specific monoclonal antibodies. 12/14 vaccine recipients developed antibody to hepatitis B surface antigen after the second injection of vaccine; however, 2 recipients remained seronegative. Prior to the vaccination, these two vaccine non-responders had been found to have a significantly reduced ratio of peripheral helper-inducer T cells to suppressor/cytotoxic T cells (1.15 +/- 0.02 vs. 1.79 +/- 0.12), and an increase in the proportion of natural killer/killer cells (25.6 +/- 1.5% vs. 13.8 +/- 1.6%) as compared to the 12 responders. Enumeration of peripheral lymphocyte subsets prior to vaccination may be useful in predicting the immune response of hepatitis B vaccine recipients.

Clinical, serologic, and immunologic effects of human leukocyte interferon in HBsAg-positive primary hepatocellular carcinoma

Five patients with hepatitis B surface antigen (HBsAg) positive chronic hepatitis and histologically confirmed primary hepatocellular carcinoma (PHC) were treated with 3 X 10(6) units/day of partially purified human leukocyte interferon intramuscularly for 2 consecutive months. During interferon therapy, one patient had stable disease, while the remaining four patients had progressive disease. Following interferon therapy no changes were noted in the hepatitis B viral markers or in serum alphafetoprotein levels. Data on the effects of human leukocyte interferon on lymphocyte subpopulations and on the cytotoxic activity of peripheral blood mononuclear cells against a hepatitis B surface antigen expressing primary hepatocellular carcinoma cell line are presented.

Prevention of hepatitis B infection by hepatitis B immune globulin in infants born to mothers with acute hepatitis during pregnancy

Eleven infants born to mothers with acute hepatitis B during the third trimester of pregnancy who were hepatitis B surface antigen-positive at delivery were treated with hepatitis B immune globulin within 24-48 h of birth. Five infants received one dose of hepatitis B immune globulin and 6 infants received a second dose at 1 mo of age. During the average 12.5-mo follow-up period, only 1 of 11 (9%) treated infants became hepatitis B surface antigen-positive and this individual developed acute hepatitis B at 9.5 mo of age and recovered. Twenty-four infants born to mothers with acute hepatitis B during the third trimester of pregnancy who were untreated served as historical controls. Of these, 17 (71%) showed evidence for hepatitis B infection and 15 (62.5%) became chronic hepatitis B virus carriers. This study shows that administration of hepatitis B immune globulin to infants born to mothers with acute hepatitis B is effective in preventing perinatal transmission of the hepatitis B virus. With the availability of the hepatitis B virus vaccine, the current recommendation is to give hepatitis B immune globulin to such infants within 24 h of birth, followed by three doses of the hepatitis B virus vaccine beginning soon after birth, and again 1 and 6 mo later.

Perinatal hepatitis B virus transmission in the United States. Prevention by passive-active immunization

Among infants born to women in whom sera are positive for both the hepatitis B surface antigen and the e antigen, 85% to 90% are infected with hepatitis B virus and become chronic hepatitis B surface antigen carriers. In a study to assess the effectiveness of passive-active prophylaxis (hepatitis B immune globulin and hepatitis B vaccine) of such infants, we screened 18,842 pregnant Asian-American women: 8.7% were positive for hepatitis B surface antigen and 3.0% were also positive for hepatitis B e antigen. Thus far, 113 infants have received hepatitis B immune globulin (0.5 mL at birth) and hepatitis B vaccine (three 20-micrograms doses beginning at birth or at 1 month) and have been followed up for nine to 18 months. Among these infants, 16 have become chronic carriers, an incidence of only 14.2%. All of the uninfected infants have retained high levels of antibody to surface antigen, suggesting that they have had an active immune response to the vaccine and should have long-term protection against hepatitis B virus.

A serological case-control study of primary hepatocellular carcinoma in Guangxi, China

Guangxi is a very high-risk area for primary hepatocellular carcinoma (PHC); the age-standardized (world population) rates for males and females in that Chinese Autonomous Region were 32.5 and 8.5, respectively. Blood specimens from 50 PHC patients and 50 age- and sex-matched controls in Guangxi were analyzed for hepatitis B surface antigen, antibody to hepatitis B surface antigen, and antibody to hepatitis B core antigen. Eighty-six % of cases were hepatitis B surface antigen positive, compared to 22% of controls (relative risk, 17.0). We estimate from the data that persistent hepatitis B virus infection can account for at least 80% of all PHC cases occurring in Guangxi. The consistency of our findings with those from Hong Kong and Taiwan strongly suggests that hepatitis B virus infection is also an important risk factor for PHC in other parts of southern China.

Effects of short-term, high-dose prednisone treatment of patients with HBsAg-positive chronic active hepatitis

We conducted a clinical trial to study the effects of a 10-week course of prednisone therapy and its withdrawal on serum aminotransferase levels and on hepatitis B virus (HBV) markers in patients with hepatitis B surface antigen (HBsAg) positive chronic active hepatitis (CAH-B). Eighteen patients with CAH-B were treated with prednisone, while another 18 patients matched for age, sex, race and sexual preference were followed simultaneously without treatment for the same duration. Nine of 18 prednisone-treated patients became transiently DNA polymerase positive. All nine patients developed a transient rise in serum alanine aminotransferase (ALT) levels of greater than 300 U/L above baseline values, which was associated with a drop in HBsAg levels from a mean of 186 micrograms/ml prior to therapy to 92 micrograms/ml at 6 months following treatment. Six of these patients developed fatigue, anorexia and dark urine, and four also developed either ascites or hemorrhage from esophageal varices, which was accompanied by hepatic encephalopathy. All six of these patients had histologic evidence of CAH with cirrhosis. In comparison, none of the control, untreated patients with CAH-B had any change in either HBV markers or serum ALT levels. Therefore, even a short course of prednisone in patients with CAH-B with cirrhosis is detrimental and its use should be discouraged.