Extrahepatic manifestations of chronic viral hepatitis

Dermatomyositis associated with hepatitis B virus-related hepatocellular carcinoma

Dermatomyositis (DM) is an idiopathic inflammatory myopathy (IIM) with typical cutaneous manifestations. It has been proposed that DM may be caused by autoimmune responses to viral infections, and previous studies have also shown that an association between DM and malignancy. However, chronic hepatitis B virus (HBV) infection associated with DM and hepatocellular carcinoma (HCC) is rarely encountered. The authors report a case of DM and HCC in a patient with a HBV infection. A 58-year-old man presented erythematous skin rashes on a sun-exposed area of 2 year's duration, and recent proximal muscle weakness. His medical history revealed that he had a chronic HBV infection. A diagnosis of DM relies on proximal muscle weakness, elevated muscle enzymes, myopathic changes (demonstrated by electromyography), muscle biopsy evidence of myositis, and its characteristic cutaneous findings. A Liver mass in the left lobe visualized by abdominal computed tomography was confirmed histologically as HCC. This case suggests that DM associated with HCC might be caused by a HBV infection.

Bone marrow-derived mesenchymal stem cells are capable of mediating hepatitis B virus infection in injured tissues

We have previously showed that endothelial progenitor cells (EPCs) through uptake of hepatitis B virus (HBV) may play a critical role in mediating extrahepatic HBV diseases. However, it remains to be elucidated whether mesenchymal stem cells (MSCs) are capable of mediating HBV trans-infection into extrahepatic tissues.

METHODS AND RESULTS

In this study, we showed that HBV antigens, HBV DNA and the viral particles were detected in MSCs after 3 days virus challenge. Neither HBV covalently closed circular DNA nor pregenomic RNA were detected in MSCs. Intravenously transplantation of HBV-exposed MSCs into myocardial infarction mouse model resulted in incorporation of HBV into injured heart and other damaged tissues.

CONCLUSION

These results indicate that MSCs could serve as an additional extrahepatic virus reservoir, which may play a role at least in part in mediating HBV trans-infection into the injured tissues through the process of MSCs recruitment.

Viral-Associated Immune Thrombocytopenic Purpura

Chronic immune thrombocytopenic purpura (CITP) is a diagnosis of exclusion that occurs either de novo or secondary to other underlying disorders. Chronic infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are now well-characterized causes of CITP. Between 6% and 15% of patients infected with HIV may develop thrombocytopenia. Patients with CITP with risk factors for HIV infection should be screened for the virus. Treatment of HIV-related CITP should be directed toward antiviral therapy with highly active antiretroviral therapy (HAART) regimens. Hepatitis C viral infection can also be associated with chronic thrombocytopenia, even in the absence of overt liver disease. While HCV-related thrombocytopenia is typically less severe than primary CITP, affected patients are at greater risk of major bleeding. Sustained suppression of HCV virus with interferon-ribavirin therapy can improve platelet counts. Screening for HCV infection should be considered in patients with ITP with risk factors for infection, from regions with high rates of infection or in patients with unexplained mild elevations of liver enzymes.

Atopy in children with chronic hepatitis B virus infection

AIM

To investigate whether immune responses against chronic HBV infection in children have an effect on prevalence of allergic diseases and atopy.

METHODS

Children with chronic HBV infection [HBV carriage (group 1) and chronic hepatitis (group 2)] were screened for allergic diseases. The results were compared with age-matched controls (group 3).

RESULTS

The frequencies of doctor-diagnosed 'asthma', 'allergic rhinitis' and 'eczema' were 29.4%, 7.8% and 7.8% in group 1; 7.8%, 5.2% and 5.2% in group 2 and 12.4%, 9% and 2.8% in group 3, respectively. 'History of ever wheezing', doctor-diagnosed 'asthma' and 'eczema' were more common in group 1 than group 3 (p < 0.05 for all parameters), and 'history of ever wheezing' and 'doctor-diagnosed asthma' were more common in group 1 than group 2 (p < 0.05 for al parameters). Atopy was more common in group 1 (35.2%) than both groups 2 (15.7%) and 3 (18%) (p < 0.05 for all parameters). Vertical transmission was more common in patients with versus without atopy in HBV carrier group (33.3% vs. 9%, p < 0.05).

CONCLUSION

Immune responses in chronic HBV infection associated with carrier state may also lead to allergic diseases, which suggests the necessity of following these patients for the allergic diseases along with their viral reactivation.

Infection of hepatitis B virus in extrahepatic endothelial tissues mediated by endothelial progenitor cells

Background

Hepatitis B virus (HBV) replication has been reported to be involved in many extrahepatic viral disorders; however, the mechanism by which HBV is trans-infected into extrahepatic tissues such as HBV associated myocarditis remains largely unknown.

Results

In this study, we showed that human cord blood endothelial progenitor cells (EPCs), but not human umbilical vein endothelial cells (HUVECs) could be effectively infected by uptake of HBV in vitro. Exposure of EPCs with HBV resulted in HBV DNA and viral particles were detected in EPCs at day 3 after HBV challenge, which were peaked around day 7 and declined in 3 weeks. Consistently, HBV envelope surface and core antigens were first detected in EPCs at day 3 after virus challenge and were retained to be detectable for 3 weeks. In contrast, HBV covalently closed circular DNA was not detected in EPCs at any time after virus challenge. Intravenous transplantation of HBV-treated EPCs into myocardial infarction and acute renal ischemia mouse model resulted in incorporation of HBV into injured heart, lung, and renal capillary endothelial tissues.

Conclusion

These results strongly support that EPCs serve as virus carrier mediating HBV trans-infection into the injured endothelial tissues. The findings might provide a novel mechanism for HBV-associated myocarditis and other HBV-related extrahepatic diseases as well.

Successful treatment of hepatitis B-associated leukocytoclastic vasculitis with lamivudine treatment in a child patient

Chronic hepatitis B infection (HBI) has many extrahepatic manifestations such as vasculitis, glomerulonephritis, arthritis, dermatitis, pulmonary disease, and skin manifestations. The mechanism of these manifestations is thought to be immune mediated. Immune-suppressive treatment may enhance viral replication and worsen hepatic disease. Lamivudine is a nucleoside analogue used in chronic HBI treatment that works by suppressing replication of the hepatitis B virus (HBV). Recently, several reports have suggested that lamivudine treats vasculitis associated with HBV infection in adults. However, there are no data in the literature for children. Herein, we report a child with leukocytoclastic vasculitis due to chronic HBI who was successfully treated with lamivudine.

Detection of surface asialoglycoprotein receptor expression in hepatic and extra-hepatic cells using a novel monoclonal antibody

The asialoglycoprotein receptor (ASGPR) is a heterodimeric membrane protein which is involved in the internalization of desialylated glycoproteins and also in the binding and uptake of various pathogenic viruses. To facilitate the analysis of ASGPR expression, we generated a monoclonal antibody, termed ASSA-1, that is specific to the ASGPR H1 subunit based on ELISA and Western blots analysis. ASSA-1 also reacted to surface-displayed ASGPR in live cells thus enabling analysis of ASGPR expression by immunofluorescence flow cytometry, which we used to analyze established human liver cell lines previously confirmed to be positive for ASGPR mRNA expression. In agreement with previous reports, surface ASGPR was also detected in extra-hepatic cells and, surprisingly, even in human T cell lines, which was then further confirmed in activated, but not in resting, primary human peripheral blood lymphocytes. These observations suggest that ASGPR has a broad pattern of expression that even extends into cells from the immune system, which biological meanings still have to be analyzed. We expect that monoclonal antibody ASSA-1 will serve as a new powerful tool in analyzing the biological role of ASGPR in hepatic and extra-hepatic cells.

Chronic hepatitis B serum promotes apoptotic damage in human renal tubular cells

AIM: To investigate the effect of the serum of patients with chronic hepatitis B (CHB) on apoptosis of renal tubular epithelial cells in vitro and to study the role of hepatitis B virus (HBV) and transforming growth factor-β1 (TGF-β1) in the pathogenesis of hepatitis B virus associated glomerulonephritis (HBV-GN).

METHODS: The levels of serum TGF-β₁ were measured by specific enzyme linked immunosorbent assay (ELISA) and HBV DNA was tested by polymerase chain reaction (PCR) in 44 patients with CHB ,and 20 healthy persons as the control. The normal human kidney proximal tubular cell (HK-2) was cultured together with the sera of healthy persons, CHB patients with HBV-DNA negative(20 cases) and HBV-DNA positive (24 cases) for up to 72 h. Apoptosis and Fas expression of the HK-2 were detected by flow cytometer.

RESULTS: The apoptosis rate and Fas expression of HK-2 cells were significantly higher in HBV DNA positive serum group 19.01±5.85% and 17.58±8.35%, HBV DNA negative serum group 8.12±2.80% and 6.96 ± 2.76% than those in control group 4.25±0.65% and 2.33 ±1.09%, respectively (P < 0.01). The apoptosis rate and Fas expression of HK-2 in HBV DNA positive serum group was significantly higher than those in HBV DNA negative serum (P < 0.01). Apoptosis rate of HK-2 cells in HBV DNA positive serum group was positively correlated with the level of HBV-DNA (r = 0.657). The level of serum TGF-β₁ in CHB group was 163.05 ± 91.35 µg/L, significantly higher as compared with 81.40 ± 40.75 µg/L in the control group (P < 0.01).

CONCLUSION: The serum of patients with chronic hepatitis B promotes apoptotic damage in human renal tubular cells by triggering a pathway of Fas up-regulation. HBV and TGF-β₁ may play important roles in the mechanism of hepatitis B virus associated glomerulonephritis.

Dermatological manifestations in hepatitis B surface antigen carriers in east region of Turkey

BACKGROUND AND DESIGN

Various cutaneous disorders associated with hepatitis B virus infection have been reported so far. Almost all of them were some peculiar eruptions or some disorders mainly based on immune complex reaction.

OBJECTIVE

The aim of this study was to compare the frequency of all dermatological disorders other than genetic ones in hepatitis B surface antigen (HBsAg) carrier patients and controls in our geographical area.

METHODS

Examinations were made on 88 hepatitis B carriers and 84 control patients, including entire skin surface, and oral and anogenital mucosa, and all the manifestations that could be seen were noted down.

RESULTS

While the number of HBsAg carrier patients with dermatological disorders was 62 (70.75%), it was only 24 (28.57%) in control patients. This seems statistically important: Yates' corrected chi-square test = 28.5; P = 0.0000001; odds ratio = 6.0 (2.94 < odds ratio < 12.2). The prevalence of oral lichen planus and pitted keratolysis in HBsAg carrier group was significantly higher than that of controls. We found the duration of positivity was not important statistically in the development of the dermatological disorders.

CONCLUSIONS

HBsAg positivity may induce or cause proneness to oral lichen planus and pitted keratolysis with some mechanism that needs to be elucidated.

Hepatitis B virus replication in damaged endothelial tissues of patients with extrahepatic disease

Hepatitis B virus (HBV) infection may be complicated by extrahepatic manifestations such as polyarteritis nodosa (PAN), glomerulonephritis, polymyositis, and dermatitis, but the etiology of these processes is not yet clear. HBV replication has been demonstrated in a variety of extrahepatic tissues and cell types, but the possible pathogenetic role of extrahepatic HBV replication has not been fully explored in patients with extrahepatic manifestations of HBV infection. In this case series, immunohistochemistry and in situ hybridization studies were performed on extrahepatic tissues from one HBsAg-positive patient with PAN and another HBsAg-positive patient with polymyositis, using HBsAg-seronegative control subjects with the same vasculitic disorders as controls. Tissue samples from the two study patients had detectable HBV RNA, replicative intermediates of HBV DNA, as well as HBsAg and HBcAg localized to vascular endothelium. In contrast, HBsAg-negative control patients had no tissue reactivity. Our results suggest that patients with HBV-related extrahepatic disease have evidence of viral replication in damaged extrahepatic endothelial tissues. While further studies would be required to support a hypothesis of causality, these findings suggest a role for both immune complex deposition and viral replication within diseased endothelial tissue in the pathogenesis of these poorly understood extrahepatic disorders.

Molecular characterization of virus-induced autoantibody responses

Here we present a comprehensive molecular mapping of virus-induced autoimmune B cell responses obtained by serological identification of antigens by recombinant expression cloning analysis. Immunoscreening of cDNA expression libraries of various organs (lung, liver, and spleen) using sera from mice infected with cytopathic (vaccinia virus [VV]) or noncytopathic (lymphocytic choriomeningitis virus [LCMV]) viruses revealed a broad specificity of the elicited autoantibody response. Interestingly, the majority of the identified autoantigens have been previously described as autoantigens in humans. We found that induction of virus-induced autoantibodies of the immunoglobulin G class largely depends on the CD40–CD40L-mediated interaction between T and B cells. Furthermore, antibody titers against a number of autoantigens were comparable to the concomitantly induced antiviral antibody response. Comparison of serum reactivity against a selected panel of autoantigens after infection with VV, LCMV, or vesicular stomatitis virus showed that the different virus infections triggered distinct autoantibody responses, suggesting that virus infections may leave specific “autoantibody fingerprints” in the infected host.