Transfusion-associated hepatitis not due to viral hepatitis type A or B

Recent advances in the identification of hepatitis viruses

Resulting directly from the discovery of virus-related antigens, rapid progress has marked the last decade of viral hepatitis research. The hepatitis B virion has been tentatively identified as a DNA virus with an endogenous DNA polymerase, and new serological markers for type B hepatitis have been discovered. Hepatitis A antigen has been identified on a virus-like particle thought to be the hepatitis A virion. Progressively more sophisticated assays for hepatitis antigens and antibodies have been applied to the study of viral hepatitis epidemiology and biochemical-biophysical characterization of the agents. Most recently, knowledge learned from such studies has been exploited to develop a prototype non-infectious but immunogenic hepatitis B vaccine using hepatitis B surface antigen (HBsAg) purified in large quantities from chronic HBsAg carriers. Especially exciting is the prospect, suggested by serological studies of viral hepatitis, that hepatitis viruses besides hepatitis A and B viruses will be identified.

Non-A, non-B post-transfusion hepatitis

To clarify the role of hepatitis-A virus (H.A.V.) in the aetiology of post-transfusion hepatitis unrelated to hepatitis-B virus, we have tested and titred pre-transfusion and convalescent serum samples from 32 patients for antibody to hepatitis-A antigen (anti-HA) by quantitative immune adherence haemagglutination. 12 patients had no detectable anti-HA in either pre-transfusion or late convalescent serum; the other 20 had anti-HA in pretransfusion serum and no significant chance in titre during convalescence. This study excludes H.A.V. as the agent responsible for these cases of post-transfusion hepatitis and supports the existence of "non-A, non-B" hepatitis virus(es).

Acute liver failure. Experience in a special unit

Acute liver failure involves disturbances of all major organ systems. The pathophysiology of these disturbances are reviewed and details of management for each system is discussed in clinical work in a special Liver Failure Unit is used to derive principles of treatment, and the use of extracorporeal charcoal haemoperfusion is outlined.

Multiple hepatitis viruses in multiple attacks of acute viral hepatitis

We evaluated the causes of 30 episodes of acute viral hepatitis in 13 patients who had multiple attacks. Two (seven per cent) of 30 bouts were caused by hepatitis A virus, and 12 (40%) by hepatitis B virus. No patient, however, had more than one attack with the serologic characteristics of Type A or Type B disease. Thus, there were 16 bouts (53 per cent) not attributable to either of the two recognized hepatitis viruses. None of these "non-A, non-B" episodes, evaluated for infectious mononucleosis and cytomegalovirus infection, could be ascribed to either. From this evidence, therefore, it appears that the clinical syndrome of viral hepatitis is produced not only by the two viruses (hepatitis A virus and hepatitis B virus) recognized since the 1940's but also, in all probability, by two non-A, non-B agents.

Hepatitis B antigen: a review of its importance in the practice of obstetrics and gynecology

Surgeons engaged in the practice of obstetrics and gynecology should have a clear understanding of the hepatitis B antigen (Australia antigen) serologic test. When positive, it serves as a marker either for the carrier state or for subclinical to overt hepatitis B (serum hepatitis). Patients or health personnel with a positive test are potentially infectious and appropriate precautions should be taken. Surgeons are at increased risk for hepatitis B and, when acutely exposed, should receive standard serum globulin, or perhaps high-titer hepatitis B immune globulin in the future. Infants born to mothers with a positive test may become hepatitis B antigen positive and develop chronic hepatitis.

Role of chronic hepatitis in development of thalassaemic liver disease

Liver function and the presence of HBsAg and anti-HBsAg were studied in 90 hypertransfused thalassaemic children. Increased serum transaminases were found in 62 patients, and persisted from more than 6 months in 45 cases. Liver biopsy in this latter group led to a diagnosis of 14 cases of chronic persistent hepatitis, 9 cases of aggressive hepatitis, and 3 cases of hepatic fibrosis. In Italy thalassaemic children undergoing hypertransfusion therapy frequently encounter SH virus infection, with a consequent hepatitis that is generally anicteric and unrecognized unless systematically sought. In a liver already stressed by the concomitant iron overload, hepatitis infection might thus play a key role in the evolution of cirrhosis which frequently affects thalassaemics.

Progress toward a National Blood System. The American Blood Commission

The success of the American Blood Commission in improving the effectiveness and efficiency of blood service delivery in the United States depends on the Commission's interactions with its members, with HEW and with the Congress. Active involvement of over 36 national organizations as dues-paying members representing both consumer/donors and providers gives the Commission considerable influence. HEW underwrites specific programs of the Commission and HEW agencies display co-operation and re-enforcement of its moves. The Congress has refrained from actions that might undercut the effort. An all-voluntary blood-donor system is a key American Blood Commission objective. The argument for voluntarism is supported by the need to control hepatitis, but other means of controlling hepatitis may be developed. The Commission's plan for a national blood system is based on securing voluntary compliance with guidelines recommended by peer groups within the Commission, and should facilitate a more effective national blood-transfusion system.

Efficacy of prophylactic gamma-globulin in preventing non-A, non-B post-transfusion hepatitis

Of 279 cardiac-surgery patients receiving a mean of twelve transfusions, 47 had significantly increased transaminase concentrations 14 to 180 days postoperatively and 10 were icteric. Preoperatively, each patient randomly received high-titre HbsAb gamma-globulin, normal gamma-globulin, or placebo and was followed at intervals for 9 months. Only 3 patients had serological evidence of hepatitis-B infection. 3 additional patients had serological evidence of cytomegalovirus infection, while none had evidence of hepatitis-A or Epstein-Barr infection. Less icteric hepatitis occurred in patients receiving the gamma-globulin preparations (P = 0-003), and the overall frequency of hepatitis was significantly reduced when compared with recipients of placebo. The protective effects of the two gamma-globulin preparations were not significantly different. Most post-transfusion hepatitis tody is neither viral hepatitis type B nor type A, and its severity and transmission are reduced by pre-transfusion gamma-globulin.

Evidence for viral hepatitis other than type A or type B among persons in Costa Rica

In studies of hepatitis in an endemic zone in Costa Rica, 103 patients were examined for antibodies against hepatitts A by the immune-adherence assay, for hepatitis B antigen and its antibody by radioimmunoassay and passive hemagglutination, respectively, and for antibodies against cytomegalovirus by complement fixation. Twelve cases were encountered in which both Type A and Type B hepatitis could be excluded on the basis of serologic testing. In all but one of these 12 patients, cytomegalovirus infection was also excluded. The patients had not had blood transfusions and available evidence pointed to person-to-person transmission. The illness in these patients was evidently neither hepatitis A nor hepatitis B and qualifies for consideration as the still hypothetical third type of hepatitis ("C"?).

Clinical and serological analysis of transfusion-associated hepatitis

Of 108 prospectively followed, multiply transfused, open-heart-surgery patients, 12 (11%) developed hepatitis. Patients received only volunteer donor blood tested for hepatitis-B surface antigen (HBsAg) prior to transfusion by counterelectrophoresis (C.E.P.). 4 of the 12 patients developed hepatitis-B-virus infection. Subsequent testing of donor serums by solid-phase radioimmunoassay (R.I.A.) revealed that an R.I.A.-positive, C.E.P.-negative blood unit was transfused to 3 of the 4 type-B hepatitis cases, but to none of the remaining 104 patients; 3 hepatitis-B cases could probably have been prevented by prescreening of donors by solid-phase R.I.A. 8 hepatitis cases were serologically unrelated to the hepatitis-B virus, the hepatitis-A virus, the cytomegalovirus, or the Epstein-Barr virus. Had R.I.A.-positive donors been excluded, 8 of the 9 residual hepatitis cases (89%) would have represented "non-A, non-B" hepatitis. The existence of previously unrecognised human hepatitis virus(es) is probable.