Detection of anti-HBc IgM following prednisone treatment in patients with chronic active hepatitis B virus infection

Probable corticosteroid-induced reactivation of latent hepatitis B virus infection in an HIV-positive patient involving immune escape

We describe a patient infected with human immunodeficiency virus who possessed a serological profile suggesting a previous cleared acute hepatitis B virus (HBV) infection, including high levels of antibodies against HBV surface antigen (anti-HBs). Following the administration of inhaled glucocorticosteroids combined with protease inhibitor-based antiretroviral treatment, the patient developed an unexpected severe acute hepatitis despite persistence of anti-HBs. A genotype A2 strain emerged with 2 major mutations in the S gene, sK122R and sD144E. Molecular and biological analyses strongly suggested reactivation of a latent HBV infection. The importance and the molecular basis of these 2 epitopes in immune-escape mechanisms and host-virus interactions are discussed.

Quantitative analysis of IgM anti-HBc in chronic hepatitis B patients using a new "gray-zone" for the evaluation of "borderline" values

BACKGROUND/METHODS

In order to define the clinical significance of borderline levels of IgM anti-HBc in chronic hepatitis B patients, we followed up 89 untreated hepatitis B patients (19 HBeAg pos and 70 anti-HBe pos) for 1 year, with monthly monitoring of IgM anti-HBc using a highly sensitive quantitative microparticle enzyme immunoassay (IMx CORE-M, Abbott). As a control group we used 304 healthy subjects: 150 HBsAg negative and anti-HBc/anti-HBs positive, and 154 without markers of HBV infection. The statistical analysis performed by Receiver Operating Characteristic curve indicated the 100% sensitivity cut-off at 0.081 IMx index and 100% specificity cut-off at 0.358 IMx index.

RESULTS

We could define the range of a chronic hepatitis B "gray-zone" between 0.100 [80.6% specificity (95% CI, 76.2%-85%), 96.6% sensitivity (95% CI, 92.8%-100%)] and 0.200 [95.7% specificity (95% CI, 93.4%-98%) and 78.7% sensitivity (95% CI, 70.2%-87.2%)] of the IgM anti-HBc-IMx index. In fact, none of the chronic hepatitis B patients had IgM anti-HBc-IMx values persistently below 0.100 during the follow-up, whereas 57.3% had values persistently higher than 0.200. In 38.2%, IgM anti-HBc values occasionally fell within the "gray-zone" limits. In the remaining four patients (4.4%), the results overlapped the "gray-zone" values.

CONCLUSIONS

These results suggest that the use of a chronic hepatitis B "gray-zone" for values of quantitative IgM anti-HBc assays helps to distinguish "true healthy carriers" from asymptomatic chronic anti-HBe positive hepatitis B patients who have been shown to have temporary remissions of liver disease and frequently undetectable serum HBV-DNA.

Monitoring the natural course and response to therapy of chronic hepatitis B with an automated semi-quantitative assay for IgM anti-HBc

The clinical significance of a semi-quantitative microparticle enzyme immunoassay (IMx Core-M, Abbott) was evaluated for detection of IgM-class antibodies against the hepatitis B core antigen (IgM anti-HBc) in 136 hepatitis B surface antigen (HBsAg) positive individuals (96 chronic HBV carriers, 20 patients with chronic HBV-HDV infections and 20 patients with acute hepatitis B) and 50 HBV-negative controls. Baseline and follow-up sera (4-11 samples) were analysed from 79 carriers with chronic hepatitis B, 44 of whom were treated with interferon. IMx indexes above 3,000 were found in 95% of the acute hepatitis B patients and above 0.300 in 91.5% of patients with ongoing chronic hepatitis B. IMx indexes between 0.200 and 0.300 were observed in (a) patients with recent HBeAg to anti-HBe seronconversion (6-12 months) and normal serum ALT levels, (b) patients immuno-tolerant to HBV infection and without liver disease despite high levels of viremia, and (c) patients with anti-HBe-positive chronic hepatitis B during 7-13-month intervals of asymptomatic carriage between episodes of disease reactivation. IMx indexes below 0.200 were detected in all HBV-negative individuals and healthy HBV carriers, in 14 (70%) of 20 chronic hepatitis D patients and in all but 1 of 22 interferon-treated patients with histological remission of liver disease, 5-12 months after clearance of viremia and normalization of serum ALT levels. In contrast, IMx indexes remained above 0.200 in all patients with hepatitis B reactivation.(ABSTRACT TRUNCATED AT 250 WORDS)

Glucocorticoid stimulates hepatitis B viral gene expression in cultured human hepatoma cells

Glucocorticoids have been shown to influence the severity of hepatitis B virus-related chronic hepatitis in human. However, very little is known about the effects of glucocorticoids on hepatitis B virus replication in vitro. In this report, we used a well-differentiated human hepatoma cell line, Hep3B, transfected with hepatitis B virus complementary DNA as a model to show that a glucocorticoid analog, dexamethasone, can directly stimulate the production of HBsAg and HBeAg. Elevation of 3.5-kb pregenomic RNA and all other viral RNAs in the transfected Hep3B cells after dexamethasone treatment supports the hypothesis that glucocorticoids directly stimulate hepatitis B virus gene expression in vitro. The concentration of dexamethasone for its half-maximal stimulatory activity toward HBsAg, HBeAg and all viral transcripts was approximately 10(-8) mol/L, close to the affinity of glucocorticoid receptors to [3H]-triamcinolone acetonide in Hep3B cells (approximately 10(-8) mol/L). Specific glucocorticoid antagonist RU38486 completely blocked dexamethasone-induced HBV gene expression, suggesting that the stimulatory effect of dexamethasone was mediated through specific glucocorticoid receptors.

Glycyrrhizin withdrawal followed by human lymphoblastoid interferon in the treatment of chronic hepatitis B

Seventeen patients with chronic hepatitis B were treated with a 4-week administration of glycyrrhizin followed by a 4-week treatment with human lymphoblastoid interferon, then followed for 6 months after the end of treatment. All were positive for hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), and hepatitis B virus-associated DNA polymerase (DNA-p) for at least 6 months before entry. All patients were Japanese and none of them were homosexuals. Eleven patients lost DNA-p activity and 10 of them lost HBeAg. Three of these 10 patients had antibody to HBeAg. In 10 patients who became HBeAg-negative, alanine aminotransferase levels after glycyrrhizin administration were higher and initial DNA-p activities relatively lower than the levels found in seven patients who remained HBeAg-positive. The immunomodulator provided by a short course of glycyrrhizin before administration of human lymphoblastoid interferon may be an effective treatment for patients with chronic hepatitis B.

Corticosteroids stimulate hepatitis B virus DNA, mRNA and protein production in a stable expression system

The effect of corticosteroids (Dexamethasone) on hepatitis B virus was investigated in human hepatoblastoma cells stable transfected with recombinant HBV DNA. Dexamethasone was found to cause elevation of HBsAg, HBeAg and viral DNA production. HBV poly(A)+ RNA was significantly increased in cells treated with Dexamethasone. Furthermore, pulse labelled nuclear HBV RNA was also stimulated by Dexamethasone. These findings, suggest that corticosteroids enhance expression of viral gene products by stimulating HBV transcription.

Spontaneous reactivation of hepatitis B virus infection in patients with chronic type B hepatitis

Eighty-eight consecutive hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) positive, heterosexual patients of Caucasian origin presenting with chronic hepatitis were followed for 1 to 15 years (mean, 5.4 years). During the study period, 45 (51%) patients cleared HBeAg and hepatitis B virus-deoxyribonucleic acid from serum and were followed for 53 +/- 29 months (mean +/- SD) after seroconversion to antibody to hepatitis B e antigen. All patients manifested biochemical improvement. During follow-up, 10 (22%) of the 45 patients experienced spontaneous reactivation of hepatitis B replication with reappearance of serum hepatitis B virus-deoxyribonucleic acid and, in 4 patients, of hepatitis B e antigen. All patients then showed biochemical exacerbation of disease. These serologic events were transient, lasting an average of 12 months, in 8 (80%) patients. All patients were asymptomatic or minimally symptomatic. Histologic findings of liver tissue from 7 patients showed progression from chronic active hepatitis to active cirrhosis in 2 (28%) patients, while in the remaining 6 cases histology remained unchanged or improved from chronic active to chronic persistent hepatitis. These data indicate that spontaneous reactivation of hepatitis B infection occurs in heterosexual patients with chronic hepatitis B and this event is usually transient and asymptomatic, although in some patients it may be the major cause of progressive hepatic damage.

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)

Serial assay for IGM anti-HBc in patients with anti-HBe-positive chronic hepatitis and its significance for long-term prognosis

Serial assays for immunoglobulin M antibody to hepatitis B core antigen (IgM anti-HBc) were performed in 51 patients with antibody to hepatitis B e antigen (anti-HBe) in their sera. IgM anti-HBc was detected periodically and persistently in 8 (53%) of 15 patients with chronic hepatitis whose serum glutamic pyruvic transaminase (GPT) levels were elevated and was not detected in 36 patients with normal serum GPT levels. Antibody to delta agent was not detected in any of the patients. Of the eight patients positive for IgM anti-HBc, four had a high titer of IgM anti-HBc and either developed liver cirrhosis (three cases) or died due to massive hepatic necrosis (one case); the other four showed a low level of IgM anti-HBc and either recovered (two cases) or developed chronic persistent hepatitis (two cases). Of seven patients negative for IgM anti-Hbc, two had a fatty liver, and five, who had a history of blood transfusion, had chronic hepatitis. Thus, even though anti-HBe may be present, if the titer of IgM anti-HBc is high, the histological activity can be expected to increase, and the prognosis will be poor. If the titer of IgM anti-HBc is low, the histological activity may be expected to decrease, and the prognosis may be good. In patients with abnormally high serum GPT but without IgM anti-HBc, another type of hepatitis or a secondary form of liver disease should be considered.

Frequency and significance of immunoglobulin M antibody to hepatitis B core antigen in corticosteroid-treated severe chronic active hepatitis B

To assess the frequency and significance of immunoglobulin M (IgM) antibody to hepatitis B core antigen (anti-HBc) in corticosteroid-treated severe chronic active hepatitis B, we tested 96 serum samples from 16 patients who were seropositive for hepatitis B surface antigen (HBsAg) (group 1) and 8 HBsAg-negative, anti-HBc-positive patients (group 2) by enzyme-linked immunoassay. Samples obtained in the presence and absence of disease activity before, during, and after long-term corticosteroid therapy (mean duration, 42 +/- 7 months) were evaluated. Seropositivity for IgM antibody was demonstrated in 12 group 1 patients, including 9 tested before corticosteroid therapy; no group 2 patients were seropositive. Seropositivity was more common in serum samples obtained during active than during inactive disease (51% versus 22%; P less than 0.05) and more frequent in serum samples that contained hepatitis B e antigen (46% versus 11%; P less than 0.02) and hepatitis B virus deoxyribonucleic acid (50% versus 24%; P less than 0.05) than in those without these markers. In some patients, seropositivity persisted or recurred intermittently during corticosteroid therapy for up to 57 months. We conclude that seropositivity for IgM antibody can be demonstrated frequently by enzyme-linked immunoassay in corticosteroid-treated patients with severe disease. Seropositivity reflects active virus replication, and it is commonly associated with inflammatory activity. The duration of seropositivity may be protracted during long-term corticosteroid therapy.

IgM antibody to hepatitis B core antigen in children with chronic type B hepatitis

IgM antibody to hepatitis B core antigen (anti-HBc IgM) was investigated by an antibody-capture radioimmunoassay (serum dilution 1:4000) in serum samples from 31 untreated children with chronic hepatitis B who were followed prospectively for 1-7 years. At the start, all patients were positive for hepatitis B e antigen (HBeAg), and anti-HBc IgM was detected in 23 cases, including 15 out of 16 with chronic active hepatitis and 7 out of 14 with chronic persistent hepatitis. A significant positive correlation was found between anti-HBc IgM levels and severity of liver damage (P less than 0.05), while an inverse relationship was found between anti-HBc IgM levels and distribution of hepatitis B core (HBcAg) antigen in the liver as detected by immunofluorescence. In fact 75% of anti-HBc IgM positive patients showed a focal HBcAg pattern (less than 40% positive nuclei), whereas 87% of antibody negative cases exhibited a diffuse HBcAg expression (more than 60% stained nuclei). During follow-up, seroconversion from HBeAg to anti-HBe with subsequent remission of liver disease occurred in 82% of patients presenting with detectable levels of anti-HBc, including three out of seven cases with chronic persistent hepatitis, but in none of the cases that were initially negative (P less than 0.01). These results indicate that during the natural course of chronic hepatitis B in children, anti-HBc IgM levels in serum reflect the degree of host immune response to infected hepatocytes. The close correlation between anti-HBc IgM seropositivity and seroconversion from HBeAg to anti-HBe suggests that anti HBc IgM may have a prognostic value during the follow-up of children with chronic HBeAg positive hepatitis B.

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.

Effect of corticosteroid therapy on levels of antibody to hepatitis B core antigen in patients with chronic type B hepatitis

Serum levels of antibody to hepatitis B core antigen and IgM antibody to hepatitis B core antigen were tested in 15 patients who participated in a randomized, placebo-controlled trial of a 28-day course of prednisolone therapy. During treatment, serum levels of antibody to hepatitis B core antigen and IgM antibody to hepatitis B core antigen decreased in all 10 treated patients, but in none of five controls (p less than 0.05). Also during therapy, ALT activity decreased by an average of 50% and serum IgG levels by 30% (both p less than 0.05). Serum levels of hepatitis B virus DNA and DNA polymerase activity did not change significantly. Four to 10 weeks after discontinuation of prednisolone, a rebound of serum ALT and IgM antibody to hepatitis B core antigen levels occurred, which usually resolved within the subsequent months of follow-up evaluation. In three patients, however, there was a prolonged exacerbation of the disease following prednisolone withdrawal; in these three, levels of IgM antibody to hepatitis B core antigen and ALT remained elevated above pretreatment values. The close correlation between changes in serum ALT activity and IgM antibody to hepatitis B core antigen levels suggests that corticosteroids can modulate disease activity in chronic type B hepatitis by suppression of the host-immune response to hepatitis B virus antigens.

The nucleocapsid of hepatitis B virus is both a T-cell-independent and a T-cell-dependent antigen

One characteristic of the immune response during hepatitis B virus (HBV) infection in humans is the vigorous production and subsequent persistence of antibodies of immunoglobulin (Ig) classes M and G to the nucleocapsid antigen (HBcAg). In this study HBcAg was shown to be similarly immunogenic in mice. When injected into athymic (nude) B10.BR and athymic BALB/c mice, HBcAg induced IgM and IgG class antibodies to HBc in spite of the absence of T cells in nude mice. In euthymic mice, HBcAg efficiently stimulated T-cell proliferation in vitro and helper T-cell function in vivo. The dual functions of HBcAg as a T-cell-independent and a T-cell-dependent antigen may explain its enhanced immunogenicity. Denaturation of HBcAg yields a nonparticulate antigen designated HBeAg; when HBeAg was used as the immunogen, antibody production required helper T-cell function. Although HBcAg and HBeAg are serologically distinct, they are structurally related, and in these experiments were highly cross-reactive at the T-cell level. These results suggest that the elevated levels of IgM antibodies to HBc and the enhanced immunogenicity of HBcAg during HBV infection in humans reflect the ability of HBcAg to directly activate B cells to produce antibodies to HBc in the presence or absence of HBcAg- or HBeAg-sensitized T cells.

Diagnostic significance of anti-HBcIgM prevalence related to symptoms in Canadian patients acutely or chronically infected with hepatitis B virus

A total of 362 sera from 295 Canadian patients were examined for HBsAg, anti-HBs, anti-HBc, anti-HBcIgM, HBeAg, and anti-HBe using commercial immunoassays. Serial samples from 70 acutely infected patients demonstrated that anti-HBcIgM may detect 10% more positives than HBsAg within 4 months after the onset of clinical symptoms, and all except two were negative for anti-HBcIgM after the fourth month. None of 66 asymptomatic (HBeAg rate 18.2%) and two of 14 (14.3%) symptomatic (HBeAg rate 64.3%) carriers of HBsAg were positive for anti-HBcIgM (P = 0.029). Elevated marker responses were measured in two symptomatic carriers for a 20-month period. Anti-HBcIgM was not detected in either 100 asymptomatic patients positive for total anti-HBc, negative for HBsAg and negative for or possessing low levels of anti-HBs, 25 patients with liver disorders not caused by HBV, or 20 healthy milk donors. In diagnostic laboratory practice this anti-HBcIgM test may be useful in the following situations: to supplement HBsAg testing, providing a theoretical 10% increase in positives within 4 months following onset of acute viral hepatitis; to replace testing for anti-HBc and anti-HBs in symptomatic HBsAg-negative patients; to confirm whether a patient is experiencing acute or chronic HBV infection or symptoms superimposed upon asymptomatic HBsAg carriage by another cause, such as nonA-nonB viral hepatitis.

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.

Follow-up studies on IgM anti-HBc during chronic hepatitis B

Sera of 190 HBsAg positive chronic hepatitis B patients were followed up for IgM class antibodies to hepatitis B virus core antigen (IgM-anti-HBc) by a commercial ELISA (Abbott) as well as a 19S(IgM) RIA until these antibodies were no longer detectable. IgM anti-HBc was detected only up to two of five years after onset of acute disease. The periods of detectable IgM anti-HBc in 34 chronic persistent and 36 chronic active hepatitis B (CPH, CAH) patients did not differ significantly on the basis of chi 2-test. 56% of the CPH and 47% of the CAH patients showed markers of infectivity in the sera recently cleared of IgM anti-HBc. Sera of both the IgM anti-HBc positive CPH and CAH patients had on the average fivefold elevated aminotransferase (SGPT) activity. In sera recently cleared of IgM anti-HBc, mean SGPT activity was detected twofold the normal value in CPH and threefold in CAH patients. Inflammatory activity in the liver biopsies was seen highly increased both in the IgM anti-HBc positive CPH and CAH patients. Fibrosis was most progressed and cirrhosis observed mainly in the liver biopsies of the IgM anti-HBc cleared CAH patients. In 3 IgM anti-HBc cleared chronic hepatitis B patients (CPH n = 1, CAH n = 2) converted to anti-HBe, IgM anti-HBc was detectable anew after a HBV superinfection with other HBsAg subtypes.

Hepatitis B virus DNA contains a glucocorticoid-responsive element

It has recently been shown that hepatitis B virus (HBV) contains a transcriptional enhancer element. In order to determine whether this enhancer responds to glucocorticoids, a series of derivatives of plasmid pA10CAT2 was constructed containing the HBV enhancer and variable lengths of further upstream sequences. Transient expression of chloramphenicol acetyltransferase (CAT) was determined after introduction of these plasmids into PLC/PRF/5, Hep 3B, Hep G2, HeLa, and mouse L cells. Highest CAT activity was noted in the human hepatocellular carcinoma line PLC/PRF/5, which contains integrated HBV DNA sequences. Dexamethasone augmented CAT expression in all cell lines tested with 40% of maximal induction at 10 nM and maximum stimulation (3- to 8-fold) at 1 microM dexamethasone. Dexamethasone augmentation of CAT expression was observed only when constructs contained HBV DNA sequences residing upstream to map position 735 from the EcoRI site. This indicates that the glucocorticoid-responsive region is distinct from the previously defined HBV enhancer sequence located at map position 1080-1234. These studies suggest that HBV DNA contains a glucocorticoid-responsive element, which may mediate expression of HBV genes in infected mammalian cells.