Hepatitis B virus-DNA in the serum of patients followed-up longitudinally with acute and chronic hepatitis B

Human Parvovirus B19 May Be a Risk Factor in Myasthenia Gravis with Thymoma

PURPOSE

Our previous studies have demonstrated that human parvovirus B19 (B19V) is involved in the pathogenesis of thymic hyperplasia-associated myasthenia gravis (MG). However, more cases need to be assessed to further elucidate the relationship between this virus and thymoma-associated MG.

MATERIALS AND METHODS

The clinicopathological characteristics, presence of B19V DNA, and B19V VP2 capsid protein expression of 708 cases of thymomas were investigated using nested polymerase chain reaction (PCR), TaqMan quantitative (q) PCR, immunohistochemistry, fluorescent multiplex immunohistochemistry, and electron microscopy.

RESULTS

Patients with MG or ectopic germinal centers (GCs) were significantly younger than those without MG (P < 0.0001) or GCs (P = 0.0001). Moreover, significantly more GCs were detected in thymomas associated with MG than in those without MG (P < 0.0001). The results of nested PCR and TaqMan qPCR were consistent, and B19V DNA positivity was only associated with presence of GCs (P = 0.011). Immunohistochemically, positive staining was primarily detected in neoplastic thymic epithelial cells (TECs) and ectopic GCs. The positive rate of B19V VP2 was significantly higher in thymoma with MG or GCs than in thymoma without MG (P = 0.004) or GCs (P = 0.006). Electron microscopy showed B19V particles in the nuclei of neoplastic TECs and B cells from GCs.

CONCLUSIONS

We conclude that the pathogenesis of MG is closely associated with the presence of GCs, and B19V infection is plausibly an essential contributor to formation of ectopic GCs in thymoma. To the best of the authors' knowledge, this is the first study to elucidate the role of B19V in thymoma-associated MG and provide new ideas for exploring the etiopathogenic mechanism of MG.

Inefficient Phosphorylation of 3′-fluoro-2′-dideoxythymidine in Liver Cells May Explain its Lack of Inhibition of Duck Hepatitis B virus Replication in vivo

Duck hepatitis B virus (DHBV) was used as a model in the search for antiviral compounds against hepatitis B. The triphosphate of 3′-fluoro-2′,3′-dideoxythymidine (FLT) inhibits DHBV DNA polymerase in vitro. The aim of this investigation was to evaluate the in vivo inhibitory effect of FLT on DHBV in ducks. Four DHBV-positive ducklings were treated with FLT by intraperitoneal injections of 25 mg kg−1, two times daily for 17 days. No decrease of DHBV DNA in serum was observed. Therefore, it was investigated if FLT could be efficiently phosphorylated in duck liver.

From DHBV-infected and non-infected duck livers protein extracts were prepared and partially purified by ion-exchange chromatography. Only one enzyme with thymidine (and deoxycytidine) kinase activity was found, corresponding to thymidine kinase 2 (i.e. the mitochondrial type of deoxynucleoside kinase). In contrast to extracts from duck spleen, the liver extracts showed a very low capacity to phosphorylate FLT, and this may explain the failure of FLT to prevent DHBV replication in vivo. These results suggest that new nucleoside analogues designed for treatment of hepatitis B should be evaluated with respect to phosphorylation by enzymes from non-dividing liver cells.

Hepatitis A, B, and D

Inflammation of the liver is known as hepatitis. Six or seven viruses, hepatitis A-G, are responsible for the majority of cases of viral hepatitis. All of the types of hepatitis present with the same flu-like symptoms. In this first of a series of three articles, current knowledge regarding hepatitis A, B, and D will be reviewed. Fifty percent of hepatitis cases are due to hepatitis A. Hepatitis B is considered a sexually transmitted disease. Hepatitis D is an incomplete virus found accompanying Hepatitis B. Every phase of patient care improves when health care professionals are knowledgeable regarding their clients' illnesses. This article presents our current scientific understanding of hepatitis A, B, and D viruses.

Quantitative detection of hepatitis B virus DNA in sera from patients with acute hepatitis B

Two hundred forty-four serial serum samples from 30 adults hospitalized with benign (nonfulminant) acute hepatitis B were tested for the presence of hepatitis B virus (HBV) DNA by a quantitative solution hybridization assay using a 125I-labeled DNA probe complementary to HBV-DNA sequences. Acute hepatitis B was self-limiting in 28 and progressed to chronicity in the remaining two patients. Of the 28 patients with self-limiting hepatitis, 21 (75%) were hepatitis B e antigen (HBeAg) positive, 26 (93%) were HBV-DNA positive, and one patient (3.6%) was negative for both markers on admission to the hospital. HBV-DNA cleared after HBeAg clearance in 20 (71.4%), before HBeAg clearance in five (17.9%) and simultaneously with the loss of HBeAg in the remaining two (7.1%) of the 27 initially HBV-DNA- and/or HBeAg-positive patients. Moreover, HBV-DNA remained detectable in serum for 13.3 +/- 6.6 (range: 4-22) days after the appearance of anti-HBe in 71.4% of these patients. In contrast, HBV-DNA and HBeAg remained persistently positive in the two patients who developed chronic HBV infection. These data show that (1) viremia frequently persists after disappearance of HBeAg and (2) appearance of anti-HBe does not indicate the cessation of HBV replication in adults with acute self-limiting hepatitis B.

Hepatitis B virus DNA in serum and liver is commonly found in Chinese patients with chronic liver disease despite the presence of antibodies to HBsAg

Sera from 410 patients from the Wuhan area in the central part of China with the diagnosis of chronic liver disease were analyzed for markers of hepatitis B, C and D virus infections. All sera, plus liver biopsy specimens from 188 of the patients, were also tested for hepatitis B virus DNA by polymerase chain reaction. Sixty-eight percent were HBsAg positive in serum, whereas 29% showed markers of past hepatitis B virus infection. Hepatitis B virus DNA was detected in all HBeAg-positive sera but also in 58% of patients with HBe antibody. In the liver specimens of the corresponding patient groups, 97% and 78%, respectively, were hepatitis B virus DNA positive. However, more noteworthy was that of the HBsAg-negative/HBs-antibody positive patients 30% had detectable hepatitis B virus DNA in serum and 32% had hepatitis B virus DNA in liver tissue, whereas in a control group of healthy blood donors, of which 90% had HBs antibody, none was hepatitis B virus DNA positive. Our results demonstrate that among patients with chronic liver disease, infections with hepatitis B virus or hepatitis B virus-related virus(es) may frequently occur without being revealed by conventional serological methods. Hepatitis C and D viruses seem to be of only minor importance in the pathogenesis of chronic liver disease in this part of China.

Screening for anti-HIV and HBsAg in pooled sera from a clinical chemistry section as a tool for epidemiological survey

With the aim of estimating the unknown spread of HIV into the general society, a program for testing pooled routine sera from a clinical chemistry laboratory has been tried. Serum samples obtained from the daily inflow of blood tubes at the Clinical Chemistry Laboratory, Malmö General Hospital, and not labelled as risk samples for blood-borne infection(s), were collected and pools of up to ten sera each were constructed according to a special protocol. All serum pools were screened for anti-HIV and HBsAg. During the 32-months period of the study 3,016 serum pools from men and the same number from women were collected and analysed. These pools together contained sera from 26,468 male and 26,891 female patients, respectively. Altogether 33 male and 2 female pools were found anti-HIV positive. Anti-HIV-positive males appeared in all age groups, without significant difference between the groups. Two female pools from the age group 15 to 24 years were anti-HIV positive; these samples were drawn during the last year of testing. HBsAg was detected in 189 male and 129 female pools. From 1989 to the first half of 1991 the mean anti-HIV prevalence among the male samples investigated was 0.10%, with 95% confidence limits from 0 to 0.25%. If the upper confidence limit is exceeded in the future, this could be a warning of increased spread of HIV of in society.

Effect of duration of hepatitis B virus infection on the association between human immunodeficiency virus type-1 and hepatitis B viral replication

This study examined the effect of duration of hepatitis B virus infection on the association between human immunodeficiency virus type-1 infection and hepatitis B viral replication. Twenty-five chronic HBsAg carriers were studied. Presence of hepatitis B virus DNA and expression of HBeAg were more frequent among 20 chronic HBsAg carriers positive for human immunodeficiency virus type-1 antibody compared with five chronic HBsAg carriers negative for human immunodeficiency virus type-1 antibody, but the associations were not statistically significant. Hepatitis B virus DNA and HBeAg were inversely related to duration of hepatitis B virus infection (p less than 0.001). Stratifying for duration of hepatitis B virus infection, the presence of viral replication was similar among patients negative and positive for antibody to human immunodeficiency virus type-1. Hepatitis B virus DNA levels did not increase with the decline of cellular immunity over time. In conclusion, hepatitis B virus replication among chronic carriers may be a function of duration of hepatitis B virus infection rather than of an effect of human immunodeficiency virus type-1.

Reactivation of hepatitis B virus infection with an unusual pattern of serological markers

A 73-year-old man presented with acute hepatitis, judged to be a reactivation of hepatitis B virus infection. His serum samples during a follow-up time of 16 months showed an unusual pattern of serological markers. He was consistently HBeAg positive, HBsAg fluctuated just under the cut-off value and he had a low level of circulating anti-HBs. By electron microscopy numerous aggregates of surface antigen particles, but not complete virions were seen. He was HBV DNA positive by hybridization. The complete precore and core genes and a region of the surface gene were amplified from his serum by PCR. These findings emphasize the need for expanded serological testing in some patients with acute clinical hepatitis.

Mother to infant transmission of hepatitis C virus infection

Eight women with chronic hepatitis C virus (HCV) infection during pregnancy gave birth to 11 children. Five of these children had elevated ALT, but only two had increased levels in more than one sample. All children tested before 6 months of age were positive for anti-HCV at most up to 7 months of age and then became negative. One child with a maximum ALT level of 8.4 mukat/l however, regained anti-HCV positivity at 12 months of age, and a liver biopsy at 21 months of age showed resolving hepatitis. Passively acquired HCV antibodies are obviously found in newborns of anti-HCV-positive mothers with chronic hepatitis. In 1 of 11 children, active anti-HCV production and concomitant liver disease suggested mother to infant transmission of hepatitis C virus infection.

The absence of hepatitis B virus DNA in hepatitis B e antigen positive sera from chronic hepatitis B surface antigen carriers in China

Sera from 20 Chinese patients with chronic hepatitis B were examined for hepatitis B e antigen and hepatitis B virus (HBV) DNA. There was considerable discordance with HBV DNA not being detectable in 10 out of 13 (77%) patients who were hepatitis B e antigen positive. Further testing for anti-HBe and HBV-DNA polymerase activity confirmed the results. Possible reasons for this discordance are discussed but neither hepatitis D (delta) infection nor the acquired immunodeficiency syndrome (AIDS) could be implicated.

Hepatitis B virus replication in hepatitis B and D coinfection

The clinical course, changes in liver function tests and the behaviour of viral markers over the course of time have been examined in 45 patients with acute hepatitis B and 14 patients with acute hepatitis caused by B and D viruses coinfection. There were no significant differences either in the clinical course or in the liver function tests, in the two groups. The changes in serum viral markers were as follows: HBV-DNA was the first marker to disappear; this was closely followed by HBeAg, and HBsAg was the last marker to become negative, during convalescence. This pattern was not altered by Delta coinfection. When we quantified serum HBV-DNA in both groups of patients, we found that Delta virus infection led to parital inhibition of HBV replication, so that serum HBV-DNA levels were significantly lower in those patients with acute hepatitis B who were simultaneously infected with Delta virus.

Chronic non-A, non-B hepatitis in pregnancy: outcome and possible transmission to the offspring

11 women with chronic non-A, non-B hepatitis (NANBH) were studied during 14 pregnancies. All women remained well, without signs of deterioration of liver function. On the contrary, serum transaminase levels were significantly lower in the latter part of the pregnancy compared to before and after. 12 children were born at full term. One child was born preterm and 1 child was stillborn after 36 gestational weeks. During follow-up, 8 of the children had elevated alanine amino transferase (ALT) levels in serum at least at one sampling occasion. Four children had ALT elevation in consecutive blood samples, 2 of whom had a longlasting ALT elevation, probably due to mother-to-infant transmission of NANBH virus(es).

Hepatitis B virus DNA in blood specimens of anti HBc IgM positive patients

This study compares the presence of hepatitis B virus (HBV) DNA and HBV e antigen in sera positive for IgM antibody to HBV core antigen. Of the 31 sera included in the study, 14 were HBV DNA positive. Eight sera were positive for HBV DNA but negative for HBeAg and 3 sera were negative for HBV DNA but positive for HBeAg. The HBV DNA positive specimens included also 3 HBsAg negative sera. The importance of the level of the anti HBc IgM antibody is discussed.

Changes of serum HBV-DNA in relation to serum transaminase level during acute exacerbation in patients with chronic type B hepatitis

To examine the relationship between changes of serum hepatitis B virus-dexoyribonucleic acid (HBV-DNA) and transaminase levels during acute exacerbation of chronic type B hepatitis, serial serum specimens from 74 patients were assayed for HBV-DNA by slot blot hybridization with 32P-labeled cloned HBV-DNA as probe. Of these patients, serial serum specimens were obtained with an interval of 2-7 days in 22 patients (Group I), 8-14 days in 30 patients (Group II) and 15-30 days in 22 patients (Group III). The peak of serum HBV-DNA was reached shortly before or simultaneously with the maximum elevation of serum alanine transaminase (ALT) in most (greater than 90%) of the acute exacerbations. In contrast, the peak of serum ALT was reached before maximum elevation of serum HBV-DNA in only 13.6% of Group I, 3.3% of Group II and 13.6% of Group III (9.5% of whole series). The results suggest that the increase of serum HBV-DNA is an event preceding, rather than the result of, hepatocytolysis in most of the acute exacerbations occurring in patients with chronic type B hepatitis.

Chronic non-A, non-B hepatitis in drug addicts--a follow-up study

Forty-seven drug addicts with histologically verified chronic non-A, non-B hepatitis were followed up for at least 12 months (mean 58 +/- 34.5 months). The patients were young, mean age 25 years and predominantly of the male sex. Forty patients (85%) had chronic persistent hepatitis (CPH) in the first biopsy and seven (15%) had chronic active hepatitis with or without cirrhosis (CAH/C). Except for bilirubin levels, standard biochemical tests at the time of the biopsy did not differ significantly between the two histologic groups. Ten patients had repeated biopsies performed and in four of them a histologic progression was observed. Six patients with CAH had evidence of cirrhosis. No patient developed hepatic failure or died because of the liver disease. Two patients seemed to resolve biochemically during follow-up. The rather benign liver morphology contrasts with chronic NANBH after blood transfusion where chronic active hepatitis and cirrhosis are much more common. Age-dependent immunologic factors might to some extent explain these differences.

Infectivity of medical staff for hepatitis B

Prior to hepatitis B vaccination, 36,000 persons of the medical staff were tested for HBs antigen, HBc antibodies, and HBs antibodies. 210 sera were found positive for HBs antigen and HBc antibodies. Of these sera, 171 were available for testing for hepatitis B virus DNA as a marker of infectivity by spot hybridization. DNA was detected in only 15. One hundred and thirty-nine had HBe antibodies but no detectable HBe antigen, and only two of these were hepatitis B virus DNA positive. 12 had neither HBe antigen nor HBe antibodies and none had hepatitis B virus DNA. Hepatitis B virus DNA was, however, detected in 13 of 20 HBe antigen-positive but HBe antibody-negative sera. Our study confirms epidemiological observations that medical staff hardly plays any role as a source of HBV infection for patients.

Chronic non-A, non-B hepatitis. A long-term follow-up study in 49 patients

Forty-nine patients with biopsy-verified chronic non-A, non-B hepatitis (NANBH) of both percutaneously transmitted and sporadic types were followed up for up to 20 years (mean, 62 months +/- 44 months). Drug addicts were not included. Twenty-four patients had chronic persistent hepatitis (CPH), and 25 had chronic active hepatitis (CAH) or cirrhosis on the basis of the first biopsy. Patients with CPH were significantly younger than patients with CAH (mean age, 31 and 51 years, respectively; p less than 0.001). Standard laboratory data (means) correlated with histology, but great variations made liver biopsy essential for the diagnosis. Twenty-one patients were rebiopsied, and 24% had more severe lesions. In total, 16 patients (33%) had signs of cirrhosis. The disease seemed to resolve in eight patients (16%), whereas two patients died of it. Some patients with CPH might progress to CAH, and the frequent finding of cirrhosis in CAH implies the possibility of hepatic failure and fatality in chronic NANBH.

Hepatitis B virus replication in acute hepatitis B, acute hepatitis B virus-hepatitis delta virus coinfection and acute hepatitis delta superinfection

To evaluate the effect of hepatitis delta virus on the level of replication of hepatitis B virus and to assess the clinical significance that such an effect might have on the final outcome of the infection, the serological profile of hepatitis B virus DNA was investigated in 153 patients with acute or chronic hepatitis B virus infection with or without associated delta infection. Serum hepatitis B virus DNA was detected in 57% of patients with acute hepatitis B, 67% of those with acute hepatitis B virus-hepatitis delta virus coinfection and 25% of HBsAg carriers with hepatitis delta virus superinfection during the first week after the onset of symptoms. Patients with acute hepatitis B and those with acute hepatitis B virus-hepatitis delta virus coinfection did not differ significantly with respect to the serological profile of hepatitis B virus DNA and final clinical outcome. Within the group of HBsAg carriers with hepatitis delta virus superinfection, all patients who were initially negative for hepatitis B virus DNA developed chronic hepatitis delta virus infection, whereas 3 of the 4 patients with active hepatitis B virus infection at the time of superinfection showed transient inhibition of hepatitis B virus replication followed by termination of hepatitis delta virus infection in two patients. Therefore, although delta virus may inhibit the replication of hepatitis B virus among chronic HBsAg carriers, this effect is not readily apparent among patients with hepatitis B virus-hepatitis delta virus coinfection.

The influence of HTLV-III infection on the natural history of hepatitis B virus infection in male homosexual HBsAg carriers

The presence of antibodies to HTLV-III and markers of active hepatitis B virus replication was examined in a longitudinal study of 33 consecutive male homosexual HBsAg carriers. The mean follow-up time was 37 months (range = 4 to 109 months). All patients were initially hepatitis B virus DNA-positive and HBeAg positive. Antibodies to HTLV-III were detectable in eight patients while they were positive for both of these markers. One of them cleared hepatitis B virus DNA and seroconverted from HBeAg to anti-HBe. This corresponds to an annual clearance/seroconversion rate of 4% (95% confidence limits = 0 to 15%). In two patients, antibodies to HTLV-III appeared after clearance of hepatitis B virus DNA and HBeAg, and in one of them, hepatitis B virus DNA reappeared. Among the 25 patients negative for HTLV-III antibodies, the annual hepatitis B virus DNA clearance rate was 20% and HBeAg to anti-HBe seroconversion rate was 11% (95% confidence limits = 11 to 31% and 4 to 20% respectively). The observed hepatitis B virus DNA clearance rates in the two groups were significantly different (p less than 0.05). Disease activity, as determined by transaminase levels, was significantly lower in HTLV-III-infected individuals as compared to individuals without HTLV-III infection (p less than 0.05). Infection with HTLV-III may extend the period of active viral replication or even reactivate hepatitis B virus replication and seems to diminish inflammatory disease activity in chronic HBsAg carriers.

Chronic hepatitis B. Impact of hepatitis D virus superinfection and the hepatitis B e-system on histological outcome, and correlation of the hepatitis B e-system to HBV-DNA in serum

Chronic evolution after acute hepatitis B virus infection. During a 13 months period 1977-1978 a total of 129 cases of acute viral hepatitis type B occurred among patients who were admitted with hepatitis to Roslagstull, Hospital, Stockholm, Sweden. Less than 1% progressed to chronicity. Prevalence of Delta superinfection was studied among 60 patients with chronic hepatitis B. Nineteen (32%) were anti-delta positive. The majority of the positive patients were either non-European immigrants or addicts, both 9/19 (47%). Infections with the delta agent was found to have occurred in Stockholm already in the early 1970s. Rate of HBeAg clearance during chronic HBV was studied among 36 HBeAg positive patients. Seroconversion to anti-HBe was noted in 17 patients (47%), whereas HBeAg persisted in 19 during a mean follow-up period of 53 months. The spontaneous annual HBeAg seroconversion rate was 11%. HBeAg clearance occurred as frequently among homosexual men as among patients in other categories. However, 12/14 homosexual men were HBeAg positive after 2 years follow-up, compared with 1/13 drug addicts. Thus, homosexual men seemed to require a longer time for HBeAg seroconversion than i.v. drug addicts. HBV-DNA in serum, a strong indicator of viral particles and infectivity was analysed among patients with HBeAg seroconversion, initial HBeAg negativity and/or delta superinfection. HBV-DNA was found in 75-80% of our HBeAg positive patients. A correlation between chronic liver disease and presence of HBV-DNA in serum was also found. Thus, HBV DNA was found in 63% of patients with CAH or CAH/CI as compared with only 39% of patients with CPH. Delta infected patients had HBV-DNA more often than those without hepatitis D infection. Seven delta infected, anti-HBe positive, patients were still HBV-DNA positive five to eight years later. Therefore delta infected anti-HBe positive patients can be infectious for prolonged periods. Histological outcome. 63% (12/19) anti-delta positive patients were classified as CAH with or without cirrhosis as against 39% (16/41) of the anti-delta negative patients. Eleven of 15 homosexual men (73%) had histological findings classified as CAH or CAH/CI. None of them were superinfected with HDV. Thus homosexual men developed severe hepatic lesions without being delta infected. In contrast 78% (7/9) i.v. drug addicts with CAH were delta infected. A numerical scoring system was applied and compared with conventional morphological classification of liver histology to assess the histological outcome of 42 patients with repetitive liver biopsies.

Long-term follow-up of 60 patients with chronic hepatitis B. II. Hepatitis B virus DNA in serum correlated to the hepatitis Be-system and presence of delta superinfection

Forty-six patients with liver biopsy-documented chronic hepatitis B were followed for a mean period of 44 months. A total of 200 serum samples from these patients was analyzed for the presence of hepatitis B virus DNA (HBV-DNA). The results were correlated to the HBeAg/anti-HBe status and to the presence of anti-delta as a marker for delta superinfection. In the initial serum samples HBV-DNA was detected in the vast majority of the patients independent of the HBeAg/anti-HBe results and whether the patients were superinfected by delta agent or not. During the complete follow-up period, HBV-DNA was detected in 88% of those patients who were positive for HBeAg, irrespective of the presence or absence of a simultaneous delta infection. When anti-HBe positive, 79% of the patients with anti-delta had detectable HBV-DNA in their sera, while only 43% of those negative for anti-delta were positive for HBV-DNA. The results indicate a high prevalence of virus release into the blood of patients with chronic hepatitis B, especially among patients positive for HBeAg and among those anti-HBe positive patients who have a delta superinfection.