1
|
Woytinek K, Glitscher M, Hildt E. Antagonism of epidermal growth factor receptor signaling favors hepatitis E virus life cycle. J Virol 2024; 98:e0058024. [PMID: 38856640 PMCID: PMC11265270 DOI: 10.1128/jvi.00580-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/09/2024] [Indexed: 06/11/2024] Open
Abstract
Hepatitis E virus (HEV) poses a global threat, which currently remains understudied in terms of host interactions. Epidermal growth factor receptor (EGFR) plays multifaceted roles in viral pathogenesis, impacting host-cell entry, viral replication, and host-defense modulation. On the one hand, EGFR signaling emerged as a major driver in innate immunity; on the other hand, a crosstalk between HEV and EGFR requires deeper analysis. We therefore aimed to dissect the receptor's involvement in the HEV life cycle. In persistently HEV-infected cells, the EGFR amount is decreased alongside with enhanced receptor internalization. As compared with the control ligand-induced EGFR, activation revealed an early receptor internalization and degradation in HEV-replicating cells, resulting in a notable EGFR signaling delay. Interestingly, inhibition or silencing of EGFR increased viral replication, extracellular and intracellular viral transcripts, and released infectious particles. The pro-viral impact of EGFR inhibition was attributed to (i) impaired expression of interferon-stimulated genes, (ii) activation of the autophagosomal system, (iii) virus-induced inhibition of lysosomal acidification, and (iv) a decrease of the cellular cholesterol level. IMPORTANCE This study identifies epidermal growth factor receptor (EGFR) as a novel host factor affecting hepatitis E virus (HEV): EGFR downregulation promotes viral replication, release, and evasion from the innate immune response. The discovery that EGFR inhibition favors viral spread is particularly concerning for HEV patients undergoing EGFR inhibitor treatment.
Collapse
Affiliation(s)
| | - Mirco Glitscher
- Division of Virology, Paul Ehrlich Institute, Langen, Germany
| | - Eberhard Hildt
- Division of Virology, Paul Ehrlich Institute, Langen, Germany
| |
Collapse
|
2
|
Nagoba BS, Rayate AS. Hepatitis E virus infections. World J Virol 2024; 13:90951. [PMID: 38984082 PMCID: PMC11229837 DOI: 10.5501/wjv.v13.i2.90951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/02/2024] [Accepted: 04/07/2024] [Indexed: 06/24/2024] Open
Abstract
Hepatitis E virus (HEV) infection is now endemic worldwide. Most patients with acute infection recover uneventfully. Outbreaks and sporadic cases, particularly in high-risk individuals are emerging increasingly. The patients with risk factors like pregnancy and pre-existing chronic liver disease, present with or progress rapidly to severe disease. Immuno-suppression in post-transplant patients is an additional risk factor. Standardized FDA-approved diagnostic tests are the need of the hour. Further studies are needed to establish guideline-based treatment regimen and outbreak preparedness for HEV to decrease global morbidity, mortality, and healthcare burden. Policies for screening donors and transplant cases are required.
Collapse
Affiliation(s)
- Basavraj S Nagoba
- Department of Microbiology, Maharashtra Institute of Medical Sciences & Research (Medical College), Latur 413531, India
| | - Abhijit S Rayate
- Department of Surgery, Maharashtra Institute of Medical Sciences & Research (Medical College), Latur 413531, India
| |
Collapse
|
3
|
Olaimat AN, Taybeh AO, Al-Nabulsi A, Al-Holy M, Hatmal MM, Alzyoud J, Aolymat I, Abughoush MH, Shahbaz H, Alzyoud A, Osaili T, Ayyash M, Coombs KM, Holley R. Common and Potential Emerging Foodborne Viruses: A Comprehensive Review. Life (Basel) 2024; 14:190. [PMID: 38398699 PMCID: PMC10890126 DOI: 10.3390/life14020190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Human viruses and viruses from animals can cause illnesses in humans after the consumption of contaminated food or water. Contamination may occur during preparation by infected food handlers, during food production because of unsuitably controlled working conditions, or following the consumption of animal-based foods contaminated by a zoonotic virus. This review discussed the recent information available on the general and clinical characteristics of viruses, viral foodborne outbreaks and control strategies to prevent the viral contamination of food products and water. Viruses are responsible for the greatest number of illnesses from outbreaks caused by food, and risk assessment experts regard them as a high food safety priority. This concern is well founded, since a significant increase in viral foodborne outbreaks has occurred over the past 20 years. Norovirus, hepatitis A and E viruses, rotavirus, astrovirus, adenovirus, and sapovirus are the major common viruses associated with water or foodborne illness outbreaks. It is also suspected that many human viruses including Aichi virus, Nipah virus, tick-borne encephalitis virus, H5N1 avian influenza viruses, and coronaviruses (SARS-CoV-1, SARS-CoV-2 and MERS-CoV) also have the potential to be transmitted via food products. It is evident that the adoption of strict hygienic food processing measures from farm to table is required to prevent viruses from contaminating our food.
Collapse
Affiliation(s)
- Amin N. Olaimat
- Department of Clinical Nutrition and Dietetics, Faculty of Applied Medical Sciences, The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan; (M.A.-H.); (M.H.A.)
| | - Asma’ O. Taybeh
- Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan; (A.O.T.); (A.A.-N.); (T.O.)
| | - Anas Al-Nabulsi
- Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan; (A.O.T.); (A.A.-N.); (T.O.)
| | - Murad Al-Holy
- Department of Clinical Nutrition and Dietetics, Faculty of Applied Medical Sciences, The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan; (M.A.-H.); (M.H.A.)
| | - Ma’mon M. Hatmal
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan;
| | - Jihad Alzyoud
- Department of Anatomy, Physiology and Biochemistry, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan; (J.A.); (I.A.)
| | - Iman Aolymat
- Department of Anatomy, Physiology and Biochemistry, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan; (J.A.); (I.A.)
| | - Mahmoud H. Abughoush
- Department of Clinical Nutrition and Dietetics, Faculty of Applied Medical Sciences, The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan; (M.A.-H.); (M.H.A.)
- Science of Nutrition and Dietetics Program, College of Pharmacy, Al Ain University, Abu Dhabi P.O. Box 64141, United Arab Emirates
| | - Hafiz Shahbaz
- Department of Food Science and Human Nutrition, University of Veterinary and Animal Sciences, Lahore 54000, Pakistan;
| | - Anas Alzyoud
- Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan;
| | - Tareq Osaili
- Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan; (A.O.T.); (A.A.-N.); (T.O.)
- Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah P.O. Box 27272, United Arab Emirates
| | - Mutamed Ayyash
- Department of Food Science, College of Agriculture and Veterinary Medicine, United Arab Emirates University, P.O. Box 15551, Al Ain 53000, United Arab Emirates;
| | - Kevin M. Coombs
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0J9, Canada;
| | - Richard Holley
- Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, MB R3T 2N2, Canada;
| |
Collapse
|
4
|
Khuroo MS. Discovery of Hepatitis E and Its Impact on Global Health: A Journey of 44 Years about an Incredible Human-Interest Story. Viruses 2023; 15:1745. [PMID: 37632090 PMCID: PMC10459142 DOI: 10.3390/v15081745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
The story of the discovery of hepatitis E originated in the late 1970s with my extreme belief that there was a hidden saga in the relationship between jaundice and pregnancy in developing countries and the opportunity for a massive epidemic of viral hepatitis, which hit the Gulmarg Kashmir region in November 1978. Based on data collected from a door-to-door survey, the existence of a new disease, epidemic non-A, non-B hepatitis, caused by a hitherto unknown hepatitis virus, was announced. This news was received by the world community with hype and skepticism. In the early 1980s, the world watched in awe as an extreme example of human self-experimentation led to the identification of VLP. In 1990, a cDNA clone from the virus responsible for epidemic non-A, non-B hepatitis was isolated. Over the years, we traversed three eras of ambiguity, hope, and hype of hepatitis E research and conducted several seminal studies to understand the biology of HEV and manifestations of hepatitis E. Many milestones have been reached on the long and winding road of hepatitis E research to understand the structure, biology, and diversity of the agent, changing the behavior of the pathogen in developed countries, and the discovery of a highly effective vaccine.
Collapse
Affiliation(s)
- Mohammad Sultan Khuroo
- Digestive Diseases Centre, Dr. Khuroo's Medical Clinic, Srinagar, Jammu & Kashmir 190010, India
| |
Collapse
|
5
|
Qian Z, Cong C, Li Y, Bi Y, He Q, Li T, Xia Y, Xu L, Mickael HK, Yu W, Liu J, Wei D, Huang F. Quantification of host proteomic responses to genotype 4 hepatitis E virus replication facilitated by pregnancy serum. Virol J 2023; 20:111. [PMID: 37264422 PMCID: PMC10233519 DOI: 10.1186/s12985-023-02080-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/23/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Hepatitis E virus (HEV) infection is a common cause of acute hepatitis worldwide and causes approximately 30% case fatality rate among pregnant women. Pregnancy serum (PS), which contains a high concentration of estradiol, facilitates HEV replication in vitro through the suppression of the PI3K-AKT-mTOR and cAMPK-PKA-CREB signaling pathways. However, the proteomics of the complex host responses to HEV infection, especially how PS facilitates viral replication, remains unclear. METHODS In this study, the differences in the proteomics of HEV-infected HepG2 cells supplemented with fetal bovine serum (FBS) from those of HEV-infected HepG2 cells supplemented with serum from women in their third trimester of pregnancy were quantified by using isobaric tags for relative and absolute quantification technology. RESULTS A total of 1511 proteins were identified, among which 548 were defined as differentially expressed proteins (DEPs). HEV-infected cells supplemented with PS exhibited the most significant changes at the protein level. A total of 328 DEPs, including 66 up-regulated and 262 down-regulated proteins, were identified in HEV-infected cells supplemented with FBS, whereas 264 DEPs, including 201 up-regulated and 63 down-regulated proteins, were found in HEV-infected cells supplemented with PS. Subsequently, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses revealed that in HEV-infected cells, PS supplementation adjusted more host genes and signaling pathways than FBS supplementation. The DEPs involved in virus-host interaction participated in complex interactions, especially a large number of immune-related protein emerged in HEV-infected cells supplemented with PS. Three significant or interesting proteins, including filamin-A, thioredoxin, and cytochrome c, in HEV-infected cells were functionally verified. CONCLUSIONS The results of this study provide new and comprehensive insight for exploring virus-host interactions and will benefit future studies on the pathogenesis of HEV in pregnant women.
Collapse
Affiliation(s)
- Zhongyao Qian
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Chao Cong
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Yi Li
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Yanhong Bi
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Qiuxia He
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Tengyuan Li
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Yueping Xia
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Liangheng Xu
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Houfack K Mickael
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Wenhai Yu
- Institute of Medical Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Kunming, People's Republic of China.
| | - Jiankun Liu
- 920th Hospital of Joint Logistics Support Force of PLA, Kunming, People's Republic of China.
| | - Daqiao Wei
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China.
| | - Fen Huang
- Medical School, Kunming University of Science and Technology, Kunming, People's Republic of China.
| |
Collapse
|
6
|
Okumura H, Miyamoto A, Suzuki F, Takaya H. Acute Hepatitis E Infection during Chemotherapy for Lung Cancer: A Case Report. Chemotherapy 2023; 68:155-159. [PMID: 37166305 DOI: 10.1159/000530802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/17/2023] [Indexed: 05/12/2023]
Abstract
Acute hepatitis E, one of the causes of acute liver injury, has been increasingly diagnosed in developed countries in recent years. Misdiagnosis of acute hepatitis E virus (HEV) infection as drug-induced liver injury (DILI) may lead to discontinuation of effective chemotherapy. Thus, viral hepatitis, including hepatitis E, must be ruled out in the diagnosis of DILI. A 78-year-old woman with lung adenocarcinoma and multiple bone metastases received maintenance therapy with pemetrexed + pembrolizumab for a year. Increased aspartate aminotransferase and alanine aminotransferase levels, indicating acute liver injury, were observed. Initially, DILI was suspected, and she was given medications to lower the levels of hepatic enzymes. She was later admitted to the hospital with the chief complaint of general malaise and anorexia. Serum aspartate aminotransferase and alanine aminotransferase levels were markedly elevated (381 and 854 U/L, respectively). Acute HEV infection was diagnosed based on the detection of serum HEV immunoglobulin A antibodies. The patient received liver support therapy, and the serum hepatic enzymes recovered to normal levels. Chemotherapy was resumed without any subsequent relapse of hepatic enzyme elevation. When DILI is suspected during chemotherapy, exclusion of viral hepatitis is mandatory, which can be achieved by measuring markers of hepatitis viruses, including HEV, and examining the patient's detailed medical history.
Collapse
Affiliation(s)
- Hiroki Okumura
- Department of Respiratory Medicine, Toranomon Hospital (Branch), Kawasaki-shi, Japan
| | - Atsushi Miyamoto
- Department of Respiratory Medicine, Toranomon Hospital (Branch), Kawasaki-shi, Japan
- Department of Respiratory Medicine, Respiratory Centre, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Fumitaka Suzuki
- Department of Hepatology, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Hisashi Takaya
- Department of Respiratory Medicine, Toranomon Hospital (Branch), Kawasaki-shi, Japan
| |
Collapse
|
7
|
Biedermann P, Klink P, Nocke MK, Papp CP, Harms D, Kebelmann M, Thürmer A, Choi M, Altmann B, Todt D, Hofmann J, Bock CT. Insertions and deletions in the hypervariable region of the hepatitis E virus genome in individuals with acute and chronic infection. Liver Int 2023; 43:794-804. [PMID: 36617681 DOI: 10.1111/liv.15517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/30/2022] [Accepted: 01/04/2023] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS Hepatitis E virus is a major cause of acute hepatitis worldwide and can progress to chronicity in immunocompromised individuals. Various virus-host recombination events have been reported in the hypervariable region of the hepatitis E virus genome, but the patterns of assembly and selection remain unclear. METHODS To gain further insight into viral evolution, we assessed the presence of low abundance variants in 16 samples from individuals with acute or chronic infection using a targeted next-generation sequencing approach. RESULTS In seven samples, different variants with insertions and/or deletions were identified. Among them, eight insertions originating either from human genes or from the hepatitis E virus genome. Five different deletions could be identified. The amino acid composition of sequences with insertions showed a higher frequency of lysine and a lower abundance of proline, and additionally acetylation and ubiquitination sites were more frequent than in hepatitis E virus wild-type sequences. CONCLUSIONS These findings suggest that the nucleotide composition of insertions and sites for post-translational modification may contribute to recombination events. Although the impact of low-level hepatitis E virus variants is uncertain, our results highlight the importance of a highly sensitive next-generation sequencing approach to capture the full diversity of hypervariable region.
Collapse
Affiliation(s)
- Paula Biedermann
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany
- German Centre for Infection Research, Institute of Virology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Patrycja Klink
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany
| | - Maximilian K Nocke
- Department of Molecular and Medical Virology, Ruhr University Bochum, Bochum, Germany
| | - Christian-Patrick Papp
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany
- German Centre for Infection Research, Institute of Virology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Dominik Harms
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany
| | - Marianne Kebelmann
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany
| | - Andrea Thürmer
- Genome Sequencing, Methodology and Research Infrastructure, Robert Koch Institute, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Intensive Medical Care, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Britta Altmann
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany
| | - Daniel Todt
- Department of Molecular and Medical Virology, Ruhr University Bochum, Bochum, Germany
- European Virus Bioinformatics Center (EVBC), Jena, Germany
| | - Jörg Hofmann
- German Centre for Infection Research, Institute of Virology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Labor Berlin, Charité-Vivantes GmbH, Berlin, Germany
| | - Claus-Thomas Bock
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, Germany
- Institute of Tropical Medicine, University of Tuebingen, Tuebingen, Germany
| |
Collapse
|
8
|
Development of recombinant infectious hepatitis E virus harboring the nanoKAZ gene and its application in drug screening. J Virol 2022; 96:e0190621. [PMID: 35107380 DOI: 10.1128/jvi.01906-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hepatitis E virus (HEV) is a quasi-enveloped virus with a single-stranded positive-sense RNA genome belonging to family Hepeviridae. Studies on molecular aspects of HEV and drug screening have benefited from the discovery of bioluminescent reporter genes. However, the stability of large foreign genes is difficult to maintain after insertion into the viral genome. Currently, ribavirin is used to treat HEV-infected patients who require antiviral therapy. This has several major drawbacks. Thus, the development of novel anti-HEV drugs is of great importance. We developed a system consisting of recombinant infectious HEV harboring small luciferase gene (nanoKAZ) in the hypervariable region (HVR) of the open reading frame 1 (ORF1) (HEV-nanoKAZ). It replicated efficiently in cultured cells, was genetically stable, and had morphological characteristics similar to the parental virus. Both membrane-associated (eHEV-nanoKAZ) and membrane-unassociated (neHEV-nanoKAZ) particles were infectious. HEV particles circulating in the blood stream and attaching to hepatocytes in HEV-infected patients are membrane-associated, thus, eHEV-nanoKAZ was applied in drug screening. The eHEV-nanoKAZ system is able to cover at least the inhibitor of HEV entry and inhibitor of HEV RNA replication. Four drugs with anti-HEV activity were identified. Their effectiveness in cultured cells was confirmed in naïve and HEV-producing PLC/PRF/5 cells. Two hit drugs (azithromycin and ritonavir) strongly inhibited HEV production in culture supernatants, as well as intracellular expression of ORF2 protein, and may therefore be candidate novel anti-HEV drugs. The HEV-nanoKAZ system was developed and applied in drug screening, and is expected to be useful for investigating the HEV life cycle. IMPORTANCE Bioluminescent reporter viruses are essential tools in molecular virological research. It has been widely used to investigate viral life cycles and in the development of antiviral drugs. For drug screening, the use of a bioluminescent reporter virus helps shorten the time required to perform the assay. A system, consisting of recombinant infectious HEV harboring the nanoKAZ gene in the HVR of ORF1 (HEV-nanoKAZ), was developed in this study, and was successfully applied to drug screening in which four hit drugs with anti-HEV activity were identified. The results of this study provide evidence supporting the use of this system in more variable HEV studies. In addition, both forms of viral particles (eHEV-nanoKAZ and neHEV-nanoKAZ) are infectious, which will enable their application in HEV studies requiring both forms of viral particles, such as in the investigation of unknown HEV receptors and the elucidation of host factors important for HEV entry.
Collapse
|
9
|
Moro O, Suffredini E, Isopi M, Tosti ME, Schembri P, Scavia G. Quantitative Methods for the Prioritization of Foods Implicated in the Transmission of Hepatititis E to Humans in Italy. Foods 2021; 11:foods11010087. [PMID: 35010213 PMCID: PMC8750432 DOI: 10.3390/foods11010087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/09/2021] [Accepted: 12/23/2021] [Indexed: 01/02/2023] Open
Abstract
Hepatitis E is considered an emerging foodborne disease in Europe. Several types of foods are implicated in the transmission of the hepatitis E virus (HEV) to humans, in particular, pork and wild boar products. We developed a parametric stochastic model to estimate the risk of foodborne exposure to HEV in the Italian population and to rank the relevance of pork products with and without liver (PL and PNL, respectively), leafy vegetables, shellfish and raw milk in HEV transmission. Original data on HEV prevalence in different foods were obtained from a recent sampling study conducted in Italy at the retail level. Other data were obtained by publicly available sources and published literature. The model output indicated that the consumption of PNL was associated with the highest number of HEV infections in the population. However, the sensitivity analysis showed that slight variations in the consumption of PL led to an increase in the number of HEV infections much higher than PNL, suggesting that PL at an individual level are the top risky food. Uncertainty analysis underlined that further characterization of the pork products preparation and better assessment of consumption data at a regional level is critical information for fine-tuning the most risky implicated food items in Italy.
Collapse
Affiliation(s)
- Ornella Moro
- Department of Food Safety, Nutrition and Veterinary Public Health, National Institute of Health, 00161 Rome, Italy; (E.S.); (G.S.)
- Department of Mathematics, University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy;
- Correspondence:
| | - Elisabetta Suffredini
- Department of Food Safety, Nutrition and Veterinary Public Health, National Institute of Health, 00161 Rome, Italy; (E.S.); (G.S.)
| | - Marco Isopi
- Department of Mathematics, University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy;
| | - Maria Elena Tosti
- National Center for Global Health, National Institute of Health, 00161 Rome, Italy;
| | - Pietro Schembri
- Regional Department for Health Activities and Epidemiological Observatory of the Sicilian Region, 90145 Palermo, Italy;
| | - Gaia Scavia
- Department of Food Safety, Nutrition and Veterinary Public Health, National Institute of Health, 00161 Rome, Italy; (E.S.); (G.S.)
| |
Collapse
|
10
|
Qian Z, Yang C, Xu L, Mickael HK, Chen S, Zhang Y, Xia Y, Li T, Yu W, Huang F. Hepatitis E virus-encoded microRNA promotes viral replication by inhibiting type I interferon. FASEB J 2021; 36:e22104. [PMID: 34918388 DOI: 10.1096/fj.202101042r] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/18/2021] [Accepted: 12/01/2021] [Indexed: 02/05/2023]
Abstract
MicroRNAs (miRNAs), the non-coding RNAs of ~22 nucleotides (nt) in length, play a vital role in regulating viral replication. Hepatitis E virus (HEV), a single-stranded RNA virus, is a predominant pathogen of acute hepatitis worldwide. Virus-encoded miRNAs regulate the viral life cycle and escape from the host innate immune system. However, it is rarely known about HEV-encoded miRNA (HEV-miR-A6). In the present study, HEV-miR-A6 was screened by microarray, and further identified in vivo and in vitro. HEV-miR-A6 originated from the methylase (MeT) of HEV open reading frame 1 (ORF1) and was highly conserved in eight HEV genotypes. HEV-miR-A6 expression was growing during HEV replication, and significantly increased in acute hepatitis E patients than convalescence patients. Furthermore, HEV-miR-A6 was specifically detected in liver, spleen, kidney and colon by in situ hybridization. To identify the specificity of HEV-miR-A6, its mutants (HEV-miR-A6M1 and HEV-miR-A6M2) were constructed to change the stem-loop structure. Interestingly, over-expression of HEV-miR-A6 or HEV-miR-A6M1 significantly facilitated viral replication, while HEV-miR-A6M2, another mutant completely changed the stem-loop structure was invalid. SIRP-α, a candidate target gene of HEV-miR-A6, was activated when HEV-miR-A6 over-expressed to inhibit the phosphorylation of IRF3, and subsequently suppressed the expression of type I interferon β (IFN-β). The promotion of viral replication by HEV-miR-A6 further identified in vivo. Significant suppression of IFN-β production in the serum of HEV-infected mice pre-treated with HEV-miR-A6 was observed. In summary, HEV-miR-A6 activates SIRP-α to promote viral replication by inhibition of IFN-β expression.
Collapse
Affiliation(s)
- Zhongyao Qian
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Chenchen Yang
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Liangheng Xu
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Houfack K Mickael
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Shuangfeng Chen
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Yike Zhang
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Yueping Xia
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Tengyuan Li
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| | - Wenhai Yu
- Institute of Medical Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Kunming, PR China
| | - Fen Huang
- Medical School, Kunming University of Science and Technology, Kunming, PR China
| |
Collapse
|
11
|
Delphin M, Desmares M, Schuehle S, Heikenwalder M, Durantel D, Faure-Dupuy S. How to get away with liver innate immunity? A viruses' tale. Liver Int 2021; 41:2547-2559. [PMID: 34520597 DOI: 10.1111/liv.15054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/20/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022]
Abstract
In their never-ending quest towards persistence within their host, hepatitis viruses have developed numerous ways to counteract the liver innate immunity. This review highlights the different and common mechanisms employed by these viruses to (i) establish in the liver (passive entry or active evasion from immune recognition) and (ii) actively inhibit the innate immune response (ie modulation of pattern recognition receptor expression and/or signalling pathways, modulation of interferon response and modulation of immune cells count or phenotype).
Collapse
Affiliation(s)
- Marion Delphin
- International Center for Infectiology Research (CIRI), INSERM U1111, CNRS UMR5308, Université de Lyon (UCBL1), Lyon, France
| | - Manon Desmares
- International Center for Infectiology Research (CIRI), INSERM U1111, CNRS UMR5308, Université de Lyon (UCBL1), Lyon, France
| | - Svenja Schuehle
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Mathias Heikenwalder
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - David Durantel
- International Center for Infectiology Research (CIRI), INSERM U1111, CNRS UMR5308, Université de Lyon (UCBL1), Lyon, France.,DEVweCAN Laboratory of Excellence, Lyon, France
| | - Suzanne Faure-Dupuy
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| |
Collapse
|
12
|
Mikulska M, Penack O, Wendel L, Knelange N, Cornelissen JJ, Blijlevens N, Passweg J, Kroger N, Bruns A, Koenecke C, Bierings M, Piñana JL, Labussiere-Wallet H, Ghesquieres H, Diaz MA, Sampol A, Averbuch D, de la Camara R, Styczynski J. HEV infection in stem cell transplant recipients-retrospective study of EBMT Infectious Diseases Working Party. Bone Marrow Transplant 2021; 57:167-175. [PMID: 34689177 DOI: 10.1038/s41409-021-01497-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/24/2021] [Accepted: 09/30/2021] [Indexed: 01/10/2023]
Abstract
HEV infection is an emerging cause of acute and chronic hepatitis in stem cell transplant (SCT) recipients. We performed a retrospective observational study among EBMT centers with the aim of describing characteristics, management and outcome of HEV after SCT. There were 34 cases of HEV infection from 12 centers in 6 countries, diagnosed in median 4.5 months after SCT; 20 of acute and 14 of chronic infection. Non-hepatic findings possibly associated with HEV infection were present in 9 (26%). Patients with chronic infection had more characteristics associated with severely immunocompromised status. Ribavirin was provided to 16 patients (47%; 40% with acute and 57% with chronic infection), in median for 75 days. Three (19%) patients discontinued it due to side effects. HEV-RNA clearance occurred in 29 patients (85%; 85% in acute and 86% in chronic infection). HEV was considered a cause of death in 3 (9%), with 2 cases with late diagnosis. Reduction of immunosuppression in those receiving it, and ribavirin treatment in those with chronic infection were associated with shorter time to HEV-RNA clearance. Policy on HEV testing varied between the centers. In conclusion, acute and chronic HEV hepatitis should be promptly diagnosed and managed in SCT recipients.
Collapse
Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, University of Genoa (DISSAL) and IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | - Olaf Penack
- Department of Department of Hematology, Oncology and Tumorimmunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lotus Wendel
- EBMT Data Office, Dept. Medical Statistics & Bioinformatics, Leiden, The Netherlands
| | - Nina Knelange
- EBMT Data Office, Dept. Medical Statistics & Bioinformatics, Leiden, The Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | | | - Nicolaus Kroger
- Department of Stem cell Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Anke Bruns
- Department of Hematology, University Medical Centre, Utrecht, Netherlands
| | - Christian Koenecke
- Hannover Medical School, Department of Haematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover, Germany
| | - Marc Bierings
- Princess Maxima Center/University Hospital for Children (WKZ) Stem cell transplantation, Utrecht, Netherlands
| | - José Luis Piñana
- Hospital Clínico Universatario of Valencia, INCLIVA foundation, Valencia, Spain
| | | | - Herve Ghesquieres
- Department Haematology, Hospices Civils de Lyon, Pierre Benite, France
| | | | | | - Diana Averbuch
- Pediatric Infectious Diseases, Faculty of Medicine, Hebrew University of Jerusalem; Hadassah Medical Center, Jerusalem, Israel
| | | | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| |
Collapse
|
13
|
Boonyai A, Thongput A, Sisaeng T, Phumchan P, Horthongkham N, Kantakamalakul W, Chaimayo C. Prevalence and clinical correlation of hepatitis E virus antibody in the patients' serum samples from a tertiary care hospital in Thailand during 2015-2018. Virol J 2021; 18:145. [PMID: 34247642 PMCID: PMC8273939 DOI: 10.1186/s12985-021-01616-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 07/02/2021] [Indexed: 02/02/2023] Open
Abstract
Background Prevalence and incidence of hepatitis caused by HEV infection are usually higher in developing countries. This study demonstrated the HEV seroprevalence and incidence of HEV infection in patients with clinical hepatitis in a tertiary hospital in Thailand. Methods A laboratory-based cross-sectional study was conducted using 1106 serum samples from patients suspected of HEV infection sent to the Serology laboratory, Siriraj Hospital, for detecting HEV antibodies during 2015–2018. Prevalence of anti-HEV IgG and IgM antibodies in general patients, including organ transplant recipients and pregnant women in a hospital setting, were determined using indirect enzyme-linked immunosorbent assay (ELISA) kits. Comparison of laboratory data between groups with different HEV serological statuses was performed. Results HEV IgG antibodies were detected in 40.82% of 904 serum samples, while HEV IgM antibodies were detected in 11.75% of 1081 serum samples. Similar IgG and IgM antibody detection rates were found in pregnant women. Interestingly, anti-HEV IgM antibodies were detected in 38.5% of patients who underwent organ transplantation. Patients who tested positive for anti-HEV IgM antibodies had higher alanine aminotransferase levels than those who had not. In contrast, patients who tested positive for anti-HEV IgG had more elevated levels of total bilirubin than those who tested negative. Conclusions HEV seroprevalence and incidence in patients with clinical hepatitis were relatively high in the Thai population, including the pregnancy and organ transplant subgroups. The results potentially benefit the clinicians in decision-making to investigate HEV antibodies and facilitating proper management for patients.
Collapse
Affiliation(s)
- Atiporn Boonyai
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anchalee Thongput
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thidarat Sisaeng
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Parisut Phumchan
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Navin Horthongkham
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wannee Kantakamalakul
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chutikarn Chaimayo
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
14
|
Capozza P, Decaro N, Beikpour F, Buonavoglia C, Martella V. Emerging Hepatotropic Viruses in Cats: A Brief Review. Viruses 2021; 13:v13061162. [PMID: 34204394 PMCID: PMC8233973 DOI: 10.3390/v13061162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/19/2022] Open
Abstract
The possible role of viruses in feline liver disease has long remained neglected. However, in 2018, an analogue of human hepatitis B virus was identified in cats. Moreover, antibodies for human hepatitis E have been detected consistently at various prevalence rates in cats. Although the correlation between these viruses and the liver injury in cats must be clarified, hepatotropic viruses might represent an increasing risk for feline and public health.
Collapse
|
15
|
Fagan O, Armstrong P, Merwe KVD, Crosnoi D, Steele C, Sopena-Falco J, Parihar V. Viral hepatitis: A brief introduction, review of management, advances and challenges. World J Meta-Anal 2021; 9:139-152. [DOI: 10.13105/wjma.v9.i2.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/26/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
Viral hepatitis represents a major public health hazard and is associated with significant global mortality. Over the last decade, there have been significant developments in the prevention and treatment of viral hepatitis. These changes have led to a situation whereby global elimination has become a realistic goal, fully endorsed by the World Health Organization (WHO). By 2030, the WHO aims to reduce viral hepatitis mortality by 65% and reduce new infections by 90% by 2030. These are ambitious targets and will only be met through a sustained programme. This will require expertise from hepatologists and virologists and the fields of public health and primary care. In this article, we review the causes of viral hepatitis, its management through prevention and treatments, and the most pressing challenges and recent advances.
Collapse
Affiliation(s)
- Olga Fagan
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Paul Armstrong
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Kevin Van Der Merwe
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Daniela Crosnoi
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Chris Steele
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Julia Sopena-Falco
- Department of Gastroenterology, Saint Vincent’s University Hospital, Dublin 04, Ireland
| | - Vikrant Parihar
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| |
Collapse
|
16
|
Identification of the interferon-inducible GTPase GBP1 as major restriction factor for the Hepatitis E virus. J Virol 2021; 95:JVI.01564-20. [PMID: 33472929 PMCID: PMC8092694 DOI: 10.1128/jvi.01564-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This study aims to gain deeper insight into HEV-induced innate immunity by characterizing the crosstalk between the virus and the host factor guanylate-binding protein 1 (GBP1). We observe that the amount of GBP1 is elevated upon infection, although number of transcripts is decreased, which is explained by a prolonged protein half-life. Modulation of GBP1 levels via overexpression significantly inhibits the viral life cycle. Use of various GBP-1 mutants revealed that the antiviral effect of GBP-1 on HEV is independent from the GTPase-activity, but depends on the capacity of GBP-1 to form GBP1 homodimers. This connects GBP-1 to the autophagosomal pathway. Indeed, dimerization competent GBP1 targets the viral capsid protein to the lysosomal compartment leading to inactivation of the viral particle. Most importantly, silencing of GBP1 abolishes the antiviral effect of IFNγ on HEV. In IFNγ treated cells the virus is targeted to lysosomal structures and destroyed therein. This process depends in part on GBP1. These observations about the relevance of GBP1 for type II interferon-mediated innate immunity against HEV could be a base for tailoring novel antivirals and improvement of disease management.IMPORTANCE Although HEV represents a worldwide public health problem with 20 million infections and 44.000 death cases per year, there are still no specific antivirals available and many aspects of the viral life cycle are not well understood. Here we identify the guanylate binding protein 1 (GBP1) as a restriction factor affecting life cycle of HEV. Surprisingly, the antiviral effect of GBP1 does not depend on its GTPase function, but on its capacity to homodimerize. We revealed that GBP1 exerts its antiviral activity by targeting HEV to the lysosomal compartment where the virus is inactivated. Most importantly, we observed that the antiviral effect of interferon-γ on HEV strongly depends on GBP1. Our observation that GBP1 impairs HEV and is crucial for the antiviral effect of interferons on HEV extends understanding of host defense-mechanisms. As the interferon-system represents a universal defense-mechanism, our study could help to design novel antivirals targeting.
Collapse
|
17
|
Zhao MY, Li D. Optimization and Implementation of the Virus Extraction Method for Hepatitis E Virus Detection from Raw Pork Liver. FOOD AND ENVIRONMENTAL VIROLOGY 2021; 13:74-83. [PMID: 33449335 DOI: 10.1007/s12560-020-09452-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/19/2020] [Indexed: 06/12/2023]
Abstract
Hepatitis E virus (HEV) has been frequently detected from pork liver and liver products, which can usually cause self-limiting diseases in healthy adults, yet may result in fatality in immunosuppressed groups. Nevertheless, there is so far no standardized method for HEV detection available from pork liver and/or liver products. The present study aimed to optimize the virus extraction method of HEV from raw pork liver, which is often consumed in Asia undercooked to avoid a grainy texture. By comparing different sample preparation protocols and by applying the selected protocol to 60 samples collected from Singapore retail markets, we demonstrated that homogenization of 0.25 g raw pork liver with FastPrep™ Lysing Matrix Y containing yttria-stabilized zircondium oxide beads in 2 ml tubes and with harsh mechanical force at 6 ms-1, 40 s/cycle, for 5 cycles with 300 s pause time after each cycle is promising in both releasing the potentially intracellular viruses and resulting in satisfactory virus recovery rates (> 1%). A high prevalence (52%) of HEV genome was detected by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) from the 60 samples collected from Singapore retail markets imported from Indonesia, Australia and Malaysia. However, RNase treatment decreased the HEV prevalence to 33.3%, and all of the 20 positive samples were with high RT-qPCR Ct values above 35, suggesting that the positive RT-qPCR signals maybe largely due to the inactive viruses and/or exposed HEV RNA traces in raw pork liver products. Therefore, conscious care should be taken when interpreting molecular detection results of viruses from food samples to be correlated with public health risks.
Collapse
Affiliation(s)
- Mitchie Y Zhao
- Department of Food Science and Technology, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Dan Li
- Department of Food Science and Technology, Faculty of Science, National University of Singapore, Singapore, Singapore.
| |
Collapse
|
18
|
Glitscher M, Martín DH, Woytinek K, Schmidt B, Tabari D, Scholl C, Stingl JC, Seelow E, Choi M, Hildt E. Targeting Cholesterol Metabolism as Efficient Antiviral Strategy Against the Hepatitis E Virus. Cell Mol Gastroenterol Hepatol 2021; 12:159-180. [PMID: 33601063 PMCID: PMC8099564 DOI: 10.1016/j.jcmgh.2021.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The Hepatitis E virus hijacks the endosomal system for its release. These structures are highly dependent on cholesterol. Hence, this study investigates the impact of HEV on cholesterol-metabolism, the effect of intracellular cholesterol content on HEV-release and the potential of cholesterol-modulators to serve as antivirals. METHODS Intracellular cholesterol-content of cells was modulated and impacts on HEV were monitored using qPCR, Western blot, microscopy, virus-titration and density-gradient centrifugation. Blood-lipids and HEV-RNA were routinely quantified in chronically infected patients during follow-up visits. RESULTS In HEV-infected cells, decreased levels of cholesterol are found. In patients, HEV infection decreases serum-lipid concentrations. Importantly, statin treatment herein increases viral titers. Similarly, reduction of intracellular cholesterol via simvastatin treatment increases viral release in vitro. On the contrary, elevating intracellular cholesterol via LDL or 25-hydroxycholesterol strongly reduces viral release due to enhanced lysosomal degradation of HEV. Drug-induced elevation of intracellular cholesterol via fenofibrate or PSC833 impairs HEV release via the same mechanism. CONCLUSIONS This study analyses the crosstalk between HEV and intracellular cholesterol. The results highlight the importance of an intact cholesterol homeostasis for HEV-release and thereby identify a potential target for antiviral strategies. Especially fenofibrate is considered a promising novel antiviral against HEV. Beyond this, the study may help clinicians evaluating co-treatments of HEV-infected patients with statins, as this may be counter indicated.
Collapse
Affiliation(s)
| | | | | | | | - Denna Tabari
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Catharina Scholl
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Julia C. Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Evelyn Seelow
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Hildt
- Department Virology, Paul-Ehrlich-Institut, Langen, Germany,Correspondence Address requests for correspondence to Eberhard Hildt, Department Virology, Paul-Ehrlich-Institut, Paul-Ehrlich-Strasse 51-59, D-63225 Langen, Germany. fax: +49610377772140.
| |
Collapse
|
19
|
Thakur V, Ratho RK, Kumar S, Saxena SK, Bora I, Thakur P. Viral Hepatitis E and Chronicity: A Growing Public Health Concern. Front Microbiol 2020; 11:577339. [PMID: 33133046 PMCID: PMC7550462 DOI: 10.3389/fmicb.2020.577339] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/03/2020] [Indexed: 12/15/2022] Open
Abstract
Hepatitis E viral infection recently emerges as a global health concern. Over the last decade, the understanding of hepatitis E virus (HEV) had changed with the discovery of new genotypes like genotype-7 and genotype-8 with associated host and mode of infection. Diversification in the mode of hepatitis E infection transmission through blood transfusion, and organ transplants in contrast to classical feco-oral and zoonotic mode is the recent medical concern. The wide spectrum of infection ranging from self-limiting to acute liver failure is now overpowered by HEV genotype-specific chronic infection especially in transplant patients. This concern is further escalated by the extra-hepatic manifestations of HEV targeting the central nervous system (CNS), kidney, heart, and pancreas. However, with the development of advanced efficient cell culture systems and animal models simulating the infection, much clarity toward understanding the pathogenetic mechanism of HEV has been developed. Also this facilitates the development of vaccines research or therapeutics. In this review, we highlight all the novel findings in every aspect of HEV with special emphasis on recently emerging chronic mode of infection with specific diagnosis and treatment regime with an optimistic hope to help virologists and/or liver specialists working in the field of viral hepatitis.
Collapse
Affiliation(s)
- Vikram Thakur
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Kanta Ratho
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Swatantra Kumar
- Centre for Advanced Research, Faculty of Medicine, King George's Medical University, Lucknow, India
| | - Shailendra K Saxena
- Centre for Advanced Research, Faculty of Medicine, King George's Medical University, Lucknow, India
| | - Ishani Bora
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pryanka Thakur
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
20
|
Akyüz F, Çavuş B, Pınarbaşı B, Bozacı M, Baran B, Akyuz U, Uyanıkoglu A, Demir K, Beşışık F, Özdil S, Boztaş G, Mungan Z, Badur S, Yenen S, Kaymakoglu S. Cryptogenic liver cirrhosis and hepatitis E virus (HEV): Are they related? Ann Hepatol 2020; 18:585-589. [PMID: 31130469 DOI: 10.1016/j.aohep.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 01/25/2019] [Accepted: 01/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Hepatitis E virus (HEV) is one of the most common causes of acute hepatitis. In recent years, its role in the development of chronic hepatitis and cirrhosis especially in immunosuppressed patients and its wide range of extrahepatic involvement have increased the amount of research on HEV. In this study we aimed to investigate the presence of HEV infection in individuals with cryptogenic cirrhosis. MATERIALS AND METHODS HEV antibodies were analysed using the Anti HEV enzyme-linked immunosorbent assay (ELISA) kit (anti-HEV ELISA; Diapro Prodiagnostic Bioprobes, Milan, Italy). HEV RNA was isolated with using QIAMP Viral RNA mini kit (QIAGEN, Hilden, Germany). The HEV RNA titre was detected with the Rotor Gene 3000 real time polymerase chain reaction (PCR) system using GenoSen's HEV (Rotor Gene) Quantitative Real Time PCR Kit (Genome Diagnostics Private Limited, the Netherlands). RESULTS Our study included 21 healthy volunteers (12 males) and 35 cryptogenic cirrhosis patients (19 males). The ages of the patients and the controls were similar (46±12.1 vs. 37.5±9.7years). The mean Child-Pugh score was 8±2.5. The anti HEV immunoglobulin G(IgG) positivity rate was 9.5% and 25.7% in the control and patient groups respectively (p>0.05). HEV RNA positivity was not detected in the control group, but 3 cases (8.6%) in the patient group were positive (p>0.05). The HEV RNA, aspartate aminotransferase (AST) and alanine aminotransferase(ALT) levels for these 3 cases were 326.461copies/mL, 91IU/L and 67IU/L; 480copies/mL, 68IU/L and 36IU/L and 72copies/mL, 42IU/L and 24IU/L respectively. There were positive correlations between HEV RNA levels and AST and ALT levels (p<0.05). CONCLUSIONS Anti HEVIgG and HEV RNA positivity rates are high in cryptogenic cirrhosis although it is not statistically significant and there is a positive correlation between HEV RNA and aminotransferases.
Collapse
Affiliation(s)
- Filiz Akyüz
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.
| | - Bilger Çavuş
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Binnur Pınarbaşı
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Mürvet Bozacı
- Department of Virology and Microbiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Bülent Baran
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Umit Akyuz
- Department of Internal Medicine, Division of Gastroenterohepatology SağlıkBilimleri University, Fatih Sultan Mehmet Educational and Research Center, Istanbul, Turkey
| | - Ahmet Uyanıkoglu
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Kadir Demir
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Fatih Beşışık
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sadakat Özdil
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Güngör Boztaş
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Zeynel Mungan
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Selim Badur
- Department of Virology and Microbiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sadi Yenen
- Department of Virology and Microbiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sabahattin Kaymakoglu
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| |
Collapse
|
21
|
Tavakoli A, Alavian SM, Moghoofei M, Mostafaei S, Abbasi S, Farahmand M. Seroepidemiology of hepatitis E virus infection in patients undergoing maintenance hemodialysis: Systematic review and meta-analysis. Ther Apher Dial 2020; 25:4-15. [PMID: 32348032 DOI: 10.1111/1744-9987.13507] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/28/2020] [Accepted: 04/24/2020] [Indexed: 12/23/2022]
Abstract
Patients undergoing regular hemodialysis (HD) are at an extreme risk of acquiring bloodstream infections compared to the general population. Hepatitis E virus (HEV) infection is an important emerging health issue in these patients. To date, numerous studies have investigated the seroprevalence of HEV among HD patients across the world; however, the data are conflicting. The present study aimed to measure the exposure rate of HD patients to HEV infection by estimating the overall seroprevalence of HEV in this high-risk group. A systematic literature search was carried out using five electronic databases from inception to January 10, 2020, with standard keywords. Pooled seroprevalence estimates with 95% confidence intervals (CIs) were calculated using a random intercept logistic regression model. The seroprevalence of HEV increased from 6.6% between the years of 1994 and 2000 to 11.13% from 2016 to 2020. Blood transfusion was associated with a nearly 2-fold increase in the rate of HEV seropositivity (OR = 1.99; 95% CI: 1.50-2.63, P < .0001, I2 = 6.5%). HEV seroprevalence among patients with HD for more than 60 months was significantly higher than those with HD for less than 60 months (27.69%, 95% CI: 20.69%-35.99% vs 15.78%, 95%CI: 8.85%-26.57%, respectively) (P = .06). Our results indicated increased exposure of HD patients with HEV infection over the last decade. We concluded that blood transfusion and duration of HD are considerable risk factors for acquiring HEV infection among HD patients.
Collapse
Affiliation(s)
- Ahmad Tavakoli
- Department of Medical Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases (BRCGL), Baqiyatallah University of Medical Sciences, Tehran, Iran.,Middle East Liver Disease (MELD) Center, Tehran, Iran
| | - Mohsen Moghoofei
- Department of Microbiology, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Medical Biology Research Center, Institute of Health and Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shayan Mostafaei
- Medical Biology Research Center, Institute of Health and Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Epidemiology and Biostatistics Unit, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Abbasi
- Department of Medical Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Farahmand
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
22
|
Forgan-Smith KR, Macdonald G. Chronic hepatitis E infection in an immunosuppressed, solid organ transplant patient. Intern Med J 2020; 49:1335-1336. [PMID: 31602774 DOI: 10.1111/imj.14458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/06/2019] [Accepted: 03/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Kate R Forgan-Smith
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Graeme Macdonald
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, PA-Southside Clinical School, the University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
23
|
Janahi EM, Parkar SFD, Mustafa S, Eisa ZM. Implications of Hepatitis E Virus in Blood Transfusions, Hemodialysis, and Solid Organ Transplants. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E206. [PMID: 32344807 PMCID: PMC7279256 DOI: 10.3390/medicina56050206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 01/05/2023]
Abstract
Hepatitis E Virus (HEV) is emerging as the primary cause of acute viral hepatitis in humans. The virus is commonly transmitted by the fecal-oral route via contaminated water in endemic regions or through the consumption of inadequately cooked swine products or game meats in industrialized regions. HEV genotypes 1 and 2 are predominantly associated with waterborne transmission in developing countries, whereas HEV3 and HEV4 are mainly zoonotically transmitted in industrialized countries. Seroprevalence in populations determined by detecting anti-HEV antibodies and serum HEV RNA is commonly used to analyze the presence of HEV. Although HEV RNA-based detection is now standardized, there is a lack of agreement between the assaying methods used for gathering seroprevalence data. Since 2004, HEV has been considered as a transmissible infectious agent through blood transfusion. Recent seroprevalence studies in European countries indicate an underestimated risk for blood transfusion and hence warrant testing the blood supply. HEV infection is usually self-limiting and spontaneously cleared. However, in about 60% of recipients of solid organ transplants, HEV progresses to chronic hepatitis. Immunosuppressive drugs such as tacrolimus are a major cause of chronic hepatitis and reducing its dosage results in viral clearance in about 30% of patients. In hemodialysis patients, the parenteral route is implicated as an important mechanism of transmission. In this review, we explore the clinical and epidemiological characteristics of various HEV genotypes in blood donors, hemodialysis patients, and transplant recipients.
Collapse
Affiliation(s)
- Essam M. Janahi
- Department of Biology, College of Science, University of Bahrain, Sakhir 32038, Bahrain; (S.F.D.P.); (S.M.)
| | - Saba F. D. Parkar
- Department of Biology, College of Science, University of Bahrain, Sakhir 32038, Bahrain; (S.F.D.P.); (S.M.)
| | - Sakina Mustafa
- Department of Biology, College of Science, University of Bahrain, Sakhir 32038, Bahrain; (S.F.D.P.); (S.M.)
| | - Zaki M. Eisa
- The National Center for Disease Prevention and Control, Jazan 82722-2476, Saudi Arabia;
| |
Collapse
|
24
|
Hepatitis E Virus Infection in an Italian Cohort of Hematopoietic Stem Cell Transplantation Recipients: Seroprevalence and Infection. Biol Blood Marrow Transplant 2020; 26:1355-1362. [PMID: 32200124 DOI: 10.1016/j.bbmt.2020.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/15/2020] [Accepted: 03/10/2020] [Indexed: 01/05/2023]
Abstract
Chronic hepatitis E virus (HEV) infection in hematopoietic stem cell transplantation (HSCT) recipients is an emerging threat. The aim of this study was to provide data on the HEV burden in an Italian cohort of HSCT recipients and analyze risk factors for HEV seropositivity. This retrospective study reports data from 596 HSCT recipients compiled between 2010 and 2019. It included patients who underwent transplantation between 2010 and 2015 for whom pretransplantation (n = 419) and post-transplantation (n = 161) serum samples were available and tested retrospectively, as well as patients in whom prospective HEV testing was performed during the standard care: pre-HSCT IgG screening in 144, pre-HSCT HEV-RNA screening in addition to IgG screening in 60, and HEV-RNA testing in case of clinical suspicion of HEV infection in 59 (26 of whom were also included in the IgG screening cohorts). The rate of pre-HSCT HEV-IgG positivity was 6.0% (34 of 563). Older age was an independent risk factor for seropositivity (P = .039). None of the 34 HEV-IgG-positive patients had detectable HEV-RNA. One case of transient HEV-RNA positivity pre-HSCT was identified through screening. Two patients were diagnosed with chronic HEV hepatitis, and 1 patient was successfully treated with ribavirin. The burden of HEV infection in HSCT recipients in Italy is limited, and pre-HSCT screening appears to be of no benefit. Timely diagnosis of HEV infection with HEV-RNA is mandatory in cases of clinical suspicion.
Collapse
|
25
|
Rawla P, Raj JP, Kannemkuzhiyil AJ, Aluru JS, Thandra KC, Gajendran M. A Systematic Review of the Extra-Hepatic Manifestations of Hepatitis E Virus Infection. Med Sci (Basel) 2020; 8:E9. [PMID: 32033102 PMCID: PMC7151617 DOI: 10.3390/medsci8010009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 02/06/2023] Open
Abstract
Hepatitis E virus (HEV) is a non-enveloped, positive-sense, single-stranded RNA icosahedral virus belongs to the genus Orthohepevirus within the Hepeviridae family. HEV infection can be asymptomatic, or it can cause icteric or fulminant hepatitis. Off late, there have been a number of publications reporting the extra-hepatic manifestations of HEV infection, and this systematic review is aimed at summarizing the available evidence in this regard. Two independent investigators searched PubMed, PubMed Central and Embase databases using the search string "(((hepatitis E) AND (Extrahepatic OR Extra-Hepatic))) OR ((Hepatitis E) AND (Neurology OR Cardiology OR Respiratory OR Lung OR Gastrointestinal OR musculoskeletal OR immunology OR pulmonary)) Filters: Abstract availability, English language, and Human studies". The extra-hepatic manifestations reported in each of the selected articles were classified and reported as neurological, cardiovascular, and hematological and miscellaneous manifestations. The total number of various manifestations reported in our study were n = 324. These include neurological manifestations (n = 178/324 (54.94%)), cardiovascular and hematological manifestations (n = 113/324 (34.88%)), gastro-intestinal/pancreaticobiliary manifestations (n = 24/324 (7.41%)) and other rarer manifestations involving systems such as renal (n = 4/324; 1.24%), endocrine (n = 1/324; 0.31%), dermatology (n = 1/324; 0.31%), respiratory (n = 1/324; 0.31%), muscular (n = 1/324; 0.31%) and immune system (n = 1/324; 0.31%). Thus, HEV can have extra-hepatic manifestations affecting any system of the human body. Further research is needed to elucidate the underlying pathophysiological manifestations of these extra-hepatic manifestations and to prove causal association with HEV.
Collapse
Affiliation(s)
- Prashanth Rawla
- Department of Medicine, Sovah Health, Martinsville, VA 24112, USA
| | - Jeffrey Pradeep Raj
- Department of Clinical Pharmacology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai 400012, India;
| | - Alan Jose Kannemkuzhiyil
- St. Johns Medical College, St. John’s National Academy of Health Sciences, Bengaluru, Karnataka 560034, India;
| | - John Sukumar Aluru
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02212, USA;
| | - Krishna Chaitanya Thandra
- Department of Pulmonary and Critical Care Medicine, Sentara Virginia Beach General Hospital, Virginia Beach, VA 23454, USA;
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA;
| |
Collapse
|
26
|
De Sabato L, Ianiro G, Monini M, De Lucia A, Ostanello F, Di Bartolo I. Detection of hepatitis E virus RNA in rats caught in pig farms from Northern Italy. Zoonoses Public Health 2019; 67:62-69. [PMID: 31592576 DOI: 10.1111/zph.12655] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/09/2019] [Accepted: 09/17/2019] [Indexed: 02/06/2023]
Abstract
Hepatitis E virus (HEV) strains belonging to the Orthohepevirus genus are divided into four species (A-D). HEV strains included in the Orthohepevirus A species infect humans and several other mammals. Among them, the HEV-3 and HEV-4 genotypes are zoonotic and infect both humans and animals, of which, pigs and wild boar are the main reservoirs. Viruses belonging to the Orthohepevirus C species (HEV-C) have been considered to infect rats of different species and carnivores. Recently, two studies reported the detection of HEV-C1 (rat HEV) RNA in immunocompromised and immunocompetent patients, suggesting a possible transmission of rat HEV to humans. The role of rats and mice as reservoir of HEV and the potential zoonotic transmission is still poorly known and deserves further investigation. To this purpose, in this study, the presence of HEV RNA was investigated in the intestinal contents and liver samples from 47 Black rats (Rattus rattus) and 21 House mice (Mus musculus) captured in four pig farms in Northern Italy. The presence of both Orthohepevirus A and C was investigated by the real-rime RT-PCR specific for HEV-1 to HEV-4 genotypes of Orthohepevirus A species and by a broad spectrum hemi-nested RT-PCR capable of detecting different HEV species including rat HEV. The intestinal content from two Black rats resulted positive for HEV-C1 RNA and for HEV-3 RNA, respectively. None of the House mice was HEV RNA positive. Sequence analyses confirmed the detection of HEV-C1, genotype G1 and HEV-3 subtype e. The viral strain HEV-3e detected in the rat was identical to swine HEV strains detected in the same farm. Liver samples were negative for the detection of either rat HEV or HEV-3.
Collapse
Affiliation(s)
- Luca De Sabato
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore di Sanità, Rome, Italy
| | - Giovanni Ianiro
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore di Sanità, Rome, Italy
| | - Marina Monini
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore di Sanità, Rome, Italy
| | - Alessia De Lucia
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Fabio Ostanello
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Ilaria Di Bartolo
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore di Sanità, Rome, Italy
| |
Collapse
|
27
|
Walker CM. Adaptive Immune Responses in Hepatitis A Virus and Hepatitis E Virus Infections. Cold Spring Harb Perspect Med 2019; 9:cshperspect.a033472. [PMID: 29844218 DOI: 10.1101/cshperspect.a033472] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Both hepatitis A virus (HAV) and hepatitis E virus (HEV) cause self-limited infections in humans that are preventable by vaccination. Progress in characterizing adaptive immune responses against these enteric hepatitis viruses, and how they contribute to resolution of infection or liver injury, has therefore remained largely frozen for the past two decades. How HAV and HEV infections are so effectively controlled by B- and T-cell immunity, and why they do not have the same propensity to persist as HBV and HCV infections, cannot yet be adequately explained. The objective of this review is to summarize our understanding of the relationship between patterns of virus replication, adaptive immune responses, and acute liver injury in HAV and HEV infections. Gaps in knowledge, and recent studies that challenge long-held concepts of how antibodies and T cells contribute to control and pathogenesis of HAV and HEV infections, are highlighted.
Collapse
Affiliation(s)
- Christopher M Walker
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children's, Columbus, Ohio 43004
| |
Collapse
|
28
|
Salines M, Rose N, Andraud M. Tackling hepatitis E virus spread and persistence on farrow-to-finish pig farms: Insights from a stochastic individual-based multi-pathogen model. Epidemics 2019; 30:100369. [PMID: 31526684 DOI: 10.1016/j.epidem.2019.100369] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 01/01/2023] Open
Abstract
Hepatitis E virus (HEV) is a zoonotic agent of which domestic pigs have been recognised as the main reservoir in industrialised countries. The great variability in HEV infection dynamics described on different pig farms may be related to the influence of other pathogens, and in particular viruses affecting pigs' immune response. The objective of this study was to develop a multi-pathogen modelling approach to understand the conditions under which HEV spreads and persists on a farrow-to-finish pig farm taking into account the fact that pigs may be co-infected with an intercurrent pathogen. A stochastic individual-based model was therefore designed that combines a population dynamics model, which enables us to take different batch rearing systems into account, with a multi-pathogen model representing at the same time the dynamics of both HEV and the intercurrent pathogen. Based on experimental and field data, the epidemiological parameters of the HEV model varied according to the pig's immunomodulating virus status. HEV spread and persistence was found to be very difficult to control on a farm with a 20-batch rearing system. Housing sows in smaller groups and eradicating immunomodulating pathogens would dramatically reduce the prevalence of HEV-positive livers at slaughter, which would drop from 3.3% to 1% and 0.2% respectively (p-value < 0.01). It would also decrease the probability of HEV on-farm persistence from 0.6 to 0 and 0.34 respectively (p-value < 0.01) on farms with a 7 batch rearing system. A number of farming practices, such as limiting cross-fostering, reducing the size of weaning pens and vaccinating pigs against immunomodulating viruses, were also shown to be pivotal factors for decreasing HEV spread and persistence.
Collapse
Affiliation(s)
- Morgane Salines
- ANSES, Ploufragan-Plouzané-Niort Laboratory, Epidemiology, Health and Welfare research unit, Ploufragan, France; Bretagne-Loire University, Rennes, France.
| | - Nicolas Rose
- ANSES, Ploufragan-Plouzané-Niort Laboratory, Epidemiology, Health and Welfare research unit, Ploufragan, France; Bretagne-Loire University, Rennes, France.
| | - Mathieu Andraud
- ANSES, Ploufragan-Plouzané-Niort Laboratory, Epidemiology, Health and Welfare research unit, Ploufragan, France; Bretagne-Loire University, Rennes, France.
| |
Collapse
|
29
|
Li TC, Wakita T. Small Animal Models of Hepatitis E Virus Infection. Cold Spring Harb Perspect Med 2019; 9:cshperspect.a032581. [PMID: 29735581 DOI: 10.1101/cshperspect.a032581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Novel hepeviruses have been recovered from many different animal species in recent years, increasing the diversity known to exist among the Hepeviridae, which now include two genera, Piscihepevirus and Orthohepevirus Multiple viral genotypes in the Orthohepevirus A species are able to replicate and cause acute hepatitis E in humans, and thus represent an important public health problem in industrialized as well as developing countries. Although hepatitis E virus (HEV) infections typically result in acute and self-limited hepatitis, immunocompromised and transplant patients are vulnerable to prolonged infections and to chronic hepatitis. Cell culture systems have been established for several HEV strains and offer new opportunities for the study of HEV biology. Similarly, a variety of new small animal models have been developed, using either nonhuman hepeviruses in their cognate hosts as surrogates for human HEV, or human HEV infection of immunodeficient mice with chimeric livers engrafted with human hepatocytes. These new models provide several advantages over previous nonhuman primate models of hepatitis E infection and will facilitate studies of pathogenicity, cross-species infection, mechanisms of virus replication, and vaccine and antiviral agent development. This article reviews the current understanding of small animal models for HEV.
Collapse
Affiliation(s)
- Tian-Cheng Li
- Department of Virology II, National Institute of Infectious Diseases, Tokyo 208-0011, Japan
| | - Takaji Wakita
- Department of Virology II, National Institute of Infectious Diseases, Tokyo 208-0011, Japan
| |
Collapse
|
30
|
Transfusion-Transmitted Hepatitis E Virus Infection in France. Transfus Med Rev 2019; 33:146-153. [DOI: 10.1016/j.tmrv.2019.06.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/27/2019] [Accepted: 06/04/2019] [Indexed: 12/14/2022]
|
31
|
Monitoring of pork liver and meat products on the Dutch market for the presence of HEV RNA. Int J Food Microbiol 2019; 296:58-64. [DOI: 10.1016/j.ijfoodmicro.2019.02.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/12/2019] [Accepted: 02/25/2019] [Indexed: 01/05/2023]
|
32
|
Rasche A, Sander AL, Corman VM, Drexler JF. Evolutionary biology of human hepatitis viruses. J Hepatol 2019; 70:501-520. [PMID: 30472320 PMCID: PMC7114834 DOI: 10.1016/j.jhep.2018.11.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/09/2018] [Accepted: 11/10/2018] [Indexed: 02/06/2023]
Abstract
Hepatitis viruses are major threats to human health. During the last decade, highly diverse viruses related to human hepatitis viruses were found in animals other than primates. Herein, we describe both surprising conservation and striking differences of the unique biological properties and infection patterns of human hepatitis viruses and their animal homologues, including transmission routes, liver tropism, oncogenesis, chronicity, pathogenesis and envelopment. We discuss the potential for translation of newly discovered hepatitis viruses into preclinical animal models for drug testing, studies on pathogenesis and vaccine development. Finally, we re-evaluate the evolutionary origins of human hepatitis viruses and discuss the past and present zoonotic potential of their animal homologues.
Collapse
Affiliation(s)
- Andrea Rasche
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, 10117 Berlin, Germany,German Center for Infection Research (DZIF), Germany
| | - Anna-Lena Sander
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, 10117 Berlin, Germany
| | - Victor Max Corman
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, 10117 Berlin, Germany,German Center for Infection Research (DZIF), Germany
| | - Jan Felix Drexler
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, 10117 Berlin, Germany; German Center for Infection Research (DZIF), Germany.
| |
Collapse
|
33
|
Abstract
Hepatitis E virus (HEV) possesses many of the features of other positive-stranded RNA viruses but also adds HEV-specific nuances, making its virus-host interactions unique. Slow virus replication kinetics and fastidious growth conditions, coupled with the historical lack of an efficient cell culture system to propagate the virus, have left many gaps in our understanding of its structure and replication cycle. Recent advances in culturing selected strains of HEV and resolving the 3D structure of the viral capsid are filling in knowledge gaps, but HEV remains an extremely understudied pathogen. Many steps in the HEV life cycle and many aspects of HEV pathogenesis remain unknown, such as the host and viral factors that determine cross-species infection, the HEV-specific receptor(s) on host cells, what determines HEV chronicity and the ability to replicate in extrahepatic sites, and what regulates processing of the open reading frame 1 (ORF1) nonstructural polyprotein.
Collapse
Affiliation(s)
- Scott P Kenney
- Food Animal Health Research Program, The Ohio State University, Wooster, Ohio 44691
| | - Xiang-Jin Meng
- Department of Biomedical Sciences and Pathobiology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24061
| |
Collapse
|
34
|
Hepatitis E virus: reasons for emergence in humans. Curr Opin Virol 2018; 34:10-17. [PMID: 30497051 DOI: 10.1016/j.coviro.2018.11.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/08/2018] [Accepted: 11/13/2018] [Indexed: 12/11/2022]
Abstract
Hepatitis E virus (HEV) infects both humans and other animal species. Recently, we have seen a steady increase in autochthonous cases of human HEV infection in certain areas especially in Europe, and large outbreaks in several African countries among the displaced population. This mini-review critically analyzes potential host, environmental, and viral factors that may be associated with the emergence of hepatitis E in humans. The existence of numerous HEV reservoir animals such as pig, deer and rabbit results in human exposure to infected animals via direct contact or through animal meat consumption. Contamination of drinking, irrigation and coastal water by animal and human wastes lead to emergence of endemic cases in industrialized countries and outbreaks in displaced communities especially in war-torn countries.
Collapse
|
35
|
Yugo DM, Cossaboom CM, Heffron CL, Huang YW, Kenney SP, Woolums AR, Hurley DJ, Opriessnig T, Li L, Delwart E, Kanevsky I, Meng XJ. Evidence for an unknown agent antigenically related to the hepatitis E virus in dairy cows in the United States. J Med Virol 2018; 91:677-686. [PMID: 30318625 DOI: 10.1002/jmv.25339] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/11/2018] [Indexed: 01/31/2023]
Abstract
Genotypes 3 and 4 hepatitis E virus (HEV) strains within the species Orthohepevirus A in the family Hepeviridae are zoonotic. Recently, a genotype 4 HEV was reportedly detected in fecal samples of cows, although independent confirmation is lacking. In this study, we first tested serum samples from 983 cows in different regions in the United States for the presence of immunoglobulin G (IgG) anti-HEV and found that 20.4% of cows were seropositive. The highest seroprevalence rate (68.4%) was from a herd in Georgia. In an attempt to genetically identify HEV in cattle, a prospective study was conducted in a known seropositive dairy herd by monitoring 10 newborn calves from birth to 6 months of age for evidence of HEV infection. At least 3 of the 10 calves seroconverted to IgG anti-HEV, and importantly the antibodies presented neutralized genotype 3 human HEV, thus, indicating the specificity of IgG anti-HEV in the cattle. However, our extensive attempts to identify HEV-related sequences in cattle using broad-spectrum reverse transcription-polymerase chain reaction assays and MiSeq deep-sequencing technology failed. The results suggest the existence of an agent antigenically related to HEV in cattle, although, contrary to published reports, we showed that the IgG recognizing HEV in cattle was not caused by HEV infection.
Collapse
Affiliation(s)
- Danielle M Yugo
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Caitlin M Cossaboom
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Connie Lynn Heffron
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Yao-Wei Huang
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Scott P Kenney
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Amelia R Woolums
- Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Starkville, Mississippi
| | - David J Hurley
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, Georgia
| | - Tanja Opriessnig
- Division of Infection and Immunity, The Roslin Institute, University of Edinburgh, Midlothian, UK
| | - Linlin Li
- Department of Laboratory Medicine, Blood Systems Research Institute, San Francisco, California
| | - Eric Delwart
- Department of Laboratory Medicine, Blood Systems Research Institute, San Francisco, California
| | - Isis Kanevsky
- Department of Dairy Sciences, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Xiang-Jin Meng
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| |
Collapse
|
36
|
Abstract
Hepatitis E virus (HEV) is an important human pathogen that historically has been difficult to study. Limited levels of replication in vitro hindered our understanding of the viral life cycle. Sporadic and low-level virus shedding, lack of standardized detection methods, and subclinical infections made the development of animal models difficult. Better diagnostic techniques and understanding of the virus increased our ability to identify and characterize animal strains and animals that are amenable to model human-relevant infection. These advances are translating into the development of useful HEV animal models so that some of the greatest concerns associated with HEV infection, including host immunology, chronic infection, severe pregnancy mortality, and extrahepatic manifestations, can now be studied. Continued development of these animal models will be instrumental in understanding the many complex questions associated with HEV infection and for assessing therapeutics and prevention strategies to minimize HEV becoming a greater risk to the human population.
Collapse
Affiliation(s)
- Scott P Kenney
- Food Animal Health Research Program, College of Veterinary Medicine, Ohio State University, Wooster, Ohio 44691, USA;
| | - Xiang-Jin Meng
- Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24060, USA;
| |
Collapse
|
37
|
Soothill G, Hessey S, Erotocritou M, Griffiths P, Ijaz S, Thorburn D, Ankcorn M, Irish D. Diagnostic utility of hepatitis E virus antigen-specific ELISA versus PCR testing in a cohort of post liver transplant patients in a large university hospital. J Clin Virol 2018; 106:44-48. [DOI: 10.1016/j.jcv.2018.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/08/2018] [Accepted: 07/20/2018] [Indexed: 01/28/2023]
|
38
|
Prevalence, morbidity, and therapy of hepatitis E virus infection in pediatric renal allograft recipients. Pediatr Nephrol 2018; 33:1215-1225. [PMID: 29500631 DOI: 10.1007/s00467-018-3905-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hepatitis E virus (HEV) infection in immunocompromised patients such as solid organ transplant recipients may bear a high risk of becoming a chronic infection with progression to liver cirrhosis. So far, data on HEV infection in pediatric renal transplant recipients are limited. METHODS This single-center cohort study investigated period prevalence, morbidity, and treatment of HEV infection in 90 pediatric renal allograft recipients aged 9.9 ± 5.6 years at transplantation (58.9% males). HEV serology was determined by enzyme-linked immunosorbent assay and immunoblot, HEV replication by quantitative nucleic acid testing. RESULTS Twelve of 90 (13.3%) patients were HEV seropositive, and 4/90 (4.4%) recipients showed active HEV replication (103-108 copies/mL, corresponding to 0.5 × 103 and 0.5 × 108 WHO IU/mL) in serum and stool. In all patients with HEV replication, genotype 3 was identified by partial sequencing of HEV ORF1 and ORF2 and phylogenetic analysis. All patients with HEV replication developed chronic infection associated with moderately elevated liver enzymes. HEV replication was unresponsive to reduction of immunosuppression, whereas ribavirin monotherapy (mean dosage 9.7 ± 3.6 mg/kg per day over 85 ± 11 days) was associated with sustained viral clearance and normalization of liver enzymes in all patients. Ribavirin therapy was associated with reversible, hyporegenerative anemia. CONCLUSIONS Given an HEV seroprevalence of 13.3% in pediatric renal transplant recipients and an HEV viremia of 4.4%, HEV infection should be considered in patients with otherwise unexplained elevation of liver enzymes. HEV infection does not necessarily respond to reduction of immunosuppressive therapy, but can be effectively and safely treated with ribavirin.
Collapse
|
39
|
Aslam A, Susheela A, Iriana S, Chan SS, Lau D. Acute hepatitis E superinfection leading to chronic hepatitis B reactivation. BMJ Case Rep 2018; 2018:bcr-2017-223616. [PMID: 29891510 DOI: 10.1136/bcr-2017-223616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Reactivation of chronic hepatitis B (CHB) can be associated with significant morbidity and mortality. There are many different causes of hepatitis B reactivation. This case describes an Asian woman with stable CHB presenting with significant hepatitis flare with markedly elevated serum aminotransferases and hepatitis B virus DNA level. The clinical symptoms were subtle with fatigue and vague right upper quadrant tenderness. We ruled out drug-associated hepatotoxicity and screened for common causes of acute hepatitis. Interestingly, she was noted to have reactive anti-hepatitis E virus (HEV) IgM at initial presentation followed by anti-HEV IgG positivity a month later. The serological pattern confirmed the diagnosis of acute hepatitis E. The combination of antiviral therapy for hepatitis B and resolution of acute hepatitis E resulted in normalisation of serum aminotransferases. This case illustrates the importance of taking a careful history and having a high index of suspicion for various aetiologies when evaluating patients with reactivation of CHB.
Collapse
Affiliation(s)
- Aysha Aslam
- Liver Center, Division of Gastroenterology, Department of, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ammu Susheela
- Liver Center, Division of Gastroenterology, Department of, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sentia Iriana
- Liver Center, Division of Gastroenterology, Department of, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Suzanne S Chan
- Liver Center, Division of Gastroenterology, Department of, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daryl Lau
- Liver Center, Division of Gastroenterology, Department of, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
40
|
Glitscher M, Himmelsbach K, Woytinek K, Johne R, Reuter A, Spiric J, Schwaben L, Grünweller A, Hildt E. Inhibition of Hepatitis E Virus Spread by the Natural Compound Silvestrol. Viruses 2018; 10:E301. [PMID: 29865243 PMCID: PMC6024817 DOI: 10.3390/v10060301] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/18/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
Every year, there are about 20 Mio hepatitis E virus (HEV) infections and 60,000 deaths that are associated with HEV worldwide. At the present, there exists no specific therapy for HEV. The natural compound silvestrol has a potent antiviral effect against the (-)-strand RNA-virus Ebola virus, and also against the (+)-strand RNA viruses Corona-, Picorna-, and Zika virus. The inhibitory effect on virus spread is due to an inhibition of the DEAD-box RNA helicase eIF4A, which is required to unwind structured 5'-untranslated regions (UTRs). This leads to an impaired translation of viral RNA. The HEV (+)-strand RNA genome contains a 5'-capped, short 5'-UTR. This study aims to analyze the impact of silvestrol on the HEV life cycle. Persistently infected A549 cells were instrumental. This study identifies silvestrol as a potent inhibitor of the release of HEV infectious viral particles. This goes along with a strongly reduced HEV capsid protein translation, retention of viral RNA inside the cytoplasm, and without major cytotoxic effects. Interestingly, in parallel silvestrol affects the activity of the antiviral major vault protein (MVP) by translocation from the cytoplasm to the perinuclear membrane. These data further characterize the complex antiviral activity of silvestrol and show silvestrol's broad spectrum of function, since HEV is a virus without complex secondary structures in its genome, but it is still affected.
Collapse
Affiliation(s)
- Mirco Glitscher
- Department of Virology, Paul-Ehrlich-Institut, 63225 Langen, Germany.
| | | | - Kathrin Woytinek
- Department of Virology, Paul-Ehrlich-Institut, 63225 Langen, Germany.
| | - Reimar Johne
- Federal Institute for Risk Assessment, 10589 Berlin, Germany.
| | - Andreas Reuter
- Department of Allergology, Paul-Ehrlich-Institut, 63225 Langen, Germany.
| | - Jelena Spiric
- Department of Allergology, Paul-Ehrlich-Institut, 63225 Langen, Germany.
| | - Luisa Schwaben
- Department of Allergology, Paul-Ehrlich-Institut, 63225 Langen, Germany.
| | - Arnold Grünweller
- Institute of Pharmaceutical Chemistry, Philipps-Universität Marburg, 35037 Marburg, Germany.
| | - Eberhard Hildt
- Department of Virology, Paul-Ehrlich-Institut, 63225 Langen, Germany.
- German Center for Infection Research (DZIF), 38124 Braunschweig, Germany.
| |
Collapse
|
41
|
Zheng X, Yu L, Xu Q, Gu S, Tang L. Guillain-Barre syndrome caused by hepatitis E infection: case report and literature review. BMC Infect Dis 2018; 18:50. [PMID: 29357816 PMCID: PMC5778630 DOI: 10.1186/s12879-018-2959-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Hepatitis E infection is a global disorder that causes substantial morbidity. Numerous neurologic illnesses, including Guillain–Barre syndrome (GBS), have occurred in patients with hepatitis E virus (HEV) infection. Case presentation We report a 58 year-old non-immunocompromised man who presented with progressive muscle weakness in all extremities during an episode of acute HEV infection, which was confirmed by measuring the anti-HEV IgM antibodies in the serum. Both cerebrospinal fluid examination and electrophysiological study were in agreement with the diagnosis of HEV-associated GBS. Following the treatment with intravenous immunoglobulin, the patient’s neurological condition improved rapidly. Conclusions HEV infection should be strongly considered in patients with neurological symptoms, especially those with elevated levels of liver enzymes. Electronic supplementary material The online version of this article (10.1186/s12879-018-2959-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Xiaoqin Zheng
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Liang Yu
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Qiaomai Xu
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Silan Gu
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China
| | - Lingling Tang
- Zhejiang University First Affiliated Hospital State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang, China.
| |
Collapse
|
42
|
Guerra JADAA, Kampa KC, Morsoletto DGB, Junior AP, Ivantes CAP. Hepatitis E: A Literature Review. J Clin Transl Hepatol 2017; 5:376-383. [PMID: 29226104 PMCID: PMC5719195 DOI: 10.14218/jcth.2017.00012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/27/2017] [Accepted: 07/20/2017] [Indexed: 12/13/2022] Open
Abstract
Hepatitis E is the fifth known form of human viral hepatitis. Although not very common in our clinical practice, the incidence in Western countries is increasing. Infection with the hepatitis E virus (HEV) may be related to acute illness, liver failure, chronic hepatitis and cirrhosis. HEV itself is an RNA virus, with eight described genotypes (HEV 1-8), four of which more commonly affect humans and have, thus, been better studied. Besides liver manifestations, genotype 3 is also related to extra-hepatic manifestations, such as neurological, renal and rheumatological. Evolution to chronic disease occurs especially in patients who underwent transplantation, have hematological malignancies requiring chemotherapy, or have infection with the human immunodeficiency virus. The diagnosis may be difficult because of the low availability of tests and due to low sensibility and specificity. The acute form of illness does not have to be treated, but the chronic one does. We present here a literature review of hepatitis E and the relation between chronic hepatitis E and transplantation.
Collapse
Affiliation(s)
- Juliana Ayres de Alencar Arrais Guerra
- Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR, Brazil
- *Correspondence to: Juliana Ayres de Alencar Arrais Guerra, Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR 80810-040, Brazil. Tel: +55-41-3240-6060, E-mail:
| | - Katia Cristina Kampa
- Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR, Brazil
| | | | - Alcindo Pissaia Junior
- Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR, Brazil
| | | |
Collapse
|
43
|
Spahr C, Knauf-Witzens T, Vahlenkamp T, Ulrich RG, Johne R. Hepatitis E virus and related viruses in wild, domestic and zoo animals: A review. Zoonoses Public Health 2017; 65:11-29. [PMID: 28944602 DOI: 10.1111/zph.12405] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 01/15/2023]
Abstract
Hepatitis E is a human disease mainly characterized by acute liver illness, which is caused by infection with the hepatitis E virus (HEV). Large hepatitis E outbreaks have been described in developing countries; however, the disease is also increasingly recognized in industrialized countries. Mortality rates up to 25% have been described for pregnant women during outbreaks in developing countries. In addition, chronic disease courses could be observed in immunocompromised transplant patients. Whereas the HEV genotypes 1 and 2 are mainly confined to humans, genotypes 3 and 4 are also found in animals and can be zoonotically transmitted to humans. Domestic pig and wild boar represent the most important reservoirs for these genotypes. A distinct subtype of genotype 3 has been repeatedly detected in rabbits and a few human patients. Recently, HEV genotype 7 has been identified in dromedary camels and in an immunocompromised transplant patient. The reservoir animals get infected with HEV without showing any clinical symptoms. Besides these well-known animal reservoirs, HEV-specific antibodies and/or the genome of HEV or HEV-related viruses have also been detected in many other animal species, including primates, other mammals and birds. In particular, genotypes 3 and 4 infections are documented in many domestic, wildlife and zoo animal species. In most cases, the presence of HEV in these animals can be explained by spillover infections, but a risk of virus transmission through contact with humans cannot be excluded. This review gives a general overview on the transmission pathways of HEV to humans. It particularly focuses on reported serological and molecular evidence of infections in wild, domestic and zoo animals with HEV or HEV-related viruses. The role of these animals for transmission of HEV to humans and other animals is discussed.
Collapse
Affiliation(s)
- C Spahr
- Wilhelma Zoological-Botanical Gardens, Stuttgart, Germany.,Faculty of Veterinary Medicine, Institute of Virology, University of Leipzig, Leipzig, Germany
| | | | - T Vahlenkamp
- Faculty of Veterinary Medicine, Institute of Virology, University of Leipzig, Leipzig, Germany
| | - R G Ulrich
- Friedrich-Loeffler-Institut, Federal Research Institute for Animal Health, Institute of Novel and Emerging Infectious Diseases, Greifswald-Insel Riems, Germany.,German Center for Infection Research (DZIF), partner site Hamburg-Luebeck-Borstel-Insel Riems, Braunschweig, Germany
| | - R Johne
- Department Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| |
Collapse
|
44
|
Ricci A, Allende A, Bolton D, Chemaly M, Davies R, Fernandez Escamez PS, Herman L, Koutsoumanis K, Lindqvist R, Nørrung B, Robertson L, Ru G, Sanaa M, Simmons M, Skandamis P, Snary E, Speybroeck N, Ter Kuile B, Threlfall J, Wahlström H, Di Bartolo I, Johne R, Pavio N, Rutjes S, van der Poel W, Vasickova P, Hempen M, Messens W, Rizzi V, Latronico F, Girones R. Public health risks associated with hepatitis E virus (HEV) as a food-borne pathogen. EFSA J 2017; 15:e04886. [PMID: 32625551 PMCID: PMC7010180 DOI: 10.2903/j.efsa.2017.4886] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hepatitis E virus (HEV) is an important infection in humans in EU/EEA countries, and over the last 10 years more than 21,000 acute clinical cases with 28 fatalities have been notified with an overall 10-fold increase in reported HEV cases; the majority (80%) of cases were reported from France, Germany and the UK. However, as infection in humans is not notifiable in all Member States, and surveillance differs between countries, the number of reported cases is not comparable and the true number of cases would probably be higher. Food-borne transmission of HEV appears to be a major route in Europe; pigs and wild boars are the main source of HEV. Outbreaks and sporadic cases have been identified in immune-competent persons as well as in recognised risk groups such as those with pre-existing liver damage, immunosuppressive illness or receiving immunosuppressive treatments. The opinion reviews current methods for the detection, identification, characterisation and tracing of HEV in food-producing animals and foods, reviews literature on HEV reservoirs and food-borne pathways, examines information on the epidemiology of HEV and its occurrence and persistence in foods, and investigates possible control measures along the food chain. Presently, the only efficient control option for HEV infection from consumption of meat, liver and products derived from animal reservoirs is sufficient heat treatment. The development of validated quantitative and qualitative detection methods, including infectivity assays and consensus molecular typing protocols, is required for the development of quantitative microbial risk assessments and efficient control measures. More research on the epidemiology and control of HEV in pig herds is required in order to minimise the proportion of pigs that remain viraemic or carry high levels of virus in intestinal contents at the time of slaughter. Consumption of raw pig, wild boar and deer meat products should be avoided.
Collapse
|
45
|
A Case of Acute Hepatitis E Infection in a Patient with Non-Hodgkin Lymphoma Treated Successfully with Ribavirin. Case Rep Gastrointest Med 2017; 2017:8941218. [PMID: 28182129 PMCID: PMC5274689 DOI: 10.1155/2017/8941218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 12/09/2016] [Accepted: 12/25/2016] [Indexed: 11/23/2022] Open
Abstract
We present the case of a man who, following immunosuppressive treatment for non-Hodgkin lymphoma, became infected with viral hepatitis E. Acute hepatitis E virus infection should be considered in patients with deranged liver function on a background of haematological malignancies or immunosuppression, even without travel to endemic regions. Whilst clearance is usually spontaneous in immune-competent individuals, these at-risk groups may develop a more complicated and protracted disease course. Thus awareness is important as additional treatment with ribavirin or pegylated interferon may be required, as in this case, in order to help achieve eradication.
Collapse
|
46
|
Shrestha AC, Flower RL, Seed CR, Keller AJ, Harley R, Chan HT, Hoad V, Warrilow D, Northill J, Holmberg JA, Faddy HM. Hepatitis E virus RNA in Australian blood donations. Transfusion 2016; 56:3086-3093. [DOI: 10.1111/trf.13799] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/16/2016] [Accepted: 07/17/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Ashish C. Shrestha
- Research and Development; The University of Queenslan; Brisbane Queensland Australia
- School of Medicine; The University of Queenslan; Brisbane Queensland Australia
| | - Robert L.P. Flower
- Research and Development; The University of Queenslan; Brisbane Queensland Australia
| | - Clive R. Seed
- Medical Services; Australian Red Cross Blood Servic; Brisbane Queensland Australia
| | - Anthony J. Keller
- Medical Services; Australian Red Cross Blood Servic; Brisbane Queensland Australia
| | - Robert Harley
- Medical Services; Australian Red Cross Blood Servic; Brisbane Queensland Australia
| | - Hiu-Tat Chan
- Medical Services; Australian Red Cross Blood Servic; Brisbane Queensland Australia
| | - Veronica Hoad
- Medical Services; Australian Red Cross Blood Servic; Brisbane Queensland Australia
| | - David Warrilow
- Public Health Virology Laboratory, Forensic and Scientific Services; Queensland Healt; Brisbane Queensland Australia
| | - Judith Northill
- Public Health Virology Laboratory, Forensic and Scientific Services; Queensland Healt; Brisbane Queensland Australia
| | | | - Helen M. Faddy
- Research and Development; The University of Queenslan; Brisbane Queensland Australia
- School of Medicine; The University of Queenslan; Brisbane Queensland Australia
| |
Collapse
|
47
|
Viral hepatitis: Indian scenario. Med J Armed Forces India 2016; 72:204-10. [PMID: 27546957 DOI: 10.1016/j.mjafi.2016.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 06/27/2016] [Indexed: 02/07/2023] Open
Abstract
Viral hepatitis is a cause for major health care burden in India and is now equated as a threat comparable to the "big three" communicable diseases - HIV/AIDS, malaria and tuberculosis. Hepatitis A virus and Hepatitis E virus are predominantly enterically transmitted pathogens and are responsible to cause both sporadic infections and epidemics of acute viral hepatitis. Hepatitis B virus and Hepatitis C virus are predominantly spread via parenteral route and are notorious to cause chronic hepatitis which can lead to grave complications including cirrhosis of liver and hepatocellular carcinoma. Around 400 million people all over the world suffer from chronic hepatitis and the Asia-Pacific region constitutes the epicentre of this epidemic. The present article would aim to cover the basic virologic aspects of these viruses and highlight the present scenario of viral hepatitis in India.
Collapse
|
48
|
Khuroo MS, Khuroo MS. Hepatitis E: an emerging global disease - from discovery towards control and cure. J Viral Hepat 2016; 23:68-79. [PMID: 26344932 DOI: 10.1111/jvh.12445] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
Hepatitis E is a systemic disease affecting the liver predominantly and caused by infection with the hepatitis E virus (HEV). HEV has marked genetic heterogeneity and is known to infect several animal species including pigs, boar, deer, mongoose, rabbit, camel, chicken, rats, ferret, bats and cutthroat trout. HEV is the sole member of the family Hepeviridae and has been divided into 2 genera: Orthohepevirus (mammalian and avian HEV) and Piscihepevirus (trout HEV). Human HEVs included within the genus Orthohepevirus are designated Orthohepevirus A (isolates from human, pig, wild boar, deer, mongoose, rabbit and camel). Hepatitis E is an important public health concern, and an estimated one-third of the world population has been infected with HEV. In recent years, autochthonous hepatitis E is recognized as a clinical problem in industrialized countries. Several animal species especially domestic swine, wild boar and wild deer are reservoirs of genotype HEV-3 and HEV-4 in these countries. Human infections occur through intake of uncooked or undercooked meat of the infected animals and pig livers or sausages made from these livers and sold in supermarkets. HEV can be transmitted through blood and blood component transfusions, and donor screening for HEV is under serious consideration. Chronic hepatitis E resulting in rapidly progressive liver cirrhosis and end-stage liver disease has been described in organ transplant patients. Ribavirin monotherapy attains sustained virological response in most patients. HEV 239 vaccine has been marketed in China and its long-term efficacy over four and a half years reported.
Collapse
Affiliation(s)
- Mehnaaz S Khuroo
- Department of Pathology, Govt: Medical College Srinagar, Kashmir, India
| | - Mohammad S Khuroo
- Gastroenterology and Chairman Dept. Medicine, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India.,Digestive Diseases Centre, Dr. Khuroo's Medical Clinic, Kashmir, India
| |
Collapse
|
49
|
Li TC, Yoshizaki S, Yang T, Kataoka M, Nakamura T, Ami Y, Yuriko S, Takeda N, Wakita T. Production of infectious ferret hepatitis E virus in a human hepatocarcinoma cell line PLC/PRF/5. Virus Res 2016; 213:283-288. [PMID: 26763355 DOI: 10.1016/j.virusres.2015.11.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/26/2015] [Accepted: 11/27/2015] [Indexed: 12/22/2022]
Abstract
A strain of ferret hepatitis E virus (HEV), sF4370, isolated from an imported ferret was used to inoculate a human hepatocarcinoma cell line, PLC/PRF/5. The virus genome and capsid protein were detected in the cell culture supernatant. Immunofluorescence microscopy indicated that the capsid protein was located in the cytoplasm. The virus particles were purified from the culture supernatant by sucrose gradient ultracentrifugation. The capsid protein with molecular mass of ∼72 kDa was detected in fractions with density of 1.150-1.162 g/cm(3), and particles of ferret HEV was associated with cell membrane. The virus recovered from the supernatant was serially passaged with PLC/PRF/5 cells and had the ability to infect ferrets by oral inoculation, indicating that the ferret HEV grown in PLC/PRF/5 was infectious. The establishment of ferret HEV cell culture system might be useful to understand the life cycle, mechanism of infection and replication of ferret HEV.
Collapse
Affiliation(s)
- Tian-Cheng Li
- Department of Virology II, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo 208-0011, Japan.
| | - Sayaka Yoshizaki
- Department of Virology II, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo 208-0011, Japan
| | - Tingting Yang
- Department of Clinical Laboratory, Affiliated Hospital of Qingdao University Medical College, Jiangsu Road 16, Qingdao 266003, China
| | - Michiyo Kataoka
- Department of Pathology, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo 208-0011, Japan
| | - Tomofumi Nakamura
- Department of Virology II, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo 208-0011, Japan
| | - Yasushi Ami
- Division of Experimental Animals Research, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo 208-0011, Japan
| | - Suzaki Yuriko
- Division of Experimental Animals Research, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo 208-0011, Japan
| | - Naokazu Takeda
- Research Institute for Microbial Diseases, Osaka University, Suita, Osaka 565-0781, Japan
| | - Takaji Wakita
- Department of Virology II, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo 208-0011, Japan
| |
Collapse
|
50
|
Bazerbachi F, Haffar S, Garg SK, Lake JR. Extra-hepatic manifestations associated with hepatitis E virus infection: a comprehensive review of the literature. Gastroenterol Rep (Oxf) 2015; 4:1-15. [PMID: 26358655 PMCID: PMC4760069 DOI: 10.1093/gastro/gov042] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 07/09/2015] [Indexed: 02/07/2023] Open
Abstract
Background and aims: Hepatitis E virus (HEV) infection is a significant public health problem that afflicts almost 20 million individuals annually and causes acute liver injury in 3.5 million, with approximately 56 000 deaths. As with other viral hepatitides, extra-hepatic manifestations could represent an important aspect of this infection. The spectrum of these manifestations is still emerging. Acute pancreatitis and neurological, musculoskeletal, hematological, renal, and other immune-mediated manifestations have been described. The aim of this article is to comprehensively review the published literature of extra-hepatic manifestations associated with HEV infection. Data sources: We searched the PubMed database using the MeSH term “hepatitis E” and each of the extra-hepatic manifestations associated with HEV infection. No language or date restrictions were set in these searches. Searches retrieving articles with non-A, non-B hepatitis were excluded. Additional articles were identified through the reference lists of included articles. Results: Several extra-hepatic manifestations associated with HEV infection have been published. The temporal association between some extra-hepatic manifestations and HEV infection and the exclusion of other possible etiologies suggests that HEV infection could have caused some of them. According to the available data, HEV infection appears to be strongly associated with acute pancreatitis, neurological disorders (with primarily dominant peripheral nerve involvement, most commonly manifested as Guillain-Barré syndrome, followed by neuralgic amyotrophy), hematological diseases (hemolytic anemia due to glucose phosphate dehydrogenase deficiency, and severe thrombocytopenia), glomerulonephritis, and mixed cryoglobulinemia. More data are needed to clarify whether an association exists with musculoskeletal or other immune-mediated manifestations. Conclusions: HEV infection should be considered in patients with acute pancreatitis, Guillain-Barré syndrome, neuralgic amyotrophy, hemolytic anemia due to glucose phosphate dehydrogenase deficiency, severe thrombocytopenia, glomerulonephritis, and mixed cryoglobulinemia. Alternatively, signs and symptoms of these conditions should be sought in patients with acute or chronic HEV infection. More data are needed to confirm the role of HEV in other extra-hepatic disorders.
Collapse
Affiliation(s)
- Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Samir Haffar
- Department of Gastroenterology and Hepatology, University of Damascus, Damascus, Syrian Arab Republic
| | - Sushil K Garg
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
| | - John R Lake
- Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN 55455, USA
| |
Collapse
|