Detection of hepatitis C virus RNA and core protein in keratinocytes from patients with cutaneous lichen planus and chronic hepatitis C

Bidirectional Association between Lichen Planus and Hepatitis C-An Update Systematic Review and Meta-Analysis

Lichen planus (LP) is a chronic, inflammatory mucocutaneous disorder associated with systemic diseases such as hepatitis C (HCV). The objective of this study is to evaluate the association between LP and HCV bidirectionally through a systematic review and meta-analysis. A comprehensive search of studies published was performed in the databases of PubMed, Embase, and Web of Science. Out of 18,491 articles, 192 studies were included. The global prevalence of HCV positive (HCV+) in LP patients registered from 143 studies was 9.42% [95% confidence interval (CI), 7.27-11.58%], and from these, 84 studies showed HCV+ 4-fold more frequent in LP than a control group (OR, 4.48; 95% CI, 3.48-5.77). The global prevalence of LP in patients HCV+ recorded from 49 studies was 7.05% (95% CI, 4.85-9.26%), and from these, 15 registered a 3-fold more LP in HCV (OR, 3.65; 95% CI, 2.14-6.24). HCV+ in LP patients showed great geographic variability (OR, 2.7 to 8.57), and the predominantly cutaneous location was higher (OR, 5.95) than the oral location (OR, 3.49). LP in HCV+ patients was more frequent in the Eastern Mediterranean (OR, 5.51; 95% CI, 1.40-15.57). There is a higher prevalence of HCV+ in LP and vice versa than in the control group, especially in certain geographical areas that should be taken into consideration when doing screening in countries with an upper prevalence of HCV among the general population.

Potential pathogenic mechanisms involved in the association between lichen planus and hepatitis C virus infection

Lichen planus (LP) is an immune-mediated inflammatory disease that particularly affects the skin and mucous membranes. Its etiology remains elusive, however some trigger factors, including viral or bacterial antigens, drugs and metals, have been postulated. There is a higher prevalence of hepatitis C virus (HCV) infection among patients with LP, with some geographical variations. HCV is an enveloped RNA virus that belongs to the Flaviviridae family and in most instances causes chronic liver infections. It has been hypothesized that HCV may contribute to LP development, but the link between the two disorders is not fully understood. It is still debatable whether HCV leads to the occurrence of LP lesions directly by replication inside the infected cells or indirectly by activating immunological pathways. Molecular studies have revealed HCV RNA in specimens collected from patients with LP. The autoimmune theory was also suggested given that several studies have revealed viral replication and immune response activation associated with autoantibody synthesis. The aim of this review is to summarize the main potential mechanisms involved in the association between LP and HCV infection. Understanding the link between the two disorders may shed some light on the pathogenesis of LP, which is a challenging issue.

Sarcoidosis and chronic hepatitis C: treatment with prednisone and colchicine

Sarcoidosis is a disease which still has uncertain etiology. Possible environmental causes are cited in the literature, like organic and inorganic particles and infectious agents. Recent studies have demonstrated the occurrence of sarcoidosis in patients with chronic C hepatitis; however, this association remains without statistical or causal evidence. In this report a case of sarcoidosis associated with chronic hepatitis C will be described, with subcutaneous lesions, considered rare, and good response to treatment with colchicine and prednisone. The hepatitis C virus was isolated in sarcoid tissue and the association between the two diseases will be discussed.

Oral manifestations of hepatitis C virus infection

Extrahepatic manifestations (EHMs) of hepatitis C virus (HCV) infection can affect a variety of organ systems with significant morbidity and mortality. Some of the most frequently reported EHM of HCV infection, involve the oral region predominantly or exclusively. Oral lichen planus (OLP) is a chronic inflammatory condition that is potentially malignant and represents cell-mediated reaction to a variety of extrinsic antigens, altered self-antigens, or super antigens. Robust epidemiological evidence support the link between OLP and HCV. As the virus may replicate in the oral mucosa and attract HCV-specific T lymphocytes, HCV may be implicated in OLP pathogenesis. Sjögren syndrome (SjS) is an autoimmune exocrinopathy, characterized by dryness of the mouth and eyes and a multitude of other systemic signs and symptoms. SjS patients have also an increased risk of non-Hodgkin lymphoma. Patients with chronic hepatitis C do frequently have histological signs of Sjögren-like sialadenitis with mild or even absent clinical symptoms. However, it is still unclear if HCV may cause a disease mimicking SjS or it is directly responsible for the development of SjS in a specific subset of patients. Oral squamous cell carcinoma is the most common oral malignant tumour and at least in some part of the world could be linked to HCV.

Emerging role for the killer-cell immunoglobulin-like receptors genotype, in the susceptibility of skin diseases

NK cells are a major group of immune cells responsible for the phenomenon of natural, innate cytotoxicity. One of the better studied receptors of human NK cells are killer cell immunoglobulin-like receptors (KIR) responsible for checking the presence of MHC class I molecules, which serve as their ligands. Although previously treated as specific for NK cells, nowadays these receptors are known to also occur on T cells. Genetics of KIR molecules is very complicated, what create a great variability of haplotypes in various populations world-wide. In addition, some KIR are known to recognize HLA-C (epitopes C1 or C2), HLA-B (Bw4) or HLA-A (A3 and/or A11) molecules. Therefore, this makes a huge diversity of reactions among individuals, depending on the presence or absence of given KIR and their ligands, hence differential susceptibility to several diseases, including various dermatoses. This paper underlines the important role of both KIR genotypes and HLA class I genes with reference to the various skin diseases.

Urban legends series: lichen planus

Oral Diseases (2012) Lichen planus (LP) is a common disorder affecting the oral cavity (OLP) and skin. Despite intensive research, LP/OLP etiology and treatment remain controversial. We investigated four controversial topics: (i) Is hepatitis C virus (HCV) infection associated with LP and involved in its pathogenesis? (ii) Should all patients with LP be screened for HCV? (iii) Should patients with OLP have all their amalgam restorations removed? (iv) Are there any new treatments for OLP? Results from extensive literature searches suggested that: (i) Robust evidence from three meta-analyses indicate that HCV is associated with LP and might be involved in OLP pathogenesis (ii) It would be prudent to screen patients with LP/OLP at significant risk with an ELISA for HCV antibodies using country-specific screening strategies (iii) There is no evidence that either OLP or oral lichenoid lesions patients would routinely benefit from having all their amalgam restorations replaced. Weak evidence from potentially very biased, small, non-randomized, unblinded studies suggests that a small fraction of patients may benefit from targeted amalgam replacement. (iv) There is weak evidence that, among new OLP treatments, topical pimecrolimus, aloe vera, and oral curcuminoids may be useful. The development of specific formulations for oral delivery of topical medications is a promising field.

Detection of hepatitis C virus in thyroid tissue from patients with chronic HCV infection

Thyroid dysfunctions are common in chronic hepatitis C virus (HCV) infection. HCV-RNA has been detected by reverse-transcription polymerase chain reaction (PCR) in thyroid from HCV infected patients with acquired immunodeficiency syndrome. However, morphological evidence of HCV replication in thyroid cells from immune competent patients has not been provided. In situ hybridization and real-time-PCR were used to analyze HCV-RNA replication in thyroid tissue from 11 patients (3 anti-HCV, serum HCV-RNA positive; 8 anti-HCV negative). Genomic and antigenomic HCV-RNA was detected in the thyroid of the 3 anti-HCV positive patients at concentrations of 2.6 x 10(4), 1.7 x 10(4), and 8.6 x 10(3) copies/microg of total RNA (genomic) and 3.2 x 10(2), 4.3 x 10(3) and 2.9 x 10(2) HCV-RNA copies/microg of total RNA (antigenomic). No HCV-RNA was detected in the thyroid tissue of the 8 anti-HCV negative patients. Presence of genomic/antigenomic HCV-RNA in the 3 anti-HCV positive cases was confirmed by in situ hybridization. Signals were observed in the cytoplasm of the thyroid cells. In conclusion, the data obtained indicate that HCV may infect cells of the thyroid in immune competent patients with chronic HCV infection. The pathogenic implications of this finding merit further research.

Oral diseases associated with hepatitis C virus infection. Part 2: lichen planus and other diseases

Some of the most frequent extrahepatic manifestations of hepatitis C virus (HCV) infection involve the oral region predominantly or exclusively. Part 2 of this review discusses the current evidences regarding the association of lichen planus (LP) and other diseases frequently involving the oral cavity with HCV. Epidemiological data suggest that LP may be significantly associated with HCV infections especially in southern Europe and Japan but not in northern Europe. These geographical differences are possibly influenced by immunogenetic factors, the duration of the HCV infection and the design of the published studies. Because of the fact that most of the studies published are retrospective, it is impossible to establish whether the HCV exposure occurred earlier to or after the onset of disease and more prospective studies are clearly warranted. As the virus may replicate in the skin and oral mucosa and HCV-specific T lymphocytes can be found in the oral mucosa of patients with chronic hepatitis C and LP, HCV may be implicated in the pathogenesis of LP. However, little attention has been paid to the variable effect of therapy with interferon-alpha (IFN-alpha), with or without ribavirin for LP. Conversely, it is unlikely that other oral diseases such as oral carcinoma, pemphigus and Behcet disease are triggered by HCV.

Hepatitis C virus does not infect muscle, the intervertebral disk, or the meniscus in patients with chronic hepatitis C

Chronic infection with hepatitis C virus (HCV) is associated with several extrahepatic manifestations, including neuromuscular and joint disorders, and HCV RNA has been detected in muscle fibers of patients with myosistis and chronic hepatitis C. However, whether HCV infects muscle cells in patients without myosistis is unknown. The presence of HCV in other sites of the musculoskeletal system has not been investigated. In the present study the presence of HCV RNA was sought in muscle (2 cases), intervertebral disk (1 case) and meniscus (1 case) samples from patients with chronic hepatitis C. HCV RNA was not detected by reverse transcription and real-time polymerase chain reaction in any of the samples tested. In conclusion, the results do not support a direct role of HCV in musculoskeletal disorders associated with chronic hepatitis C.

Cytokine gene polymorphisms in hepatitis C virus-related oral lichen planus

Cytokine polymorphisms may influence both the risk of developing oral lichen planus (OLP) and the outcome of hepatitis C virus (HCV)-infected patients and OLP has been frequently associated with HCV infection. The aim of the present study was to analyse whether cytokine polymorphisms may influence the susceptibility to HCV-related OLP. Thirty-five patients with OLP and chronic HCV infection (OLP-HCV+ve) took part in the study. As controls, 44 patients with OLP but without HCV (OLP-HCV-ve) infection and 140 healthy donors were studied. Thirteen cytokine genes with 22 single nucleotide polymorphisms (SNP) were studied. IFN-gamma UTR 5644 genotype frequencies showed an increase in number of A/T heterozygote in OLP-HCV+ve patients compared with OLP-HCV-ve that approached the statistical significance [P = 0.03, P-corrected (PC) = 0.66]. Contrarily, in OLP-HCV+ve patients, the frequency of genotype -308 G/A of the TNF-alpha was decreased, whereas the genotype -308 G/G was increased compared with OLP-HCV-ve (P = 0.0005, PC = 0.011 and P = 0.0016, PC = 0.0352, respectively). OLP patients with and without HCV infection showed a different genetic cytokine background suggesting distinct pathogenetic mechanisms.

Dermatologic disorders associated with chronic hepatitis C: effect of interferon therapy

Chronic hepatitis C virus infection (HCV) is associated with extrahepatic manifestations, including such dermatologic conditions as mixed cryoglobulinemia, porphyria cutanea tarda, and lichen planus. Patients with chronic HCV and extrahepatic manifestations are often excluded from clinical trials evaluating interferon (IFN) therapy due to concerns about poor response, adverse events, and toxicity. Thus, data regarding the efficacy of IFN not only on the underlying chronic HCV, but also on extrahepatic manifestations, are limited in these patients. Case reports suggest that the response of dermatologic extrahepatic manifestations to IFN in patients with chronic HCV is highly variable. This review summarizes available data on dermatologic conditions associated with chronic HCV and their response to IFN therapy.

Necrolytic acral erythema: a cutaneous sign of hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) infection is globally epidemic. Several mucocutaneous diseases are well established in association with HCV infection. Few case reports describe the recently recognized HCV-related skin disorder termed necrolytic acral erythema (NAE).

METHODS

Thirty patients with NAE were identified in a university-based dermatology clinic in Cairo, Egypt. These patients were observed over time to document the clinical and histologic findings of this disorder.

RESULTS

All patients were infected with HCV. Erythematous papules arose most commonly on the dorsal aspect of the feet, particularly the dorsal surface of the great toe. Progression resulted in confluence into erythematous dusky plaques with adherent scale and central erosion. The eruption extended to involve the lower leg and other regions in some patients but never affected palms or soles, the nail bed, nail plate, or mucous membranes. Skin biopsy specimens from fully evolved lesions displayed psoriasiform changes in association with more characteristic findings of keratinocyte necrosis and papillomatosis.

LIMITATIONS

We did not perform a prospective review of patients known to be infected with HCV. Patients were identified from a general clinic population and then assayed for HCV serology.

CONCLUSIONS

NAE is a distinctive skin disorder associated with HCV infection in all cases reported to date. Recognition of this disease should alert practitioners to the need for viral testing and appropriate counseling of patients.

Molecular diagnosis of infectious diseases in dermatology

The molecular diagnosis of infectious disease has been growing considerably over the past decade. Nucleic acid amplification techniques, such as polymerase chain reaction, ligase chain reaction, transcription-mediated amplification, and nucleic acid sequence-based amplification, provide highly accurate diagnosis of numerous bacterial, viral, fungal, and parasitic infections involved in a variety of dermatologic diseases. In addition, signal amplification with hybrid capture, branched-DNA assays, and in situ hybridization have been used to detect numerous viral pathogens with high degrees of sensitivity and specificity. New technology that involves the use of DNA and protein microarrays has also enabled the detection of a variety of genes and gene mutations. With time, these diagnostic assays are decreasing in cost, gaining approval of the U.S. Food and Drug Administration, and becoming easier and more efficient to use. In the future, these assays will be able to deliver rapid and accurate diagnosis of infectious diseases within a single clinic visit.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with molecular diagnosis of infectious diseases in dermatology.

Current controversies in oral lichen planus: Report of an international consensus meeting. Part 1. Viral infections and etiopathogenesis

Despite recent advances in understanding the immunopathogenesis of oral lichen planus (LP), the initial triggers of lesion formation and the essential pathogenic pathways are unknown. It is therefore not surprising that the clinical management of oral LP poses considerable difficulties to the dermatologist and the oral physician. A consensus meeting was held in France in March 2003 to discuss the most controversial aspects of oral LP. Part 1 of the meeting report focuses on (1) the relationship between oral LP and viral infection with special emphasis on hepatitis C virus (HCV), and (2) oral LP pathogenesis, in particular the immune mechanisms resulting in lymphocyte infiltration and keratinocyte apoptosis. Part 2 focuses on patient management and therapeutic approaches and includes discussion on malignant transformation of oral LP.

Detection of hepatitis C virus RNA in formalin-fixed paraffin-embedded sections with digoxigenin-labeled cRNA probes

Although recent studies have analyzed Hepatitis C (HCV) infections in liver tissue by in situ hybridization (ISH), many of these studies have been of limited diagnostic utility because of the low copy numbers of HCV in formalin-fixed paraffin-embedded (FFPE) tissue and failure to correlate the ISH analysis with other methods of detecting HCV. Thirty six cases of liver biopsies from patients with known HCV antibody status including 20 cases of serum HCV positive and 16 cases of serum HCV negative were analyzed. All cases showed histologic features suggestion of HCV infection. Analyses of all 36 cases were done by RT-PCR combined with Southern hybridization (RT-PCR-SH) and in situ hybridization (ISH). A prolactin riboprobe was used as a negative control. Immunohistochemistry (IHC) with an antibody against HCV (Rb 246) was also used to analyze HCV viral protein in the tissues. Of the 20 serum antibody-positive cases, RT-PCR-SH detected 18 positive cases, while ISH and IHC detected 19 and 16 positive cases, respectively. Of the 16 serum antibody-negative cases, RT-PCR-SH detected 8 positive cases while ISH and IHC detected 8 and 11 positive cases, respectively. A positive ISH signal for HCV was also detected in some lymphocytes and bile ducts in the liver. These results show that ISH with a highly specific riboprobe is comparable to RT-PCR-SH for detection of HCV infection in liver tissue.

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