Hepatitis B and immune-complex disease

Autoimmune Kidney Diseases Associated with Chronic Viral Infections

Autoimmune kidney diseases triggered by viruses are an important cause of kidney disease in patients affected by chronic viral infection. Hepatitis B virus (HBV) infection is associated with membranous nephropathy and polyarteritis nodosa. Hepatitis C virus (HCV) infection is a major cause of cryoglobulinemic glomerulonephritis. Patients with human immunodeficiency virus (HIV) may develop HIV-associated nephropathy, a form of collapsing focal segmental glomerulosclerosis, or various forms of immune-complex-mediated kidney diseases. This article summarizes what is known about the pathogenesis, diagnosis, and management of immune-mediated kidney diseases in adults with chronic HBV, HCV, and HIV infections.

Cutaneous manifestations of viral hepatitis

There are several extrahepatic cutaneous manifestations associated with hepatitis B and hepatitis C virus infection. Serum sickness and polyarteritis nodosa are predominantly associated with hepatitis B infection, whereas mixed cryoglobulinemia associated vasculitis and porphyria cutanea tarda are more frequently seen in hepatitis C infection. The clinico-pathogenic associations of these skin conditions are not completely defined but appear to involve activation of the host immune system including the complement system. Management of the aforementioned cutaneous manifestations of viral hepatitis is often similar to that done in cases without viral hepatitis, with control of immune activation being a key strategy. In cases associated with hepatitis B and C, control of viral replication with specific antiviral therapy is also important and associated with improvement in most of the associated clinical manifestations.

Mononeuropathy multiplex in a patient with chronic active hepatitis B

Background

Mononeuropathy multiplex is a rare complication during the course of chronic hepatitis B, despite various neuropathies following acute hepatitis B having been reported previously.

Case Report

A 30-year-old man presented with sensorimotor symptoms in multiple peripheral nerves. The serological tests for hepatitis were consistent with chronic active hepatitis B. After treatment with oral prednisone combined with an antiviral agent, the sensory and motor symptoms improved and hepatitis B virus replication was reduced.

Conclusions

We suggest that chronic immune-mediated neuropathy associated with hepatitis B virus infection should be considered in the differential diagnosis of patients with hepatitis B.

Behçet's disease and close contact with pigs

Six male patients out of seven with Behçet's disease were found to have a very similar and close contact with pigs and pork. These six cases are reported and we ask the question whether the contacts with pigs are just coincidental findings or whether an external agent, e.g. a virus, could be forwarded to man from pigs and pork. Immune complex associated vasculitis is described e.g. in patients with hepatitis B and the same mechanisms might be operating in patients with Behçet's disease.

Gastrointestinal involvement in polyarteritis nodosa

Polyarteritis nodosa (PAN) is a necrotizing, focal segmental vasculitis that affects predominantly medium-sized arteries in many different organ systems. It is associated with hepatitis B virus (HBV) in about 7% of cases, a decline from about 30% before the mandatory testing of blood products and the widespread vaccination programs. HBV PAN is an early postinfectious process. The hepatitis is silent in most cases, with mild transaminase level increases in 50% of patients. Gastrointestinal involvement occurs in 14% to 65% of patients with PAN. Postprandial abdominal pain from ischemia is the most common symptom. When transmural ischemia develops, there may be necrosis of the bowel wall with perforation, associated with a poor prognosis. Liver involvement occurs in 16% to 56% of patients, although clinical manifestations related to liver disease are quite rare. Acalculous gangrenous cholecystitis may develop owing to arteritis involving the wall of the gallbladder. Microaneurysms on arteriography or computed tomography angiography are characteristic of PAN, but are seen in other conditions. Tissue biopsy may confirm the diagnosis, although involvement is segmental. Corticosteroids are used for non-HBV PAN with cyclophosphamide added for severe disease. For PAN related to HBV, a 2-week course of corticosteroids is begun, with plasma exchanges and an antiviral agent. Corticosteroids and cyclophosphamide have improved patient outcome so that the 1-year survival rate is now about 85%.

Hepatitis B virus replication in damaged endothelial tissues of patients with extrahepatic disease

Hepatitis B virus (HBV) infection may be complicated by extrahepatic manifestations such as polyarteritis nodosa (PAN), glomerulonephritis, polymyositis, and dermatitis, but the etiology of these processes is not yet clear. HBV replication has been demonstrated in a variety of extrahepatic tissues and cell types, but the possible pathogenetic role of extrahepatic HBV replication has not been fully explored in patients with extrahepatic manifestations of HBV infection. In this case series, immunohistochemistry and in situ hybridization studies were performed on extrahepatic tissues from one HBsAg-positive patient with PAN and another HBsAg-positive patient with polymyositis, using HBsAg-seronegative control subjects with the same vasculitic disorders as controls. Tissue samples from the two study patients had detectable HBV RNA, replicative intermediates of HBV DNA, as well as HBsAg and HBcAg localized to vascular endothelium. In contrast, HBsAg-negative control patients had no tissue reactivity. Our results suggest that patients with HBV-related extrahepatic disease have evidence of viral replication in damaged extrahepatic endothelial tissues. While further studies would be required to support a hypothesis of causality, these findings suggest a role for both immune complex deposition and viral replication within diseased endothelial tissue in the pathogenesis of these poorly understood extrahepatic disorders.

Extrahepatic manifestations of chronic hepatitis B

Several extrahepatic manifestations are associated with chronic HBV infection, many with significant morbidity and mortality. The cause of these extrahepatic manifestations is generally believed to be immune mediated. PAN is a rare, but serious, systemic complication of chronic HBV affecting the small- and medium-sized vessels. PAN is seen more frequently in North American and European patients and rarely in Asian patients. PAN ultimately involves multiple organ systems, some with devastating consequences, though the hepatic manifestations are often more mild. The optimal treatment of HBV-associated PAN is thought to include a combination of antiviral and immunosuppressive therapies. HBV-associated GN occurs mainly in children, predominantly males, in HBV endemic areas of the world, but is only occasionally reported in the United States. In children, GN is usually self-limited with only rare progression to renal failure. In adults, the natural disease course of GN may be more relentless, slowly progressing to renal failure. Immunosuppressive therapy in HBV-related GN is not recommended, but antiviral therapy with alpha-interferon has shown promise. The serum-sickness like "arthritis-dermatitis" prodrome is seen in approximately one third of patients acquiring HBV. The joint and skin manifestations are varied, but the syndrome spontaneously resolves at the onset of clinical hepatitis with few significant sequelae. Occasionally, arthritis following the acute prodromal infection may persist; however, joint destruction is rare. The association between HBV and mixed essential cryoglobulinemia remains controversial; but a triad of purpura, arthralgias, and weakness, which can progress to nephritis, pulmonary disease, and generalized vasculitis, has characterized the syndrome. Finally, skin manifestations of HBV infection typically present as palpable purpura. Though papular acrodermatitis of childhood has been reported to be caused by chronic HBV, this association remains controversial.

Reversible bilateral hydronephrosis without obstruction in hepatitis B-associated polyarteritis nodosa

The manifestations of polyarteritis nodosa (PAN) are varied, but urological abnormalities other than ureteric stenosis and orchitis have not been described. We report a case of hepatitis B-associated PAN with bilateral hydronephrosis without obstruction. Retrograde urography conclusively demonstrated the absence of obstruction. Vasculitis-related myopathy, or neuropathy of the ureter, is the most likely cause of this finding. The patient was treated with high-dose steroids, cyclophosphamide, and plasmapheresis with resolution of hydronephrosis. Although the patient required dialysis at initiation of therapy, she went on to recover sufficient renal function to discontinue dialysis. We review the literature on the treatment of hepatitis B-associated PAN and discuss the pitfalls in diagnosis of this condition.

Necrotizing peripheral nerve vasculitis

Necrotizing vasculitis of the type in polyarteritis nodosa is a treatable cause of neuropathy. The diagnosis must be confirmed histologically by demonstration of characteristic arterial lesions in nerve and muscle biopsy specimens. Ischemic neuropathy which results from occlusion of nerve arteries in polyarteritis nodosa also occurs as a consequence of inflammatory arterial lesions in other connective tissue disorders, in some infectious neuropathies and in patients with malignant lymphomas. Patients with vasculitic neuropathy may also present with isolated peripheral neuropathy.

Treatment of hepatitis B-related polyarteritis nodosa with famciclovir and interferon alfa-2b

BACKGROUND

The association between polyarteritis nodosa and viral hepatitis B infection is well established and still remains a therapeutic challenge. Famciclovir--a new nucleoside analog--has a broad spectrum of antiviral activity against herpes viruses and the human hepatitis B virus.

CASE REPORT

A 56-year-old man with hepatitis B-related polyarteritis nodosa presented with symptoms correlating to high levels of HBV DNA. The patient did not respond to treatment with steroids (prednisolone started with 100 mg daily) and two courses of interferon alfa-2b (5 x 10(6) units 3 times per week for 6 months). Therefore, a combination therapy of interferon alfa-2b (5 x 10(6) units 3 times per week) and famciclovir (500 mg tid, orally) was started; 5 mg daily prednisolone was given at this time. Under this regimen HBV DNA rapidly declined, with a reduction of 79% after the first week (HBV DNA 53 pg/ml), and 88% after the second week (29 pg/ml), accompanied by a significant improvement in clinical symptoms. After 1 year of famciclovir treatment, HBeAg-anti-HBe seroconversion was noted; HBsAg still remained positive. Long-term famciclovir therapy has been continued at a reduced dose of 125 mg tid for 3 years now. HBV DNA values have been stable below 100 pg/ml, transaminases have normalized and clinical symptoms of polyarteritis nodosa have disappeared.

CONCLUSIONS

Famciclovir has been successfully administered to a patient with hepatitis B-related polyarteritis nodosa. A reduction in viral replication and an improvement of symptoms were noted within 4 weeks of starting famciclovir. The oral nucleoside analog famciclovir is effective and well tolerated, even in long-term therapy, and might offer new treatment options in immunosuppressed patients for whom hepatitis B replication is critical for the disease process.

Enhancement of HBsAg detection in serum of patients with chronic liver disease following removal of circulating immune complexes

Patients with chronic liver disease and hepatocellular carcinoma may lack serological evidence of previous hepatitis B virus infection. The purpose of the present study was to test the hypothesis that circulating immune complexes may interfere with the detection of low levels of HBsAg in such patients. Sera from 190 patients were initially screened for the presence of circulating immune complexes. Patients belonged to three clinical categories: asymptomatic HBsAg carriers (50 patients), chronic liver disease (30 patients) and hepatocellular carcinoma (110 patients). Forty-one of the group of 190 patients (21%) were positive for circulating immune complexes. Sera from 21 patients were selected for further evaluation. The sera of 13 chronic liver disease or hepatocellular carcinoma patients (HBsAg negative, hepatitis B virus-DNA negative, with or without evidence of previous hepatitis B virus infection) and eight HBsAg positive carriers (four asymptomatic, three with chronic liver disease and one with hepatocellular carcinoma) were passed through a Clq affinity column (first column) to remove circulating immune complexes. Unbound material was then passed through a monoclonal IgG2a anti-HBs affinity column (second column). Unbound material (following both columns) contained free HBsAg, as determined by monocolonal radio-immunoassay, in eight patients in whom HBsAg had been undetectable in the original serum. Removal of circulating immune complexes from the serum of the three HBsAg positive patients with chronic liver disease also caused a significant increase in measurable circulating HBsAg compared with the original serum.(ABSTRACT TRUNCATED AT 250 WORDS)

Combinations of low concentrations of cytokines and acute agonists synergize in increasing the permeability of endothelial monolayers

The deposition of circulating immune reactants in blood vessels, an important event in the pathogenesis of certain types of vasculitis, requires an increase in permeability in the endothelial monolayer. An in vitro model to examine the integrity of endothelial cell monolayers and their response to inflammatory mediators has been developed. Human umbilical vein endothelial cells were grown to confluence on an FITC-labelled matrix and monolayer integrity was assessed by the exclusion of a 125I-anti-FITC antibody. Alteration in endothelial monolayer permeability was associated with an increase in uptake of 125I-anti-FITC antibody, expressed as a percentage of the maximal uptake of antibody on to FITC-matrix from which endothelial cells had been stripped. We determined the effects on endothelial monolayer permeability of acute agonists (thrombin and histamine), cytokines (tumour necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), IL-1 and IL-4) and combinations of acute agonists and cytokines. Addition of thrombin in concentrations ranging from 0.5 to 15 U/ml led to an increased uptake of 125I-anti-FITC antibody from 2% to 15% relative to unstimulated endothelium. For other agonists and cytokines the increases in permeability were: (i) histamine (50-400 pmol/ml) increased uptake 5-22%; (ii) TNF (12.5-100 ng/ml) increased uptake 2-12%; (iii) IFN-gamma (125-250 U/ml) increased uptake 1.5-3%. IL-1 beta (50-100 U/ml) and IL-4 (50-100 U/ml) had no effect. Synergistic interactions on endothelial monolayer permeability were seen with the following combinations: (i) IL-4 (100 U/ml) and TNF (12.5 ng/ml) uptake 11%; (ii) IL-4 (100 U/ml) and IFN-gamma (125 U/ml) uptake 6.5%; (iii) TNF (12.5 ng/ml) and IFN-gamma (125 ng/ml) uptake 7%; (iv) thrombin (0.5 U/ml) and histamine (50 pmol/ml) uptake 13.5%; and (v) TNF (12.5 ng/ml) and thrombin (0.5 U/ml) uptake 8.5%. These observations suggest that interactions between cytokines and acute inflammatory mediators such as thrombin and histamine may be important in determining whether immune complexes are deposited in vessel walls. This model system may now be useful for the further investigation in vitro of the mechanisms involved in the pathogenesis of immune complex-mediated vascular damage.

Portal pressure in patients with exudative ascites in the course of acute hepatitis B

We describe three patients who developed ascites during the course of acute viral hepatitis B. Two of them had exudative ascites, with a high protein and cell content, and the other transudative ascites, with low protein and cell content. Both patients with exudative ascites had a benign clinical course, and their liver disease was milder than in the patient with transudative ascites, who had signs of severe liver failure and a submassive hepatic necrosis on liver biopsy. Moreover, the patient with transudative ascites had evidence of portal hypertension (as indicated by a hepatic vein pressure gradient of 12.5 mmHg, normal 1-6 mmHg), whereas patients with exudative ascites did not (hepatic vein pressure gradient of 5 and 5.5 mmHg, respectively). These data support our previous suggestion that "exudative" ascites during acute viral hepatitis B represents a self-limited immunopathetic sign that is not related to portal hypertension or severe hepatic disease.

Hepatitis B-associated polyarteritis nodosa in Alaskan Eskimos: clinical and epidemiologic features and long-term follow-up

We analyzed the demographic, clinical, laboratory and histologic features of 13 patients who were diagnosed as having polyarteritis nodosa associated with hepatitis B virus infection over a 12-year period, 1974 to 1985. All 13 patients were Yupik Eskimos and resided in southwest Alaska, an area hyperendemic for hepatitis B virus infection. The annual incidence of hepatitis B virus-associated polyarteritis nodosa for this population is 7.7 cases per 100,000 population. All patients presented with multisystem disease, and all had biopsy or angiographic findings consistent with polyarteritis nodosa. All 13 were positive for hepatitis B surface antigen and hepatitis B e antigen at diagnosis. Two untreated patients and two of five patients who received corticosteroids died, vs. none of six who received corticosteroids plus cyclophosphamide. None of the patients who survived the initial bout of polyarteritis nodosa has relapsed after a mean follow-up of 55 months, but all have become chronic HBsAg carriers. In eight patients, clinical or serologic evidence indicated that polyarteritis nodosa followed recent hepatitis B virus infection. We concluded that hepatitis B virus-associated polyarteritis nodosa is a serious, life-threatening complication that occurs early in the course of hepatitis B virus infection, is ameliorated by immunosuppressive therapy and can be prevented by hepatitis B vaccine.

Antibody dependent cytotoxicity in chronic active liver disease

Twenty-six patients with chronic active liver disease (CALD) and a control group (8 patients with atrophic gastritis and 10 healthy people) underwent a microcytotoxicity (MCT) test using a primary line of human hepatocytes (5 1/2 month old human embryo) in the presence of rabbit complement. In 57.6% of the cases with CALD the test was positive (over 60% of hepatocytes lysed on contact with the patients' serum). The controls showed a negative MCT test, except for one case (12.5%) of atrophic gastritis. The positive results of the test in the CALD patients coincided with the evolutive stage of the disease and with obvious immune, humoral and cellularly, disturbances. The mechanism of the antibody dependent cytotoxicity mechanism in the hepatocytolysis in CALD is being demonstrated; the MCT test may be a marker of the evolution of the disease.

The peripheral neuropathy of necrotizing arteritis: a clinicopathological study

We have reviewed the clinical and morphological data from 100 patients with necrotizing arteritis in muscle and/or in nerve samples taken by biopsy. The neuropathy occurred in the context of a multisystem disorder (Group 1) or in apparent isolation (Group 2). The average age of patients was 59 in Group 1 and 61 in Group 2. Females were more commonly affected than males, especially in the first group. Necrotizing arteritis complicated the course of rheumatoid arthritis in 25 patients. In 3 patients necrotizing arteritis was associated with infection with the human immunodeficiency virus, the agent of AIDS. Tests for hepatitis B surface antigen were positive in 19 patients. Mononeuritis was present in 13, mononeuritis multiplex in 62, and distal symmetrical sensory or sensorimotor neuropathy in 19 patients. In both groups of patients, the muscle biopsy was more frequently diagnostic for arteritis than was the nerve biopsy (80% versus 55%). The average incidence of isolated fibers undergoing axonal degeneration was 64.8%; that of demyelinated/remyelinated fibers was 1.9%. We conclude that the combination of nerve and muscle sampling increases the chance of visualizing characteristic arterial lesions in vasculitic neuropathy.

Demonstration of HBsAg as the antigen component in circulating immune complexes detected by peg-solid phase test

The development of an enzyme-linked immunosorbent assay to identify HBsAg as the antigen component within circulating immune complexes using immobilized polyethylene glycol (PEG) is described. The method utilizes, on one hand, the ability of PEG to bind stably to plastic supports and, on the other, to precipitate circulating macromolecules. This method is easily performed, very cheap, quick and, above all, it helps define the biological nature of the immune complexes. HBsAg can be revealed as the antigen component of HBsAg/anti-HBs soluble immune complexes at concentrations of at least 20 ng/ml and either in antigen or antibody excess. Our results indicate that HBsAg circulates in a complexed form in 47% of HBsAg chronic carriers and in 10.7% of patients with liver disease who are positive for serum antibody to hepatitis B surface antigen (anti-HBs) and to core antigen (anti-HBc). None of the other groups of patients in the study had circulating HBsAg in the complexed form.

Cryoglobulins and infectious diseases

The relationship between infectious diseases due to various pathogenetic factors and cryoglobulin production mechanisms has been investigated. Cryoglobulins have been evidenced in infections caused by very heterogeneous pathogens, i.e. leptospirosis, psittacosis, Mediterranean tick typhus, brucellosis, gram-negative bacterial septicemias, in which they had never been previously reported. In type A hepatitis a high cryoglobulin prevalence (91%) has been confirmed during the acute phase, with a rapid decrease both in prevalence and concentration in the subsequent stages of the disease. Cryoglobulins were all of type III and were mainly represented by IgM; anti-HAV-IgM antibodies have been evidenced in all but one cryoprecipitates. In non-A, non-B hepatitis a lower cryoglobulin prevalence (44.7%) was shown during the acute phase and the same fast decrease has been noted in the subsequent stages. Cryoglobulins were all of type III and in some cases polyclonal IgG was the only Ig class present in cryoprecipitates. The cryoglobulin prevalence in the acute phase of HBsAg-positive hepatitis amounted to 73.4%; all the cryoprecipitates were of type III. No correlation between the presence of cryoglobulins and HBeAg positivity or between cryoglobulins and delta agent infections was found. In all the cases studied the presence of cryoglobulins was related to the persistence of liver damage. Cryoglobulins were not found in HBsAg chronic carriers, while they have been evidenced, by a preliminary study, in 41.6% of HTLV-III antibody-positive subjects complaining of a persistent generalized lymphadenopathy without clinical or laboratory signs of liver impairment. No HTLV-III antibodies were found by ELISA method in the type III cryoprecipitates.

Hepatitis in clinical practice. 1. Hepatitis A and B

As is evident from the foregoing discussion, hepatitis A and hepatitis B are not static, passé disease. Knowledge concerning these illnesses continues to expand at a fantastic rate--all of it of extreme practical clinical significance. Most interesting is the elucidation of the etiology of the acquired immune deficiency syndrome (AIDS) and the increase this knowledge is hoped to produce on the utilization of hepatitis B vaccine. Also extremely important is the development of recombinant DNA vaccine, which will permit total circumvention of the question of AIDS and safety of the hepatitis B vaccine.

Multisystemic disease with intracranial hypertension and autoimmune cytopenia in chronic active hepatitis

A 14-year-old girl with postinfectious chronic hepatitis developed a life threatening autoimmune multisystemic illness with arthralgias, intracranial hypertension, Coomb's positive hemolytic anemia and hemorrhagic diathesis (due to antiplatelet and antifactor X antibodies). Mannitol and immunosuppressive therapy abolished acute symptoms. During the first year of follow-up, two attempts of decreasing prednisone below 15 mg/day caused recurrence of the hemolytic anemia and appearance of low titer antinuclear antibodies, while doses above 15 mg/day caused an increase in transaminase levels. Daily prednisone dose was therefore fixed at 15 mg. The patient was well and, although signs of mild hemolysis persisted, there was no anemia. Transaminases were found greatly elevated on two occasions. An autoimmune multisystemic steroid sensitive disease was seemingly initiated by a postinfectious steroid irresponsive chronic hepatitis.

HBsAg-serum protein complexes stimulate immune T lymphocytes more efficiently than do pure HBsAg

HBsAg from plasma of chronic hepatitis B carriers was purified by affinity chromatography using a mouse monoclonal antibody specific for HBsAg. Elution with buffer at two different pH values separated HBsAg into two fractions: one contained high amounts of immune complexes associated with HBsAg; the other contained larger quantities of the HBsAg polypeptides P24 and GP27 and only small amounts of immunoglobulin. When compared for effects on stimulating the proliferative response of freshly isolated lymphocytes and an HBsAg-specific T cell clone, the HBsAg fraction containing a high proportion of immunoglobulin was much more potent than HBsAg with low amounts of immunoglobulins or pure HBsAg, which was isolated from the culture supernatant of the human hepatoma cell line (PLC/PRF/5). The plasma-derived HBsAg with low amounts of complexed immunoglobulins became more immunogenic in the presence of an anti-HBsAg monoclonal IgG. The present results, combined with earlier findings, suggest that HBsAg associated with immune complexes is a more potent stimulator of T cells than purer HBsAg preparations due to an increase in the efficiency of monocytes to capture the antigen through binding to immune complexes for subsequent processing and presentation of the antigen. These observations could be of relevance for the preparation of effective hepatitis B vaccines from recombinant DNA and peptide synthesis technologies.