Hepatitis C: a review and update

Approach to Elevated Liver Enzymes

Abnormal liver tests are one of the most common challenges in the primary care setting. Primary care practitioners order these tests for numerous reasons, including investigating abdominal signs and symptoms or suspected alcohol-use disorder, or to determine medication adverse effects. Evaluation should be guided by both the clinical presentation and the pattern of injury. In this article, we will focus on the epidemiology, pathophysiology, clinical presentation, diagnostic work-up, and management of elevated liver enzymes, with an emphasis on the most common causes of abnormal liver testing.

Evaluation of MicroRNA-122 as a Biomarker for Chronic Hepatitis C Infection and as a Predictor for Treatment Response to Direct-Acting Antivirals

Background

Treatment response to antiviral drugs is a challenging issue in patients with chronic hepatitis C virus (HCV) infection. Although microRNA-122 represents the majority of the microRNA content in hepatic tissues, few studies have evaluated its role in the treatment response, so we aimed to study its role in chronic HCV patients and in predicting the treatment response to direct-acting antivirals (DAAs).

Methods

The study included 125 chronic HCV patients (89 naïve and 36 with a prior failed peginterferon/ribavirin response) and 50 apparently healthy subjects. Complete blood count, liver function, α-fetoprotein, lipid profiles, serum creatinine, abdominal ultrasound, and FibroScan^® were assessed. Viral markers, HCV antibodies, and hepatitis B surface antigen were measured by enzyme-linked fluorescent immunoassay, with quantitative estimation of HCV RNA and microRNA-122 levels by real-time PCR.

Results

The microRNA-122 level in HCV patients (those with a sustained virologic response 12 weeks after finishing therapy [SVR12] and non-responders) was significantly increased compared with controls and expressed more in non-responders versus SVR12 (p=0.042). ROC curve analysis of microRNA-122 for differentiating HCV patients from healthy controls revealed that a cut-off point of >1.45 had a sensitivity of 67.20%, specificity of 94.0%, AUC=0.861, and p<0.001; and for predicting response to treatment a cut-off point ≤5.66 could significantly (p=0.022) predict the occurrence of SVR, with a sensitivity of 60.34%, specificity of 66.67%, and AUC=0.729. Logistic regression analysis showed significant values for microRNA-122 in multivariate and univariate analysis for the prediction of response to DAAs.

Conclusion

The results demonstrated the possible function of microRNA-122 as an indicative tool for distinguishing chronic HCV patients from controls and in the assessment of the therapeutic reaction to DAAs.

Hepatitis C virus associated skin manifestations in upper Egypt: Before and after direct acting antiviral treatment

Egypt displays a high-hepatitis C virus (HCV) burden and almost 20% of the patients develop cutaneous manifestations HCV-related. Direct acting antivirals (DAAs) drastically changed HCV patient's morbidity and mortality but their impact of the cutaneous manifestations remains elusive. Our aim was to find out the prevalence of different dermatological manifestations accompaning HCV infection in Egyptian patients. Also, to highlight the impact of DAAs on such manifestations and any potential dermatological side effects. A descriptive study was carried out at the Department of Tropical medicine and Gastroenterology in collaboration with the Department of Dermatology, Venerology and Andrology, Assiut University Hospitals. Medical history, full general, dermatological examination and photography were performed for all patients before the start of treatment with the full regimen of DAAs, every month and 3 months after reaching sustained virological response (SVR), and the changes of skin lesions were recognized and rated by two blinded dermatologists. Out of 1000 examined patient, 36.9% had skin manifestation. Itching was the commonenst presented in 190 patients (51.5%). Three months after reaching SVR, skin examination revealed improvement in the majority of patients (23 764.22%). Pruritis had significant clinical improvement in 152(80%) of patients with significant change in the Visual Analog Score (P = .000). Also, patients with both cutaneous vasculitis and eczema experienced improvement in their skin manifestations. Skin manifestations are common in Egyptian patients with HCV infection. Pruritis is the commonest. The use of DAAs in treatment of HCV is associated with significant improvement of skin lesions with very limited cutaneous adverse effects.

Genital lichen planus: An underrecognized entity

Genital lichen planus (LP) is an underrecogonized dermatosis. The appearance is often unlike classical LP elsewhere, and hence, the condition goes undiagnosed in many. Vulvo-vaginal LP in particular, can be a distressing condition often leading to scarring and a poor quality of life. Treatment for most of the genital LP variants is similar to managing LP elsewhere; however, the erosive variant requires special attention as treatment outcomes are often disappointing and the disease runs a protracted course. Potential for development of malignancy also exists, as in oral LP, and hence close follow up is essential.

Randomised controlled trial conducted in injecting equipment provision sites to compare the effectiveness of different hepatitis C treatment regimens in people who inject drugs: A Direct obserVed therApy versus fortNightly CollEction study for HCV treatment-ADVANCE HCV protocol study

INTRODUCTION

Hepatitis C is a blood-borne virus (HCV) that can seriously damage the liver and is spread mainly through blood-to-blood contact with an infected person. Over 85% of individuals who have HCV in Scotland became infected following injecting drug use. Since people who inject drugs (PWID) are the main source of new infections, theoretical modelling has suggested that treatment of HCV infection in PWID may effectively reduce HCV prevalence and accomplish elimination. This protocol describes a clinical trial delivering HCV treatment within injecting equipment provision sites (IEPS) in Tayside, Scotland.

METHODS AND ANALYSIS

PWID attending IEPS are tested for HCV and, if they are chronically infected with HCV and eligible, invited to receive treatment within the IEPS. They are randomised to one of three treatment regimens; daily observed treatment, treatment dispensed every 2 weeks and treatment dispensed every 2 weeks together with an adherence psychological intervention (administered before treatment begins). The primary outcome is comparison of the rate of successful treatment (SVR12) in each treatment group. Secondary analyses include assessment of adherence, reinfection rates, viral resistance to treatment and interaction of the treatment with illicit drugs.

ETHICS AND DISSEMINATION

The ADVANCE (A Direct obserVed therApy versus fortNightly CollEction) HCV trial was given favourable opinion by East of Scotland Research Ethics Committee (LR/17/ES/0089) prior to commencement.

TRIAL REGISTRATION NUMBERS

European Clinical Trials Database (EudraCT) (2017-001039-38) and ClinicalTrials.gov (NCT03236506).

Association between hepatitis C infection in Thai patients with oral lichen planus: A case-control study

AIM

The aim of the present study was to investigate the prevalence of hepatitis C virus (HCV) infection and evaluate liver enzyme levels in patients from upper northern Thailand with oral lichen planus (OLP).

METHODS

A case-control study of 101 patients with OLP and 101 patients without OLP was conducted. Peripheral blood was taken from each patient and screened for anti-HCV antibody using immunochromatography. Positive samples were further confirmed using chemiluminescent microparticle immunoassay (CMIA) and reverse transcription-polymerase chain reaction. In addition, liver enzyme levels, alanine transaminase, aspartate transaminase, and alkaline phosphatase were evaluated using spectrophotometry.

RESULTS

Immunochromatography and CMIA revealed that nine patients with OLP (8.9%) were positive for anti-HCV antibodies, whereas only one patient without OLP was HCV positive (odds ratio = 9.78). All patients who were HCV positive had significantly higher liver enzyme levels than patients who were HCV negative.

CONCLUSIONS

The results of the present study indicated that OLP in certain patients was significantly associated with HCV. This could warrant screening for HCV-infected patients with OLP in Thailand.

Lack of Any Relationship Between Circulating Autoantibodies and Interleukin–6 Levels in Egyptian Patients Infected with the Hepatitis C Virus

Introduction: Elevated serum interleukin (IL) 6 has been reported in patients infected with the hepatitis C virus (HCV), but it remains debatable whether this influences the production of autoantibodies and the biochemical profile of HCV disease. Therefore, this current study was conducted to evaluate the relationship between IL-6 and circulating autoantibody levels in HCV positive patients. Methods: Levels of IL-6 in serum samples from 102 patients with HCV and 103 normal controls were determined by enzyme linked immunosorbent assay (ELISA). Autoantibodies were detected by immunofluorescence. Results: Levels of IL-6 were significantly higher (p=0.028) in patients infected with (HCV) compared with normal group. Autoantibodies were noted in in 43.1% of the patients; of these, 23.5% featured anti-nuclear antibodies (ANA+), 16.7% anti-smooth muscle antibodies (ASMA+), 7.8% anti-mitochondrial antibodies (AMA+), 17.6% anti-parietal cell antibodies (APCA+), 7.8% anti canalicular antibodies, and 2.9% anti reticulin antibodies (ARA+). No patients were found to be positive for anti-brush border antibodies (ABBA) or anti-ribosomal antibodies. (ARiA). No links with IL-6 levels were apparent. Conclusions: IL-6 levels are increased in patients infected with HCV disease and could influence the production of autoantibodies. However, this study did not provide evidence of a specific relationship between IL6 and circulating autoantibodies in such cases.

Parallel expression profiling of hepatic and serum microRNA-122 associated with clinical features and treatment responses in chronic hepatitis C patients

MicroRNAs (miRNAs) are small, non-coding RNAs that regulate a variety of biological processes. Recently, human liver-specific miRNA miR-122 has been reported to facilitate hepatitis C virus (HCV) replication in liver cells. HCV is one of the leading causes of liver diseases worldwide. In Pakistan, the estimated prevalence is up to 10%. Here, we report hepatic and serum miR-122 expression profiling from paired liver and serum samples from treatment-naive chronic hepatitis C (CHC) patients and controls. We aimed to elucidate the biomarker potential of serum miR-122 for monitoring disease progression and predicting end treatment response (ETR). Hepatic miR-122 levels were significantly down-regulated in CHC patients. A significant inverse correlation was observed between hepatic and serum miR-122 levels, indicating that serum miR-122 levels reflect HCV-associated disease progression. Both hepatic and serum miR-122 were significantly correlated (P < 0.05) with several clinicopathological features of CHC. Receiver operator curve analysis showed that serum miR-122 had superior discriminatory ability even in patients with normal alanine transaminase levels. Multivariate logistic regression analysis highlighted pre-treatment serum miR-122 levels as independent predictors of ETR. In conclusion, serum miR-122 holds the potential to serve as a promising biomarker of disease progression and ETR in CHC patients.

Dermatologic Extrahepatic Manifestations of Hepatitis C

Hepatitis C virus (HCV) affects millions of people worldwide, and an estimated 3.2 million people in the United States. HCV is a hepatotropic and lymphotropic virus that causes not only liver disease, but also a significant number of extrahepatic manifestations (EHMs). Up to 74% of patients affected by HCV will have HCV-related EHMs of some severity in their lifetime. The EHMs vary from simple cutaneous palpable purpura to complex lymphoproliferative disorders, including lymphomas and immune-complex deposit diseases causing local and/or systemic complications. Mixed cryoglobulinemia (MC) is manifested by multiple systemic organ involvement, mainly skin, kidney, peripheral nerves, and salivary glands, and less frequently causes widespread vasculitis and malignant lymphoma. MC affects up to 3% of HCV-infected patients with cryoglobulinemia of clinical significance, i.e. >6%. Severe disease requires immunosuppressive or plasma exchange therapy. HCV prevalence in the United States in patients with porphyria cutanea tarda (PCT) was reported to be 66%, much higher than that in general population. Therefore, all patients with PCT should be screened for HCV. The skin rash of PCT varies from large blisters to small vesicles and/or milia on the hands. Skin manifestations due to PCT usually respond to anti-HCV treatment together with reducing skin sun exposure, avoiding triggers, having routine phlebotomy (especially for people with chronic iron overload states), and using chloroquine. Lichen planus (LP), which typically affects both the skin and oral mucosa is a chronic inflammatory disease of squamous cell origin affecting about 1% of the worldwide population. The prevalence of HCV in patients with LP varies based on geographic location. We review here the basic pathophysiology, clinical features, and management of dermatologic manifestations of HCV.

Occurrence of genetic modifications in core, 5'UTR and NS5b of HCV associated with viral response to treatment

Background

It is becoming progressively more understandable that genetic variability of viruses is a major challenge in translating the laboratory findings to clinic. Genetic variability is the underlying cause of variant viral proteins which are not targetable by host immunological machinery.

Methods

500 patients were enrolled in study and amongst them, 451 patients were followed and categorized into two groups on the basis of their treatment response. Group 1 consisting of the 376 patients exhibited SVR while group 2 comprised 75 patients who were non-responders on the basis of viral load as evidenced by Real-Time PCR. Comparative sequence analysis was done between 75 non-responders and 75 responders (randomly picked from 376) by targeting three genomic regions, 5′UTR, core and NS5B and amplified products were directly sequenced and obtained sequences were cleaned, aligned and submitted to GenBank. Maximum Parsimony (MP) method was used for phylogenetic analysis and dendrograms were dragged using MEGA 5. Heterogeneity at nucleotide and amino acid level was determined using software BioEdit and DNAman while phosphorylation and N-linked glycosylation sites were determined using NetPhos 2.0 and SignalP-NN.

Results

Genotype 3 was prevalent in group 1 whereas non-responders indicated rare genotypes of Pakistan i.e. 4 and 5, genotype 6q and 6v were reported first time from Pakistan in this study. At nucleotide and amino acid level, the genetic distance and mutation, number of predicted N-phosphorylation and N-glycosylation sites was higher in group 2 as compared to group 1. Difference in percentage composition of individual amino acids was noted to be different between the two groups.

Conclusions

It can be concluded that heterogeneity both at nucleotide and amino acid level contributed in developing drug resistant phenotype. Moreover, occurrence of rare genotypes might hurdle the way to positive response of conventional treatment. Furthermore, prediction of phosphorylation and glycosylation sites could help in targeting the proper sites for drug designing.

Prevalence of photosensitivity in chronic hepatitis C virus patients and its relation to serum and urinary porphyrins

BACKGROUND & AIMS

HCV is a major cause of chronic liver disease in Egypt. The aim was to study the prevalence of photosensitivity among asymptomatic HCV-infected patients and its possible relation to porphyrins levels and whether it can be considered an alarm for early diagnosis of the disease, which is the most important goal in the management.

METHODS

This study included 100 accidentally discovered HCV positive cases and 100 HCV negative healthy controls. All patients and controls were subjected to: Detailed history and clinical examination, dermatological examination including evaluation of reaction to solar exposure, measurement of serum AST, ALT, albumin, bilirubin, serum and urinary porphyrins levels.

RESULTS

The prevalence of photosensitivity among HCV-positive cases (33%) was significantly higher compared to 10% in the control group. Serum porphyrins were positive in 46 cases (46%), twenty-three cases (23%) had positive urinary porphyrins, while only four controls (4%) showed positive serum porphyrins and one (1%) showed positive urinary porphyrins, the difference was statistically significant. Cases with photosensitivity showed significantly higher prevalence of serum and urinary porphyrins existence as well as serum porphyrins levels. Levels of viraemia showed statistically significant relation to levels of porphyrins.

CONCLUSION

Asymptomatic chronic HCV infection cases showed significantly high prevalence of photosensitivity, which is related to the associated disturbance of porphyrins metabolism. Photosensitivity can thus be considered an early marker of HCV infection. Patients discovered to have recently acquired photosensitivity should be screened for HCV infection especially in endemic areas like Egypt.

Is There Any Association between Hepatitis G Virus (HGV), Other Hepatitis Viruses (HBV, HCV) and Behçet's Disease?

Infectious agents, especially viruses, have been implicated in the pathogenesis of Behçet's disease (BD). The aim of this study was to determine whether BD is associated with hepatitis viruses. In this study, the serological markers of hepatitis (HBsAg, anti-HBs, anti-HBc and anti-HCV) and viral nucleic acid (HGV-RNA) were studied in the sera of 35 patients, all of whom fulfilled the diagnostic criteria of the International Study Group for BD, and the results were compared with those of 36 healthy controls. The prevalences of HBsAg, anti-HBs, anti-HBc in BD patients were 2.9%, 45.7%, and 31.4%, respectively, which were not significantly different from those in healthy controls. None of the subjects in either group were found to be positive for anti-HCV. HGV-RNA was detected in two patients with BD and in none of the healthy controls. In conclusion, BD does not seem to be associated with hepatitis viral infections including hepatitis B, C, or G.

Diabetes and Hepatitis Frequency in 140 Lichen Planus Cases in Çukurova Region

The aim of the present study was to determine the Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and diabetes mellitus (DM) frequencies in lichen planus (LP) cases in our region. We performed a retrospective review of records from all cases that were diagnosed with LP at the our department between 1997 and 2002. The results were compared with the control group (any type of dermatosis other than LP). The 260 LP cases included 108 (41.5%) males and 152 (58.5%) females aged between 5 and 78 years. The clinical distribution of the lesions were 127 (48.8%) with skin lesions and 133 (51.2%) with oral mucosal lesions. The duration of disease ranged from 1 to 240 months. In 140 of 260 LP cases, hepatitis serology and pre-prandial blood glucose were examined. We found HBV positivity in 24 (17.1%) cases, Anti-HCV positivity in 7 (5%) cases, and DM in 22 (15.7%) cases. The control group included 116 (41.4%) males and 164 (58.6%) females. Their ages ranged between 10 and 82 years. In this group, we found HBV positivity in 20 (7.1%), Anti-HCV positivity in 4 (1.4%), and DM in 20 (7.1%) cases. We believe that the co-association of LP with HCV is significant and this co-association ratio indicates variance depending on clinical attributes of the lesions and racial characteristics of the patients. Although we found co-associations between HBV and LP or DM and LP, we believe that further studies are necessary to determine if they are significant.

Borderline tuberculoid leprosy and type 1 leprosy reaction in a hepatitis C patient during treatment with interferon and ribavirin

Hepatitis C is an inflammatory disease of the liver caused by a single-stranded RNA virus belonging to the Hepacivirus genus in the Flaviviridae family, called the hepatitis C virus. After initial infection, 70% to 85% of the patients develop chronic hepatitis C with hepatic fibrosis. In addition to specific liver changes, various extrahepatic manifestations have been associated with the hepatitis C virus infection or with medications used to treat the condition. We report the case of a patient with chronic hepatitis C who presented with the signs and symptoms of borderline tuberculoid leprosy and type 1 reaction four months after the start of treatment with a pegylated interferon/ribavirin combination.

Altered coronal tissue of the human dental pulp in chronic hepatitis C virus infected patients

INTRODUCTION

Hepatitis C virus (HCV) infection is characterized by a high rate of chronicity and concerns 170 million individuals worldwide. Extrahepatic manifestations are frequently observed in patients with chronic viral hepatitis. Although extrahepatic manifestations do exist with all hepatitis viruses, they are more commonly associated with chronic HCV infection. This study aimed to evaluate qualitatively and quantitatively the effect of chronic HCV infection on the coronal tissue of the human dental pulp.

METHODS

Thirty sound impacted teeth were obtained from healthy individuals as healthy controls. The patient group included another 30 sound impacted teeth obtained from chronic HCV-infected patients. The coronal pulp tissues were carefully removed, fixed, and processed to be stained with hematoxylin-eosin, alcian blue (2.5)/periodic acid-Schiff, van Gieson, and fibronectin.

RESULTS

The tissue sections of chronic HCV patients revealed disorganized pulp tissue, chronic inflammatory cell infiltrate, thickening, stenosis and occlusion of large-sized blood vessel arteriole, and collapsed venule and lymphatic system. The acidic, neutral, and mixed mucins were increased, whereas the amount of collagen was decreased, accompanied with marked decrease in the distribution and quantity of fibronectin glycoprotein. Application of Kruskal-Wallis test showed that there were statistically significant changes between the 2 groups (P ≤ .05).

CONCLUSIONS

The coronal tissue of the dental pulp, like any other body tissues, is affected by chronic HCV infection, with an inappropriate cellularity, vasculature, and extracellular matrix proteins. The clinician should be alerted to these histologic changes and their subsequent implications.

Screening of hepatitis C virus genotypes in urticaria patients in Saudi Arabia

OBJECTIVE

The main objective of this study was to estimate the prevalence of hepatitis C virus (HCV) infection and to determine the HCV genotypes in urticaria patients of Saudi Arabia.

METHODS

After thorough clinical examination by a consultant dermatologist, urticaria patients and individual healthy controls were enrolled. Venous blood collected from subjects was analyzed for LFT (aspartate transaminase [AST], alanine transaminase [ALT], albumin, and bilirubin), hepatitis B surface antigen (HBsAg), and HCV antibodies--HCV-RNA-PCR screening and genotyping.

RESULTS

Upon enzyme immunoassay (EIA) screening for HCV infection, 5/70 (7.1%) urticaria patients and none among the controls tested positive for the presence of anti-HCV antibodies (p=0.005). Genotyping analysis revealed that HCV belongs to types 3 and 4 with subtypes 3a, 4a, and 4c. No significant variations were seen in the mean serum levels of ALT, AST, albumin, and bilirubin between the patients based on their HCV sero-positivity status.

CONCLUSION

This prospective study indicated that HCV infection plays a significant role in urticaria. However, larger studies in different ethnicities could ascertain the association between different HCV genetic variants and the urticaria.

Different patterns of dermatological presentations in patients co-infected with human immunodeficiency virus and hepatitis C virus (HCV), and those infected with HCV alone

BACKGROUND

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) share the same transmission routes. About 30% of HIV-positive patients are co-infected with HCV. Of the various HCV-related extrahepatic events, those involving the skin may be the first sign of infection.

AIM

To specify the skin presentations in patients co-infected with HIV and HCV (co-infected patients; CP) and compare them with those found in patients with HCV mono-infection (mono-infected patients; MP).

METHODS

This was a cross-sectional study, in which the studied population consisted of MP and CP from a tertiary hospital in the South of Brazil, who underwent complete skin examination and laboratory tests.

RESULTS

In total, 201 patients were assessed, of whom 108 were CP, and 93 were MP. Pruritus tended to be more common in MP. MP also had significantly more dermatological conditions (mean of 5.2) than CP (mean of 4.5). In total, 104 different skin diseases were identified. There was a higher prevalence of infectious diseases and pigmentation disorders, such as verruca vulgaris and facial melasma, in CP, whereas trunk and facial telangiectasias, palmar erythema, and varicose veins were more common in MP.

CONCLUSION

We found a high prevalence of skin conditions both in MP and in CP; however, the patterns of the dermatological conditions were different. CP were found to have significantly fewer skin lesions than MP, but had a higher prevalence of infectious and pigmentation disorders. By contrast, vascular conditions were more common in MP.

Determination of hepatitis C virus genotypes in pruritus patients in saudi arabia

The main objective of this study was to estimate the prevalence of Hepatitis C virus (HCV) genotypes in 56 pruritus patients and 50 healthy blood donors on the basis of clinical and laboratory investigations. Both demographic and clinical data were collected from each subject after obtaining informed consent and approval from an ethics committee. Ten milliliters of venous blood was collected from fasting patients (8-10 h) and serum was used for aspartate transaminase and alanine transaminase tests, anti-HCV antibody testing, HCV-RNA polymerase chain reaction screening, and genotyping analysis. HCV was found to be significantly predominant over HBV infection among the pruritus patients (p<0.001). Twelve pruritus patients (21.42%) were positive for anti-HCV antibodies and nine of them were confirmed positive for HCV RNA presence. Of the two major genotypes revealed, genotype 4 was found to be significantly predominant over the mixed genotype, that is, 4a/c+3a (p<0.001). Subtyping results showed that a significant majority of the type 4 were of the HCV subtype 4a (five patients), followed by 4c (two patients) and 4b genotypes (one patient) and mixed genotype 4a/c+3a (one patient). Results of this prospective study indicated the significant association between pruritus and HCV infection. HCV genotype 4 is the most predominant genotype among the pruritus patients and warrants larger studies in different ethnicities to find the molecular association between HCV genetic variants and pruritus.

Immune-mediated myelitis associated with hepatitis virus infections

Virus-induced spinal cord damage results from a cytolytic effect on anterior horn cells or from predominantly cellular immune-mediated damage of long white matter tracts. Infection with the hepatitis virus group, most notably hepatitis C virus, has infrequently been associated with the occurrence of myelitis. The pathogenesis of hepatitis virus-associated myelitis has not been clarified: virus-induced autoimmunity (humoral or cell-mediated, possibly vasculitic) seems the most likely disease mechanism. Limited available information offers no evidence of direct hepatitis virus infection of the spinal cord. Virus neuropenetration may occur after virus-infected mononuclear cells penetrate the blood-brain barrier, but a true neurolytic effect has not been demonstrated. Attacks of acute myelitis usually respond favorably to immunomodulatory therapy. Antiviral therapy plays no confirmed role in the treatment of acute bouts of myelitis, but may limit the relapsing course of HCV-associated myelitis.

Dermatologic disorders and the liver

Chronic liver disease is associated with several cutaneous manifestations. Although many of these changes are nonspecific, some are associated with distinct liver diseases and correlate with the severity of hepatic pathology. Often the first clue to a liver disease is manifested through skin. Although cirrhosis is associated with spider nevi and palmar erythema, disorders can result in noncirrhotic cutaneous manifestations. It is important for physicians to be familiar with the spectrum of these manifestations, to recognize, help detect, and treat the underlying hepatic disease. This article reviews the medical literature and discusses the spectrum of dermatologic manifestations of liver disorders and their pathogenesis, significance, and treatment.

Endemic hepatitis B and C virus infection in a Brazilian Eastern Amazon region

CONTEXT

Hepatitis B and hepatitis C infection has been an important cause of morbidity and mortality around the world. However there are few investigations regarding the prevalence and possible risk factors for these diseases in Brazil, particularly in Amazon region, where there are some endemic focus.

OBJECTIVES

To determine the prevalence of hepatitis B and hepatitis C in the city of Buriticupu, MA, located in the Brazilian Eastern Amazon region, and try to explore the risk factors for these infections in that area.

METHODS

Two hundred forty three subjects (46.5% male and 53.5% female) were investigated.

RESULTS

The prevalence of past or current infection of hepatitis B and C virus was, respectively, 40.74% and 5.76%. Positivity for HBsAg was found in 2.88% of the subjects. The prevalence of current infection or chronic virus carriers found was 2.88% (HBsAg). There was a statistically significant relationship between the sera-prevalence of anti-HBc and the distance of the residence from the city center which may reflect an indirect association between the infection and precarious conditions of existence. Individuals with age equal or greater than 60 years were also more likely to be anti-HBc positive which could only reflect that older people have a longer history of exposure to hepatitis B infection. The prevalence of hepatitis C is higher than the worldwide estimate.

CONCLUSION

Buriticupu may be considered endemic for hepatitis B and C. Hepatitis B infection could be related to precarious living conditions and old age. Hepatitis C was not associated with the variables investigated in the present investigation.

Hepatitis C and kidney disease

Multiple extrahepatic manifestations have been associated with chronic hepatitis C, the most important among them being cryoglobulinemia, glomerulonephritis, porphyria cutanea tarda, lichen planus, seronegative arthritis, and lymphoproliferative disorders as in the sudies of Bonkovsky and Mehta (2001) and El-Serag et al. (2002). We will discuss in this paper chronic hepatitis C- related kidney disease and course and management of patients with chronic hepatitis C in special circumstances like hemodialysis and kidney transplantation.

Leukocytoclastic vasculitis and necrolytic acral erythema in patients with hepatitis C infection: do viral load and viral genotype play a role?

BACKGROUND

Leukocytoclastic vasculitis (LCV) and necrolytic acral erythema (NAE) are skin disorders associated with hepatitis C virus (HCV) infection. However, they have not been found to occur simultaneously in the same patient.

OBJECTIVE

We sought to analyze the role of serum HCV-RNA levels and HCV genotype in the pathogenesis of both LCV and NAE in an attempt to assess whether these two parameters play a role in mutual exclusivity of LCV and NAE in the same patient.

METHODS

The study included 11 patients with LCV and 13 with NAE, all of whom were infected with HCV. All 24 patients were evaluated for the quantitative levels of HCV-RNA, using real-time polymerase chain reaction. HCV genotyping was performed on 10 patients in each group (N = 20).

RESULTS

Patients with LCV had a higher prevalence of moderate and high levels of HCV-RNA viremia (P = .038) than those with NAE. However, there was no significant difference in HCV genotype between LCV and NAE groups (P = .211).

LIMITATIONS

Small number of cases is a limitation.

CONCLUSION

Viral load seems to play a role in determining the response of the skin to HCV infection. High levels of HCV viremia were found to be significantly associated with LCV but not with NAE. HCV viremia may play a role in the development of LCV in HCV-infected patients.

[Skin signs of systemic diseases]

Many aspects of cutaneous signs are of importance to nondermatologists, as skin manifestations can reflect internal disease states, either directly or as a result of a complication or treatment and therefore can lead to the diagnosis of systemic illness. Serious morbidity and mortality can be avoided by early recognition of only minor cutaneous manifestations signaling internal problems. Limited forms of collagen vascular disease exemplify the important marker function of the skin for diagnosis as well as for prognosis with their typically favorable course permitting a less aggressive treatment. The utmost important prerequisite of diagnosing skin conditions is an accurate and thorough examination of the skin, the adjacent mucous membranes and the integumentary appendages. In a first step, the primary site of the cutaneous condition should be identified (e.g. epidermal, dermal or subdermal) and then the form, the pattern, and distribution should be recognized. There are many comprehensive and excellent textbooks available for guidance. This article focuses on the more common dermatologic conditions linked to different organ systems involved (excluding infectious diseases, metabolic diseases and drug induced conditions).

Dermatologic Manifestations of Underlying Infectious Disease among Illicit Injection-Drug Users

Background:

Drug use patterns and serious bloodborne infections commonly have dermatologic manifestations among illicit injection-drug users (IDUs).

Objective:

To assess how self-reported skin conditions of IDUs may correlate with underlying infectious diseases after adjustment for drug use patterns.

Methods:

Prospective analysis of factors associated with self-reports of skin rashes, cellulitis, oral lesions, and lymphadenopathy obtained from 1,065 IDUs enrolled in a large cohort study. Variables potentially associated with each outcome were evaluated using multivariate generalized estimating equations.

Results:

In multivariate analyses, drug use patterns were associated with cellulitis, whereas human immunodeficiency virus (HIV) infection and hepatitis C (HCV) were not. HCV infection was independently associated with skin rashes (odds ratio [OR] 1.85; 95% Cl 1.17–2.94). HIV infection was independently associated with lymphadenopathy (OR 2.00; 95% CI 1.52–2.63), skin rash (OR 2.12; 95% CI 1.57–2.86), and oral lesions (OR 14.95; 95% CI 9.41–23.76).

Conclusions:

Self-reports of IDUs, which could easily be obtained as part of a functional inquiry in a clinical setting, correlate with specific drug use patterns and underlying bloodborne infections.

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 in Egyptian patients with hepatitis C virus infection

BACKGROUND

Necrolytic acral erythema (NAE) is a distinctive skin lesion that was first described in 1996 with only few cases being reported, mostly from Egypt. It is unique in its acral distribution and exclusive association with hepatitis C virus (HCV) infection.

METHODS

Twenty-three patients (mean age 41.7 +/- 11.5 years; M:F 10:13) with clinical features consistent with NAE were enrolled in a 3-year period. Five of those were known HCV-infected individuals and 18 were referred by the dermatologist for evaluation and HCV screening. Liver function tests, serum zinc, hepatitis B markers, HCV antibodies and HCV-RNA were tested. All patients were subjected to skin biopsy examination; five lesional biopsies were selected for electron microscopic examination and capillary endothelium was scanned for hepatitis C viral particles. An additional five patients were subjected to detection of HCV-RNA in their skin biopsies by polymerase chain reaction. All patients received oral zinc sulfate supplementation while interferon-alpha therapy combined with ribavirin was available for four patients.

RESULTS

Most NAE patients were adults (91.3%) and the skin lesions were predominantly chronic (78.3%), with affection of the dorsa of toes and/or feet in all cases. Skin biopsies showed hyperkeratosis, psoriasiform epidermis and upper epidermal necrosis. Electron microscope examination demonstrated clumped tonofilaments in the keratinocytes, yet HCV-RNA could not be detected in the skin lesions of examined cases. Interferon-alpha combined with ribavirin caused regression of skin lesions in three patients and complete clearance in one patient. Some improvement was induced by oral zinc administration.

CONCLUSION

Necrolytic acral erythema is considered to be a cutaneous marker for HCV infection. The majority of patients are diagnosed by dermatologists. Therefore, improved awareness of this cutaneous lesion should prompt early diagnosis and treatment of HCV, which should in turn cure the lesion and prevent progression of liver disease.

Extrahepatic manifestations of hepatitis C virus

Given the high prevalence of chronic hepatitis C virus (HCV) infection, its clinical sequelae account for a significant proportion of patients presenting to gastroenterologists and hepatologists. Whereas the hepatic manifestations of hepatitis C are well described, including hepatitis, cirrhosis, and the development of hepatocellular carcinoma, the extrahepatic manifestations, though common, are less well appreciated. Although nonspecific, fatigue and arthralgias are very common in those with chronic hepatitis C. Extrahepatic syndromes have been reported in as much as 36% of HCV patients, but the exact prevalence is not known. Patients with these syndromes can be divided into those with a high degree of association and those with a more moderate or mild association with HCV. The most prevalent extrahepatic diseases with the highest degree of association with HCV are the essential mixed cryoglobulins with skin, neurologic, renal, and rheumatologic complications. Non-cryoglobulin diseases with a less definite relationship to HCV include systemic vasculitis, splenic lymphoma, porphyria cutanea tarda, and the sicca syndromes. This article highlights the pathophysiology and clinical manifestations of these disorders.

Epidermolysis bullosa acquisita occurring in 2 patients with hepatitis C

We report 2 patients with documented chronic hepatitis C infection and epidermolysis bullosa acquisita (EBA). Both patients clinically represent classic EBA, exhibiting skin fragility and blistering occurring both spontaneously and secondary to trauma, which heal with milia and scar formation. EBA often is a disease of altered immune status and debility. Further work is necessary to show whether hepatitis C plays a causative role in EBA in these 2 patients and in general.

Epidemiology of transfusion-transmitted infections among multi-transfused patients in seven hospitals in Peru

BACKGROUND

Transfusion-transmitted infections (TTIs) constitute a major health problem worldwide where routine screening of blood or blood products is improperly done, and where non-medical injecting medications and/or drug use are prevalent. Prevalence and risk factors vary by geographic location and by the specific TTI (including HIV-1, HBV, HCV and HTLV-I).

OBJECTIVE

To determine the prevalence and risk factors associated with TTIs among a sample of multi-transfused adult patients in Peru.

STUDY DESIGN

A cross-sectional multi-center study was conducted across seven major hospitals in Peru from February 2003 to September 2004. Self-reported behavior information (medical procedures, number of sexual partners, and drug use history) was analyzed, along with a review of exposure history from hospital medical records. Prevalences were calculated by TTI for different exposures, along with unadjusted and adjusted odds ratios for infection risk.

RESULTS

Overall, 192 (54.7%) of 351 multi-transfused patients were found infected with one or more TTIs. Number of transfusion units, years of transfusion history (6 or more), and number of treatment facilities (2 or more) were associated with HCV infection. Hemodialysis history was a common risk factor associated with HBV, HCV and HTLV-I infection. HIV infection was associated only with total number of transfusion units received.

CONCLUSIONS

High prevalences of HBV and HCV infection were found among Peruvian multi-transfused patients and were associated with a past history and number of blood transfusions, as well as with past hemodialysis procedures. TTIs continue to represent a significant public health problem in Peru. Continued vigilant attention to blood safety procedures, including universal screening and health care provider education, is recommended.

The relationship between lichen planus and hepatitis C in dermatology outpatients in Kerman, Iran

BACKGROUND

Lichen planus (LP) is classified as a papulosquamous disease. It has been associated with liver disease, particularly hepatitis C virus (HCV) infection, in several studies. Most of these reports, especially the larger series, were conducted in Europe and Japan.

OBJECTIVE

We conducted a case-control study in Kerman, Iran to explore the association between LP and HCV.

METHODS

The study included 66 patients with LP (as cases; mean age = 39.7 +/- 15.8 years; 31 female, 35 male) and 140 volunteer blood donors (as controls; mean age = 29.5 +/- 8.4 years; 43 females, 97 males). An enzyme-linked immunosorbent assay (ELISA) was used to determine the presence of anti-HCV antibodies in all subjects in both groups. To confirm positive diagnoses, a second generation recombinant immunoblot assay (RIBA II) test was performed.

RESULTS

Lichen planus lesions were most frequently located on the trunk and extremities, and the most common clinical type was generalized LP (48.5%). One of the patients with LP (1.5%) and three of the controls (2.1%) were HCV-Ab positive. No significant difference was observed in HCV-Ab positive between the two groups (OR = 0.7; 95% CI = 0.1-6.9).

CONCLUSION

The findings indicate that an investigation for HCV infection should not necessarily be performed in all patients with LP. It is recommended that further studies should focus on larger groups in other regions of Iran to determine whether testing for HCV infection is necessary in patients with LP.

Associação entre líquen plano e infecção pelo vírus da hepatite C: um estudo prospectivo envolvendo 66 pacientes da clínica de dermatologia da Santa Casa de Misericórdia de São Paulo

FUNDAMENTOS: O líquen plano é dermatose inflamatória crônica de etiologia desconhecida. Sua associação com doença hepática, particularmente a hepatite C, é tema de diversos trabalhos em todo o mundo, desde 1990, quando a sorologia para detecção do vírus da hepatite C (VHC) se tornou disponível. OBJETIVOS: Este estudo visa avaliar uma possível relação causal entre a infecção pelo vírus C e o líquen plano. MÉTODOS: Tomaram-se por grupo de estudo 66 pacientes com líquen plano matriculados na Clínica de Dermatologia da Santa Casa de Misericórdia de São Paulo, no período de 2000 a 2003. O grupo comparativo foi constituído pelos doadores de sangue voluntários do Banco de Sangue da Santa Casa de Misericórdia de São Paulo, durante o período de outubro de 2001 a outubro de 2002. RESULTADOS: Dos 66 pacientes com líquen plano, cinco apresentaram sorologia positiva para VHC, representando 7,5% em comparação com 0,69% dos doadores de sangue. CONCLUSÕES: Esse resultado é compatível com muitos dados contidos na literatura médica mundial. Entretanto, são necessários novos estudos para o melhor conhecimento dessa controversa relação.

The prevalence of hepatitis C in patients with porphyria cutanea tarda in Stockholm, Sweden

In many countries hepatitis C virus infection has been considered a major factor triggering overt porphyria cutanea tarda. The prevalence of hepatitis C virus infection was retrospectively studied in 87 patients who during a period of 11 years were diagnosed with porphyria cutanea tarda in Stockholm. Among patients with the sporadic form of porphyria cutanea tarda, the prevalence of hepatitis C virus infection was 36.4%. As hepatitis C virus infection may today be successfully treated and as the infection may be clinically silent and thus unknown to the patient, it is important to screen all patients with porphyria cutanea tarda for hepatitis C virus infection.

Oral lichen planus in childhood

Oral lichen planus is rare in childhood, and only a few reports on this subject have appeared in the literature. Our objective was to report individual cases of oral lichen planus in childhood from our practice and to review the literature on this subject. We recruited patients younger than 18 years with oral lichen planus and documented several clinical aspects, the histopathology, patch tests, and blood examination findings. Three patients from about 10,000 dermatology patients younger than 18 years seen from 1994 to 2003 were included. Of these three, an Asian girl aged 11 years had an asymptomatic, hyperkeratotic variant of oral lichen planus, which disappeared without any treatment after 1 year. An Asian boy aged 16 years had an erosive oral lichen planus with severe pain, which healed after intensive local and systemic treatment in 2 years. A Caucasian girl aged 14 years had a hyperkeratotic variant with a little soreness, which disappeared with local treatment after 3 months. Our findings indicated that oral lichen planus in childhood is rare and therefore at present it is not possible to draw firm conclusions considering its nature and etiology. Oral lichen planus in childhood seems to occur preferentially in those of Asian race. The clinical features resemble those of oral lichen planus in adults. However, generally the prognosis of oral lichen planus in childhood seems to be more favorable than in adults.

Association of lichen planus with hepatitis C virus infection

BACKGROUND

An association between HCV infection and lichen planus is uncertain because the prevalence of HCV infection in patients with lichen planus varies considerably from one geographic area to another. The purpose of this study was to determine the frequency of anti-HCV antibodies and its association with various clinical types of lichen planus in Mekkah, Saudi Arabia.

METHODS

A total of 114 cases of lichen planus were selected for the study. These were divided into four categories, including patients with skin lesions, skin and oral lesions, and oral or genital lesions alone. The sera of these patients were tested for HCV antibodies by means of a third-generation ELISA and serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were simultaneously determined. A group of 65 volunteers served as a control group.

RESULTS

Of the 114 patients with lichen planus, 30 had HCV antibodies (26.3%). In the 65 control group subjects anti-HCV antibodies were observed in 3 volunteers (4.6%). There was a significant difference between the two groups (P<0.0001). The ALT was raised in 22 patients and the AST level was elevated in 14 of the 114 cases of lichen planus. In the control group, the AST level was raised in 3 of the 65 controls while 2 had an elevated ALT level. The number of patients with an abnormal transaminase level also significantly differed in the two groups.

CONCLUSION

A high prevalence of HCV infection was detected in patients with lichen planus. These results support a possible relationship between lichen planus and hepatitis C.

Seroprevalence of hepatitis B virus and hepatitis C virus in Monte Negro in the Brazilian western Amazon region

PURPOSE

This study was carried out in Monte Negro (state of Rondônia), a village in the Brazilian western Amazon region, where a University of São Paulo Medical School program for medical student training in rural assistance took place. It aimed to determine the prevalence of hepatitis B virus and hepatitis C virus, to investigate risk factors for infection, and to evaluate the State immunization program against hepatitis B virus in the region.

METHODS

The study is a cross-sectional seroprevalence survey, comprising 267 volunteers who answered a comprehensive questionnaire and had blood samples collected, which were analyzed in São Paulo for the presence of antibodies against hepatitis B virus (Hbs Ag, anti-Hbs, and anti-Hbc) and hepatitis C virus using commercial kits. Data were stored in a specific data bank, and the association between seropositivity and potential risk factors was analyzed by means of uni-, bi-, and multi-variate analysis, considering +/- 5%.

RESULTS

The seroprevalence of hepatitis B virus was 61.79% and of hepatitis C virus was 0.38%. Statistical analysis on the data bank showed that the prevalence of hepatitis B virus rose significantly with age, especially after adolescence. Infection was higher in those coming from outside the state of Rondônia. Exposure to vaccination against hepatitis B virus was higher in younger individuals and in those who were born in Rondônia.

CONCLUSION

Monte Negro is a highly endemic region for hepatitis B virus but not for hepatitis C virus. Our results also provide indirect evidence indicating a significant improvement in the immunization program in Rondônia in recent years.

Is there any relationship between hepatitis C virus and vitiligo?

GOALS AND BACKGROUND

Hepatitis C virus (HCV) is a hepatotropic and lymphotropic virus. This agent can promote development of a panel of autoimmune diseases. The relationship between HCV infection and vitiligo, in which autoimmune mechanisms are believed to play a role is not yet elucidated. In this study we investigated HCV seropositivity in vitiligo patients and compared this with non-vitiligo population.

STUDY

A total of 102 consecutive patients with vitiligo were included in the study (47 male, 55 female, mean age: 36.8 +/- 16.9 years, range: 5-75). Control population was 670 age and sex matched healthy blood donors (406 male, 264 female, mean age: 32.8 +/- 11.3 years, range: 20-58). Third generation enzyme immunoassay was used for serum anti-HCV determination. When positive, qualitative confirmation was performed by HCV-RNA determination using RT-PCR.

RESULTS

Anti-HCV antibody was detected only in 1 patient and confirmed by RT-PCR test. This patient was a 6-year-old girl with a non-segmental form of vitiligo, which is more frequently associated with autoimmune disorders, hence the incidence of HCV seropositivity found as 0.98%. There was no statistically significant difference between this figure and 0.6% prevalence in healthy blood donors.

CONCLUSION

Seroprevalence of HCV in vitiligo patients is not different from that of a control group in Turkey, and HCV infection may not be involved in the pathogenesis of vitiligo despite case reports showing co-existence of these 2 diseases.

Dermatologic drug reactions

Cutaneous drug reactions have a variety of clinical presentations. This review focuses on the most common or severe cutaneous reaction patterns. Knowledge of the clinical morphology and the most commonly associated medication aids in rapid diagnosis and institution of the appropriate therapy.

No association between hepatitis B or C viruses and vulval lichen planus in a UK population

The aim of the study was to investigate the prevalence of hepatitis C (HCV) antibodies, hepatitis B surface antigen (HBsAg) carriage and liver disease in 100 females with genital lichen planus (LP) in Oxfordshire. Sera were screened for HCV antibodies (AxSYM HCV 3.0 Abbott), HBV surface antigen (AxSYM HBsAg V2 Abbott), mitochrondrial and anti-smooth muscle antibodies. Liver function tests were undertaken. All sera were negative for HCV antibody and HBsAg. Transiently abnormal liver function tests (2) and liver specific antibodies (2) were detected in four patients with no underlying liver disease. We found no association between HBV or HCV and genital LP in this population.

Varicella glomerulonephritis mimicking microscopic polyangiitis

Varicella in childhood is usually a self-limiting illness with few complications. Varicella nephritis is an uncommon entity and seen mostly in immunocompromized individuals. We report a 14-year-old boy with juvenile rheumatoid arthritis who developed varicella nephritis and in whom the renal manifestations preceded the skin lesions by 1 week. This is an extremely unusual occurrence, and only one case has been described before. Such a presentation can mimic the clinical features of microscopic polyangiitis.