Association of Cytomegalovirus with Infantile Hepatitis

Human Cytomegalovirus-IE2 Affects Embryonic Liver Development and Survival in Transgenic Mouse

BACKGROUND & AIMS

Congenital human cytomegalovirus (HCMV) infection is a common cause of liver injury. The major immediate-early protein 2 (IE2) of HCMV is critical for the progression of HCMV infection. As a result of species isolation, there are no animal models suitable for HCMV infection, which aimed to study the long-term effects of IE2 on embryonic liver development in vivo. Hence, this study aimed to investigate the role of IE2 in liver development using a transgenosis mouse model.

METHODS

Rosa26-Loxp-STOP-Loxp (LAS)-IE2^+/-, cre mice that could specifically and stably express IE2 in the liver, were constructed. Phenotypic analysis, immunolocalization studies, messenger RNA analyses, transcriptome sequencing, and flow cytometry analysis were performed on Rosa26-LSL-IE2^+/-, cre mice during hepatogenesis.

RESULTS

Rosa26-LSL-IE2^+/-, cre mice could consistently express IE2 at different embryonic stages in vivo. With the development of Rosa26-LSL-IE2^+/-, cre embryos from embryonic day 17.5 to postnatal day 1, progressive liver hypoplasia and embryonic deaths were observed. Furthermore, molecular evidence that IE2 expression inhibited hepatocyte proliferation, increased cell apoptosis, and impaired hepatocyte maturation was provided.

CONCLUSIONS

Rosa26-LSL-IE2^+/-, cre mice could stably express IE2 in the liver. IE2 expression resulted in embryonic liver hypoplasia by disrupting hepatic morphogenesis and hepatocyte maturation, which may be responsible for embryonic deaths. This study is helpful in understanding the mechanism of liver injuries induced by HCMV infection.

Diagnosis of Peripheral Facial Palsy Associated with Parvovirus B19 Infection by Polymerase Chain Reaction

Human parvovirus B19 (PVB19) infection causes neurological manifestations, including encephalitis, meningitis, and neuropathy, but facial nerve palsy is rare. Moreover, no case of facial nerve palsy related to PVB19 infection that was diagnosed by PCR and serology has been reported. A 19-month-old boy without the medical history developed facial nerve palsy and was treated with prednisolone and valacyclovir. On the 19th day, erythema appeared on his body, and the PVB19-specific IgM and PVB19 DNA were detected in the serum, leading to the diagnosis of infectious erythema associated with PVB19 infection. This case indicates that PVB19 may be one of the causative agents of facial nerve palsy.

Identification of potential pathogenic viruses in patients with acute myocarditis using next-generation sequencing

Myocarditis is an inflammatory disease of the myocardium and leads to cardiac dysfunction and heart failure. Although viral infections are considered to be the most common etiology of myocarditis, the identification of the causative virus is still challenging. Recently, next-generation sequencing (NGS) has been applied in the diagnosis of infectious diseases. The aim of the current study was to comprehensively analyze potential pathogenic microorganisms using NGS in the sera of patients with myocarditis. Twelve pediatric and five adult patients hospitalized for acute myocarditis were included. Serum samples in the acute phase were obtained and analyzed using NGS to detect pathogen-derived DNA and RNA. Viral sequence reads were detected in 7 (41%) of the 17 myocarditis patients by NGS. Among these patients, detection of Epstein-Barr virus, human parvovirus B19, torque teno virus, and respiratory syncytial virus reads by NGS was consistent with polymerase chain reaction or antigen test results in one patient each. A large number of human pegivirus reads were detected from one patient by RNA sequencing; however, its pathogenicity to human is unknown. Conversely, the number of detected virus-derived reads was small in most cases, and the pathophysiological role of these viruses remains to be clarified. No significant bacterial or fungal reads other than normal bacterial flora was detected. These data indicate that comprehensive detection of virus-derived DNA and RNA using NGS can be useful for the identification of potential pathogenic viruses in myocarditis.

Disturbance in Plasma Metabolic Profile in Different Types of Human Cytomegalovirus-Induced Liver Injury in Infants

Human cytomegalovirus (HCMV) infection in infants is a global problem and the liver is a target organ of HCMV invasion. However, the mechanism by which HCMV causes different types of liver injury is unclear, and there are many difficulties in the differential diagnosis of HCMV infantile cholestatic hepatopathy (ICH) and extrahepatic biliary atresia (EHBA). We established a non-targeted gas chromatography-mass spectrometry metabolomics method in conjunction with orthogonal partial least squares-discriminate analysis based on 127 plasma samples from healthy controls, and patients with HCMV infantile hepatitis, HCMV ICH, and HCMV EHBA to explore the metabolite profile of different types of HCMV-induced liver injury. Twenty-nine metabolites related to multiple amino acid metabolism disorder, nitrogen metabolism and energy metabolism were identified. Carbamic acid, glutamate, L-aspartic acid, L-homoserine, and noradrenaline for HCMV ICH vs. HCMV EHBA were screened as potential biomarkers and showed excellent discriminant performance. These results not only revealed the potential pathogenesis of HCMV-induced liver injury, but also provided a feasible diagnostic tool for distinguishing EHBA from ICH.

Acute liver dysfunction not resulting from hepatitis virus in immunocompetent children

BACKGROUND

The aim of the present study was to clarify the roles of cytomegalovirus (CMV), Epstein-Barr virus (EBV), and human herpesvirus 6 (HHV-6) in immunocompetent children with acute liver dysfunction not resulting from hepatitis virus.

METHODS

Sixty-eight children (median age, 3 years) hospitalized as a result of acute liver dysfunction were enrolled in this study. Hepatitis A, B, and C were excluded. The prevalence of CMV, EBV, and HHV-6 and viral DNA load in whole blood was prospectively evaluated on multiplex real-time polymerase chain reaction (PCR).

RESULTS

Of the 68 children with acute liver dysfunction, multiplex real-time PCR was positive in 30 (44%). CMV, EBV, and HHV-6 DNA were detected in 13 (19%), 14 (21%), and seven (10%), respectively. Serum CMV immunoglobulin (Ig)G/IgM and EBV viral capsid antigen IgG/IgM were measured in 40 (CMV DNA positive, n = 10; negative, n = 30) and 45 (EBV DNA positive, n = 14; negative, n = 31) of the 68 children, respectively. Eighteen percent (CMV, 7/40) and 9% (EBV, 4/45) were positive for both PCR and viral-specific IgM. There was no significant difference in CMV and EBV viral load between IgM-positive and -negative children with viremia.

CONCLUSIONS

CMV, EBV, and HHV-6 DNA were frequently detected in immunocompetent children with acute liver dysfunction, but primary CMV and EBV infection were confirmed in 10-20% of the children with acute liver dysfunction. The combination of PCR assay and serology is necessary to make a diagnosis of acute liver dysfunction due to primary CMV, EBV and/or HHV-6 infection in immunocompetent children.

Dynamic relationship between infantile hepatitis syndrome and cytomegalovirus infection

We investigated the correlation between cytomegalovirus (CMV) infection and infantile hepatitis syndrome and the correlation between blood ammonia levels in children with CMV-induced hepatitis syndrome and liver function indicators. To analyze the relationship between the positive-negative attributes of CMV infection and the recurrence rate of infantile hepatitis syndrome, a total of 86 cases of children with hepatitis syndrome admitted to Xuzhou Children's Hospital from January 2014 to March 2015 were selected for the study group. Furthermore, 86 cases of healthy children who visited our hospital for a physical examination during the same period were selected as the control group. From the two groups, serum CMV-immunoglobulin M (IgM) levels were determined via enzyme-linked immunosorbent assay, and urinary CMV-deoxyribonucleic acid (DNA) was ascertained by fluorescent ratio polymerase chain reaction. These levels were then compared between the two groups and analyzed. A fully automatic biochemical analyzer was utilized to evaluate the blood ammonia and liver function indicators of the children with infantile hepatitis syndrome induced by CMV infection and to analyze the correlation of these factors. A mean follow-up of 12 months after the children's discharge was adopted to observe the relationship between the negative-positive attributes of CMV infection and the recurrence rate in the children upon cure. The positive detection rate for the serum CMV-IgM was 24.4%, and that for the urinary CMV-DNA was 34.9%; both values were significantly higher than that for the control group (P<0.05). The blood ammonia levels of the children with infantile hepatitis syndrome induced by CMV infection were not correlated with the liver function indicators, such as total bilirubin, direct bilirubin, alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase, total bile acid, and cholinesterase (P>0.05), but they were negatively correlated with blood albumin (ALB) (P<0.05). The recurrence rate of hepatitis syndrome among the children with negative CMV infection was 3.8%, which was significantly lower than that among the children with positive CMV infection (62.5%, P<0.05). A significant correlation was found between CMV infection and infantile hepatitis syndrome, with the former being a risk factor for the latter. Changes in the conditions of infantile hepatitis syndrome may be reflected by blood ammonia and ALB indicators. Through improved monitoring, these indicators facilitate the early diagnosis and treatment of children with hepatitis syndrome induced by CMV infection. Sufficient attention should be paid to preventive measures to reduce the incidence rate of infantile hepatitis syndrome.

Cryptic Hepatitis B and E in Patients With Acute Hepatitis of Unknown Etiology

BACKGROUND

Up to 30% of acute viral hepatitis has no known etiology. To determine the disease etiology in patients with acute hepatitis of unknown etiology (HUE), serum specimens were obtained from 38 patients residing in the United Kingdom and Vietnam and from 26 healthy US blood donors. All specimens tested negative for known viral infections causing hepatitis, using commercially available serological and nucleic acid assays.

METHODS

Specimens were processed by sequence-independent complementary DNA amplification and next-generation sequencing (NGS). Sufficient material for individual NGS libraries was obtained from 12 HUE cases and 26 blood donors; the remaining HUE cases were sequenced as a pool. Read mapping was done by targeted and de novo assembly.

RESULTS

Sequences from hepatitis B virus (HBV) were detected in 7 individuals with HUE (58.3%) and the pooled library, and hepatitis E virus (HEV) was detected in 2 individuals with HUE (16.7%) and the pooled library. Both HEV-positive cases were coinfected with HBV. HBV sequences belonged to genotypes A, D, or G, and HEV sequences belonged to genotype 3. No known hepatotropic viruses were detected in the tested normal human sera.

CONCLUSIONS

NGS-based detection of HBV and HEV infections is more sensitive than using commercially available assays. HBV and HEV may be cryptically associated with HUE.

Human cytomegalovirus quantification in toddlers saliva from day care centers and emergency unit: a feasibility study

BACKGROUND

Cytomegalovirus (CMV) infection is the most important cause of congenital viral infection in developed countries. In utero transmission occurs at higher rates in seronegative women during primary infection, especially those in contact with young children in day-care centers (DCC). Nevertheless data on variability of CMV excretion among children in French DCCs are lacking, and are important for public health planning.

OBJECTIVES

Our main objective was to assess the feasibility of a salivary sample in DCCs in order to study CMV excretion among toddlers. Our secondary aims were to assess prevalence of CMV excretion in children attending Hospital Emergency Unit (EU) in comparison with various types of DCCs and to validate the analytical chain for collected specimens.

STUDY DESIGN

Excretion of CMV in saliva was quantified using a real-time PCR assay in children aged from 3 months to 6 years old in EU and in DCC, with gB, gH and gN genotypes determined in infected children. Salivary sampling was performed using small sponges placed into a DNA conservation medium. Socio cultural and medical information were collected from attending parents.

RESULTS

A total of 625 children were included, with 256 from six DCCs and 369 from one EU. In DCCs, the acceptability of the procedure was 87.3% (95%CI 78.5-96.2) amongst parents and children, and in the EU, acceptability was higher at 97.6% (95%CI 95.5-98.9). CMV shedding overall prevalence was 21.7% (95%CI 17.6-26.2), with CMV shedding prevalence in DCCs of 51.9% (95%CI 22.8-81.1).

CONCLUSION

We validated the feasibility and acceptability of measuring CMV shedding in the saliva of French toddlers. The discrepancy between CMV infection rates in day care centers and in the general population (as sampled in the EU) indicates the need for a further study to determine risk factors and shedding levels in the DCC population.

Cytomegalovirus frequency in neonatal intrahepatic cholestasis determined by serology, histology, immunohistochemistry and PCR

AIM: To determine cytomegalovirus (CMV) frequency in neonatal intrahepatic cholestasis by serology, histological revision (searching for cytomegalic cells), immunohistochemistry, and polymerase chain reaction (PCR), and to verify the relationships among these methods.

METHODS: The study comprised 101 non-consecutive infants submitted for hepatic biopsy between March 1982 and December 2005. Serological results were obtained from the patient’s files and the other methods were performed on paraffin-embedded liver samples from hepatic biopsies. The following statistical measures were calculated: frequency, sensibility, specific positive predictive value, negative predictive value, and accuracy.

RESULTS: The frequencies of positive results were as follows: serology, 7/64 (11%); histological revision, 0/84; immunohistochemistry, 1/44 (2%), and PCR, 6/77 (8%). Only one patient had positive immunohistochemical findings and a positive PCR. The following statistical measures were calculated between PCR and serology: sensitivity, 33.3%; specificity, 88.89%; positive predictive value, 28.57%; negative predictive value, 90.91%; and accuracy, 82.35%.

CONCLUSION: The frequency of positive CMV varied among the tests. Serology presented the highest positive frequency. When compared to PCR, the sensitivity and positive predictive value of serology were low.

Analysis of the histologic features in the differential diagnosis of intrahepatic neonatal cholestasis

AIM: To compare the histologic features of the liver in intrahepatic neonatal cholestasis (IHNC) with infectious, genetic-endocrine-metabolic, and idiopathic etiologies.

METHODS: Liver biopsies from 86 infants with IHNC were evaluated. The inclusion criteria consisted of jaundice beginning at 3 mo of age and a hepatic biopsy during the 1st year of life. The following histologic features were evaluated: cholestasis, eosinophilia, giant cells, erythropoiesis, siderosis, portal fibrosis, and the presence of a septum.

RESULTS: Based on the diagnosis, patients were classified into three groups: group 1 (infectious; n = 18), group 2 (genetic-endocrine-metabolic; n = 18), and group 3 (idiopathic; n = 50). There were no significant differences with respect to the following variables: cholestasis, eosinophilia, giant cells, siderosis, portal fibrosis, and presence of a septum. A significant difference was observed with respect to erythropoiesis, which was more severe in group 1 (Fisher’s exact test, P = 0.016).

CONCLUSION: A significant difference was observed in IHNC of infectious etiology, in which erythropoiesis was more severe than that in genetic-endocrine-metabolic and idiopathic etiologies, whereas there were no significant differences among cholestasis, eosinophilia, giant cells, siderosis, portal fibrosis, and the presence of a septum.

Human cytomegalovirus infection in infants with prolonged neonatal jaundice

BACKGROUND

Although human cytomegalovirus (HCMV) infection in infants has been associated with liver disease, the role of HCMV in infants presenting with prolonged neonatal jaundice is unclear as this clinical picture can be caused by a broad spectrum of underlying conditions.

OBJECTIVES

This study aimed to determine a possible role for HCMV infection in infants with prolonged cholestatic neonatal jaundice that could facilitate the appropriate use of diagnostic assays and specific treatment in this condition.

STUDY DESIGN

HCMV immunohistochemical staining was performed on liver biopsy specimens received for histopathological examination from 85 infants (mean age 3 months) with a clinical history of prolonged neonatal jaundice. HCMV serology was also performed.

RESULTS

One infant with a histological diagnosis of HCMV hepatitis was also positive by immunohistochemical staining, while all other tissue specimens were negative for HCMV. HCMV IgG was positive in 92.3% and HCMV IgM in 39.7% of the infants (n=78).

CONCLUSIONS

The serological results confirm the ubiquitous nature of HCMV with many primary infections occurring within the first year of life. Despite this, HCMV hepatitis was uncommon in this cohort.

Clinical and laboratory evaluation of 101 patients with intrahepatic neonatal cholestasis

BACKGROUND

Intrahepatic neonatal cholestasis can be the initial manifestation of a very heterogeneous group of illnesses of different etiologies.

AIM

To evaluate and compare clinical and laboratory data among intrahepatic neonatal cholestasis groups of infectious, genetic-endocrine-metabolic and idiopathic etiologies.

METHODS

The study evaluated retrospectively clinical and laboratory data of 101 infants, from March 1982 to December 2005, 84 from the State University of Campinas Teaching Hospital, Campinas, SP, Brazil, and 17 from the Child's Institute of the University of São Paulo, SP, Brazil. The inclusion criteria consisted of: jaundice beginning at up to 3 months of age and hepatic biopsy during the 1st year of life. It had been evaluated: clinical findings (gender, age, birth weight, weight during the first medical visit, stature at birth, jaundice, acholia/hipocholia, choluria, hepatomegaly and splenomegaly) and laboratorial (ALT, AST, FA, GGT, INR).

RESULTS

According to diagnosis, patients were classified into three groups: group 1 (infectious) n = 24, group 2 (genetic-endocrine-metabolic) n = 21 and group 3 (idiopathic) n = 56. There were no significant differences in relation to the variables: age, gender, stature at birth, jaundice, acholia/hipocholia, choluria, hepatomegaly, splenomegaly, AST, ALT, ALP, GGT, DB and albumin. Significant differences were observed in relation to the following variables: birth weight and weight during the first medical visit. Birth weight of group 1 was lower in relation group 2 and 3. Weight during the first medical visit followed the same pattern. There was a statistically significant difference in relation to the INR, as the patients of the group 2 presented higher values in relation to groups 2 and 3, despite the median was still pointing out normal values.

CONCLUSIONS

There were no significant differences in relation to age, gender, stature at birth, jaundice, acholia/hipocholia, choluria, hepatomegaly, splenomegaly, AST, ALT, ALP, GGT, BD and albumin. Birth weight and the weight during the first medical visit were lower in the group with infectious etiology. In addition, a significant difference in INR reflected impaired coagulation of patients of the group of the genetic-endocrine-metabolic disease.

Hepatitis por virus del grupo herpes

In immunocompetent patients, primary infection by herpes simplex virus (HSV), varicella-zoster virus (VZV), cytomegalovirus (CMV), human herpesvirus 6, and Epstein-Barr virus (EBV) generally produces mild, self-limited hepatitis. Primary infection by HSV in neonates and pregnant women, and infection by VZV in hematological and bone marrow recipients can cause fulminant hepatitis without characteristic skin lesions. In liver transplant recipients, hepatitis is the most common expression of CMV infection and the related symptoms are indistinguishable from those of acute rejection. Persistent hepatitis is a manifestation of the syndrome of active chronic infection by the EBV. Fulminating hepatitis due to herpes virus can be treated effectively if therapy is started early; hence, a high degree of clinical suspicion and inclusion of herpes virus in the differential diagnosis of this syndrome is necessary.