Liver findings in infantile cytomegalovirus infection: similarity to extrahepatic biliary obstruction

Insight into the distinctive paradigm of Human Cytomegalovirus associated intrahepatic and extrahepatic cholestasis in neonates

Human Cytomegalovirus has been implicated as a probable cause for the development of hepatic cholestasis among neonates. Our study tried to ascertain the exact demographic, biochemical and immunological markers to differentially diagnose patients with HCMV associated intrahepatic and extrahepatic cholestasis and also decipher the phylogenetic variability among the viral strains infecting the two groups. A total of 110 neonates collected over a span of 2 years were selected for the study classified into four different groups based on the presence of hepatic cholestasis and active HCMV infection. Our analysis predicted that total Cholesterol, GGT, ALP and TNFα were the only significant biological markers with exact cut-off scores, capable of distinguishing between HCMV associated intrahepatic and extrahepatic cholestasis. We confirmed that in patients belonging to both of these groups, the inflammasome is activated and the extent of this activation is more or less same except for the initial activators NLRP3 and AIM2 respectively. When we performed two separate phylogenetic analyses with HCMV gM and gN gene sequences, we found that in both cases the sequences from the IHC and EHC groups formed almost separate phylogenetic clusters. Our study has shown that the HCMV clinical strains infecting at intrahepatic and extrahepatic sites are phylogenetically segregated as distinct clusters. These two separate groups show different physiological as well as immunological modulations while infecting a similar host.

Vanishing bile duct syndrome in human immunodeficiency virus infected adults: A report of two cases

Vanishing bile duct syndrome (VBDS) is a group of rare disorders characterized by ductopenia, the progressive destruction and disappearance of intrahepatic bile ducts leading to cholestasis. Described in association with medications, autoimmune disorders, cancer, transplantation, and infections, the specific mechanisms of disease are not known. To date, only 4 cases of VBDS have been reported in human immunodeficiency virus (HIV) infected patients. We report 2 additional cases of HIV-associated VBDS and review the features common to the HIV-associated cases. Presentation includes hyperbilirubinemia, normal liver imaging, and negative viral and autoimmune hepatitis studies. In HIV-infected subjects, VBDS occurred at a range of CD4+ T-cell counts, in some cases following initiation or change in antiretroviral therapy. Lymphoma was associated with two cases; nevirapine, antibiotics, and viral co-infection were suggested as etiologies in the other cases. In HIV-positive patients with progressive cholestasis, early identification of VBDS and referral for transplantation may improve outcomes.

A reduced segment II/III graft for neonatal liver failure with absence of detectable hepatocytes. A case report and literature review

When hepatic failure occurs in newborns, most cases are because of viral hepatitis, metabolic diseases, and neonatal hemochromatosis. It is rare to have liver failure presenting in the first day after birth. We report a unique case of a newborn baby with liver failure in the first day of life who received a reduced segment II and III graft when she was 19 days old and became the youngest survivor of LDLT. Common and rare causes of liver failure in this age group were excluded by appropriate testing. She underwent a liver biopsy that showed a liver devoid of hepatocytes. Similar pathological findings were found in the explanted liver. She was discharged from the hospital with normal graft function three months after the transplant.

Biliary atresia: color doppler US findings in neonates and infants

PURPOSE

To describe color Doppler ultrasonographic (US) findings in livers of neonates with biliary atresia (BA) and to compare them with US findings in livers of neonates with non-BA and control subjects.

MATERIALS AND METHODS

Institutional review board approval was obtained; acquisition of informed consent was exempted. US and color Doppler US findings were retrospectively reviewed in 64 patients with neonatal cholestasis and 19 control subjects. BA and non-BA were confirmed in 29 and 35 patients, respectively. Three pediatric radiologists assessed US and color Doppler US images, independently documented their findings, and resolved discrepancies by consensus. Triangular cord (TC) sign, gallbladder length, and hepatic artery and portal vein diameters were evaluated on US images. The presence of hepatic subcapsular flow was evaluated on color Doppler US images. Diagnostic value of TC sign and hepatic subcapsular flow in the diagnosis of BA were evaluated. Significance of hepatic artery and portal vein diameters in each group was assessed.

RESULTS

In the diagnosis of BA, sensitivity and specificity of the TC sign on US images were 62% and 100%, respectively. On color Doppler US images, hepatic subcapsular flow was detected in all patients with BA and in five patients with non-BA. At the first review, there was a discrepancy between radiologists in interpretation of hepatic subcapsular flow in patients with non-BA. However, consensus was reached at the second review. There was no hepatic subcapsular flow in control subjects. Sensitivity and specificity of hepatic subcapsular flow on color Doppler US images were 100% and 80%-86%, respectively, on the basis of individual interpretations of reviewers. Sensitivity and specificity of hepatic subcapsular flow on color Doppler US images were 100% and 86%, respectively, on the basis of consensus reading. Mean diameter of the hepatic artery in patients with BA (2.1 mm +/- 0.7 [standard deviation]) was significantly larger than that in patients with non-BA (1.5 mm +/- 0.4, P < .001) and control subjects (1.5 mm +/- 0.4, P = .001).

CONCLUSION

The presence of hepatic subcapsular flow is useful for differentiating between BA and other causes of neonatal jaundice.

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.

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.

High frequency of human cytomegalovirus DNA in the liver of infants with extrahepatic neonatal cholestasis

Background

Biliary atresia (BA) is the most severe hepatic disorder in newborns and its etiopathogenesis remains unknown. Viral involvement has been proposed, including the human cytomegalovirus (HCMV). The aims of the study were to use the polymerase chain reaction (PCR) to screen the liver tissue of infants with extrahepatic cholestasis for HCMV and to correlate the results with serological antibodies against HCMV and histological findings.

Methods

A retrospective study in a tertiary care setting included 35 patients (31 BA, 1 BA associated with a choledochal cyst, 2 congenital stenosis of the distal common bile duct and 1 hepatic cyst). HCMV serology was determined by ELISA. Liver and porta hepatis were examined histologically. Liver samples from infants and a control group were screened for HCMV DNA.

Results

Twelve patients had HCMV negative serology, 9 were positive for IgG antibodies and 14 were positive for IgG and IgM. Nine liver and seven porta hepatis samples were positive for HCMV DNA but none of the control group were positive (general frequency of positivity was 34.3% – 12/35). There was no correlation between HCMV positivity by PCR and the histological findings. The accuracy of serology for detecting HCMV antibodies was low.

Conclusion

These results indicate an elevated frequency of HCMV in pediatric patients with extrahepatic neonatal cholestasis. They also show the low accuracy of serological tests for detecting active HCMV infection and the lack of correlation between HCMV positivity by PCR and the histopathological changes.

Biliary atresia

BA is a rare disease of unclear etiology; nevertheless, its impact in the field of pediatric hepatology is significant. It is the most common surgically correctable cause of neonatal cholestasis and is the most common pediatric disease referred for liver transplantation. Little progress has been made with regard to improving outcome or understanding its pathogenesis in the past decade. Fortunately, however, a national, government-sponsored collaborative endeavor has begun that will hopefully make a significant impact upon the progress of designing new treatments for BA and develop a better understanding of its pathogenesis.

Fibrosing cholestatic hepatitis-like syndrome in hepatitis B virus-negative and hepatitis C virus-negative renal transplant recipients

Cholestatic hepatitis and diffuse liver fibrosis have been described in immunosuppressed patients with hepatitis B virus or hepatitis C virus infection as fibrosing cholestatic hepatitis (FCH). FCH is characterized by cholestasis, with only a modest increase in aminotransferase levels. The pathologic picture typically shows periportal and perisinusoidal fibrosis, scarce mixed infiltrates, hepatocellular ballooning, and histologic cholestasis. We report two patients with diffuse fibrosis and cholestasis quite similar to the histologic picture of FCH, but in whom neither hepatitis B virus nor hepatitis C virus infection could be shown, highlighting the potential contribution of cytomegalovirus infection and azathioprine toxicity in the development of this severe complication of solid-organ transplantation.

Biliary atresia and cytomegalovirus infection: a DNA study

The cause of extrahepatic biliary atresia (EHBA) is undetermined in most instances, but an infectious agent is widely suspected. Cytomegalovirus (CMV) infection has been associated with intrahepatic bile duct destruction and paucity, raising the question of its role in EHBA. We identified 12 children in the past 5 years with biliary atresia and examined the bile duct biopsy. These showed acute/chronic inflammation and epithelial degeneration. CMV inclusions were not identified. We used in situ hybridization and the polymerase chain reaction (PCR) for CMV-DNA on formalin-fixed, paraffin-embedded tissue. All samples showed the presence of amplifiable DNA using beta-globin primers. No biopsy tissue showed CMV DNA using specific probes and primers. The absence of demonstrable CMV DNA by in situ hybridization and PCR in EHBA biopsies implies that it is unlikely that this virus has any major role in the pathogenesis of this condition.

Clinicopathological study of liver involvement in cytomegalovirus infection in infant autopsy cases

To clarify the pathogenesis of hepatic cytomegalovirus (CMV) infection, we clinicopathologically investigated 18 infants and 10 adults with cytomegalic inclusion bodies (CIB) in the liver among a total of 75 autopsy cases with CIB in any organ of the body. CMV infection was confirmed by immunohistochemistry and in situ hybridization. When CIB were present in the liver, CMV infection also tended to be systemic. All the adults were immunocompromised patients, but diseases inducing immunodeficiency were present in only two of the infants. The severe and systemic CMV infections we found in infants might have been associated with congenital CMV infection. Histologically, hepatocyte necrosis, cholestasis, extramedullary hematopoiesis and fatty degeneration were more frequent and prominent in infants than in adults. However, inflammatory cell infiltration was only slight. In addition, the frequent association with premature birth and hypoplasia of the thymus suggested that insufficient development of immunity may result in hepatic CMV involvement in infants. CIB were most frequently observed in hepatocytes in both infants and adults, but in infants they were also frequently seen in the bile duct epithelium. These histopathological findings and the high incidence of jaundice in infant patients suggest that the bile duct is also an important site of CMV proliferation in infants, and that CMV infection may be one cause of infantile jaundice.