Microtubular aggregates in human chronic non-A, non-B hepatitis with bridging hepatic necrosis and multinucleated hepatocytic giant cells

Postinfantile Giant Cell Hepatitis in Native and Allograft Livers: A Multi-Institutional Clinicopathologic Study of 70 Cases

Postinfantile giant cell hepatitis (PIGCH) is a rare hepatitis pattern in adults with variable etiologies and clinical outcomes. We conducted a multi-institutional retrospective study to define the clinicopathologic characteristics of patients with PIGCH. A total of 70 PIGCH cases were identified and reviewed for pathological features, including fibrosis, cholestasis, inflammation, steatosis, necrosis, and apoptosis, as well as the distribution of giant cells and the maximum number of giant cells per high-power field. Demographic and clinical data, including age, sex, laboratory results, etiologies, and follow-up results, were recorded. Among the 70 cases, 40% (28/70) were associated with autoimmune liver diseases, followed by 9 (13%) with unknown etiology, 8 (11%) with viral infection, 5 (7%) with medications, 5 with combined etiologies, and 4 (6%) with malignancies (mostly chronic lymphocytic leukemia). Notably, another 16% were de novo PIGCH in liver allografts, most of which occurred after a rejection event. During follow-up, 26 (37%) patients died of the disease and 44 (63%) were alive. Deceased patients were characterized by older age (mean age, 54.9 vs 45.5 years; P = .02), higher alkaline phosphatase level (mean value, 253.3U/L vs 166.3 U/L; P = .03), higher fibrosis stage (stage 3-4 vs stage 0-2, 57.7% vs 29.6%; P = .03), being more likely to have de novo PIGCH after transplantation (23.1% vs 11.4%; P = .04), and being less likely to have primary autoimmune liver disease etiology (26.9% vs 47.7%; P = .04). These results indicate that PIGCH is a rare pattern of liver injury associated with different etiologies and variable clinical outcomes. Autoimmune liver disease with PIGCH is associated with better survival, whereas de novo PIGCH in allografts is associated with poorer survival. Older age, higher alkaline phosphatase level, and advanced fibrosis are adverse prognostic factors.

Post-infantile Giant Cell Hepatitis: A Literature Review and Meta-analysis

Post-infantile giant cell hepatitis (PIGCH) is a rare disease entity in adults with a multifactorial etiology and widely variable clinical courses and outcomes. The factors associated with the worse outcomes of this disease entity are still unclear. We identified 68 PIGCH patients by searching PubMed and performed meta-analysis. Among the 68 patients, 32% of the cases were associated with autoimmune disorders, followed by 21% associated with viral infections, 10% with medication, and 7% with malignancy. Twenty-four percent of the patients had more than one etiological factor, and 6% had other uncommon etiologies or an etiology that could not be identified. At the time of this report, 17 patients had died of the disease (poor outcome), and 51 patients remained alive with the disease (good outcome). Compared to the patients with a good outcome, the patients with a poor outcome were characterized by older age, lower levels of platelets and albumin, higher level of total bilirubin, and a diffuse distribution pattern of giant cells in the liver. There were no differences in gender distribution, aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, etiological distribution, or other histological features, including interface hepatitis, necrosis, lobular inflammation, portal inflammation, cholestasis, or fibrosis. Further studies would be needed to better understand the disease mechanisms and unmask any additional etiological factors and targeted therapies.

Synergistic inhibition of hepatitis C virus infection by a novel microtubule inhibitor in combination with daclatasvir

Even though substantial progress has been made in the treatment of hepatitis C virus (HCV) infection, viral resistance and relapse still occur in some patients and additional therapeutic approaches may ultimately be needed should viral resistance become more prevalent. Microtubules play important roles in several HCV life cycle events, including cell attachment, entry, cellular transportation, morphogenesis and progeny secretion steps. Therefore, it was hypothesized that microtubular inhibition might be a novel approach for the treatment of HCV infection. Here, the inhibitory effects of our recently developed microtubule inhibitors were studied in the HCV replicon luciferase reporter system and the infectious system. In addition, the combination responses of microtubule inhibitors with daclatasvir, which is a clinically used HCV NS5A inhibitor, were also evaluated. Our results indicated that microtubule targeting had activity against HCV replication and showed synergistic effect with a current clinical drug.

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Microtubule inhibition affects HCV replication.

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Compound 9f displays time and concentration dependent inhibitory activities against HCV production.

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Combination of compound 9f with Daclatasvir shows modest synergistic effects against HCV replication.

Human ezrin-moesin-radixin proteins modulate hepatitis C virus infection

Host cytoskeletal proteins of the ezrin-moesin-radixin (EMR) family have been shown to modulate single-stranded RNA virus infection through regulating stable microtubule formation. Antibody engagement of CD81, a key receptor for hepatitis C virus (HCV) entry, induces ezrin phosphorylation. Here we tested the role of EMR proteins in regulating HCV infection and explored potential therapeutic targets. We show that HCV E2 protein induces rapid ezrin phosphorylation and its cellular redistribution with F-actin by way of spleen tyrosine kinase (SYK). Therapeutically blocking the functional roles of SYK or F-actin reorganization significantly reduced Huh7.5 cell susceptibility to HCV J6/JFH-1 infection. Using gene regulation, real-time quantitative polymerase chain reaction, western blot, and fluorescent microscopy analysis, we found that proteins of the EMR family differentially regulate HCV infection in the J6/JFH-1/Huh7.5 cell system. Moesin and radixin, but not ezrin, expression were significantly decreased in chronic HCV J6/JFH-1-infected Huh7.5 cells and HCV-infected patient liver biopsies compared to controls. The decreases in moesin and radixin in HCV J6/JFH-1-infected Huh7.5 cells were associated with a significant increase in stable microtubules. Ezrin knockdown inhibited immediate postentry events in HCV infection. Overexpression of moesin or radixin significantly reduced HCV protein expression. In contrast, transient knockdown of moesin or radixin augmented HCV infection. Making use of the Con1 HCV replicon system, we tested the effect of EMR proteins on HCV replication. We found that transient knockdown of moesin increased HCV RNA expression while overexpression of EMR showed no significant effect on HCV replication.

CONCLUSION

Our findings demonstrate the important role of EMR proteins during HCV infection at the postentry level and highlight possible novel targets for HCV treatment.

Black cohosh hepatotoxicity: quantitative causality evaluation in nine suspected cases

OBJECTIVE

Black cohosh (BC), synonym for Actaea racemosa and Cimicifuga racemosa, is a herbal remedy for the treatment of menopausal symptoms. Recently, worldwide discussions have emerged as to whether its use maybe associated with the risk of rare hepatotoxicity in a few susceptible women.

METHODS

We have evaluated the causal relationship in nine cases with suspected hepatotoxicity by the use of BC. The updated Council for International Organizations of Medical Sciences scale was used to quantitatively assess the causality for BC.

RESULTS

In eight of nine patients with liver disease, causality for BC +/- comedication was excluded (n = 4) or unlikely (n = 4). The failure to ascribe causality in these cases was mainly due to alternative diagnosis, missing temporal association and dechallenge, and presentation of low quality data. In only one case, causality was possible for a BC preparation of an unknown brand taken for 2 months with an unknown daily dose. Confounding factors in this case include symptomatic cholelithiasis and fatty liver. Comedication with synthetic drugs and herbal or other dietary supplements was reported in five of nine patients.

CONCLUSIONS

In nine cases of patients with liver disease, causality for BC +/- comedication was possible (n = 1), unlikely (n = 4), or excluded (n = 4). Due to this lack of significant circumstantial evidence, the present study shows little, if any, hepatotoxic risks by the use of BC in the analyzed cases.

Cytoskeletal requirements for hepatitis C virus (HCV) RNA synthesis in the HCV replicon cell culture system

Hepatitis C virus (HCV) induces microtubule aggregates in infected hepatocytes. To determine if cytoskeletal elements are important for HCV RNA synthesis, we examined the effect of cytoskeleton inhibitors on HCV replicon transcription in Huh7 cells. The data demonstrate that HCV replication complex-mediated RNA synthesis requires microtubule and actin polymerization.

Recurrent, progressive giant cell hepatitis in two consecutive liver allografts in a middle-aged woman

In this report, we present a 41-year-old woman who developed rapidly progressive "giant cell hepatitis" that lead to end-stage liver disease. She underwent a successful liver transplantation in 1989. However, the giant cell hepatitis recurred in the allograft, resulting in cirrhosis within 4 years. She underwent a second liver transplantation in 1993. After 2 years of a relatively stable course, she again developed cirrhosis and was awaiting liver transplantation at the time of this report. The histopathologic features in the two allografts were identical to her original disease. Despite extensive investigations, no etiology for her liver disease could be found.

Postinfantile giant cell hepatitis complicating ulcerative colitis: a case report and review of the literature

Giant cell hepatitis is common in the neonatal period. When present in adults, it is known as postinfantile giant cell hepatitis (PGCH). PGCH can arise in the context of viral, drug-related, and autoimmune disorders but, in many other cases, its etiology remains unclear. We report a case of PGCH occurring in the setting of autoimmune hepatitis and ulcerative colitis. This case highlights the close association between PGCH and autoimmune disorders and the need to recognize it as a hepatic complication of inflammatory bowel disease.

A case of syncytial giant cell hepatitis with features of a paramyxoviral infection

Adult syncytial giant cell hepatitis (GCH) is an uncommon and often fulminant form of hepatitis that may be caused by infection with a novel paramyxo-like virus. We present the case of a 69-yr-old man who presented with acute, community-acquired hepatitis and chronic lymphocytic leukemia. A liver biopsy showed the typical findings of panlobular syncytial giant cell hepatitis. Electron microscopic examination demonstrated abundant nucleocapsid-like protein material in the cytoplasm and nuclei of affected hepatocytes. These structures were similar to, but distinct from, those of known paramyxoviridae, suggesting infection with a novel, related virus. In situ hybridization studies with a probe directed against the measles fusion protein gene gave a positive signal with a hepatocyte distribution. No signal was obtained with the measles nucleocapsid protein probe, suggesting that the disease agent was genetically distinct from, but related to, the measles virus. Subsequent liver biopsies were characterized by the gradual disappearance of the giant cell changes and by the concomitant development of cirrhosis. This is a case of adult GCH that resolved spontaneously and led to cirrhosis, thus implicating GCH as a potential cause of "cryptogenic" liver disease. Our findings provide further support for the existence of a distinct, as yet unidentified viral species as a cause of this disease.

Postinfantile giant cell hepatitis associated with anti-M2 mitochondrial antibodies

Whereas giant cell hepatitis (GCH) is a common diagnosis made in neonates, it is rare in the adult population. The diagnosis of GCH is based on the presence of giant cell transformation of hepatocytes. It is commonly associated with either viral hepatitis or autoimmune disorders. A patient with GCH who had anti-M2 mitochondrial antibodies is described. This combination, which has not been previously reported, underscores the association of GCH with autoimmune disorders and stresses the importance of corticosteroids as an empirical initial therapy.

Post-infantile giant cell hepatitis in an elderly female patient with systemic lupus erythematosus

A 69-year-old Japanese female was admitted because of general fatigue. Laboratory data showed elevation of serum total bilirubin, transaminase, gamma-glutamyl transpeptidase, and creatinine levels. An immunological study revealed hypergammaglobulinemia, low titer of complement, and high titers of antinuclear antibody, anti-DNA antibody, and circulating immune complexes. Antibodies to parainfluenza virus 3 were positive. Histology of the liver disclosed numerous giant cell hepatocyte transformations with the lobular architecture being slightly distorted by portal inflammation and fibrosis. These findings led us to make a diagnosis of giant cell hepatitis associated with systemic lupus erythematosus. Prednisolone was effective in improving the anemia and the serum immunoglobulin, immune complex, and antinuclear antibody levels. The addition of cyclosporine to the initial corticosteroid therapy was also beneficial in decreasing the transaminase level and in improving liver histology. The patient died of acute pneumonitis and renal failure on the 166th day after admission. Parainfluenza virus 3 and autoimmune mechanisms were thus considered to be the causes of the giant cell hepatitis.

Postinfantile giant-cell transformation in hepatitis

Giant-cell hepatitis is a frequent pattern of liver injury in the neonate, but it is rare after infancy. Such cases have been attributed to autoimmune disease, to non-A, non-B hepatitis and, most recently, to paramyxovirus infection. To better define the entity of postinfantile (syncytial) giant-cell hepatitis, we reviewed 24 biopsy specimens from 20 patients with this finding, either alone or in combination with other diagnoses. The number of multinucleated giant cells varied greatly from one specimen to another. Varying degrees of portal inflammation appeared in all but one of the patients, and all had hepatitislike acinar inflammation associated with hepatocellular injury. Fibrosis was a common finding, varying from mild periportal fibrosis to established cirrhosis (33%). The changes were interpreted as acute giant-cell hepatitis in 25%, as CAH in 42% and as active cirrhosis in the remainder. The patients ranged in age from 2 to 80 yr, with a mean of 35 yr and a male/female ratio of approximately 1:1. The signs and symptoms of liver disease were present for more than 1 mo in most patients. A positive antinuclear antibody titer was found in seven of the patients. Three patients had a direct Coombs reaction and anemia. Overall, evidence of autoimmune disease was found in 40% of the patients. One patient had non-Hodgkin's lymphoma involving the liver. Only one patient had a history of blood transfusion or risk factors for hepatitis C. No patient underwent serological study for paramyxovirus antibodies. Liver tissue from one patient was examined ultrastructurally, but no viral particles could be identified.(ABSTRACT TRUNCATED AT 250 WORDS)

Syncytial giant-cell hepatitis--a specific disease entity?

Syncytial giant-cell hepatitis was recently reported to be related to a paramyxovirus and carried a poor prognosis. Twelve patients with syncytial giant-cell hepatitis seen in an 8 1/2-year period in our institute were reviewed. Seven patients had an identifiable aetiological cause: two had autoimmune chronic active hepatitis, one had primary sclerosing cholangitis and autoimmune chronic active hepatitis, two presented with prolonged jaundice after acute hepatitis A and B, one had chronic Epstein-Barr virus infection and the remaining patient was seropositive for antibody to hepatitis C virus. One patient with autoimmune chronic active hepatitis who had frequent syncytial giant cells in the liver responded promptly to corticosteroid treatment and a repeated biopsy 3 years later showed histological improvement with a marked decrease in the number of syncytial giant cells. Of the remaining five patients, three ran a clinical course of fulminant hepatic failure and two had severe chronic active hepatitis. These data indicate that syncytial giant-cell hepatitis is unlikely to be related to only one single aetiological agent and that syncytial giant-cell hepatitis does not always carry an ominous prognosis.

Postinfantile giant cell hepatitis in association with hypereosinophilia

Fatal giant cell hepatitis and hypereosinophilia developed in a 39-year-old man. The coexistence of these two rare disorders has not been previously described. Despite extensive testing, no specific causes could be identified. Evidence for a viral etiology of some cases of giant cell hepatitis is briefly reviewed.

Syncytial giant-cell hepatitis. Sporadic hepatitis with distinctive pathological features, a severe clinical course, and paramyxoviral features

BACKGROUND AND METHODS

We describe a new form of hepatitis, occurring in 10 patients over a period of six years, characterized clinically by manifestations of severe hepatitis, histologically by large syncytial giant hepatocytes, and ultrastructurally by intracytoplasmic structures consistent with paramyxoviral nucleocapsids.

RESULTS

The patients ranged in age from 5 months to 41 years. The tentative clinical diagnosis before biopsy was non-A, non-B hepatitis in five patients and autoimmune chronic active hepatitis in the others. Five patients underwent liver transplantation; the others died. The diagnosis of syncytial giant-cell hepatitis was established pathologically. The liver cords were replaced in all 10 patients by syncytial giant cells with up to 30 nuclei. In 8 of the 10 the cytoplasm contained pleomorphic particles of 150 to 250 microns, filamentous strands, and particles of 14 to 17 nm with peripherally disposed spikes resembling paramyxoviral nucleocapsids. Structures resembling degenerated forms were found in the other two patients. One of two chimpanzees injected with a liver homogenate from the index patient had an increase in the titer of paramyxoviral antibodies, probably an anamnestic reaction to previous paramyxoviral infection, suggesting that a paramyxoviral antigen but not viable virus was present in the liver homogenate.

CONCLUSIONS

Although further virologic studies will be required for precise classification, we believe that paramyxoviruses should be considered in patients with severe sporadic hepatitis.

[Hepatitis non-A, non-B: epidemiologic, clinical, serologic and morphologic aspects]

Hepatitis non-A, non-B (HNANB) is due to one or more transmissible agents, probably viruses. Epidemiologically, HNANB is transmitted predominantly by transfusion of blood or plasma derivatives, and percutaneous inoculation, but a non-percutaneous transmission by the fecal-oral route is also established. However, despite 10 years of intense world-wide research, the transmissible agent, or agents, have not been identified and there are no serological assays for either an antigen or an antibody that can be used to detect this infection. The clinical diagnosis of HNANB remains, therefore, a diagnosis of exclusion mainly of hepatitis A and B, Epstein-Barr virus, cytomegalovirus and drug-induced liver disease. In contrast to hepatitis A and B, the clinical and biochemical course of HNANB tends to be less severe and the proportion of asymptomatic and anicteric cases is higher, but fulminant hepatitis and fatalities also occur. Typically, there is a fluctuating waxing and waning pattern of the serum aminotransferase activities in HNANB. HNANB has a relative high tendency to progress to a chronic stage. The exact frequency of HNANB-induced liver cirrhosis and convincing evidence for an association with hepatocellular carcinoma cannot be assessed, although the persistence of the infectious agent in chronic HNANB and the existence of a chronic asymptomatic carrier state have been proved. By light microscopy there is a broad morphologic spectrum of acute and chronic viral hepatitis, but no single pathognomonic lesion exists that allows a reliable distinction to be made of HNANB from hepatitis A and B. Electron microscopy of liver biopsy specimens of chimpanzees, experimentally infected with HNANB agents, permits the visualisation of cytoplasmic changes, which appear to be specific for infection with HNANB viruses. In human liver biopsy specimens from patients with HNANB, identical ultrastructural cytoplasmic changes could not consistently be demonstrated. In contrast, intranuclear aggregates of spherical and tubular particles measuring 20-29 nm, first described in experimental HNANB in chimpanzees, have been repeatedly demonstrated in acute and chronic HNANB in man. These nuclear particles have been considered as compelling evidence of human HNANB infection. The specificity has been challenged, however, by the demonstration of identical particles in other viral and non-viral hepatopathies and in liver biopsies of healthy volunteers. By immune electron microscopy, a multiplicity of virus-like particles are described in association with HNANB.(ABSTRACT TRUNCATED AT 400 WORDS)

Production of antibody associated with non-A, non-B hepatitis in a chimpanzee lymphoblastoid cell line established by in vitro transformation with Epstein-Barr virus

A continuous cell line of chimpanzee lymphocytes producing an antibody specifically associated with non-A, non-B hepatitis (NANB) was established. Peripheral blood lymphocytes of a chimpanzee convalescent from experimental infection with NANB hepatitis were transformed in vitro by Epstein-Barr virus infection into lymphoblastoid cell lines. Supernatants of the cell cultures were screened by immunofluorescence for antibody activity against the liver tissue of a chimpanzee with NANB hepatitis. Nineteen of the 1402 cultures were found to be positive for the activity. Ten of these 19 gave cytoplasmic reactions and the remaining 9 gave nuclear reactions in hepatocytes. One culture (48-1) stably producing the antibody was further characterized. The antibody produced in 48-1 was IgM and gave granular cytoplasmic reactions in hepatocytes. Cloning of 48-1 was performed by the soft agar method and cloned cell lines stably producing the antibody were obtained. The 48-1 antibody reacted with liver biopsy specimens from 12 chimpanzees obtained during the acute or chronic phase of hepatitis caused by five different NANB strains, but not with biopsy specimens from chimpanzees with hepatitis A or B or from normal chimpanzees. In addition, examinations of serial liver biopsy specimens obtained from 2 chimpanzees experimentally infected with NANB hepatitis demonstrated that the antibody reacted with the biopsies obtained during the preacute, acute, and chronic hepatitis, but not with those obtained before inoculation, early incubation period, or during convalescence. The present results indicate the specific association of the antibody with NANB hepatitis. Immunoelectron microscopy revealed that the antibody reacted with the microtubular aggregates identical to those previously described in a patient and chimpanzees with NANB hepatitis.

Nuclear particles of non-A, non-B type in healthy volunteers and patients with hepatitis B

In an electron microscopic study, nuclear aggregates of virus-like spherical and tubular particles measuring 20 to 29 nm in diameter were found in 5 of 7 clinically healthy volunteers with normal liver histology, 6 of 10 patients with hepatitis B and 17 of 18 patients with hepatitis non-A, non-B. The incidence of hepatocytes containing nuclear particles was approximately 0.5 to 2% in all three groups. We conclude that these nuclear particles are not specific ultrastructural markers of hepatitis non-A, non-B in man as originally claimed for experimental hepatitis non-A, non-B in chimpanzees.

Simultaneous infection with non-A, non-B and B viruses in a patient exhibiting different histologic patterns of acute hepatitis

We present the case of an elderly female patient who developed acute and severe hepatitis with two distinct peaks following blood transfusion. The serological markers and histopathology during the first attack were characteristic for hepatitis non-A, non-B(NANBH), whereas the second peak was due to hepatitis B virus (HBV) infection. Electron microscopy revealed morphologic equivalents for both hepatitis agents.

Liver biopsy interpretation in hepatitis. Part II: Histopathology and classification of acute and chronic viral hepatitis/differential diagnosis

The morphological classification of acute and chronic viral hepatitis has been subject of considerable controversy. Main problems in nomenclature have arisen from the confusion of pathologically defined lesions with purely clinical designations. The classification used in this article is based on a number of recent reviews in which a certain measure of agreement has been reached between clinicians and histopathologists. As a general rule, in acute forms of hepatitis diffuse lobular changes predominate over portal lesions while chronic hepatitis is characterized by conspicuous alterations of portal (and periportal) areas. This report will merely summarize main diagnostic features of the different forms of viral hepatitis. For more detailed information the reader is referred to several leading articles discussing in detail morphology, and putting emphasis on pathogenesis. An exact "staging" of viral hepatitis by histologic criteria is an important tool in the evaluation of prognosis, indication and control of therapy as well as for comparison with immunologic findings.