Prognostic significance of piecemeal necrosis in acute viral hepatitis

Do serum ALAT values reflect the inflammatory activity in the liver of patients with chronic viral hepatitis?

A retrospective study was carried out in 40 patients with chronic viral hepatitis, to assess whether serum alanine aminotransferase reflects the inflammatory process in the liver. Twenty liver biopsy specimens were included for each disease. Five histological aspects were scored: periportal inflammation, lobular inflammation, ballooning, Councilman bodies and lymphocyte follicles. Logarithmic values of alanine aminotransferase were correlated with each aspect using the Spearman correlation coefficient. For the hepatitis B cohort a statistical significant correlation was found between alanine aminotransferase and periportal inflammation (p = 0.0001), lobular inflammation (p = 0.0002) and Councilman bodies/area (p = 0.003). In the hepatitis C study population alanine aminotransferase correlates with both periportal inflammation (p = 0.007) and lymphocyte follicles/Area (p = 0.02). In conclusion, these results suggest that alanine aminotransferase can be used as an indicator of inflammatory activity. A prospective study is needed, to further analyze the use of alanine aminotransferase, as a monitor of disease activity in patients with chronic viral hepatitis.

Detection of 2',5' oligoadenylate synthetase activity in acute viral hepatitis with special reference to histologic features in the acute stage

We measured the sequential changes in 2',5' oligoadenylate synthetase activity in 21 patients with acute viral hepatitis (5 with type A, 6 with type B, and 10 with type non-A, non-B hepatitis) by radioimmunoassay. Liver biopsies were performed during the acute phase in all patients. Among patients with acute hepatitis A and B, the 2',5' oligoadenylate synthetase levels were transiently elevated at the time of the peak alanine aminotransferase level in the patients in whom a liver biopsy showed acute hepatitis or non-specific reactive hepatitis. Of 10 patients with acute non-A, non-B hepatitis, 4 showed a similar 2',5' oligoadenylate synthetase activity pattern and liver histology to those observed in acute hepatitis A and B. In the remaining 6, the 2',5' oligoadenylate synthetase levels remained elevated for 3.5 to 6 months while the alanine aminotransferase was elevated. Liver biopsy in these patients showed chronic hepatitis. Persistent detection of raised 2',5' oligoadenylate synthetase activity levels during the acute stage of non-A, non-B hepatitis may thus be an indicator of progression of the disease.

Histology and virus expression in the liver: a prognostic puzzle in chronic hepatitis B

Forty chronic untreated paediatric carriers of hepatitis B virus (HBV) infection, with no other causes of liver disease, were biopsied on presentation, when the disease was in the active viral replication phase. After a period ranging from 1 to 13 years, all patients underwent a control biopsy. At the time of the last biopsy, 31 of the patients were anti-HBe positive, whereas 9 persisted in the active replication phase. In this latter phase, necrotic and inflammatory lesions and the presence of nuclear HBcAg were found significantly more frequently than when replication had terminated. The necrotic and inflammatory lesions detected in the first biopsy of patients who subsequently underwent anti-HBe seroconversion were significantly more severe than in patients failing to reach seroconversion. All patients who maintained viral replication showed generalized nuclear reactivity for HBcAg on presentation; such reactivity was also found in 16 of 31 (52%) patients who reached anti-HBeAg seroconversion. All these cases had piecemeal necrosis (PMN) in the biopsy. PMN may therefore be considered as a positive prognostic factor in that it identifies those patients who may seroconvert with significant remission of liver disease.

Histological features in liver biopsy specimens of patients with acute reactivation of chronic type B hepatitis

The histological features in liver biopsy specimens from seven patients with acute exacerbation of chronic type B hepatitis were analysed. In all the cases typical changes of acute hepatitis were superimposed on signs of chronicity, namely peripheral piecemeal necrosis, plasma cell infiltration and porto-portal bridges, which in three cases contained elastic fibres. Reactivation of silent hepatitis B virus chronic infection should be considered as a possible diagnosis in any patient with histological findings of acute and chronic hepatitis.

Application of a numerical scoring system for assessment of histological outcome in patients with chronic posttransfusion non-A, non-B hepatitis with or without antibodies to hepatitis C

A numerical scoring system was applied and compared to the conventional histological classification to assess the histological status of liver specimens from 37 patients with chronic posttransfusion non-A, non-B hepatitis followed for 7 to 105 months (mean 35 months). Four histological categories of alterations were assessed and scored: piecemeal necrosis (PMN), fibrosis and cirrhosis, lobular necrosis and portal inflammation. Sequential liver biopsies were obtained from 19 patients. PMN was generally mild but still predictive of progressing fibrosis. Thus, in none of the biopsies from four patients with initial PMN score 0 was there any increase in the fibrosis score in the follow-up biopsy, while in 10/15 (67%) patients with an initial PMN score of greater than or equal to 1 the fibrosis score increased with time (p = 0.033). Lobular necrosis and portal inflammation were not predictive of progressing fibrosis. Judging from the scoring method, 22% of all the 37 patients displayed cirrhosis and 27% bridging fibrosis in the latest liver biopsy performed. Patients with antibodies to hepatitis C did not differ in histological status or outcome from those without antibodies to hepatitis C. It is concluded that the scoring system can be used to monitor the histological long-term follow-up in patients with chronic posttransfusion non-A, non-B hepatitis, and offers a means of predicting the histological outcome.

The application of a numerical scoring system for evaluating the histological outcome in patients with chronic hepatitis B followed in long-term

A numerical scoring system was applied and compared with conventional histological classification to assess the histological outcome in 42 patients with chronic hepatitis B followed for 16 to 162 months (mean = 75 months). Four histological categories in the biopsies were assessed and scored: (i) piecemeal necrosis; (ii) lobular necrosis; (iii) portal inflammation, and (iv) fibrosis and cirrhosis. The sum of all four categories was defined as the "Histological Activity Index." Altogether, 102 liver specimens, including 2 to 4 repeats from each patient, were investigated. A good correlation was noted between a high value of the Histological Activity Index score and several liver histology as monitored by conventional terminology for chronic hepatitis. Among patients with HBeAg persistence, 8 of 14 (57%) deteriorated during follow-up as judged by an increase in the Histological Activity Index score compared to 3 of 13 (23%) of the patients with HBeAg seroconversion (0.5 less than p less than 0.1). Piecemeal necrosis has been postulated to be a predictive marker for the eventual development of cirrhosis. Here, we found that a low score for piecemeal necrosis in the initial liver biopsy was significantly less predictive of a high fibrosis score in the follow-up biopsy than was a high score for initial piecemeal necrosis (p less than 0.001). It is concluded that the scoring system used can be applied to monitor the histological long-term follow-up, especially when separated into its four constituent categories. It also offers a means of predicting a chronic hepatitis outcome.

Chronic hepatitis B. Impact of hepatitis D virus superinfection and the hepatitis B e-system on histological outcome, and correlation of the hepatitis B e-system to HBV-DNA in serum

Chronic evolution after acute hepatitis B virus infection. During a 13 months period 1977-1978 a total of 129 cases of acute viral hepatitis type B occurred among patients who were admitted with hepatitis to Roslagstull, Hospital, Stockholm, Sweden. Less than 1% progressed to chronicity. Prevalence of Delta superinfection was studied among 60 patients with chronic hepatitis B. Nineteen (32%) were anti-delta positive. The majority of the positive patients were either non-European immigrants or addicts, both 9/19 (47%). Infections with the delta agent was found to have occurred in Stockholm already in the early 1970s. Rate of HBeAg clearance during chronic HBV was studied among 36 HBeAg positive patients. Seroconversion to anti-HBe was noted in 17 patients (47%), whereas HBeAg persisted in 19 during a mean follow-up period of 53 months. The spontaneous annual HBeAg seroconversion rate was 11%. HBeAg clearance occurred as frequently among homosexual men as among patients in other categories. However, 12/14 homosexual men were HBeAg positive after 2 years follow-up, compared with 1/13 drug addicts. Thus, homosexual men seemed to require a longer time for HBeAg seroconversion than i.v. drug addicts. HBV-DNA in serum, a strong indicator of viral particles and infectivity was analysed among patients with HBeAg seroconversion, initial HBeAg negativity and/or delta superinfection. HBV-DNA was found in 75-80% of our HBeAg positive patients. A correlation between chronic liver disease and presence of HBV-DNA in serum was also found. Thus, HBV DNA was found in 63% of patients with CAH or CAH/CI as compared with only 39% of patients with CPH. Delta infected patients had HBV-DNA more often than those without hepatitis D infection. Seven delta infected, anti-HBe positive, patients were still HBV-DNA positive five to eight years later. Therefore delta infected anti-HBe positive patients can be infectious for prolonged periods. Histological outcome. 63% (12/19) anti-delta positive patients were classified as CAH with or without cirrhosis as against 39% (16/41) of the anti-delta negative patients. Eleven of 15 homosexual men (73%) had histological findings classified as CAH or CAH/CI. None of them were superinfected with HDV. Thus homosexual men developed severe hepatic lesions without being delta infected. In contrast 78% (7/9) i.v. drug addicts with CAH were delta infected. A numerical scoring system was applied and compared with conventional morphological classification of liver histology to assess the histological outcome of 42 patients with repetitive liver biopsies.

In situ characterisation of the (peri)portal inflammatory infiltrate in acute hepatitis A

The portal and acinar zone 1 (periportal) inflammatory infiltrate in acute hepatitis A (HA) strongly resembles piecemeal necrosis (PMN) in chronic hepatitis B (HB). The latter infiltrate has been characterized in detail previously, and a predominance of suppressor/cytotoxic T cells has been demonstrated. For comparison we analyzed the infiltrate in acute HA in three liver biopsies, applying a broad panel of monospecific and monoclonal antibodies. In two cases, helper/inducer T cells surrounded by B lymphoid cells represented the main lymphoid subset in all portal areas. In the third liver biopsy, a case of acute HA superimposed on a pre-existing chronic HB, the cellular composition of the inflammatory infiltrate varied from one portal tract to another. Despite the morphological resemblance between the inflammatory infiltrate in acute HA and PMN in chronic HB, a clear-cut difference in the composition of both infiltrates is obvious from our results. By virtue of the presence of numerous suppressor/cytotoxic T cells, PMN in chronic HB represents the morphological expression of a cellular immune response, whereas the predominance of helper/inducer T cells, admixed with B cells and plasma cells in acute HA represents the morphological expression of a humoral immune response.

Acute hepatitis B in children with papular acrodermatitis

Thirteen children who had repeated liver biopsies over a period of 2-16 years after the onset of papular acrodermatitis (PAC) were studied retrospectively. Six patients, rebiopsied within 36 months after the onset of PAC, had histologic evidence of chronic periportal hepatitis. However, repeated biopsies in 3 of the patients revealed a normal liver or chronic portal hepatitis. Whereas all patients had at the end of the observation markers of hepatitis B virus infection, 8 of the 10 patients studied had HBs antigenemia. These data indicate that severe active liver disease may regress without treatment in patients who have had PAC. However, the high frequency of a chronic HBsAg-carrier state among these patients suggests either an inefficient clearance of the virus or an altered immune reaction.

Comparative histology of acute hepatitis B and non-A, non-B in Leuven and Padova

A histological study was performed on liver biopsies from patients with acute hepatitis A (n = 13), B (n = 35) and non-A, non-B (nAnB) (n = 35) in search for microscopical features characteristic for each type of hepatitis. Biopsies from two centres (Padova, Italy and Leuven, Belgium) were studied in order to determine whether the histological pattern in acute hepatitis A, B and nAnB may differ from one centre to another. The histology of cases of hepatitis A and B from Italy and Belgium did not differ. Less liver cell plemorphism was found in hepatitis A than in B. Clear differences were observed between acute hepatitis nAnB occurring in Padova when compared with cases from Leuven. The Padova-biopsies obtained from patients with transfusion-induced viral hepatitis were mainly characterized by a high degree of lympho-histiocytic intrasinusoidal infiltration whereas the Leuven-biopsies, mostly taken in patients with sporadic hepatitis, were characterized by the presence of numerous acidophilic bodies and Mallory body-like cytoplasmic alterations. Morphologically, the latter cases appear to be closely related to hepatitis B.