1
|
Pham HN, Pham L, Sato K. Bioinformatic analysis identified novel candidate genes with the potentials for diagnostic blood testing of primary biliary cholangitis. PLoS One 2023; 18:e0292998. [PMID: 37844121 PMCID: PMC10578581 DOI: 10.1371/journal.pone.0292998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023] Open
Abstract
Primary biliary cholangitis (PBC) is an autoimmune disorder characterized by intrahepatic bile duct destruction and cholestatic liver injury. Diagnosis of PBC is generally based on the existence of anti-mitochondrial antibody (AMA) in blood samples; however, some PBC patients are negative for serum AMA tests, and invasive liver histological testing is required in rare PBC cases. The current study seeks novel candidate genes that are associated with PBC status and have potentials for blood diagnostic testing. Human transcriptomic profiling data of liver and blood samples were obtained from Gene Expression Omnibus (GEO). Three GEO data series (GSE79850, GSE159676, and GSE119600) were downloaded, and bioinformatic analyses were performed. Various differentially expressed genes were identified in three data series by comparing PBC patients and control individuals. Twelve candidate genes were identified, which were upregulated in both liver tissues and blood samples of PBC patients in all three data series. The enrichment analysis demonstrated that 8 out of 12 candidate genes were associated with biological functions, which were closely related to autoimmune diseases including PBC. Candidate genes, especially ITGAL showed good potentials to distinguish PBC with other diseases. These candidate genes could be useful for diagnostic blood testing of PBC, although further clinical studies are required to evaluate their potentials as diagnostic biomarkers.
Collapse
Affiliation(s)
- Hoang Nam Pham
- Department of Life Sciences, University of Science and Technology of Hanoi, Hanoi, Vietnam
| | - Linh Pham
- Department of Science and Mathematics, Texas A&M University–Central Texas, Killeen, Texas, United States of America
| | - Keisaku Sato
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| |
Collapse
|
2
|
Theodory B, Dopp M, Swisher AR, Flores RM, Robb PM. Epstein-Barr virus induced acute hepatitis with hyperferritinemia: A rare presentation. IDCases 2023; 33:e01872. [PMID: 37609447 PMCID: PMC10440503 DOI: 10.1016/j.idcr.2023.e01872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 08/24/2023] Open
Abstract
Elevated aminotransaminases and hyperbilirubinemia are common in primary Epstein-Barr Virus (EBV) infection in the adult and pediatric population and the disease course is usually subclinical and self-limited. However, EBV-induced hepatitis is an uncommon diagnosis, accounting for less than 1% of acute hepatitis causes. Acute EBV-hepatitis usually affects immunocompromised and older populations, with nearly half of patients being aged greater than 60 years. Significantly elevated ferritin levels correlate with severe infection and have been associated with EBV complications such as infectious mononucleosis, autoimmune hemolytic anemia, and hemophagocytic lymphohistiocytosis. We present a case of isolated acute cholestatic EBV-hepatitis and hyperferritinemia in an adult immunocompetent patient.
Collapse
Affiliation(s)
- Bassam Theodory
- University of California, Riverside, School of Medicine, Riverside, CA, USA
| | - Meena Dopp
- Department of Internal Medicine, Kaiser Permanente, Inland Empire, Fontana, CA, USA
| | - Austin R. Swisher
- University of California, Riverside, School of Medicine, Riverside, CA, USA
| | - Roberto M. Flores
- University of California, Riverside, School of Medicine, Riverside, CA, USA
| | - Paul M. Robb
- Department of Internal Medicine, Kaiser Permanente, Inland Empire, Fontana, CA, USA
| |
Collapse
|
3
|
Althurwi HN, Alharthy KM, Albaqami FF, Altharawi A, Javed MR, Muhseen ZT, Tahir ul Qamar M. mRNA-Based Vaccine Designing against Epstein-Barr Virus to Induce an Immune Response Using Immunoinformatic and Molecular Modelling Approaches. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13054. [PMID: 36293632 PMCID: PMC9602923 DOI: 10.3390/ijerph192013054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/03/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
Epstein-Barr Virus (EBV) is a human pathogen that has a morbidity rate of 90% in adults worldwide. Infectious mononucleosis is caused by EBV replication in B cells and epithelial cells of the host. EBV has also been related to autoimmune illnesses, including multiple sclerosis and cancers like nasopharyngeal carcinomas and Burkitt's lymphoma. Currently, no effective medications or vaccinations are available to treat or prevent EBV infection. Thus, the current study focuses on a bioinformatics approach to design an mRNA-based multi-epitope (MEV) vaccine to prevent EBV infections. For this purpose, we selected six antigenic proteins from the EBV proteome based on their role in pathogenicity to predict, extract, and analyze T and B cell epitopes using immunoinformatics tools. The epitopes were directed through filtering parameters including allergenicity, toxicity, antigenicity, solubility, and immunogenicity assessment, and finally, the most potent epitopes able to induce T and B cell immune response were selected. In silico molecular docking of prioritized T cell peptides with respective Human Leukocytes Antigens molecules, were carried out to evaluate the individual peptide's binding affinity. Six CTL, four HTL, and ten linear B cell epitopes fulfilled the set parameters and were selected for MEV-based mRNA vaccine. The prioritized epitopes were joined using suitable linkers to improve epitope presentation. The immune simulation results affirmed the designed vaccine's capacity to elicit a proper immune response. The MEV-based mRNA vaccine constructed in this study offers a promising choice for a potent vaccine against EBV.
Collapse
Affiliation(s)
- Hassan N. Althurwi
- Department of Pharmacology and Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia
| | - Khalid M. Alharthy
- Department of Pharmacology and Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia
| | - Faisal F. Albaqami
- Department of Pharmacology and Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia
| | - Ali Altharawi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia
| | - Muhammad Rizwan Javed
- Department of Bioinformatics and Biotechnology, Government College University Faisalabad (GCUF), Faisalabad 38000, Pakistan
| | - Ziyad Tariq Muhseen
- Department of Pharmacy, Al-Mustaqbal University College, Hillah 51001, Babylon, Iraq
| | - Muhammad Tahir ul Qamar
- Department of Bioinformatics and Biotechnology, Government College University Faisalabad (GCUF), Faisalabad 38000, Pakistan
| |
Collapse
|
4
|
He HC, Han R, Xu BH, Huang C, Li MM, He CY, Lin WQ. Circulating Epstein-Barr virus DNA associated with hepatic impairment and its diagnostic and prognostic role in patients with gastric cancer. Front Med (Lausanne) 2022; 9:1028033. [PMID: 36275793 PMCID: PMC9583533 DOI: 10.3389/fmed.2022.1028033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022] Open
Abstract
Epstein–Barr virus (EBV) infection may affect all tissues and organs of the body. Little is known about the impact of this entity on its systematic incorporation in patients with gastric cancer (GC). This study enrolled a total of 113 GC patients with EBV infection (EBVaGC) and 167 GC patients without EBV infection (EBVnGC). It was found that the CRP levels (indicative of inflammatory status) were significantly increased in EBVaGC compared with those in EBVnGC (12.11 mg/L vs. 5.72 mg/L, P = 0.008), but WBC and neutrophils counts were similar in both groups (P > 0.05). Consistent elevations in the levels of liver enzymes, ALP and GGT, with incompatible alterations in ALT or AST were observed in EBVaGC. Slightly prolonged coagulation indices, PT and INR, and decreased albumin consistently suggested impaired synthesis capability of the liver in EBVaGC (all P < 0.05). The level of circulating EBV DNA was positively correlated with the level of GGT, tumor marker CA72-4 and the lymphocyte infiltration in tumor tissues (all P < 0.05). Of note, the EBV associated high-lymphocyte infiltrated tissues presented rich CD8 + T cells. Circulating EBV DNA further showed a predictive role in distinguishing EBVaGC from EBVnGC (AUC 0.79, 95% CI 0.73 to 0.85, P < 0.001), and was associated closely with better overall survival (HR 0.45, 95% CI 0.21 to 0.96, P = 0.039). EBV infection in patients with gastric cancer may be linked to hepatic impairment and immune response. Circulating cell-free EBV DNA is not only a biomarker for the screening of an EBV-related GC subtype but is also an independently prognosis factor for the long-term survival benefit in GC patients.
Collapse
Affiliation(s)
- Hui-Chan He
- State Key Laboratory of Oncology in South China, Department of Blood Transfusion, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China,Center for Clinical Laboratory, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Rui Han
- State Key Laboratory of Oncology in South China, Department of Blood Transfusion, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Bo-Heng Xu
- State Key Laboratory of Oncology in South China, Department of Molecular Diagnostics, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chan Huang
- State Key Laboratory of Oncology in South China, Department of Molecular Diagnostics, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Min-Min Li
- Center for Clinical Laboratory, The First Affiliated Hospital of Jinan University, Guangzhou, China,*Correspondence: Min-Min Li,
| | - Cai-Yun He
- State Key Laboratory of Oncology in South China, Department of Molecular Diagnostics, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China,Cai-Yun He,
| | - Wen-Qian Lin
- State Key Laboratory of Oncology in South China, Department of Blood Transfusion, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China,Wen-Qian Lin,
| |
Collapse
|
5
|
Chen WJ, Wolff E, Varma CR, Shoela R. Biliary Intraepithelial Neoplasia With Gallbladder Adenoma and Cirrhosis: A Case Report. Cureus 2022; 14:e27780. [PMID: 36106242 PMCID: PMC9449331 DOI: 10.7759/cureus.27780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/17/2022] Open
Abstract
Biliary intraepithelial neoplasia (BilIN) is a precursor lesion of cholangiocarcinoma that has been rarely reported. The present study reports a 56-year-old male with low-grade BilIN of the bile ducts and the cystic duct margin. Stent exchange endoscopy demonstrated an irregular, intraductal mass extending along the common bile duct, common hepatic duct, and hepatic duct bifurcation. The peribiliary mass was found to abut the right portal vein, inferior vena cava, and pancreatic head, and replaced the right hepatic artery. In addition, there was evidence of gallbladder adenoma managed with cholecystectomy and a right-lobed liver lesion and cirrhosis, which prompted the discussion of prophylactic liver transplantation. We emphasize the radiological features of BilIN and associated pathological findings through multiple imaging modalities. Consideration of this diagnosis is indicated in western countries and requires timely management based on available guidelines.
Collapse
|
6
|
Autoimmune Hepatitis—Challenging Diagnosis. Medicina (B Aires) 2022; 58:medicina58070896. [PMID: 35888614 PMCID: PMC9318073 DOI: 10.3390/medicina58070896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/23/2022] [Accepted: 06/30/2022] [Indexed: 12/04/2022] Open
Abstract
The incidence of Autoimmune Hepatitis (AIH) increases worldwide. If undiagnosed, it may progress end-stage liver disease. Unfortunately, there is no characteristic clinical presentation of this disease, which makes the illness hard to recognize. A case report illustrates the difficulties of diagnosing the patient during his two hospitalizations and his final treatment with prednisolone which improved the patient’s condition.
Collapse
|
7
|
Manzoor R, Ahmed W, Afify N, Memon M, Yasin M, Memon H, Rustom M, Al Akeel M, Alhajri N. Trust Your Gut: The Association of Gut Microbiota and Liver Disease. Microorganisms 2022; 10:1045. [PMID: 35630487 PMCID: PMC9146349 DOI: 10.3390/microorganisms10051045] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/08/2022] [Accepted: 05/16/2022] [Indexed: 02/07/2023] Open
Abstract
The gut microbiota composition is important for nutrient metabolism, mucosal barrier function, immunomodulation, and defense against pathogens. Alterations in the gut microbiome can disturb the gut ecosystem. These changes may lead to the loss of beneficial bacteria or an increase in potentially pathogenic bacteria. Furthermore, these have been shown to contribute to the pathophysiology of gastrointestinal and extra-intestinal diseases. Pathologies of the liver, such as non-alcoholic liver disease, alcoholic liver disease, cirrhosis, hepatocellular carcinoma, autoimmune hepatitis, viral hepatitis, and primary sclerosing cholangitis have all been linked to changes in the gut microbiome composition. There is substantial evidence that links gut dysbiosis to the progression and complications of these pathologies. This review article aimed to describe the changes seen in the gut microbiome in liver diseases and the association between gut dysbiosis and liver disease, and finally, explore treatment options that may improve gut dysbiosis in patients with liver disease.
Collapse
Affiliation(s)
- Ridda Manzoor
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates; (R.M.); (W.A.); (N.A.); (M.M.); (M.Y.); (H.M.); (M.R.)
| | - Weshah Ahmed
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates; (R.M.); (W.A.); (N.A.); (M.M.); (M.Y.); (H.M.); (M.R.)
| | - Nariman Afify
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates; (R.M.); (W.A.); (N.A.); (M.M.); (M.Y.); (H.M.); (M.R.)
| | - Mashal Memon
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates; (R.M.); (W.A.); (N.A.); (M.M.); (M.Y.); (H.M.); (M.R.)
| | - Maryam Yasin
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates; (R.M.); (W.A.); (N.A.); (M.M.); (M.Y.); (H.M.); (M.R.)
| | - Hamda Memon
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates; (R.M.); (W.A.); (N.A.); (M.M.); (M.Y.); (H.M.); (M.R.)
| | - Mohammad Rustom
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates; (R.M.); (W.A.); (N.A.); (M.M.); (M.Y.); (H.M.); (M.R.)
| | - Mohannad Al Akeel
- Division of Family Medicine, Department of Health, Abu Dhabi P.O. Box 5674, United Arab Emirates;
| | - Noora Alhajri
- Department of Medicine, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi P.O. Box 11001, United Arab Emirates
| |
Collapse
|
8
|
Khedr MA, Salem TA, Boghdadi GM, Elharoun AS, El-Shahaway AA, Atallah HR, Sira MM. Seronegative autoimmune hepatitis in children : A real diagnostic challenge. Wien Klin Wochenschr 2022; 134:195-201. [PMID: 34283299 DOI: 10.1007/s00508-021-01907-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Classical autoimmune hepatitis (AIH) is characterized by the presence of conventional autoantibodies (anti-smooth muscle, antinuclear and anti-liver-kidney-microsomal antibodies). The absence of such autoantibodies in some patients does not preclude AIH diagnosis or the need for its treatment. This group of patients was termed seronegative AIH. Whether non-conventional autoantibodies can identify this group of patients is still elusive. We aimed to study the prevalence of seronegativity of conventional autoantibodies and the occurrence of non-conventional autoantibodies in children with AIH. METHODS In this study, 55 children with AIH were investigated for non-conventional autoantibodies (anti-neutrophil cytoplasmic antibodies, antibodies to soluble liver antigen, anti-tissue transglutaminase and antiplatelet antibodies). All the patients received immunosuppressive therapy and were assessed for treatment response. RESULTS Of the patients 44 had classical AIH (type 1, 70.09%, type 2, 9.09%) and 20% were seronegative. The four studied non-conventional autoantibodies occurred in four patients, one for each. All non-conventional autoantibodies were exclusively associated with type 1 AIH. The clinical profile, ultrasonographic findings, liver biochemistry and histopathological findings were comparable in the classical and seronegative AIH. The majority of patients with classical (72.7%) and seronegative (54.5%) AIH were treatment responders. CONCLUSION Seronegative AIH represents a substantial percentage of pediatric patients diagnosed with AIH. They were even negative for non-conventional autoantibodies. Furthermore, apart from autoantibodies, seronegative AIH is almost indistinguishable from the classical AIH and the majority of patients were treatment responders. This favorable response to immunosuppression deserves sustainable efforts for considering such a diagnosis and start therapy to halt disease progression is worthwhile.
Collapse
Affiliation(s)
- Mohammed A Khedr
- Department of Pediatric Hepatology, Gastroenterology and Nutrition, National Liver Institute, Menoufia University, 32511, Shebin El-koom, Menoufia, Egypt
| | - Tahany A Salem
- Department of Pediatric Hepatology, Gastroenterology and Nutrition, National Liver Institute, Menoufia University, 32511, Shebin El-koom, Menoufia, Egypt.
| | - Ghada M Boghdadi
- Department of Immunology Research Laboratories, Microbiology and Immunology, Faculty of Medicine, Zagazig University, 44519, El-Sharkiya, Egypt
| | - Ahmed S Elharoun
- Department of Microbiology and Immunology, Faculty of Medicine, Menoufia University, Shebin El-koom, Menoufia, Egypt
| | - Allia A El-Shahaway
- Department of Immunology Research Laboratories, Microbiology and Immunology, Faculty of Medicine, Zagazig University, 44519, El-Sharkiya, Egypt
| | - Hany R Atallah
- Department of Pediatrics, Ahmed Maher Teaching Hospital, Ministry of Health, Cairo, Egypt
| | - Mostafa M Sira
- Department of Pediatric Hepatology, Gastroenterology and Nutrition, National Liver Institute, Menoufia University, 32511, Shebin El-koom, Menoufia, Egypt
| |
Collapse
|
9
|
Nayagam JS, Heneghan MA, Samyn M, Joshi D. Epstein-Barr virus status and immunosuppression use in paediatric autoimmune liver disease. Aliment Pharmacol Ther 2022; 55:455-463. [PMID: 34796537 DOI: 10.1111/apt.16708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/23/2021] [Accepted: 11/09/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Since azathioprine is associated with lymphoproliferative disorders in Epstein-Barr virus (EBV)-naïve patients with inflammatory bowel disease, guidelines advise avoidance. No recommendations exist for autoimmune liver disease (AILD). AIMS To evaluate EBV status and EBV-related complications in paediatric AILD. METHODS Single-centre, retrospective, observational study of paediatric AILD. RESULTS In 245 paediatric patients with AILD, azathioprine was used in 168 (68.6%) and mycophenolate mofetil in 69 (28.2%). EBV status was assessed in 18 (10.7%) prior to azathioprine and 6 (8.7%) MMF. Acute EBV infection was diagnosed in five patients while on immunosuppression, resulting in one transient hepatitis and one persistent hepatitis. There were no cases of lymphoproliferative disorder in native livers. Liver transplantation (LT) was performed in 39 (15.9%) patients, with 8 EBV IgG-negative at LT. Post-LT EBV viraemia developed in 29 (74.4%), first detected at median 26 days (IQR, 13-86). EBV IgG-negative recipients had higher peak viraemia (266 984 IU/mL [IQR, 41108-2429050] v 5333 [IQR, 2036-38770], P = .004) and longer time to peak viraemia (375 days [IQR, 251-884] v 70 [IQR, 21-604], P = .04). Early EBV-associated post-transplant lymphoproliferative disorder (PTLD) was diagnosed in two patients, both EBV-IgG negative with prior azathioprine. CONCLUSIONS Real-world data demonstrate that EBV serostatus is not routinely checked before immunosuppression for paediatric AILD. Lymphoproliferative disorder was not diagnosed in those with native livers; however, EBV IgG-negative LT recipients receiving EBV IgG-positive donor organs are at risk of early PTLD. Large multicentre studies with longer follow-up are required to further evaluate the risk.
Collapse
Affiliation(s)
- Jeremy S Nayagam
- Institute of Liver Studies, King's College Hospital, London, UK.,Department of Inflammation Biology, King's College London, London, UK
| | | | - Marianne Samyn
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
| |
Collapse
|
10
|
Skoric J, Pavković B. INFECTIOUS MONONUCLEOSIS AND AUTOIMMUNE HEPATITIS. SANAMED 2021. [DOI: 10.24125/sanamed.v16i1.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
11
|
Ramachandran K, Agarwal R, Bihari C, Bhatia V, Gupta E. Diagnostic dilemmas in Epstein-Barr virus hepatitis mimicking autoimmune hepatitis: A case report. J Family Med Prim Care 2020; 9:2502-2504. [PMID: 32754529 PMCID: PMC7380741 DOI: 10.4103/jfmpc.jfmpc_98_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/12/2020] [Accepted: 03/30/2020] [Indexed: 11/15/2022] Open
Abstract
We report a case of 55-year-old female with chief complaints of fever and deranged liver function tests, diagnosed as autoimmune hepatitis (AIH) and under immunosuppressive therapy for two years. Following the failure in clinical improvement, she was started on anti-tubercular therapy (ATT). While investigating the underlying etiology, virological markers for Hepatitis A to E were found to be negative with plasma Epstein-Barr virus (EBV) viral load of 5 log10 copies/ml. Additional investigation of the liver biopsy showed Hodgkin's lymphoma (HL). The patient was initiated on chemotherapy but eventually succumbed to the illness. This case report underlines the dilemma in the initial diagnosis of AIH and the importance of considering hepatic involvement of EBV as one of the differential diagnosis among clinically suspected AIH cases not responding to immunosuppressive medications.
Collapse
Affiliation(s)
- Krithiga Ramachandran
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Reshu Agarwal
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ekta Gupta
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India
| |
Collapse
|
12
|
Abstract
The syndrome of infectious mononucleosis is commonly seen with Epstein-Barr virus (EBV) infection. It may cause acute hepatitis, which is usually self-limiting and characterised by mildly elevated liver enzymes, but rarely jaundice. The patient being reported showcases EBV infection with jaundice, which is an uncommon scenario.
Collapse
Affiliation(s)
- Robin G Manappallil
- Department of Internal Medicine, Baby Memorial Hospital, Calicut, Kerala, India
| | - Neena Mampilly
- Department of Pathology, Baby Memorial Hospital, Calicut, Kerala, India
| | - Blessy Josphine
- Department of Internal Medicine, Baby Memorial Hospital, Calicut, Kerala, India
| |
Collapse
|
13
|
Hu J, Zhang X, Yu G, Cai H, Gu J, Hu M, Xiang D, Lian J, Yu L, Jia H, Zhang Y, Yang Y. Epstein-Barr virus infection is associated with a higher Child-Pugh score and may predict poor prognoses for patients with liver cirrhosis. BMC Gastroenterol 2019; 19:94. [PMID: 31215410 PMCID: PMC6582562 DOI: 10.1186/s12876-019-1021-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 06/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Studies on Epstein-Barr virus (EBV) have focused mostly on neoplastic disease. Few studies have considered immunocompetent patients who are not severely immunocompromised. Liver cirrhosis is associated with various levels of immune dysfunction. In the current study, we determined EBV infection rates, the influence on liver function, and analyzed the risk factors for death in patients with liver cirrhosis. METHODS The medical records of patients diagnosed with liver cirrhosis between 1 January 2014 and 31 December 2016 were reviewed. Patients who were or were not infected with EBV were enrolled in this study. Liver functions were compared. The risk factors for 28-, 90-, and 180-day mortality rates were analyzed by univariate and multivariate logistic regression. RESULTS The medical records hospitalized patients diagnosed with liver cirrhosis were reviewed. Of these patients, 97 had assessed EBV deoxyribonucleic acid (DNA) and 36 (37.1%) patients were EBV DNA-positive. The age of the EBV-infected patients was older than patients not infected with EBV. EBV-infected patients had a lower level of albumin, and a lower albumin-to-globulin ratio (P = 0.019 and P = 0.013, respectively). EBV-infected patients had higher Child-Pugh scores (P = 0.033) and higher acute-on-chronic liver failure (ACLF) rate (P = 0.050). The Child-Pugh score and ACLF were the risk factors for the 28-, 90-, and 180-day mortality rates. CONCLUSIONS This study revealed that patients with liver cirrhosis had higher EBV infection rates, especially patients > 60 years of age, which likely reflected viral reactivation. And liver injury was aggravated in EBV-infected patients. Thus, EBV infection indirectly influenced the prognosis of EBV-infected patients by increasing the Child-Pugh score and ACLF rate.
Collapse
Affiliation(s)
- Jianhua Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Xiaoli Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Guodong Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Huan Cai
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Jueqing Gu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Menglin Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Dairong Xiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Jiangshan Lian
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Liang Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Hongyu Jia
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Yimin Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang, China.
| |
Collapse
|
14
|
Valota M, Thienemann F, Misselwitz B. False-positive serologies for acute hepatitis A and autoimmune hepatitis in a patient with acute Epstein-Barr virus infection. BMJ Case Rep 2019; 12:12/5/e228356. [PMID: 31079040 DOI: 10.1136/bcr-2018-228356] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acute hepatitis remains a diagnostic challenge, and numerous infectious, metabolic and autoimmune diseases need to be effectively excluded. We present a case of a young woman with malaise, fever, jaundice and deranged liver function tests. Testing for Epstein-Barr virus (EBV) virus capsid antigen IgM/IgG was positive. Total IgG was elevated, along with positive serology for anti-hepatitis A virus (HAV)-IgM, antinuclear antibodies (ANAs) and soluble liver antigen (SLA) leading to the differential diagnosis of acute hepatitis A and autoimmune hepatitis. No specific treatment was started and liver function gradually improved. At week 4, HAV IgG and IgM were negative. At month 4, ANA and SLA were negative and total IgG normalised; EBV nuclear antigen became positive. Testing for EBV is an investigation required at baseline in acute hepatitis and physicians should carefully evaluate serological results, including those for viral and autoimmune hepatitis that may be falsely positive in infectious mononucleosis.
Collapse
Affiliation(s)
- Marika Valota
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Friedrich Thienemann
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland.,Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Benjamin Misselwitz
- Department of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
15
|
Christen U, Hintermann E. Pathogens and autoimmune hepatitis. Clin Exp Immunol 2018; 195:35-51. [PMID: 30113082 DOI: 10.1111/cei.13203] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 07/30/2018] [Accepted: 08/06/2018] [Indexed: 12/12/2022] Open
Abstract
Autoimmune hepatitis (AIH) is a severe form of hepatitis resulting in the autoimmune-mediated destruction of the liver parenchyma. Whereas many of the immunopathogenic events have been elucidated and some of the drivers of the disease have been identified, little is known about the aetiology of the disease. There are certain risk factors, such as particular human leucocyte antigen (HLA) haplotypes, that enhance the susceptibility for AIH or influence the severity of the disease. However, as for many other autoimmune diseases, the mere presence of such risk factors does not warrant the occurrence of the disease. Not all individuals carrying risk factors develop AIH, and not all patients with AIH are carriers of high-risk alleles. Thus, additional environmental factors need to be considered as triggers for AIH. Environmental factors include diet, sunlight exposure, stress, medication and hygiene, as well as pathogen infections and vaccinations. This review discusses if pathogens should be considered as triggers for the initiation and/or propagation of AIH.
Collapse
Affiliation(s)
- U Christen
- Pharmazentrum Frankfurt / ZAFES, Goethe University Hospital, Frankfurt am Main, Germany
| | - E Hintermann
- Pharmazentrum Frankfurt / ZAFES, Goethe University Hospital, Frankfurt am Main, Germany
| |
Collapse
|
16
|
Buechter M, Manka P, Heinemann FM, Lindemann M, Baba HA, Schlattjan M, Canbay A, Gerken G, Kahraman A. Potential triggering factors of acute liver failure as a first manifestation of autoimmune hepatitis-a single center experience of 52 adult patients. World J Gastroenterol 2018; 24:1410-1418. [PMID: 29632422 PMCID: PMC5889821 DOI: 10.3748/wjg.v24.i13.1410] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/21/2018] [Accepted: 03/03/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate potential triggering factors leading to acute liver failure (ALF) as the initial presentation of autoimmune hepatitis (AIH). METHODS A total of 565 patients treated at our Department between 2005 and 2017 for histologically-proven AIH were retrospectively analyzed. However, 52 patients (9.2%) fulfilled the criteria for ALF defined by the "American Association for the Study of the Liver (AASLD)". According to this definition, patients with "acute-on-chronic" or "acute-on-cirrhosis" liver failure were excluded. Following parameters with focus on potential triggering factors were evaluated: Patients' demographics, causation of liver failure, laboratory data (liver enzymes, MELD-score, autoimmune markers, virus serology), liver histology, immunosuppressive regime, and finally, outcome of our patients. RESULTS The majority of patients with ALF were female (84.6%) and mean age was 43.6 ± 14.9 years. Interestingly, none of the patients with ALF was positive for anti-liver kidney microsomal antibody (LKM). We could identify potential triggering factors in 26/52 (50.0%) of previously healthy patients presenting ALF as their first manifestation of AIH. These were drug-induced ALF (57.7%), virus-induced ALF (30.8%), and preceding surgery in general anesthesia (11.5%), respectively. Unfortunately, 6 out of 52 patients (11.5%) did not survive ALF and 3 patients (5.7%) underwent liver transplantation (LT). Comparing data of survivors and patients with non-recovery following treatment, MELD-score (P < 0.001), age (P < 0.05), creatinine (P < 0.01), and finally, ALT-values (P < 0.05) reached statistical significance. CONCLUSION Drugs, viral infections, and previous surgery may trigger ALF as the initial presentation of AIH. Advanced age and high MELD-score were associated with lethal outcome.
Collapse
Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
- Division of Transplantation Immunology and Mucosal Biology, King’s College, London SE59RJ, United Kingdom
| | | | - Monika Lindemann
- Institute of Transfusion Medicine, University Clinic of Essen, Essen 45147, Germany
| | - Hideo Andreas Baba
- Institute of Pathology, University Clinic of Essen, Essen 45147, Germany
| | - Martin Schlattjan
- Institute of Pathology, University Clinic of Essen, Essen 45147, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology, and Infectious Diseases, Otto-von-Guericke University, Magdeburg 39120, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
| |
Collapse
|
17
|
Abu-Shanab A, Ged Y, Ullah N, Houlihan D, McCormick A. Increased Incidence of Post-transplant Lymphoproliferative Disorder in Autoimmune Liver Disease: An Irish National Experience. J Clin Exp Hepatol 2018; 8:42-49. [PMID: 29743796 PMCID: PMC5938325 DOI: 10.1016/j.jceh.2017.05.209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/31/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Post-Transplant Lymphoproliferative Disorder (PTLD) is a well-recognized complication post solid organs transplant. PTLD represents a broad spectrum of abnormalities ranging from an infectious mononucleosis like illness to malignant lymphoma. METHODS A retrospective study was performed by collecting data of orthotopic liver transplant (OLT) patients in the National Liver Unit in Ireland from December 1993 to December 2014. Data was analyzed to identify PTLD patients and determine their demographic details, the indication for liver transplant, presenting symptoms, immunosuppression regimens, Epstein"Barr virus (EBV) status and PTLD outcome. RESULTS From a total of 756 liver transplants recipients, 20 patients (2.6%) were diagnosed with PTLD. The median time from OLT to PTLD diagnosis was 83 months. The main primary indication for OLT of the PTLD cohort was Autoimmune Liver Disease (AiLD) (n = 13, 65%, mainly primary sclerosing cholangitis (PSC) n = 8, 40%). The combined group of auto-immune hepatitis, PSC and primary biliary cholangitis had a significantly higher incidence of PTLD compared to other etiologies (P < 0.01). In AiLD PTLD subgroup, 61.5% were positive for EBV. Five patients (38.5%) had extra-nodal disease and 3 patients had CNS disease. 61% of PTLD AiLD patients (n = 8) achieved complete response following their treatment. CONCLUSION PTLD has high mortality however early diagnosis and complete remission are achievable. Our study suggests that the incidence of PTLD is increased in AiLD and notably PSC patients.
Collapse
Affiliation(s)
- Ahmed Abu-Shanab
- Liver National Unit, St Vincent's University Hospital, Elm Park, Dublin, Ireland
- Menofiya University Hospital, Menofiya, Egypt
| | - Yasser Ged
- Oncology Department, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Naeem Ullah
- Liver National Unit, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Diarmaid Houlihan
- Liver National Unit, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Aiden McCormick
- Liver National Unit, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| |
Collapse
|
18
|
Chaouali M, Kochkar R, Messadi A, Tezeghdenti A, Azaiez MB, Abdallah HB, Yacoubi-Oueslati B, Ghazouani E. Distribution of HLA-DRB1/DQB1 alleles and DRB1-DQB1 haplotypes among Tunisian patients with autoimmune hepatitis. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2017. [DOI: 10.1016/j.ejmhg.2017.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
|
19
|
Oh SH, You CR, Kim EO, Bae SH, Choi JY, Yoon SK, Choi SW. A Case of Ulcerative Colitis Following Acute Hepatitis Induced by Epstein-Barr Virus Infection. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 68:104-8. [PMID: 27554218 DOI: 10.4166/kjg.2016.68.2.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Epstein-Barr virus (EBV) infection varies in its clinical manifestations and severity. EBV can be a causative agent of hepatitis and may have a role in the pathogenesis of chronic autoimmune diseases including inflammatory bowel disease. A 24-year-old woman was admitted to our hospital, presenting with fever and elevated liver enzymes. She was diagnosed with acute hepatitis and EBV infection according to serologic tests and liver biopsy. Within two months, she was re-admitted to our hospital, presenting with hematochezia and lower abdominal pain. She was diagnosed with ulcerative colitis. In situ hybridization for EBV was positive in initial liver biopsy and colon biopsy. Here we report an unusual case of acute EBV hepatitis followed at a short interval by ulcerative colitis.
Collapse
Affiliation(s)
- Seung Hyun Oh
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan Ran You
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Young Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Kew Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Wook Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
20
|
Thodou V, Buechter M, Canbay A, Baba HA, Kalsch J, Gerken G, Kahraman A. De-Novo Autoimmune Hepatitis with Consecutive Acute Liver Failure Induced by Hepatitis E Infection: A Case Report. HEPATITIS MONTHLY 2017; 17. [DOI: 10.5812/hepatmon.40744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
21
|
Liver immunology: How to reconcile tolerance with autoimmunity. Clin Res Hepatol Gastroenterol 2017; 41:6-16. [PMID: 27526967 DOI: 10.1016/j.clinre.2016.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/01/2016] [Indexed: 02/04/2023]
Abstract
There are several examples of liver tolerance: the relative ease by which liver allografts are accepted and the exploitation of the hepatic microenvironment by the malarial parasite and hepatotrophic viruses are notable examples. The vasculature of the liver supports a unique population of antigen presenting cells specialised to maintain immunological tolerance despite continuous exposure to gut-derived antigens. Liver sinusoidal endothelial cells and Kupffer cells appear to be key to the maintenance of immune tolerance, by promoting T cell anergy or deletion and the generation of regulatory cell subsets. Despite this, there are three liver diseases with likely autoimmune involvement: primary biliary cirrhosis, primary sclerosing cholangitis and autoimmune hepatitis. How can we reconcile this with the inherent tolerogenicity of the liver? Genetic studies have uncovered several associations with genes involved in the activation of the innate and adaptive immune systems. There is also evidence pointing to pathogenic and xenobiotic triggers of autoimmune liver disease. Coupled to this, impaired immunoregulatory mechanisms potentially play a permissive role, allowing the autoimmune response to proceed.
Collapse
|
22
|
Moniri A, Tabarsi P, Marjani M, Doosti Z. Acute Epstein - Barr virus hepatitis without mononucleosis syndrome: a case report. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2017; 10:147-149. [PMID: 28702140 PMCID: PMC5495904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/08/2017] [Indexed: 10/31/2022]
Abstract
Elevated liver enzymes accompanied by Infectious Mononucleosis syndrome are widely seen in primary Epstein-Barr virus infection while acute symptomatic hepatitis without typical presentations of EBV is extremely rare. In the following report, we present a patient with acute isolated hepatitis due to laboratory confirmed Epstein-Barr virus.
Collapse
Affiliation(s)
- Afshin Moniri
- Virology Research Center (VRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Tabarsi
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Marjani
- Clinical Tuberculosis and Epidemiology Research Center (CTERC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Doosti
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
23
|
Temajo NO, Howard N. The virus-induced HSPs regulate the apoptosis of operatus APCs that result in autoimmunity, not in homeostasis. Immunol Res 2015; 60:208-18. [PMID: 25403694 DOI: 10.1007/s12026-014-8585-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The viruses stand salient as environmental factors that trigger autoimmunity. The virus realizes its effects through induction of heat-shock proteins (HSPs) as well as by the viral IE-axis-mediated conversion of organ epithelial cells into virgin de novo professional antigen-presenting cells (APCs). The HSP is the accomplished operator in homeostasis by the logic of it being the regulator of apoptosis. By virtue of its regulation of apoptosis, the HSP is also involved in autoimmunity: (1) adornment of viral IE-axis-generated virgin de novo professional APCs with HSP-induced co-stimulatory molecules which transform these otherwise epithelial cells to competent antigen presenters, the operatus APCs, liable to apoptosis that becomes the initiator of organ damages; (2) molecular mimicry mechanism: epitopes on the HSP may be mistaken for viral peptides and be presented by operatus APCs to autoreactive TCRs resulting in the apoptosis of the operatus APCs; (3) regulation of MHC class II DR-mediated apoptosis of operatus APCS which can result in organ-specific autoimmune syndromes. We should remember, however, that Nature's intended purpose for apoptosis of the professional APCs is benevolence: as a principal regulator of immune homeostasis. But the apoptosis of our postulated operatus APCs can result in autoimmunity. The transformation of virgin de novo professional APCs to operatus APCs mirrors the maturation of DCs through their acquisition of HSP-induced costimulatory molecules. What happens to mature DCs as antigen presenters that end in homeostasis is replicated by what happens to operatus APCs that ends instead in autoimmunity.
Collapse
Affiliation(s)
- Norbert O Temajo
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia,
| | | |
Collapse
|
24
|
Abstract
The term "autoimmunity" refers to a pathological condition in which the immunological tolerance of self-antigens is broken through, cross-reactive T cells are activated, and autoantibodies are produced by B cells. The intricate interplay among those aberrantly activated immune cells as well as inflammatory cytokines secreted by them contributes to the development of proinflammatory cascade which eventually leads to the occurrence of autoimmune diseases (AIDs) and organ damage. Autoimmune diseases occupy a broad spectrum of human diseases with more than 70 different disorders and afflict approximately 5-8 % of the world's population. AIDs can be categorized into organ-specific and systemic. Although the exact mechanism of AIDs remains elusive, it is generally believed that both genetic polymorphism and environmental exposure are involved in the development of AIDs. Aberrant epigenetic marks are also identified in patients with AIDs. In addition, dysregulation of innate immune system and molecular mimicry are indicated to play important roles in the initiation and maintenance of autoreactive inflammation. Based on the progress made in elucidating molecular mechanisms underlying AIDs, novel biomarkers for prediction, early diagnosis, prognosis and treatment response, and therapeutic strategies are proposed, which represents a promising future in the battle against AIDs. However, challenges remain regarding the clinical application of these potential new tools.
Collapse
Affiliation(s)
- Qianjin Lu
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenetics, Second Xiangya Hospital, Central South University, #139 Renmin Middle Rd, Changsha, Hunan, 410011, People's Republic of China,
| |
Collapse
|
25
|
Temajo NO, Howard N. The virus-induced HSPs regulate the apoptosis of operatus APCs that results in autoimmunity, not in homeostasis. Autoimmun Rev 2014; 13:1013-9. [PMID: 25183243 DOI: 10.1016/j.autrev.2014.08.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 05/30/2014] [Indexed: 12/20/2022]
Abstract
The viruses are salient in the roles of environmental factors that trigger autoimmunity. The virus realizes its effects by the power of its induction of heat shock proteins (HSPs) as well as by the viral IE-axis-mediated conversion of organ epithelial cells into virgin de novo professional antigen-presenting cells (APCs). The HSP is the accomplished operator in homeostasis by the logic of it being the regulator of apoptosis. That HSP which regulates and controls different points in the pathways of apoptosis is rationally propitious as both HSP and apoptosis are highly conserved in multicellular organisms. By virtue of its regulation of apoptosis, the HSP is also involved in human autoimmunity and this involvement is tripartite: (i) adornment of viral IE-axis-generated virgin de novo professional APCs with HSP-induced co-stimulatory molecules which transform these otherwise epithelial cells to achieve the status of fledged competent antigen-presenters, the operatus APCs, which are liable to apoptosis that becomes the initiator of organ damages that can culminate in the autoimmune syndrome(s); apoptosis is a routine fate that befalls all APCs following their antigen presentation; (ii) molecular mimicry mechanism: epitopes on the HSP may be mistaken for viral peptides and be presented by operatus APCs to autoreactive TCRs resulting in the apoptosis of the operatus APCs; and (iii) regulation of MHC class II-DR-mediated apoptosis of operatus APCs which can ultimately consequent in organ-specific autoimmune syndromes. We should remember, however, that Nature's intended purpose for the apoptosis of the professional APCs is benevolence: as a principal regulator of homeostasis. It is only from the apoptosis of our postulated operatus APCs that the apoptotic consequence can be deleterious, an autoimmune syndrome(s). The transformation of virgin de novo professional APCs to operatus APCs mirrors the maturation of DCs, through their acquisition of HSP-induced co-stimulatory molecules; and what happens to mature DCs as antigen-presenters that ends in homeostasis is replicated by what happens to operatus APCs that ends instead in autoimmune syndromes (Fig. 1).
Collapse
Affiliation(s)
- Norbert O Temajo
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| | - Neville Howard
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| |
Collapse
|
26
|
Abstract
Autoimmune disorders afflicting the liver comprise the bona fide autoimmune diseases, primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis as well as drug-induced autoimmune-like diseases, such as halothane hepatitis. Whereas drug-induced forms of acute or chronic hepatitis often have a clear triggering factor, the etiology of classical autoimmune liver diseases is only poorly understood. Besides a genetic component present in disease susceptible individuals, environmental triggering factors are likely to play a role in the initiation and/or propagation of the disease. In this article, we will review on current evidence obtained from epidemiological associations, case studies, and findings in animal models for pathogens, to be involved in the etiology of autoimmune liver disease with a special focus on autoimmune hepatitis.
Collapse
Affiliation(s)
- Urs Christen
- Pharmazentrum Frankfurt/ZAFES, Goethe University Hospital , Frankfurt am Main , Germany
| | | |
Collapse
|
27
|
Abstract
We recently introduced the concept of the infectome as a means of studying all infectious factors which contribute to the development of autoimmune disease. It forms the infectious part of the exposome, which collates all environmental factors contributing to the development of disease and studies the sum total of burden which leads to the loss of adaptive mechanisms in the body. These studies complement genome-wide association studies, which establish the genetic predisposition to disease. The infectome is a component which spans the whole life and may begin at the earliest stages right up to the time when the first symptoms manifest, and may thus contribute to the understanding of the pathogenesis of autoimmunity at the prodromal/asymptomatic stages. We provide practical examples and research tools as to how we can investigate disease-specific infectomes, using laboratory approaches employed from projects studying the “immunome” and “microbiome”. It is envisioned that an understanding of the infectome and the environmental factors that affect it will allow for earlier patient-specific intervention by clinicians, through the possible treatment of infectious agents as well as other compounding factors, and hence slowing or preventing disease development.
Collapse
|
28
|
Temajo NO, Howard N. The mosaic of environment involvement in autoimmunity: the abrogation of viral latency by stress, a non-infectious environmental agent, is an intrinsic prerequisite prelude before viruses can rank as infectious environmental agents that trigger autoimmune diseases. Autoimmun Rev 2014; 13:635-40. [PMID: 24418293 DOI: 10.1016/j.autrev.2013.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 12/10/2013] [Indexed: 12/14/2022]
Abstract
An autoimmune disease (AD), organ-specific or systemic, results from an aberrant response in which the protective immune system normally schooled to recognize and destroy invading infectious agents (viruses, etc.) instead fails to distinguish self-antigens and proceeds to attack and destroy the host's organs. There can be familial aggregation in which a single AD may occur in members of a family, or a single family may be afflicted with multiple ADs. Finally, sometimes multiple ADs co-occur in a single individual: the kaleidoscope of autoimmunity. Autoimmunity is a multifactorial process in which genetic, hormonal, immunological and environmental factors act in concert to materialize the mosaic of autoimmunity phenomenon. A genetically primed individual may yet not develop an AD: the contribution by an environmental factor (non-infectious or infectious) is essential for completion of the act. Of the non-infectious factors, stress plays a determinative step in autoimmunity in that it abrogates viral latency and thereby ordains the viruses to qualify as infectious environmental factors that trigger ADs. This is note-worthy as viruses rank first as the most important environmental triggers of ADs. Furthermore, all these viruses experience going through latency. Hence the hypothesis: "The abrogation of viral latency by stress, a non-infectious environmental agent, is an intrinsic prerequisite prelude before viruses can rank as infectious environmental agents that trigger autoimmune diseases". There is collaboration here between non-infectious- and infectious-agent to achieve the cause of autoimmunity. We say viral latency and stress have a covenant: continued perpetration of autoimmunity is dependent on the intervention by stress to reactivate latent infections.
Collapse
Affiliation(s)
- Norbert O Temajo
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| | - Neville Howard
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| |
Collapse
|
29
|
Vera-Lastra O, Medina G, Cruz-Dominguez MDP, Jara LJ, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvants (Shoenfeld's syndrome): clinical and immunological spectrum. Expert Rev Clin Immunol 2013; 9:361-73. [PMID: 23557271 DOI: 10.1586/eci.13.2] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An adjuvant is a substance that enhances the antigen-specific immune response, induces the release of inflammatory cytokines, and interacts with Toll-like receptors and the NALP3 inflammasome. The immunological consequence of these actions is to stimulate the innate and adaptive immune response. The activation of the immune system by adjuvants, a desirable effect, could trigger manifestations of autoimmunity or autoimmune disease. Recently, a new syndrome was introduced, autoimmune/inflammatory syndrome induced by adjuvants (ASIA), that includes postvaccination phenomena, macrophagic myofasciitis, Gulf War syndrome and siliconosis. This syndrome is characterized by nonspecific and specific manifestations of autoimmune disease. The main substances associated with ASIA are squalene (Gulf War syndrome), aluminum hydroxide (postvaccination phenomena, macrophagic myofasciitis) and silicone with siliconosis. Mineral oil, guaiacol and iodine gadital are also associated with ASIA. The following review describes the wide clinical spectrum and pathogenesis of ASIA including defined autoimmune diseases and nonspecific autoimmune manifestations, as well as the outlook of future research in this field.
Collapse
Affiliation(s)
- Olga Vera-Lastra
- Hospital de Especialidades Centro Médico La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | | | | | | |
Collapse
|
30
|
Smyk DS, Rigopoulou EI, Bogdanos DP. Potential Roles for Infectious Agents in the Pathophysiology of Primary Biliary Cirrhosis: What's New? Curr Infect Dis Rep 2013. [PMID: 23188623 DOI: 10.1007/s11908-012-0304-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary biliary cirrhosis (PBC) is a progressive cholestatic liver disease serologically characterized by the presence of high-titer antimitochondrial antibodies and, histologically by chronic nonsuppurative cholangitis and granulomata. The aetiology of the disease remains elusive, although genetic, epigenetic, environmental, and infectious factors have been considered important for the induction of the disease in genetically prone individuals. The disease shows a striking female predominance and becomes clinically overt at the fourth to sixth decade. These characteristics have prompted investigators to consider infections that predominate in women at these ages as the likely candidates for triggering the disease. Recurrent urinary tract infections due to Escherichia coli were the first infections to be considered pathogenetically relevant. Over the years, several other microorganisms have been linked to the pathogenesis of PBC owing to epidemiological, immunological, microbiological, or experimental findings in animal models. Recent studies have provided data supporting the pathogenic role of Novosphingobium aromaticivorans and betaretroviruses. Several reports have linked other organisms to the induction of the disease and/or the maintenance of the auto-aggressive responses that are perpetuated over the course of the disease. This review highlights the findings of the most recent studies investigating the link between infections and PBC. We also discuss the close interplay of the infectious agents with other environmental and genetic factors, which may explain the multifaceted nature of this puzzling disease.
Collapse
Affiliation(s)
- Daniel S Smyk
- Institute of Liver Studies, Division of Transplantation Immunology and Mucosal Biology, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London, SE5 9RS, United Kingdom,
| | | | | |
Collapse
|
31
|
Bogdanos DP, Smyk DS, Invernizzi P, Rigopoulou EI, Blank M, Pouria S, Shoenfeld Y. Infectome: a platform to trace infectious triggers of autoimmunity. Autoimmun Rev 2012; 12:726-40. [PMID: 23266520 PMCID: PMC7105216 DOI: 10.1016/j.autrev.2012.12.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 12/12/2012] [Indexed: 02/06/2023]
Abstract
The "exposome" is a term recently used to describe all environmental factors, both exogenous and endogenous, which we are exposed to in a lifetime. It represents an important tool in the study of autoimmunity, complementing classical immunological research tools and cutting-edge genome wide association studies (GWAS). Recently, environmental wide association studies (EWAS) investigated the effect of environment in the development of diseases. Environmental triggers are largely subdivided into infectious and non-infectious agents. In this review, we introduce the concept of the "infectome", which is the part of the exposome referring to the collection of an individual's exposures to infectious agents. The infectome directly relates to geoepidemiological, serological and molecular evidence of the co-occurrence of several infectious agents associated with autoimmune diseases that may provide hints for the triggering factors responsible for the pathogenesis of autoimmunity. We discuss the implications that the investigation of the infectome may have for the understanding of microbial/host interactions in autoimmune diseases with long, pre-clinical phases. It may also contribute to the concept of the human body as a superorganism where the microbiome is part of the whole organism, as can be seen with mitochondria which existed as microbes prior to becoming organelles in eukaryotic cells of multicellular organisms over time. A similar argument can now be made in regard to normal intestinal flora, living in symbiosis within the host. We also provide practical examples as to how we can characterise and measure the totality of a disease-specific infectome, based on the experimental approaches employed from the "immunome" and "microbiome" projects.
Collapse
Affiliation(s)
- Dimitrios P Bogdanos
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London, UK.
| | | | | | | | | | | | | |
Collapse
|
32
|
Mavropoulos A, Orfanidou T, Liaskos C, Smyk DS, Billinis C, Blank M, Rigopoulou EI, Bogdanos DP. p38 mitogen-activated protein kinase (p38 MAPK)-mediated autoimmunity: lessons to learn from ANCA vasculitis and pemphigus vulgaris. Autoimmun Rev 2012. [PMID: 23207287 DOI: 10.1016/j.autrev.2012.10.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Evidence is beginning to accumulate that p38 mitogen activated protein kinase (p38 MAPK) signaling pathway plays an important role in the regulation of cellular and humoral autoimmune responses. The exact mechanisms and the degree by which the p38 MAPK pathway participates in the immune-mediated induction of diseases have started to emerge. This review discusses the recent advances in the molecular dissection of the p38 MAPK pathway and the findings generated by reports investigating its role in the pathogenesis of autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, and autoimmune hepatitis. Application of newly-developed protocols based on sensitive flow cytometric detection has proven to be a useful tool in the investigation of the phosphorylation of p38 MAPK within different peripheral blood mononuclear cell populations and may help us to better understand the enigmatic role of this signaling cascade in the induction of autoimmunity as well as its role in immunosuppressive-induced remission. Special attention is paid to reported data proposing a specific role for autoantibody-induced activation of p38 MAPK-mediated immunopathology in the pathogenesis of autoimmune blistering diseases and anti-neutrophilic antibody-mediated vasculitides.
Collapse
Affiliation(s)
- Athanasios Mavropoulos
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, Denmark Hill Campus, London SE5 9RS, UK
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Koutsoumpas AL, Kriese S, Rigopoulou EI. Popular and unpopular infectious agents linked to primary biliary cirrhosis. AUTOIMMUNITY HIGHLIGHTS 2012; 3:95-104. [PMID: 26000132 PMCID: PMC4389080 DOI: 10.1007/s13317-012-0039-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 10/03/2012] [Indexed: 12/12/2022]
Abstract
Primary biliary cirrhosis (PBC) is a progressive cholestatic liver disease characterized by the autoimmune destruction of the biliary epithelial cells of the small and medium-size bile ducts. The disease affects middle aged women and usually affects more than one member within a family. The pathognomonic serological hallmark of the disease is the presence of circulating anti-mitochondrial antibodies, and disease-specific anti-nuclear antibodies. Susceptibility genes and environmental risk factors such as infections and smoking have been reported as important for the development of the disease. Among the environmental agents, infectious triggers are the best studied. Most of the work published so far has investigated the role of infections caused by Novosphingobium aromaticivorans and Escherichia coli. This review will discuss the popular and unpopular infectious agents causatively linked to PBC. It will also examine reports investigating the epidemiological aspects of the disease and their direct or indirect implications to bacterial-induced PBC.
Collapse
Affiliation(s)
| | | | - Eirini I Rigopoulou
- Department of Medicine, University of Thessaly Medical School, Viopolis, Mezourlo, 41110 Larissa, Greece
| |
Collapse
|
34
|
Abstract
Primary biliary cirrhosis (PBC) is a chronic progressive cholestatic autoimmune liver disease characterized by the destruction of small intrahepatic bile ducts and the presence of highly specific serum antimitochondrial antibodies (AMAs). The human leukocyte antigen (HLA) gene has been proved to have strongest association with PBC susceptibility, and non-HLA genes, including IL12A, IL12RB2, STAT4, IRF5-TNPO3, ORMDL3/IKZF3, MMEL1, SPIB, CTLA-4, FCRL3 and A2BP1, are also closely associated with PBC susceptibility. Four AMAs including anti-M2, anti-M4, anti-M8 and anti-M9, and antinuclear antibodies (ANAs), such as antinuclear dot antibodies (SP100, PML, NDP52, SP140), antinuclear pore antibodies (gp210, p62), antinuclear envelope antibodies (Lamin and Lamin B receptor), and anti-centromere antibodies, may also be involved in the pathogenesis of PBC. The imbalance between Th17 cells and regulatory T lymphocytes (Treg) may also play an important role in the pathogenesis of PBC. In addition, senescence, autophagy, apoptosis of biliary epithelial cells (BECs), and environmental factors, such as Epstein-Barr virus (EBV) infection and smoking, may also contribute to the pathogenesis of PBC. Understanding of the mechanisms responsible for the pathogenesis of PBC has important implications for the treatment of PBC.
Collapse
|
35
|
Tuberculosis Is Not a Risk Factor for Primary Biliary Cirrhosis: A Review of the Literature. Tuberc Res Treat 2012; 2012:218183. [PMID: 23213506 PMCID: PMC3504403 DOI: 10.1155/2012/218183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 10/03/2012] [Indexed: 11/17/2022] Open
Abstract
Primary biliary cirrhosis (PBC) is a progressive cholestatic liver disease characterised serologically by cholestasis and the presence of high-titre antimitochondrial antibodies, and histologically by chronic nonsuppurative cholangitis and granulomata. As PBC is a granulomatous disease andMycobacterium tuberculosisis the most frequent cause of granulomata, a causal relation between tuberculosis and PBC has been suggested. Attempts to find serological evidence of PBC-specific autoantibodies such as AMA have been made and, conversely, granulomatous livers from patients with PBC have been investigated for molecular evidence ofMycobacterium tuberculosis. This paper discusses in detail the reported data in support or against an association betweenMycobacterium tuberculosisinfection and PBC. We discuss the immunological and microbiological data exploring the association of PBC with exposure toMycobacterium tuberculosis. We also discuss the findings of large epidemiologic studies investigating the association of PBC with preexistent or concomitant disorders and the relevance of these findings with tuberculosis. Genome-wide association studies in patients with tuberculosis as well as in patients with PBC provide conclusive hints regarding the assumed association between exposure to this mycobacterium and the induction of PBC. Analysis of these data suggest thatMycobacterium tuberculosisis an unlikely infectious trigger of PBC.
Collapse
|