Human cytomegalovirus and Epstein-Barr virus infections, risk factors, and their influence on the liver function of patients with acute-on-chronic liver failure

Early predictors of Epstein-Barr virus infection in patients with severe fever with thrombocytopenia syndrome

BACKGROUND

Epstein-Barr virus (EBV) can be reactivated and proliferated with fatal outcome in immuno-compromised people, but the clinical consequences of EBV infection in patients with severe fever with thrombocytopenia syndrome (SFTS) remain uncertain. In this study, we investigated the infection rate, the influence and the early predictors of EBV infection in SFTS patients.

METHODS

In this retrospective study, SFTS patients who were treated in the First Affiliated Hospital of Nanjing Medical University from May 2011 to August 2021 were enrolled and divided into infected and non-infected groups. We compared the demographic characteristics, clinical manifestations and signs, laboratory tests and prognosis, and explored the risk factors of EBV infection by receiver operating characteristic (ROC) curve and logistic regression.

RESULTS

A total of 120 hospitalized SFTS patients with EBV-DNA testing were enrolled in this study. Patients with EBV infection had statistically significant higher mortality rate (32.0% vs. 11.43%, P = 0.005). Compared with the non-infected group, the EBV-infected group had higher levels of C-reactive protein (CRP), creatine-kinase (CK), fasting blood glucose (FBG), blood urea nitrogen (BUN), D-dimer, and CD56+ cell counts, lower levels of immunoglobulin G (IgG), IgM, complement 3 (C3), and C4. The proportion of patients with age ≥ 60 years and ferritin > 1500.0 ng/ml in the EBV-infected group was significantly higher than that in the non-infected group. The results of ROC analysis showed that the cut-off values of CRP, IgG, C3, C4, and CD56+ cell counts to predict EBV infection were 13.2 mg/l, 12.5 g/l, 1.1 g/l, 0.6 g/l, 0.3 g/l, and 94.0 cells/µl. Multivariable logistic analysis showed that age ≥ 60 years old, CRP > 13.2 mg/l, BUN > 5.4 mmol/l, ferritin > 1500.0 ng/ml, IgG < 12.5 g/l, IgM < 1.1 g/l, C4 < 0.3 g/l, and CD56+ cell counts > 94.0 cells/µl were the independent risk factors of EBV infection in SFTS patients.

CONCLUSIONS

SFTS combined with EBV infection is associated with high morbidity and mortality. It is necessary to strengthen screening for EBV infection and its early predictive markers after admission in SFTS patients.

Risk prediction for liver injury in Epstein-Barr virus infection in pediatric respiratory tract infections

BACKGROUND

Epstein-Barr virus (EBV) infection is likely to co-occur in pediatric respiratory tract infections (RTIs). Liver injury is the common complication of EBV infection. The detailed risk factors for liver injury in EBV infection remain elusive. We aimed to investigate the incidence, characteristics and potential risk factors for liver injury in EBV infection for early risk prediction.

METHODS

We retrospectively recruited the pediatric RTIs cases with EBV infection according to a predefined criteria from our hospital between January 2015 and December 2017. We extracted the clinical and laboratory data from the electronical medical records. The impact of age, gender, and various parameters on the liver injury risk was investigated. Univariate logistic regression analysis was performed to analyse the association between clinical/laboratory parameters and liver injury. The related indexes were enrolled in the multivariate logistic regression analysis. Decision curve analysis was used to yield the value of related parameters in predicting liver injury. Receiver operating curve (ROC) analysis was applied to produce the C-index of white blood cell (WBC) count for liver injury. We also tested the non-linear association between WBC count and alanine aminotransferase (ALT).

RESULTS

A total of 216 pediatric RTIs with EBV infection were enrolled. EBV infection is more likely to occur during the winter season. Cytomegalovirus infection was independently associated with liver injury in EBV infection (OR = 6.972, 95% CI = 1.648-29.490, p = 0.008). WBC count was independently associated with liver injury in EBV infection (OR = 1.169, 95% CI = 1.051-1.301, p = 0.004). The P interaction value between WBC count and cytomegalovirus was 0.149. The decision curve analysis showed that WBC count had larger area under curve compared with platelet (PLT) and birthweight (BW). ROC analysis yielded the c-index of WBC count: 0.75 and cut-point of 8.3. The turning point of WBC count in its association with ALT was 16.8. The p value before and after the turning point was < 0.001 and 0.123, respectively.

CONCLUSIONS

Cytomegalovirus co-infection demonstrated 5.972 more times of liver injury risk in EBV infection. WBC count was an independent biomarker for liver injury before the turning point of 16.8 in EBV infection. More attention should be paid to the risk of EBV infection in the winter. Cytomegalovirus infection and WBC count merit attention in the monitoring of possible liver injury in EBV infection among pediatric RTIs.

Viral Hepatitis and Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a potentially reversible syndrome that develops in patients with cirrhosis or with underlying chronic liver disease (CLD) and is characterized by acute decompensation, organ failure, and high short-term mortality. Hepatitis A and hepatitis E are major causes of ACLF. Hepatitis B may also cause ACLF through a flare of hepatitis B, acute infection, or reactivation. Besides supportive care, nucleoside/nucleotide analog therapy should also be initiated in this setting. Nonhepatotropic viruses may rarely also cause ACLF with the severe acute respiratory syndrome coronavirus 2 virus recently being identified with poorer outcomes in those with underlying CLD.

Interleukin-35 has a Protective Role in Infectious Mononucleosis-Induced Liver Inflammation Probably by Inhibiting CD8+ T Cell Function

Interleukin (IL)-35 plays an immunosuppressive role in infectious diseases, autoimmune disorders, and cancers. However, IL-35 expression and its regulation of CD8⁺ T cells in infectious mononucleosis (IM) are not fully understood. In this study, three groups of participants were compared, including twenty-three patients of IM without liver inflammation, twenty-eight patients of IM with liver inflammation, and twenty-one controls. Plasma and peripheral blood mononuclear cells (PBMCs) were isolated. CD8⁺ T cells were purified. Plasma IL-35 was measured by ELISA. PBMCs and CD8⁺ T cells were stimulated with recombinant human IL-35 in vitro. Perforin and granzyme B secretion was assessed by ELISPOT. Immune checkpoint molecule expression was investigated by flow cytometry. CD8⁺ T cells were co-cultured with HepG2 cells in direct contact and indirect contact manner. The cytotoxicity of CD8⁺ T cells was calculated by measuring lactate dehydrogenase release and proinflammatory cytokine expression. There was no significant difference in plasma IL-35 levels between patients with IM without liver inflammation and the controls, but the IL-35 level was notably increased in patients with IM who presented with liver inflammation and negatively correlated with aminotransferase. CD8⁺ T cells in patients with IM with liver inflammation showed stronger cytotoxicity. IL-35 stimulation inhibited CD8⁺ T cell-induced target cell death in patients with IM, mainly through suppression of IFN-γ/TNF-α secretion and elevation of immune checkpoint molecule expression, but did not affect perforin or granzyme B secretion. The current data indicated that IL-35 dampened the cytotoxicity of CD8⁺ T cells in patients with IM probably via repression of cytokine secretion. Elevated IL-35 may protect against CD8⁺ T cell-induced liver inflammation in patients with IM.

OUP accepted manuscript

Hepatitis B virus (HBV) remains a global public health problem despite the availability of effective vaccine and antiviral therapy. Cytomegalovirus (CMV), another hepatotropic virus, is also very prevalent in the general population worldwide. Both HBV and CMV can persist in the host and have potential to reactivate especially with weakened host cellular immunity. Superimposed CMV infection can lead to severe HBV reactivation. The pathogenesis of the co-infection of HBV and CMV remains poorly understood. Studies reported conflicting results regarding the inhibitory effect of CMV on HBV replication. There is an unmet need on the management of co-infection of HBV and CMV; research initiatives dedicated to understanding their interactions are urgently needed.

Invasive Pulmonary Aspergillosis in Acute-on-Chronic Liver Failure Patients: Short-Term Outcomes and Antifungal Options

Introduction

Acute-on-chronic liver failure (ACLF) patients are susceptible to invasive fungal infections. We evaluated the prognosis and antifungal options in ACLF patients with invasive pulmonary aspergillosis (IPA).

Methods

ACLF patients with IPA from 15 hospitals were retrospectively screened from 2011 to 2018, and 383 ACLF patients without lung infections were included from a prospective cohort (NCT02457637). Demographic, laboratory, clinical data, and 28-day outcomes were documented in the two cohorts.

Results

ACLF patients with probable IPA (n = 145) had greater 28-day mortality (33.6% vs. 15.7%, p < 0.001) than those without (n = 383). The respiratory failure-associated 28-day mortality was greater in ACLF patients with IPA than in those without before (17.1% vs. 0.3%, p < 0.001) and after (16.0% vs. 0.0%, p < 0.001) propensity score matching in 116 pairs. IPA patients with lung injury had greater 28-day all-cause mortality (66.5% vs. 24.2%, p < 0.001) and IPA-associated mortality (45.8% vs. 8.1%, p < 0.001) than patients without lung injury (PaO2/FiO2 ≥ 400 mmHg). Antifungal therapy was prescribed to 139 of 145 patients, and 102 patients were treated with voriconazole alone (n = 59) or sequential/combined therapy (n = 43) with varying loading doses (100–800 mg) and daily maintenance doses (0–800 mg). A proposed optimal voriconazole regimen (loading dose, 200 mg twice daily; daily maintenance dose, 100 mg) achieved comparable short-term survival and optimal trough drug concentrations (1–5 μg/mL) on therapeutic drug monitoring in 26 patients.

Conclusion

Presence of IPA increases the short-term mortality of ACLF patients mainly due to respiratory failure. An optimal voriconazole regimen is needed for such critical patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00524-5.

Study on correlation between coagulation indexes and disease progression in patients with cirrhosis

OBJECTIVE

To inquire into the significance of coagulation indexes in the progression of cirrhosis.

METHODS

A total of 108 patients with cirrhosis treated in our hospital were collected as the research group (RG), and 105 healthy people who underwent concurrent physical examination were selected as the control group (CG). The coagulation indexes of all the participants were tested to determine their significance in cirrhosis progression.

RESULTS

Compared with the CG, prothrombin time (PT), activated partial thrombin time (APTT) and thrombin time (TT) in the RG were statistically prolonged, while fibrinogen (FIB) was notably decreased (P<0.05). With the increase of Child-Pugh score, PT, APTT and TT prolonged and FIB reduced gradually (P<0.05). The coagulation indexes of patients were correlated with Child-Pugh score (P<0.05). Patients in the RG showed markedly higher alanine aminotransferase (ALT), total bilirubin (TBil), total bile acid (TBA), mean platelet volume (MPV), platelet distribution width (PDW) and platelet-large cell ratio (P-LCR), with notably lower albumin (ALB), prealbumin (PA), platelet count (PLT) and coagulation factors compared with the CG. As the Child-Pugh score increased, the ALT, TBil, TBA, MPV, PDW and P-LCR gradually elevated in the RG (P<0.05), whilst coagulation factors, ALB, PLT and PA all gradually decreased (P<0.05). The value of area under the curve (AUC) of each coagulation index for early diagnosis of cirrhosis was >0.80, and the sensitivity was >80% (P<0.05).

CONCLUSION

Coagulation indexes, coagulation factors, platelet parameters and liver function all effectively reflect the level of liver injury; especially which, coagulation indexes are related to the severity of liver injury, and can provide evidence for the early diagnosis of cirrhosis patients, with clinical significance.

Latent Cytomegalovirus Reactivation in Patients With Liver Failure: A 10-Year Retrospective Case-Control Study, 2011-2020

Background

The aim of this study was to explore potential risk factors for cytomegalovirus (CMV) reactivation and their impact on liver failure patient outcomes.

Methods

A 10-year retrospective case-control study was conducted in adult participants, who were diagnosed with liver failure and had undergone CMV DNA tests. CMV reactivation cases were matched with controls at a 2:1 ratio based on age, sex, and year of admission. Univariate and multivariate analyses were used to explore risk factors for CMV reactivation.

Results

Between January 2011 and April 2020, 198 adult patients with liver failure and available CMV DNA test results were enrolled into the study. Among them, 33 patients had detectable CMV DNA in their plasma (16.7%). Clinical manifestations and liver function were comparable between the CMV reactivation and non-reactivation groups. However, CMV reactivation may triple mortality in patients with liver failure. We found that nearly 50% of patients in the CMV-positive group received glucocorticoids, compared to 13.6% in the CMV-negative group (P=0.000). The median total glucocorticoid dose included 836.5 mg of methylprednisolone (IQR 308.7-1259.0 mg) in the CMV-positive group, which was significantly higher than that in the CMV-negative group. A multivariate analysis revealed that glucocorticoid use significantly increased the risk of CMV reactivation (adjusted OR, 4.84; 95% CI, 1.61-14.49; P=0.005). Patients with CMV reactivation tended to be associated with higher white cell counts (adjusted OR, 1.21; 95% CI, 1.08-1.36; P=0.002).

Conclusions

High intravenous glucocorticoid doses may be the most important risk factor for CMV reactivation in liver failure.

[The role of Epstein-Barr viral infection and hepatitis B and C in liver pathology.]

A review of scientific literature data on clinical and epidemiological characterization of viral hepatitis B, C and Epstein-Barr viral infection is presented. Scopus, Web of Science, MedLine, The Cochrane Library, PubMed, CyberLeninka, RSCI databases were used to find the necessary literature. It was shown that Epstein-Barr virus along with hepatitis B and C viruses plays a significant role in the development of virus-mediated autoimmune liver diseases, as well as other organs (intestine, heart, kidneys, thyroid gland, etc.). The similarity of these nosologies is also evident in the nature of the course of the disease: the presence of a primary infection in a manifest or latent form, with possible subsequent chronization of the process and its periodic reactivation. Wide distribution of pathogens in the human population determines the possibility of mixed infections with Epstein-Barr virus and hepatitis B and C viruses, however, this problem has not been adequately described in the scientific literature. The review suggests that the role of Epstein-Barr virus in the development of liver diseases and extrahepatic pathology should not be ignored, and the combination of this pathogen with hepatitis B and C viruses required further in-depth studies.

Efficacy and safety of spleen aminopeptide oral lyophilized powder in ameliorating liver injury in infants and children with human cytomegalovirus infection: a single-center study in China

BACKGROUND

Liver injury is both very common in infants and children and associated with low immune function. This study aimed to investigate the effect of spleen aminopeptide oral lyophilized powder (SAOLP) on liver injury in infants and children with human cytomegalovirus (HCMV) infection.

METHODS

In this prospective observational study, 217 infants and children with both liver damage and HCMV infection who were admitted to the Department of Pediatric Gastroenterology, Children's Hospital of Nanjing Medical University between July 2018 and May 2020 were investigated. The median age of patients was 0.75 years (0.36-3.77 years), with 105 male and 112 female participants. All 217 patients received ursodeoxycholic acid (UDCA) and/or reduced glutathione (GDC) therapy. Of these 217 patients, 114 also received SAOLP. Liver function, cellular immunity levels, HCMV antibody titer, and HCMV-DNA load values were measured 1 day before treatment, and on the second and fourth week after treatment.

RESULTS

After 4 weeks, patients treated with SAOLP showed median levels of serum alanine aminotransferase (ALT), total bilirubin (TB), and direct bilirubin (DB) which were significantly lower than those seen in patients who did not receive it. In addition, the percentage of CD4+ cells was significantly higher in those treated with SAOLP in comparison to those treated with UDCA and/or GDC alone. The number of positive HCMV-immunoglobin M (IgM) patients was also sharply decreased in the group receiving SAOLP.

CONCLUSIONS

The addition of SAOLP to UDCA and/or GDC therapy may significantly relieve liver injury and reduce the jaundice index by enhancing immune function and anti-HCMV infection ability in infants and children.

Epstein-Barr Virus and Cytomegalovirus Infections of the Liver

Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections are common and are associated with a variety of liver manifestations. EBV and CMV infections, in immunocompetent hosts, commonly manifest as acute hepatitis, with severity varying from asymptomatic, self-limited icteric hepatitis to acute liver failure. Atypical manifestations, such as cholestasis, chronic hepatitis, precipitation of acute-on-chronic liver failure, and autoimmune hepatitis, are reported with EBV infection, whereas cholestasis, portal vein thrombosis, and Budd-Chiari syndrome are reported with CMV infection. In the setting of liver transplantation, CMV is the most common infectious complication and carries significant morbidity; EBV is the major cause of post-transplant lymphoproliferative disorders.

Epstein-Barr virus infection is associated with a higher Child-Pugh score and may predict poor prognoses for patients with liver cirrhosis

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.