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Contributing awareness of autoimmune hepatitis in HIV patients. AIDS 2019; 33:2103-2105. [PMID: 31577575 DOI: 10.1097/qad.0000000000002299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chaiteerakij R, Sanpawat A, Avihingsanon A, Treeprasertsuk S. Autoimmune hepatitis in human immunodeficiency virus-infected patients: A case series and review of the literature. World J Gastroenterol 2019; 25:5388-5402. [PMID: 31558881 PMCID: PMC6761245 DOI: 10.3748/wjg.v25.i35.5388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/14/2019] [Accepted: 08/24/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Abnormal liver chemistry is a common problem in human immunodeficiency virus (HIV)-infected patients. Common causes of abnormal liver enzymes in this population include viral hepatitis B/C or opportunistic infection, drug toxicity, and neoplasm. Autoimmune hepatitis is a rare cause of hepatitis in HIV-infected individuals; however, this condition has been increasingly reported over the past few years.
CASE SUMMARY We present 13 HIV-infected patients (5 males and 8 females) who developed autoimmune hepatitis (AIH) after their immune status was restored, i.e. all patients had stable viral suppression with undetectable HIV viral loads, and median CD4+ counts of 557 cells/× 106 L. Eleven patients presented with chronic persistent elevation of aminotransferase enzyme levels. One patient presented with acute hepatitis and the other patient presented with jaundice. The median levels of aspartate aminotransferase and alanine aminotransferase enzymes were 178 and 177 U/mL, respectively. Elevation of immunoglobulin G levels was present in 11 (85%) patients. Antinuclear antibody and anti-smooth muscle antibody were positive in 11 (85%) and 5 (38%) patients. Liver biopsy was performed in all patients. They had histopathological findings compatible with AIH. The patients were started on prednisolone for remission induction, with good response. After improvement of the liver chemistry, the dose of prednisolone was tapered, and azathioprine was added as life-long maintenance therapy. At the last follow-up visit, all were doing well, without HIV viral rebound or infectious complications.
CONCLUSION This report underscores the emergence of autoimmune hepatitis in the context of HIV infection.
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Affiliation(s)
- Roongruedee Chaiteerakij
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Anapat Sanpawat
- Department of Pathology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Anchalee Avihingsanon
- Medical Department, The HIV Netherlands Australia Thailand Research Collaboration, Bangkok 10330, Thailand
| | - Sombat Treeprasertsuk
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
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Mubder M, Azab M, Jayaraj M, Cross C, Lankarani D, Dhindsa B, Pan JJ, Ohning G. Autoimmune hepatitis in patients with human immunodeficiency virus infection: A systematic review of the published literature. Medicine (Baltimore) 2019; 98:e17094. [PMID: 31517833 PMCID: PMC6750342 DOI: 10.1097/md.0000000000017094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Liver disease in patients with HIV is common and typically has complex and multifactorial presentations that represent a major cause of morbidity and mortality. Autoimmune hepatitis (AIH) is rarely reported in patient with HIV and the disease course and clinical outcomes for treatment have not been well characterized. We are aiming to determine the patient characteristics, disease prevalence, and treatment outcomes from published articles of patients with HIV and AIH. METHOD A systematic search of PubMed, Web of Science, and Google Scholar through February 20, 2019 identified 15 studies that reported the outcomes of AIH in patients with HIV. Because of the small sample sizes and skewed distributions, resampling tests of mean differences using permutation distributions (MAXn = 10,000 permutations) were utilized; analyses were performed using R (v. 3.5.1). Categorical differences were calculated using Fisher exact test for odds ratio = 1 (equal odds), and Cramer V was calculated for effect size; analyses were completed in SPSS (v. 25). RESULTS By reviewing 15 studies reporting a total of 35 patients with AIH and HIV, male patients were found to have significantly higher aspartate transaminase and alanine transaminase levels at time of diagnosis. No other significant findings identified. The CD4 count and viral load did not show significant correlation with AIH diagnosis or its prognosis. All patients but one who presented with severe immune deficiency and responded to highly active anti-retroviral therapy received immunosuppressive treatment without side effects and achieved remission except 2 lost to follow-up and 3 expired. CONCLUSION Although rare, but AIH can develop in patients with HIV and physicians should consider it in the differential diagnosis for HIV patients presented with abnormal liver function tests, especially after excluding hepatitis C virus and drug-induced liver injury.Patients with immune deficiency disorders who present with AIH can be treated safely with steroid either as monotherapy or in combination with another immune suppressant therapy.
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Affiliation(s)
- Mohamad Mubder
- Department of Internal Medicine, University of Nevada, Las Vegas, NV
| | - Mohamed Azab
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, CA
| | - Mahendran Jayaraj
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nevada, Las Vegas, NV
| | | | - Daisy Lankarani
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nevada, Las Vegas, NV
| | - Banreet Dhindsa
- Department of Internal Medicine, University of Nevada, Las Vegas, NV
| | - Jen-Jung Pan
- Department of Internal medicine, Division of Gastroenterology and Hepatology, University of Arizona-College of Medicine, Phoenix, AZ
| | - Gordon Ohning
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nevada, Las Vegas, NV
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Ofori E, Ramai D, Ona MA, Reddy M. Autoimmune hepatitis in the setting of human immunodeficiency virus infection: A case series. World J Hepatol 2017; 9:1367-1371. [PMID: 29359021 PMCID: PMC5756727 DOI: 10.4254/wjh.v9.i36.1367] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/16/2017] [Accepted: 12/06/2017] [Indexed: 02/06/2023] Open
Abstract
Liver injury in the setting of human immunodeficiency virus (HIV) infection is more commonly attributed to viral hepatitis or highly active antiretroviral treatment (HAART) toxicity. The severity of liver injury is an important cause of morbidity and mortality. The emergence of autoimmune diseases, particularly autoimmune hepatitis (AIH) in the setting of HIV infection, is rare. Previous reports indicate that elevated liver enzymes are a common denominator amongst these patients. We present two patients with HIV infection, on HAART, with virological suppression. Both patients presented with elevated liver enzymes, and following liver biopsies, were diagnosed with AIH. The clinical course of these patients underscore the therapeutic value of corticosteroids, and in some cases, addition of immunosuppression for AIH treatment.
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Affiliation(s)
- Emmanuel Ofori
- Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY 11201, United States
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY 11201, United States.
| | - Mel A Ona
- Division of Advanced Endoscopy, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, the Brooklyn Hospital Center, Academic Affiliate of the Icahn School of Medicine at Mount Sinai, Clinical Affiliate of the Mount Sinai Hospital, Brooklyn, NY 11201, United States
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5
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Noreña I, Morantes-Caballero JA, Garcés A, Gómez BJ, Rodríguez G, Saavedra C, Otero W. Autoimmune hepatitis in human immunodeficiency virus infection: Case report and literature review. World J Clin Infect Dis 2017; 7:50-57. [DOI: 10.5495/wjcid.v7.i4.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/02/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
The infection due to human immunodeficiency virus (HIV) is characterized by the progressive reduction of CD4+ T lymphocytes and the compromise of other cell lines of the immune system, resulting in immunosuppression. In this context, autoimmune diseases could be considered contradictory, however, cases of autoimmune diseases during this infection have been described, including autoimmune hepatitis (AIH), which is uncommon and has few case reports within medical literature, none of them from Latin America. In this case report where a patient with an HIV infection on combined antiretroviral treatment developed acute elevation of transaminases, hyperbilirubinemia, and deterioration in hepatic synthetic function. Although initially an antiretroviral drug-induced liver injury was suspected, during the study a diagnosis of autoimmune hepatitis was proven, which required treatment with corticosteroid and azathioprine, obtaining a satisfactory response and managing to continue the antiretroviral therapy. Autoimmune diseases in HIV infection must be taken into account. In the case of hepatitis in patients with HIV on antiretroviral treatment, the differentiation between viral hepatitis caused by autoimmune diseases or medications is essential to establish an adequate treatment, and avoid the suspension of the antiretroviral therapy.
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Affiliation(s)
- Ivan Noreña
- Infectious Diseases Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Jairo A Morantes-Caballero
- Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Andrés Garcés
- Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Brian José Gómez
- Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Gabriel Rodríguez
- Infectious Diseases Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - Carlos Saavedra
- Infectious Diseases Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
| | - William Otero
- Gastroenterology Section, Department of Internal Medicine, Universidad Nacional de Colombia and Hospital Universitario Nacional de Colombia, Bogotá 11321, Colombia
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Kaleidoscope of autoimmune diseases in HIV infection. Rheumatol Int 2016; 36:1481-1491. [DOI: 10.1007/s00296-016-3555-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/13/2016] [Indexed: 12/23/2022]
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Hagel S, Bruns T, Herrmann A, Tannapfel A, Stallmach A. Autoimmune hepatitis in an HIV-infected patient: an intriguing association. Int J STD AIDS 2013; 23:448-50. [PMID: 22807544 DOI: 10.1258/ijsa.2009.009337] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abnormal levels of liver enzymes are common in HIV-infected patients and may be caused by multiple factors, including co-infection with hepatitis C virus (HCV) or hepatitis B virus (HBV) infection and in the majority of cases by antiretroviral drug-related liver injury. This report, however, describes a patient with HIV infection and abnormal liver function tests where further diagnostics revealed concomitant autoimmune hepatitis (AIH). The association of immune dysfunction in patients with HIV infection/AIDS and the development of autoimmune diseases is intriguing. The precise mechanism causing the emergence or unmasking of autoimmune conditions in HIV infection remains unclear, but it is important to demonstrate that autoimmune diseases do occur in HIV-infected patients. Therefore, clinicians should include AIH in the differential diagnosis of increased liver enzymes when there is no improvement despite changing antiretroviral therapy.
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Affiliation(s)
- S Hagel
- Division of Gastroenterology, Hepatology and Infectious Diseases, Department of Internal Medicine II, Friedrich-Schiller-University, Erlanger Allee 101, 07747 Jena, Germany.
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Macaluso FS, Alessi N, Cabibi D. Antimitochondrial antibody -M2 positive autoimmune hepatitis during standard of care for chronic hepatitis C. Hepatol Res 2012; 42:428-32. [PMID: 22443693 DOI: 10.1111/j.1872-034x.2011.00931.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The current standard of care (SoC) for chronic hepatitis C, i.e. the combination of a pegylated-interferon (PEG-IFN) with ribavirin (RBV), may activate underlying autoimmune conditions. Particularly, interferon (IFN) has been known to induce or exacerbate autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) in hepatitis C virus patients. We describe a severe, acute-onset antimitochondrial antibody (AMA)-M2 positive AIH appearing during the last weeks of SoC in a woman with chronic hepatitis C and no previous history of autoimmunity, and resolving on protracted steroids. In this context, the relevance of the characterization of the immunoglobulin isotype of portal plasma cells for a more appropriate diagnosis of autoimmune liver diseases can be emphasized.
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Affiliation(s)
- Fabio Salvatore Macaluso
- Biomedical Department of Internal and Specialist Medicine, Section of Gastroenterology, University of Palermo, Palermo, Italy Department of Human Pathology, University of Palermo, Palermo, Italy
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Oeda S, Mizuta T, Isoda H, Kuwashiro T, Oza N, Iwane S, Takahashi H, Kawaguchi Y, Eguchi Y, Toda S, Ozaki I, Anzai K, Fujimoto K. Efficacy of pegylated interferon plus ribavirin in combination with corticosteroid for two cases of combined hepatitis C and autoimmune hepatitis. Clin J Gastroenterol 2012; 5:141-5. [PMID: 22593772 PMCID: PMC3328672 DOI: 10.1007/s12328-012-0295-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 03/06/2012] [Indexed: 01/03/2023]
Abstract
The treatment strategy for cases of combined autoimmune hepatitis (AIH) and chronic hepatitis C (CHC) has not yet been established. A 47-year-old woman and a 53-year-old-woman were hospitalized for treatment of CHC. Ultrasonography and histological findings revealed that their liver was not cirrhotic but did have chronic damage. The histological findings of both patients were suggestive of AIH. The patients were systematically treated with pegylated interferon-alpha 2b plus ribavirin which was preceded by and combined with corticosteroid (CS), and showed sustained virological responses and normal liver function. Although these two patients with combined AIH and CHC were successfully treated with this regimen, careful attention to exacerbation of hepatic inflammation is needed because hepatitis C viral load was increased due to immunosuppression during CS treatment.
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Affiliation(s)
- Satoshi Oeda
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Toshihiko Mizuta
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Hiroshi Isoda
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Takuya Kuwashiro
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Noriko Oza
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Shinji Iwane
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Hirokazu Takahashi
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Yasunori Kawaguchi
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Yuichiro Eguchi
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Shuji Toda
- Department of Pathology, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Iwata Ozaki
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Keizo Anzai
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Kazuma Fujimoto
- Department of Internal Medicine, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501 Japan
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Daas H, Khatib R, Nasser H, Kamran F, Higgins M, Saravolatz L. Human immunodeficiency virus infection and autoimmune hepatitis during highly active anti-retroviral treatment: a case report and review of the literature. J Med Case Rep 2011; 5:233. [PMID: 21702972 PMCID: PMC3141694 DOI: 10.1186/1752-1947-5-233] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 06/25/2011] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The emergence of hepatic injury in patients with human immunodeficiency virus infection during highly active therapy presents a diagnostic dilemma. It may represent treatment side effects or autoimmune disorders, such as autoimmune hepatitis, emerging during immune restoration. CASE PRESENTATION We present the case of a 42-year-old African-American woman with human immunodeficiency virus infection who presented to our emergency department with severe abdominal pain and was found to have autoimmune hepatitis. A review of the literature revealed 12 reported cases of autoimmune hepatitis in adults with human immunodeficiency virus infection, only three of whom were diagnosed after highly active anti-retroviral treatment was initiated. All four cases (including our patient) were women, and one had a history of other autoimmune disorders. In our patient (the one patient case we are reporting), a liver biopsy revealed interface hepatitis, necrosis with lymphocytes and plasma cell infiltrates and variable degrees of fibrosis. All four cases required treatment with corticosteroids and/or other immune modulating agents and responded well. CONCLUSION Our review suggests that autoimmune hepatitis is a rare disorder which usually develops in women about six to eight months after commencing highly active anti-retroviral treatment during the recovery of CD4 lymphocytes. It represents either re-emergence of a pre-existing condition that was unrecognized or a de novo manifestation during immune reconstitution.
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Affiliation(s)
- Hanady Daas
- Department of Internal Medicine, Division of Infectious Diseases, St John Hospital & Medical Center, 19251 Mack Avenue, Suite 340, Grosse Pointe Woods, MI 48236, USA.
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Trikudanathan GV, Ahmad I, Israel JL. Concurrent autoimmune hepatitis and grave's disease in hepatitis C during pegylated interferon α-2a and ribavirin therapy. Saudi J Gastroenterol 2011; 17:348-52. [PMID: 21912063 PMCID: PMC3178924 DOI: 10.4103/1319-3767.84494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Classical interferon-α has been shown to be associated with the development of a variety of autoimmune disorders. A 34-year-old white woman with chronic hepatitis C virus infection who was treated with pegylated interferon α-2a and ribavirin, developed Grave's disease and autoimmune hepatitis (AIH) at 32 and 44 weeks, respectively, following initiation of the therapy. The diagnosis of AIH was made based on the new development of anti-smooth muscle antibodies, anti-mitochondrial antibodies, and liver biopsy findings. It was confirmed by positive response to steroid challenge and was assessed according to the international AIH scoring system. Based on the previous case reports, we review the existing literature. Clinicians should be aware of the possibility of multiple autoimmune disorders during interferon-based therapy for chronic hepatitis.
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Affiliation(s)
- Guru V. Trikudanathan
- Department of Internal Medicine, University of Connecticut Medical Center, Farmington, USA
| | - Imad Ahmad
- Department of Internal Medicine, University of Connecticut Medical Center, Farmington, USA
| | - Jonathan L Israel
- Division of Gastroenterology, Hartford Hospital, Hartford, CT, USA,Address for correspondence: Dr. Jonathan Israel, Division of Gastroenterology, Hartford Hospital, 85 Seymour Street, Suite 1000, CT-06106, USA. E-mail:
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Safety, Tolerability, and Immunogenicity of Interferons. Pharmaceuticals (Basel) 2010; 3:1162-1186. [PMID: 27713294 PMCID: PMC4034027 DOI: 10.3390/ph3041162] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 04/03/2010] [Accepted: 04/12/2010] [Indexed: 02/08/2023] Open
Abstract
Interferons (IFNs) are class II cytokines that are key components of the innate immune response to virus infection. Three IFN sub-families, type I, II, and III IFNs have been identified in man, Recombinant analogues of type I IFNs, in particular IFNα2 and IFNβ1, have found wide application for the treatment of chronic viral hepatitis and remitting relapsing multiple sclerosis respectively. Type II IFN, or IFN gamma, is used principally for the treatment of chronic granulomatous disease, while the recently discovered type III IFNs, also known as IFN lambda or IL-28/29, are currently being evaluated for the treatment of chronic viral hepatitis. IFNs are in general well tolerated and the most common adverse events observed with IFNα or IFNβ therapy are “flu-like” symptoms such as fever, headache, chills, and myalgia. Prolonged treatment is associated with more serious adverse events including leucopenia, thrombocytopenia, increased hepatic transaminases, and neuropsychiatric effects. Type I IFNs bind to high-affinity cell surface receptors, composed of two transmembrane polypeptides IFNAR1 and IFNAR2, resulting in activation of the Janus kinases Jak1 and Tyk2, phosphorylation and activation of the latent cytoplasmic signal transducers and activators of transcription (STAT1) and STAT2, formation of a transcription complex together with IRF9, and activation of a specific set of genes that encode the effector molecules responsible for mediating the biological activities of type I IFNs. Systemic administration of type I IFN results in activation of IFN receptors present on essentially all types of nucleated cells, including neurons and hematopoietic stem cells, in addition to target cells. This may well explain the wide spectrum of IFN associated toxicities. Recent reports suggest that certain polymorphisms in type I IFN signaling molecules are associated with IFN-induced neutropenia and thrombocytopenia in patients with chronic hepatitis C. IFNγ binds to a cell-surface receptor composed of two transmembrane polypeptides IFGR1 and IFGR2 resulting in activation of the Janus kinases Jak1 and Jak2, phosphorylation of STAT1, formation of STAT1 homodimers, and activation of a specific set of genes that encode the effector molecules responsible for mediating its biological activity. In common with type I IFNs, IFNγ receptors are ubiquitous and a number of the genes activated by IFNγ are also activated by type I IFNs that may well account for a spectrum of toxicities similar to that associated with type I IFNs including “flu-like” symptoms, neutropenia, thrombocytopenia, and increased hepatic transaminases. Although type III IFNs share the major components of the signal transduction pathway and activate a similar set of IFN-stimulated genes (ISGs) as type I IFNs, distribution of the IFNλ receptor is restricted to certain cell types suggesting that IFNλ therapy may be associated with a reduced spectrum of toxicities relative to type I or type II IFNs. Repeated administration of recombinant IFNs can cause in a break in immune tolerance to self-antigens in some patients resulting in the production of neutralizing antibodies (NABs) to the recombinant protein homologue. Appearance of NABs is associated with reduced pharmacokinetics, pharmacodynamics, and a reduced clinical response. The lack of cross-neutralization of IFNβ by anti-IFNα NABs and vice versa, undoubtedly accounts for the apparent lack of toxicity associated with the presence of anti-IFN NABs with the exception of relatively mild infusion/injection reactions.
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Abstract
PURPOSE OF REVIEW This review focuses on some of the recent advances in the understanding of HIV immunopathogenesis and the diagnosis and treatment of several autoimmune conditions associated with HIV in the era of potent antiretroviral therapy. RECENT FINDINGS Chronic immune activation with progressive immune exhaustion are central features of HIV pathogenesis. The role of self-reactive T cells in the generation and maintenance of this process has recently been described. The understanding of the impact of immune dysregulation on the generation of autoimmune phenomena in HIV infection remains incomplete. The diagnosis of autoimmune diseases in the context of HIV is often difficult due to similarities in clinical presentations and laboratory markers. The antiretroviral therapy-associated immune reconstitution syndrome can present as autoimmune disease. SUMMARY The cause, frequency and prognosis of autoimmune conditions associated with HIV infection remain somewhat uncertain. Their management is often empirical with the use of novel immunosuppressive medication.
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Wan DW, Marks K, Yantiss RK, Talal AH. Autoimmune hepatitis in the HIV-infected patient: a therapeutic dilemma. AIDS Patient Care STDS 2009; 23:407-13. [PMID: 19405870 DOI: 10.1089/apc.2008.0149] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Autoimmune hepatitis (AIH) is a progressive, chronic hepatitis that has rarely been reported in HIV-infected individuals. Among patients who are candidates for hepatitis C virus (HCV) treatment, screening for AIH should be considered, because interferon has the potential to cause fulminant hepatic failure in the setting of immune-mediated injury. During a 4-year period, we identified four HIV-infected patients who were referred for evaluation of persistently elevated aminotransferases, two of whom were also infected with HCV. Serologic testing and the hepatic histologic appearance were consistent with AIH. Although each patient initiated treatment with corticosteroids and immunosuppressive agents, all four eventually developed life-threatening infectious or adverse metabolic effects that resulted in treatment discontinuation. Of note, one HIV/HCV co-infected patient was able to initiate HCV treatment with interferon after AIH remission was documented. While these cases illustrate that AIH can produce hepatic injury in virally infected individuals, we recommend that treatment for AIH in HIV-infected patients should be individualized after careful consideration of the potential risks and likely benefits.
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Affiliation(s)
- David W. Wan
- Department of Medicine, Weill Medical College of Cornell University, New York, New York
| | - Kristen Marks
- Division of International Medicine and Infectious Diseases, Weill Medical College of Cornell University, New York, New York
| | - Rhonda K. Yantiss
- Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, New York, New York
| | - Andrew H. Talal
- Division of Gastroenterology and Hepatology, Weill Medical College of Cornell University, New York, New York
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Ferri S, Muratori L, Quarneti C, Muratori P, Menichella R, Pappas G, Granito A, Ballardini G, Bianchi FB, Lenzi M. Clinical features and effect of antiviral therapy on anti-liver/kidney microsomal antibody type 1 positive chronic hepatitis C. J Hepatol 2009; 50:1093-101. [PMID: 19398235 DOI: 10.1016/j.jhep.2009.02.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 01/31/2009] [Accepted: 02/03/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Anti-liver/kidney microsomal antibody type 1 (anti-LKM1), a serological marker of type 2 autoimmune hepatitis, is also detected in a small proportion of patients with hepatitis C. This study aimed to evaluate clinical features and effect of antiviral therapy in patients with hepatitis C who are anti-LKM1 positive. METHODS Sixty consecutive anti-LKM1 positive and 120 age and sex-matched anti-LKM1 negative chronic hepatitis C patients were assessed at diagnosis and during follow-up. Of these, 26 anti-LKM1 positive and 72 anti-LKM1 negative received antiviral therapy. Anti-LKM1 was detected by indirect immunofluorescence and immunoblot. Number of HCV-infected hepatocytes and intrahepatic CD8+ lymphocytes was determined by immunohistochemistry. RESULTS At diagnosis anti-LKM1 positive patients had higher IgG levels and more intrahepatic CD8+ lymphocytes (p 0.022 and 0.046, respectively). Viral genotypes distribution and response to therapy were identical. Hepatic flares during antiviral treatment only occurred in a minority of patients in concomitance with anti-LKM1 positivity. CONCLUSIONS Immune system activation is more pronounced in anti-LKM1 positive patients with hepatitis C, possibly representing the expression of autoimmune mechanisms of liver damage. Antiviral treatment is as beneficial in these patients as in anti-LKM1 negative patients, and the rare necroinflammatory flares are effectively controlled by corticosteroids, allowing subsequent resumption of antiviral therapy.
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Affiliation(s)
- Silvia Ferri
- Department of Clinical Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy.
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Vispo E, Maida I, Moreno A, Barreiro P, Soriano V. Autoimmune hepatitis induced by pegylated interferon in an HIV-infected patient with chronic hepatitis C. J Antimicrob Chemother 2008; 62:1470-2. [PMID: 18835807 DOI: 10.1093/jac/dkn416] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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