Longitudinal analysis within one hospital in sub-Saharan Africa over 20 years reveals repeated replacements of dominant clones of Klebsiella pneumoniae and stresses the importance to include temporal patterns for vaccine design considerations

BACKGROUND

Infections caused by multidrug-resistant gram-negative bacteria present a severe threat to global public health. The WHO defines drug-resistant Klebsiella pneumoniae as a priority pathogen for which alternative treatments are needed given the limited treatment options and the rapid acquisition of novel resistance mechanisms by this species. Longitudinal descriptions of genomic epidemiology of Klebsiella pneumoniae can inform management strategies but data from sub-Saharan Africa are lacking.

METHODS

We present a longitudinal analysis of all invasive K. pneumoniae isolates from a single hospital in Blantyre, Malawi, southern Africa, from 1998 to 2020, combining clinical data with genome sequence analysis of the isolates.

RESULTS

We show that after a dramatic increase in the number of infections from 2016 K. pneumoniae becomes hyperendemic, driven by an increase in neonatal infections. Genomic data show repeated waves of clonal expansion of different, often ward-restricted, lineages, suggestive of hospital-associated transmission. We describe temporal trends in resistance and surface antigens, of relevance for vaccine development.

CONCLUSIONS

Our data highlight a clear need for new interventions to prevent rather than treat K. pneumoniae infections in our setting. Whilst one option may be a vaccine, the majority of cases could be avoided by an increased focus on and investment in infection prevention and control measures, which would reduce all healthcare-associated infections and not just one.

Anti-Ri paraneoplastic neurological syndrome presenting with bilateral cranial nerve VI palsy and jaw dystonia-a distinctive syndrome within the anti-Ri spectrum? : Case report and literature review

OBJECTIVE

Paraneoplastic neurological syndromes (PNS) are rare disorders associated with various onconeuronal antibodies. Anti-Ri antibodies (ANNA-2) are typically found in patients with opsoclonus myoclonus syndrome (OMS) and ataxia.

CASE REPORT

We present an anti-Ri antibody-positive 77-year-old woman with subacute progressive bilateral cranial nerve VI palsy, gait disturbance and jaw dystonia. MRI of the brain showed hyperintense signals on T2 bitemporal without contrast enhancement. Cerebrospinal fluid (CSF) examination exhibited mild pleocytosis of 13 cells/µl and positive oligoclonal bands. CSF was overall inconspicuous for a malignant or inflammatory etiology. Immunofluorescence analysis revealed anti-Ri antibodies in both serum and CSF. Subsequent diagnostic work up resulted in a newly diagnosed ductal carcinoma of the right breast. PNS in this case partially responded to the anti-tumor therapy.

CONCLUSION

This case shows similarities with recently published anti-Ri syndromes, which might form a distinct triad within the anti-Ri spectrum.

Polysaccharide BAP1 of Bifidobacterium adolescentis CCDM 368 is a biologically active molecule with immunomodulatory properties

Bifidobacteria are among the most common bacteria used for their probiotic properties and their impact on the maturation and function of the immune system has been well-described. Recently, scientific interest is shifting from live bacteria to defined bacteria-derived biologically active molecules. Their greatest advantage over probiotics is the defined structure and the effect independent of the viability status of the bacteria. Here, we aim to characterize Bifidobacterium adolescentis CCDM 368 surface antigens that include polysaccharides (PSs), lipoteichoic acids (LTAs), and peptidoglycan (PG). Among them, Bad368.1 PS was observed to modulate OVA-induced cytokine production in cells isolated from OVA-sensitized mice by increasing the production of Th1-related IFN-γ and inhibition of Th2-related IL-5 and IL-13 cytokines (in vitro). Moreover, Bad368.1 PS (BAP1) is efficiently engulfed and transferred between epithelial and dendritic cells. Therefore, we propose that the Bad368.1 PS (BAP1) can be used for the modulation of allergic diseases in humans. Structural studies revealed that Bad368.1 PS has an average molecular mass of approximately 9,99 × 10⁶ Da and it consists of glucose, galactose, and rhamnose residues that are creating the following repeating unit: →2)-β-D-Glcp-1→3-β-L-Rhap-1→4-β-D-Glcp-1→3-α-L-Rhap-1→4-β-D-Glcp-1→3-α-D-Galp-(1→_n.

Paraneoplastic Ataxia: Antibodies at the Forefront Have Become Routine Biomarkers

Paraneoplastic cerebellopathies are immune-mediated disorders targeting primarily the cerebellar circuitry, often presenting in a subacute course. The syndrome often develops before the cancer. Therefore, its identification often leads secondarily to a diagnosis of cancer, a critical step to stabilize symptoms. Two categories of antibodies have been identified these last 30 years: (a) onconeuronal antibodies which are directed against intracellular antigens, and (b) antibodies which are directed against synaptic and cell surface proteins. These latter impact on the location and function of the antigens, causing a genuine neuronal dysfunction. Appropriate and fast tumor screening has emerged as a recommendation facing a subacute cerebellar syndrome suspected to be paraneoplastic. Search for antibodies is now a milestone for the diagnosis.

Assaying Interactions Between Neutrophils and Plasmodium falciparum-Infected Red Blood Cells

Plasmodium falciparum, which causes the deadliest form of human malaria, is able to evade antibody-mediated immune responses through switches in expression of surface antigens. Thus, over the years, the focus of most research has been on the role of the adaptive immune response in the course of malaria. However, in recent years there is mounting evidence for the role of the innate immune response to Plasmodium infections. In this context, very little is known on the protective role of neutrophils against blood-stage parasites and the mechanisms by which they recognize and eliminate infected red blood cells. Here we describe several useful methodologies that enable the study and quantification of the interactions between human neutrophils and P. falciparum-infected red blood cells.

Production and Purification of Functional Cryptosporidium Glycoproteins by Heterologous Expression in Toxoplasma gondii

Development of an effective vaccine against cryptosporidiosis is a medical and veterinary priority. However, many putative Cryptosporidium vaccine candidates such as surface and apical complex antigens are posttranslationally modified with O- and N-linked glycans. This presents a significant challenge to understanding the functions of these antigens and the immune responses to them. Isolation of large amounts of native antigen from Cryptosporidium oocysts is expensive and is only feasible for C. parvum antigens. Here, we describe a method of producing recombinant, functional Cryptosporidium glycoprotein antigens in Toxoplasma gondii. These functional recombinant proteins can be used to investigate the role of glycotopes in Cryptosporidium immune responses and parasite-host cell interactions.

Expression of in vivo biotinylated recombinant antigens SAG1 and SAG2A from Toxoplasma gondii for improved seroepidemiological bead-based multiplex assays

BACKGROUND

Few bead-based multiplex assays have been described that detect antibodies against the protozoan parasite Toxoplasma gondii in large-scale seroepidemiological surveys. Moreover, each multiplex assay has specific variations or limitations, such as the use of truncated or fusion proteins as antigens, potentially masking important epitopes. Consequently, such an assay must be developed by interested groups as none is commercially available.

RESULTS

We report the bacterial expression and use of N-terminal fusion-free, soluble, in vivo biotinylated recombinant surface antigens SAG1 and SAG2A for the detection of anti-T. gondii IgG antibodies. The expression system relies on three compatible plasmids. An expression construct produces a fusion of maltose-binding protein with SAG1 (or SAG2A), separated by a TEV protease cleavage site, followed by a peptide sequence recognized by E. coli biotin ligase BirA (AviTag), and a terminal six histidine tag for affinity purification. TEV protease and BirA are encoded on a second plasmid, and their expression leads to proteolytic cleavage of the fusion protein and a single biotinylated lysine within the AviTag by BirA. Correct folding of the parasite proteins is dependent on proper disulfide bonding, which is facilitated by a sulfhydryl oxidase and a protein disulfide isomerase, encoded on the third plasmid. The C-terminal biotinylation allowed the oriented, reproducible coupling of the purified surface antigens to magnetic Luminex beads, requiring only minute amounts of protein per determination. We showed that an N-terminal fusion partner such as maltose-binding protein negatively influenced antibody binding, confirming that access to SAG1's N-terminal epitopes is important for antibody recognition. We validated our bead-based multiplex assay with human sera previously tested with commercial diagnostic assays and found concordance of 98-100% regarding both, sensitivity and specificity, even when only biotinylated SAG1 was used as antigen.

CONCLUSIONS

Our recombinant in vivo-biotinylated T. gondii antigens offer distinct advantages compared to previously described proteins used in multiplex serological assays for T. gondii. They offer a cheap, specific and sensitive alternative to either parasite lysates or eukaryotic-cell expressed SAG1/SAG2A for BBMA and other formats. The described general expression strategy can also be used for other antigens where oriented immobilization is key for sensitive recognition by antibodies and ligands.

Characterization of surface antigens of reticulated immature platelets

Reticulated platelets (RPs) are immature platelets with high dense granules content and a residual amount of megakaryocyte-derived of mRNA. Increased level of RPs has been found to be an independent predictor of cardiovascular ischemic events, and has been associated with impaired response to various anti-platelet drugs. The study aimed to characterize and compare the surface antigenic properties of reticulated versus mature platelets. Platelets from healthy individuals and diabetic patients were tested at rest and after activation with adenosine diphosphate (ADP). For each patient, we calculated the proportion of RPs and mature platelets using flow cytometry analysis with thiazole orange staining (for RPs) and CD42b platelet-specific antibody. We also tested the surface expression of P-selectin and Annexin V, by double staining flow cytometry in RPs versus mature platelets. A total of 20 subjects were recruited (10 healthy individuals, 10 diabetics). Activation with ADP did not cause a significant change in the proportion of RPs. Following activation, RPs demonstrated a significant increase in the expression of both P-selectin and Annexin V, while mature platelets exhibited a non-significant increase in both markers. These findings were consistent in both healthy subjects and patients with diabetes. In conclusion, RPs have a significantly higher capacity to increase the expression of platelet activation markers compared with mature platelets.

Detection of antibody-secreting cells specific for the cytomegalovirus and herpes simplex virus surface antigens

Infections with the herpes simplex virus (HSV) and the human cytomegalovirus (HCMV) can lead to life-threatening diseases, particularly in immunosuppressed patients. Furthermore, HSV infections at birth (herpes neonatorum) can result in a disseminated disease associated with a fatal multiorgan failure. Congenital HCMV infections can result in miscarriage, serious birth defects or developmental disabilities. Antibody-based interventions with hyperimmunoglobulins showed encouraging results in clinical studies, but clearly need to be improved. The isolation of highly neutralizing monoclonal antibodies is a promising strategy to establish potent therapy options against HSV and HCMV infections.

Monoclonal antibodies are commonly isolated from hybridomas or EBV-immortalized B-cell clones. The screening procedure to identify virus-specific cells from a cell mixture is a challenging step, since most of the highly neutralizing antibodies target complex conformational epitopes on the virus surface. Conventional assays such as ELISA are based on purified viral proteins and inappropriate to display complex epitopes.

To overcome this obstacle, we have established two full-virus based methods that allow screening for cells and antibodies targeting complex conformational epitopes on viral surface antigens. The methods are suitable to detect surface antigen-specific cells from a cell mixture and may facilitate the isolation of highly neutralizing antibodies against HSV and HCMV.

Lapine periodontal ligament stem cells for musculoskeletal research in preclinical animal trials

Background

Human periodontal ligament stem cells (hPDLSCs) have been shown to be a reliable source of mesenchymal stem cells (MSCs). On the other hand, rabbits have been commonly used in preclinical trials for musculoskeletal research. However, there is a lack of sufficient data on using rabbit periodontal ligament stem cells (rPDLSCs) for regenerative dentistry. This study, for the first time, comprehensively compared rPDLSCs against hPDLSCs in terms of clonogenicity, growth potential, multi-differential capacity and surface antigens.

Methods

Periodontal ligament (PDL) was obtained from the rabbit and human teeth. rPDL and hPDL cells were isolated from PDL using enzymatic digestion method. After culturing for 2 weeks, the cells were first analyzed microscopically. STRO-1⁺CD146⁺ PDLSCs were then sorted from PDL cells by fluorescence-activated cell sorting (FACS) followed by examination of CD34, CD45, CD90, vimentin and desmin markers. The cells were also evaluated by immunohistocytochemical and multi-differentiation potential tests. The clonogenicity and growth of PDL cells were analyzed by Independent T test and 2-way repeated measures ANOVA respectively.

Results

rPDL cells were broader and less elongated as compared to hPDL cells. STRO-1⁺CD146⁺ hPDLSCs were isolated from hPDL cells but not from the rPDL cells. Therefore, heterogeneous population of rabbit and human PDL cells were subsequently used for latter comparative studies. FACS analysis and immunohistocytochemistry revealed that rPDL cells were partially positive for STRO-1 as compared to hPDL cells. Furthermore, both rPDL cells and hPDL cells were positive for CD146, CD90, vimentin, and desmin, while negative for CD34 and CD45. No difference in clonogenicity between rPDL and hPDL cells was found (p > 0.05). The proliferative potential of rPDL cells displayed significantly slower growth as compared to hPDL cells (p < 0.05). Osteogenic, adipogenic, and chondrogenic differentiation potential was comparatively less in rPDL cells than that of hPDL cells, but the neurogenic differential potential was similar.

Conclusion

Although rPDL cells manifested variable differences in expression of stem cell markers and multi-differential potential as compared to hPDL cells, they demonstrated the attributes of stemness. Further studies are also required to validate if the regenerative potential of rPDL cells is similar to rPDLSCs.

Expression of hepatitis B virus surface antigens induces defective gonad phenotypes in Caenorhabditis elegans

AIM

To test whether a simple animal, Caenorhabditis elegans (C. elegans), can be used as an alternative model to study the interaction between hepatitis B virus antigens (HBsAg) and host factors.

METHODS

Three plasmids that were able to express the large, middle and small forms of HBsAgs (LHBsAg, MHBsAg, and SHBsAg, respectively) driven by a ubiquitous promoter (fib-1) and three that were able to express SHBsAg driven by different tissue-specific promoters were constructed and microinjected into worms. The brood size, egg-laying rate, and gonad development of transgenic worms were analyzed using microscopy. Levels of mRNA related to endoplasmic reticulum stress, enpl-1, hsp-4, pdi-3 and xbp-1, were determined using reverse transcription polymerase reaction (RT-PCRs) in three lines of transgenic worms and dithiothreitol (DTT)-treated wild-type worms.

RESULTS

Severe defects in egg-laying, decreases in brood size, and gonad retardation were observed in transgenic worms expressing SHBsAg whereas moderate defects were observed in transgenic worms expressing LHBsAg and MHBsAg. RT-PCR analysis revealed that enpl-1, hsp-4 and pdi-3 transcripts were significantly elevated in worms expressing LHBsAg and MHBsAg and in wild-type worms pretreated with DTT. By contrast, only pdi-3 was increased in worms expressing SHBsAg. To further determine which tissue expressing SHBsAg could induce gonad retardation, we substituted the fib-1 promoter with three tissue-specific promoters (myo-2 for the pharynx, est-1 for the intestines and mec-7 for the neurons) and generated corresponding transgenic animals. Moderate defective phenotypes were observed in worms expressing SHBsAg in the pharynx and intestines but not in worms expressing SHBsAg in the neurons, suggesting that the secreted SHBsAg may trigger a cross-talk signal between the digestive track and the gonad resulting in defective phenotypes.

CONCLUSION

Ectopic expression of three forms of HBsAg that causes recognizable phenotypes in transgenic worms suggests that C. elegans can be used as an alternative model for studying virus-host interactions because the resulting phenotype is easily detected through microscopy.

Multiplexed Phenotyping of Small Extracellular Vesicles Using Protein Microarray (EV Array)

The Extracellular Vesicle (EV) Array is based on the technology of protein microarray and provides the opportunity to detect and phenotype small EVs from unpurified starting material in a high-throughput manner (Jørgensen et al., J Extracell vesicles 2:1-9, 2013). The technology was established to perform multiplexed phenotyping of EVs in an open platform. This protocol outlines the microarray printing procedure followed by the steps of capture and detection of small extracellular vesicles from plasma/serum or cell culture supernatants. The principles of data treatment and analysis are thoroughly described as well.

Immunological basis for treatment of graft versus host disease after liver transplant

Graft versus host disease (GVHD) after liver transplant, although a rare disease, has a very high mortality rate. GVHD occurs due to immunoreactions caused by donor T lymphocytes and host cell surface antigens resulting in proliferation and clonal expansion of T lymphocyte. Migration of effector cells, including macrophages, NK cells and cytotoxic T lymphocyte, to the target organs such as skin, intestine and bone marrow results in skin rashes, diarrhea and bone marrow depression. GVHD is diagnosed by clinical symptoms, histopathological findings and by the presence of chimerism. The delayed diagnosis, opportunistic infections and lack of definitive treatment of post orthotopic liver transplant (OLT)-GVHD results in sepsis and multi-organ failure leading to very low survival rates. In this review, we have focused on early diagnosis and critically discuss novel treatment modalities to decrease the incidence of GVHD.

High expression of CD38, CD69, CD95 and CD154 biomarkers in cultured peripheral T lymphocytes correlates with an increased risk of acute rejection in liver allograft recipients

The mayor goal still outstanding into the solid organ transplantation field involves the search of surrogate biomarkers able to predict several clinical events, such as acute rejection (AR) or opportunistic infection. In the present multicenter study, a series of interesting surface antigens with important activator or inhibitory immune functions on cultured peripheral T cells were monitored in liver transplant recipients drawn at baseline and up to one year after transplantation. Sixty-four patients were included in the multicenter study during 3 years. Pre- and post-transplantation surface antigens levels displayed significant differences between AR and non acute rejection (NAR) groups, and also this differential expression was used to construct a risk predictive model based on a composite panel of outcome biomarkers (CD38, CD69, CD95 and CD154). The model was able to stratify these patients at high risk of AR. These preliminary results could provide basic information to improve the immunosuppressive treatment and it might better help to predict AR episodes.

Transplantation of Photoreceptor Precursors Isolated via a Cell Surface Biomarker Panel From Embryonic Stem Cell-Derived Self-Forming Retina

Loss of photoreceptors due to retinal degeneration is a major cause of untreatable blindness. Cell replacement therapy, using pluripotent stem cell-derived photoreceptor cells, may be a feasible future treatment. Achieving safe and effective cell replacement is critically dependent on the stringent selection and purification of optimal cells for transplantation. Previously, we demonstrated effective transplantation of post-mitotic photoreceptor precursor cells labelled by fluorescent reporter genes. As genetically labelled cells are not desirable for therapy, here we developed a surface biomarker cell selection strategy for application to complex pluripotent stem cell differentiation cultures. We show that a five cell surface biomarker panel CD73(+)CD24(+)CD133(+)CD47(+)CD15(-) facilitates the isolation of photoreceptor precursors from three-dimensional self-forming retina differentiated from mouse embryonic stem cells. Importantly, stem cell-derived cells isolated using the biomarker panel successfully integrate and mature into new rod photoreceptors in the adult mouse retinae after subretinal transplantation. Conversely, unsorted or negatively selected cells do not give rise to newly integrated rods after transplantation. The biomarker panel also removes detrimental proliferating cells prior to transplantation. Notably, we demonstrate how expression of the biomarker panel is conserved in the human retina and propose that a similar selection strategy will facilitate isolation of human transplantation-competent cells for therapeutic application.

Vaccination efficiency of surface antigens and killed whole cell of Pseudomonas putida in large yellow croaker (Pseudosciaena crocea)

Large yellow croaker (Pseudosciaena crocea), a major marine fish aquacultured in the southeastern coastal region of China, has become endangered by the pathogen Pseudomonas putida in recent years. P. putida infections occur in low water temperatures when fish reduce food intake, thus oral antibiotic administration is not practical. Therefore, vaccination may be the only method to prevent the infection. In the present study, main surface antigens of P. putida, including lipopolysaccharide (LPS), outer membrane proteins (OMP), extracellular biofilm polysaccharide (EPS), and formalin-killed cell (FKC) bacterin, were prepared and the fish vaccinated. On post-immunization day 28, serum antibody titers, phagocytic responses of leukocytes, and lysozyme activities of the fish were evaluated. The efficiency of vaccination was tested by artificial challenge via intraperitoneal injection of live bacteria on post-immunization day 28 and 35, respectively. The results showed that although significant humoral and innate immune responses were elicited in all vaccination groups, the challenge produced similar poor protection in both tests, with a relative percent survival (RPS) of 0-40%. Although the EPS group showed a complete lack of protection, LPS reached the highest RPS value (40%), suggesting that LPS may be involved in protection immunity against the pathogen. Further analysis of the ultra-structures of tissues from infected fish via TEM revealed macrophage survival and intracellular replication ability of the pathogen. New strategies for development might put more emphasis on efficient clearance of intracellular bacteria. The present study is the first to report vaccination against the fish pathogen P. putida and the first investigation of intracellular survival of this pathogen in host macrophages.

Expression of surface markers and myogenic potential of rat bone marrow- and adipose-derived stem cells: a comparative study

In recent years, examination and comparison of the biological characteristics of bone marrow- and adipose-derived mesenchymal stem cells (MSCs) from various perspectives have come into the focus of stem cell research, as these cells should be well characterized in order to utilize them in future cellular therapies. Therefore, in the present study, surface protein markers and the skeletal myogenic differentiation potential of rat bone marrow- and adipose-derived MSCs were examined. The expression of CD44, CD45, CD73, and CD90 on bone marrow- and adipose-derived MSCs was characterized using flow cytometry. Subsequently, the stem cells were differentiated into myogenic lineages, and the expression of the skeletal myogenic markers MyoD1, Myog, and Myh2 was studied in cells using real time polymerase chain reaction and immunofluorescence. Our results reveal that the pattern of CD marker expression differs between these 2 types of MSCs to some extent, whereas no significant difference was observed with respect to their myogenic differentiation potential. Therefore, we concluded that despite the differences observed in the biological features of these 2 types of MSCs, their myogenic potential appears to be similar, and that adipose-derived stem cells may be useful in skeletal muscle tissue engineering, due to their easy isolation and capacity for rapid expansion in a short time span.

Identification and Characterization of the Antigens Expressed On the Surface of Human Erythrocytes Infected With Plasmodium falciparum

BACKGROUND

Molecules expressed on the surface of infected erythrocytes (IE) with Plasmodium falciparum play important roles in malaria pathogenesis and immune evasion. Some of these molecules are specific adhesive ligands mediating adhesion of IE to the vascular endothelium. In the current study, the antigens exposed on the surface of IE with different isolates and various binding subpopulations of P. falciparum were studied.

METHODS

A pooled hyper immune serum (HIS) from Malawian adults and eluted antibodies from the surface of the homologous and heterologous parasites were used. The parasite surface molecules were analyzed by Immuno-Gold-Silver enhancement (IGSE) and Western blotting. Mini-column cytoadherence method was used to select various parasite-binding subpopulations.

RESULTS

Surface antigens of all the isolates were recognized by HIS and high recognition of antigens was observed in all isolates with homologous eluted antibodies. Western blot analysis showed that the eluted antibodies reacted with a small subset of antigens compared with HIS. Three bands, PfEMP-1, were detected in the Triton X- insoluble fraction of the ICAM-1 binding subpopulation. Another interesting band was ∼ 52-55 kDa in various isolates of P. falciparum. This molecule as defined by its low molecular weight, Triton X-100 solubility, surface location and sensitivity to 1 mg/ml trypsin.

CONCLUSION

The IE's surface antigens differed in parental population compared with the selected subpopulations. These molecules could induce isolate-specific immunity. Antibodies purified from the surface of IE can be used as specific reagents to investigate parasite-derived proteins expressed on the surface of IE.

Predictors of loss of hepatitis B surface antigen in HIV-infected patients

AIM: To study factors associated with loss of hepatitis B surface antigen (HBsAg) in patients co-infected with human immunodeficiency virus (HIV) and hepatitis B virus (HBV).

METHODS: We retrospectively reviewed the medical records of 5681 patients followed up at two New York City HIV clinics from January 1999 to May 2007. Clinical and laboratory parameters including baseline and follow-up HIV viral loads, CD4 cell counts, alanine transaminase levels, demographics, presence of hepatitis C infection, and treatment with highly active antiretroviral therapy dually active against both HIV and HBV infection, were analyzed to determine factors associated with loss of HBsAg.

RESULTS: Three hundred and fifty five patients (355/5681, 6.84%) were co-infected with HIV and HBV and were evaluated. Of these, 226 patients with more than 12 mo follow-up were included in further analysis to determine factors associated with loss of HBsAg in the long-term follow-up. In the univariate analysis, baseline CD4 cell count was associated with loss of HBsAg (P = 0.052). Cox regression analysis revealed that loss of HBsAg was associated with baseline CD4 cell count > 500 cells/mm³ (P = 0.016, odds ratio: 76.174, 95% confidence interval: 2.233-2598.481).

CONCLUSION: Our study showed an interesting association of loss of HBsAg in HIV-HBV co-infected patients with higher CD4 cell count, suggesting that T-cell cytolytic activity against HBV may still be effective in clearing HBV infection.