Liver Enzyme Elevation in Coronavirus Disease 2019: A Multicenter, Retrospective, Cross-Sectional Study

INTRODUCTION

Elevated liver enzyme levels are observed in patients with coronavirus disease 2019 (COVID-19); however, these features have not been characterized.

METHODS

Hospitalized patients with COVID-19 in Zhejiang Province, China, from January 17 to February 12, 2020, were enrolled. Liver enzyme level elevation was defined as alanine aminotransferase level >35 U/L for men and 25 U/L for women at admission. Patients with normal alanine aminotransferase levels were included in the control group. Reverse transcription polymerase chain reaction was used to confirm severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and patients symptomatic with SARS-CoV-2 infection were defined as patients with COVID-19. Epidemiological, demographic, clinical, laboratory, treatment, and outcome data were collected and compared.

RESULTS

Of 788 patients with COVID-19, 222 (28.2%) patients had elevated liver enzyme levels (median [interquartile range {IQR}] age, 47.0 [35.0-55.0] years; 40.5% women). Being male, overweight, and smoking increased the risk of liver enzyme level elevation. The liver enzyme level elevation group had lesser pharyngalgia and more diarrhea than the control group. The median time from illness onset to admission was 3 days for liver enzyme level elevation groups (IQR, 2-6), whereas the median hospitalization time for 86 (38.7%) discharged patients was 13 days (IQR, 11-16). No differences in disease severity and clinical outcomes were noted between the groups.

DISCUSSION

We found that 28.2% of patients with COVID-19 presented with elevated liver enzyme levels on admission, which could partially be related to SARS-CoV-2 infection. Male patients had a higher risk of liver enzyme level elevation. With early medical intervention, liver enzyme level elevation did not worsen the outcomes of patients with COVID-19.

Serum superoxide dismutase activity in acute and chronic paediatric liver diseases

BACKGROUND AND STUDY AIMS

Measuring serum superoxide dismutase (SOD) levels in infants and children having acute or chronic liver disease of different aetiologies, and correlating these levels with disease aetiology in an attempt to clarify the role of SOD as an antioxidant in these diseases.

PATIENTS AND METHODS

We prospectively enrolled 58 infants and children and divided them into four groups: Group I, 24 patients with surgical cholestasis; group II, 11 patients with medical cholestasis; group III, nine patients with autoimmune chronic hepatitis; and group IV, 14 patients with viral hepatitis. Forty healthy age- and sex-matched children served as controls. Serum SOD activity was measured in all patients and controls using spectrophotometry.

RESULTS

The level of SOD showed a statistically significant increase in patients with medical cholestasis compared to healthy controls (p<0.0001). SOD activity of other groups showed no significant difference compared to controls.

CONCLUSIONS

Significantly increased serum SOD in infants and children with medical cholestasis is probably consequent to its increase in liver tissue in response to the liberation of reactive oxygen species. This suggests that products of free radical reactions might be involved in the pathogenesis and/or progression of medical cholestasis, and that SOD might attempt to minimise the liver injury.

An elderly man with syncytial giant cell hepatitis successfully treated by immunosuppressants

Here, we report an elderly man with acute-on-chronic hepatitis accompanied by massive ascites. He showed elevated serum transaminase and anti-nuclear antibody (ANA) levels. Liver biopsy showed diffuse multinucleated giant hepatocytes with interface hepatitis, and he recovered with administration of azathioprine in addition to corticosteroids. Follow-up liver biopsy after recovery showed improvement of hepatic inflammation and reduction of giant hepatocyte formation. The patient is receiving low-dose corticosteroid maintenance therapy and he has remained healthy for 8 years to date. Active immunosuppressive treatment may be beneficial in patients with adult syncitial giant cell hepatitis (AGCH).

[Adenosine deaminase as costimulatory molecule and marker of cellular immunity]

Adenosine deaminase (ADA) is an enzyme of purine metabolism which has been the subject of much interest because the congenital defect of this enzyme causes severe combined immunodeficiency syndrome. One of the three isoforms of the enzyme (ecto-ADA) is capable of binding to the glycoprotein CD26 and adenosine receptors A1 and A2B. ADA-CD26 interaction produces a costimulatory signal in the events of T cell activation and secretion of IFN-gamma, TNF-alpha and IL-6. During this activation, the enzyme activity is regulated positively by IL-2 and IL-12 and negatively by IL-4, based on the mechanism of translocation. Diverse studies suggest that seric and plasmatic levels of ADA rise in some diseases caused by microorganisms infecting mainly the macrophages and in hypertensive disorders, which may represent a compensatory mechanism resulting from increased adenosine levels and the release of hormones and inflammatory mediators estimulated by hipoxia.

[The etiological pattern of diseases in pregnant women with enhanced blood ALT and AST activities, admitted to the obstetric unit of infectious disease hospital]

AIM

to define a role of hepatotropic (HAV, HBV, HCV, and HDV) and opportunistic hepatotropic (HGV, CMV, EBV, HHV types 1, 2, and 6) viruses in the etiological pattern of diseases accompanied by enhanced blood AlAT and AsA T activities in pregnant women.

SUBJECTS AND METHODS

Two hundred and eleven pregnant women, including 123 patients with chronic viral hepatitis, 74 with enhanced blood AlAT activity and no markers of viral hepatitis (EAlA T-NMVH), and 14 with acute viral hepatitis were examined.

RESULTS

Most pregnant women with chronic HBV and HCV infections were found to have HBV DNA and HCV RNA in the blood in the presence of normal and enhanced activities of transaminases. In the EAlAT-NMVH group, there was none of the opportunistic hepatotropic viruses in more than 7% of cases. No genetic material of HAV, HBV, HCV, HDV, HGV, CMV, EBV, HHV types 1, 2, and 6 was found in the blood of all 10 patients with hepatitis of unspecified etiology.

CONCLUSION

In the absence of serologic data supporting the presence of infectious pathology, blood testing using the polymerase chain reaction is of low informative value in detecting opportunistic hepatotropic viruses in pregnant women with hepatitis of unspecified etiology. However, by keeping in mind that the spectrum of opportunistic hepatotropic viruses is not confined to those included in this study, it is expedient to examine additionally pregnant women with enhanced blood AlAT and AsAT activity in order to identify TTV, B19V, HHV-8, SEN and NV-F in the blood.

Fulminant hepatitis in dengue haemorrhagic fever

Dengue virus is estimated to cause over 100 million infections throughout the world annually. While dengue infections can have a wide range of infections, atypical manifestations have been described. These involve the central nervous system, cardiac alterations and hepatitis. Here, we highlight a case of dengue haemorrhagic fever (DHF) with fulminant hepatitis. A 55-year-old male was admitted for 16 days, developing severe thrombocytopenia as low as 6x10(9)/L, haematocrit of 48% with transaminitis: ALT: 3,515 U/L, AST: 12,541 U/L, GGT: 1,094 U/L. Subsequent investigations excluded any occult liver lesions, hepatitis A, B and C, Wilson's disease, Epstein-Barr virus and Cytomegalo virus as possible causes. His dengue PCR was positive. His condition subsequently improved with supportive treatment. Liver injury from dengue virus is mediated by its direct infection of hepatocytes and kupffer cells. While mild to moderate elevations of serum aminotransferases (ALT and AST<5X normal) are common in dengue virus infection, liver failure rarely dominate the clinical picture. Liver dysfunction was commoner in DHF, with case reports indicating that severe hepatic dysfunction (ALT and AST>10X normal) was seen with DHF associated with spontaneous bleeding tendencies. Overall prognosis depends on age and other concomitant co-morbidities. We seek to review the literature on dengue infections with hepatitis and discuss issues pertaining to pathophysiology of liver impairment in dengue, the frequency of transaminitis associated with DHF and the overall prognosis.

Molecular detection of transfusion transmitted virus coinfection with some hepatotropic viruses

CONTEXT

A novel human DNA virus was isolated from the serum of a patient with posttransfusion hepatitis; it was named transfusion transmitted virus (TTV).

OBJECTIVE

To ascertain the influence of TTV (detected by polymerase chain reaction amplification of a conserved region of the viral genome) coinfection in individuals infected with hepatitis viruses (A, B, and C) and to investigate the putative role played by TTV in hepatic dysfunction in individuals with acute non-A-E hepatitis.

DESIGN

Sixty-two patients with viral hepatitis were included in the study in addition to 18 blood donors. Viral study of 4 hepatotropic viruses (A, B, C, and E) was carried out. Study for TTV DNA was performed by nested polymerase chain reaction.

RESULTS

The prevalence of TTV was not statistically different between hepatitis patients and blood donors, and it was not correlated to the levels of the hepatic aspartate aminotransferase and alanine aminotransferase between individuals evidencing dual infection with hepatitis B and C viruses and healthy blood donors. However, in the group of patients with viral hepatitis of unknown etiology (non-A-E), those evidencing TTV viremia had statistically significant lower levels of alanine aminotransferase (P = .03) and aspartate aminotransferase (P = .04) than those who were TTV negative.

CONCLUSIONS

We can conclude that TTV is a frequent virus isolated from patients with various types of viral hepatitis, from cases of hepatitis without obvious viral agent, and from the healthy population. TTV has no effect on biochemical markers of associated viral hepatitis. It may be associated with a mild form of non-A-E hepatitis.

Assessment of liver fibrosis in co-infected patients

The evaluation of liver injury in HIV patients co-infected with HBV and HCV should follow the same principles as the evaluation of any patient with chronic liver disease. The initial clinical evaluation should include documentation of risk factors for progressive disease. HIV history is important particularly with respect to a past history of significant or prolonged immunosuppression as this has been clinically correlated with more advanced liver disease. Liver transaminases are an important predictor of disease severity and progression in HIV patients. Liver biopsy has remained the 'gold standard' for the grading of inflammation and staging of disease. We would still recommend liver biopsy in HIV patients particularly those with HCV because recent community-based studies in the HAART era have suggested slower rates of progression for HIV/HCV than studies from tertiary care centres and older cohorts. Since, liver biopsy is invasive and expensive, non-invasive techniques including serological tests and novel imaging techniques have evolved to stage liver fibrosis. A novel technique for measuring hepatic elasticity has recently been validated alone and in combination with serum markers for HCV mono-infection. Future trends for staging liver disease must not only focus on cross sectional diagnosis but on utilizing novel techniques to stratify risk for disease progression over time.

Prevalence and clinical significance of immunoglobulin A antibodies against tissue transglutaminase in patients with diverse chronic liver diseases

The prevalence of celiac disease (CD) and the prevalence and clinical significance of anti-tissue transglutaminase (tTG) antibodies (tTGAbs) in a large series of patients with chronic liver diseases were assessed. We studied 738 patients (462 with chronic viral hepatitis, 117 with autoimmune liver diseases, 113 with alcoholic or nonalcoholic fatty liver disease, and 46 with other liver disorders) and 1,350 healthy controls (HC). Immunoglobulin A (IgA) tTGAbs were measured by enzyme-linked immunosorbent assay and a microsphere-based flow cytometric assay. Positive sera were investigated for IgA antiendomysial antibodies (EmA). IgA tTGAb-positive subjects were invited to undergo a small-intestinal biopsy and HLA-DQ allele typing. Four of 1,350 HC (0.3%) tested tTGAb(+) EmA(+) and underwent a biopsy (CD confirmation in all). Four of 738 liver disease patients tested tTGAbs(+) EmA(+) (0.54%; not statistically significant). Two were HCV infected (1.24%; not statistically significant), and two had transaminasemia of unknown origin. Forty-three patients tested tTGAbs(+) EmA(-) (5.8%; P<0.001 compared to HC). Inhibition experiments verified the existence of specific IgA anti-tTG reactivity. Twenty-six of 43 patients underwent a biopsy (all negative for CD). Binary logistic regression analysis revealed age (P=0.008), cirrhosis (P=0.004), alkaline phosphatase (P=0.026), and antinuclear antibodies (P=0.012) as independent risk factors for tTGAb reactivity among the patients. It was concluded that CD prevalence is the same in HC and patients with chronic liver diseases. The prevalence of tTGAbs is higher in hepatic patients compared to HC, but their specificity for CD diagnosis in this group of patients is low. tTGAbs in patients appear to be associated with the presence of autoimmunity, cirrhosis, and cholestasis, irrespective of the origin of the liver disease.

Diverse cellular localizations of secretory phospholipase A2 enzymes in several human tissues

The secretory phospholipase A2 (sPLA2) family in mammals contains more than 10 enzymes. In this study, we examined by immunohistochemistry the localization of six sPLA2s (IIA, IID, IIE, IIF, V and X) in human heart, kidney, liver and stomach. In normal hearts, sPLA2-IIA was detected in coronary vascular smooth muscle cells (VSMC) and sPLA2-V in cardiomyocytes beneath the endocardium. In infarcted hearts, expression of these two enzymes was markedly increased in damaged cardiomyocytes, and expression of sPLA2-IID and-IIE, which was undetectable in normal hearts, was elevated in damaged cardiomyocytes and VSMC, respectively. In infarcted kidneys, sPLA2-IIA and-V were markedly induced in the uriniferous tubular epithelium. In livers affected by viral hepatitis, sPLA2-IIA and-V were expressed in hepatocytes with fatty degeneration. In the gastric glands exhibiting intestinal metaplasia, sPLA2-IIA was localized in the glandular base, sPLA2-IID and-V in the glandular body epithelium, sPLA2-IIE and-IIF in goblet cells in the foveolar epithelium, and sPLA2-X in both glandular body epithelial cells and foveolar epithelial goblet cells. In the gastric submucosal tissues, sPLA2-IIA and-IIE were located in VSMC and sPLA2-V was in the interstitial fibroblasts. In addition, sPLA2-IIA,-IIE,-IIF and-X were highly expressed in gastric signet ring cell carcinoma. Thus, individual sPLA2s exhibit unique cellular localizations in each tissue, suggesting their distinct roles in pathophysiology.

Differential expression of matrix metalloproteinases in viral and non-viral chronic liver diseases

BACKGROUND

Fibrosis is a common consequence of chronic liver diseases irrespective of aetiology. Metalloproteinases play an important role in the fibrotic process participating in the balance between collagen synthesis and degradation. We examined whether matrix gelatinases and stromelysins are similarly involved in the development of viral (HCV, HBV) and non-viral (NASH) liver diseases.

METHODS

Hepatic mRNA levels of matrix metalloproteinase MMP-2, MMP-9, MMP-10 and MMP-11 isolated from liver biopsies were measured by semi-quantitative RT-PCR. Seventy-three patients were examined in this study: non-diseased controls (10), patients with chronic hepatitis B (14), chronic hepatitis C (33) and non-alcoholic steatohepatitis (16).

RESULTS

A significant increase of MMP-9 and MMP-10 expression was found in patients with non-viral (non-alcoholic steatohepatitis) liver disease. Patients with chronic hepatitis B and hepatitis C showed an increase in MMP-2 mRNA expression compared to controls. Moreover, chronic hepatitis B and hepatitis C patients had significantly different mRNA expression patterns.

CONCLUSIONS

These findings indicate that matrix metalloproteinases are differentially involved in the fibrotic process of viral and non-viral chronic liver diseases. Differences exist between HBV and HCV chronic hepatitis. Differences between early and late fibrosis indicate that in future studies, careful staging of patients is mandatory for interpretation of results.

Detection of autoantibody against carbonic anhydrase II in various liver diseases by enzyme-linked immunosorbent assay using appropriate conditions

BACKGROUND

Immunoglobulin G autoantibody against carbonic anhydrase (CA) II has been detected in the sera of patients with a variety of autoimmune diseases. Antibody against CAII has also been described as a serological marker for distinguishing between cases of autoimmune cholangitis (AIC) and those of primary biliary cirrhosis (PBC). However, the optimal antibody measurement conditions (enzyme-linked immunosorbent assay: ELISA) have not yet been established. Moreover, we also found that a small amount of an IgG-like material exists in purchased CAII reagents, which causes pseudopositive reactions.

METHODS

The sera of 96 patients with liver disease were examined for the presence of anti-CAII antibody using antigen (CAII) not containing the IgG-like material as the most suitable measurement conditions. Compared with the anti-CAII antibody prevalence of 3.8% found in normal subjects, a significantly higher seroprevalence of the antibody was detected in patients with PBC (31.0%, P<0.02), autoimmune hepatitis (AIH) (50.0%, P<0.01) and chronic viral hepatitis (27.5%, P<0.01). But, in cases of PBC, no significant correlation was noted between the level of anti-CAII antibody and the presence of anti-mitochondrial antibodies (AMA).

CONCLUSIONS

While CAII may be a target antigen in autoimmune diseases, the anti-CAII antibody is not likely to be a specific marker of AIC. The optimum measurement conditions for the ELISA for anti-CAII antibody would provide us with valuable information to elucidate the underlying immunological abnormalities in liver diseases.

[Influence of pyridoxal phosphate in measuring aminotransferases activities in patients with viral hepatitis]

Effect of a pyridoxal phosphate (PP) supplementation of reagents used for ALT and AST measurement was studied in serum of 20 patients suffering from viral hepatitis. Measurements of enzyme activities were carried out at 37 degrees C, using an automate (AU 600, Olympus). Significant differences (p < 0.0001) were observed both for ALT and AST, meanwhile they were more marked for ALT than for AST. This difference was associated with a strong interindividual variability regarding PP activation effect on ALT. In conclusion, aminotransferase measurements should be carried out with a reagent supplemented with PP, when the enzyme activity is used to evaluate a cytolysis. The same recommendation applies when ALT results are integrated into various combinations developed for the evaluation of liver status.

[Clinical research on the effect of Oxymatrine on serum cholinesterase]

BACKGROUND

To investigate the effect of Oxymatrine (OM) on serum cholinesterase (ChE) during the treatment of viral hepatitis and the relationship between the change of ChE and the change of albumin (ALB), prothrombin activity (PTA) and other liver function tests.

METHODS

A total of 98 patients with viral hepatitis were divided into four groups. Group A consisted of 31 patients and were treated with OM intravenous infusion; Group B consisted of 30 patients, treated with OM orally; Group C consisted of 7 patients and were treated with OM intramuscular injection while Group D consisted of 30 patients, and were not treated with OM. ChE, ALB, PTA, liver function, renal function, soluble complement receptor-1 (sCR1) and erythrocyte innate immune adhesion function (EIIAF) were regularly determined.

RESULTS

ChE in Group A,B,C was dropped obviously during the treatment (P less than 0.001, less than 0.001, 0.023=. But there were no change in ALB, PTA, sCR1, EIIAF (P greater than 0.05), and remarkable improvement of ALT, AST, TBiL was seen during the treatment in Groups A, B, C. After the treatment with OM, the level of ChE recovered soon.

CONCLUSION

Serum level of ChE significantly declined during the treatment of viral hepatitis with OM, but no change was found in ALB, PTA, sCR1, EIIAF while liver function tests showed better results. So the drop of ChE does not mean deprivation of patient's liver disease.

Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases

INTRODUCTION

Type 3 dengue virus caused an extensive epidemic in the state of Rio de Janeiro in summer 2002. In some of the patients, it was found in an atypical form with increased aminotransferase levels and acute hepatitis.

MATERIAL AND METHODS

An analysis was made of 1,585 serologically confirmed dengue cases at the Dengue Reference Center in Campos dos Goytacazes, Rio de Janeiro state. The grade of hepatic aggression was established according to the alterations in the aminotransferase levels: grade A -- normal levels of aminotransferase; grade B -- elevated aminotransferase, with increased levels of at least one of the enzymes; grade C -- elevated aminotransferase, with the levels of at least one of the enzymes increased to more than three times the reference values; grade D -- acute hepatitis, with aminotransferase levels increased to at least 10 times their normal values.

RESULTS

Among the 1,585 serologically confirmed dengue cases, 44.5% presented alterations in the aminotransferase levels (grade B), 16.9% presented grade C liver involvement and 3.8% of the patients had progressed to acute hepatitis (grade D). The average values for the rise in aspartate aminotransferase and alanine aminotransferase were 93.3 U/L and 86.0 U/L. The greatest alterations were observed among females (p<0.001), cases of dengue hemorrhagic fever (p<0.001), and cases with sequential infections (p=0.001).

CONCLUSIONS

Liver damage with elevation of aminotransferases and reactive hepatitis was a common complication of dengue virus infection in these patients.

[Aminotransferase activity during convalescence in infectious hepatitis in older adolescents]

The objective of the research were consolidate the correlation the greatest values ALT and AST, and the recovery from hepatitis infection. To the group of 237 adolescents, male sex of 18, 19 and 20 years is measured the activity of ALT and AST. The examinees are questionnaired to the recovery from hepatitis infection. Had to the significant increased values AST, and only mildly increased values in relation to the upper referent values.

Impaired health-related quality of life in Romanian patients with chronic viral hepatitis before antiviral therapy

BACKGROUND AND AIM

Chronic hepatitis is a disabling condition leading to impairment of a patient's quality of life. We investigated the impact of chronic viral hepatitis on health-related quality of life. The relationship between transaminase level and score in the quality-of-life questionnaire was also investigated.

METHODS

We studied 66 patients with chronic viral hepatitis (27 with hepatitis B, 38 with hepatitis C, 1 with hepatitis B+C; 32 men, 34 women) naive to any previous antiviral therapy. All had high levels of transaminases. Patients with chronic disease or those using drugs to modify their quality of life were discarded. The control group consisted of 36 healthy volunteers (17 men, 19 women). Both groups completed the Short Form 36 health survey, with the exception of the items concerning bodily pain.

RESULTS

Significant differences between the two groups for every domain of quality of life (physical functioning, role physical, mental health, role emotional, social functioning, vitality and general health) were recorded. We found no significant correlation between the level of transaminases and any item of the health-related quality-of-life questionnaire. In hepatitis B patients, several quality-of-life scores (general health, social functioning, mental health) were better than in hepatitis C patients.

CONCLUSIONS

Patients with chronic viral hepatitis not receiving antiviral therapy have an impaired quality of life as estimated by the Short Form 36 health survey.

Dihydropyrimidine dehydrogenase and thymidylate synthase activities in hepatocellular carcinomas and in diseased livers

BACKGROUND/PURPOSE

Dihydropyrimidine dehydrogenase (DPD) and thymidylate synthase (TS) are key enzymes for predicting the efficacy of 5-FU in the treatment of malignant tumors. However, 5-FU is not commonly commonly chosen for chemotherapeutic treatment of hepatocellular carcinoma (HCC) in practice. The aim of this study was to determine the activities of both DPD and TS in HCCs and corresponding liver parenchyma and to assess the correlation between the activities of these enzymes and clinicopathological features. The possibility of using 5-FU as a first-choice chemotherapeutic agent for HCC was also evaluated.

METHODS

The study material comprised 33 pairs of hepatocellular carcinoma and noncancerous liver samples. The DPD and TS activities were quantified by a radiometric enzymatic assay and a 5-fluoro-2'-deoxyuridine-5'- monophosphate (FdUMP) ligand-binding assay, respectively.

RESULTS

Pathologically invasive HCCs tended to show higher DPD activity and lower TS activity with some exceptions. DPD activity was lower in the HCCs regardless of their clinical features than in the noncancerous liver parenchyma, whereas TS activity was generally lower in HCCs except for those with certain clinical features. HCCs with multiple nodules showed lower DPD activity and those with a diameter of more than 5 cm showed lower TS activity. In the noncancerous liver parenchyma, a gradual decrease in DPD activity and an increase in TS activity were associated with the age of the patient, liver damage and z-factor. Of 30 HCC samples, 10 exhibited comparatively low DPD and TS activity, and these could be considered 5-FU-sensitive HCC.

CONCLUSIONS

DPD and TS activity may be affected by the clinicopathological status in both the HCC and the corresponding liver parenchyma. However, further investigation is necessary. Some HCC patients may be good candidates for 5-FU-based chemotherapy based on measurements of tumor levels of DPD and TS.

Synergistic effect of hepatitis virus infection and occupational exposures to vinyl chloride monomer and ethylene dichloride on serum aminotransferase activity

AIMS

To study the synergistic effect of occupational chemical exposure and hepatitis virus infection on serum aminotransferase activity.

METHODS

A total of 568 male workers who were employed in five polyvinyl chloride (PVC) or four vinyl chloride monomer (VCM) manufacturing factories were studied. Information relating to current job title, alcohol consumption, and cigarette smoking was obtained. Exposure level of chemical mixtures was classified by hygienic effect (a summation of personal time weighted average/reference permissible exposure level of each chemical) into high, moderate, and low exposure groups. Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT), hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), and anti-hepatitis C antibody were assayed.

RESULTS

Hepatitis virus infection and increased body mass index were associated with abnormal serum aminotransferase activity. In workers with hepatitis virus infection, those with high exposure had a higher prevalence of abnormal AST and ALT compared to low exposure; among those without hepatitis virus infection, the differences of prevalence of abnormal AST and ALT were not significant between different chemical exposure groups. There was a significant trend of increasing risks of increased AST and ALT in moderate and high exposure groups with hepatitis virus infection. Such a synergistic effect was more prominent among HBeAg-positive workers.

CONCLUSIONS

Mixed exposures to 1,2-ethylene dichloride and VCM have a positive synergistic effect with hepatitis virus infection on liver damage. Assessment of fitness for work should be considered in workers with hepatitis B and C infection, when they have potential exposure to hepatotoxins in the workplace.

Screening, diagnosis, and monitoring of hepatic injury

Although prophylactic vaccines and a better screened blood supply have contributed to a decreased incidence of viral hepatitis, liver injury remains a common problem. It is important that nurse practitioners know which patients are at risk for hepatic injury, when and how to screen for hepatic injury, and how to monitor patients diagnosed with hepatic damage. The National Academy of Clinical Biochemistry guidelines related to hepatic injury provide a framework for the screening, diagnosis, and monitoring of hepatic injury resulting from a variety of causes.

[Perfluorocarbonic compounds application as a new approach in pathogenic treatment of severe forms of viral hepatitis]

Perfluorocarbonic blood substitute Perftoran (PF) was used in combined intensive therapy of 79 patients with severe viral hepatitis B as a polyfunctional pathogenetic drug according to the following scheme: intravenously 400 ml 1-2 times a day for 2-6 days (800-2400 ml per course). PF exhibited immunomodulating, antioxidant, membrane-stabilizing and disintoxicating properties. The immunomodulating effect of the drug manifested itself in its influence on functional activity of macrophages, reduction of their oversection of proinflammatory cytokines: IL-1 beta, IL-6, IL-8, TNF-alpha. Antioxidant properties were established on the basis of the ability of PF to lower activity of prooxidant factors (myeloperoxidase of neutrophilic granulocytes) and to stimulate antioxidant factors (catalase, glucose-6-phosphatedehydrogenase), reduced glutathione in erythrocytes). As a membranostabilizer, PF increased resistance of erythrocyte membranes to peroxide hemolysis and improved their rheological indices (deformability and viscosity). A disintoxication effect of PF led to reduction of middle-molecular peptides content in plasma. PF had a noticeable effect on basic clinicobiochemical indices in patients with a severe course of viral hepatitis B as well as the disease course and outcomes. Finally, PF reduced the duration of treatment of patients with severe viral hepatitis B in hospital and intensive care units. It is inferred that administration of infusion drugs on the basis of perfluorocarbonic compounds holds promise in pathogenetic therapy of viral hepatitides.

Mix-infections with different genotypes of HCV and with HCV plus other hepatitis viruses in patients with hepatitis C in China

AIM

Clinical therapy and prognosis in HCV infections are not good, and mix-infections with different HCV genotypes or quasispecies and mix-infections with HCV plus other hepatitis viruses are important concerns worldwide. The present report describes the sequence diversity and genotying of the 5'NCR of HCV isolates from hepatitis patients mix-infected with different HCV genotypes or variants, and the conditions of mix-infections with HCV plus other hepatitis viruses, providing important diagnostic and prognostic information for more effective treatment of HCV infections.

METHODS

The 5' non-coding region (5'NCR) of HCV was isolated from the patients sera and sequenced, and sequence variability and genotypes of HCV were defined by nucleotide sequence alignment and phylogenetic analysis, and the patients mix-infected with HCV plus other hepatitis viruses were analyzed. The conditions and clinical significance of mix-infections with HCV plus other hepatitis viruses were further studied.

RESULTS

Twenty-four out of 43 patients with chronic hepatitis C were defined as mix-infected with different genotypes of HCV. Among these 24 patients, 9 were mix-infected with genotype 1 and 3, 7 with different variants of genotype 1, 2 with different variants of genotype 2, 6 with different variants of genotype 3. No patients were found mix-infected with genotype 1 and 2 or with genotype 2 and 3. The clinical virological analysis of 60 patients mix-infected with HCV plus other hepatitis viruses showed that 45.0 % of the patients were mix-infected with HCV plus HAV, 61.7 % with HCV plus HBV, 6.7 % with HCV plus HDV/HBV, 8.4 % with HCV plus HEV, 3.3 % with HCV plus HGV. Infections with HCV plus other hepatitis viruses may exacerbate the pathological lesion of the liver.

CONCLUSION

The findings in the present study imply that mix-infections with different HCV genotypes and mix-infections with HCV plus other hepatitis viruses were relatively high in Yunnan, China, providing important diagnostic and prognostic information for more effective treatment of HCV infections.

[GB virus C: lack of association with transaminases levels, CD4 and HIV viral load in aids patients]

OBJECTIVE

To study the prevalence of GBV-C-RNA in sera of HIV-infected patients and determine whether differences in immunological condition and hepatic disease exist between GBV-C positive and negative patients.

METHODS

The presence of GBV-C-RNA was determined in sera of 222 HIV-positive patients by semi-automated RT-PCR. A comparison of GBV-C-RNA positive and negative patients was made by studying a series of clinical and analytical parameters. This same comparison was made in particular between those coinfected with HCV and GBV-C and those who only presented GBV-C.

RESULTS

Prevalence of GBV-C-RNA was 28.8%. The most frequent hepatotropic virus was HCV, appearing in 71.6% of cases. Coinfection with HCV and HGV was present in 17% and 8.6% only had GBV-C. Patients positive for GBV-C-RNA showed clinical and analytical characteristics similar to those found in GBV-C-RNA negative patients. Among the HCV-GBV-C coinfected and those presenting HGV as the only virus it was observed that the coinfected group presented alterations in transaminases and predominance of parenteral transmission as a risk factor for HIV, whereas the GBV-C group presented normal transaminases and predominance of sexual transmission. No differences were perceived in mean CD4 and HIV-RNA values in both groups.

CONCLUSIONS

Being positive for GBV-C in HIV-positive patients does not influence the presence of hepatic disease that in these patients is frequently accompanied by coinfection with other hepatotropic viruses. Moreover, it does not seem to influence the viremia of the HIV nor the CD4 cell counts.

Cyclooxygenase-2 and inducible nitric oxide synthase in omental arteries harvested from patients with severe liver diseases: immuno-localization and influence on vascular tone

OBJECTIVE

To investigate the expression of inducible cyclooxygenase (COX-2) and inducible nitric oxide synthase (iNOS) and the role of vasodilatory prostanoids and endogenous nitric oxide (NO) in small omental arteries harvested from patients with severe liver diseases.

DESIGN

Ex vivo study of resistance arteries. SETTING. Intensive care unit.

PATIENTS

Twenty patients undergoing liver transplantation for fulminant hepatic failure (FHF, n=6), cirrhogenous viral hepatitis (CH, n=6) and limited hepatocarcinoma (controls, n=8).

INTERVENTIONS

Western blot and immunohistochemical labeling for assessment of COX-2 and iNOS expression and localization and ex vivo vascular reactivity studies.

MEASUREMENTS AND RESULTS

Significant upregulation of COX-2 and iNOS expressions were detected in arteries from FHF and CH patients with a greater increase in the former than in the latter. Ex vivo contractile responses to norepinephrine and the thromboxane A(2) analog, U46619, were not significantly different between patients with severe liver dysfunction and controls. Exposure to either the NO-synthase inhibitor, N(G)-nitro-L-arginine methyl ester (L-NAME), the cyclooxygenase inhibitor, indomethacin, or their combination did not significantly modify contractions of agonists in controls and CH patients. In FHF, the specific COX-2 inhibitor, N-(2-cyclohexyloxy-4-nitrophenyl) methanesulfonamide (1 micro m/l), but not L-NAME, significantly enhanced the maximal effect ( p<0.01) and the sensitivity ( p<0.01) to norepinephrine.

CONCLUSIONS

COX-2 and iNOS are upregulated in omental arteries from patients with cirrhogenous hepatitis and fulminant hepatic failure. Whereas neither NO nor vasodilatory prostaglandins seem to play a major role in counteracting arterial contractility of arteries from control patients, COX-2 derivatives are involved in lowering the arterial contractility of vessels harvested from FHF patients.

[Biochemical characterization of viral hepatitis in humans, using and not using narcotics]

AIM

To compare biochemical changes in viral hepatitis (VH) in drug abusers (DA) and non-abusers (NA).

MATERIAL AND METHODS

Hepatic function was examined in 1125 patients with parenteral hepatitis, 540 of them were DA. Transaminases tests and protein precipitation tests were made at the disease height and in convalescence.

RESULTS

In DA patients with VH biochemical changes were found more frequently than in NA. In convalescence, elevation of alaninaminotransferase was higher in DA than in NA.

CONCLUSION

Drug abuse in VH patients influences biochemical indices. In DA with VH correlations of biochemical indices with the disease severity are less frequent than in NA, while changes of biochemical indices reflecting hepatic function occur more frequently and persist longer.

[Diagnostic strategy when confronted with a moderate and prolonged increase of transaminases]

TWO TYPES OF SITUATIONS: Measurement of transaminase serum activity is a common biological test. Although the etiological scope of acute and severe hyper-aminotransferase is codified and limited, that of prolonged and moderate hyper-aminotransferase is much broader. IN THE CASE OF PROLONGED AND MODERATE INCREASE IN TRANSAMINASE SERUM ACTIVITY: The discovery of this abnormality during systematic biological controls is a frequent situation, and its management is relatively well standardised. It requires a rigorous diagnostic strategy, which includes the search for consumption of alcohol, overweight, chronic hepatic disease of viral origin and the nature of the medicinal products ingested. FROM AN ETIOLOGICAL POINT OF VIEW: The most frequent causes of moderate and prolonged hyper-aminotransferase are alcohol abuse, overweight, non-insulin-dependent diabetes, dyslipaemia, viral hepatitis and medicinal products. However, less frequent hepatic or extra-hepatic causes must not be neglected.

[Role of the antioxidative defense system in the pathogenesis of acute viral hepatitides]

AIM

To study the activity of antioxidative defense enzymes and the total plasma antioxidative activity in patients with viral hepatitis B, C, and mixed hepatitis B + C.

MATERIALS AND METHODS

77 patients with viral hepatitis B, 90 with viral hepatitis C, and 25 with mixed hepatitis B + C were followed up. The activity of superoxide dismutase and catalase of leukocytes, and the total plasma antioxidative activity were determined at the peak of the disease, alleviation of clinical symptoms, and before discharge from hospital.

RESULTS

At the peak of the disease, the patients with viral hepatitides showed suppressed activities of superoxide dismutase and catalase of leukocytes and suppressed total plasma antioxidative activity with increased these parameters by early convalescence, but without their normalization. There were the most pronounced changes in patients with severe mixed hepatitis B + C.

CONCLUSION

The changes found in the body's antioxidative defense have been ascertained to depend on the etiology, stage, and severity of viral hepatitis.

Plasma levels of the von Willebrand factor-cleaving protease in physiological and pathological conditions in children

The hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are rare disorders characterized by thrombocytopenia, hemolytic anemia, and ischemic organ failure due to thrombotic occlusions in arterioles. The recent observation that a von Willebrand factor-cleaving protease (VWF-CP) is low in the plasma of patients with TTP but normal in those with HUS has potentially offered a new specific tool for differential diagnosis. In this study, the authors evaluated the plasma levels of the VWF-CP during the neonatal state and healthy childhood and in some pathological pediatric conditions. The protease was measured in 16 healthy newborns, 20 healthy children aged 5-18 years, patients with diabetes mellitus type 1 (n = 7), acute viral hepatitis (n = 10), chronic viral hepatitis (n = 10), transfusion-dependent beta-thalassemia major (n = 10), acute varicella infection (n = 11), the nephrotic syndrome (n = 11), and familial Mediterranean fever (n = 10). Mean protease levels were significantly lower in newborns than in healthy children (50.5 +/- 16.1% vs. 83.3 +/- 16.3%)(p = .0001). In patients with acute viral hepatitis, protease levels were also significantly reduced (40.2 +/- 27% v s. 83.3 +/- 16.3% in healthy children)(p = .0001). Other patient groups had normal protease levels. In conclusion, low protease levels are far from being a specific beacon for TTP. The current paradigm that a single laboratory test may enable physicians to distinguish TTP from HUS seems to be challenged by these and other findings.

Matrix metalloproteinases and their inhibitors in acute viral hepatitis

Matrix metalloproteases (MMPs) and their inhibitors are effector molecules involved in extracellular matrix remodelling. The serum profile for these proteolytic enzymes and their inhibitors during acute self-limiting viral hepatitis has not been studied. We therefore determined serum concentrations of MMP-1, MMP-3, MMP-2, MMP-9 and their inhibitors (tissue inhibitors of metalloproteinase) TIMP-1, TIMP-2 and alpha2 macroglobulin (AMG) in the serum of patients during the icteric stage of self-limiting acute viral hepatitis. Transforming growth factor-beta (TGF-beta) and interleukin (IL)-10, two cytokines involved in the regulation of MMPs and TIMPs were also assessed. Nineteen patients (12 men, seven women) with a mean age of 29.9 years (range 16-65 years) participated in the study. Fifteen had hepatitis B virus (HBV, two HCV and two HAV infection. The values of patients were compared with those obtained from 15 blood donor controls (eight men, seven women), mean age 36.2 years (range 18-55 years). Serum levels of TGF-beta, IL-10, MMP-1, MMP-3, MMP-2, MMP-9, TIMP-1 and TIMP-2 were assessed by ELISA. MMP-2 and MMP-9 were also measured by a zymogram protease assay. alpha2 macroglobulin (AMG) was measured by nephelometry. Compared with the healthy controls the mean serum concentrations of all MMPs were significantly decreased in the acute hepatitis patients. There was no difference in the serum concentration of TIMP-1 between patients and the controls. Serum levels of TIMP-2 (P < 0001), TGF-beta (P < 0.05), IL-10 (P < 0.001) and AMG (P < 0001) were increased in patients compared to healthy controls. A statistically significant negative correlation by linear regression analysis was found between AMG and MMP-1 (P=0003). The decreased levels of MMPs observed, together with normal and increased levels of TIMP-1 and TIMP-2, may indicate an attempt to limit matrix degradation at this stage of disease resolution. The increased levels of the anti-inflammatory cytokines IL-10 and TGF-beta might be the underlying mechanism responsible for the above effect. AMG inhibition especially for MMP-1 may play an additional important role.

TT virus infection in acute non-A to E hepatitis in northern Thailand

TT virus is a novel DNA virus widely distributed in the general population. We examined the prevalence of TTV infection in a population with acute non-A to E hepatitis and in comparison groups located in Northern Thailand. The prevalence of TTV in subjects with non-A-E hepatitis was 19% (21/112), 6% (4/72) in healthy volunteers, 17% (12/72) in those with hepatitis A or B, and 17% (8/48) in hospitalized patients with non-hepatitis illnesses. A significant association with TTV infection and non-A-E hepatitis was seen in all groups (OR 3.9, p = 0.02) and in children (OR 25.8, p = 0.001). Among subjects with non-A-E hepatitis, TTV was associated with higher alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels (significant for AST, p = 0.02). Our observations suggest that TTV in our study population may be associated with non-A-E hepatitis and that children in particular may be at risk of hepatocellular injury as a result of TTV infection.

Guinea pig transglutaminase immunolinked assay does not predict coeliac disease in patients with chronic liver disease

BACKGROUND

It has been suggested that serological screening for coeliac disease (CD) should be performed in patients with chronic unexplained hypertransaminasaemia.

AIMS

To evaluate the specificity for CD diagnosis of serum IgA antitissue transglutaminase (tTG) determination in consecutive patients with chronic hypertransaminasaemia using the most widely utilised ELISA based on tTG from guinea pig as the antigen.

PATIENTS AND METHODS

We studied 98 patients with chronic hypertransaminasaemia, evaluated for the first time in a hepatology clinic. Serum anti-tTG and antiendomysial (EmA) assays were performed. Patients positive for EmA and/or anti-tTG were proposed for intestinal biopsy. Finally, all sera were reassayed for anti-tTG using an ELISA based on human recombinant tTG as the antigen.

RESULTS

A total of 94/98 hypertransaminasaemic patients were positive for hepatitis virus markers, with 82/98 (83%) positive for anti-hepatitis C virus. Liver histology showed that most patients had mild or moderate chronic hepatitis while severe fibrosis or overt liver cirrhosis was found in 20/98. CD screening showed that 15/98 (16%) hypertransaminasaemic subjects had anti-tTG values in the same range as CD patients; however, IgA EmA were positive in only 2/98 (2%). Distal duodenal biopsy, performed in nine patients, showed subtotal villous atrophy in the two EmA+/anti-tTG+ patients but was normal in 7/7 EmA-/anti-tTG+ subjects. The presence of anti-tTG+ values in EmA- patients was unrelated to particular gastrointestinal symptoms, other associated diseases, severity of liver histology, or distribution of viral hepatitis markers. There was a significantly higher frequency of positive serum autoantibodies (antinuclear, antimitochondrial, antismooth muscle, and anti-liver-kidney microsomal antibodies) in anti-tTG+/EmA- patients than in the other subjects (9/13 v 10/83; p<0.003). Also, a correlation was found between serum gamma globulin and anti-tTG values (p<0.01). When sera were tested with the ELISA based on human tTG as the antigen, no false positive results were observed: only the two EmA+ patients with atrophy of the intestinal mucosa were positive for anti-tTG while all others were negative, including those false positive in the ELISA based on guinea pig tTG as the antigen.

CONCLUSIONS

In patients with elevated transaminases and chronic liver disease there was a high frequency of false positive anti-tTG results using the ELISA based on tTG from guinea pig as the antigen. Indeed, the presence of anti-tTG did not correlate with the presence of EmA or CD. These false positives depend on the presence of hepatic proteins in the commercial tTG obtained from guinea pig liver and disappear when human tTG is used as the antigen in the ELISA system. We suggest that the commonly used tTG ELISA based on guinea pig antigen should not be used as a screening tool for CD in patients with chronic liver disease.

Serum xanthine oxidase in human liver disease

OBJECTIVES

High concentrations of serum xanthine oxidase (XO) have been reported during human liver disease and hepatocyte injury in experimental settings. However, it is unclear whether this elevation reflects hepatocyte necrosis or has a different meaning.

METHODS

The serum level of XO in 64 patients with chronic liver disease (17 patients with cirrhosis, 30 with chronic hepatitis, and 17 with cholestatic disorders) and in 12 control subjects was determined by a competitive ELISA. Conventional serum markers of liver damage were assessed in all patients, and grading and staging were scored in the chronic hepatitis group according to Knodell.

RESULTS

The XO serum levels were significantly higher in the patients than in the controls. The differences were also significant when controls were compared to patients with chronic hepatitis and cholestatic disorders separately, but not when compared to the cirrhosis group. Patients with cholestatic disorders had XO values higher than those of patients with cirrhosis or chronic hepatitis. XO levels did not correlate with stage and grade in chronic hepatitis group. We found a weak but significant positive correlation in patients between XO serum level and gamma-glutamyl transpeptidase (r = 0.37). This correlation was stronger when chronic hepatitis (r = 0.42) and, especially cholestatic disorders (r = 0.71), were separately tested, but was absent in the cirrhosis group. The XO values positively correlated with alkaline phosphatase in patients with cholestatic disorders. A level of serum XO >32 microg/ml specifically identified cholestatic disorders in our study population.

CONCLUSIONS

A marked elevation of serum XO in patients with chronic liver disease seems to reflect the presence of cholestasis. No correlation between XO levels and histological or serum evidence of hepatocyte necrosis was found in these patients.

[Biochemical characteristics of liver involvement in patients with antiphospholipid syndrome]

The incidence of hepatitis B and C virus and cytomegalovirus infection is high in patients with the antiphospholipid syndrome (APS). The specific features of virus infection in APS patients are determined by the activity of APS. During clinically manifest stage, the activities of aminotransferases, lactate dehydrogenase (LDH), and alkaline phosphatase increase, while during remission only aspartate aminotransferase and LDH levels remain high, for this latter enzyme high activities of isoenzymes LDH5 and LDH4 being recorded. These data indicate that the pathological process in APS involves not only the liver, but the sinusoidal endothelium as well. This seems to account for some other clinical and laboratory manifestations of APS, such as increased level of circulating immune complexes, dysfunction of physiological anticoagulants, etc.

Lack of association between TTV viral load and aminotransferase levels in patients with hepatitis C or non-B-C

TT virus (TTV) is a newly identified un-enveloped single-stranded DNA virus. Although TTV was initially thought to be a new hepatitis virus, it is still unclear whether it causes hepatitis. To clarify the natural history and pathogenesis of TTV infection, serial serum samples from patients with chronic hepatitis were analysed. TTV DNA was quantified by real-time detection polymerase chain reaction assay (RTD-PCR), which was adapted for TTV. Five patients with chronic hepatitis, 4 with hepatitis C and 1 with non-B-C, were studied. The study period ranged from 9 to 50 months. In 3 patients there were frequent increases in TTV DNA titres, but no concomitant elevation of the aminotransferase (ALT) levels. In 2 patients who were treated with interferon, the changes in TTV titres were not synchronized with those of the ALT levels. Thus, in cases of chronic hepatitis, no correlation was observed between the serum TTV DNA titres and the ALT levels.

[Isoenzymes of gammaglutamyltransferase in patients with obstructive and hepatocellular icterus]

We have been determining the GGT IE isoenzyme in patients with hepatitis A and B with decomposed liver cirrhosis, with obstructive hepatitis caused by the gall stones. In patients with hepatitis A and B the IE is located between albumin and betaglobulin, as well as in patients with obstructive hepatitis caused by the gall stones; in the latter partly between Alpha 1 and Alpha 2 globulin. In patients with decompensated liver cirrhosis (37.7% of the patients) there was IE activity 100% in Alpha 2 globulin area; in 6.25% of patients the activity was in the prealbumin area. In patients with secondary liver tumors we got a rather high increase of the GGT IE activity in Alpha 1 globulin area, in 77.7% of the patients even 80 to 100%. In some patients with disease progression we noticed the GGT IE activity in Beta globulin area. The results in primary liver malignomas were different. In 68.5% of the patients the GGT IE activity dominated in Alpha 1 globulin area.

Adenosine deaminase and guanosine deaminase activities in sera of patients with viral hepatitis

In order to investigate purin and primidin metabolism pathways in hepatitis, adenosine deaminase (ADA) and guanosine deaminase (GDA) activities in sera of patients with different types and manifestations of viral hepatitis disease (A, B, C, D, E, chronic, acute) were investigated and compared with the control group of healthy individuals. Hepatitis cases were classified with respect to their serological findings and clinics. When compared all the hepatitis cases with the controls, levels of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase enzymes, as well as ADA and GDA, were significantly higher than the control group (p<0.01). Levels of ADA and GDA in hepatitis cases were determined as 26.07 11.98 IU/l and 2.37 1.91 IU/l, respectively. When compared their ADA and GDA levels amongst the classified hepatitis groups, there was no difference in ADA levels amongst cases (p>0.05). However, GDA levels in hepatitis A group were closed to the controls. Increase in serum ADA activities in hepatitis forms may be dependent on and reflect the increase in phagocytic activity of macrophages and maturation of T-lymphocytes, and may be valuable in monitoring in viral hepatitis cases.

Hepatitis G virus infection in a high-risk subgroup of hospitalized dental patients

OBJECTIVE

The prevalence of hepatitis G virus infection was evaluated in dental patients whose clinical laboratory test results were positive for hepatitis C virus antibody, hepatitis B virus surface antigen, or elevated serum alanine transaminase concentrations.

STUDY DESIGN

Frozen serum samples from patients with hepatitis C virus antibody (n = 63), hepatitis B virus surface antigen (n = 20), or alanine transaminase concentrations greater than 100 IU (n = 14) were assessed for GB virus C (GBV-C)/hepatitis G virus RNA by a reverse transcriptase-polymerase chain reaction.

RESULTS

Six of 63 patients with hepatitis C virus antibodies had serum hepatitis G virus RNA (9.5%), and 2 of 20 subjects with hepatitis B virus surface antigen had hepatitis G virus RNA (10.0%). None of 14 patients whose alanine transaminase concentration was greater than 100 IU/L had hepatitis G virus RNA. Of 4 subjects with both hepatitis C virus antibody and hepatitis B virus surface antigen, 2 had hepatitis G virus RNA (50%). In the total study population (N = 92), 6 subjects (6.5%) had hepatitis G virus RNA. All hepatitis G virus-infected patients also had hepatitis C virus antibody. Neither serum alanine transaminase nor aspartate transaminase concentrations were different between subjects with and subjects without hepatitis G virus RNA. The lack of a relationship between hepatitis G virus infection and elevation of alanine transaminase and aspartate transaminase might suggest that this virus is not truly a hepatitis virus.

CONCLUSIONS

Hospitalized dental patients are infected with hepatitis G virus at a prevalence similar to or slightly higher than that seen in the general population. Dentists should pay close attention to infection control with respect to the potential new hepatitis virus known as hepatitis G virus.

[Coexistent hepatitis G virus infection and autoimmune hepatitis]

Report a case of a girl with HGV-RNA in the serum, which was detected during the treatment of autoimmune hepatitis. Infection HGV may cause aminotransferases abnormalities because they were elevated despite of the 2.5-year immunosuppressive therapy.

[The clinical and enzymatic changes in patients with viral hepatitis G infection]

For the purpose of making sure the clinical significance of hepatitis G virus, RT-nested PCR was applied to detect HGV RNA in 165 hepatitis patients, which included 24 acute hepatitis, 78 chronic hepatitis, 18 hepatitic cirrhosis, 4 hepatocellularcarcinom and 41 HBV and HCV carriers. The results showed that the infection of HGV existed in all kinds of hepatitis patients. Among the acute hepatitis 12.5% (3/24) was HGV RNA positive. 19 (24.4%) cases were HGV RNA positive in chronic hepatitis, among which 4 cases were simply HGV RNA positive (5.13%). The serum ALT level in 3 cases of simple acute HGV patients was between 488 +/- 65 U/L, the value of AST between 452 +/- 71 U/L, the TBiL at about 77.1 +/- 14.3 mumol/L. All these showed that only HGV infection could lead to acute hepatitis. The rising enzyme dropped to normal about a month later in acute hepatitis while HGV RNA would remain. The problem whether HGV infection is caused by simple acute and chronic hepatitis infection is under investigation.

[Parvovirus B19 as a cause of acute liver symptoms in adults]

Parvovirus B19 (B19), also known as "erythema infectiosum", is a disease that occurs in smaller outbreaks during late winter and early summer; and in Denmark an epidemic occurs every three years. The symptoms vary from fever, fatigue and the characteristic maculopapoulous erythema to asymptomatic cases in 50% of the infected patients. Two-thirds of the Danish population have been infected. The virus has a broad spectrum of clinical manifestations ranging from erythema nodosum in children, arthralgia/arthritis (especially in adults), aplastic crisis in patients with haemolytic anaemia, chronic anaemia in immunocompromised patients, to hydrops foetalis following acute infection during pregnancy. In two adult females aged 41 and 35 years with persisting fatigue, malaise, transitory swelling and arthralgia we found elevated ALT and alkaline phosphatase (pt. 1), despite no serological evidence of hepatitis, cytomegalovirus (CMV), or Epstein-Barrvirus and no story of alcohol consumption or recent travelling outside Denmark. Ongoing B19 infection was diagnosed by ELISA and confirmed by B19 DNA PCR in case 2 and IgG avidity and epitope-type specificity in case 1, who was B19 DNA negative in three different samples. The concentrations of alkaline phosphatase and ALT returned to normal as the antibody response shifted from acute B19 infection to IgG positivity. In conclusion we suggest that a serological test and/or B19 DNA for B19 infection is a relevant test to undertake when screening patients for viral hepatitis especially during B19 epidemics and in exposed individuals.

Antibodies to E2 protein of hepatitis G virus in children: different responses according to age at infection

OBJECTIVES

To study viral persistence and antibody responses after hepatitis G virus (HGV) infection in children of various ages.

STUDY DESIGN

We performed an enzyme immunoassay for antibodies to E2 protein (anti-E2) of HGV and reverse-transcription polymerase chain reaction assay for HGV RNA on serum samples.

RESULTS

Of 28 infants born to HGV RNA-positive mothers, 17 were found to be positive for HGV RNA. None were positive for anti-E2. All 17 infected infants continued to have viremia except 1 who converted to HGV RNA-negative status at 24 months. Six infants had mild elevations of alanine aminotransferase levels (5 HGV-positive and 1 HGV-negative). An additional 14 HGV-infected children (aged 6 months to 14 years) with posttransfusion HGV infection were tested for anti-E2 3 months and 12 months after blood transfusion. None of the HGV RNA-positive serum samples were positive for anti-E2; however, 4 of the 8 children with resolving HGV infection were positive for anti-E2 1 year later.

CONCLUSIONS

Mother-to-infant transmission of HGV resulted in a high viral persistence rate and lack of immune responses to HGV. In contrast, anti-E2 appeared in children who recovered from posttransfusion HGV infection. Mode of transmission and age at infection may be important factors in determining persistent HGV infection and defective immune response to HGV.

Hepatitis G virus in the general population and in patients on hemodialysis

To determine the routes of transmission of hepatitis G virus (HGV) and the relationship between HGV and hepatitis C virus (HCV) infections, we tested for HGV RNA by polymerase chain reaction and antibody to HCV (anti-HCV) in 494 hemodialysis patients, 638 inhabitants of two HCV endemic areas, and in 400 blood donors in Japan. HGV RNA was detected in 6.9% of hemodialysis patients, in 1.4% of inhabitants, and in 0.8% of donors, and anti-HCV was detected in 39.3%, 12.4%, and 1.8%, respectively. Of HGV RNA-positive hemodialysis patients, and HGV RNA-positive inhabitants, 64.7% and 11.1%, respectively, had been given blood transfusions. The prevalences of HGV RNA and anti-HCV significantly increased with the duration of hemodialysis. Of all HGV RNA positives, 74.4% were coinfected with HCV and subjects with HGV RNA alone had normal liver function. In conclusion, HGV is transmitted by blood transfusion and within the hemodialysis unit itself. HGV does not seem to injure hepatocytes.

Prevalence of hepatitis G virus infection in Slovenian hemodialysis patients as determined by the detection of viral genome and E2 antibodies

The prevalence of hepatitis G virus (HGV) infection was assessed by the detection of viral genome and HGV E2 antibodies in hemodialysis patients from a dialysis unit with the highest prevalence of hepatitis C virus infection in Slovenia. HGV RNA was detected in 7 (11.9%) and HGV E2 antibodies in 20 (33.9%) of 59 hemodialysis patients. One patient had detectable HGV RNA as well as HGV E2 antibodies in her serum sample at the time of the study. The total prevalence of HGV infection was 44.1%. Our results clearly indicate that the mere detection of HGV RNA in serum samples would seriously underestimate the real prevalence of HGV infection in hemodialysis patients. Therefore, when assessing the prevalence of HGV infection in hemodialysis patients, detection of both antibody and nucleic acid is requisite.

Prevalence of hepatitis G virus RNA and anti-E2 in a Japanese haemodialysis population

BACKGROUND

Patients on maintenance haemodialysis (HD) are at greater risk of parenterally transmitted infection with not only A-E hepatitis virus but also with hepatitis G virus (HGV) that has been recovered from patients with non A-E hepatitis. The prevalence of HGV infection in HD patients, which is based on the detection of HGV RNA using reverse transcription-polymerase chain reaction techniques, differs widely between countries. Recently, a new assay has been developed that detects an antibody to the envelope protein (E2) of HGV (anti-E2) that appears to be associated with the loss of HGV RNA from the serum and which may be a useful marker for previous HGV infection.

METHODS

To determine the actual prevalence of HGV infection in maintenance HD patients, we examined both HGV RNA and anti-E2 antibody in sera from 200 patients undergoing maintenance HD.

RESULTS

Thirty patients (15%) tested positive for HGV RNA, and 14 (7%) tested positive for E2 antibody. Of these, two individuals tested positive for both markers. Overall, 21% of these HD patients had been exposed to HGV. A logistic regression analysis failed to show any clinical feature associated with the detection of HGV RNA. The duration of HD and the presence of HCV RNA were associated with anti-E2. Male gender and HCV RNA were risk factors for the elevation of serum ALT activities. HGV RNA sequences of the patients were not identical to each other.

CONCLUSIONS

Our data indicate that HGV infection is prevalent in patients undergoing HD but that liver abnormalities are rare. The nosocomial transmission of HGV in the HD unit was not confirmed.