[Occult hepatitis B virus infection in chronic viral hepatitis patients with non-A to E hepatitis virus infection]

OBJECTIVE

To observe the status of occult hepatitis B virus infection in chronic viral hepatitis patients with non-A to E hepatitis virus infection and explore the diagnostic value of fluorescence quantitative polymerase chain reaction (FQ-PCR) technique for occult hepatitis B virus infection.

METHODS

The amount of HBV-DNA in serum and liver tissue from 57 patients with non-A to E hepatitis virus infection who were diagnosed as chronic viral hepatitis by Menghini method liver biopsy were detected by using FQ-PCR technique, then the relation between the viral load of HBV DNA in liver tissue and hepatic inflammatory activity were analyzed.

RESULTS

Thirteen (22.81%), 22 (38.60%) patients were positive for HBV DNA in serum and liver tissue, respectively. The positive rate and the level of HBV DNA quantity in liver tissue were significantly higher than those in serum; HBV DNA was found positive in both serum and liver tissue in 13 cases, negative in both serum and liver tissue in 35, positive in liver tissue but negative in serum in 9, and in none of the cases HBV DNA was positive in serum but negative in liver tissue (P < 0.01). The logarithmic value of HBV DNA from 13 patients in liver tissue and in serum was respectively: (6.62 +/- 1.21) copies/g vs.(4.03 +/- 1.06) copies/ml, P < 0.01. The hepatic lesions of all HBV DNA positive patients were active pathologic changes, but the level of HBV DNA in liver tissue was not significantly correlated with the grade of hepatic inflammation activity (P > 0.05).

CONCLUSION

Occult HBV infection is the etiology of part of the chronic viral hepatitis patients with non-A-E hepatitis virus infection. Missed diagnosis will occur if diagnosis of hepatitis B is only based on detection of serum HBV markers. It is useful for improvement of the diagnostic level of HBV infection via detection of HBV DNA quantitatively in serum especially in liver tissue of chronic viral hepatitis patients with non-A-E hepatitis virus infection by using FQ-PCR technique. The chronic viral hepatitis patients with occult HBV infection should be also given effective anti-viral therapy.

Epidemiology and clinical pattern of hepatitis delta virus infection in Pakistan

BACKGROUND AND AIMS

The global epidemiology of hepatitis delta virus (HDV) infection is changing. This study was performed to determine the epidemiology and clinical impact of hepatitis delta in Pakistan.

METHODS

Countrywide data was collected from 1994 to 2001. A total of 8721 patients were tested for hepatitis delta antibody. A subset of 97 hepatitis delta antibody reactive inpatients with chronic liver disease were compared to 97 patients admitted with liver disease due to hepatitis B alone.

RESULTS

Of the 8721 patients tested, 1444 (16.6%) were reactive for hepatitis delta antibody. Most were males (87.4%, P < 0.001) and younger (mean age 31 years, P < 0.001) compared to HDV non-reactive patients. Prevalence of delta infection was highest in the rural (range 25-60%) compared to the urban population (range 6.5-11%). Analysis of the inpatient data showed that delta infected patients had significantly less severe clinical liver disease and a trend towards lesser development of hepatocellular carcinoma compared to delta negative patients.

CONCLUSIONS

(i) HDV infection is present in 16.6% of hepatitis B infected patients in Pakistan, most commonly in younger males living in rural areas; and (ii) delta virus infected patients have less severe clinical liver disease compared to delta negative, hepatitis B patients.

[Effect on the pregnant woman and fetus by multiple hepatitis virus infection]

OBJECTIVE

To evaluate the effect on the pregnant woman and fetus by infection of multiple hepatitis virus during pregnancy.

METHODS

Hepatitis virus A, hepatitis virus B, hepatitis virus C, hepatitis virus D and hepatitis virus E were determined in the pregnant women with abnormal liver function during 1994-1999. Patients diagnosed to be infected by single hepatitis virus or multiple hepatitis virus were divided into two groups and complications of the pregnant woman and fetus and their prognosis were evaluated.

RESULTS

There were no significant differences in the levels of alamine transaminase (ALT), aspartama transaminase (AST) and total bilirubin (TBIL) between the multiple hepatitis virus infection group (multiple group) and the single hepatitis virus infection group (single group) (P > 0.05). The positive rate of HbeAg (35.7%) in multiple group was significantly lower than in single group (P < 0.05). However, the positive rate of HbeAb (57.1%) in multiple group was significantly higher than in single group (P < 0.01). There were no significant differences in incidences of pregnancy induced hypertension (PIH), postpartum hemorrhage, serious symptoms and mortality between the multiple hepatitis virus infection group and the single hepatitis virus infection group (P > 0.05). However, the incidences of premature rupture of membrane (PROM), premature delivery, 28.1%, 25.0% fetal distress and newborn infant asphyxia 31.3%, 25.0% in multiple hepatitis virus infection group were significantly higher than in single hepatitis virus infection group (P < 0.05, P < 0.01).

CONCLUSIONS

Multiple hepatitis virus infection during pregnancy has no more serious effect on the pregnant woman, but has worse effect on fetus than single hepatitis virus infection. The obstetrician should pay more attention to the health care of the pregnant woman with the multiple hepatitis virus infection to prevent PROM and premature delivery, at the same time monitor fetus carefully and deal with labor actively to decrease the mortality of the fetus.

Animal models of hepatitis delta virus infection and disease

Hepatitis delta virus (HDV) is a defective RNA virus with similarities to unusual subviral pathogens of higher plants. It requires hepatitis B virus (HBV) for its replication/transmission, and HBV-infected humans are the only established host. HDV causes both severe acute hepatitis and rapidly progressive chronic disease in some individuals. The HDV life cycle involves remarkable features, such as ribozyme- mediated autocatalytic processes, Pol II-directed RNA synthesis from a single-stranded circular RNA template, and RNA editing. Much of our understanding of the nature of this pathogen derives from experimental studies in the chimpanzee model of HBV infection. The hepadnavirus-infected eastern woodchuck also is capable of supporting HDV replication and offers opportunities for the development of control strategies that might be applicable to human type D hepatitis.

Virologic and clinical expressions of reciprocal inhibitory effect of hepatitis B, C, and delta viruses in patients with chronic hepatitis

We studied 648 hepatitis B surface antigen (HBsAg)- and/or anti-hepatitis C virus (HCV)-positive patients to evaluate the virologic and clinical characteristics of multiple hepatitis viral infection. We defined as Case B-C an HBsAg/anti-HCV positive patient and as Case b-C an anti-HCV/anti-HBc-positive, HBsAg/anti-HBs-negative patient. For each Case B-C we scheduled as Control-B an HBsAg positive and anti-HCV negative patient and as Control-C an HBsAg/anti-HBs/anti-hepatitis B core antigen (HBc)-negative and anti-HCV-positive patient. Control group C was used as the control also for Case group b-C. Serum HBV DNA by molecular hybridization was found more frequently in Control group B (54% of 161 patients) than in Case group B-C (35.7% of 84, P <.01). The prevalence of HBV wild type was similar in Case group B-C (14. 3%) and in Control group B (17.4%), whereas the e-minus strain was less frequent in Case group B-C (10.7% vs. 33%; P <.01). HBV DNA by polymerase chain reaction (PCR) was detected in 40.8% of 71 patients in Case group b-C. HCV RNA was detected more frequently in Control group C (90.7% of 130 patients) than in Case group B-C (65.2% of 69, P <.0001). Moderate or severe chronic hepatitis or cirrhosis were more frequent in Case group B-C (62.9% of 65 patients) than in Control group B (46.7% of 90, P <.05) or C (40.8% of 98, P <.005), and in Case group b-C (71.1% of 76) than in Control group C. Thus, in multiple hepatitis we observed a reciprocal inhibition of the viral genomes and a more severe liver disease. In Case group b-C, serum HBV DNA was frequent and the clinical presentation was severe.

Multiple hepatitis virus infections in chronic HBsAg carriers in Naples

In order to determine the prevalence of multiple infections with hepatitis viruses in chronic HBsAg carriers in Naples, to assess the interaction between HBV, HDV and HCV infections and to evaluate the influence of multiple virus hepatitis infections on the clinical presentation, we studied 198 HBsAg chronic carriers observed consecutively from 1971 to 1988 at our Liver Unit. Of the 198 HBsAg chronic carriers, 171 had undergone percutaneous liver biopsy. The presence of HBcAg or HDAg in the liver biopsy was considered a marker of HBV or HDV replication, respectively; the presence of anti-HCV was considered a marker of HCV infection. Anti-HCV was observed in 13.6% of the 22 subjects with normal liver, in 27.7% of the 47 patients with minimal chronic hepatitis, in 40% of the 50 with mild chronic hepatitis, in 70.6% of the 17 with moderate hepatitis, in 66.7% of the 3 with severe chronic hepatitis and in 65.6% of the 32 with active cirrhosis. Anti-HCV positive cases were antiHD positive more frequently than the anti-HCV negative (59.2% vs. 43%, p = 0.05). HDV infection exerted a clear inhibition on the HBV genome. Among the 171 HBsAg chronic carriers, the finding of an active chronic hepatitis (moderate chronic hepatitis + severe chronic hepatitis + active cirrhosis) is less frequent in subjects with HBV replication alone than in those with HDV replication or HCV infection. Patients with both HBV replication and HCV infection and those with both HDV replication and HCV infection showed a very high prevelance of active chronic hepatitis.

Chronic delta hepatitis: is the prognosis worse when associated with hepatitis C virus and human immunodeficiency virus infections?

Eighty-six patients were followed for 6.5 years to study the epidemiological, virological, and histological course of chronic delta hepatitis and the relationship of this disease with HIV and HCV infection. Patients were classified into four groups according to simultaneous HCV and/or HIV infection: group 1, HDV infection (20 cases); group 2, HDV and HCV infection (11 cases); group 3, HDV and HIV infection (12 cases), and group 4, HDV, HCV, and HIV infection (43 cases). All but 14 patients were asymptomatic at presentation. Liver histology showed chronic active hepatitis in 53 cases and cirrhosis in 19 cases. During followup, 52 patients remained asymptomatic, 34 developed hepatic dysfunction, 28 died, and 1 received a liver transplant. Among the 28 patients who died, 4 had HDV infection; 3 HDV and HCV infection; 3 HDV and HIV infection; and 18 HDV, HCV, and HIV infection. Death was due to liver failure in 16 (57%), AIDS in 10 (36%), and was unrelated to liver disease in 2 (8%) cases. There results demonstrate that chronic delta hepatitis is a severe disease, especially among drug users with HIV and HCV infection. The high morbidity and mortality of chronic delta hepatitis justifies the use of antiviral therapy to modify the natural course of the disease.

Prevalence and type of precore hepatitis B virus mutants in hepatitis D virus superinfection and its clinical implications

To study the prevalence and type of the hepatitis B e antigen (HBeAg)-negative mutant in hepatitis D virus (HDV) superinfection, the precore region of hepatitis B virus (HBV) was analyzed by cycle sequencing. Of the 58 samples sequenced, 24 were wild type and 34 carried mutants. The precore stop mutation (TAG) at the 28th codon was found in 32 cases, other mutations were found in 7, and double mutations were found in 5. The absence of HBeAg showed a substantial agreement with the presence of mutants (kappa value, 0.74). Of the acute hepatitis patients, HDV replication and clinical manifestations were not significantly different between those with mutant and wild type virus, except that those with mutant virus were older (mean age, 48 vs. 28 years; P < .002). The absence of HBeAg in these patients is mainly due to HDV superinfection in older HBV carriers who already had precore mutant.

[Decimeter-wave physiotherapy in viral hepatitis]

Effectiveness was evaluated of magnetotherapy, inductothermy, UNF electric field and electromagnetic waves of decimetric wave band (460 MHz) on the projection of the liver, adrenals and thyroid gland in controlled trials enrolling a total of 835 patients with viral hepatitis (type A, B, associated forms). A conclusion is reached that optimum effectiveness of decimetric field on the projection of the adrenals and thyroid gland can be achieved through the application of minimum power and everyday alternation of exposures. It has been estimated that as many as 69 percent of the patients derive benefit from the above treatment.

Natural history of hepatitis D viral superinfection: significance of viremia detected by polymerase chain reaction

BACKGROUND/AIMS

Polymerase chain reaction (PCR) is very sensitive. The aim of the study was to reevaluate viral replication in hepatitis D virus (HDV) superinfection by PCR.

METHODS

HDV and hepatitis B virus (HBV) were detected by PCR in 185 patients.

RESULTS

The acute hepatitis group had the highest detection rate of HDV RNA compared with chronic hepatitis, cirrhosis, hepatocellular carcinoma, and remission groups (63 of 64 vs. 35 of 47, 17 of 23, 19 of 30, and 7 of 21) and the highest alanine aminotransferase (ALT) levels (mean, 1741 U/L vs. 266 to 27 U/L; P < 0.05). The detection rate of HBV DNA was the lowest in the acute group (41%) compared with 66%, 70%, 80%, and 57% in the remaining groups (P < 0.02). At the chronic stage, 13%-25% of cases had HDV RNA, and 30%-48% of cases had HBV DNA detected by PCR but not by traditional method. HDV RNA was associated with ALT levels in horizontal and longitudinal analyses.

CONCLUSIONS

HDV superinfection may be divided into the following three phases: acute phase, active HDV replication and suppression of HBV with high ALT levels; chronic phase, decreasing HDV and reactivating HBV with moderate ALT levels; and late phase, development of cirrhosis and hepatocellular carcinoma caused by replication of either virus or remission resulting from marked reduction of both viruses.

[The efficacy of decimeter-wave therapy with exposure of the neuroendocrine organs in the treatment of viral hepatitis]

A controlled trial entered 343 patients with virus hepatitis A, B and associated forms. In addition to standard treatment the patients' adrenals and thyroid were exposed to electromagnetic waves (460 MHz) in alternative daily regimens and under minimal power. As shown by clinical, rheohepatographic, hormonal, immunological and follow-up evidence, positive results were achieved in 69% of the patients.

Long-term evolution of chronic delta hepatitis in children

Twenty-three children, aged 3 to 15 years, with chronic delta hepatitis have been followed for 5 to 12 years to evaluate long-term outcome. Although 83% of patients had chronic active hepatitis when first seen, with cirrhosis in 26%, the clinical and biochemical features of the disease remained reasonably stable during observation; liver histologic findings, obtained in 14 patients, worsened in only two.

Recurrence of hepatitis D (delta) in liver transplants: histopathological aspects

BACKGROUND

The viral/pathological correlates of recurrent hepatitis delta virus (HDV) disease in orthotoptic liver transplants are reported.

METHODS

We examined the histological features of recurrent HDV disease in nine patients with transplants for terminal HDV cirrhosis were examined; intrahepatic HDV and hepatitis B virus (HBV) antigens were detected by immunoperoxidase techniques. Sera were tested for the battery of HDV and HBV markers.

RESULTS

In four patients, HDV reinfection was accompanied by the recurrence of an HBV infection with features of active viral replication. In the other five, HDV reinfection was accompanied by an atypical recurrence of HBV infection without evidence of active HBV replication (no expression of intrahepatic hepatitis B core antigen). In four of the latter patients, the atypical HBV pattern changed during the follow-up into a pattern of active viral replication accompanied by chronic necroinflammation detected during histology.

CONCLUSION

The pattern of recurrent HBV infection can influence the pathological aspects of the relapses of HDV disease in liver grafts.

Course of hepatitis B and D virus infection in auxiliary liver grafts in hepatitis B-positive patients. A light-microscopic and immunohistochemical study

Four patients who received an auxiliary partial liver graft for decompensated liver cirrhosis due to hepatitis B (HBV), associated in two cases with hepatitis D virus (HDV) superinfection, were studied. The sequential appearance of hepatitis B and D antigens in the grafts was investigated in serial liver biopsies by immuno-histochemical methods and compared with the viral antigenic profiles of the host livers. The histological changes in the liver grafts were studied in relation to the viral expression patterns. One week after transplantation, expression of HBsAg was already apparent in two grafts. HBcAg was found in the graft of the only patient with HBcAg in the host liver. HDAg was expressed in the grafts of both patients with HDV superinfection; in one of these cases HDAg was present without HBsAg. At 3 months, viral antigen expression was maximal. Expression of HBsAg and HBcAg in the grafts of the two HDV-positive patients was, however, less extensive than in the two HBV-positive patients. All patients developed a mild lobular hepatitis, histologically demonstrated between the 47th and 107th posttransplantation day. In the two HBV-positive, HDV-negative patients, cirrhotic transformation of the graft occurred within 1 year. In the HDV-positive patients only a mild chronic active hepatitis with slight or moderate fibrosis was observed after 1 year. We conclude that recurrence of HBV and HDV infection in auxiliary liver grafts is demonstrable within 1-3 weeks. HBV infection in liver grafts may be a rapidly progressive disease. Coinfection with HDV does not aggravate the acute hepatitis and may even suppress the progression of chronic HBV.

IgA class antibodies to hepatitis delta virus antigen in acute and chronic hepatitis delta virus infections

Sera from 31 patients with chronic hepatitis delta virus infection and 18 patients with acute hepatitis delta virus infection were examined for IgA class antibodies to this virus using a newly developed enzyme immunoassay. IgA antibody to hepatitis D virus was detected in 21 (67.7%) of 31 patients with chronic delta viral hepatitis, but in only 1 (5.6%) of the 18 patients with acute infection (p less than 0.0005). Of the 21 patients with chronic delta hepatitis with IgA antibody to hepatitis D virus, 19 (90.5%) had moderate-to-severe activity on liver biopsy: 18 of the 21 had histological features of chronic active hepatitis and three had chronic lobular hepatitis. In all, 23 patients with chronic delta hepatitis had moderate-to-severe activity, and 19 (82.6%) had IgA antibody to hepatitis D virus. No statistically significant correlations were found between IgA antibody to hepatitis D virus and biochemical markers of liver injury (p greater than 0.4), or the presence of hepatitis delta virus antigen in liver biopsies (p greater than 0.2), in the patients with chronic delta hepatitis. The finding that IgA antibody to hepatitis D virus was almost exclusively associated with chronic hepatitis delta virus infection and correlated independently with moderate-to-severe histological activity (with a specificity of 90.5% and a sensitivity of 82.6%) suggests that this antibody might be a useful serological marker of underlying liver damage in chronic delta hepatitis.

Follow-up of recurrent hepatitis B and delta infection in liver allograft recipients after treatment with recombinant interferon-alpha

Reinfection of the graft with hepatitis B virus (HBV) and hepatitis delta virus (HDV) is a potential complication in patients undergoing orthotopic liver transplantation (OLT). Therefore, we added recombinant interferon-alpha (rIFNa) to the standard immunosuppressive regimen in 11 patients who received transplants following liver failure attributed to cirrhosis B (n = 10, with HDV co-infection in four cases) or fulminant hepatitis B (n = 1). Patients were treated with rIFNa for periods ranging from 2 to 3 months between the first and the 13th month after OLT. All patients received immunosuppressive treatment with low-dose corticosteroids, azathioprine and cyclosporine. Anti-HBs hyperimmune globulin was also administered. None of the patients showed evidence of severe allograft rejection. Seven patients suffered HBV reinfection of the graft with histological signs of acute hepatitis in five cases and transition to chronic hepatitis in one patient. Treatment with rIFNa did not prevent or reduce HBV replication. Reinfection of the graft with HDV was demonstrated by PCR in four patients co-infected with HDV. During treatment with rIFNa liver biopsy specimens from three reinfected patients were transiently negative for HDV antigen but not for HDV RNA, and the sera from two patients were transiently negative for HDV RNA. The data indicate that rIFNa can reduce HDV replication in reinfected liver allografts.

Hepatitis delta virus (HDV) infections. Epidemiological and clinical heterogeneity

Heterogeneity is a feature of all aspects of HDV infection and biology. Epidemiological studies indicate wide variations in the global distribution of the virus, often with different and bizarre rates of prevalence within apparently homogeneous populations. The medical expression of the infection is likewise manifold, ranging from the asymptomatic carrier of HDV to terminal cirrhosis. The clinical variability is matched at the biological level by extensive molecular heterogeneities, as expected with a small RNA virus such as the HDV.

Smouldering hepatitis B virus replication in patients with chronic liver disease and hepatitis delta virus superinfection

Hepatitis B virus deoxyribonucleic acid (HBV-DNA) was studied by Southern blot analysis in liver biopsy specimens from 75 HBsAg-positive patients with chronic liver disease living in southern Italy. Twenty-seven of the patients were hepatitis delta virus (HDV) superinfected. Intrahepatic HBV-DNA was detected in 54 (72%) patients, 32 (59%) of them with replicative forms. The presence of replicative forms was directly related to liver HBcAg and inversely related to liver HDAg, as shown by multivariate analysis. However, 14 patients with intrahepatic HBV-DNA non-replicative pattern and about half of HDV-infected patients were liver HBcAg and/or serum HBV-DNA positive, mostly in low amounts. Histological inflammatory activity was strongly related to liver HBcAg expression regardless of HDV superinfection, as confirmed by multivariate analysis. Our results confirm previous studies about the concordance between intrahepatic HBV-DNA replicative pattern and liver HBcAg expression and about inhibition by HDV of high-level HBV replication. However, they suggest that low-level HBV replication may have an important role in causing liver damage also among HDV-infected patients, in a population where the spreading of HBV and HDV is a naturally occurring event.

The molecular basis of heterogeneity of hepatitis delta virus

HDV-RNA displays genetic heterogeneity at several different levels. This heterogeneity is likely reflected in the biological properties, such as pathogenicity and evolution, of HDV. The variation and progression of the clinical picture of delta hepatitis is likely associated with the heterogeneity of the virus. The mechanism of the generation of the heterogeneity remains largely to be studied.

Hepatitis D virus infection among intravenous drug abusers in Taiwan: analysis of risk factors and liver function tests

To investigate the prevalence of hepatitis D virus (HDV) and hepatitis B virus (HBV) infection among intravenous drug abusers in Taiwan, a total of 761 male prisoners, including 680 intravenous drug abusers, were studied for serological markers of HBV and HDV. Questionnaires were distributed to evaluate the risk factors for HDV infection and also to estimate the strength of association among HDV infection and the risk factors. HBV infection was common, and the positive rates of HBV markers between intravenous drug abusers and non-drug abusers were not statistically different. However, the positive rate of the antibody to HDV was significantly higher among intravenous drug abusers than among non-drug abusers (21.3% vs. 8.6%). Of 131 chronic HBV carriers with intravenous drug abuse, 119 (91%) were anti-HD positive. Using multiple logistic regression models, we found that the most important risk factor for HDV infection was hepatitis B surface antigen (HBsAg) carriage, and intravenous drug addiction the next. A matched case-control study also was conducted to compare liver function tests among both anti-HD- and HBsAg-positive group anti-HD-negative, and HBs-AG-positive group as well as those with neither positive. Statistically significant difference in liver function tests was not found. It is concluded that the HBsAg carriers with intravenous drug abuse in Taiwan are commonly HDV infected with and that the infection does not seem to affect the liver as assessed by liver function tests.

Hepatitis delta: the virus and the disease

In general, the biological and structural properties of the hepatitis delta virus resemble those of the viroids and related satellite RNA viruses of plants. This resemblance has been strengthened by the discovery that, in analogy to the self-cleaving of some plant RNA viruses, hepatitis delta virus RNA possesses autocleaving and autoligating sites located in sequences that are homologous with highly conserved domains in the viroids. The catalytic properties identify the hepatitis delta virus as the first mammalian ribozyme. The current interpretation of the pathobiology of delta hepatitis rests on the postulates that the hepatitis delta virus invariably requires hepatitis B virus for infection and is highly pathogenic. Accordingly, delta hepatitis is thought to occur when hepatitis delta virus coinfects with hepatitis B virus or when it superinfects hepatitis B virus carriers. However, new evidence from the liver transplantation model suggests that hepatitis delta virus is capable of establishing latent, asymptomatic infections without the apparent assistance of hepatitis B virus: in this model, disease was only reactivated when hepatitis B virus also returned to the graft. Thus, hepatitis B virus superinfection on a latent hepatitis delta virus state may be a third pathobiological mechanism conducive to delta hepatitis.

Acute hepatitis delta virus superinfection in patients with liver cirrhosis

A clinicopathologic study in a total of 164 patients with acute hepatitis delta virus (HDV) infection showed that nine male patients (5.5%) had evidence of liver cirrhosis prior to or during the episode of acute hepatitis. All nine patients had typical clinical presentations and laboratory findings of acute viral hepatitis. Four of them had prolonged prothrombin time, three developed ascites and one finally died of hepatic failure. Clinical ascites occurred more frequently in cirrhotic patients with severe but non-fulminant hepatitis than their non-cirrhotic counterparts (p less than 0.05). In addition, histologic studies in five patients with cirrhosis disclosed diffuse lobular necrotizing inflammatory activity, with four showing bridging hepatic necrosis, which also occurs more frequently in cirrhotic than in non-cirrhotic patients (p less than 0.05). The data suggest that HBsAg positive patients with cirrhosis are susceptible to acute HDV infection which may lead to extensive necrosis or even decompensation and failure, simulating decompensation of the underlying liver disease. Therefore, careful clinicopathologic work-ups are required for accurate diagnosis and correct assessment of their outcomes.

Study of reactivation of chronic hepatitis delta infection

Five patients with chronic hepatitis delta virus (HDV) infection suffered spontaneous episodes of liver enzyme elevation on a background of otherwise biochemically stable liver disease. In all five patients these episodes were accompanied by a rise in serum levels of anti-HDV IgM, HDV antigen and HDV RNA. These episodes of increased HDV replication accompanied by biochemical evidence of liver injury are reminiscent of reactivation in chronic hepatitis B. Surges of increased HDV replication may be important in the progression of liver disease in chronic HDV infection.

Hepatitis D virus infection

The hepatitis D virus (HDV) was first detected in Italy in 1977 and is the etiologic agent of type D hepatitis. A defective RNA virus, HDV depends completely on the hepatitis B virus for its expression and replication. HDV infection can cause a severe form of hepatitis with high mortality rates. In the United States, hepatitis D most commonly affects intravenous drug abusers and hemophiliacs. Diagnosis is based on interpretation of the body's immune response to the hepatitis D antigen. At present, there is no specific treatment for type D hepatitis. Prophylaxis against HDV infection depends entirely on the prevention of hepatitis B. Patients found to have hepatitis D virus infection should be referred to a gastroenterologist for management.

Propagation of woodchuck hepatitis delta virus in primary woodchuck hepatocytes

Monolayer cell cultures of primary woodchuck hepatocytes, prepared by perfusing the liver in situ with collagenase type I, yielded hepatocytes with a viability of greater than 90% which could be held in culture for up to 3 months. Cultures of primary woodchuck hepatocytes were infected one day after plating with hepatitis delta virus (HDV) which had been passaged five times in woodchucks and was therefore identified as woodchuck hepatitis delta virus (WHDV). Replication of WHDV was demonstrated by the appearance of genomic WHDV RNA of ca. 1.7 kb beginning 7 days after infection, with an increase of copy numbers up to 2 weeks after inoculation. Synthesis of hepatitis delta virus-associated antigen (HDAg) in hepatocytes was detected by immunofluorescence staining of hepatocytes. Preincubation of the inoculum with rabbit sera containing antibodies against woodchuck hepatitis virus surface antigen (anti-WHs) reduced the infectivity of WHDV to an undetectable level compared with inocula which were treated with anti-WHs negative sera.

Clinical and serological outcome of acute delta infection

To assess the clinical and serological outcome of hepatitis delta virus (HDV) infection, 59 patients with acute delta hepatitis were followed for 6-28 months. Forty-two patients had simultaneous HDV and HBV coinfection (anti-HBc IgM-positive, group I) and 17 were HBsAg carriers with HDV superinfection (anti-HBc IgM-negative, group II). Overall, serum HD-Ag and anti-HD IgM were the most sensitive markers for diagnosis of delta infection during the first 2 weeks after onset of symptoms. The clinical presentation was similar in both groups; 4 patients (1 in group I and 3 in group II) (7%) developed fulminant hepatitis, but none of them died. The majority of patients with HBV-HDV coinfection (group I) eventually recovered, whereas all HBsAg carriers with HDV superinfection (group II) developed chronic liver disease. Liver histology in these patients showed chronic active hepatitis and/or cirrhosis in 90%. The hepatic lesion was probably due to persistent HDV infection, as indicated by the presence of intrahepatic HD-Ag and/or persistence of serum anti-HD IgM in 90% of the patients.