Filippo Fatuzzo

HCV and HBV infection among multitransfused thalassemics from eastern sicily

SummarySerum specimens from 152 Sicilian multitransfused thalassemic subjects were tested for antibodies to hepatitis C virus (anti- HCV) and for HBV markers by enzyme linked immunoassay and with reference to anti-HCV, confirmed by recombinant immunoblot assay. A high rate (47%) of subjects was anti-HCV positive. HBsAg was found in 8% of patients and 55% had anti-HBs or anti-HBc antibodies or both. Contrary to HBV infection, anti-HCV seropositivity was related to the number of transfused units. The highest anti-HCV prevalence was observed between 16 and 20 years; 100% of persons older than 50 years had at least one marker of HBV infection. In conclusion, HCV and HBV are widespread among multitransfused thalassemics. Probably in our area, particularly during the pre-HBsAg screening era, several multitransfused patients were infected by HBV more readily than by HCV.ZusammenfassungDie Seren von 152 Thalassämie-Patienten, die häufig Bluttransfusionen erhalten hatten, wurden auf Antikörper gegen Hepatitis-C-Virus und HBV-Marker getestet. Ein hoher Prozentsatz (47%) erwies sich als anti-HCV positiv, was mit RIBA bestätigt wurde. HBsAg wurde bei 8% der Patienten gefunden und 55% hatten anti-HBc-oder Anti-HBs-Antikörper. Die dominierende anti-HCV-Prävalenz stand in Beziehung zur Transfusionshäufigkeit und war zwischen dem 16. und 20. Lebensjahr am höchsten. Im Gegensatz dazu stand die HBV-Infektion nicht im Verhältnis zu der Anzahl der Bluttransfusionen; bei 100% der Patienten über 50 Jahre wurde mindestens ein HBV-Infektionsmarker beobachtet. Bei Thalassämie-Patienten sind HCV- und HBV-Infektionen verbreitet. Wahrscheinlich haben sich vor dem Beginn des HBsAg-Screening in den Blutbanken viele Patienten mit dem HB-Virus infiziert.

Current practice of hepatitis C treatment in Southern Italy

BACKGROUND Only a small proportion of subjects referring to hospitals for hepatitis C virus (HCV) positivity receives antiviral therapy. AIM To evaluate the rate of antiviral treatment and the causes for no treatment in HCV-RNA positive subjects seen in hospital settings. PATIENTS AND METHODS A prospective study enrolling over a 6-month period (February-July 2009) all consecutive anti-HCV positive subjects initially referred (naïve patients) to 12 liver units in Southern Italy for HCV treatment. RESULTS Out of 608 subjects evaluated, 74 (12.2%) had no detectable HCV-RNA in the serum and thus were excluded. Of the remaining 534 HCV-RNA positive subjects, 357 (66.9%) were not treated for the following reasons: 49.9% were older than 65 years of age (75% of them >70 years), 14.3% had normal liver enzymes, 13.2% had compensated/decompensated cirrhosis, 10.4% refused treatment, 9.8% had ongoing substance or alcohol abuse. Multivariate analysis showed that females (O.R. 2.27; C.I. 95% 1.05-4.90) and subjects with low educational level (O.R. 4.38; C.I. 95% 1.27-15.11) were more likely to decline therapy. CONCLUSIONS The majority of patients with HCV infection does not receive antiviral treatment. The effectiveness of the current standard therapy for HCV infection is low despite its good efficacy.

Does transient elastography (FibroScan®) have a role in decision making in hepatocellular carcinoma?

OBJECTIVES Portal hypertension has been reported as a negative prognostic factor and a relative contraindication for liver resection. This study considers a possible role of fibrosis evaluation by transient elastography (FibroScan(®)) and its correlation with portal hypertension in patients with cirrhosis, and discusses the use of this technique in planning therapeutic options in patients with hepatocellular carcinoma (HCC). METHODS A total of 77 patients with cirrhosis, 42 (54.5%) of whom had HCC, were enrolled in this study during 2009-2011. The group included 46 (59.7%) men. The mean age of the sample was 65.2 years. The principle aetiology of disease was hepatitis C virus (HCV)-related cirrhosis (66.2%). Liver function was assessed according to Child-Pugh classification. In all patients liver stiffness (LS) was measured using FibroScan(®). The presence of portal hypertension was indirectly defined as: (i) oesophageal varices detectable on endoscopy; (ii) splenomegaly (increased diameter of the spleen to ≥ 12 cm), or (iii) a platelet count of <100,000 platelets/mm(3). RESULTS Median LS in all patients was 27.9 kPa. Portal hypertension was recorded as present in 37 patients (48.1%) and absent in 40 patients (51.9%). Median LS values in HCC patients with and without portal hypertension were 29.1 kPa and 19.6 kPa, respectively (r = 0.26, P < 0.04). Liver stiffness was used to implement the Barcelona Clinic Liver Cancer algorithm in decisions about treatment. CONCLUSIONS   The evaluation of liver fibrosis by transient elastography may be useful in the follow-up of patients with cirrhosis and a direct correlation with portal hypertension may aid in the evaluation of surgical risk in patients with HCC and in the choice of alternative therapies.

HCV and HIV infection among intravenous drug abusers in eastern Sicily.

In a study of 175 intravenous drug addicts from Eastern Sicily, 58.3% were found to be anti-HCV positive. In this population, the presence of anti-HCV was independent of HIV infection, age, duration of drug use and the practice of needle sharing. This may indicate that HCV is more readily transmitted (or spread earlier in this population) among drug addicts than is HIV.

Treatment induced seroconversion to HBsAb following HBV reactivation in the immunosuppressed haematology and oncology patient: A clinical survey of 5 cases in Catania, Italy

BACKGROUND In onco-haematological patients inactive or occult HBV infection may be reactivated as a result of disease-related immuno-suppression and/or chemotherapy with rituximab. OBJECTIVES This study reports the clinical features of five patients affected by onco-haematological disorders who experienced hepatitis B reactivation. STUDY DESIGN From 2005 to 2010, five onco-haematological patients with hepatitis B reactivation were admitted to the department of Infectious Diseases, Ferrarotto Hospital, Catania, Italy. RESULTS At the time of onco-haematological disease diagnosis, 3 patients were HBcAb positive; 1 HBsAb and HBcAb positive; and 1 HBsAg positive, HBV DNA negative. None of the patients received hepatitis B prophylaxis. Reactivation was observed following chemotherapy. One patient was treated with lamivudine, 2 with tenofovir and 2 with telbivudine. Following treatment all patients achieved undetectable HBV DNA and normalization of transaminases. Three patients, those treated with lamivudine and tenofovir, cleared HBsAg and developed protective titres of HBsAb. The remaining patients, who were treated with telbivudine, were HBV DNA negative and HBsAg positive one at 27 months and the other at 5 months of therapy. Treatment thus continued in these patients. CONCLUSION HBV reactivation can be a severe complication in onco-haematological patients undergoing chemotherapy with rituximab. In our experience all nucleos(t)ide analogues were safe and effective. Three patients seroconverted to HBsAb. This may be as a result of the antivirals enhancing the immune response to HBV. A similar role may also be played by immune recovery following the withdrawal of immune-suppressive treatment. This report confirms the importance of anti-viral prophylaxis in patients with a high risk of HBV reactivation.

Telbivudine use in a patient affected by occult hepatitis B virus and B-cell non-Hodgkin lymphoma

With an estimated prevalence of 350 million infected people, hepatitis B virus (HBV) is a worldwide agent of chronic hepatitis [1]. In Italy, the prevalence of chronic HBV infection determined by Hepatitis B surface Antigen (HBsAg) positivity is considered to be low (52%), while for anti-Hepatitis B core (HBc) positivity prevalence is higher at 12–18% [2]. In some subjects with resolved HBV infection (HBsAg negative and anti-HBc positive), virus replication can persist in liver and mononuclear cells. However, the rare presence of detectable viremia in serum of HBcAb positive patients indicates that such subjects are in fact occult carriers [3]. In these patients a reemergence of HBsAg antigen can also be observed [4]. In onco-hematological patients the prevalence of chronic HBV infection is comparable or higher than local endemicity [1,5]. A recent study showed that in Italy prevalence of HBsAg and HBcAb is significantly higher in patients with B-cell non-Hodgkin lymphomas (B-NHL) compared to the control group (8.5% vs. 2.8% and 41.5% vs. 29.1%, respectively) [6]. Immunosuppression due to both onco-hematological disease and chemotherapy may reactivate inactive or occult HBV infection [7]. The clinical picture of HBV reactivation in hematologic patients ranges from spontaneous resolution to severe hepatitis with a fatality rate of up to 40% [8]. Lamivudine has been considered the primary agent in the prevention of HBV reactivation. However, a mortality rate of up to 20% has been reported when lamivudine has been used to treat reactivated cases [9]. Lamivudine has also been associated with the development of mutations and resistance to treatment is well documented [10]. New nucleos(t)ide analogs are now available for the treatment of chronic viral hepatitis B and obtain a more rapid viral suppression. Moreover, studies suggest that these new analogs present a lower risk of subsequent resistance compared to lamivudine [11]. To our knowledge however, no reports are currently available on the use of the new anti-viral agents (telbivudine or entecavir) in the management of already reactivated hepatitis B. We report a case of hepatitis B reactivation treated with telbivudine in a patient affected by B-NHL and occult hepatitis. The case patient was a 52-year-old male. In 2007, he was first diagnosed with grade 1 follicular lymphoma BCL-2 positive. At the time of diagnosis he was found to be HBsAg-negative, HBsAb negative, HBcAb positive, HBcAb IgM negative, Hepatitis B e Antigen (HBeAg) negative, and antiHBe positive. Alanine aminotransferase (ALT) levels were normal. In the course of 2007 the patient underwent eight cycles of combination chemotherapy of R-CVP (1 R only) (rituximab – cyclophosphamide – vincristine – prednisolone). In January 2008 at the end of the eighth cycle the patient went into NHL remission. As HBV-DNA levels tested positive with a value of 319.117 UI/ml, on April 2008 the patient was referred to the Unit of Infectious Diseases. The patient was asymptomatic. Transaminase levels and liver function tests (bilirubin,

Preliminary investigation on intrafamilial spread of hepatitis C virus (HCV)

To determine the risk of cohabitant HCV infection, we investigated the sera of 101 family members of 53 anti-HCV antibody positive chronic liver disease patients. Altogether 14.8% of the cohabitants were also anti-HCV antibody positive, compared to a prevalence of 1.4% in the general population. These results suggest that hepatitis-C-virus may spread by person-to-person infection.

HCV infection in HBsAg positive chronic liver disease.

The prevalence of anti-HCV antibodies was determined for a group of 68 patients with various forms of chronic liver disease. All patients that were anti-HCV positive but did not show signs of HBV replication had severe liver disease. We therefore suggest that HCV may be responsible for liver damage in HBsAg positive subjects when there are no evident signs of HBV replication.