Haruki Yamada

Emergence of the precore mutant late in chronic hepatitis B infection correlates with the severity of liver injury and mutations in the core region

OBJECTIVE:The reason that precore negative mutants (e-minus DNA) gradually become predominant in some patients during chronic hepatitis B virus infection is not clear. Theoretically, as long as both e-plus and e-minus DNA share the same epitopes in the core region, HBcAg-specific cytotoxic T lymphocytes (CTLs) cannot distinguish between the target peptides expressed by e-plus and e-minus DNA. Therefore, e-minus DNA may be accompanied by additional mutations in the core region, which may affect cytotoxic T lymphocyte recognition. To examine this possibility, the sequences of the precore and the entire core region of the hepatitis B virus genome were analyzed from paired serum samples in CH-B patients who experienced HBeAg to anti-HBe seroconversion (SC).METHODS:Patients were divided into two groups. Group A patients (n = 17) genome-converted to e-minus DNA in the precore region, which abolished HBeAg secretion within 3–4 yr after SC. Group B patients (n = 16) retained precore wild-type DNA for more than 3–4 yr after SC. To investigate the impact of the emergence of precore mutant type DNA on liver injury, alanine aminotransferase (ALT) levels were also examined.RESULTS:ALT flares were more severe among patients in group A than in group B. The average mean ALT level during the HBeAg negative phase of chronic infection was 54 ± 38 in group A and 28 ± 24 in group B. The average maximal ALT level during the HBeAg negative phase was 235 ± 249 in group A and 83 ± 106 in group B. Furthermore, all 17 patients in group A developed new core mutants during genome conversion. The average number of mutations in the core gene was 0.9 ± 1.2 before genome conversion (e-plus DNA dominant phase) and increased to 2.8 ± 1.3 for the 3–4 yr during genome conversion (e-minus DNA dominant phase). In contrast, only 56% (nine of 16) of patients in group B developed new core mutations after the loss of HBeAg. The average number of mutations in the core gene was 1.8 ± 1.3 before SC (HBeAg-positive and e-plus DNA dominant phase), and decreased to 1.1 ± 1.1 for 3–4 yr after seroconversion (anti-HBe–positive and e-plus DNA dominant phase).CONCLUSIONS:These data indicate that the emergence of a predominant precore negative genotype late in chronic hepatitis B virus infection is associated with the selection of additional mutations in the core gene, as well as with liver injury.

Down-regulation of prostaglandin E2 receptors in regenerating rat liver and its physiological significance.

The properties of prostaglandin (PG) E2 receptors in regenerating liver were studied using rat hepatocytes in primary culture. The control cells possessed stereo-specific PGE2 receptors with Bmax and Kd values, at 4 degrees C, of 526 fmol/mg protein and 6.5 nM respectively. In cells from regenerating liver after 70% hepatectomy, Bmax was reduced to 42-43% that of the controls; Kd did not change. Administration of indomethacin before surgery prevented Bmax reduction. These results indicate that PGE2, produced during the regeneration process, evoked cellular events and regulated the density of its receptors.

Acute onset of nephrotic syndrome during interferon-α retreatment for chronic active hepatitis C

A 57-year-old woman was scheduled to receive recombinant interferon-α retreatment for chronic active hepatitis C. During the course of therapy, the patient showed rapid onset of oliguria, dizziness, edema, and a pre-shock state. She was subsequently admitted to hospital and was diagnosed as having nephrotic syndrome. After admission, albumin-dominant proteinuria persisted despite the discontinuation of interferon therapy. Light microscopy of a renal needle biopsy specimen showed interstitial lymphoid cell infiltration, but no marked changes of the glomeruli and no staining for immunoglobulin or complement. Electron microscopy showed diffuse effacement of the glomerular epithelial foot processes, leading to a diagnosis of minimal change nephrotic syndrome with interstitial nephritis. Proteinuria resolved after the initiation of oral prednisolone therapy (1 mg/kg per day). The number of patients with chronic hepatitis C requiring interferon retreatment is increasing rapidly. We herein report this rare case of acute onset of nephrotic syndrome during interferon-α retreatment.

Detection of anti‐interferon‐α2a antibodies in chronic liver disease

The occurrence of antibodies to interferon‐α2a (anti‐IFN‐α2a) to recombinant human IFN‐α2a was examined in chronic liver disease by a sensitive enzyme‐linked immunosorbent assay (ELISA). Naturally occurring IgG and/or IgM anti‐IFN‐α2a were found in one of 12 cases of chronic persistent hepatitis, four of 18 cases of chronic active hepatitis (CAH), two of 12 cases of liver cirrhosis, six of seven cases of primary biliary cirrhosis, nine of 11 cases of auto‐immune CAH and none of 21 normal control subjects. Fifteen patients with viral CAH were treated with recombinant IFN‐α2a. Two of them were positive prior to receipt of IFN‐α2a and their titres increased after the therapy. Two patients became positive for anti‐IFN‐α2a after the therapy. Absorption experiments revealed that anti‐IFN‐α2a cross‐reacted with native human leucocyte IFN‐α and recombinant IFN‐α2b but not with recombinant IFN‐β and ‐γ. The immunoblotting experiment confirmed the binding of antibodies to IFN. The results of anti‐IFN‐α2a obtained by antiviral, cytopathic effect assay were in good agreement with those of IgG anti‐IFN‐α2a, but not with those of IgM antibodies obtained by the ELISA. The ELISA described in the present study is a simple, sensitive and quantitative assay for anti‐IFN‐α2a. It should be useful in assessing sub‐specificities of anti‐IFN and provide valuable information to predict the effect of IFN therapy and to elucidate the immunological abnormality in liver disease.

The B subunit of cholera toxin enhances DNA synthesis in rat hepatocytes induced by insulin and epidermal growth factor

The B subunit of cholera toxin, which binds to ganglioside GM1, enhanced DNA synthesis in rat hepatocytes in primary culture induced by insulin and/or epidermal growth factor. The effect was dose-dependent, and whole cholera toxin, activating adenylate cyclase, showed a higher effect than the B subunit alone. The B subunit acted additively with other agents that also increase cyclic AMP levels. A competitive antagonist of cyclic AMP could not suppress the effect of the B subunit completely. These data suggest that the effect is independent of the cyclic AMP signal pathway, and that GM1 plays a role in hepatocyte proliferation.

An autopsy case of autoimmune pancreatitis after a 6-year history of steroid therapy accompanied by malignant dissemination of unknown origin.

Little is known about the long-term outcome of autoimmune pancreatitis (AIP), and whether AIP possesses malignant potential. We report herein a 68-year-old Japanese AIP patient who rapidly developed systemic malignant dissemination of unknown origin, resulting in death. The patient was diagnosed histopathologically as having AIP in 1999. After a 6-year history of 5 mg/day of prednisolone therapy, a sudden onset of abdominal pain and convulsive seizure occurred, and the patient died on the tenth hospital day owing to diffuse peritoneal disseminations and metastases in the bilateral lungs and brain. Autopsy disclosed that the primary site was renal cell carcinoma, detectable only by autopsy, originating in the left kidney. On microscopy, metastatic cells obtained from the brain, lung, and peritoneum were composed of pleomorphic malignant cells identical to those from the renal cell carcinoma. Unexpectedly, abundant IgG4-positive plasma cell infiltration, suggesting high activity of AIP in pancreatic parenchyma and around dilated bile ducts, was still observed.

Fulminant hepatic failure accompanied by fatal rhabdomyolysis following exertional heatstroke

We present a previously healthy 38-year-old Japanese man who developed exertional heatstroke (EHS) following a long-distance run and presented with fulminant hepatic failure (FHF) accompanied by a life-threatening flare-up of rhabdomyolysis. Intensive life-supporting medical procedures, including plasma exchange, hemodiafiltration, steroid pulse therapy, and anticoagulant treatment enabled the patient to survive FHF. Initially, his general condition was thought to be improving; however, smoldering rhabdomyolysis suddenly flared up with a marked increase in creatine kinase levels when the dose of steroids was reduced, subsequent to which his condition deteriorated rapidly, eventually resulting in death. The serum levels of interleukin-6 measured retrospectively were found to be markedly elevated and to have fluctuated synchronously with the disease activity. This case report demonstrates that EHS can cause FHF and severe rhabdomyolysis, the outcome of which was tragic even though FHF was substantially well managed; however, the clinical evidence suggests the possible therapeutic efficacy of steroid therapy for refractory rhabdomyolysis occurring in EHS.

IgG1 anti‐P2 as a marker of response to interferon in patients with chronic hepatitis C

To study the relations of antibody production to long‐term outcomes after interferon (IFN) treatment in patients with chronic hepatitis C (CH‐C), we used ELISA to measure the levels of antibodies against HCV core protein and peptides. Samples from 21 complete responders and 36 non‐responders were collected before IFN therapy, soon after the end of IFN therapy and 6 months later. Using a set of 19 synthesized HCV core peptide antigens, we found that anti‐P2 (11–25a.a.) was the most prevalent of all IgG antibodies (93%: 39/42). Among complete responders, IgG1 anti‐P2 levels had fallen by the end of IFN therapy (from 79·8 ± 60·4–46·1 ± 44·2: P < 0·01), and were lower still 6 months after the end of IFN therapy (31·0 ± 35·2: P < 0·001); this change was the greatest of all antibodies studied. Among the non‐responders, there was no change within the follow‐up period. Soon after the end of IFN therapy, IgG1 anti‐P2 levels were more than 30% lower than the initial value in more than two‐thirds of the complete responders, but in only one‐third of the non‐responders (14/20 vs. 8/25: P < 0·05). Six months after the end of IFN therapy, IgG1 anti‐P2 levels were more than 30% lower than the initial value in more than 85% of the complete responders, but in only 12% of the non‐responders (17/20 vs. 3/25: P < 0·001). In conclusion, the changes in levels of IgG1 anti‐P2 paralleled the activity of chronic hepatitis C after IFN therapy, and IgG1 anti‐P2 levels may be markers of the efficacy of IFN therapy.

Esophageal smooth muscle tumor in a 25-year-old woman with congenital malformations

We recently treated a 25-year-old woman with an esophageal smooth muscle tumor with congenital malformations. Although the large size of the tumor and the presence of hemonecrotic lesion suggested the tumor to be leiomyosarcoma, histological studies revealed it to be leiomyoma. According to previous reports in the English-language literature, the coincidence of esophageal smooth muscle tumor with congenital malformations is relatively rare, and the coincidence of such a tumor with malformations of the type seen in this patient has never been reported. The congenital malformations in our patient were ocular hypertelorism, platyrrhiny, bilateral divergent strabismus, clubbed fingers and toes, fingerprint abnormality, and mild mental retardation. These congenital malformations cannot be explained by any reported syndromes.

Splenic Marginal Zone Lymphoma with Acquired von Willebrand Syndrome Diagnosed via Splenic Bleeding

An 85-year-old woman underwent emergent splenectomy due to left abdominal pain and active bleeding in a massively enlarged spleen. The histological diagnosis was splenic marginal zone lymphoma (SMZL). A prolonged activated partial thromboplastin time (APTT) was noted, and additional tests led to the diagnosis of type 2A-like acquired von Willebrand syndrome (AVWS). An APTT cross mixing test ruled out the presence of inhibitors. She received eight courses of rituximab monotherapy. The coagulation data showed no improvement, possibly because the lymphoma showed a poor response to the treatment. AVWS rarely causes bleeding in solid organs. This is the first case of SMZL with AVWS diagnosed via splenic bleeding.