L. La Civita

Hepatitis C virus and mixed cryoglobulinaemia

I

Hepatitis C virus infection in mixed cryoglobulinemia and B-cell non-Hodgkin’s lymphoma: evidence for a pathogenetic role

SummaryWe investigated the pathogenetic relevance of hepatitis C virus (HCV) infection in mixed cryoglobulinemia (MC) with or without complicating B-cell Non-Hodgkin’s lymphoma (NHL) in comparison with other immunological and lymphoproliferative disorders. The following groups of patients were studied: A) 25 patients with MC in 7 cases evolved into B-cell NHL; B) 25 healthy subjects; C) 22 patients with different systemic immune diseases; D) 24 patients with chronic HCV infection without MC; E) 25 patients with B-cell idiopathic NHL. Methods used included: i) Polymerase chain reaction (PCR) for HCV RNA detection in serum and peripheral blood mononuclear cells (PBMC) (uncultured or mitogen-stimulated); ii) Branched DNA (b-DNA) for HCV RNA quantification; iii) HCV genotyping by genotype-specific primers localized in the core region and by hybridization of amplification products of the 5′ untranslated region (5′UTR), obtained with universal primers, using genotype-specific probes. Serum anti-HCV and HCV RNA were detected in 88% and 73% of MC patients, respectively, and in a significantly lower percentage of healthy controls and patients with autoimmune diseases. HCV RNA concentration was significantly lower in supernatants than in corresponding whole sera (p<0.001). Plus-strand HCV RNA was detected in 81% of peripheral blood mononuclear cell (PBMC) samples and minus-strand in the majority of fresh or mitogen stimulated cells. All MC patients with NHL had HCV RNA sequences in PBMC. HCV genotype 2a/III was detected in MC patients with a prevalence that was significantly higher than in HCV infected patients without MC. Surprisingly, HCV markers (anti-HCV and/or HCV RNA) were found in 32% of patients with idiopathic NHL. These data suggest that HCV infection is involved in the pathogenesis of MC through both direct participation in the immune complex related vasculitis and by triggering the lymphoproliferative disorder underlying the disease. This latter disorder seems to be related to HCV lymphotropism which could also be responsible for the evolution of MC to malignant lymphoma. This study also suggests that HCV infection may be involved in the pathogenesis of idiopathic B-cell NHL through a similar pathogenetic mechanism.

Hepatitis C virus-related autoimmunity in patients with porphyria cutanea tarda.

Abstract. Hepatitis C virus (HCV) infection is frequently found in autoimmune hepatitis and mixed cryoglobulinaemia. In these conditions HCV could be responsible for immuno‐mediated organ alterations. The aim of this study was to evaluate the presence of immunological alterations in PCT patients, in which HCV infection has been frequently found. Twenty‐three PCT patients were evaluated for clinical and serological alterations, including: chronic hepatitis, other systemic symptoms, serum cryoglobulins and rheumatoid factor (RF), haemolytic complement, serum immunoglobulins, anti‐nuclear (ANA), anti‐smooth muscle (ASMA), anti‐liver‐kidney‐microso‐mal (anti‐LKMl), anti‐soluble‐liver‐antigen (SLA), anti‐mitochondrial (AMA), anti‐GOR antibodies, anti‐HCV and HCV RNA. Abnormal serum ALT were present in the majority of cases (20/23, 87%), while liver biopsy revealed a chronic persistent hepatitis or chronic active hepatitis in 15/20 (75%) PCT patients. In a high percentage of subjects (91%) the presence of anti‐HCV was detected by ELISA and RIBA II (Chiron, Emeryville CA, USA). In 17/22 (77%) cases the ongoing HCV replication in the serum was demonstrated by the detection of HCV genomes (polymerase chain reaction). The prevalence of both anti‐HCV and HCV RNA in PCT was significantly higher if compared to 22 systemic immunological diseases (P< 0.00l) and 47 healthy subjects (P<0.001). A possible HCV‐induced autoimmunity in PCT was suggested by the presence of the following immunological parameter alterations: anti‐GOR in 13/23 (57%), ANA in 4/23 (17%), ASMA in 18/23 (78%), anti‐LKMI in 1/23 (4%), RFin 23/23 (100%), mixed cryoglobulins in 4/23 (170/0), complement consumption in 10/23 (43%). The high prevalence of HCV infection and various immunological abnormalities suggest that HCV in combination with other factors (genetic, alcohol, etc.) could play a relevant role in the pathogenesis of hepatic and metabolic alterations of PCT.

Viruses and cancers: possible role of hepatitis C virus

Oncogenesis is a multifactorial process in which environmental, genetic and infectious factors are variably involved. A possible role of specific viruses has been suggested in at least 15% of human cancers. Hepatitis C virus (HCV), which is both hepato‐ and lymphotropic, is responsible for various liver disorders, i.e. chronic hepatitis, cirrhosis and hepatocellular carcinoma, as well as for a constellation of extrahepatic immune‐mediated manifestations, among which is mixed cryoglobulinaemia. This is a systemic disorder secondary to a chronic, benign B‐lymphocyte proliferation, which in some subjects may evolve to a malignant non‐Hodgkins lymphoma (NHL). Interestingly, recent studies reported the appearance of malignant B‐cell neoplasias in patients with type C chronic hepatitis; moreover, in a significant number (from 22% to 50%) of ‘idiopathic’ NHLs, the presence of HCV infection has been demonstrated. The presence of a geographical etherogeneity in the prevalence of HCV‐positive NHL suggests that other co‐factors, i.e. genetic and environmental, could be involved in the lymphomagenesis. HCV may exert its oncogenic potential in two different directions, leading to liver cancer or B‐cell lymphoma.

Mixed cryoglobulinaemia: a cross-road between autoimmune and lymphoproliferative disorders

Mixed cryoglobulinaemia (MC) is a systemic vasculitis, secondary to the deposition in small and medium-sized blood vessels of circulating immune complexes, mainly the cryoglobulins, and complement. MC is characterised by a typical clinical triad (purpura, weakness, arthralgias) and by one or more organ involvement: chronic hepatitis, glomerulonephritis, peripheral neuropathy, skin ulcers and diffuse vasculitis. In a limited number of MC patients, a malignancy, that is B-cell non-Hodgkins lymphoma or hepatocellular carcinoma, may also develop. Hepatitis C virus (HCV) infection has been found in the majority of patients with MC; the frequency of HCV markers (91%) was significantly higher than other rheumatic diseases (6.4%), namely systemic lupus, Sjùgrens syndrome, rheumatoid arthritis and systemic sclerosis, or healthy controls (1.2%). The HCV infection of lymphoid tissues may represent the remote event leading to B-lymphocyte proliferation responsible for autoantibodies and immune-complex production. In a similar way, HCV infection may also be involved in the pathogenesis of other autoimmune (glomerulonephritis, thyroiditis, lung fibrosis, autoimmune hepatitis, porphyria cutanea tarda) and lymphoproliferative disorders (monoclonal gammopathies, B-cell lymphomas). MC shares numerous clinico-serological and pathological features with the above disorders. HCV seems to be their common etiological agent; however, a variable combination of unknown co-factors (infectious, genetic, environmental) should be determinant for the appearance of different clinical patterns.

Microvascular involvement in systemic sclerosis: laser Doppler evaluation of reactivity to acetylcholine and sodium nitroprusside by iontophoresis

OBJECTIVES To investigate the skin vasodilatory response to iontophoretically applied acetylcholine (Ach), an endothelium dependent vasodilator, and to sodium nitroprusside (SNP), an endothelium independent vasodilator, in patients with systemic sclerosis (SSc). METHODS Eleven SSc patients were preliminarily studied (10 females, mean age 40.5; mean disease duration 6.5 years), and 16 age and sex matched control subjects. By means of laser Doppler flowmetry skin blood flow was evaluated at third finger, at baseline, and after post-ischaemic hyperaemia test and during iontophoretically transcutaneous application of 1% solution of Ach and SNP. RESULTS No significant differences in basal skin blood flow were detected between SSc patients and controls. Cutaneous vasodilatory response to ischaemia, Ach, and SNP was significantly less pronounced in SSc patients compared with controls (p<0.001). Moreover, among SSc patients a lower (p< 0.05) vasodilatory response to Ach compared with ischaemia and SNP was recorded. CONCLUSIONS These data confirm a reduction of skin digital vasodilatory reserve in SSc patients and suggest a defect of both endothelial dependent arteriolar relaxation and wall compliance in the pathogenesis of this dysfunction.

Hepatitis C virus chronic infection as a common cause of mixed cryoglobulinaemia and autoimmune liver disease

Abstract. Objectives. Mixed cryoglobulinaemia (MC) and autoimmune chronic hepatitis (AI‐CH) are frequently associated with hepatitis C virus (HCV) chronic infection. Because HCV represents a possible common aetiological factor, the aim of the present study is to investigate the clinico‐serological alterations of both MC and AI‐CH and to verify a possible overlap between these disorders.

Effect of alpha-interferon on hepatitis C virus chronic infection in mixed cryoglobulinemia patients

SummarySince a striking association between hepatitis C virus (HCV) infection and mixed cryoglobulinemia has been demonstrated, the aim of this study is to investigate the effect of alpha-interferon (α-IFN) on HCV viraemia and clinico-serological manifestations of 15 patients (ten female and five male, mean [±SD] age 53±7 years). In 14/15 patients pre-study steroid dosage remained unchanged during treatment. α-IFN was administered at a dose of 2×106 IU daily for a month, then every other day for five months. On the whole, a statistically significant improvement of purpura (p<0.001), serum transaminases (p<0.001), and cryocrit (p<0.01) was observed after α-IFN treatment. HCV viraemia was detected by polymerase chain reaction technique in 13/15 patients with mixed cryoglobulinemia and anti-GOR antibodies, expression of HCV-related autoimmunity, were present in 8/15. After α-IFN treatment, HCV RNA levels showed a clear-cut reduction in five persons and disappeared in another, while anti-HCV antibodies (Chiron ELISA and RIBA II) did not change after the six-month period of therapy. These data further support the possible etiopathogenetic role of HCV in patients with mixed cryoglobulinemia and suggest that α-IFN may be regarded as the elective treatment in this disease.ZusammenfassungZwischen der Hepatitis C Virus-Infektion (HCV) und gemischter Kryoglobulinämie wurden bemerkenswerte Beziehungen festgestellt. Bei 15 Patienten mit gemischter Kryoglobulinämie wurde daher die Wirkung von alpha- Interferon (α-IFN) auf die HCV-Virämie und die klinischen und serologischen Parameter der Kryoglobulinämie geprüft (zehn Frauen, fünf Männer, mittleres Alter (±SD) 53±7 Jahre). α-IFN wurde während eines Monats täglich in einer Dosis von 2×106 IU und dann fünf Monate lang jeden zweiten Tag verabreicht. Die Kortikosteroiddosen blieben dabei in 14/15 Fällen unverändert. Nach der α-IFN-Therapie war eine signifikante Besserung der Purpura (p<0,001), der Serumtransaminasen (p<0,001) und des Kryokrit (p<0,01) festzustellen. Bei 13/15 Patienten wurde mittels Polymerase-Kettenreaktion (PCR) eine HCV-Virämie nachgewiesen. Bei 8/15 fanden sich anti-GOR-Antikörper, die als Zeichen der HCV-assoziierten Autoimmunreaktion zu werten sind. Die HCV-RNA-Spiegel waren nach Behandlung mit α-IFN in fünf Fällen deutlich zurückgegangen und in einem Fall verschwunden. Zu einer änderung der anti-HCV Antikörper (Chiron ELISA und RIBA II) kam es während der sechsmonatigen Behandlung mit α-IFN jedoch nicht. Die Ergebnisse unterstützen die Annahme einer ätiopathogenetischen Beziehung zwischen HCV-Infektion und gemischter Kryoglobulinämie. Möglicherweise stellt α-IFN eine gezielte Therapie bei dieser Krankheit dar.

Slow-releasing nicardipine in the treatment of Raynaud's phenomena without underlying diseases

SummaryCalcium channel blockers have been used in the treatment of primary and secondary Raynauds phenomenon (RP), and a beneficial effect was often recorded. The efficacy of slow-releasing nicardipine was assessed in a clinically homogeneous series of RP without underlying diseases in a randomized, double blind, cross-over and placebo controlled trial. Out of twenty-one selected patients (18 women and 3 men, mean age 46±12 yrs) eighteen completed the study and three dropped out, one for inadequate compliance and two due to headache. After a threeweek period, slow-releasing nicardipine (20 mg two times daily) was significantly more useful than placebo: the number of RP episodes per week decreased (p<0.02), severity of discomfort and hand disability scores, evaluated after single RP attack, clearly improved (p<0.005 and p<0.02, respectively). According to clinical improvement, time of peak flow after postischemic reactive hyperaemia test was significantly reduced only after nicardipine (p<0.01). These results show that slow-releasing nicardipine is generally well tolerated and can provide effective improvement in RP patients without underlying diseases.

Amlodipine in the Treatment of Raynaud’s Phenomenon

SummaryTreatment with calcium antagonists has been shown to be beneficial in patients with primary and secondary Raynaud’s phenomenon. A double-blind placebo-controlled crossover trial was performed to assess the efficacy of amlodipine, a new long-acting calcium antagonist, in patients with Raynaud’s phenomenon without underlying disease. 20 of the 24 patients enrolled (20 women and 4 men, mean age 45 years) completed the trial.The number of episodes of Raynaud’s phenomenon per week and the severity of discomfort significantly improved during amlodipine (p < 0.0001 and p < 0.0004, respectively) but not placebo treatment. Perfusion-pressure index, evaluated with Doppler sonography using a postischaemia reactive hyperaemia test, significantly improved (p < 0.04) after treatment with amlodipine but not placebo.These results indicate that amlodipine is a useful treatment for primary and suspected secondary Raynaud’s phenomenon, at least in the short term.