Miyuki Nakaji

Significance of Serum Matrix Metalloproteinases and Their Inhibitors on the Antifibrogenetic Effect of Interferon-Alfa in Chronic Hepatitis C Patients

Objective and Methods: The imbalance between matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) is considered to be an important determination of deposition and breakdown of the extracellular matrix. To investigate the antifibrogenetic effect of interferon-α (IFN-α) treatment on factors regulating hepatic fibrosis, serum MMP-1, MMP-2, TIMP-1 and TIMP-2 levels were measured by the one-step sandwich enzyme immunoassay in 27 patients with chronic hepatitis C and compared with the histological status of the patients before and at the end of treatment. Results: After 6 months of IFN-α treatment, the histological status of liver fibrosis showed improvement in 9 patients (IF group) and no change or a worsening in 18 patients (NIF group). Compared with pretreatment levels, in the IF group, IFN treatment caused a significant increase in the MMP-1/TIMP-1 ratio. In the NIF group, however, the MMP-1/TIMP-1 ratio tended towards a decrease; moreover, there was not only a significant increase in TIMP-2 levels but also a tendency towards an increase in TIMP-1 levels. Conclusion: These results suggested that an elevated MMP-1/TIMP-1 ratio may ameliorate liver fibrosis by interferon in cases of chronic hepatitis C, whereas elevated levels of TIMP-1 and TIMP-2 might impede improvement.

An outbreak of fulminant hepatitis B in immunocompromised hemodialysis patients

BackgroundWe aimed to clarify the pathogenesis of an outbreak of fulminant hepatitis B in hemodialysis (HD) patients whose compromised cell-mediated immunity in turn contributed to chronic hepatitis B virus (HBV) carriage.MethodsFive consecutive adult HD patients with acute hepatitis B were evaluated. Viral genotype, mutations, and HBV-DNA levels were studied in relation to viral clearance, liver disease severity, and liver histology by immunostaining.ResultsAll five patients had hepatitis B surface antigen (HBsAg) genotype C, a G-to-A stop codon mutation at nucleotide (nt) 1896 in the precore region, an A-to-T mutation at nt 1762 and an G-to-A mutation at nt 1764 in the basal core promoter. The possible index patient, who suffered from liver cirrhosis, had HBsAg genotype C, anti-hepatitis B envelope (HBe), and these mutations. The level of HBV-DNA declined by about 10 percent per week and no difference in viral kinetics between the patients who died and the survivor was found, irrespective of therapies. The amount of liver cell apoptosis, as assessed by single-stranded DNA, was scarce. The risk of fulminant hepatic failure did not correlate with the preexistent liver histopathological changes. Acute HBV superinfection was associated with hepatitis C virus (HCV) elimination and increased mortality.ConclusionsThis outbreak of fulminant hepatitis B suggests that HD patients can foster highly virulent HBV strains (possibly owing to their compromised immune responses), which may place others at risk of severe, life-threatening acute liver damage and at increased risk of mortality if chronic carriers of HCV should be infected.

Histological grading and staging in chronic hepatitis: Its practical correlation

Although the histological features of various causes of chronic liver disease have been well described, usually the inflammatory activity of the disease is important after the cause has been established. Some patients have co‐infection or concomitant liver disease and on occasion it is difficult to decide the treatment. In order to clarify the histological differences, we investigated the inflammatory activity among autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), chronic hepatitis C (CHC) and chronic hepatitis B (CHB) in a standardized way using the modified histological activity index (HAI). According to the modified HAI, inflammatory activity is divided into four categories; categories A/D explains portal/periportal inflammation and categories B/C explains lobular activity. The inflammatory score of AIH tended to be greater in all categories from the early stage of fibrosis, whereas scores of PBC were lower, except for portal inflammation. Chronic hepatitis C patients had portal or periportal inflammation, and their inflammatory scores were linked to the development of fibrosis. Chronic hepatitis B patients tended to have severe lobular injury, but did not have a relationship between the inflammatory score and their stage. To know the distribution of inflammation using the modified HAI scoring system may be helpful and convenient in evaluating patients with chronic inflammatory liver disease.

CEA producing primary hepatic carcinoid

Imaging studies of a hepatic tumor in a 53-year-old woman with elevated serum levels of neuron-specific enolase (NSE), carcinoembryonic antigen (CEA) and 5-hydroxyindole acetic acid (5HIAA) revealed a hypervascular tumor in the right lobe. Grossly, the brownish tumor was measured 13.5x12 cm with four daughter nodules. Microscopically, the majority of these columnar and round tumor cells had ribbon-or rosette-like patterns with the expression of neuroendocrine marker proteins, such as Grimelius, NSE, chromogranin A, and synaptophysin, and moderate expression of CEA but without the expression of cytokeratin nos 7,8,14,18,19 and OV-6; the minority had glandular patterns with a strong expression of CEA but without the expression of cytokeratin nos 7,8,14,18,19 and OV-6. Ultrastructurally, most tumor cells contained populations of electron-dense core granules ranging between 100 and 200 nm in diameter. After hepatectomy, serum CEA, NSE, and 5HIAA reverted to normal ranges and persisted for 19 months. These findings suggested that the diagnosis of primary hepatic carcinoid was tenable and that the tumor might derive from hepatic stem cells which acquired the additional nature of producing CEA without cytokeratins characteristic of hepatocytes or bile duct cells. Some molecular based approaches have attributed unique biological behavior and histogenesis to this carcinoid tumor.

Histological study of PIVKA-II expression in hepatocellular carcinoma and adenomatous hyperplasia

Although serum concentration of protein induced vitamin K absence or antagonist II (PIVKA‐II) has been widely used for diagnosing hepatocellular carcinoma (HCC), little information is available concerning tissue PIVKA‐II as an immunohistochemical marker for liver histology. In this study, we examined the expression of PIVKA‐II in precancerous nodules (adenomatous hyperplasia) and various differentiation grades of HCC by immunohistochemical study using the monoclonal anti‐PIVKA‐II antibody (MU‐3). We examined the relationship between tissue PIVKA‐II staining and serum PIVKA‐II level, tumor histology and tumor size. PIVKA‐II was mainly detected in the cytoplasm of the HCC cells. The positive rates of PIVKA‐II were as follows: adenomatous hyperplasia (AH), 0% (0/9); well‐differentiated HCC, 65% (15/23); moderately differentiated HCC, 85% (22/26); poorly differentiated HCC, 54% (7/13). The expression of tissue PIVKA‐II staining in moderately differentiated HCC was significantly higher than in well‐ or poorly differentiated HCC, whereas the serum PIVKA‐II level in poorly differentiated HCC was higher than well‐ or moderately differentiated HCC. There was no relationship between the expression of PIVKA‐II in cancer tissues and serum levels of PIVKA‐II. Immunohistochemical studies revealed that PIVKA‐II was expressed even in small‐sized or well‐differentiated HCC cells, but expression was not detected in AH. It was concluded that PIVKA‐II is a useful immunohistochemical marker, even in small‐sized or well‐differentiated HCC.

Multiple hypervascular liver nodules in a heavy drinker of alcohol

Abstract  A case of hypervascular nodules in the liver, but without hepatitis B or C virus infection in a 38‐year‐old woman with a history of alcohol abuse is presented. An ultrasound disclosed 1–2‐cm hypoechoic tumors in the right and left lobes. Magnetic resonance imaging showed high‐intensity tumors at both the T1‐weighted and T2‐weighted sequences. Incremental dynamic computed tomography and hepatic angiography revealed hypervascular tumors. Ultrasound‐guided needle biopsy revealed no evidence of hepatocellular carcinoma, metastatic liver cancer, hemangioendothelioma, inflammatory pseudotumors or pseudolymphoma, but demonstrated stellate‐scar fibrosis septa, which contained small unpaired arteries without hyperplasia dividing the nodule. Moreover, marked pericellular fibrosis, neutrophilic infiltration and Mallory bodies were observed in the cytoplasm. There was no evidence of bile duct proliferation. From these findings, the diagnosis of alcohol‐induced fibrosis, distinctly different from focal nodular hyperplasia, was tenable. Further studies may provide insights into the pathogenesis of nodule formation and hypervascularity in heavy drinkers of alcohol.

Response to Interferon-α in Chronic Hepatitis B With and Without Precore Mutant Strain Detected by Mutation Site–specific Assay

Goals: We investigated whether the presence of precore mutant (stop codon mutation at codon 28) affects the response to interferon-α in patients with chronic hepatitis B. Background: Mutations of hepatitis B virus (HBV) may influence the response to treatment. The association of precore mutant with the response to interferon is controversial. Study: Thirty-one Japanese patients with hepatitis B e antigen–positive chronic hepatitis were treated with natural interferon-α. HBV DNA with the precore mutation was assayed in serum using a mutation site–specific assay before and after treatment. Results: Before treatment, precore mutant was detected in 22 cases (group A) and not detected in 9 cases (group B). Serum HBV DNA level before treatment was not different between the 2 groups. At the end of treatment, serum HBV DNA was decreased to undetectable levels in 13% (4 of 31). Six months after treatment, the percentage of cases with loss of hepatitis B e antigen and a decrease in the transaminase level to within the normal range was significantly higher in group B than in group A (67%, 18%, P = 0.015). Conclusions: Chronic hepatitis without precore mutant strain before treatment is more responsive to IFN-α.

Eosionophilic pseudotumor of the liver due to Ascaris suum infection

A case of eosinophilic pseudotumor of the liver due to Ascaris (A) suum is described in a 34-year-old-man with a high serum level of immunoglobulin E and hypereosinophilia ascribed to a history of atopic dermatitis since childhood. Multiple hepatic hypoechoic nodules detected by ultrasound were confirmed as low-density nodules on computed tomography (CT), and as low and high signal intensity lesions on T1-and T2-weighted magnetic resonance imaging (MRI), respectively. CT during arteriography (CTA) and arterial portography revealed multiple nodules with ring-shaped enhancement and perfusion defect, respectively. Biopsied liver tissue specimens did not contain tumor cells or atypical cells; instead, they showed marked infiltration of eosinophils with necrosis and Charcot-Leyden crystals in the portal tracts and hepatic sinusoides, suggesting parasitic infection, although neither larvae nor eggs were detected. The diagnosis of visceral larva migrans (VLM) due to A. suum was based on immunoserological tests. The patient was a habitual consumer of raw bovine liver, which may explain the A. suum infection. After drug therapy with albendazole, the hypoechoic nodules disappeared. Differential diagnoses and the possible transfection route of A. suum are discussed.

Development of multicentric hepatocellular carcinoma after completion of interferon therapy

6 international units (IU) of IFNα, 3 days a week for a total of 24 weeks. After the IFN therapy, the patient demonstrated a normal serum ALT level, and was continuously negative for HCV-RNA, and histology improved from chronic active hepatitis to chronic persistent hepatitis. Follow-up studies with ultrasonography (US) every 3 months and computed tomography (CT) every 6 months revealed no space-occupying lesion (SOL) for 3 years after IFN treatment.US-guided biopsies of two 15-mm hypoechoic SOLs in segments eight (S8) and seven (S7) 34 and 74 months, respectively, after IFN treatment showed well-differentiated hepatocellular carcinoma (HCC). Clinical data, imaging studies, and histologic examinations showed that both tumors were multicentric HCC. Further studies may provide insights into the possible role of HCV in hepatocarcinogenesis in patients demonstrating HCV eradication by IFN treatment.

Hepatitis B Virus DNA in Anti-HBe-Positive Asymptomatic Carriers

Objectives: We examined the level of hepatitis B virus (HBV) DNA and the mutations in the precore, core and polymerase regions of HBV in sera from anti-HBe-positive asymptomatic carriers (ASC). Methods: The amount of HBV DNA was determined semiquantitatively by mutation site-specific assay in sera from 19 anti-HBe-positive ASC and 31 HBeAg-positive patients with chronic liver disease (CLD). The mutations in the precore, core and polymerase (terminal protein) regions, spanning 1,037 nucleotides, of HBV in sera from three cases each of anti-HBe-positive ASC, HBeAg-positive ASC and HBeAg-positive CLD were examined by directly sequencing the amplified HBV DNA. Results: The level of HBV viremia in anti-HBe-positive ASC was significantly lower than that in HBeAg-positive CLD patients (p < 0.01). By sequence analysis, there were a few missense mutations detected in HBeAg-positive ASC and HBeAg-positive CLD patients. In contrast, many mutations, especially in the central or N-terminal half of the core region and N-terminal part of the polymerase region, were detected in anti-HBe-positive ASC. Conclusion: Mutations not only in the precore/core region, but also in the polymerase region of HBV might cause damage to some important functions for efficient replication of HBV and be involved in the reduced amount of HBV in anti-HBe-positive ASC.