Roberto Bertoni

Different clinical behaviors of acute hepatitis C virus infection are associated with different vigor of the anti-viral cell-mediated immune response.

The anti-viral T cell response is believed to play a central role in the pathogenesis of hepatitis C virus infection. Since chronic evolution occurs in > 50% of HCV infections, the sequential analysis of the T cell response from the early clinical stages of disease may contribute to define the features of the T cell response associated with recovery or chronic viral persistence. For this purpose, 21 subjects with acute hepatitis C virus infection were sequentially followed for an average time of 44 wk. Twelve patients normalized transaminase values that remained normal throughout the follow-up period; all but two cleared hepatitis C virus-RNA from serum. The remaining nine patients showed persistent viremia and elevated transaminases. Analysis of the peripheral blood T cell proliferative response to core, E1, E2, NS3, NS4, and NS5 recombinant antigens and synthetic peptides showed that responses to all hepatitis C virus antigens, except E1, were significantly more vigorous and more frequently detectable in patients who normalized transaminase levels than in those who did not. By sequential evaluation of the T cell response, a difference between the two groups of patients was already detectable at the very early stages of acute infection and then maintained throughout the follow-up period. The results suggest that the vigor of the T cell response during the early stages of infection may be a critical determinant of disease resolution and control of infection.

Human histocompatibility leukocyte antigen-binding supermotifs predict broadly cross-reactive cytotoxic T lymphocyte responses in patients with acute hepatitis.

The present study was designed to determine if highly conserved hepatitis B virus (HBV)-derived peptides that bind multiple HLA class I alleles with high affinity are recognized as cytotoxic T lymphocyte (CTL) epitopes in acutely infected patients. Peripheral blood mononuclear cells from 67 patients with acute hepatitis B, and 12 patients convalescent from acute hepatitis B, were stimulated with three panels of peptides, each of which bind with high affinity to several class I alleles from the HLA-A2-, HLA-A3-, or HLA-B7-supertypes. In these patients, 8 of the 19 peptides tested were found to represent CTL epitopes recognized by two or more alleles in each supertype. Two sets of nested peptides were recognized in the context of alleles with completely unrelated peptide binding specificities. Finally, promiscuous recognition by the same CTL of a given peptide presented by target cells expressing different A2 subtypes was also commonly observed. In conclusion, several HBV-specific CTL epitopes, recognized by acutely infected or convalescent patients in the context of a wide range of HLA alleles have been identified. These results demonstrate the functional relevance of the supertype grouping of HLA class I molecules in a human viral disease setting. Furthermore, they represent a significant advance in the development of a totally synthetic vaccine to terminate chronic HBV infection and support the feasibility of a systematic approach to development of similar vaccines for prevention and treatment of other chronic viral infections.

Immunopathogenesis of hepatitis C virus infection

ESOLUTION of acute hepatitis C is generally associR ated with detection of neutralizing antibodies, a high frequency of circulating HCV-specific T cells with a predominant production of Thl cytokines. In contrast, T cell responses in the peripheral blood are usually undetectable in the acute phase of disease and are oriented towards a predominant production of Th2 cytokines when infection becomes chronic. Therefore, different strengths and quality of T cell responses at the early stages of infection may influence the evolution of hepatitis C but the primary causes of these different behaviors are still undefined. A good proportion of patients with long-lasting chronic HCV infection display detectable levels of peripheral blood cytotoxic T lymphocyte (CTL) responses and produce neutralizing anti-envelope antibodies. Moreover, the frequency of intrahepatic HCVspecific CTL seems to be high in these patients, the CTL response is multispecific and the liver environment is characterized by a predominant production of Thl cytokines. Therefore, at this stage of infection the virus appears to have acquired the capacity to escape immune surveillance and to persist in the face of an active antiviral immune response. If these observations derived from in vitro studies actually reflect the strength and the quality of the immune responses in vivo, inhibition of viral replication rather than modulation of the immune response should represent the main objective of anti-HCV therapies once a chronic

Antiviral CD8-mediated responses in chronic HCV carriers with HBV superinfection

Hepatitis B virus (HBV) superinfection in chronic hepatitis C represents a natural model to investigate whether or not hepatitis C virus (HCV) can influence priming and maturation of antiviral T cells; whether or not HBV superinfection, which is known to determine control of HCV replication, can restore HCV‐specific T cell responsiveness; and whether or not cytokines stimulated by HBV infection can contribute to HCV control. To address these issues, the function of CD8 cells specific for HBV and HCV was studied longitudinally in two chronic HCV patients superinfected with HBV. Patients with acute hepatitis B were also examined. Frequency and function of HBV tetramer+ CD8 cells were comparable in patients acutely infected with HBV with or without chronic HCV infection. HBV‐specific CD8 cell function was efficiently expressed irrespective of serum HCV‐RNA levels. Moreover, fluctuations of HCV viremia at the time of HBV superinfection were not associated with evident changes of CD8 responsiveness to HCV. Finally, no correlation was found between serum levels of interferon α, interleukin (IL)‐12, IL‐10, or IL‐18 and control of HCV replication. In conclusion, HCV did not affect the induction of primary and memory HBV‐specific CD8 responses. HCV‐specific CD8 responses were undetectable when HCV‐RNA was negative, showing that inhibition of HCV replication in the setting of a HBV superinfection was not sufficient to induce a restoration of CD8 reactivity against HCV. (H EPATOLOGY 2004;40:289–299.)

Is Steroid Therapy Needed in the Treatment of Destructive Thyrotoxicosis Induced by α-Interferon in Chronic Hepatitis C?

Objective: Treatment with interferon (IFN) of patients affected by chronic hepatitis C (CH-C) may produce alterations in thyroid function, such as hypothyroidism, Graves’-like hyperthyroidism and destructive thyrotoxicosis (DT). IFN-induced DT is characterized by suppressed serum TSH levels, normal or elevated FT4 and FT3 concentrations, with the presence or absence of thyroid peroxidase antibodies and antithyroglobulin antibodies, the absence of thyroid receptor antibodies and radioactive iodine uptake suppressed or <5%. Design: IFN-induced DT is a mild clinical disease, because thyroid-destructive processes last for a short time and involve a small portion of the gland. At present, the therapeutic approach in DT suggests IFN withdrawal and 1–2 months of methylprednisolone treatment. Methods: In consideration of possible untoward side effects of steroid treatment in patients with CH-C, we studied two groups of patients with CH-C who developed DT after treatments with various preparations of recombinant IFN (with or without ribavirin). Patients sequentially entered the study during a 4-year period, at the time of DT diagnosis, when IFN therapy was discontinued. The first 12 subjects (group A) were treated with 8–16 mg/day methylprednisolone for 30–40 days after IFN withdrawal; in the following 15 patients (group B), IFN withdrawal was not followed by any additional treatment. All patients underwent clinical and laboratory controls of thyroid function at 1, 2, 3 and 6 months after DT diagnosis. Results: The results showed restoration of euthyroidism in both group A and group B patients at 6 months after DT diagnosis, regardless of steroid treatment. Conclusions: The simple withdrawal of IFN therapy in patients with CH-C, who had developed DT, appears to be effective in the treatment of the thyroid disease. This therapeutic approach should be preferred in order to avoid possible undesired side effects of steroid therapy in patients with CH-C.

Cell-mediated Immune Response in Hepatitis C Virus (HCV) Infection: Are Different Strategies Adopted by HCV and Hepatitis B Virus to Persist?

Immune-mediated mechanisms play an important role in the pathogenesis of liver cell injury and viral persistence in both HCV and hepatitis B virus (HBV) infections. However, the different vigor of HLA class I and class II restricted, anti-viral T cell responses in chronic hepatitis C and B and the different cytokine profiles within HCV and HBV infected livers suggest that these hepatotropic viruses have evolved different strategies to persist within their hosts and that different pathogenetic mechanisms are operative during HCV and HBV infections.