Vincenzo Guadagnino

Changes in the prevalence of hepatitis C virus (HCV) genotype 4 in Calabria, Southern Italy

The aim of this study was to assess changes in the prevalence of hepatitis C virus (HCV) genotypes, focusing on genotype 4, by surveying population of chronic hepatitis C patients within an area of Southern Italy. HCV-RNA was detected in serum using two commercial hepatitis C RNA PCR assays (Amplicor Roche Diagnostic System, and AmpliSensor HCV, Nuclear Laser Medicine). PCR products were analyzed for genotyping using a reverse hybridization of the amplified product by a line probe assay (INNO LIPA, Innogenetics). In our Institution we have previously observed, in a period of 18 months (January 1997-May 1998) an initial increase of the genotype 4 which appeared in 3.3% of HCV patients versus a percentage of 1.3%, during 1996. Later data obtained from 702 HCV-RNA positive patients, collected from June 1998 until December 1999 indicated a 3.7% of genotype 4. This percentage increased until to 4.7% in the most recent period studied (January 2000-February 2001). Drug addiction, blood transfusion and sporadically acquired infections represented the most frequent risk factors. In the Calabria region, genotype 1b, the most prevalent isolate (53.3%) and genotype 2a/2c (26.2%) were associated with older age, confirming our previous study. Genotype 4 was the fifth most prevalent genotype observed, just after 3a and 1a subtypes. Spread of genotype 4 in Calabria region is mostly associated to older age when compared to genotype 3a and 1a, but is statistically associated with a younger group of patients when compared with genotype 1b. In conclusion we demonstrated a fourfold increased prevalence of HCV genotype 4 during the last 5 years.

Hepatitis C virus infection in an endemic area of Southern Italy 14 years later: Evidence for a vanishing infection

BACKGROUND In a 1996 survey, prevalence of hepatitis C virus antibodies (anti-HCV) in a southern Italian town was 12.6%. AIMS To identify changes in the epidemiology of hepatitis C virus (HCV) infection. METHODS Anti-HCV, HCV-RNA (PCR, detection limit 15 IU/mL), HCV genotype (Innolipa). Were performed in a random 1:4 systematic sample of the general population. Multiple logistic regression analysis was used to estimate factors independently associated with the likelihood of anti-HCV positivity. RESULTS Of 1012 subjects, 58 (5.7%) were anti-HCV-positive, compared to 12.6% 14 years earlier. Prevalence was 0.4% in individuals <30 years old and 31.8% in those ≥ 70 years old. Among 139 HCV-negative in 1996 re-sampled in 2010, only one had seroconverted (incidence: 0.05 × 100 persons/year). Alanine transaminase levels were elevated in 8 (13.8%). HCV-RNA was detected by PCR in 46.5% anti-HCV-positive subjects. In 2010 59% were genotype 2-infected, in 1996 50.7% genotype 1-infected. Previous use of non-disposable glass syringes was a strong independent predictor (OR 3.2; CI 95%=1.4-7.3). CONCLUSION Epidemiology of HCV infection in an endemic area of south Italy has changed over 14 years, now largely confined to the oldest age group; this seems to be due to the disappearance of its past main mode of transmission, namely the use of glass syringes.

Hepatitis C virus infection in family setting

To evaluate risk factors associated with intrafamiliar transmission of hepatitis C virus (HCV), 113 hepatitis C virus index subjects with chronic HCV infection and their 267 family contacts were studied from January 1994 to October 1995. Overall, 16 family contacts (6%) were positive for anti-HCV by ELISA II generation. The prevalence was 11.3% in spouses and 2.9% in other relatives (odds ratios: 4.2; 95% CI: 1.4–12.6). Spouses who had been married to the index cases longer than 20 years had a 7.5–fold risk (95% CI: 1.0–336.3) of HCV seropositivity as compared to those married less than 20 years. In univariate analysis HCV seropositivity was associated with surgical intervention, use of glass syringes and hospitalization. The results of multivariate logistic analysis showed that any parenteral exposure (odds ratios: 3.8; 95% CI: 1.2–12.8) and sexual contact with an anti-HCV index case (odds ratios: 3.0; 95% CI: 1.0–9.4) were both independent predictors of HCV seropositivity among household contacts of HCV positive index cases. These findings indicate that sexual contact and any parenteral exposure both play an independent role in the spread of HCV infection in the family setting.

Molecular characterisation of HCV genotype 4 isolates circulating in Italy.

The characteristics of genotype 4 subtype variability of HCV isolates circulating in Italy were studied. The viral isolates were identified from 736 HCV‐RNA positive sera originated from seroepidemiological studies undertaken in 4 different regions of North, South Italy and Sardinia. 24 out of 28 genotype 4 isolates (86%) were classified by phylogenetic analysis of E1 genome region (915–1128) as belonging to subtype 4d (Neighbour Joining Method). Three isolates classified as subtype 4a were detected in haemophilic patients, possibly related to infections from blood products. One isolate classified as a new subtype derived from an Eritrean patient subjected to haemodialysis. Very high genome homogeneity (mean 4.3%) was shown by genetic comparisons (DNA dist programs Phylip Package) for all the 4d isolates relative to the studies performed in Veneto, Calabria and Sardinia and originated from subjects from the general population and outpatients (19 subtype 4d isolates out of 24). In the 3 studies different prevalence rates of HCV genotype 4 (3.1%, 1.3%, 14% respectively) were found. In contrast a considerable degree of heterogeneity, both intragroup and with the other groups (mean 8.2% and 8.7%, respectively) was observed among subtype 4d isolates identified in the patients of a haemodialysis centre in Apulia region. In conclusion the subtype 4d of genotype 4 was highly prevalent and endemic in Italy. An elevated level of viral heterogeneity was observed in one study carried out in a region of Southern Italy. This can be related to a longer period of past endemicity of this genotype and to a high level of exposure to reinfections in particular categories of patients such as haemodialysis patients. J. Med. Virol. 62:84–90, 2000.

The impact of a vaccination campaign against hepatitis B on the further decrease of hepatitis B virus infection in a southern Italian town over 14 years

BACKGROUND Hepatitis B virus infection has decreased in Italy. The aims of this study were to identify changes, if any, in the epidemiological pattern of HBV infection in a southern Italian town first surveyed in 1996 and to assess the effectiveness of vaccination campaign against hepatitis B. METHODS In 2010, subjects were selected from the census by a systematic 1:4 random sampling procedure. Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (anti-HBc) were detected by ELISA. Associations (odds ratios) linking exposure to hepatitis B virus infection to potential risk factors were estimated by univariate and multivariate analyses. RESULTS Of the 1100 eligible subjects, 1020 (92.0%) agreed to participate. The prevalences of HBsAg (0.6%) and anti-HBc (15.2%) were significantly lower than in 1996 (0.8% and 21.5%) (p<0.01). No subject below 30 years of age (those that had been targeted for compulsory immunization) had been exposed to HBV infection. At multiple logistic regression analysis, age>45 years (OR=9.8; 95% CI=5.1-18.7) and past use of glass syringes (OR=1.9; 95% CI=1.2-3.1) independently predicted the likelihood of anti-HBc positivity. CONCLUSIONS These results, albeit obtained in a small town and thus not generalizable, confirm the continuous decreasing trend of HBV infection and demonstrate the effectiveness of the Italian hepatitis B vaccination program.

Cutaneous Ulceration Induced by Interferon Alfa

1.32 × 103/mm3, platelets 124 × 103/mm3, serum creatinine 0.6 mg/dL, and albumin 4.5 g/dL. Creatinine clearance was 79 mL/min. Treatment with methotrexate had been initiated 2 years earlier (4 mg/wk, total cumulative dose 416 mg). Concomitant medications included prednisolone 1 mg/d and sulindac 200 mg/d, which had been given for 9 years. Methotrexate was discontinued, and folic acid 5 mg/d was started. Upon hospital admission 2 months after the regular checkup, the patient was anemic, with normal temperature. Laboratory findings were hemoglobin 7.7 g/dL, hematocrit 20.9%, leukocytes 2.0 × 103/mm3, neutrophils 0.89 × 103/mm3, and platelets 23 × 103/mm3. Bone marrow biopsy (Figure 1) revealed severe hypoplasia without the presence of malignant cells, and a chromosome test with bone marrow cells revealed abnormalities (46XX, t [10;18] [q11;q21]). From these findings, the patient was diagnosed as having MDS. She received red blood cell and platelet transfusions, empiric antibiotic therapy, prednisolone 60 mg/d, granulocyte colony-stimulating factor (75 μg/w), danazol 200 mg/d, and folic acid supplementation 5 mg/d. Two months after admission, the patient was discharged. Laboratory results at that time were: hemoglobin 9.0 g/dL, hematocrit 26.9%, leukocytes 4.0 × 103/mm3, and platelets 25 × 103/mm3. One year later, the laboratory findings were almost normal: hemoglobin 12.04 g/dL, hematocrit 39.8%, leukocytes 5.0 × 103/mm3, and platelets 127 × 103/mm3. During that time, the dosage of prednisolone had been tapered from 60 to 10 mg/d. Discussion. The Naranjo probability scale indicated a possible relationship between methotrexate therapy and pancytopenia in our patient.2 The role of the other drugs in the development of this complication could be ruled out since they were continued during the pancytopenic period and are still given without further adverse reactions. Methotrexate therapy is widely used as a potent disease-modifying treatment in patients with RA. Various rheumatic diseases have been reported to be associated with MDS.3 However, as of November 15, 2003, there have been no reports showing an association of low-dose oral methotrexate therapy and RA with the development of MDS. MDS constitutes a heterogeneous group of refractory anemias resulting from a clonal stem-cell disorder often associated with chromosomal abnormalities (deletions, inversions, translocations, trisomies, monosomies).4 Methotrexate mainly inhibits dihydrofolate reductase, has antiproliferative effects, and has only minor transforming ability even if given at high doses. Therefore, to understand the exact mechanism by which methotrexate induces chromosomal abnormalities resulting in the development of MDS, more cases similar to ours must be studied chromogenetically and accumulated. Additional studies are needed to see which actually came first in these cases: the chromosomal abnormalities or the methotrexate. Clinicians should be aware of such a risk for the development of MDS with this low-dose methotrexate therapy.

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.

Serum transaminase elevations during pegylated interferon treatment of chronic HCV hepatitis probably induced by polyethylene glycol.

Objective: We report elevated serum alanine aminotransferase (ALT) levels during pegylated interferon (PEG-IFN)-α-2a in a patient with chronic HCV without other clinical manifestations. Case Summary: A 38-year-old man presented for HCV infection evaluation. Serum aspartate aminotransferase (AST) and ALT levels were 43 and 116 U/l, respectively; RT-PCR blood analysis revealed HCV-RNA infection. PEG-IFN-α-2b plus ribavirin treatment induced both a rapid virologic response and a normalization of transaminase plasma levels. During follow-up, an increase in transaminase and HCV-RNA values prompted us to start a new antiviral treatment with PEG-IFN-α-2a plus ribavirin. Four months later, after the follow-up, a new blood test documented both a HCV-RNA titer <50 U/ml and an increase in ALT and AST plasma levels. Immunostaining of the liver biopsy showed an accumulation of PEG-IFN-α-2a. PEG-IFN-α-2a elimination and the addition of recombinant IFN-α-2a induced normalization of the plasma transaminase levels in about 2 months. Conclusion: We postulate PEG-IFN-α-2a treatment because both the molecular weight and the distribution volume of the PEG-IFN may accumulate in the liver resulting in an increase of plasma transaminase levels. In contrast, during PEG-IFN-α-2b treatment, we did not document any increase in plasma transaminase values probably because of the lower molecular weight of the PEG.

Bilateral skin ulceration after injection of pegylated interferon-α-2b in a patient with chronic hepatitis C

1 Chair of Infective Diseases, Department of Experimental and Clinical Medicine, University‘Magna Graecia’ of Catanzaro, Regional Pharmacovigilance Center, ‘Mater Domini’ UniversityHospital, Catanzaro, Italy2 Chair of Pharmacology, Department of Experimental and Clinical Medicine, University‘Magna Graecia’ of Catanzaro, Regional Pharmacovigilance Center, ‘Mater Domini’ UniversityHospital, Catanzaro, Italy

Natural history and clinical response: "it's the virus, stupid, or is it the host?".

SummaryA major goal of modern medicine is the application of personalized therapies, consisting of decisions and practices tailored to the individual patient. Information about genetic variants, either mutant or polymorphic, represents the basis for the development of this clinical approach. Recently, several independent genome-wide association studies (GWAS) have identified two single nucleotide polymorphisms (SNPs) on the IL28B locus associated with HCV containment, spontaneous clearance, treatment response, and disease progression. In this minireview we will concisely discuss some critical genetic concepts that may have possible implications for clinical decisions in the treatment of HCV infection.