Yoshiyuki Nakatsuji

EFFECT OF HEPATITIS G VIRUS INFECTION ON CHRONIC HEPATITIS C

Hepatitis C virus (HCV) is a major cause of acute and chronic hepatitis throughout the world [1-3]. A new virus, tentatively called hepatitis G virus (HGV), was recently cloned and sequenced [4]. This virus is closely related to HCV in genomic structure; like HCV, HGV is transmitted through transfusion and may be associated with acute and chronic hepatitis [4-6]. We analyzed the role of HGV infection in patients with chronic hepatitis C, including patients treated with interferon-. Methods Patients We enrolled 189 patients with chronic hepatitis C who were seen at Shinshu University Hospital, Matsumoto, Japan (122 men and 67 women; mean age, 51.1 11.0 years). All patients were positive for antibody to HCV according to a second-generation assay and were negative for hepatitis B virus (HBV) surface antigen and antibody to human immunodeficiency virus. No patients had hepatocellular carcinoma or a history of alcohol intake exceeding 80 g/d. Of the 189 patients, 101 (66 men and 35 women; mean age, 50.0 11.2 years) had been retrospectively selected so that our sample would include all patients who had received a single course of interferon- therapy between October 1991 and December 1993. The remaining 88 (47%) patients (56 men and 32 women; mean age, 52.5 10.7 years) were consecutively selected from patients with chronic hepatitis C who had been followed for more than 1 year and had had liver biopsy within the same period but had not received antiviral therapy. Interferon- 2a had been administered at a dosage of 9 million U daily for 2 weeks, followed by 9 million U three times a week for 22 weeks (total dose, 720 million U). Treated patients had histologic examination within the 6 months before interferon- therapy was initiated and were followed for at least 6 months after therapy was completed. For all patients, serum samples were obtained at the time of liver biopsy and were stored at 70C until testing. For patients receiving interferon- therapy, serum samples were also collected just before therapy began, just after therapy was completed, and 6 months after therapy was completed. Serum alanine aminotransferase levels (normal range, 5 to 45 IU/L) were measured at liver biopsy and, in patients receiving interferon- therapy, at least once every 4 weeks during therapy and follow-up. The grade (extent of hepatic inflammation and hepatocellular destruction) and stage (degree of fibrosis) of liver histologic findings [7] were judged by three authors; the final diagnosis was established by consensus. Investigators involved in separate portions of the study were blinded to the results of other portions. Serologic Markers of and Molecular Assays for Hepatitis C Virus RNA Levels of HCV antibody, HBV surface antigen, and antibody to human immunodeficiency virus were measured by using commercially available second-generation enzyme-linked immunosorbent assays (Abbott Laboratories, North Chicago, Illinois). Serum levels of HCV RNA were measured by using nested reverse-transcription polymerase chain reaction (PCR) with primers in the 5 noncoding region [8] and were quantified by using the branched-DNA signal amplification assay [9, 10]. The detection limit of the branched-DNA assay was set at 105.7 equivalents/mL. Hepatitis C virus genotypes were tested by nested PCR using genotype-specific primers of core region [11] and were categorized according to the classification system of Simmonds and colleagues [12]. Serum Levels of Hepatitis G Virus RNA Levels of HGV RNA in serum were measured by using reverse-transcription PCR as described elsewhere [5]. Total nucleic acids were extracted from 50 mL of serum. After reverse transcription, 45 PCR cycles (for detection) or 35 PCR cycles (for quantitation) were done with primers in the putative NS5 region of the HGV RNA genome. The PCR products were analyzed by dot-blot hybridization with a 32P-labeled oligonucleotide probe. The sensitivity of this assay system was 20 RNA copies/mL of starting serum. Quantitative measurement of HGV RNA levels was done using standards of known HGV RNA levels. Statistical Analysis Statistical analyses were done using the Student t-test, the Mann-Whitney U test, the Wilcoxon rank-sum test, the chi-square test, the Fisher exact test, and the Somers D test. A P value of 0.05 or less indicated statistical significance. Results Clinical Features and Hepatitis C Virus Markers Twenty-one (11.1%) of the 189 enrolled patients were positive for HGV RNA. The rate of detection of HGV RNA was similar in the subgroup of 88 untreated patients (12.5%; 11 of 88) and the 101 patients who received interferon- therapy (9.9%; 10 of 101). Mean age and the number of men and women were also similar in the two subgroups. Thus, the clinical features of patients who had chronic hepatitis C could be compared with those of patients who had HCV and HGV infection without respect to interferon- therapy (Table 1). Patients with HGV infection were significantly younger than those without HGV infection. Other clinical features did not differ between HGV RNA-positive and HGV RNA-negative patients (Table 1). Table 1. Clinical Features in HGV RNA-Positive and HGV RNA-Negative Patients with Chronic Hepatitis C* Hepatitis C virus genotype and serum HCV RNA level were compared between the 21 patients with HGV RNA and the 52 patients without HGV RNA who were randomly selected from the 168 HGV-negative persons. The HCV genotypes and HCV RNA levels were distributed similarly in the two groups (Table 2). Table 2. Markers of HCV and Response of HCV to Interferon- in HGV RNA-Positive and HGV RNA-Negative Patients with Chronic Hepatitis C* Effect of Hepatitis G Virus Infection on Response of Hepatitis C Virus to Interferon- Therapy Of the 101 patients receiving interferon-, 36 had a sustained loss of HCV RNA and normalization of alanine aminotransferase levels; they were therefore considered to have responded to interferon-. The remaining 65 patients were positive for HCV RNA 6 months after completing therapy and thus were classified as nonresponders. The rate of HCV response to interferon- did not differ between patients with and those without HGV infection (Table 2). Response of Hepatitis G Virus to Interferon- Response of HGV to interferon- was analyzed in 9 of 10 patients with HGV infection. The serum HGV RNA level decreased during interferon- therapy in all 9 patients. The geometric mean titer of HGV RNA just after interferon- therapy (mean, 6.3 RNA copies/mL; range, 0.0 to 5000 RNA copies/mL) was significantly (P = 0.008; Wilcoxon rank-sum test) lower than the titer just before therapy (mean, 3200 RNA copies/mL; range, 20 to 1 000 000 RNA copies/mL). Two patients had a sustained loss of HGV RNA 6 months after discontinuation of therapy. In the remaining 7 patients, HGV RNA level increased after cessation of therapy to levels similar to those just before therapy. Thus, the sustained response rate of HGV (22%; 2 of 9 patients) was lower than but not significantly different from (P > 0.2; Fisher exact test) the sustained response rate of HCV (36%; 36 of 101 patients). However, a dichotomy was seen in the response to interferon-; two patients who had a sustained loss of HGV RNA did not clear HCV RNA, and three patients who had a sustained loss of HCV RNA did not clear HGV RNA. In the latter three HCV responders, alanine aminotransferase levels remained normal despite the reappearance of HGV viremia. Discussion Approximately 10% of patients with chronic hepatitis C are also infected with HGV [5, 6]. Although the precise routes of HGV transmission have not been established, this agent is parenterally transmitted through blood transfusion and exposure to shared needles during injection drug use [4]. In our study, the frequency of previous blood transfusion was similar in patients with HGV and HCV co-infection and patients with hepatitis C alone. The apparent link between HGV and HCV infections probably reflects common exposures and transmission patterns rather than a specific interdependence of the two agents. Patients with chronic hepatitis often harbor more than one hepatitis agent [4, 13-15], and important interactions between HBV and HCV have been documented [15]. The relation between HCV and HBV replication is reciprocal: Increasing replication of one agent can diminish the replication of the other. The key question underlying our study is whether coexistent HGV infection alters the level of viremia, clinical course, or treatment response of HCV infection. Although it is unclear whether our findings are applicable to non-Japanese persons, we found no evidence of such an effect on any of these variables. The following findings support this claim. First, the HCV RNA level in patients with HGV and HCV infection was the same as in patients with HCV infection alone. In addition, Nakatsuji and colleagues [5] reported that the serum level of HGV RNA did not differ between these two groups of patients. These two studies showed no evidence of unidirectional or bidirectional viral interference between HGV and HCV. Second, no evidence suggested that HGV infection increased the severity of hepatitis C. When patients with chronic hepatitis C were compared with those who had HCV and HGV infection, no differences were seen in the mean alanine aminotransferase level or liver histologic findings. Further, in five co-infected patients in whom HGV and HCV responses to interferon- therapy were dissociated, hepatic inflammation after discontinuation of therapy seemed to depend on HCV replication, not on HGV replication. These data suggest that HGV has limited pathogenicity compared with HCV, and they are consistent with previous observations that HGV-positive blood donors were no more likely to have elevated alanine aminotransferase than were HGV-negative donors [4]. Several viral and host factors have been reported to influence the response of HCV to interferon- [8, 16-18]. We found no effect of HGV on the HCV respo

Persistence and Clinical Significance of Hepatitis G Virus Infections in Injecting Drug Users

To assess the persistence of hepatitis G virus (HGV) infection and its association with liver disease, HGV RNA was assessed in the most recent serum sample for 246 long-term injecting drug users (IDUs) and in prior specimens for those found HGV RNA-positive. HGV RNA was detected at the most recent visit in 38 (15.4%). For 31 (82%), HGV RNA was also found at all prior visits occurring a median of 6.1 years earlier. HGV-positive IDUs were younger and had fewer years of drug use, suggesting that HGV RNA had previously been cleared. Serial samples from 29 short-term IDUs were then assessed. HGV RNA was detected in 9 (31%) of 29 short-term IDUs, and 5 (56%) of the 9 HGV infections cleared. No differences were detected in serum levels of liver-related enzymes among HGV RNA-positive and -negative participants (P > .20). HGV infection is not associated with hepatic inflammation. HGV clearance occurs after many acute infections but uncommonly in persons who remain RNA-positive years after exposure.

Clinical significance of hepatitis G virus infection in patients on long-term haemodialysis

Infection with the newly discovered hepatitis G virus (HGV) was analysed in 163 patients on long‐term haemodialysis to clarify its prevalence and clinical significance. Hepatitis G virus RNA in serum was measured by polymerase chain reaction with primers corresponding to the putative non‐structural 5’ region. Of the 163 patients, three (1.8%) were positive for hepatitis B surface antigen, 40 (24.5%) were positive for hepatitis C virus (HCV)‐RNA and 16 (9.8%) were positive for HGV‐RNA. Five of the 16 patients with HGV‐RNA were also positive for HCV‐RNA. Patients with HCV and HGV coinfection had undergone a longer duration of haemodialysis (P=0.001) and had higher units of transfusion (P=0.031) compared with those without hepatitis virus infection. Transfusion history was significantly higher (P=0.039) in patients with only HGV infection than in those without hepatitis virus infection. Hepatitis C virus RNA concentration was higher (P=0.032) in patients with HCV and HGV coinfection than in those with HCV infection only, but alanine aminotransferase (ALT) levels were similar between these two groups. In conclusion, about 10% of patients on haemodialysis were infected with HGV and the infection was closely associated with transfusion history.

Autoimmune hepatitis type 1 without evidence of hepatitis G virus infection

Abstract Hepatitis G virus (HGV) RNA was measured in sera from 60 patients satisfying the international diagnostic criteria of definite autoimmune hepatitis type 1 using a reverse transcription and polymerase chain reaction with primers of the putative NS5 region of the HGV genome. Five patients had a history of blood transfusion. Of the 60 patients, 55 (92%) were confirmed as having human leukocyte antigen (HLA) DR4 or DR2 which are genetic markers for susceptibility to autoimmune hepatitis in Japanese. None of the 60 patients had any serum markers suggesting hepatitis B virus infection and 5 (8%) had evidence of on-going hepatitis C virus infection. No patients had HGV RNA in serum. The absence of active HGV infection in this cohort suggests that HGV does not play a casual role in the development of autoimmune hepatitis in Japan.

Gastric inflammatory fibroid polyp manifesting massive bleeding and marked morphological changes for a short period.

was difficult to restore the tumor into the stomach by snare wire, requiring several tries. EUS showed a homogeneous hypoechoic tumor with a distinct border in the third sonographic gastric layer. Endoscopic snare polypectomy was performed 5 days after EUS. At this time, the shape of the tumor was markedly changed compared with findings of the prior endoscopy; most of the mucosa covering the tumor had peeled off, its oval shape had become distorted, and it had reduced in size (Fig. 1d). Moreover, fresh blood was oozing from the tumor, and coffee grounds-like material adhered to its surface (Fig. 1d). The resected specimen was 4.5 2.5 cm in size. This tumor was diagnosed as an IFP according to the microscopic findings, which revealed proliferation of fibroblasts and collagen fibers with infiltration of mononuclear cells and eosinophils (Fig. 2). Since endoscopic polypectomy, no further symptoms of anemia or tarry stools have occurred in this patient. In this case, the tumor was observed prolapsing to the duodenal bulb. This tumor was quite large; possibly, the tumor was incarcerated in the duodenal bulb in association with strangulation by the pyloric ring at the time of prolapse. This process could cause necrosis and depletion of the tumor surface mucosa, which resulted in the marked morphological changes observed in our case. Although prolapse to the duodenal bulb has sometimes been reported in gastric IFP,1 prolapse was reversible in all previous cases, and no previous report has described morphological changes resembling those seen in our case.

Anti-c100 antibodies to hepatitis C virus in patients with chronic hepatitis C virus infection treated with interferon.

To assess the role of anti-c100 antibodies to hepatitis C virus (anti-c100 HCV) in the response to interferon (IFN) administered to patients for the treatment of chronic hepatitis C, we assayed serum anti-c100 HCV serially by means of an enzyme-linked immunosorbent assay (ELISA) kit and titrated anti-c100 HCV level by a radioimmunoassay (RIA) kit in 28 IFN-treated and 20 untreated patients with chronic hepatitis C. IFN-alpha or -beta was administered for 4 to 12 weeks, and the patients were observed for over 24 months. The IFN-treated patients were divided into 3 groups (4 sustained responders, 18 transient responders, and 6 non-responders) in accordance with their responses on the basis of the serum alanine aminotransferase levels. In three of the four sustained responders whose HCV-RNA decreased, anti-c100 HCV became negative at 13, 15, and 17 months after beginning the IFN therapy. The 18 transient responders and 6 non-responders remained positive for anti-c100 HCV throughout the observation period. In all four sustained responders the anti-c100 HCV titer decreased significantly with time after initiation of the therapy, whereas the titer fluctuated in the other groups. These findings suggest that monitoring the serum anti-c100 HCV level is useful in assessing the effects of IFN therapy on chronic hepatitis C.

Hepatitis G virus/GB virus C infection in an area of high endemic hepatitis C virus infection

We previously reported an area of high endemic hepatitis C virus (HCV) in which over 30% of the inhabitants were positive for HCV antibody. Folk remedies such as acupuncture and cutting of the skin using nonsterilized knives were considered to be possible routes of HCV transmission in this area. Hepatitis G virus/ GB virus C (HGV/GBV-C), a newly discovered hepatitis virus, was analyzed to determine the role and transmission of its infection in this area. A total of 100 individuals were selected randomly from 420 inhabitants who were medically screened for liver disease in 1993, and were subjected to this study. HGV/GBV-C RNA in serum was measured by reverse transcription and polymerase chain reaction with primers in the putative non-structural 5 region. Of the 100 subjects, five (5%) were positive for HGV/GBV-C RNA and 40 (40%) were positive for HCV antibody (34 were also positive for HCV RNA). The prevalence of HCV antibody in five individuals with HGV/GBV-C RNA (100%) was significantly (P < 0.008) higher than in 95 individuals without HGV/GBV-C RNA (37%). None of five individuals with HGV/GBV-C infection had a history of blood transfusion, but 80% of those had a history of folk remedies. Serum level of alanine aminotransferase was similar between individuals with HCV and HGV/GBV-C infections and those with only HCV infection. In conclusion, 5% of the inhabitants in an area of high endemic HCV were infected with HGV/GBV-C. HGV/GBV-C infection in this area was closely associated with HCV infection and seems to have mainly been spread by folk remedies.

EVALUATION OF COLONOSCOPIC FINDINGS IN PATIENTS WITH DIARRHEAGENIC ESCHERICHIA COLI-INDUCED HEMORRHAGIC COLITIS

Background:  We evaluated the clinical significance of colonoscopic findings in the acute infectious phase of diarrheagenic Escherichia coli (E. coli)‐induced hemorrhagic colitis.

TWO PATIENTS WITH ACUTE HEPATITIS B WITH SUSPECTED SEXUAL TRANSMISSION OF HEPATITIS G VIRUS

Abstract: Two patients with acute hepatitis B with suggested sexual transmission of hepatitis G virus (HGV) are reported. A total of 18 patients with community acquired acute hepatitis B were analyzed in this study. Two of the 18 patients (patients 1 and 2) were positive for serum HGV RNA at the initial consultation. Both patients had had sexual contact with prostitutes several weeks before the onset of acute hepatitis, and hepatitis B virus (HBV) was suggested to be infected through the sexual contacts. These patients showed no other history of exposure to possible transmission routes for blood-borne hepatitis viruses. Patient 1 was diagnosed as with acute HGV infection because the antibody to HGV envelope-2 protein seroconverted to positive during the course of acute hepatitis. HGV RNA was negative in a serum sample collected from patient 2 before the onset of acute hepatitis, also suggesting acute HGV infection. These results indicate that in patients 1 and 2 HGV was infected along with HBV through sexual contact. The clinical manifestations of acute hepatitis in the two patients with HGV co-infection did not differ from those in the 16 patients with HBV infection alone.