Case report: Hepatitis A preceding Guillain-Barré syndrome

A case of acute hepatitis A with Guillain-Barré Syndrome subtype AMAN (acute motor axonal neuropathy) in a 17-year-old male is reported. Serum and cerebrospinal fluid were positive for anti-hepatitis A virus (HAV) IgM, IgG, and IgA. The onset of the syndrome was evident in week 3 of illness. The remarkably high titers of serum anti-HAV IgG appeared unique to a hepatitis A patient with the syndrome. Phylogenetic analysis of the HAV genome detected in the serum and feces revealed genotype IIIA, circulating commonly in Pune, western India.     

New bacterial absorption method for determination of hepatitis A IgM and IgA antibodies

Antibodies against hepatitis A virus (anti-HAV) can be determined by a commercially available radioimmunoassay (RIA) (HavabTM, Abbott). To discriminate between recent and past hepatitis A infection this RIA was used in combination with absorption with protein A-containing staphylococci. However, nonabsorbable anti-HAV was repeatedly detected in late-convalescent sera using this methods. The nature of these antibodies was studied in serum samples from 12 such patients. In all patients, the late-convalescent sera contained no IgM class anti-HAV as judged by sucrose density gradient centrifugation. The restricted specificity of staphylococcal protein A explains the lack of absorption. Some recently described streptococcal strains capable of binding all IgG subclasses (including IgG3) as well as both IgA subclasses were, therefore, added to the staphylococci. Absorption studies using these strains indicated that the previously nonabsorbable anti-HAV in these 12 patients was mainly of the IgA class. A bacterial mixture including IgA-binding streptococci seems preferable to routine determination of IgM anti-HAV in acute hepatitis A diagnosis. The results also indicate that IgA anti-HAV in serum can persist for more than two years after a hepatitis A infection.     

Evaluation of urine as a clinical specimen for diagnosis of hepatitis a

The present study pertains to the evaluation of urine as a specimen for detection of anti-hepatitis A virus (anti-HAV) antibodies. Immunoglobulin M (IgM), IgG, and IgA capture enzyme-linked immunosorbent assays for hepatitis A were performed on paired serum and urine specimens collected from hepatitis A patients (n = 92), healthy individuals (n = 100), non-A hepatitis patients (n = 70), and patients with nonhepatic diseases (n = 64, including 37 renal disease patients). Hepatitis A patients seropositive for anti-HAV IgM showed 95.65% uropositivity. No false-positive reactions were observed in control groups. The uropositivity of anti-HAV IgM persisted during the convalescent phase of the disease. Anti-HAV IgG uropositivity correlated well with corresponding seropositivity in all groups (P > 0.05 for each). No significant difference between the proportions of serum and urine positivity for anti-HAV IgA was noted (P > 0.05 for each). Using seroreactivity as a "gold standard," the sensitivity and specificity for anti-HAV IgM, anti-HAV IgG, and anti-HAV IgA tests with urine as a specimen were found to be 95.65 and 100%, 97.76 and 76.47%, and 92.23 and 88.18%, respectively. Urine appears to be comparable to serum for diagnosis of recent and past infection with hepatitis A.     

Diagnosis of hepatitis A and B by testing saliva

The use of salivary samples to diagnose acute viral hepatitis was investigated. Tests for IgM antibody to hepatitis A virus (anti-HAV) on 29 acute-phase samples from serologically confirmed cases of hepatitis A were strongly reactive. Follow-up samples indicated that IgM anti-HAV persisted at moderate levels for 2-4 months and was not usually detectable thereafter. The ratio of IgM to IgG anti-HAV (RIA index) correlated closely with the interval from onset of infection. Significant levels of IgM anti-HAV were not detected in the saliva of 103 IgG anti-HAV positive and 102 IgG anti-HAV negative individuals nor of 4 individuals with hepatitis B. Similarly, IgM anti-HBc was present in the saliva of acute cases of hepatitis B, but not in the saliva of 25 IgG anti-HBc positive and 85 IgG anti-HBc negative individuals, nor of 24 individuals with recent hepatitis A. It is concluded that saliva is a convenient and satisfactory alternative to serum for the diagnosis of hepatitis A infection.     

Immunoglobulin isotypes of anti-HBc and anti-HBe and hepatitis B virus (HBV) DNA elimination in acute hepatitis B

Antibodies to hepatitis B core antigen (anti-HBc) and e antigen (anti-HBe) were assayed in 46 sera from ten patients with acute hepatitis B utilizing immunoglobulin class- and subclass-specific enzyme immunoassays (EIAs). The sera were sampled 1 to 512 days after onset of hepatic symptoms. Four patients cleared HBsAg rapidly, within 24 days, and six patients cleared HBsAg slowly, within 27-74 days after the onset of symptoms. In three of the patients with rapid clearance of HBsAg, hepatitis B virus (HBV) DNA was not detected in sera tested during the first week after onset. The fourth patient was not tested until 12 days after onset and was then found to be negative for HBV DNA. In four of the patients with slow clearance of HBsAg, HBV DNA was present during the first week of illness. In the other two patients, HBV DNA was not detected in the first serum, 11 and 17 days after the onset of illness. Anti-HBc IgM and IgA1 were detected in all patients, with maximum titers shortly after onset. Anti-HBc IgG1 was present in all sera tested. Anti-HBc IgG2 was not detected in any of the sera. Anti-HBc IgG3 and IgG4 were detected in all patient sera, with IgG3 paralleling IgG1, and IgG4 mainly in sera long after onset. Anti-HBe IgG1, IgG3, and IgG4 were detected in three, two, and two patients, respectively. Anti-HBe IgG2, IgM, IgA1, or IgA2 was not found in any patient. The time required for maximum titer of anti-HBc IgG1 was shorter in the patients with rapid clearance of HBsAg.(ABSTRACT TRUNCATED AT 250 WORDS)     

Specific immunoglobulin M response to hepatitis A virus determined by solid-phase radioimmunoassay.

Immunoglobulin M antibody to hepatitis A virus (IgM anti-HAV) is found in most patients with acute type A hepatitis. To determine the duration of this IgM response as well as to confirm that IgM anti-HAV is a specific marker for acute infection, we developed a solid-phase radioimmunoassay for IgM anti-HAV. This new assay is 25-fold more sensitive than a conventional blocking radioimmunoassay for anti-HAV, and interference due to rheumatoid factor was eliminated by simultaneously testing sera against virus-free control antigen. Maximum IgM anti-HAV titers (1:6,400 to greater than or equal to 1:51,200) were detected during the first 30 days after the onset of illness. Although the IgM anti-HAV titer subsequently declined 64-fold over the ensuing 90 days, low-titer IgM anti-HAV (1:100 to 1:400) persisted in many sera for 90 to 150 days. Acute sera having an IgM anti-HAV titer of greater than or equal to 1:25,600 possessed a significantly higher mean IgM concentration (492 mg/dl) than acute sera with an IgM anti-HAV titer of less than or equal to 1:12,800 (344 mg/dl; P < 0.05). IgM anti-HAV titers did not correlate with other clinical or laboratory measures of disease severity. Detection of IgM anti-HAV proved to be both a highly specific (>99%) and a sensitive (>99%) method for the diagnosis of type A hepatitis.     

Determination of immunoglobulin M antibodies against hepatitis B core antigen and hepatitis A virus by reorienting sucrose gradient high-speed centrifugation for diagnosis of acute viral-hepatitis

Immunoglobulin M (IgM) antibodies against hepatitis B core antigen (anti-HBc) and hepatitis A virus (anti-HAV) were determined in 41 cases of acute viral hepatitis. In sera positive for anti-HBc or anti-HAV, IgM was separated from IgG by reorienting sucrose gradient high-speed centrifugation, and the IgG- and IgM-containing serum fractions were tested for the presence of specific antibody by radioimmunoassay. At the onset of illness, 4 of the 41 cases were classified as hepatitis A, 31 were hepatitis B, and 6 were non-A, non-B hepatitis, based on the results of these tests and of assays for hepatitis B surface antigen and antibody and hepatitis B e antigen and antibody. Fourteen of these 41 patients (34%) required IgM anti-HBc or IgM anti-HAV testing or both for appropriate classification. IgM anti-HBc persisted for at least 7 weeks after onset but no longer than 17 weeks in all patients tested with transient hepatitis B surface antigen-positive acute hepatitis. IgM anti-HAV persisted up to but not longer than 62 days in the patients with hepatitis A. Therefore, IgM anti-HBc and IgM anti-HAV determinants are valuable tools for the differential diagnosis of acute A, B, and non-A, non-B hepatitis.     

Time course of hepatitis A viremia and viral load in the blood of human hepatitis A patients

The hepatitis A virus (HAV) is the most common etiological cause of acute hepatitis infections in humans in industrialized countries. Investigations into the viral load during HAV viremia, however, are rare. Therefore, correlation studies between viral load, biochemical, and specific serological markers have been undertaken. The group of sera comprised a series of multiple consecutive blood samples drawn from 11 patients at different times after onset of the disease. During the period up to 70 days after the onset of icterus, the individual range was at 1 x 10(3) to 3 x 10(4) HAV genome equivalents/ml. From day 75 until 120 after onset of the disease, the levels traced were at 10(3). In one case, it was possible to trace 1.25 x 10(4) genome equivalents/ml up to 180 days after onset of icterus and in two cases even up to 408 and 490 days viral load levels of 5 x 10(3) and 4 x 10(4) were detected, respectively. The same sera were used to measure IgM class antibodies to hepatitis A virus and the total anti-HAV. The results demonstrate that a direct correlation to peak levels of viral load exists with peak serum transaminase levels, but neither with peak anti-HAV IgM levels nor with total anti-HAV. Decreasing amounts of anti-HAV IgM tend to occur with decreasing amounts of HAV genome equivalents; and, vice versa, increasing amounts of total anti-HAV are accompanied by decreasing amounts of HAV genome equivalents. The longest duration of viremia was found in patients infected with HAV genotype IA.     

Evaluation of Urine as a Clinical Specimen for Diagnosis of Hepatitis A

The present study pertains to the evaluation of urine as a specimen for detection of anti-hepatitis A virus (anti-HAV) antibodies. Immunoglobulin M (IgM), IgG, and IgA capture enzyme-linked immunosorbent assays for hepatitis A were performed on paired serum and urine specimens collected from hepatitis A patients (n = 92), healthy individuals (n = 100), non-A hepatitis patients (n = 70), and patients with nonhepatic diseases (n = 64, including 37 renal disease patients). Hepatitis A patients seropositive for anti-HAV IgM showed 95.65% uropositivity. No false-positive reactions were observed in control groups. The uropositivity of anti-HAV IgM persisted during the convalescent phase of the disease. Anti-HAV IgG uropositivity correlated well with corresponding seropositivity in all groups (P > 0.05 for each). No significant difference between the proportions of serum and urine positivity for anti-HAV IgA was noted (P > 0.05 for each). Using seroreactivity as a “gold standard,” the sensitivity and specificity for anti-HAV IgM, anti-HAV IgG, and anti-HAV IgA tests with urine as a specimen were found to be 95.65 and 100%, 97.76 and 76.47%, and 92.23 and 88.18%, respectively. Urine appears to be comparable to serum for diagnosis of recent and past infection with hepatitis A.     

The use of dried blood spots for assessing antibody response to hepatitis A virus after natural infection and vaccination

During recent years, vaccination against hepatitis A has been implemented in several countries. It is expected that the increase in mass vaccination against hepatitis A will eventually result in a decreased prevalence of anti-HAV antibodies in the general population. For this reason, a suitable clinical sample for diagnosis of hepatitis A must be sufficiently sensitive to enable detection of lower antibodies titers. In this study, the feasibility of using dried blood spots (DBS) was assessed for the detection of anti-HAV antibodies after a natural infection and vaccination. Seventy-four DBS and paired plasma samples were obtained from a group of college students for a cross-sectional hepatitis A seroepidemiological study. Forty-six students seronegative for anti-HAV were selected randomly and immunized with an inactivated hepatitis A vaccine using an 0-6 month schedule. Seroconversion was monitored in paired plasma and DBS samples 6 months after the first dose followed by a period of 8 and 24 months after the second dose. A strong correlation between OD/CO rates of paired plasma and DBS samples for the detection of anti-HAV was observed. The sensitivity and specificity of the DBS compared with plasma for the detection of anti-HAV antibodies after natural infection was 100%. The sensitivity of DBS in samples collected 24 months after the second dose of hepatitis A vaccine was 95.4%. The results showed that DBS samples can be used for the detection of anti-HAV antibodies both after natural infection or vaccination.     

Safety and immunogenicity of inactivated hepatitis A vaccine in patients with chronic liver disease

The safety and immunogenicity of inactivated hepatitis A vaccine was evaluated in patients with chronic liver disease. Sixty hepatitis A virus antibody (anti-HAV) seronegative patients A virus antibody (anti-HAV) seronegative patients with chronic liver disease (56 chronic hepatitis B and four chronic hepatitis C) and from 17 to 47 years of age received a dose of 1440 ELISA units of the inactivated hepatitis A vaccine at month 0, and a booster at month 6. Anti-HAV seroconversion (⩾ 33 mlU/mL) was 57.6% (34/59) on day 15, and reached 93.2% (55/59) 1 month after primary vaccination. At month 6, the seropositivity of anti-HAV decreased before the booster to 69.0% (40/58). All vaccinees had measurable titers of anti-HAV 1 month after booster vaccination, and were still seropositive at month 12. After initial vaccination, the geometric mean titers of anti-HAV among vaccine responders were 158, 264, 74, 1309, and 409 mlU/ml at day 15 and months 1, 6, 7, and 12. Overall, 59.7% (71/119) of the vaccine doses administered were followed by mostly minor reactions. The majority of symptoms reported were local, all of which resolved within 3 days after vaccination. No significant changes in serum liver enzyme levels were detected after vaccination. Thus, an inactivated hepatitis A vaccine was safe in patients with chronic liver disease while the immune response was inferior to that observed in healthy subjects reported in a previous study. J. Med. Virol. 52:215–218, 1997. © 1997 Wiley-Liss, Inc.     

甲型肝炎患者血清特异性IgM、IgA及总抗体动态变化与临床意义

对６０例甲型肝炎患者血清抗甲型肝炎病毒（ＨＡＶ）ＩｇＭ、ＩｇＡ及总抗体从发病起进行了１年动态观测，并以病程、病情不同分组观察分析。发现病程、病情不同患者抗－ＨＡＶ－ＩｇＡ滴度变化不同，病程长、病情重者，该抗体下降缓慢，持续阳性时间稍长。     

Etiopathogenetic aspects of hepatitis A. I. Excretion of hepatitis A virus, biochemistry of liver function, and humoral immune response in patients with hepatitis A on admission to hospital

The excretion of hepatitis A virus (HAV) in stools from 30 patients with clinically overt hepatitis A infection on the day of their admission to the hospital was determined and compared with the dynamics and values of biochemical indices of hepatocyte injury as well as with the immune response to HAV. Virus was found in 16 out of 30 stools (53%) collected within 1 week after the appearance of clinical symptoms. In sera obtained on the day of hospitalization both IgM and IgA anti-HAV were detected in all of the 30 patients, while IgG anti-HAV were found in 20 (67%). There was a correlation between HAV excretion and increasing SGPT upon admission to hospital, while the level of SGPT or bilirubin as well as presence or absence of IgG anti-HAV did not correlate with excretion of HAV. HAV from stools was characterized morphologically and physicochemically. The majority of particles visualized by immune electron microscopy had electrondense appearance, while electron-lucid particles were only occasionally encountered. Isopycnic banding of HAV in CsCl revealed a broad range of densities with HAV activity. Rebanding of pooled fractions containing HAV revealed peak amounts of the virus in fractions with densities 1.32-1.33 gm/cm3.     

Comparison of solid phase test systems for demonstrating antibodies against hepatitis A virus (anti-Hav) of the IgM-class

Three methods were compared for determining anti-HAV of the IgM class. In the first method flat-bottomed microtiter plates coated consecutively with anti-HAV of the IgG class and HAAg were incubated with patient serum and, after washing, peroxidase conjugated anti-mu was added. After subsequent incubation with substrate the enzymatic reaction was stopped and the optical density was measured. In the second method the solid phase was coated first with antibodies to IgM and after incubation with patient serum and subsequent incubations with HAAg and 125I anti-HAV of the IgG class radioactivity was counted. These two methods were compared with reorienting sucrose gradient ultracentrifugation, an established method for demonstrating specific IgM antibodies. The persistence of IgM anti-HAV in 103 sera drawn at different times after onset of jaundice was evaluated. Sera drawn up to 30 days after onset of hepatitis A were IgM anti-HAV positive with both of the first two methods. Forty-one to 90 days after onset of illness IgM anti-HAV could be demonstrated with the first method in 47% of the patients, in 94% with the second method, and in 82% with gradient centrifugation. The second method was most sensitive and could be adjusted so that at a serum dilution of 1:10(4) anti-HAV IgM was detected only up to six months after infection. In contrast to the first method, nonspecific reactions caused by rheumatoid factor were not detected with the second method. During a one-year period about 15,000 sera of patients with clinical diagnoses of acute hepatitis were tested; the positive results correlated well with the clinical data, and there was no indication of nonspecific positive results.     

Anti-hepatitis A virus immunoglobulin M antibodies in urine samples for rapid diagnosis of outbreaks

The main goal of this study was to test the feasibility of using urine for diagnosing hepatitis A virus (HAV) infections. A correlation of 90.78% between the test results of urine and serum samples was obtained. Four outbreaks of hepatitis A were confirmed by testing only urine samples. The levels of anti-HAV immunoglobulin M (IgM) antibodies in urine samples remained stable during 6 months of storage at -70 degrees C but decreased when the samples were stored at 4 degrees C. The results of tests of samples obtained 2 and 6 months after infection suggested that IgM levels decline more rapidly in urine than in serum.     

Detection of total antibody against hepatitis A virus by an automated microparticle enzyme immunoassay.

A fully automated microparticle enzyme immunoassay, IMx HAVAB, was developed for the detection of antibody against hepatitis A virus (anti-HAV). In the IMx HAVAB assay which is run on the IMx instrument, 24 tests are completed in less than 45 minutes. IMx HAVAB sensitivity was 18-25 World Health Organization U/l and was more sensitive than the commercial RIA or EIA, HAVAB and HAVAB EIA, respectively. Specimens from blood donors, diagnostic and hospital patients and individuals with a variety of infectious and immune diseases were tested in parallel with IMx HAVAB and RIA or EIA. Overall agreement of 99.9% (2118/2121) was obtained. Prevalence of anti-HAV tested by IMx ranged from 12.3% in volunteer blood donors in St. Louis to 64.3% for hospital patients in New York City. Discordant specimens were reactive by IMx HAVAB but borderline negative by EIA or RIA, due to the better sensitivity of the IMx assay. IMx HAVAB detected both IgM and IgG subclasses of anti-HAV. Serial bleeds from six intravenous drug users with acute HAV infection were tested over 8 months for the presence of anti-HAV. At all time points, patients were strongly reactive for anti-HAV (titers greater than 1/1000). Anti-HAV titers rose during the first 20 weeks after presentation of symptoms and then declined with time.     

Detection of immunoglobulin M antibodies to hepatitis A virus by enzyme-linked immunosorbent assay.

An enzyme-linked immunosorbent assay for the detection of immunoglobulin M (IgM) antibodies to hepatitis A virus is described. The test uses the principle of binding of IgM antibodies to anti-IgM-coated microtiter plates to determine whether the IgM antibodies attached have specificities for hepatitis A virus. In three patients with hepatitis type A followed up to 12 months, IgM antibodies to hepatitis A virus could be demonstrated from the onset of illness and during the following 2 to 3 months. When acute-phase sera from 48 patients with acute hepatitis were tested, IgM antibodies to hepatitis A virus could only be demonstrated in 18 patients previously classified as type A, whereas 30 patients with type B and non-A non-B hepatitis were negative. IgM antibodies to hepatitis A virus could not be demonstrated in 108 normal sera nor in 55 sera containing rheumatoid factor. These results indicate that the enzyme-linked immunosorbent assay for IgM antibodies to hepatitis A virus is useful in the serodiagnosis of acute hepatitis type A on a single serum sample taken during the acute phase of illness.     

Recurrences of viral hepatitis A

The aim of the study was to examine the frequency, severity, persistence and etiology of relapses occurring during the hepatitis A viral infection. Therefore, a prospective study of 910 patients suffering from hepatitis A (HA) was carried out. The clinical examination and determination of glutamyl pyruvic transaminase (GPT) in the serum every 7-14 days till recovery (usually during 6--8 months) were performed. HAV infection was confirmed by detecting anti-HAV IgM in the blood of all the examined by radioimmunoassay. In 876 (93.3%) patients HA had typical clinical features and a monophasic course. All cases made a rapid clinical recovery and liver function tests improved strikingly between 1 and 4 months after the onset of illness. However, in 34 (3.7%) of 910 patients, after an asymptomatic interval of 4--8 weeks, relapsing hepatitis occurred. Mild clinical symptoms: fatigue, myalgia, nausea, epigastric discomfort accompanied by the elevated levels of GPT in the serum were noticed in 11 patients, while 3 of them redeveloped jaundice. In 23 remaining patients relapses of hepatitis were asymptomatic, except for the reappearance of icterus in six cases. The only way to establish the exacerbation of the disease was through the pathological findings of GPT in the serum, which increased 10--60 times above the upper limit of the normal value. While 25 patients had one relapse, in 9 there were two or more relapses, so that hepatitis had a biphasic or polyphasic course. The second relapse was registered 3--6 weeks after the first one disappeared. Through biochemical tests the average values of the GPT were established: 1566 U/L in the acute stage, 107 U/L during the early stage of convalescence and 1016 U/L during the first relapse of hepatitis. After the first relapse and during remission, in 9 patients the average values of GPT in the serum were 84 U/L, while during the second relapse 518 U/L. Clinical signs of relapsing hepatitis disappeared approximately in 4 days, but liver function tests decreased slowly and persisted elevated between 5 and 12 months. A possibility of establishing the etiology of relapsing hepatitis, which has yet remained unknown, is discussed. Anti-HAV IgM were present in all 34 patients during the initial and relapsing phase of hepatitis and in 26 cases in the latter phase of convalescence between 9 and 11 months after the beginning of the disease. Serological tests excluded infection with hepatitis B, cytomegalovirus and Epstein-Barr virus. With a great probability other infections and toxic agents damaging the liver could have been excluded.(ABSTRACT TRUNCATED AT 400 WORDS)     

Antibodies to single-stranded DNA: An aid in diagnosis of viral hepatitis

In clinical and subclinical viral hepatitis a significant increase of antibodies to single-stranded DNA revealed the prepatent stage of the disease before any elevation of serum transaminases. In type A hepatitis, a rise in anti-DNA titers was detectable one to two weeks before onset of clinical and biochemical signs; in type B hepatitis, the rise of anti-DNA coincided with or preceded the appearance of HB_sAg, several weeks before the onset of clinical illness. In both hepatitis types anti-DNA titers reached a peak (640–2,560) at onset and dropped shortly after serum transaminases returned to normal at the end of acute illness. The anti-DNA response in non-A/non-B hepatitis was of similar magnitude. Anti-DNA elevation was the only positive sign found in most silent infections of either type that later showed specific seroconversion. Anti-DNA levels in noninfected contacts were in the same range as those found in a group of healthy individuals. The anti-DNA test is useful for early diagnosis of viral hepatitis and should be a valuable addition to current epidemiological and clinical procedures.