Seroconversion to hepatitis C virus antibodies in patients with acute posttransfusion non-A,non-B hepatitis in Sweden

Summary Seventy-four patients in 1978 and 316 in 1986, all transfused during open-heart surgery in Stockholm, Sweden, were studied prospectively for the development of posttransfusion non-A, non-B (NANB) hepatitis, seroconversion to hepatitis C virus antibodies (anti-HCV) (C-100), time lag to seroconversion to anti-HCV and outcome of posttransfusion NANB/C hepatitis. Anti-HCV was tested up to six months after transfusions in patients from 1978 and up to one year after transfusions in patients from 1986. Fifty-four percent of the patients who developed posttransfusion NANB hepatitis seroconverted to anti-HCV, 7/15 (47%) in 1978 and 8/13 (62%) in 1986. Four (27%) of the 15 patients who seroconverted to anti-HCV were anti-HCV reactive within one week, 12 (80%) within eight weeks and all within 18 weeks after the onset of hepatitis. The ELISA optical density/cut-off (OD/CO) ratio was above 4.0 in all patients with hepatitis C who seroconverted. One transfused patient with normal serum aminotransferase levels throughout follow-up seroconverted after six months. He had a temporary positive anti-HCV reactivity with a maximal ELISA OD/CO ratio for anti-HCV of only 1.2, which became negative three years later. Development of chronic hepatitis was noticed in 9/15 (60%) patients who seroconverted to anti-HCV and in 5/13 (38%) patients with posttransfusion NANB hepatitis who did not seroconvert.

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Anti-HBC-Serokonversion bei Patienten mit akuter Non-A, Non-B-Hepatitis nach Transfusion in Schweden

Zusammenfassung 74 Patienten, die 1978, und 316 Patienten, die 1986 während offener Herzchirurgie in Stockholm, Schweden, Transfusionen erhielten, wurden in eine prospektive Studie aufgenommen und im Hinblick auf das Auftreten einer Non-A, Non-B-Posttransfusions-hepatitis, Serokonversion für Hepatitis C Virus-Antikörper (anti-HCV, C-100), Zeitspanne bis zur Serokonversion für anti-HCV und Verlauf der NANB/C-Posttransfusionshepatitis untersucht. Bei Patienten, die 1978 transfundiert worden waren, wurden Untersuchungen auf anti-HCV bis zu sechs Monate nach der Transfusion und bei 1986 Transfundierten bis zu einem Jahr nach Transfusion durchgeführt. Eine Serokonversion zu anti-HCV trat bei 54% der Patienten mit NANB-Posttransfusions-hepatitis ein, 7/15 (47%) der Patienten aus dem Jahr 1978 und 8/13 (62%) aus dem Jahr 1986. Die Serokonversion zu anti-HCV trat bei vier der 15 Patienten (27%) schon innerhalb einer Woche ein, bei 12 (80%) innerhalb acht Wochen und bei allen innerhalb 18 Wochen nach Beginn der Hepatitis. Bei den Patienten mit Hepatitis C, die eine Serokonversion entwickelten, lag der Quotient von ELISA Meßwert zu Grenzwert (Optical density/ Cut-off, OD/CO) in allen Fällen über 4,0. Ein Patient, bei dem nach der Transfusion stets normale Serum- Aminotransferase-Spiegel vorlagen, zeigte nach sechs Monaten eine Serokonversion. Er war vorübergehend anti-HCV positiv, der ELISA OD/CO- Quotient für anti-HCV betrug maximal 1,2; nach drei Jahren war er seronegativ. Bei neun der 15 Patienten (60%) war eine chronische Hepatitis nach Serokonversion für anti-HCV zu beobachten. Unter den 13 Patienten mit NANB-Posttransfusionshepatitis, die keine Serokonversion zeigten, entwickelten fünf eine chronische Hepatitis (38%).

     

Serum hepatitis C virus sequences in posttransfusion non-A, non-B hepatitis.

We investigated 17 patients (12 males and 5 females, ages 2 to 57 years old) with posttransfusion non-A, non-B hepatitis to determine relationships between clinical courses and hepatitis C virus (HCV) markers. The patients were grouped according to time course of abnormal serum alanine aminotransferase (ALT) levels into three categories (chronic biochemical disease, biochemically resolved chronic disease, and acute disease). Latest serum samples (1.3 to 10.8 years after blood transfusion) were used to detect antibodies against C100-3 antigen (anti-HCV) by enzyme-linked immunosorbent assay and HCV sequences by polymerase chain reaction (PCR) assay. Of the 17 patients, 13 patients (76.5%) were anti-HCV positive and 8 patients (47.1%), including one anti-HCV negative case, were positive for HCV RNA. In total, 14 patients (82.4%) were positive for either HCV markers. With respect to clinical course, HCV RNA was detected in six of eight patients (75%) with chronic biochemical disease, and in two of five patients (40%) with biochemically resolved chronic disease. HCV RNA was not detectable in convalescent sera from four patients with acute disease. These results show that there is a relationship between clinical status and HCV viremia, but that normal liver function tests do not always represent the clearance of the virus. Viremia in two patients with normal ALT level suggests that hepatitis is not only caused by viral cytopathic effects, but also by immunologic reactions against virus-infected cells. Thus, PCR is useful in determining the persistence of HCV infection as well as to diagnose anti-HCV negative HCV infection.     

Immunological abnormalities in acute posttransfusion hepatitis non-A non-B

ABSTRACT— A variety of immunological parameters has been serially examined in the blood of 12 patients with acute post-transfusion hepatitis non-A non-B (PTHNANB). Several alterations of these tests were transiently detected when comparing with healthy, extensively transfused subjects as well as with normal volunteers: 1. Low proportions of CD8+ T lymphocytes were observed at the disease onset, and these returned to normal after 1 month; 2. A diminution of the proliferative response of blood lymphocytes to mitogens was detected during the same period of time; 3. By the third month of disease, an enhanced spontaneous IgG secretion by cultured lymphocytes was found, and this observation was restricted to those patients who had not recovered. These alterations suggest that the immune system might be involved in the course of hepatitis C virus infection.     

Antibodies to hepatitis C virus in community-acquired acute non-A, non-B hepatitis.

Circulating antibodies to the recently identified hepatitis C virus (anti-HCV) have been investigated by ELISA in a series of 129 adult Italian patients with acute, community-acquired non-A, non-B hepatitis. Anti-HCV was detected in 50 (38%) cases with a prevalence rate which increased from 19%, in sera taken during the first 2 weeks of illness to 52% in samples obtained 5-6 weeks after onset, indicating a rather late appearance of the antibody. Anti-HCV positivity was independent of risk factors in the clinical history, but correlated with the outcome of the disease. Eighteen (26%) of 68 patients who recovered were anti-HCV positive compared to 10 of 14 (71%) who progressed to chronicity (p less than 0.01). In this latter group the antibody persisted for more than 12 months after the onset of the illness. Conversely, in 12 (85%) of 14 serially tested patients who recovered, anti-HCV positivity was transient, lasting from a few weeks to a few months. These findings indicate that HCV is implicated in a consistent proportion of acute community-acquired non-A, non-B hepatitis cases, particularly cases which progress to chronicity. A large proportion of cases remained unclassified, however, and it will be important to define whether they represent cases of HCV infection with poor serologic response, or are due instead to other, as yet unidentified, non-A, non-B agents.     

Hepatitis C virus antibodies in acute icteric and chronic non-A, non-B hepatitis.

Hepatitis C virus antibodies were measured in 213 patients who had acute (n = 122) and chronic (n = 91) non-A, non-B hepatitis. In acute infection, anti-hepatitis C virus was detected in 61% of IV drug abusers, in 33% of patients with transfusion-associated hepatitis, and in 22% of patients with sporadic infections (P less than 0.0005, drug abusers vs. sporadic). Mean time to seroconversion was 11.6 weeks (range, 1-80 weeks). Anti-hepatitis C virus was more common in chronic infection (P less than 0.001) and was more often detected in IV drug users (89%; P less than 0.0001) and after transfusion (71%; P less than 0.005) compared with chronic sporadic infection (27%). Antibody persisted for up to 8 years. Six chronic case patients (8.3%) later lost antibody (mean, 24 months; range, 12-48 months).     

Long-term follow-up of posttransfusion and sporadic chronic hepatitis non-A, non-B and frequency of circulating antibodies to hepatitis C virus (HCV)

The natural course of chronic hepatitis non-A, non-B (HNANB) was documented for 3-20 yr (mean 8 yr) in 86 patients, who attended our special ambulance between 1981 and 1988. Sixty five of the 86 patients (75%) were positive for circulating antibodies against hepatitis C virus (HCV) (anti-HCV). Twenty four patients had chronic posttransfusion (PT)-HNANB (18 anti-HCV-positive; 75%), and 62 patients had sporadic (S)-HNANB (47 anti-HCV-positive; 75%). Twenty nine per cent of patients with chronic PT-HNANB had sustained normalization of aminotransferases after a period up to 5 yr, 55% demonstrated chronic persistent hepatitis (CPH) and 16% progressed to chronic active hepatitis (CAH) with transition to cirrhosis. In the group with chronic S-HNANB, 2% of patients showed remission, 43% had stable CPH and 55% progressed to CAH or cirrhosis. However, development of cirrhotic complications required many years. Transition from CAH to CPH or remission was not observed. The results indicate that 75% of both patients groups with chronic PT- and S-HNANB are infected with the same agent, of which antibodies are detected by the new anti-HCV assay. There was no statistical association between the severity of the disease and the presence of anti-HCV. The different proportions of progressive courses in chronic PT- and S-HNANB might be explained by the patient recruitment.     

Application of a numerical scoring system for assessment of histological outcome in patients with chronic posttransfusion non-A, non-B hepatitis with or without antibodies to hepatitis C

A numerical scoring system was applied and compared to the conventional histological classification to assess the histological status of liver specimens from 37 patients with chronic posttransfusion non-A, non-B hepatitis followed for 7 to 105 months (mean 35 months). Four histological categories of alterations were assessed and scored: piecemeal necrosis (PMN), fibrosis and cirrhosis, lobular necrosis and portal inflammation. Sequential liver biopsies were obtained from 19 patients. PMN was generally mild but still predictive of progressing fibrosis. Thus, in none of the biopsies from four patients with initial PMN score 0 was there any increase in the fibrosis score in the follow-up biopsy, while in 10/15 (67%) patients with an initial PMN score of greater than or equal to 1 the fibrosis score increased with time (p = 0.033). Lobular necrosis and portal inflammation were not predictive of progressing fibrosis. Judging from the scoring method, 22% of all the 37 patients displayed cirrhosis and 27% bridging fibrosis in the latest liver biopsy performed. Patients with antibodies to hepatitis C did not differ in histological status or outcome from those without antibodies to hepatitis C. It is concluded that the scoring system can be used to monitor the histological long-term follow-up in patients with chronic posttransfusion non-A, non-B hepatitis, and offers a means of predicting the histological outcome.     

Activity of antibodies to hepatitis C virus of patients with chronic non-A, non-B hepatitis decreases during interferon α therapy

The activity of antibodies to hepatitis C virus (anti-HCV) was investigated in 80 patients with chronic non-A, non-B liver diseases. Anti-HCV antibodies were positive in 82.5% (66/80), and the titers were 1 for 18 patients, 2 for 40 and 3 for 8, respectively. The frequency of anti-HCV was significantly lower in patients with chronic persistent hepatitis (8/13, 61.5%) than in those with chronic active hepatitis (42/49, 85.7%) (P<0.05). there was no significant difference in the distribution of anti-HCV titers among the different stages of hepatitis. There was no correlation between anti-HCV titer and histology activity index score in chronic hepatitis. Activity of anti-HCV decreased more frequently in the patients who responded to interferon α (IFNα) therapy (8/22, 36.4%) than in those who did not (0/9, 0%) (P<0.05). These results indicate that anti-HCV activity does not correlate with the activity or disease stage of chronic hepatitis, but that anti-HCV activity decrease more frequently during IFNα treatment in patients who responded to IFNα therapy.     

Hepatitis C virus RNA genome in plasma of patients with non-A, non-B hepatitis.

Recently, the assay system of anti-hepatitis C virus antibody (HCV-Ab) was developed. However, there is no clinically useful method to detect hepatitis C virus (HCV) itself. The authors recently developed a method to detect the HCV-RNA genome in plasma using polymerase chain reaction (PCR). In the present study, the specificity of this assay in detecting HCV infection was investigated. Freshly obtained 1 ml plasma specimens from 100 patients with various liver diseases and from 11 control subjects were studied. In patients with non-A, non-B (NANB) hepatitis-related liver diseases, HCV-RNA was detected in 2 out of 7 cases of acute hepatitis, in 29 out of 31 cases of chronic hepatitis, in 17 out of 21 cases of cirrhosis and in 2 out of 6 cases of hepatocellular carcinoma. On the other hand, no HCV-RNA was detected in 15 cases of various types of alcoholic liver diseases, in 12 cases of hepatitis B related liver diseases, and in 11 controls. HCV-RNA was detected in 2 of 6 drinkers with chronic hepatitis. The prevalence of HCV-RNA was not closely related to a history of blood transfusions. These results suggest that our method for HCV-RNA is specific for HCV infection and HCV infection is the likely etiology of most chronic NANB hepatitis cases. The clinical usefulness of our method is illustrated by the fact that we were able to study 100 patients and needed only 1 ml plasma per HCV-RNA assay.     

Hepatitis C virus antibodies among different groups at risk and patients with suspected non-A,non-B hepatitis

Summary 4000 sera were tested for antibodies against hepatitis C virus (HCV) by means of an ELISA using the C100-3 antigen. 38.9% of patients with non-A, non-B hepatitis following blood transfusion (n=108) had HCV antibodies. Among patients with chronic liver damage of unknown origin (n=316) 30.4% were anti-HCV positive, and in 2,506 patients with transitional or chronic elevation of transaminases 14.8% showed HCV antibodies. Haemophiliacs (n=26) with 65.4% anti-HCV positives and drug addicts (n=46) with 56.5% anti-HCV positives had the highest prevalence among high risk groups. Addicts dying from drug abuse (n=216) and HIV 1 positives (n=127) were anti-HCV positive in 37.5% and 26.0%, respectively. Patients on haemodialysis (n=331) had antibodies against HCV in 12.4%. Health care workers (n=217) appear to be at a comparably low risk with only 2.8% anti-HCV positives. Up to now we could not find a single case of intrafamilial spread of HCV in 46 examined cases. We suggest that HCV infectivity of contaminated body fluids and blood is lower than that of hepatitis B virus or human immunodeficiency virus type 1 carriers. In suspected non-A, non-B hepatitis negative test results should be confirmed in a second sample because it may take three to six months after infection before HCV antibodies occur. However, about 10% of chronic HCV infections are not detectable with the presently available test. This may change when new tests become available using HCV specific antigens other than C100-3.

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Antikörper gegen das Hepatitis-C-Virus in verschiedenen Risikogruppen sowie bei Patienten mit Verdacht auf Hepatitis Non-A, Non-B

Zusammenfassung Wir untersuchten bislang 4000 Seren auf das Vorliegen von Antikörpern gegen das Hepatitis-C-Virus (HCV). In unserer Studie hatten Patienten mit einer Non-A, Non-B Hepatitis nach Bluttransfusion (n=108) in 38,9% HCV-Antikörper. Patienten mit chronischen Lebererkrankungen (n=316) zeigten diese Antikörper in 30,4%, und Patienten mit vorübergehenden oder anhaltenden Transaminasenerhöhungen (n=2506) waren in 14,8% anti-HCV positiv. Unter den Risikogruppen mit parenteralem Blutkontakt waren Hämophiliepatienten (n=26) mit 65,4% am häufigsten HCV-Antikörper-positiv, gefolgt von Drogenabhängigen (n=46; 56,5%) und Drogentoten (n=216; 37,5%). HIV-infizierte Patienten (n=127) zeigten HCV-Antikörper in 26,0%, und Hämodialysepatienten (n=331) waren in 12,4% positiv. Die Gefährdung für medizinisches Personal ist offenbar relativ gering: nur 2,8% der untersuchten 217 Mitarbeiter mit parenteralem Infektionsrisiko hatten HCV-Antikörper. Bisher konnten wir noch in keinem Fall eine HCV- Übertragung durch Nadelstich-oder Skalpellverletzung belegen; auch familiäre Kontakte führten bei den von uns untersuchten 46 Angehörigen HCV-positiver Patienten bislang nicht zur Infektion. Die Infektiösität HCV-positiver Patienten ist möglicherweise geringer als die von HBV- oder HIV-infizierten Patienten. Wenn der Verdacht auf eine Hepatitis Non-A, Non-B vorliegt, so sollte ein negatives Testergebnis jedoch unbedingt in einer weiteren Serumprobe bestätigt werden, da es nach erfolgter Infektion drei bis sechs Monate dauern kann, bis die Serokonversion auftritt. Ein Teil der HCV- Infektionen kann mit dem derzeit zur Verfügung stehenden Test nicht erkannt werden, bei der chronischen HCV-Infektion sind dies ca. 10% der Fälle. Vielleicht wird deren Nachweis erst dann gelingen, wenn es weitere Teste gibt, die Antikörper gegen andere antigene Epitope des Hepatitis-C-Virus nachweisen können.

     

Histological outcome in interferon alpha-2b treated patients with chronic posttransfusion non-A, non-B hepatitis.

The histological outcome in liver biopsies following 9 months of interferon alpha-2b treatment was assessed in detail in 19 patients with chronic posttransfusion non-A, non-B hepatitis (PTH-NANB) and compared with 12 untreated PTH-NANB patients. Fourteen (74%) treated and 7 (58%) control patients were reactive for antibodies against hepatitis C virus (anti-HCV). Liver biopsies taken before and after the 9-month period were scored numerically for portal inflammation, piecemeal necrosis (PMN) and fibrosis, without knowledge of whether the specimens came from control or treated patients. There were no score differences in the initial biopsies between the treated and control group. In the follow-up biopsies the treated group showed significantly less portal inflammation, PMN and fibrosis than the control group (p less than 0.05-0.01). When paired samples from the treated group were compared, significantly regressed portal inflammation, PMN and fibrosis were noted in the follow-up biopsies (p less than 0.05-0.001). The presence or not of anti-HCV antibodies in serum had no impact on the histological response to interferon treatment. We conclude that a 9-month course of interferon alpha-2b treatment significantly diminishes not only inflammation but also fibrosis in the liver of patients with PTH-NANB whether they are anti-HCV reactive or not.     

Hepatitis C virus RNA genome in plasma of patients with non-A,non-B hepatitis

Recently, the assay system of anti-hepatitis C virus antibody (HCV-Ab) was developed. However, there is no clinically useful method to detect hepatitis C virus (HCV) itself. The authors recently developed a method to detect the HCV-RNA genome in plasma using polymerase chain reaction (PCR). In the present study, the specificity of this assay in detecting HCV infection was investigated. Freshly obtained 1 ml plasma specimens from 100 patients with various liver diseases and from 11 control subjects were studied. In patients with non-A, non-B (NANB) hepatitis-related liver diseases, HCV-RNA was detected in 2 out of 7 cases of acute hepatitis, in 29 out of 31 cases of chronic hepatitis, in 17 out of 21 cases of cirrhosis and in 2 out of 6 cases of hepatocellular carcinoma. On the other hand, no HCV-RNA was detected in 15 cases of various types of alcoholic liver diseases, in 12 cases of hepatitis B related liver diseases, and in 11 controls. HCV-RNA was detected in 2 of 6 drinkers with chronic hepatitis. The prevalence of HCV-RNA was not closely related to a history of blood transfusions. These results suggest that our method for HCV-RNA is specific for HCV infection and HCV infection is the likely etiology of most chronic NANB hepatitis cases. The clinical usefulness of our method is illustrated by the fact that we were able to study 100 patients and needed only 1 ml plasma per HCV-RNA assay.     

Histological outcome in interferon alpha-2b treated patients with chronic posttransfusion non-A,non-B hepatitis

ABSTRACT— The histological outcome in liver biopsies following 9 months of interferon alpha-2b treatment was assessed in detail in 19 patients with chronic posttransfusion non-A, non-B hepatitis (PTH-NANB) and compared with 12 untreated PTH-NANB patients. Fourteen (74%) treated and 7 (58%) control patients were reactive for antibodies against hepatitis C virus (anti-HCV). Liver biopsies taken before and after the 9-month period were scored numerically for portal inflammation, piecemeal necrosis (PMN) and fibrosis, without knowledge of whether the specimens came from control or treated patients. There were no score differences in the initial biopsies between the treated and control group. In the follow-up biopsies the treated group showed significantly less portal inflammation, PMN and fibrosis than the control group (p < 0.05–0.01). When paired samples from the treated group were compared, significantly regressed portal inflammation, PMN and fibrosis were noted in the follow-up biopsies (p < 0.05–0.001). The presence or not of anti-HCV antibodies in serum had no impact on the histological response to interferon treatment. We conclude that a 9-month course of interferon alpha-2b treatment significantly diminishes not only inflammation but also fibrosis in the liver of patients with PTH-NANB whether they are anti-HCV reactive or not.     

Molecular cloning of the human hepatitis C virus genome from Japanese patients with non-A, non-B hepatitis.

The nucleotide sequence of the Japanese type of hepatitis C virus (HCV-J) genome, consisting of 9413 nucleotides, was determined by analyses of cDNA clones from plasma specimens from Japanese patients with chronic hepatitis. HCV-J genome contains a long open reading frame that can encode a sequence of 3010 amino acid residues. Comparison of HCV-J with the American isolate of HCV showed 22.6% difference in nucleotide sequence and 15.1% difference in amino acid sequence. Thus HCV-J and the American isolate of HCV are probably different subtypes of HCV. The relationship of HCV-J with other animal RNA virus families and the putative organization of the HCV-J genome are discussed.