Chronic hepatitis B virus (HBV) infection in pregnancy

Background  Hepatitis B is a considerable disease burden among Asians. Little is known about its disease behaviour in pregnant women. Methods  Clinical, laboratory and radiological data of pregnant and peri-partum females with chronic hepatitis B virus (HBV) infection who were seen between years 1999 and 2004 were studied. Their progress was documented up to 6 months post-partum. This was compared with the age-matched and HBe status-matched, non-pregnant, female patients with chronic HBV infection, who were consecutively selected from the department’s registry as controls (ratio 1 mother: 4 non-pregnant controls), over the corresponding period. Results  A total of 35 mothers and 140 controls were studied. Mean age of patients was 30.7 ± 3.6 years. Majority of mothers (74.3%) presented during pregnancy itself. 1st:2nd:3rd trimester presentation = 20.0%:48.6%:5.7%. Majority (65.7%) were positive for HBe antigen (HBeAg) at the time of presentation. About 57.1% mothers had a clinical event in the form of alanine transferase (ALT) elevation and/or loss of HBeAg vs 28.8% among controls (P = 0.002). Among HBeAg-positive subjects, more mothers (14.3%) than controls (2.2%) had resultant HBeAg loss (P = 0.02). Among HBeAg negative subjects, more mothers than controls had serum ALT elevations in the post-partum period (P = 0.007). Overall, more mothers had elevated ALT levels than controls, regardless of their HBeAg status. Neither mothers nor control subjects decompensated clinically, neither required liver transplantation nor died during the study period. Conclusions  Pregnancy is associated with serum ALT elevation and HBeAg loss in patients with chronic HBV infection in the peri-partum period.     

Glomerulonephropathy associated with hepatitis B virus (HBV) infection

Forty-seven renal biopsies of glomerulonephropathy with persistent Australian antigenaemia (HBsAg is mostly positive) were studied with light microscope, electron microscope and direct immunofluorescence. Immunohistochemical method (ABC method) was used to examine HBsAg, HBeAg and HBcAg deposits in renal tissue. In addition 20 cases of idiopathic membranous nephropathy (MN) were studied for comparison. These 47 cases included 19 children and 28 adults. The results indicated that Australian antigens diffusely deposited in glomeruli in 14 cases (29.7%), with HBsAg in 7 cases (50.0%), HBeAg in 13 cases (92.8%) and HBcAg in 2 cases (14.3%). The 14 positive cases included 11 children and 3 adults. The pathologic types were membranous nephropathy in 12 and membranoproliferative glomerulonephritis in 2 cases. The membranous type was characterized by irregular thickening of capillary wall and double contour, bubble-like appearance and spike formation of glomerular basement membrane (GBM); immune complexes and electron dense deposits may be present in different sites of glomeruli. Coarse granular deposits of IgG and C3 along GBM were the principal pattern, but IgA, IgM and C1q were often present. Among the 20 idiopathic MN, 2 were found to have HBeAg deposition along GBM, one was a child and the other an adult IgG, IgA, IgM, C3 and C1q with HBeAg deposits were present in glomeruli.     

Histopathological analysis of chronic hepatitis B virus (HBV) infection in relation to HBV replication

The interrelationship among expression patterns of hepatitis B surface and core antigens (HBsAg and HBcAg) in the liver, hepatitis B virus (HBV) DNA in sera, HBeAg/anti-HBe status and histological features was examined in 189 liver specimens and 106 sera from Japanese patients with chronic HBV infection, utilizing immunoperoxidase methods and a spot hybridization technique. HBsAg and HBcAg were distributed uniformly among the lobules in 8 viral carriers with "normal" liver (NVC) and 30 patients with persistent hepatitis (PB) seropositive for HBcAg. This uniform staining pattern was quite distinct from the non-uniform and irregular patterns in 137 patients with chronic active hepatitis (CAH) associated with or not associated with cirrhosis. HBcAg was often found to be stained strongly in the cytoplasm as well as in the nucleus of hepatocytes in HBeAg-positive CAH, in contrast to NVC/PH, in which cytoplasmic HBcAg was very weak. Serum HBV DNA was detected in all 22 cases with HBeAg-positive NVC/PH, 41 of 46 (89.1%) cases with HBeAg-positive CAH, 6 of 23 (26.1%) casew with anti-HBe-positive CAH and none of 3 cases with anti-HBe-positive NVC/PH. The level of serum HBV DNA and staining of HBcAg were in decreasing order in these groups. While the presence of serum HBV DNA and HBcAg staining was always associated with HBeAg seropositivity in NVC/PH, this was not always found in CAH. Moreover, necroinflammatory activity in the liver did not always parallel viral replication in CAH. These findings seem to confirm that NVC/PH and CAH have different biologic processes; viral replication is always concordant in the former, but is sometimes discordant in the latter with HBeAg/anti-HBe status. The immunologic response of the host seems to suppress and distort replication of the virus to a varying degree among patients and areas of the same liver in CAH differently to that in NVC/PH. The different life cycle of the virus, including integration of viral DNA into the cellular genome, may subsequently result in discordant states of various virus markers in CAH.     

Genomic heterogeneity of hepatitis B virus (HBV) and outcome of perinatal HBV infection

BACKGROUND/AIMS: Data regarding hepatitis B virus (HBV) genomic heterogeneity in perinatal infection are incomplete, although HBV variants might be involved in neonatal fulminant hepatitis (ALF). We investigated HBV variability in infected babies showing different clinical courses. METHODS: We analyzed HBV genomes isolated from nine vertically infected babies and the mothers of four of them. Two infants born to HBe-antigen (HBeAg)-positive women developed a chronic infection; seven babies (six born to anti-HBe mothers) developed acute hepatitis that had a fulminant course in four cases and a benign course in three. Two babies developing ALF received anti-HBV immunoprophylaxis at birth. RESULTS: Viruses carrying no significant mutation infected infants born to HBeAg-positive women. HBeAg-defective viruses were detected both in children with benign and fulminant hepatitis and their mothers. A double nucleotide mutation at positions 1762 and 1764 of the HBV core-promoter was found in two of the four infants with ALF, although it was not detected in isolates from the mother of one of them. No significant S gene mutation was found in HBV from any of the babies. CONCLUSIONS: This study indicates that HBV genomic heterogeneity is not primarily involved either in the evolution of the infection or the failure of neonatal HBV immunoprophylaxis.     

Quantification of intrahepatic hepatitis B virus (HBV) DNA in patients with chronic HBV infection

No data are available about the amount of hepatitis B virus (HBV) genomes in liver of patients with chronic HBV infection. The aim of this study was to quantify the intrahepatic HBV DNA in hepatitis B surface antigen (HBsAg)-positive patients with either active or suppressed viral replication and in HBsAg-negative subjects with occult HBV infection. We optimized the Roche "Amplicor HBV Monitor" kit for quantifying liver HBV DNA and analyzed hepatic DNA extracts and serum samples from 19 HBs-Ag-positive and 43 HBsAg-negative individuals. Eight of the HBsAg carriers had active HBV replication, and for 3 of them we analyzed samples obtained before and at the end of 1 year of lamivudine treatment. Five hepatitis Delta virus (HDV) coinfected patients and 6 healthy HBsAg carriers had inhibited HBV activity. Among the HBsAg-negative subjects 21 had occult HBV infection and 22 had no evidence of HBV infection. The median of HBV genomes per microgram of liver DNA milliliter of serum was 34,500 to 2,620,000 in patients with active viral replication, 20,000 to 3,900, 000 before and 10,000 to 2,800 at the end of therapy in lamivudine-treated individuals, 9,800 to 600 in HDV-infected individuals, and 7,450 to 17,400 in healthy HBsAg carriers. These data indicate that cases with suppressed HBV activity, despite the very low levels of viremia, maintain a relatively high amount of intrahepatic viral genomes. This virus reservoir is likely involved in HBV reactivation, which is usually observed after stopping lamivudine treatment. Finally, the analysis of cases with occult HBV infection showed that the assay we used was able to specifically detect and quantify as few as 100 copies of viral genomes per microgram of liver DNA.     

慢性乙型肝炎患者体内乙型肝炎病毒准种特点的初步研究

探讨乙型肝炎病毒（HBV）在慢性患者中存在状态，以HBV基因序列为依据。设计特异性多聚酶链反应（PCR）引物，自2例慢性患者体内扩增HBV全S基因片段，克隆入T载体。限制片段长度多态性（RFLP）法确定HBV的变异现象，DNA测序确定病毒的变异程度，质粒EcoRI酶切RFLP结果提示自2例患者血清中克隆出的29和28个阳性克隆中各有5种不同的长度带型，PCR产物XhoI酶切RFLP结果则表现为高度保守，测序结果发现HBV体内毒株碱基序高度一致，同一患者两株全S区序列测序结果表明DNA序列的同源性大于97%。本结果提示HBV慢性患者体内有HBV准种共存，且呈现出一定的优势克隆现象。     

慢性乙型肝炎患者体内乙型肝炎病毒准种特点的初步研究

目的 探讨乙型肝炎病毒（HBV）准种在慢性乙型肝炎患者中的存在状态。方法 以已知中国株HBV基因序列为依据。设计特异性聚合酶链反应（PCR）引物,自3例慢性乙型肝炎患者体内扩增HBV全S基因片段,克隆人pGEMTeasy质粒,用限制性片段长度多态性（RFLP）法确定HBV的变异现象,DNA测序确定病毒的变异程度。结果 分别自3例患者血清中克隆出29、28和8个阳性克隆,以EcoRⅠ酶切患者1和2的RFLP结果提示各有5种不同的长度带型,PCR产物XhoI酶切RFLP结果表现为高度保守,测序结果发现HBV体内毒株DNA序列高度一致,同一患者两株全S区序列测序结果表明DNA序列的同源性大于97%。结论 慢性乙型肝炎患者体内有HBV准种共存,且呈现出一定的优势克隆现象。可能与患者预后有关。     

Serologic markers of hepatitis B virus (HBV) and hepatitis D virus infection in carriers of hepatitis B surface antigen who are frequently exposed to HBV

Serum hepatitis B e antigen (HBeAg) and HBV DNA are indicators of active replication of HBV, whereas IgM antibody to hepatitis B core antigen (IgM anti-HBc) may indicate an active immune response to chronic HBV infection. Fifty-eight carriers of hepatitis B surface antigen (HBsAg) who had frequent parenteral exposures were studied for the presence of HBeAg, HBV DNA, IgM anti-HBc and hepatitis delta virus (HDV) serologic markers. Active replication of HBV was detected in 36.2% (25% of drug addicts, 16.7% of thalassemia patients, and 46.9% of hemodialysis patients) and seropositivity for IgM anti-HBc in 55.2% of the HBsAg carriers. Among the 39 HBsAg carriers who were negative for HBeAg, IgM anti-HBc was detected significantly more frequently than HBV DNA (46.1% vs. 5.1%, p less than 0.001). Serologic evidence of HDV infection was detected in 35% of drug addicts, 50% of thalassemia patients and in 9.4% of hemodialysis patients. These data revealed that continued replication of HBV was more frequent in hemodialysis patients than in drug addicts and thalassemia patients who are HBsAg carriers and the opposite was true for the prevalence of HDV infection.     

Geographic distribution of hepatitis B virus (HBV) genotype in patients with chronic HBV infection in Japan

The geographic distribution of hepatitis B virus (HBV) genotypes in Japan and its clinical relevance are poorly understood. We studied 731 Japanese patients with chronic HBV infection. HBV genotype was determined by the restriction fragment length polymorphism (RFLP) method after polymerase chain reaction (PCR). Of the 720 patients with positive PCR, 12 (1.7%) were HBV genotype A, 88 (12.2%) were genotype B, 610 (84.7%) were genotype C, 3 (0.4%) were genotype D, and 7 (1.0%) were of mixed genotype. Over 94% of patients on the Japanese mainland had genotype C, while 60% of the patients on Okinawa, the most southern islands, and 22.9% in the Tohoku area, the northern part of the mainland, harbored genotype B. Compared with genotype C patients, genotype B patients were older (53.6 to 42.2 years; P <.01), had a lower rate of positive hepatitis B e antigen (HBeAg) (18.4% to 50.6%; P <.01), and a lower level of serum HBV DNA (5.02 to 5.87 log genome equivalents (LGE)/mL; P <.01). The mean age of the genotype B patients with hepatocellular carcinoma was 70.1 +/- 9.2 years, compared with 55.2 +/- 9.7 of genotype C patients (P <.01). These results indicate that genotypes C and B are predominant in Japan, and there are significant differences in geographic distribution and clinical characteristics among the patients with the different genotypes.     

Lack of evidence for hepatitis B virus (HBV) infection in fulminant non-A,non-B hepatitis

We studied eight patients who had orthotopic liver transplantation for fulminant hepatic failure in the course of acute non-A, non-B hepatitis. HBV DNA was searched for extensively in the liver tissue by PCR using several sets of primers in conventional and heminested reactions. All patients were negative for HBV DNA in liver tissue by all assays employed; furthermore, they were negative for HEV RNA, HCV RNA, and HBV DNA in serum. Although the causative role of HEV and HCV in fulminant non-A, non-B hepatitis cannot be excluded, our data do not support a causative association between this syndrome and HBV infection.This study was supported by Grant CR20 from the Mayo Clinic and Foundation. D.H.P. is supported by Public Health Service grants AI 32403, AR 41497, and AI 30548 from the National Institutes of Health.     

Latent hepatitis B virus infection with full-length viral genome in a patient serologically immune to hepatitis B virus infection

The presence, state, physical structure and cellular localization of hepatitis B virus (HBV) DNA were investigated in a patient with hepatitis B surface antigen (HBsAg)-negative chronic liver disease. HBV serology was positive for antibodies to hepatitis B core antigen (anti-HBc), to hepatitis B e antigen (anti-HBe) and to HBsAg (anti-HBs); no HBV DNA was detectable in serum. Southern blot analyses of DNA extracted from the liver demonstrated free monomeric HBV DNA as two distinct species: a predominant species of fully double-stranded relaxed circular molecules and a minor species of linear molecules of 3.2 kilobase pairs (kbp) length. Restriction enzyme analyses identified the HBV genome as HBsAg subtype adw2. Cell fractionation studies further revealed that the free viral DNA species were localized exclusively in liver cell nuclei. These findings in a patient serologically immune to HBV infection demonstrate that in hepatocytes HBV can establish a latent infection, characterized by the extrachromosomal presence of a full-length viral genome without production of infectious virus or synthesis of viral antigens.     

Efficacy of hepatitis B virus (HBV) vaccination in treating lamivudine-resistant HBV reactivation following hepatitis B surface antigen seroconversion.

BACKGROUND: HBsAg vaccination might help to control HBV replication following nucleos(t)ide analog therapy. We tested HBsAg vaccine in a patient who developed lamivudine resistance. PATIENT AND RESULTS: An HBeAg negative HBV chronically-infected patient developed HBsAg seroconversion after 3 years of treatment by lamivudine. However, the control of HBV replication was transient and HBV DNA could be detected in the serum one year after lamivudine was stopped. Concurrently, the anti-HBs antibodies (HBsAb) titre had decreased from more than 100 IU/L to 23 IU/L. Due to the presence of rtM204V resistance mutation, lamivudine was not reintroduced and the patient was treated by HBsAg vaccination. After three injections, HBV DNA was no more detectable and the HBsAb titre reached more than 200 IU/L. CONCLUSION: This observation suggests that a regular follow up of patients presenting HBsAg seroconversion following lamivudine therapy is necessary. In these patients, a low titre of HBsAb may not prevent from lamivudine-resistant HBV reactivation. Evaluation of HBsAg vaccination to maintain HBsAb at a high titre in these patients deserves further studies.     

Latent hepatitis B virus infection in healthy individuals with antibodies to hepatitis B core antigen

Several recent reports have shown that hepatitis B virus (HBV) could be frequently transmitted to the recipients from donors who have antibodies to hepatitis B core antigen (anti-HBc) through liver transplantation. We provide here the molecular evidence of latent HBV infection accompanied with ongoing viral replication in the liver tissue of anti-HBc-positive healthy individuals. HBV DNA was detectable in 13 of 14 healthy donors who were positive for both anti-HBc and antibodies to hepatitis B surface antigen (anti-HBs), but in none of 3 who were positive for anti-HBs alone. The detected HBV genomes from these subjects included covalently closed circular DNA and pregenomic RNA, the replication intermediate of HBV. Notably, 5 of 7 cases tested were predominantly infected with wild type HBV strains without any mutations in the precore and core promoter regions under the presence of circulating antibody to hepatitis B e antigen. Interestingly, a predominant clone detected in one donor showed a 63-nucleotide deletion in the precore region including an encapsidation signal sequence. Our findings indicate that the majority of healthy individuals positive for anti-HBc, which had been assumed to denote a past history of transient HBV infection, were latently infected with the episomal form of HBV accompanied by ongoing viral replication and few nucleotide mutations in the precore and core regions.