Extrahepatic manifestations associated with hepatitis C virus infection. A prospective multicenter study of 321 patients. The GERMIVIC. Groupe d'Etude et de Recherche en Medecine Interne et Maladies Infectieuses sur le Virus de l'Hepatite C

Anti-extractable Nuclear Antigens (ENA) Antibodies in Patients with Chronic Hepatitis C before and after Treatment with Interferon

A high prevalence of serological markers classically associated with autoimmune hepatitis or other autoimmune diseases has been reported in patients with chronic hepatitis C. However, the prevalence of antibodies to extractable nuclear antigens (anti-ENA) are rarely reported in such patients and the effect of treatment with interferon (IFN) on their prevalence is not known. In the present study, serum samples collected from 44 patients with chronic hepatitis C and 44 patients with non-hepatitis C virus (HCV) infected liver diseases were tested for anti-ENAs (U1 RNP, Sm, Ro/SS-A, La/SS-B and Scl-70) antibodies by enzyme-linked immunosorbent assay (ELISA). In 26 patients with chronic hepatitis C who received IFN treatment, serum samples were also collected just after completion of IFN treatment, and/or at 6-40 months after completion of the treatment, and tested for these antibodies. Sixteen (36%) of 44 sera from patients with chronic hepatitis C were positive for at least one of the above anti-ENA antibodies, whereas only 7 (16%) of 44 sera from patients with non-HCV infected liver diseases were positive for such antibodies (p = 0.0290). There was no significant difference in the prevalence of each of anti-ENA antibody between men and women. Results of anti-ENA antibodies in most IFN-treated patients with chronic hepatitis C did not change after treatment. However, in some cases serum anti-U1 RNP, anti-La/SS-B and anti-Scl-70 became negative or converted to the gray zone after completion of IFN treatment regardless of HCV elimination. Our results showed that the overall prevalence of anti-ENA antibodies was significantly higher in patients with chronic hepatitis C than in those with non-HCV-infected liver diseases. However, the disappearance of anti-ENA antibodies after IFN treatment in patients with chronic hepatitis C may be due to the immunomodulating effects of IFN rather than HCV elimination.

[Kidney diseases in HIV-infected patients]

HIV infection has become a global disease, both in geographic terms, since it has spread worldwide, and at the individual level since it affects every organ of the human body. Antiretroviral treatments, in countries where they are easily available, have modified HIV infection into a systemic chronic disease, the life expectancy of which is yet to be determined precisely. Treatments have dramatically changed the pattern of the disease and clinicians now have to face a number of new challenges. Kidneys, like all the other organs, can be involved in a great number of diseases in HIV-infected patients. We have voluntarily chosen to present "kidney diseases in HIV-infected patients" in their wider meaning, with a discussion of renal diseases that are directly caused by the virus, nephropathies due to frequent viral co-infections in HIV-infected patients such as HCV and HBV, nephropathies induced by anti-HIV, HBV and HCV therapies. Physicians in charge of HIV-infected patients should be aware of the key role they have to play in the screening for kidney abnormalities. This participates not only in improving patients' kidney prognosis but also their long-term general outcome. Renal screening strategies must refer to simple routine laboratory tests. Enclosed at the end of this article are a few suggestions for the renal management of situations that frequently occur in HIV infected patients (kidney dysfunction screening, serum creatinine increase and discovery of a proteinuria).

Systemic autoimmune diseases in patients with hepatitis C virus infection: characterization of 1020 cases (The HISPAMEC Registry)

OBJECTIVE

To describe the clinical and immunologic characteristics of a large series of patients with systemic autoimmune diseases (SAD) associated with chronic hepatitis C virus (HCV) infection.

METHODS

The HISPAMEC Registry is a multicenter international study group dedicated to collecting data on patients diagnosed with SAD with serological evidence of chronic HCV infection. The information sources are cases reported by physicians of the HISPAMEC Study Group and periodic surveillance of reported cases by a Medline search updated up to December 31, 2007.

RESULTS

One thousand twenty HCV patients with SAD were included in the registry. Patients were reported from Southern Europe (60%), North America (15%), Asia (14%), Northern Europe (9%), South America (1%), and Australia (1%). Countries reporting the most cases were Spain (236 cases), France (222 cases), Italy (144 cases), USA (120 cases), and Japan (95 cases). The most frequently reported SAD were Sjögren's syndrome (SS; 483 cases), rheumatoid arthritis (RA; 150 cases), systemic lupus erythematosus (SLE; 129 cases), polyarteritis nodosa (78 cases), antiphospholipid syndrome (59 cases), inflammatory myopathies (39 cases), and sarcoidosis (28 cases). Twenty patients had 2 or more SAD. Epidemiological data were available in 677 cases. Four hundred eighty-seven (72%) patients were female and 186 (28%) male, with a mean age of 49.5 +/- 1.0 years at SAD diagnosis and 50.5 +/- 1.1 years at diagnosis of HCV infection. The main immunologic features were antinuclear antibody (ANA) in 61% of patients, rheumatoid factor (RF) in 57%, hypocomplementemia in 52%, and cryoglobulins in 52%. The main differential aspect between primary and HCV-related SAD was the predominance of cryoglobulinemic-related markers (cryoglobulins, RF, hypocomplementemia) over specific SAD-related markers (anti-ENA antibodies, anti-dsDNA, anti-cyclic citrullinated peptide) in patients with HCV.

CONCLUSION

In the selected cohort, the SAD most commonly reported in association with chronic HCV infection were SS (nearly half the cases), RA and SLE. Nearly two thirds of SAD-HCV cases were reported from the Mediterranean area. In these patients, ANA, RF and cryoglobulins are the predominant immunological features.

Prevalence of hepatitis C serum antibody in autoimmune diseases

OBJECTIVE

To evaluate the prevalence of serum antibodies against hepatitis C virus and other infectious agents in a large cohort of well-characterized patients with autoimmune diseases (AID).

METHODS

We utilized 1322 sera from patients with 18 different AID and 236 sera from healthy controls from the same countries and with similar age and sex distribution. All sera were tested for the presence of serum anti-hepatitis C virus (HCV) antibodies as well as antibodies directed at other infectious agents and autoantibodies.

RESULTS

Anti-HCV antibody was detected in 115/1322 (8.7%) of patients with AID and 0.4% of matched healthy controls (P < 0.0001). The prevalence of anti-HCV antibody was significantly higher in 7/18 different AID (i.e. cryoglobulinemia, mixed cryoglobulinemia pemphigus vulgaris, vasculitis, secondary anti-phospholipid syndrome, Hashimoto's thyroiditis, and inflammatory bowel disease) compared to controls. Patients with AID and serum anti-HCV positivity had an increased prevalence of antibodies against hepatitis B virus, Toxoplasma gondii and Cytomegalovirus as opposed to a lower frequency of serum autoantibodies.

CONCLUSIONS

The enhanced prevalence of anti-HCV serum antibodies in AID may suggest a role for HCV in tolerance to breakdown, similarly to its established role in mixed cryoglobulinemia. This immune mediated effect does not rule out the role of other infectious agents.

The role of infectious agents in the pathogenesis of vasculitis

Numerous human studies and animal models have implicated various infectious agents in the pathogenesis of vasculitis in susceptible hosts. However, the link between infection and vasculitis is very complex and only incompletely understood. In fact, different agents can induce the same type of vasculitis, as the case of leukocytoclastic vasculitis exemplifies. Conversely, the same agent can give rise to a panoply of host responses ranging from a clinically silent infection or localized organ involvement to devastating, widespread vasculitis.

Hepatitis C virus infection induced vasculitis

Cryoglobulinemia are immune complexes that may induce systemic cryoglobulinemic vasculitis, a small-vessel vasculitis involving the skin, the joints, the peripheral nerve system, and the kidneys. During the last 15 years, progresses have been done after the discovery of the hepatitis C virus, the main cause of cryoglobulins. Main factors associated with cryoglobulin production are female gender, alcohol intake above 50 g/day, extensive liver fibrosis, and steatosis. Symptomatic cryoglobulins (i.e., vasculitis) are associated with older age, longer duration of infection, and main characteristics of cryoglobulin (type II, IgM kappa, high serum levels). The physiopathology is complex, and it involves humoral immunity, B- and T-cellular immunity but not the virus itself. Peg-Interféron alpha Ribavirine combination leads to a virological and clinical response of the vasculitis in about 70% of patients. In nonresponders, recent open series suggested the efficacy of Rituximab with a good response in up to 80% of patients but a relapse in 42% after 7 months after the last infusion. For future prospects and projects, new therapeutic strategies include a combination of best antiviral treatment with Peg-Interferon plus Ribavirin and Rituximab. Multicenter controlled trials are mandatory.

[Antiphospholipid antibodies, antiphospholipid syndrome and viral infections]

Since the association between antiphospholipid antibodies and syphilis was first described, many other viral, bacterial and parasitic infections have been shown to induce antiphospholipid antibodies, notably anticardiolipin antibodies. These aPL are usually associated neither with anti-beta2 glycoprotein I antibodies (anti-beta2-GPI) nor with thrombotic events, even if cases of arterial and deep venous thrombosis have been reported in such circumstances. A literature review shows that anticardiolipin antibodies occur frequently in viral infections, particularly in HIV (49.8%), HBV (24%) and HCV (20%). The prevalence of anti-beta2 glycoprotein I antibodies (anti-beta2GPI) is lower (HCV: 1.7%, HIV: 5.6%, HBV: 3.3%) and there is no demonstrated association with a risk of thrombotic events or hematological manifestations defining antiphospholipid syndrome (APS). Regarding other viral infections, including viral hepatitis A, herpes virus (CMV, EBV, VZV), parvovirus B19 and HTLV-1 infections, only a few studies are available but data confirm the high prevalence of antiphospholipid antibodies at the acute phase. Finally, antiphospholipid antibodies, mainly anticardiolipin, are frequently associated with viral infections. Their presence may probably reflect an intense or chronic antigenic stimulation of the immune system. However, their evolution under antiviral therapy and correlation with the quality of the virological control and/or the immune restoration remain to be determined.

Biological autoimmunity screening in hepatitis C patients by anti-HepG2 lysate and anti-heat shock protein 70.1 autoantibodies

Viruses require viral and cellular chaperones during their life cycle and interactions of these molecules with the immune system are probable during the infection. Thus, an anti-chaperone antibody response has been firstly investigated in hepatitis C patients in this paper. A HepG2-lysate antigen (90, 79, 72, 70, 62, 54 and 48 kDa) was assayed in sera from 59 (19F/40M) chronic hepatitis C patients without cirrhosis before therapy. Forty of them were positive for anti-HepG2 lysate antigen antibodies and this test may evaluate biological autoimmunity. Hsp70.1, Hsp90 and calreticulin levels were significantly higher in this antigen than in a control HepG2 antigen. Secondly, Hsp70.1 was identified as Hsp 70 kDa protein-1 by proteomic analysis and studied as a possible antibody target. Fourteen out of 59 patients were positive for anti-Hsp70.1 antibodies that were inversely correlated with alanine aminotransferase levels, the Metavir activity index and viraemia. Finally, for comparative purposes, 50 sera from systemic lupus erythematosus (SLE) patients have been tested: eight and 41 of them were positive for anti-Hsp70.1 and anti-HepG2 lysate antigen antibodies, respectively. Therefore, anti-Hsp70.1 autoantibodies may be produced and can partially lead to biological autoimmunity in chronic hepatitis C patients.

Hepatitis C virus infection and primary Sjögren's syndrome: a clinical and serologic description of 9 patients

OBJECTIVE

To define the clinical and immunologic profile of 9 patients with Sjögren's Syndrome (SS) and Hepatitis C virus (HCV) infection.

PATIENTS

9 out of 305 patients with SS, diagnosed according to the criteria proposed in 2002, had repeated positive serology for HCV.

RESULTS

9 female patients were studied. The mean age at onset of SS was 59 years, with a mean period of follow-up of 7.1 years. All the patients had glandular manifestations and they were all positive for dacryologic tests. Salivary gland biopsy was performed in 4 patients, all showing characteristic lymphocytic infiltrate. The main extraglandular features were arthralgias, photosensitivity, purpura, thyroiditis. All the patients were positive for anti-nuclear antibodies (ANA): 6 anti-Ro/SSA, 3 anti-Ro/SSA and anti-La/SSB positive. HCV-positive SS were compared with 296 patients with primary SS. They showed higher mean age (p=0.01), higher prevalence of photosensitivity (p=0.0266) and circulating cryoglobulins (p=0.0372). In primary SS, most patients had anti-Ro/SSA antibodies alone (49.8%) or associated to anti-La/SSB (46.5%). Five patients (1.8%) had other ANA specificities.

CONCLUSIONS

A chronic HCV infection is concomitant in about 3% of patients with pSS. They differ from patients without HCV infection for the higher prevalence of photosensitivity and cryoglobulins, without clinical manifestations of cryoglobulinemia.

Cryofibrinogen in patients with hepatitis C virus infection

BACKGROUND

Mixed cryoglobulin is usually associated with hepatitis C virus (HCV) infection and might cause systemic vasculitis. The presence and impact of cryofibrinogen, another cryoprotein, in the serum of HCV-infected patients have not yet been evaluated. The objective was to study the prevalence and the clinical and therapeutic impacts of cryofibrinogen in HCV-infected patients.

METHODS

A total of 143 consecutive HCV-infected (RNA+) patients (including 57 patients with HCV-related vasculitis) were screened for cryofibrinogen and cryoglobulin (positive if >0.05 g/L). The main characteristics and outcome were evaluated according to the cryofibrinogen/cryoglobulin status at baseline.

RESULTS

At baseline, 53 of 143 patients (37%) were cryofibrinogen positive, most of whom (47/53 [89%]) were also cryoglobulin positive. Only 37 of 90 cryofibrinogen-negative patients (41%) were cryoglobulin positive (P<.001). In patients with HCV-related vasculitis, 28 of 57 (49%) were cryofibrinogen positive compared with 25 of 86 patients (29%) without vasculitis (P=.03). There was a higher rate of renal involvement in cryofibrinogen-negative/cryoglobulin-positive patients than in cryofibrinogen-positive/cryoglobulin-positive patients (10/25 [40%] vs 3/27 [11%], respectively; P=.02). After a mean follow-up of 32.6 months, among patients who were cryofibrinogen positive at baseline, 12 of 26 (46%) of those who received an HCV treatment were cryofibrinogen negative at the end of follow-up compared with 4 of 16 (25%) of those who did not receive antiviral drugs. Most patients who became cryofibrinogen negative also became cryoglobulin negative (93%).

CONCLUSION

Cryoproteins, including cryoglobulin and cryofibrinogen, are frequently found in the serum of HCV-infected patients. In such patients, a positive cryofibrinogen status is closely related to the presence of cryoglobulin at baseline and after antiviral therapy.

In the clinic. Hepatitis C

Chronic hepatitis C virus (HCV) infection is the most common blood-borne infection in the United States, with an estimated overall prevalence of 3.2 million persons (1.3%) and prevalence peaks between age 40 to 49 years (1). The worldwide prevalence of HCV infection is even higher at 2.0%, corresponding to 140 million persons (2). In terms of complications, cirrhosis due to HCV disease is the most frequent indication for liver transplantation in the United States (3), and the overall incidence of hepatocellular carcinoma, a complication of HCV cirrhosis, continues to increase at alarming rates. In an evaluation of population-based registries of the Surveillance, Epidemiology, and End Results (SEER) program in the United States, the overall age-adjusted incidence rates of hepatocellular carcinoma increased from 1.4 per 100 000 in 1975 to 1977 to 3.0 per 100 000 in 1996 to 1998 (4).

Antiphospholipid antibodies and hepatitis C virus infection in Iranian thalassemia major patients

Although the precise nature of Antiphospholipid antibodies is still not clearly defined, they are known to have association with thromboembolic events and have been found in hepatitis C virus (HCV) infection. Moreover, high prevalence of HCV infection and thrombotic risk is described in thalassemia. We aimed at investigating the prevalence of anticardiolipin antibodies (aCLAbs), lupus anticoagulant (LA), and their relation with HCV infection in Iranian thalassemic patients. Presence of anti-HCV antibody, serum HCV-RNA, aCLAbs, and LA activity was determined in 131 patients with thalassemia major (male/female: 63/68 aged 3-29 years) registered at thalassemia unit, Dastgheib Hospital, Shiraz, Iran. Sixty-one healthy controls were also included. Anti-HCV antibody was positive in 24 (18.3%), IgG aCLAbs in 56 (42.7%), and LA activity in 9 (6.9%) patients. 87.5% of patients positive for aCLAbs had a low titer of aCLAbs. Although none of the participants had a previous history of thrombosis, higher prevalence of aCLAbs was detected in thalassemic patients compared with controls. No significant difference in the prevalence of aCLAbs was found between HCV-infected and noninfected patients. A high prevalence of aCLAbs, the majority in low titers, was detected in Iranian thalassemic patients irrespective of previous history of thrombosis and presence of HCV infection.

Antiphospholipid syndromes in infectious diseases

Antiphospholipid antibodies are essential in the diagnosis of antiphospholipid syndrome (APS), or the classic "Hughes syndrome," which is a systemic disorder that is autoimmune in nature. They are also found in various infections in low titers without any evidence of thrombotic manifestations of APS. However, in a few infections, when antiphospholipid antibodies are associated with protein cofactor, there can be associated thrombosis. Different infections are also responsible for triggering a subset of lethal APS, acute catastrophic APS. This situation requires prompt diagnosis and aggressive treatment of the infection to prevent severe complications.

Antinuclear antibody is associated with a more advanced fibrosis and lower RNA levels of hepatitis C virus in patients with chronic hepatitis C

AIMS

Positive serum antinuclear antibody (ANA) is present in a number of patients with chronic hepatitis C virus (HCV) infection. This study aimed to evaluate the prevalence of ANA in patients with chronic hepatitis C (CHC) and to elucidate its clinical implications in virological and histological characteristics of CHC infection.

METHODS

A total of 614 CHC patients were enrolled in this prospective, hospital-based study. The serum levels of aspartate aminotransferase, alanine aminotransferase and ANA, and HCV genotype, HCV RNA level, and histological activity index scores for liver histopathology, were determined.

RESULTS

The prevalence of positive ANA (titre >1:40) was 35.0%. Women had a significantly higher prevalence than men (41.2 vs 31.0%; p = 0.012). Patients positive for ANA were significantly older (mean (SD), 53.7 (10.5) vs 49.7 (11.3) years; p<0.001) and had higher mean (SD) alanine aminotransferase levels (186.9 (178.8) vs 155.50 (113.5) IU/l; p<0.001) and lower mean (SD) HCV RNA levels (5.2 (0.9) vs 5.4 (1.0) log IU/ml; p = 0.048) than those without ANA. Among 447 patients undergoing liver biopsy, those positive for ANA had a significantly higher mean (SD) fibrosis score (2.0 (1.3) vs 1.5 (1.1); p<0.001) and a higher frequency of F3-4 (69/187, 36.9% vs 50/260, 19.2%; p<0.001) than those negative for ANA. Multivariate logistic regression analyses showed that advanced fibrosis, lower HCV RNA levels and age were significant factors related to positive ANA.

CONCLUSION

ANA is associated with a more advanced liver fibrosis and lower serum HCV RNA level in patients with CHC.

Oral diseases associated with hepatitis C virus infection. Part 1. sialadenitis and salivary glands lymphoma

Morbidity associated with hepatitis C virus (HCV) infection is due not only to the sequelae of chronic liver disease, but also to a variety of extraheaptic manifestations (EHM). Some of the most frequently reported EHM of HCV infection involves the oral region predominantly or exclusively and they are the topics of this 2-part review. The current part 1 discusses the evidences on the association of salivary glands disorders with HCV. HCV- infected patients may frequently have histological signs of Sjögren-like sialadenitis with mild or even absent clinical symptoms. However, the pathogenetic role of HCV in Sjogren Syndrome (SS) development and the characteristics distinguishing classic SS from HCV-related sialadenitis are still an issue. It is unclear if the virus may cause a disease mimicking primary SS or if HCV is directly responsible for the development of SS in a specific subset of patients. Notably, some patients may present a triple association between HCV, SS-like sialadenitis and salivary gland lymphoma and the virus may be involved in the lymphomagenesis. The risk of having a salivary gland lymphoma is particularly high in patients with mixed cryoglobulinemia. Little attention has been paid to the effects of anti-HCV treatment on sialadenitis or lymphoma development.

Viral-Associated Immune Thrombocytopenic Purpura

Chronic immune thrombocytopenic purpura (CITP) is a diagnosis of exclusion that occurs either de novo or secondary to other underlying disorders. Chronic infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are now well-characterized causes of CITP. Between 6% and 15% of patients infected with HIV may develop thrombocytopenia. Patients with CITP with risk factors for HIV infection should be screened for the virus. Treatment of HIV-related CITP should be directed toward antiviral therapy with highly active antiretroviral therapy (HAART) regimens. Hepatitis C viral infection can also be associated with chronic thrombocytopenia, even in the absence of overt liver disease. While HCV-related thrombocytopenia is typically less severe than primary CITP, affected patients are at greater risk of major bleeding. Sustained suppression of HCV virus with interferon-ribavirin therapy can improve platelet counts. Screening for HCV infection should be considered in patients with ITP with risk factors for infection, from regions with high rates of infection or in patients with unexplained mild elevations of liver enzymes.

Chronic hepatitis C virus infection: Prevalence of extrahepatic manifestations and association with cryoglobulinemia in Bulgarian patients

AIM: To assess the prevalence of extrahepatic manifestations in Bulgarian patients with chronic hepatitis C virus (HCV) infection and identify the clinical and biological manifestations associated with cryoglobulinemia.

METHODS: The medical records of 136 chronically infected HCV patients were reviewed to assess the prevalence of extrahepatic manifestations. Association between cryoglobulin-positivity and other manifestations were identified using χ² and Fisher’s exact test. Risk factors for the presence of extrahepatic manifestations were assessed by logistic regression analysis.

RESULTS: Seventy six percent (104/136) of the patients had at least one extrahepatic manifestation. Clinical manifestations included fatigue (59.6%), kidney impairment (25.0%), type 2 diabetes (22.8%), paresthesia (19.9%), arthralgia (18.4%), palpable purpura (17.6%), lymphadenopathy (16.2%), pulmonary fibrosis (15.4%), thyroid dysfunction (14.7%), Raynaud’s phenomenon (11.8%), B-cell lymphoma (8.8%), sicca syndrome (6.6%), and lichen planus (5.9%). The biological manifestations included cryoglobulin production (37.5%), thrombocytopenia (31.6%), and autoantibodies: anti-nuclear (18.4%), anti-smooth muscle (16.9%), anti-neutrophil cytoplasm (13.2%) and anti-cardiolipin (8.8%). All extrahepatic manifestations showed an association with cryoglobulin-positivity, with the exception of thyroid dysfunction, sicca syndrome, and lichen planus. Risks factors for the presence of extrahepatic manifestations (univariate analysis) were: age ≥ 60 years, female gender, virus transmission by blood transfusions, longstanding infection (≥ 20 years), and extensive liver fibrosis. The most significant risks factors (multivariate analysis) were longstanding infection and extensive liver fibrosis.

CONCLUSION: We observed a high prevalence of extrahepatic manifestations in patients with chronic HCV infection. Most of these manifestations were associated with impaired lymphoproliferation and cryoglobulin production. Longstanding infection and extensive liver fibrosis were significant risk factors for the presence of extrahepatic manifestations in HCV patients.

High molecular weight form of adiponectin levels of Japanese patients with chronic hepatitis C virus infection

AIM

The aim of the present study was to clarify the correlation between serum adiponectin level and the properties of hepatitis C virus (HCV).

METHODS

A meal test was carried out for insulin resistance assessment in 81 patients with chronic HCV infection. Blood samples were taken before and after the test to measure serum insulin and plasma glucose (PG). The adiponectin level was measured by enzyme-linked immunosorbent assay in each patient.

RESULTS

Serum adiponectin levels were significantly correlated with the area under the insulin curve (AUC-insulin)during the meal test and with serum HCV-RNA level. Multiple regression analysis showed age to be a significant independent parameter associated with an increased adiponectin level, whereas male sex, fasting insulin, and serum HCV-RNA level were significant independent parameters associated with a decreased adiponectin level.

CONCLUSION

It is possible that insulin resistance in patients with chronic HCV infection is related to adiponectin secretion.

Hepatitis C and ocular surface disease

PURPOSE

To assess the frequency of changes in the ocular surface and the presence of hepatitis C virus (HCV) in tear samples of patients with chronic HCV infection.

DESIGN

Prospective, nonrandomized, clinical, interdisciplinary, single-center study.

METHODS

Seventy-one patients with previously untreated chronic HCV infection and a control group consisting of 66 patients without systemic HCV infection were enrolled in the trial. The patients with HCV infection were screened for ocular symptoms, visual acuity, and ocular changes. Tear production was measured by the Jones test. Conjunctival impression cytologic analysis was performed. The presence of HCV ribonucleic acid (RNA) in tear and blood samples was determined by quantitative polymerase chain reaction.

RESULTS

On examination, systemic HCV infection was present for a median of 30 months. Fifty percent of all HCV patients showed a decrease in tear production measured by the Jones test. Apart from epithelial changes related to dry eye syndrome in 12 patients, two patients presented mild peripheral corneal thinning. Polymerase chain reaction analysis detected HCV RNA in five (10%) of 52 tear samples. HCV RNA levels in tear samples (mean, 1.0 x 10(4) copies/ml) were considerably lower than in blood samples (mean, 5.3 x 10(5) copies/ml).

CONCLUSIONS

Dry eye syndrome is the most frequently observed ocular feature in HCV infection. Patients with HCV infection (age range, 21 to 60 years) compared with the controls had a significant lower tear production (P = .05). The presence of HCV RNA in 10% of tear samples emphasizes the potential risk of viral transmission through tears.

Infectious neuropathy

PURPOSE OF REVIEW

Infectious neuropathy affects a large number of people worldwide. There is evidence of direct involvement of nerves by the infective agent, from the immune reaction of the patient or secondary to the toxicity of the drugs used during treatment. This group of neuropathies is often treatable or preventable.

RECENT FINDINGS

There is a complex clinical picture of the neuropathy of leprosy, different pathological features and immunological mechanisms. If the skin is unaffected in leprosy it is not always easy to demonstrate that the neuropathy is due to leprosy. Peripheral neuropathy in patients with chronic infection with hepatitis C virus may be due to the virus, the development of vasculitis or direct neurotoxic effects of the treatment. Peripheral neuropathy has become the chief neurological syndrome in individuals infected with HIV-1. The antiretroviral therapies themselves can cause peripheral neuropathies clinically indistinguishable from those caused by the virus. The occurrence of chronic polyneuropathy as a late manifestation in Lyme disease is extremely rare and is not well understood.

SUMMARY

Although infectious neuropathies are very frequent, mainly in developing countries, further studies are needed to elucidate their mechanisms of action, focusing on preventive interventions.

Peripheral neuropathy in patients with hepatitis virus C infection in the Amazon region

INTRODUCTION

Hepatitis virus C (HCV) infection is considered a health problem in the State of Acre localized in the Brazilian Amazon which has a prevalence rate of 5.9%. Peripheral neuropathy is a common extra-hepatic manifestation in patients with HCV.

OBJECTIVE

To determine the prevalence of peripheral neuropathies using clinical and neurophysiological parameters.

METHOD

A cross sectional study was performed in patients assisted by a specialized center of infectious diseases in the State of Acre. All patients completed a clinicoepidemiological questionnaire, physical examination and nerve conduction studies (NCS).

RESULTS

We studied 78 patients with mean age 45.5 years (range from 10 to 76 years), two thirds were male, 51% had at least 8 years of formal education and 96% lived in the capital city of Acre State. Roughly 34% of patients complained about paresthesias mainly in upper limbs. The NCS diagnosed multiple mononeuropathy in 11 (14.1%; IC95% 7.6-23.2) patients and carpal tunnel syndrome in 4 (5.1%) patients.

CONCLUSION

Subclinical involvement of peripheral nerves seems common in patients with HCV, with multiple mononeuropathy the main manifestation of nerve injury in this region as suggested by electrophysiological studies.

Severe hepatitis C virus-related cryoglobulinaemic sensory-motor polyneuropathy treated with pegylated interferon-a2b and ribavirin: clinical, laboratory and neurophysiological study

BACKGROUND/AIMS

Severe involvement of central and/or peripheral nervous system is a rare complication of hepatitis C virus (HCV)-related cryoglobulinaemia.

METHOD

Four patients with HCV-related type II/III cryoglobulinaemia (three males with genotype 1, one female with genotype 3) who presented with severe sensory-motor polyneuropathy, one with central nervous system involvement as well, were treated with pegylated IFNa-2b 1.5 microg/kg/week and ribavirin 10.6 mg/kg/daily for 48 weeks. Neurological evaluation involved detailed clinical motor and sensory scores/scales and neurophysiological studies before and after treatment.

RESULTS/CONCLUSION

Three out of four patients had undetectable serum HCV-RNA, normal levels of aminotransferases and substantially lower or undetectable levels of cryoglobulins at the end of treatment and at 24 weeks follow-up period. Treatment was well tolerated and all patients exhibited significant improvement of neuropathy based on solid clinical and laboratory criteria that was associated with the virological response.

Antiphospholipid antibodies in HIV-positive patients

Antiphospholipid (aPL) antibodies classically have been associated with thrombotic phenomena and abortion in patients with autoimmune diseases. The objective of the present work was to evaluate the frequency of such antibodies in patients infected with HIV and study its association with the presence of clinical manifestations of antiphospholipid syndrome (APS). Using a transversal study, a population of patients diagnosed with HIV, identified through an enzyme-linked immunosorbent assay (ELISA) test and confirmed by Western blotting, aged above 17 years old, was investigated. Through a standard questionnaire, the presence of APS manifestations was investigated, as well as the frequency of rheumatic manifestations. Antibodies against beta2 glycoprotein I (anti-beta2 GPI) and anticardiolipin (aCL) IgA, IgG, and IgM were investigated by the ELISA method using commercial kits (QUANTA Lite, INOVA Diagnostics). Ninety patients were studied, 47 (52.2%) male and 43 (47.8%) female. Clinical manifestations of APS were detected in 12 patients (13.3%) of the studied population, whereas arthralgia was the most common rheumatic manifestation (38.9%). Of the 90 patients, 40 (44.4%) were reactive for at least one type of aPL antibody (aCL and/or anti-beta2 GPI). The frequency of aCL was 17.8%, from which 15 (16.7%) had aCL IgG, 3 (3.3%) IgM, and 1 (1.1%) IgA. The frequency of the anti-beta2 GPI antibody was 33.3%, from which 29 (32.2%) were positive for isotype IgA, 4 (4.4%) isotype IgM, and 1 (1.1%) isotype IgG. No association was observed between immunoreactivity for aPL antibodies in general or each isotype in particular and the presence of APS manifestation. In the present study, it was possible to observe a relatively high frequency of aPL antibodies, particularly for isotype IgA anti-beta2 GPI in HIV. However, there was no association to APS manifestations, suggesting that such antibodies had no etiopathogenic role in these complications in patients with such retroviral infection.

Hepatitis C and arthritis: an update

Extrahepatic symptoms during chronic hepatitis C virus (HCV) infection are common and varied. Arthritis can be seen either as part of autoimmune processes (eg, associated with cryoglobulinemia) or independently. Whether the manifestation is specifically attributable to HCV infection or rather to the nonspecific result of a chronic inflammatory process is not clear. The literature available at this time is insufficient to guide the most appropriate course of treatment of HCV arthritis. Standard antirheumatic treatment can be considered, but with caution, because some of these medications occasionally may be hepatotoxic and response to therapy seems variable. Treatment decisions should be determined on a case-by-case basis.

Dermatologic disorders associated with chronic hepatitis C: effect of interferon therapy

Chronic hepatitis C virus infection (HCV) is associated with extrahepatic manifestations, including such dermatologic conditions as mixed cryoglobulinemia, porphyria cutanea tarda, and lichen planus. Patients with chronic HCV and extrahepatic manifestations are often excluded from clinical trials evaluating interferon (IFN) therapy due to concerns about poor response, adverse events, and toxicity. Thus, data regarding the efficacy of IFN not only on the underlying chronic HCV, but also on extrahepatic manifestations, are limited in these patients. Case reports suggest that the response of dermatologic extrahepatic manifestations to IFN in patients with chronic HCV is highly variable. This review summarizes available data on dermatologic conditions associated with chronic HCV and their response to IFN therapy.

Novel Thrombopoietic Agents

Thrombocytopenia is a primary manifestation of immune thrombocytopenic purpura (ITP) and may occur as a result of hepatitis C, malignancy, and treatment with chemotherapy. There is a need for additional means to treat thrombocytopenia in these settings. Recombinant thrombopoietin-like agents became available after the cloning of thrombopoietin in 1994. In clinical trials, these agents showed some efficacy in chemotherapy-induced thrombocytopenia, but their use was ultimately discontinued due to the development of neutralizing antibodies that cross-reacted with endogenous thrombopoietin and caused thrombocytopenia in healthy blood donors and other recipients. Subsequently, “second-generation” thrombopoietic agents without homology to thrombopoietin were developed. In the past 5 years, these second-generation thrombopoeitic growth factors have undergone substantial clinical development and have demonstrated safety, tolerability and efficacy in subjects with ITP and hepatitis C–related thrombocytopenia. These completed studies, many of which are available only in abstract form, and other ongoing studies suggest that thrombopoietic agents will enhance the hematologist’s ability to manage these and other causes of thrombocytopenia.

Clinical significance of organ- and non-organ-specific autoantibodies on the response to anti-viral treatment of patients with chronic hepatitis C

BACKGROUND

Development of organ- and non-organ-specific autoantibodies has been reported in hepatitis C virus patients treated with interferon-alpha plus/minus ribavirin.

AIMS

To address whether prevalence and the titre of gastric parietal autoantibodies and non-organ-specific autoantibody in hepatitis C virus-treated patients were affected by therapy, and if the development of these antibodies carries any clinical significance on the response to treatment, as few studies in adults have been strictly designed to address the above hypothesis.

METHODS

Samples at three time-points (baseline, end of treatment, end of follow-up) from 102 hepatitis C virus patients (39 sustained responders, 26 relapsers, 33 non-responders; four lost in follow-up) were studied for gastric parietal autoantibodies and/or non-organ-specific autoantibody by indirect immunofluorescence, commercial and in-house enzyme-linked immunosorbent assays.

RESULTS

Sustained virological and biochemical response was associated with antinuclear antibody absence (end of treatment or end of follow-up), decrease of smooth-muscle antibody titres during therapy and gastric parietal autoantibodies negativity at baseline. However, after multivariate analysis only antinuclear antibody positivity at the end of treatment and increase of smooth-muscle antibody titres were associated with worst treatment response, independently of known factors of worst treatment outcome.

CONCLUSIONS

We were able to demonstrate a negative correlation between the efficacy of anti-viral treatment for hepatitis C virus and the presence of antinuclear antibody and smooth-muscle antibody before treatment, or their increase during therapy.