Diagnostic significance of quantitative determination of hepatitis B surface antigen in acute and chronic hepatitis B infection

Unusual serological profile in hepatitis B virus (HBV) infection associated with a probable clinical case of acute exacerbation of pre-existing chronic HBV infection

BACKGROUND

Acute or chronic HBV infection in an individual can be laboratory characterized according to the serological profile of the viral markers in the bloodstream, and the dynamics monitoring of these markers is necessary to assess the disorder course and the infection outcome. However, under certain circumstances unusual or atypical serological profiles may be observed in both acute and chronic HBV infection. They are considered as such because they do not properly characterize the form or infection clinical phase or because they seem inconsistent, considering the viral markers dynamics in both clinical contexts. This manuscript comprises the analysis of an unusual serological profile in HBV infection.

METHODS AND RESULTS

This clinical-laboratory study, had as reference a patient who presented clinical profile suggestive of acute HBV infection after recent exposure, whose laboratory data were initially compatible with this clinical presentation. However, the serological profile analysis and its monitoring demonstrated unusual pattern of viral markers expression, which has been observed in several clinical contexts, and is often associated a number of agent- or host-related factors.

CONCLUSION

The serological profile analyzed here, associated with the biochemical markers serum levels found, is indicative of active chronic infection, consequence of viral reactivation. This finding suggests that in the event of unusual serological profiles in HBV infection, if the influence of agent- or host-related factors is not properly considered and neither the viral markers dynamics properly analyzed, there may be mistake in the infection clinical diagnosis, especially when the patient's clinical and epidemiological history is unknown.

Modeling reveals no direct role of the extent of HBV DNA integrations on the outcome of infection

Hepatitis B virus (HBV) with its high prevalence and death toll is one of the most important infectious diseases to study. Yet, there is very little progress in the development of within-host models for HBV, which has subsequently hindered our understanding of this virus. The uncertainty around the proliferation of infected hepatocytes has been studied but never in association with other important biological continuous events such as integrations and superinfections. This is despite the fact that these processes affect the diversity and composition of infected cell population in the liver and an improved understanding of the cellular composition will undoubtedly assist in strategizing against this viral infection. Here, we developed novel mathematical models that incorporate these key biological processes and analyzed them both analytically and numerically. Unaffected by the extent of integrated DNA (IDNA), the outcome of HBV infection was primarily dictated by the balance between processes generating and killing infected hepatocytes containing covalent closed circular DNA (cccDNA). The superinfection was found to be a key process in the spread of HBV infection as its exclusion could not reproduce experimentally observed composition of infected hepatocytes at peak of acute HBV infection, a stage where our model predicts that infected hepatocytes most likely carry both cccDNA and IDNA. Our analysis further suggested the existence of some form of selective advantage of infected hepatocytes containing only IDNA to explain the viral dynamics observed during antiviral treatment and the transition from peak to acute infection. Finally, the fine line between liver destruction and resolution of acute HBV infection was found to be highly influenced by the fate of cccDNA during cellular proliferation.

The dilemma of differentiating between acute hepatitis B and chronic hepatitis B with acute exacerbation: Is quantitative serology the answer?

Background/Aims

Acute exacerbations of chronic hepatitis B (CHB-AEs) are common in endemic areas and are often presumed to be acute hepatitis B (AHB) due to their similarities in clinical and serological pictures, presenting a major diagnostic dilemma. This study aimed to identify laboratory markers for differentiating between the two groups, and to establish the cut-off value for significant markers.

Methods

A retrospective analysis of records was conducted for patients who presented with clinical features of acute hepatitis along with hepatitis B surface antigen (HBsAg) and IgM antibody to hepatitis B core antigen (IgM anti-HBc) positivity from May 2015 to May 2017. A total of 172 patients were enrolled and grouped as AHB (n=89) and CHB-AE (n=83) based on their history of hepatitis B virus infection and duration of HBsAg persistence. Virological and biochemical parameters were analyzed and compared. Cut-off values, sensitivity, and specificity of the variables were calculated.

Results

The median value of signal by cut-off (S/Co) ratio for IgM anti-HBc was significantly higher in AHB group (30.44) compared to CHB-AE group (8.63) with a sensitivity and specificity of 97% and 84%, respectively, at a cut-off of 20.5 (P<0.01). The mean international normalized ratio (INR) was significantly greater in CHB-AE (1.88±1.24) group compared to AHB group (1.62±0.17) with a sensitivity and specificity of 57.9% and 45.1%, respectively, at a cut-off value of 1.27.

Conclusions

A value of 20.5 S/Co of IgM anti-HBc and 1.27 INR could be helpful in differentiating between AHB and CHB-AE. (Clin Mol Hepatol 2020;26:187-195)

Acute hepatitis B virus infection or acute exacerbation of chronic hepatitis B infection: the differential serological diagnosis

Acute exacerbations of chronic hepatitis B are common, and may even be the first presentation of hepatitis B virus (HBV) infection. Sometimes, patients involved in these scenarios may have mistaken diagnosis of acute hepatitis B. The reason for the confusion is that the two forms of infection manifestation resemble remarkably in clinical, biochemical, and serological features, such as apparent rapid onset of severe disease, advanced grades of encephalopathy, high aminotransferases and prolonged international normalized ratios (INRs), as well as positivity for HBsAg and for IgM anti-HBc antibodies and DNA detection. Therefore, these two entities cannot be distinguished easily without historical information of HBV-associated chronic infection or recent HBV exposure, information that is often inaccurate. Considering the different prognoses, treatment strategies, and the epidemiological impact in the public health context, the correct diagnosis is extremely important. Despite the lack of effective and reliable tests to differentiate between acute infection and acute exacerbation of chronic HBV infection, the expression and kinetic evaluation of viral markers present in the circulation of individuals infected, the observation of physical-chemical properties of specific antibodies, and the combination of these findings represent some strategies in serology that could assist in differentiating between the two entities, or at least in the guidance for the correct diagnosis.

Re-appraisal of old and new diagnostic tools in the current management of chronic hepatitis B

Hepatitis B virus (HBV) is a very complex and intricate DNA structure associated with a particular genomic organization and replication cycle. However, many years of investigations allowed clarification of the real HBV natural history, through a deeper knowledge of the behavior of HBV antigens and viral structures. Several of the old diagnostic tools, such as HBV surface antigen (HBsAg) and HBV e antigen (HBeAg) determinations, gained prominence now, since the variation of both HBsAg and HBeAg plasma levels was shown to predict treatment response. In addition, the availability of more sensitive methods, such as HBV DNA detection by real-time PCR, has improved the current knowledge of the relationships between HBV replication levels and the natural history of the disease. It is now well established that some HBV genotypes are associated with a better response to treatment with pegylated interferon. Despite the widely accepted value of liver biopsy as a staging tool, transient elastography is being increasingly acknowledged as a non-invasive method to assess liver stiffness, chiefly for detection of advanced fibrosis. Current international guidelines for the management of chronic hepatitis B have provided several accurate biochemical and serological criteria for selecting patients for treatment, allowing a higher number of cases to be enrolled into antiviral therapy. This review describes the different serological markers used for the study of HBV and their clinical significance. It also deals with methods used for detection of genotypes and HBV DNA, emphasizing the effectiveness of such determinations for both patient selection and chronic hepatitis B therapy/monitoring.

Therapy of acute and fulminant hepatitis B

Although new hepatitis B virus (HBV) infections are decreasing due to improving vaccination coverage, patients without vaccination coverage can still suffer from manifestation of acute hepatitis B with jaundice and (although rarely) liver failure. No treatment is indicated for mild acute hepatitis B; however, antiviral therapy should be initiated for patients showing signs of significant liver impairment as exemplified by deterioration of prothrombin time to an equivalent of 1.5 or 50% of the 'Quick test'. For fulminant hepatitis, there is no complete agreement on whether antiviral treatment would alter the course, but it should still be started, as it would reduce the risk of reinfection in case there is a need for liver transplantation. Patients in danger of progression towards acute liver failure should be referred to transplant centers as early as possible.

Clinical implications of the titer of serum hepatitis B surface antigen during the natural history of hepatitis B virus infection

Although there are some differences in hepatitis B surface antigen (HBsAg) titers in infection with different hepatitis B virus (HBV) genotypes, the HBsAg titers for each HBV genotype have not been evaluated extensively. The aim of this study was to investigate HBsAg titers during the natural history of patients infected with HBV in Korea, where the HBV genotype C is endemic exclusively. Four hundred fifteen patients were enrolled retrospectively and classified according to definitions of the natural phases of HBV infection. In total, 73, 118, 147, and 77 patients were classified in the immune tolerance, immune clearance, low replicative, and HBeAg-negative hepatitis phases, respectively. HBsAg titers (4.35 ± 0.67, 3.74 ± 0.68, 2.39 ± 1.23, and 3.29 ± 0.64 log(10)  IU/ml) were significantly different in the immune tolerance, immune clearance, low replicative, and HBeAg-negative hepatitis phases, respectively (P < 0.001). The ratio of HBsAg to HBV DNA was highest in the low replicative phase (1.13 ± 0.71, all P < 0.001) and second highest in the HBeAg-negative hepatitis phase (0.58 ± 0.18, all P < 0.05). In multivariate analysis of all patients, the HBsAg titers did not correlate with alanine aminotransferase. However, the HBsAg titers correlated with age (P = 0.038), platelet count (P < 0.001) and HBV DNA (P < 0.001). In subgroup analysis, the HBsAg titers correlated with HBV DNA in all phases (P < 0.001), except for the HBeAg-negative hepatitis phase. HBsAg titers were significantly different across the four phases of the natural history of the infection and correlated significantly with HBV DNA titer in genotype C chronic hepatitis B patients. The HBsAg titer could be used as a biomarker to differentiate the natural history of HBV infection.

Hepatitis B surface antigen quantification: why and how to use it in 2011 - a core group report

Quantitative HBsAg had been suggested to be helpful in management of HBV, but assays were cumbersome. The recent availability of commercial quantitative assays has restarted the interest in quantitative serum hepatitis B surface antigen (HBsAg) as a biomarker for prognosis and treatment response in chronic hepatitis B. HBsAg level reflects the transcriptional activity of cccDNA rather than the absolute amount of cccDNA copies. Serum HBsAg level tends to be higher in hepatitis B e antigen (HBeAg)-positive than HBeAg-negative patients. Among patients with a low HBV DNA (<2000IU/ml), HBsAg <1000IU/ml in genotype D HBV infection and HBsAg <100IU/ml in genotype B/C HBV infection is associated with inactive carrier state in HBeAg-negative patients. The HBsAg reduction by nucleos(t)ide analogues (NA) is not as pronounced as by interferon treatment. On peginterferon treatment, sustained responders tend to show greater HBsAg decline than the non-responders. The optimal on-treatment HBsAg cutoff to predict response needs further evaluation in HBeAg-positive patients, but an absence of HBsAg decline together with a <2 log reduction in HBV DNA at week 12 can serve as stopping rule in HBeAg-negative patients with genotype D HBV infection. A rapid serum HBsAg decline during NA therapy may identify patients who will clear HBsAg in the long-term. There are early reports among Asian patients that an HBsAg level of <100IU/ml might predict lower risk of relapse after stopping NA treatment. In clinical practice, serum HBsAg level should be used together with, but not as a substitute for, HBV DNA.

Facile preparation of carbon nanotube-conducting polymer network for sensitive electrochemical immunoassay of Hepatitis B surface antigen in serum

A novel electrochemical immunosensor built on three dimensional carbon nanotube-conducting polymer (CNT-CP) network is reported for detection of Hepatitis B surface antigen (HBsAg) in human serum. The CNT-CP network is prepared by drop-drying of CNT solution on glassy carbon electrode, followed by electrochemical polymerization of poly (pyrrole propionic acid) (pPPA) film to crosslink and stabilize the CNTs, wherein the CNTs form the backbone of the network, and offer great specific surface areas for antibody attachment, and confer good conductivity for electrochemical detection, while the conducting film integrates the carbon nanotubes into a stable network due to its self-limiting growth behavior and provides abundant carboxyl groups for covalent immobilization of probe proteins. As a unique matrix, the CNT-CP network enables sensitive electrochemical detection of HBsAg biomarker by using alkaline phosphatase (ALP)-conjugated secondary antibodies under sandwich format coupling with the ALP substrate solution, p-aminophenyl phosphate (PAPP), reaching a detection limit of 0.01ng/mL with a dynamic range of 5 orders of magnitude.

Acute hepatitis B or exacerbation of chronic hepatitis B-that is the question

Hepatitis B virus (HBV) infection constitutes a serious global health problem. In countries with intermediate or high endemicity for HBV, exacerbations of chronic hepatitis B may be the first presentation of HBV infection. Some of these patients may be diagnosed mistakenly as having acute hepatitis B. Accurate diagnosis in these cases is very important for deciding whether to start treatment or not, because acute hepatitis B does not require therapy, while exacerbation of chronic hepatitis may benefit from it. Clinical and routine laboratory findings cannot help distinguishing between these two conditions. Therefore, several assays have been proposed for this purpose during the last few years. The presence of high levels of anti-HBe antibodies, HBsAg and HBV DNA are typical of chronic disease, whereas high titers of IgM anti-HBc, together with their high avidity index, characterize acute HBV infection. Starting from the description of a patient with acute hepatitis B-who recently came to our observation-we critically review the currently available assays that may help distinguishing between the different conditions and lead to the optimal management of each patient.

Deficiencies in the standardization and sensitivity of diagnostic tests for hepatitis B virus

The patterns of hepatitis B virus (HBV) markers described in textbooks apply to acute and chronic infection with wild-type HBV. Deviations from these patterns occur in the very early phase, in low-level (or occult) infection and under immunosuppression. Variability may originate from the virus, the host or the test kits. In order to obtain a reliable diagnosis under these conditions, tests for all three markers of HBV infection have to be applied: HBsAg, HBV DNA and anti-HBc. All tests should be as sensitive as feasible, but even then occult infection may be missed. Reliable detection of occult or mutated HBV is particularly important in blood and organ donors and in patients before or with immunosuppression.

Quantitative analysis of HBsAg, IgM anti-HBc and anti-HBc avidity in acute and chronic hepatitis B

BACKGROUND AND OBJECTIVES

We evaluated hepatitis B virus (HBV) serological markers by novel, quantitative immunoassays in order to study their behaviours and possible role in the various phases of HBV infection.

STUDY DESIGN

The quantitative determination of HBsAg and anti-HBc/IgM by chemiluminescent immunoassays (Abbott Architect) and the calculation of anti-HBc avidity index have been carried out on repository specimens from patients with acute or chronic hepatitis B.

RESULTS

In acute hepatitis the levels of HBsAg were generally >10,000 UI/mL and decreased sharply in the recovery phase. In 35 anti-HBe-positive chronic hepatitis cases HBsAg levels were generally lower than 10,000 UI/mL (mean: 2655), whereas in five HBeAg-positive chronic hepatitis patients the mean value was 78,756 UI/mL and 90% of specimens exceeded 10,000 UI/mL. The lowest values (mean: 1029 IU/mL) were found in the seven patients with minimal hepatic damage. IgM anti-HBc antibodies were positive in all acute cases and in 68/207 samples (32.85%) from patients with chronic hepatitis, with significantly lower levels (average sample/cutoff (S/CO) ratio: 2.95 in chronic cases versus 25.96 in acute cases; p<0.005). A S/CO value of 10 for anti-HBc IgM had a 100% negative predictive value and a 99.13% positive predictive value for acute hepatitis B. The study of anti-HBc avidity by an experimental procedure showed that an avidity index (AI) threshold of 0.7 had a good efficacy to discriminate the cases of chronic hepatitis, among whom only 2 specimens out of 193 (1.04%) had an AI<0.7.

CONCLUSION

The quantitative determination of HBsAg, anti-HBc/IgM and anti-HBc avidity provides additional information and may be useful in the differential diagnosis of acute and chronic HBV infections and in the follow-up of chronically infected patients.

Quantitation of hepatitis B surface antigen by an automated chemiluminescent microparticle immunoassay

A fully automated chemiluminescent microparticle immunoassay (Architect HBsAg QT) was used for the detection and quantitation of hepatitis B surface antigen (HBsAg). The assay is capable of processing up to 800 HBsAg tests per hour. The concentration of HBsAg is determined by utilizing a previously generated Architect HBsAg calibration curve. Architect HBsAg QT sensitivity was found to be around 0.2ng/ml which is equivalent or superior to other known and commercially available enzyme immunoassays and/or chemiluminescent immunoassays. We performed a quantitative study of HBsAg, HBeAg, HBV-DNA and HBV-DNA polymerase in over 733 sera obtained from 43 chronic hepatitis B carriers. Serum HBsAg levels detected by Architect HBsAg QT were found to be higher in HBeAg-positive than in anti-HBe-positive HBV chronic carriers and correlated with the level of serum HBV-DNA and HBV-DNA polymerase.

Alterations in intrahepatic expression of duck hepatitis B viral markers with ganciclovir chemotherapy

Ducks congenitally infected with duck hepatitis B virus (DHBV) were treated with the guanosine analogue, ganciclovir, and the effect on serum and intrahepatic expression of DHBV DNA and viral proteins was examined. After 21 days of ganciclovir treatment, a substantial reduction in viraemia occurred; in contrast, the level of circulating DHBV surface antigen was unchanged. Ganciclovir therapy also substantially reduced the level of DHBV DNA replicative intermediates and the expression of viral core and surface antigen in hepatocytes. However, despite the antiviral treatment some liver cells, including the bile duct epithelial cells and putative oval cells, maintained their intense staining for the viral proteins. Furthermore, DHBV-infected cells in extrahepatic sites such as the pancreas, kidney and spleen were also unaffected by ganciclovir treatment. These results suggest that monotherapy with nucleoside analogues is unlikely to eliminate chronic hepadnaviral infection, and antiviral programs should be designed to target all cell populations infected by the virus.

Measurement of HBsAg to monitor hepatitis B viral replication in patients on alpha-interferon therapy

HBsAg was measured quantitatively in serum samples collected serially before and after the HBeAg seroconversion date from 69 patients with HBeAg seroconversion and 17 patients with both HBeAg and HBsAg seroconversion. In patients with only HBeAg seroconversion the median HBsAg level decreased from 8.39 micrograms/ml (range 0.01-57.51) before HBeAg seroconversion to 3.53 micrograms/ml (range 0.002-68.66) after seroconversion (P < 0.001). No significant drop in HBsAg was found for the control group (18 HBeAg-positive patients without seroconversion). From 12 other patients on alpha-interferon therapy HBsAg was quantitatively assayed monthly during and after therapy; HBsAg levels were compared to the levels of HBV-DNA and HBeAg. We observed a good correlation between the HBsAg level and both the HBV-DNA (r = 0.76; P < 0.001) and the HBeAg (r = 0.70; P < 0.001) level, irrespective of the response to alpha-interferon. Quantified assessment of HBsAg appears promising as a simple and cheap method for monitoring viral replication in chronic hepatitis B in patients undergoing interferon therapy.

The use of ampligen alone and in combination with ganciclovir and coumermycin A1 for the treatment of ducks congenitally-infected with duck hepatitis B virus

Ampligen, a known immunomodulator and interferon inducer, was used alone and in combination with other antiviral agents to treat ducks congenitally-infected with duck hepatitis B virus. These antiviral agents included the conventional nucleoside analogue ganciclovir and the prokaryotic DNA gyrase B inhibitor coumermycin A1. When used alone, ampligen decreased the amount of serum and liver viral DNA, but had no effect on circulating duck hepatitis B surface antigen (DHBsAg). In combination with ganciclovir, the antiviral effect appeared at least additive with a greater inhibition of viral DNA replication within the liver. The combination of ampligen with coumermycin A1 also resulted in inhibition of viral replication but to a lesser extent than ampligen alone. When all three agents were used together, viral DNA replication was again inhibited, but as with previous treatment regimes, serum DHBsAg levels remained unchanged. At the end of the treatment period for all regimes, analysis of viral DNA forms in the liver showed that the viral relaxed circular and supercoiled DNA forms had persisted. Within 1 week of cessation of therapy, viral replication had often returned to pre-treatment levels. Interferon-like activity was detected in the sera of the majority of the treated ducks during the ampligen therapy, but no clear relationship between the presence of interferon and antiviral effect could be established. These observations in the duck hepatitis B model may provide a rational basis for the use of combinations of antiviral and immunomodulatory regimes for the management of chronic hepatitis B infection in man.

Diagnostic performance: a comparative study of the leukocyte differential count on four automated haematology analysers

The diagnostic performance of the haematology analysers, Technicon H1, Sysmex NE 8000, Coulter STKS and Sequoia Cell Dyn 3000 was determined by comparing their results for automated differential counting with the result obtained for 400 cells by the manual microscopic method. These comparative studies were performed on a group of adults, containing both normal individuals (n = 150) and those affected by various pathologies (n = 113). The number of morphologically false negatives is low for all the systems (from 1.8% for the Cell Dyn 3000 to 6.2% for the NE 8000), while the number of distributionally false negatives was slightly higher (from 4.4% for the Cell Dyn 3000 to 7% for the H1 and NE 8000). The morphological flags, though useful for improving the diagnostic performance of the instruments, show a rather modest sensitivity when taken individually: immature granulocytes/bands from 71% for the STKS to 43% for the NE 8000; blasts from 66.6% for the H1 to 53.3% for the STKS, atypical lymphocytes from 59% for the H1 to 13.6% for the NE 8000; erythroblasts from 42.8% for the STKS to 7% for the NE 8000.

Serologic diagnosis of viral hepatitis

Serologic tests are the most accurate method of identifying a viral cause for a liver disorder and distinguishing between the different forms of viral hepatitis. Although such characteristics of viral hepatitis as route of transmission and incubation period may be helpful in differential diagnosis, they seldom are sufficient to make an exact diagnosis. Laboratory tests or liver biopsy may help to differentiate liver disorders but again usually do not identify the form of viral hepatitis that is present. However, liver biopsy is often of value in patients with chronic hepatitis to determine the severity of disease, aid in prognosis, and, in some cases, serve as a guide to antiviral therapy.

Effect of nonspecific interactions of the hepatitis B surface antigen with the solid phase on its detection by two-site immunoradiometric assay

Two-site immunoradiometric assay (Austria II-125, procedure B, Abbott) was used to detect hepatitis B surface antigen (HBsAg) in chronic carrier sera from clinically healthy subjects or from kidney transplant or hemodialysis patients. The titration curves of some high-titered sera showed a prozone-like effect; this corresponded in two such sera LB and MA, to congruent to 80% inhibition of HBsAg detection in undiluted serum relative to a 1:800 dilution. The nature of the inhibition in the above two sera was investigated. We found that the inhibition depended on the time of first incubation but not on the affinity of capture antibodies. Nonspecific adsorption of HBsAg to the solid phase during the first incubation with inhibitory sera and elution of the thus adsorbed antigen during the second incubation, with the resulting neutralization of 125I-labeled anti-HBs, appeared to cause the inhibition of detection observed. The inhibition was prevented by addition of the detergent Triton X-100 to serum or by elution of adsorbed antigen prior to the second incubation, thus indicating that further improvements of the HBsAg immunoradiometric assay may be possible.

T cell-mediated hepatitis in mice infected with lymphocytic choriomeningitis virus. Liver cell destruction by H-2 class I-restricted virus-specific cytotoxic T cells as a physiological correlate of the 51Cr-release assay?

A model for immunologically T cell-mediated hepatitis was established in mice infected with lymphocytic choriomeningitis virus (LCMV). The severity of hepatitis was monitored histologically and by determination of changes in serum levels of the enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), glutamate dehydrogenase (GLDH), and alkaline phosphatase (AP). Kinetics of histological disease manifestations, increases of liver enzyme levels in the serum, and cytotoxic T cell activities in livers and spleens all correlated and were dependent upon several parameters: LCMV-isolate; LCMV-WE caused extensive hepatitis, LCMV-Armstrong virtually none. Virus dose. Route of infection; i.v. or i.p. infection caused hepatitis, whereas infection into the footpad did not. The general genetic background of the murine host; of the strains tested, Swiss mice and A-strain mice were more susceptible than C57BL or CBA mice; BALB/c and DBA/2 mice were least susceptible. The degree of immunocompetence of the murine host; T cell deficient nu/nu mice never developed hepatitis, whereas nu/+ or +/+ mice always did. B cell-depleted anti-IgM-treated mice developed immune-mediated hepatitis comparably or even more extensively than control mice. Local cytotoxic T cell activity; mononuclear cells isolated from livers during the period of overt hepatitis were two to five times more active than equal numbers of spleen cells. Adoptive transfer of nylon wool-nonadherent anti-Thy-1.2 and anti-Lyt-2 plus C-sensitive, anti-L3T4 plus C-resistant lymphocytes into irradiated mice preinfected with LCMV-WE caused a rapid time- and dose-dependent linear increase of serum enzyme levels. This increase was caused by adoptive transfer of lymphocytes if immune cell donors and recipient mice shared class I, but not when they shared class II histocompatibility antigens. The donor cell dose-dependent increase of these enzymes was first measurable 6-18 h after transfer with 2 X 10(8) cells or 3 X 10(6) cells, respectively. The time-dependent increase caused by the adoptive transfer of 1-2 X 10(8) cells was strictly linear during a period of up to 25-40 h. These results indicate single-hit kinetics of liver cell death and suggest that effector T cells destroy infected liver cells via direct contact rather than via soluble toxic mediators. The results may represent the best in vivo correlate of the in vitro 51Cr-release assay that has been analyzed so far, and strongly support the view that antiviral cytotoxic T cells are directly cytolytic in vivo.(ABSTRACT TRUNCATED AT 400 WORDS)

Serum inhibitory factors (SIF) are of prognostic value in acute viral hepatitis

Serum inhibitory factors (SIF) were analysed in relation to the natural course of acute viral hepatitis in 81 patients followed over a period of 1 year. 63 patients recovered completely (group 1), and 18 had a protracted course of hepatitis (group 2) as shown by persistent transaminase activity 6 months after onset. 11 patients in group 2 still had signs of liver disease after 1 year. A gradual fall of SIF activity (in 47 patients) heralded resolving hepatitis, whereas persistence of SIF (in 8 patients) correlated with inflammatory activity and failure of hepatitis B viral antigen elimination. Absence of SIF activity was associated with either an uncomplicated or a chronic course of hepatitis in 23 and 3 patients, respectively. Repeated determination of SIF may help to predict the final outcome of hepatitis. Both excessive and failure of SIF production may result in the development of chronic liver disease.

(+)-Cyanidanol-3 in the treatment of acute viral hepatitis: a randomized controlled trial

One-hundred sixty patients (81 cyanidanol, 79 placebo) were included in a double-blind placebo-controlled clinical trial to evaluate the effect of 3 gm (+)-cyanidanol-3 per day for 8 weeks on the clinical course of acute viral hepatitis and HBsAg elimination. Quantitative determination of HBsAg was performed at frequent intervals. The mean time for serum bilirubin to decrease to 1.3 mg per dl was 30.8 +/- 3.5 days in the treated group and 52.2 +/- 9.8 days in the control group, (p less than 0.025). The time for SGOT to decrease to 100 IU per liter was 17.98 +/- 1.82 in the treated group and 26.53 +/- 3.7 in the control group (p less than 0.025). No significant difference in the evolution of other laboratory values or symptoms was found. The elimination rate of HBsAg was identical in both groups. Treatment did not alter the incidence of chronicity.

Immunosuppressive serum factors in viral hepatitis. III. Prognostic relevance of rosette inhibitory factor and serum inhibition factor in acute and chronic hepatitis

Two immunosuppressive serum factors, serum inhibition factor (SIF) and rosette inhibitory factor (RIF), were studied in sera from patients with acute and chronic viral hepatitis. In a study of 30 patients with acute viral hepatitis, an association was found between RIF, SIF, and biochemical and virological parameters in 27 patients (90%), 25 of whom recovered completely; two had a protracted course. In three patients, the clinical course was not reflected by the immunosuppressive factors. In 26 patients with chronic persistent hepatitis, 3 had RIF and 7 had SIF of low activity. In patients with HBsAg-positive and -negative chronic active hepatitis, 32 of 47 had RIF and 24 had SIF. SIF activity was significantly increased in HBsAg positive as compared to -negative cases. There was no correlation between RIF and SIF activity at any stage of viral hepatitis. Although SIF was demonstrated in patients with various infectious and other inflammatory diseases, RIF was infrequently detected in nonviral liver disorders, and was not present in any of the nonhepatic diseases tested. It was confirmed that RIF is associated with the beta-lipoprotein fraction. RIF was easily separated from SIF by density gradient ultracentrifugation. The evaluation of SIF and RIF may be helpful in determining the outcome of acute viral hepatitis. In chronic hepatitis, RIF was a better indicator of disease activity than was SIF. These clinical data support previous findings that SIF may be related to the immune response whereas RIF is associated with liver cell damage.

Hepatitis A infection in chronic carriers of hepatitis B virus

By routine screening for serologic markers of hepatitis A and B in patients with acute hepatitis, 30 chronic carriers of hepatitis B virus with serologic evidence of acute hepatitis A and two patients with simultaneous acute infection with hepatitis A virus and hepatitis B virus were detected. For evaluation of clinical data, two major risk groups were distinguished. Nine patients were drug addicts and 17 were children and young adults from Mediterranean countries or southeast Asia. During the acute phase of illness, serum bilirubin and SGPT levels did not differ from those in other patients with acute hepatitis A. In three patients for whom follow-up sera were available, HBsAg concentration decreased during the acute stage of hepatitis A.