High incidence of extrahepatic manifestations in an HCV hyperendemic area

Successful Treatment of Oral Lichen Planus with Direct-Acting Antiviral Agents after Liver Transplantation for Hepatitis C Virus-Associated Hepatocellular Carcinoma

Hepatitis C virus (HCV) infection is frequently associated with various extrahepatic manifestations, such as autoimmune features and immune complex deposit diseases. Oral lichen planus (OLP) is one such extrahepatic manifestation of HCV infection. Recently, direct-acting antivirals (DAA) have proved to be highly effective and safe for the eradication of HCV. Herein, we report a case of OLP accompanied by HCV-related hepatocellular carcinoma (HCC) that disappeared after liver transplantation and achievement of sustained virological response following interferon (IFN)-free treatment with ledipasvir (LDV) and sofosbuvir (SOF). The 50-year-old patient developed erosive OLP during IFN therapy, with hyperthyroidism at 53 years of age and HCC at 55 years. He received immunosuppressive drugs and IFN-free DAA treatment after liver transplantation at 60 years of age, which led to disappearance of the symptoms of OLP. The patient was treated safely and effectively with LDV/SOF, although it is not known whether the disappearance of OLP resulted from the eradication of HCV or the immunosuppressive therapy.

Economic Burden of Hepatitis C Infection

The economic burden of chronic hepatitis C might exceed $10 billion annually in the United States alone. This disease has a worldwide prevalence of up to 3%, making the global burden of the disease comparably tremendous. The cost of the disease includes direct medical expenses for its hepatic and extrahepatic manifestations, and also indirect costs incurred from impaired quality of life and the loss of work productivity. Recent emergence of treatment options that are not only highly effective and safe but also costly has emphasized the need to study the disease from the economic point of view.

The impact of hepatitis C virus outside the liver: Evidence from Asia

Between 80 and 115 million people worldwide are chronically infected with hepatitis C virus, with 60%-90% of these being undiagnosed. Untreated chronic hepatitis C (CHC) is associated with progressive liver disease, cirrhosis, hepatocellular carcinoma and liver-related mortality. A number of extrahepatic manifestations are also reported in CHC patients, further adding to the burden of the disease. CHC also impacts patients in terms of lower health-related quality of life, higher levels of fatigue and reduced productivity. Furthermore, the later stages of disease are costly for both healthcare systems and society. Pegylated-interferon (PEG-IFN)+ribavirin (RBV), for many years the mainstay of treatment, leads to sustained virological response (SVR) in 40%-70% of patients. However, a substantial number of patients are ineligible for treatment, and many patients fail to achieve SVR with this regimen. Furthermore, PEG-IFN+RBV leads to impairment of patient-reported outcomes during treatment, and most patients suffer from adverse events, associated with poor adherence, treatment discontinuation and treatment failure. The approval of second-generation direct-acting antivirals (DAAs) has revolutionized the treatment of CHC patients. All-oral, PEG-IFN and RBV-free regimens have higher efficacy rates, shorter treatment durations, fewer adverse events, higher adherence rates and improvement in PROs from as early as Week 4, compared to PEG-IFN+RBV regimens. The aim of this article is to review the evidence for HCV infection as a systemic disease, summarizing the impact of hepatitis C and its treatments on clinical, patient and economic outcomes, with a focus on data from Asia and Japan specifically.

Clinicopathological features and malignant transformation of oral lichen planus: a 12-years retrospective study

OBJECTIVE

Oral lichen planus (OLP) is known to be associated with the risk of developing oral squamous cell carcinoma (OSCC). The objective of this study was to investigate the clinicopathological features of OLP and the prevalence of malignant transformation in this setting.

MATERIALS AND METHODS

This retrospective study was carried out on 204 medical records of patients with histologically proven OLP who received long-term follow-up (range 6 months-12 years). Data were entered in an informatic database. The statistical analysis, when needed, was performed with the chi-squared test for significance (p < 0.05).

RESULTS

At the moment of the diagnosis, out of 204 patients (163 female and 41 male; mean age 54.5 years), 107 patients (52.45%) suffered from systemic chronic diseases, in particular 46 (22.5%) from hepatitis C. Clinically, the reticular form of OLP was the predominant one and most patients had multiple oral sites of involvement. Fourteen patients showed extra-oral lesions. A percentage of malignant transformation less than 1% was found. In fact, two patients (0.98%) underwent a malignant transformation at a site previously diagnosed as OLP.

CONCLUSIONS

At present, OLP is accepted as being a potential malignant disorder, therefore lifelong follow-up is recommended.

Positive association between hepatitis C infection and oral cavity cancer: a nationwide population-based cohort study in Taiwan

OBJECTIVES

The association between viral hepatitis (B and C) and oral cavity cancer has been widely debated. This nationwide, population-based cohort study assessed the subsequent risk of oral cavity cancer among patients with chronic viral hepatitis infection.

MATERIALS AND METHODS

Data were retrieved from insurance claims data of 1,000,000 randomly sampled individuals covered under the Taiwan National Health Insurance system. We identified a total of 21,199 adults with chronic viral hepatitis infection (12,369 with HBV alone, 5,311 with HCV alone, and 3,519 with HBV/HCV dual infections) from 2000-2005. Comparison group comprised 84,796 sex- and age-matched subjects without viral hepatitis during the same study period. Incidence and risk of subsequent oral cavity cancer were measured until 2008.

RESULTS

The incidence of oral cavity cancers was 2.28-fold higher among patients with HCV alone than non-viral hepatitis group (6.15 versus 2.69 per 10,000 person-years). After adjusting for sociodemographic covariates, HCV alone was significantly associated with an increased risk for oral cavity cancer (hazard ratio (HR) = 1.90, 95% confidence interval (CI) = 1.20-3.02). This positive association was highest among individuals in the 40-49-year age group (HR = 2.57, 95% CI = 1.21-5.46). However, there were no significant associations between HBV alone or HBV/HCV dual infections and risk for oral cavity cancer.

CONCLUSION

Our data suggest that HCV but not HBV infection is a risk factor for oral cavity cancer. In addition, subjects with HCV infection tend to be at early onset risk for oral cavity cancer. This finding needs to be replicated in further studies.

Hepatitis C virus-host interactions: Etiopathogenesis and therapeutic strategies

Hepatitis C virus (HCV) is a significant health problem facing the world. This virus infects more than 170 million people worldwide and is considered the major cause of both acute and chronic hepatitis. Persons become infected mainly through parenteral exposure to infected material by blood transfusions or injections with nonsterile needles. Although the sexual behavior is considered as a high risk factor for HCV infection, the transmission of HCV infection through sexual means, is less frequently. Currently, the available treatment for patients with chronic HCV infection is interferon based therapies alone or in combination with ribavirin and protease inhibitors. Although a sustained virological response of patients to the applied therapy, a great portion of patients did not show any response. HCV infection is mostly associated with progressive liver diseases including fibrosis, cirrhosis and hepatocellular carcinoma. Although the focus of many patients and clinicians is sometimes limited to that problem, the natural history of HCV infection (HCV) is also associated with the development of several extrahepatic manifestations including dermatologic, rheumatologic, neurologic, and nephrologic complications, diabetes, arterial hypertension, autoantibodies and cryglobulins. Despite the notion that HCV-mediated extrahepatic manifestations are credible, the mechanism of their modulation is not fully described in detail. Therefore, the understanding of the molecular mechanisms of HCV-induced alteration of intracellular signal transduction pathways, during the course of HCV infection, may offer novel therapeutic targets for HCV-associated both hepatic and extrahepatic manifestations. This review will elaborate the etiopathogenesis of HCV-host interactions and summarize the current knowledge of HCV-associated diseases and their possible therapeutic strategies.

Extrahepatic manifestations associated with chronic hepatitis C infections in Poland

PURPOSE

To assess the prevalence and predictive factors of extrahepatic manifestation (EM) in patients with chronic hepatitis C (CHC) infection in Poland.

MATERIAL AND METHODS

340 consecutive patients (mean age: 42 years) with untreated CHC were studied between 2000 and 2006. The HCV infection was defined by positive serology and serum HCV RNA. The inflammation grade and fibrosis stage were assessed according to Ishak. Demographic, laboratory and liver biopsy data were collected. The patients with liver cirrhosis, concomitant HBV or HIV infection, autoimmune liver diseases and alcohol abusers were excluded from the analysis.

RESULTS

210 patients with CHC (61.7%) presented at least 1 extrahepatic manifestation, including mixed cryoglobulinemia (37.1%), thrombocytopenia (27.6%), thyroid autoimmunity (16.2%), dermatological disorders (4.1%) and type 2 diabetes (4.1%). Other EM such as the sicca syndrome, nephropathy, polyneuropathy and B-cell lymphoma were observed in single cases. In multivariate analysis lower platelet count was found as a predictive factor of EM in patients with CHC.

CONCLUSIONS

The majority of patients with CHC, living in Poland, have EM, of which cryoglobulinemia, thrombocytopenia, thyroid autoimmunity, dermatological disorders and type 2 diabetes are most common. Through the multivariate analysis the lower platelet predicts extrahepatic manifestations associated with chronic hepatitis C.

Importance of hepatitis C virus-associated insulin resistance: Therapeutic strategies for insulin sensitization

Insulin resistance is one of the pathological features in patients with hepatitis C virus (HCV) infection. Generally, persistence of insulin resistance leads to an increase in the risk of life-threatening complications such as cardiovascular diseases. However, these complications are not major causes of death in patients with HCV-associated insulin resistance. Indeed, insulin resistance plays a crucial role in the development of various complications and events associated with HCV infection. Mounting evidence indicates that HCV-associated insulin resistance may cause (1) hepatic steatosis; (2) resistance to anti-viral treatment; (3) hepatic fibrosis and esophageal varices; (4) hepatocarcinogenesis and proliferation of hepatocellular carcinoma; and (5) extrahepatic manifestations. Thus, HCV-associated insulin resistance is a therapeutic target at any stage of HCV infection. Although the risk of insulin resistance in HCV-infected patients has been documented, therapeutic guidelines for preventing the distinctive complications of HCV-associated insulin resistance have not yet been established. In addition, mechanisms for the development of HCV-associated insulin resistance differ from lifestyle-associated insulin resistance. In order to ameliorate HCV-associated insulin resistance and its complications, the efficacy of the following interventions is discussed: a late evening snack, coffee consumption, dietary iron restriction, phlebotomy, and zinc supplements. Little is known regarding the effect of anti-diabetic agents on HCV infection, however, a possible association between use of exogenous insulin or a sulfonylurea agent and the development of HCC has recently been reported. On the other hand, insulin-sensitizing agents are reported to improve sustained virologic response rates. In this review, we summarize distinctive complications of, and therapeutic strategies for, HCV-associated insulin resistance. Furthermore, we discuss supplementation with branched-chain amino acids as a unique insulin-sensitizing strategy for patients with HCV-associated insulin resistance.

Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies

Lichen planus (LP) is an inflammatory disease of the stratified squamous epithelia of unknown etiology. LP affects most frequently the oral mucosa, but it may also involve other mucosa and the skin. Oral LP (OLP) most frequently affects woman aged between 30 and 60 years. Histopathologic examination typically shows orthokeratotic hyperkeratosis, basal cell degeneration, and a dense well-defined infiltrate of lymphocytes in the superficial dermis. OLP lesions may result from the induction of keratinocytes apoptosis by cytotoxic CD8+ T cells stimulated by a yet unidentified self-antigen on a genetically predisposed patient. The association of OLP with hepatitis C virus (HCV) has been more consistently demonstrated in the Mediterranean area. Although HCV RNA and HCV-specific CD4+ and CD8+ T cells have been retrieved in the mucosal lesions of patients with chronic HCV infection and OLP, the eventual pathophysiology of HCV in OLP lesions remains unclear. Available treatments of OLP are not curative, and many have potentially prominent side effects. The objectives of OLP management should be to prevent and screen for malignant transformation and alleviate symptoms on the long-term. Avoidance of potential precipitating drugs, tobacco, alcohol, and local trauma, as well as strict oral hygiene, is essential. The first-line pharmacologic treatment relies on topical steroids. Systemic steroids should be limited to the short-term cure of severe refractory OLP. Life-long clinical follow-up, at least annually, is fundamental.

Oral mucosal conditions in chronic hepatitis C Brazilian patients: a cross-sectional study

OBJECTIVE

Our purpose was to carry out an epidemiological study to assess the prevalence of oral mucosal conditions in Brazilian patients with chronic hepatitis C.

METHODS

A cross-sectional survey was carried out on 215 patients with chronic hepatitis C who were examined for oral mucosal conditions, including oral mucosal lesions and variations of normality.

RESULTS

The prevalence of patients with chronic hepatitis C presenting oral mucosal conditions was 96.3 percent (207 patients). Oral mucosal lesions were present in 147 patients (68.4 percent), whereas variations of normality were observed in 173 patients (80.5 percent). The most common lesions included cheek biting in 42 cases (19.5 percent), candidiasis in 39 cases (18.1 percent), and leukoplakia in 28 cases (13.0 percent). The association of oral lichen planus with hepatitis C virus (HCV) infection proved to be statistically significant (P = 0.002). The most frequent variations of normality included Fordyce's spots in 96 cases (44.7 percent), lingual varicosities in 67 cases (31.2 percent), and fissured tongue in 60 cases (27.9 percent).

CONCLUSION

The prevalence of patients with chronic hepatitis C presenting oral mucosal conditions was 96.3 percent. Despite this high prevalence, only the association between oral lichen planus and hepatitis C showed statistical significance. Considering that HCV infection may be associated with extrahepatic disorders, such as oral manifestations, efforts should be made to clarify the possible relation between oral conditions and HCV infection. This may be helpful in the earlier diagnosis of the infection mainly in asymptomatic patients.

Oral lichenoid lesions in HIV-HCV-coinfected subjects during antiviral therapy: 2 cases and review of the literature

Some dental materials and certain drugs may induce epithelial alterations, which clinically resemble oral lichen planus (OLP), on oral mucosa. But these alterations do not have all the clinical and/or the histological features of OLP; these lesions are known as oral lichenoid lesions (OLLs). Some researchers describe the onset and/or the worsening of OLL/OLP after the administration of anti-hepatitis C virus (HCV) therapy. In this article, we describe the development of symptomatic OLLs, as a consequence of anti-HCV therapy (interferon-alpha and ribavirine), in 2 human immunodeficiency virus-HCV-coinfected subjects. An immunological cause related to coinfection and administration of different medications could be responsible for the onset of OLLs. These new cases, together with the previous reports of a possible association between OLP and/or OLL and anti-HCV therapy, highlight the absolute need to monitor carefully the human immunodeficiency virus-HCV-coinfected subjects who are about to start the anti-HCV therapy and to define better the clinical and histopathological criteria to distinguish OLP from OLL.

Oral diseases associated with hepatitis C virus infection. Part 2: lichen planus and other diseases

Some of the most frequent extrahepatic manifestations of hepatitis C virus (HCV) infection involve the oral region predominantly or exclusively. Part 2 of this review discusses the current evidences regarding the association of lichen planus (LP) and other diseases frequently involving the oral cavity with HCV. Epidemiological data suggest that LP may be significantly associated with HCV infections especially in southern Europe and Japan but not in northern Europe. These geographical differences are possibly influenced by immunogenetic factors, the duration of the HCV infection and the design of the published studies. Because of the fact that most of the studies published are retrospective, it is impossible to establish whether the HCV exposure occurred earlier to or after the onset of disease and more prospective studies are clearly warranted. As the virus may replicate in the skin and oral mucosa and HCV-specific T lymphocytes can be found in the oral mucosa of patients with chronic hepatitis C and LP, HCV may be implicated in the pathogenesis of LP. However, little attention has been paid to the variable effect of therapy with interferon-alpha (IFN-alpha), with or without ribavirin for LP. Conversely, it is unlikely that other oral diseases such as oral carcinoma, pemphigus and Behcet disease are triggered by HCV.

Prevalence of oral lichen planus in Brazilian patients with HCV infection

OBJECTIVE

The objective of this investigation was to assess the prevalence of oral lichen planus (OLP) in Brazilian patients infected with hepatitis C virus (HCV) from the state of Rio de Janeiro.

STUDY DESIGN

The study group consisted of 134 patients with HCV infection. The control group consisted of 95 individuals. All patients were physically examined for evidence of OLP. The diagnosis of OLP was established on the basis of usual clinical features and histological findings.

RESULTS

The prevalence of OLP was 1.5% in patients with HCV infection and 1.1% in the control group. There was no statistically significant difference between the 2 groups (P = .63).

CONCLUSION

Our findings indicate that there is no association between OLP and HCV infection in Brazilian patients from the state of Rio de Janeiro.

Current controversies in oral lichen planus: Report of an international consensus meeting. Part 1. Viral infections and etiopathogenesis

Despite recent advances in understanding the immunopathogenesis of oral lichen planus (LP), the initial triggers of lesion formation and the essential pathogenic pathways are unknown. It is therefore not surprising that the clinical management of oral LP poses considerable difficulties to the dermatologist and the oral physician. A consensus meeting was held in France in March 2003 to discuss the most controversial aspects of oral LP. Part 1 of the meeting report focuses on (1) the relationship between oral LP and viral infection with special emphasis on hepatitis C virus (HCV), and (2) oral LP pathogenesis, in particular the immune mechanisms resulting in lymphocyte infiltration and keratinocyte apoptosis. Part 2 focuses on patient management and therapeutic approaches and includes discussion on malignant transformation of oral LP.

Hepatitis C virus and lichen planus

Hepatitis C virus (HCV) is an important factor in the development of chronic liver disease and hepatocellular carcinoma. In recent years it has become known that HCV induces various extrahepatic manifestations including mixed cryoglobulinemia, membranoproliferative glomerulonephritis, Sjögren's syndrome, autoimmune thyroiditis, malignant lymphoma, porphyria cutanea tarda and lichen planus. Although the mechanisms of extrahepatic manifestations remain unclear, it is known that interferon (IFN) therapy and coadministration of IFN with ribavirin are effective in promoting the disappearance or alleviation of such extrahepatic lesions, which have tended to be overlooked. The present review focuses on lichen planus, one of the major extrahepatic manifestations.

Hepatitis C virus and lichen planus: A review

INTRODUCTION

The relationship between hepatitis C virus (HCV) infection and oral lichen planus (OLP) remains a matter of controversy. It is important to determine whether there is an association between OLP and HCV infection so that guidelines regarding the routine HCV testing of patients with OLP can be developed for clinicians.

OBJECTIVES

The objective of this article was to review and summarize the published literature on the association between OLP and HCV and to describe future directions.

METHODS

A search of the computerized database MEDLINE (1966-June 2003) was conducted. The bibliographies of articles identified by means of MEDLINE were also searched. Any studies reporting the prevalence of HCV in a group of patients with LP either with or without a control group were included in this review. Also included were studies comparing the clinical and histologic features of LP among patients with and without HCV infection, studies on the presence of HCV within LP lesions, and studies of HCV genotypes among patients with LP.

RESULTS

Thirty-two studies conducted in various parts of the world were identified. Study types included prevalence studies on HCV exposure among patients with OLP (0%-62%), prevalence of OLP among patients with HCV infection (1.6%-20%), and case-control studies of this association. In addition, the results from 3 studies on the replication of HCV in the oral mucosa, 3 studies on the genotype of HCV in OLP patients, and 4 studies comparing the clinical and histologic features of OLP in HCV-infected and uninfected individuals have been summarized.

CONCLUSION

At present, studies on the association of OLP and HCV provide enough information to raise a number of interesting questions about this association. Important biases-including selection bias; investigator bias due to lack of blinding and the possible resultant nondifferential misclassification of disease; and possible confounding by age in the studies published-make it difficult to draw firm conclusions. However, the need for future studies that take into consideration all these factors in the study methodology is highlighted by this review.

Managing occupational risks for hepatitis C transmission in the health care setting

Hepatitis C virus (HCV) infection is a significant contemporary health problem in the United States and elsewhere. Because it is primarily transmitted via blood, hepatitis C infection presents risks for both nosocomial transmission to patients and occupational spread to health care workers. Recent insights into the pathogenesis, immunopathogenesis, natural history, and treatment of infection caused by this unique flavivirus provide a rationale for the use of new strategies for managing occupational hepatitis C infections when they occur. This article reviews this developing information. Recently published data demonstrate success rates in the treatment of "acute hepatitis C syndrome" that approach 100\%, and although these studies are not directly applicable to all occupational infections, they may provide important clues to optimal management strategies. In addition, the article delineates approaches to the prevention of occupational exposures and also addresses the difficult issue of managing HCV-infected health care providers. The article summarizes currently available data about the nosocomial epidemiology of HCV infection and the magnitude of risk and discusses several alternatives for managing exposure and infection. No evidence supports the use of immediate postexposure prophylaxis with immunoglobulin, immunomodulators, or antiviral agents. Based on the very limited data available, the watchful waiting and preemptive therapy strategies described in detail in this article represent reasonable interim approaches to the complex problem of managing occupational HCV infections, at least until more definitive data are obtained.

Oral diseases possibly associated with hepatitis C virus

Morbidity associated with hepatitis C virus (HCV) infection can involve a variety of extrahepatic conditions, including lichen planus (LP) and sialadenitis, predominantly or exclusively involving the oral region, conditions which have been largely neglected in reviews. The literature suggests that HCV-infected patients may frequently have Sjögren-like sialadenitis with mild clinical symptoms, whereas oral LP may be significantly associated with HCV infections in Southern Europe and Japan but not in Northern Europe. These geographical differences could be related to immunogenetic factors such as the HLA-DR6 allele, significantly expressed in Italian patients with OLP and HCV. Analysis of experimental data suggests that HCV could be involved in the pathogenesis of both these diseases. Moreover, parotid lymphoma may arise in patients with sialadenitis, mainly with type II cryoglobulinemia. Little attention has been paid to oral health needs in HCV-infected patients and the variable effect of interferon-alpha therapy on oral tissues. Further research is needed, because of the potentially great influence of oral diseases possibly linked to HCV on the quality of life of millions of patients.

Incidence of Sjögren's syndrome in Japanese patients with hepatitis C virus infection

BACKGROUND AND AIM

Hepatitis viruses induce not only chronic liver diseases but also the impairment of other organs and tissues as extrahepatic manifestations. In particular, hepatitis C virus (HCV) is involved in various extrahepatic manifestations. The purpose of the present study was to evaluate Sjögren's syndrome (SS) and lichen planus (LP) involvement, which are various extrahepatic manifestations in patients with liver diseases related to hepatitis B virus (HBV) or HCV.

METHODS

We examined a total of 110 Japanese patients with chronic liver disease: 29 with HBV infections and 81 HCV infections.

RESULTS

The prevalence of SS according to European and Japanese criteria in patients with chronic HCV infection was significantly higher than in patients with chronic HBV infection (European criteria: 25.9 vs 3.4%; P < 0.05, Japanese criteria: 21.0 vs 3.4%; P = 0.05). Lichen planus was observed in one (3.4%) of 29 patients with chronic HBV infection, and in 11 (13.6%) of 81 patients with chronic HCV infection. Simultaneously combined LP and SS occurred in 8.6% (seven of 81) of patients with HCV infection, but in none with HBV infection.

CONCLUSIONS

Clinicians should routinely follow the HCV-infected patients, paying sufficient attention to the presence of SS and LP, and they should also carefully monitor their prognosis.