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Xian MF, Li W, Lan WT, Zeng D, Xie WX, Lu MD, Huang Y, Wang W. Strategy for Accurate Diagnosis by Contrast-Enhanced Ultrasound of Focal Liver Lesions in Patients Not at High Risk for Hepatocellular Carcinoma: A Preliminary Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1333-1344. [PMID: 36534591 DOI: 10.1002/jum.16151] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/30/2022] [Accepted: 11/07/2022] [Indexed: 05/18/2023]
Abstract
OBJECTIVE To develop an effective strategy for accurate diagnosis of focal liver lesions (FLLs) in patients with non-high risk for hepatocellular carcinoma (HCC). METHODS From January 2012 to December 2015, consecutive patients with non-high risk for HCC who underwent contrast-enhanced ultrasound (CEUS) were included in this retrospective double-reader study. All patients were stratified into 2 different risks (intermediate, low-risk) groups according to criteria based on clinical characteristics, known as clinical risk stratification criteria. For the intermediate-risk group, the CEUS criteria for identifying benign lesions and HCCs were constructed based on selected CEUS features. The diagnostic performance of the clinical risk stratification criteria, and CEUS criteria for identifying benign lesions and HCCs was evaluated. RESULTS This study included 348 FLLs in 348 patients. The sensitivity and specificity of the clinical risk stratification criteria for malignancy was 97.8 and 69.8%. Patients were classified as intermediate risk if they were male, or older than 40 years of age, or HBcAb positive, or having positive tumor markers. Otherwise, patients were classified as low risk. Among the 348 patients, 327 were in the intermediate-risk group and 21 were in the low-risk group. In the intermediate-risk group, the CEUS criteria for identifying benign lesions were any of the following features: 1) hyper/isoenhancement in the arterial phase without washout, 2) nonenhancement in all phases, 3) peripheral discontinuous globular enhancement in the arterial phase, 4) centrifugal enhancement or peripheral enhancement followed by no central enhancement, or 5) enhanced septa. The accuracy, sensitivity, and specificity of the CEUS criteria for identifying benign lesions were 94.5, 83.0, and 99.6%, respectively. Arterial phase hyperenhancement followed by mild and late washout (>60 seconds) was more common in HCC patients than in non-HCC patients (P < .001). Using arterial phase hyperenhancement followed by mild and late washout as the CEUS criteria for identifying HCCs, the sensitivity and specificity were 52.6 and 95.3%, but unfortunately, the positive predictive value was only 82.0%. For the low-risk group, no further analysis was performed due to the small sample size. CONCLUSIONS Initial clinical risk stratification followed by assessment of certain CEUS features appears to be a promising strategy for the accurate diagnosis of FLLs in patients not at high risk for HCC.
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Affiliation(s)
- Meng-Fei Xian
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Li
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wen-Tong Lan
- Department of Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dan Zeng
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wen-Xuan Xie
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ming-De Lu
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yang Huang
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Khamseh A, Poortahmasebi V, Soltani S, Nasiritoosi M, Jafarian A, Ghaziasadi A, Norouzi M, Ghorbani S, Eslami N, Jazayeri SM. Characterization of occult hepatitis B infection among Iranian liver transplant recipients. J Clin Lab Anal 2022; 36:e24614. [PMID: 36086860 PMCID: PMC9551123 DOI: 10.1002/jcla.24614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background The prevalence of occult hepatitis B infection (OBI) among Iranian liver transplant recipient patients has not been explored yet. The present study aimed to determine the OBI prevalence among Iranian liver transplant recipients. Methods This study encompassed 97 patients having undergone liver transplantation due to several clinical backgrounds in the Liver Transplantation Center, Tehran, Iran. After serological evaluation, two different types of PCR methods were applied for amplification of HBV DNA, followed by the direct sequencing of whole hepatitis B virus (HBV) surface genes. Results At the time of admission, none of the patients were positive for HBsAg. However, 24 (25%), 12 (12.3%), and 5 (5.1%) cases were positive for anti‐HBc, hepatitis C virus (HCV), and hepatitis delta virus (HDV) antibodies, respectively. Moreover, two males were positive for OBI (2.1%). Both were positive for anti‐HBc and negative for anti‐HBs, anti‐HCV, and anti‐HDV. HBV‐related cirrhosis was the underlying reason for their liver transplantation. HBsAg sequences revealed no amino acid substitution. Conclusions The prevalence of OBI in the Iranian liver transplantation patients was relatively low. Future longitudinal studies with a larger sample size are suggested to explore the significance of this clinical finding, including the reactivation of cryptic HBV DNA, in liver transplant subjects.
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Affiliation(s)
- Azam Khamseh
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran.,Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahdat Poortahmasebi
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran.,Infectious and Tropical Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Bacteriology and Virology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saber Soltani
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran.,Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Nasiritoosi
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Jafarian
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Azam Ghaziasadi
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran.,Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Norouzi
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran.,Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Saied Ghorbani
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran.,Department of Virology, Iran University of Medical Sciences, Tehran, Iran
| | - Narges Eslami
- Infectious and Tropical Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Bacteriology and Virology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Mohammad Jazayeri
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran.,Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Virology, Iran University of Medical Sciences, Tehran, Iran
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Vaziri M, Shahshahani HJ. Frequency of hepatitis B virus-DNA among hepatitis B surface-Ag negative, anti-hepatitis B core antibody-positive blood donors in Yazd, Iran. Asian J Transfus Sci 2021; 15:179-182. [PMID: 34908751 PMCID: PMC8628228 DOI: 10.4103/ajts.ajts_155_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/02/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND: The diagnosis of hepatitis B infection in most blood transfusion centers is based on hepatitis B surface (HBs) antigen detection by an enzyme immunoassay method. This study aimed to determine the frequency of hepatitis B core (HBc) antibody, HBs antibody, and hepatitis B virus (HBV) DNA among HBs antigen-negative healthy blood donors of Yazd province, Iran. MATERIALS AND METHODS: This cross-sectional study was conducted on 1500 healthy blood donor samples negative for HBs antigen, hepatitis C virus antibody, human immunodeficiency virus antigen/antibody, and rapid plasma regain tests. All samples were screened for HBc antibody test. HBs antibody and real-time polymerase chain reaction were performed for HBc antibody-positive samples. RESULTS: HBc antibody was positive in 74 (4.9%) samples and 11 (14.9%) of 74 positive samples for HBc antibody were negative for HBs antibody. Sixty-three (85.1%) positive samples for HBc antibody had HBs antibody titer over 10 IU/L, and 43 (58.1%) had HBs antibody titer over 100 IU/L. There was no hepatitis B DNA-positive sample in the present study. CONCLUSIONS: The study results suggest that there is a very low risk for transmission of HBV through blood donors of Yazd, Iran.
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Affiliation(s)
- Mahtab Vaziri
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Yazd, Iran
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Shahram F, Ghorbani S, Mahmoudi M, Akhlaghi M, Jadali Z, Imeni V, Norouzi M, Faezi ST, Monavari SHR, Mostafaei S, Poortahmasebi V, Barfi S, Alavian SM, Jazayeri SM. Characterization of Occult Hepatitis B Virus Infection Among Iranian Patients with Behcet's Disease; Correlation with Clinical Status. HEPATITIS MONTHLY 2021; 21. [DOI: 10.5812/hepatmon.105078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 02/13/2021] [Accepted: 02/13/2021] [Indexed: 08/30/2023]
Abstract
Background: Behcet's disease (BD) is a chronic multisystem vasculitis with an unknown etiology. During the past years, several reports are published on the occult hepatitis B infection (OBI), the presence of hepatitis B virus (HBV) DNA in the absence of HBsAg, in rheumatic diseases. Objectives: The current study aimed to, firstly, investigate the prevalence of OBI in patients with BD, and, secondly, its potential association with the clinical and therapeutic status of BD. Methods: HBV serological markers and HBV DNA were evaluated in 220 consecutive BD patients to detect OBI. Demographic and clinical data of OBI positive and negative groups were compared. Results: The mean age of patients was 39.24 (± 10.57), and 134 (62.9%) were male. The mean disease duration was 14.13 (± 8.63) years. No HBsAg positive case was found, but HBV DNA was found in 19 (8.6%) patients. The median viral load value was 475.84 copy/mL. We compared clinical data of 10 OBI positive and 156 OBI negative BD patients with complete and accessible data. There was no difference between the two groups concerning demographic characteristics (age, sex, and disease duration), different clinical manifestations, or types of medications (immunomodulatory, cytotoxic, and corticosteroids). Conclusions: This is the first study showing a rather high prevalence of OBI among BD patients. We did not find any correlation between OBI positivity and different clinical manifestations, medications, or HLA-B51. Further studies are needed on a larger group of patients and by molecular HBV evaluation (as well as serologic) regarding this possible association.
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Occult hepatitis B infection and hepatocellular carcinoma: Epidemiology, virology, hepatocarcinogenesis and clinical significance. J Hepatol 2020; 73:952-964. [PMID: 32504662 DOI: 10.1016/j.jhep.2020.05.042] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 12/12/2022]
Abstract
Occult hepatitis B infection (OBI) refers to a condition where replication-competent HBV DNA is present in the liver, with or without HBV DNA in the blood, in individuals with serum HBsAg negativity assessed by currently available assays. The episomal covalently closed circular DNA (cccDNA) in OBI is in a low replicative state. Viral gene expression is mediated by epigenetic control of HBV transcription, including the HBV CpG island methylation pathway and post-translational modification of cccDNA-bound histone, with a different pattern from patients with chronic HBV infection. The prevalence of OBI varies tremendously across patient populations owing to numerous factors, such as geographic location, assay characteristics, host immune response, coinfection with other viruses, and vaccination status. Apart from the risk of viral reactivation upon immunosuppression and the risk of transmission of HBV, OBI has been implicated in hepatocellular carcinoma (HCC) development in patients with chronic HCV infection, those with cryptogenic or known liver disease, and in patients with HBsAg seroclearance after chronic HBV infection. An increasing number of prospective studies and meta-analyses have reported a higher incidence of HCC in patients with HCV and OBI, as well as more advanced tumour histological grades and earlier age of HCC diagnosis, compared with patients without OBI. The proposed pathogenetic mechanisms of OBI-related HCC include the influence of HBV DNA integration on the hepatocyte cell cycle, the production of pro-oncogenic proteins (HBx protein and mutated surface proteins), and persistent low-grade necroinflammation (contributing to the development of fibrosis and cirrhosis). There remain uncertainties about exactly how, and in what order, these mechanisms drive the development of tumours in patients with OBI.
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Hedayati-Moghaddam MR, Soltanian H, Behzadifar M. Occult Hepatitis B Virus Infection Prevalence Among Different Populations of Iran: A Systematic Review and Meta-Analysis. HEPATITIS MONTHLY 2020; 20. [DOI: 10.5812/hepatmon.101722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 08/30/2023]
Abstract
Context: Various frequency rates of occult hepatitis B virus infection (OBI) are reported from different parts of Iran. This systematic review and meta-analysis aimed to characterize the OBI epidemiology in Iran and estimate the pooled prevalence among different populations. Evidence Acquisition: Nine international and Persian electronic databases, as well as some conference proceedings, were searched. Original cross-sectional studies up to December 2018 were included if they investigated the prevalence of OBI by the detection of serum hepatitis B virus surface antigen and hepatitis B virus nucleic acid in at least 30 samples selected with any sampling methods. Comprehensive meta-analysis software was used to analyze the data, and Cochran’s Q-test and I-square statistics were applied to assess the heterogeneity. Meta-regression analysis was performed to assess the impact of the year of study on the OBI frequency. A P value < 0.05 was considered as the level of significance. Results: Of 412 citations found in electronic sources and 35 relevant citations added by searching the gray literature, 83 non-duplicated non-overlapping studies were evaluated. A total of 55 documents comprising 14,485 individuals from 16 provinces met the inclusion criteria and were used in the analysis. The prevalence of OBI considerably varied in different parts of the country with the highest prevalence (63.1%) reported among the HIV-positive population in Fars province. The rates of the OBI prevalence were estimated at 0.06% (95% CI: 0.02 - 0.16%) among blood donors (BDs) regardless of their anti-HBc status, 7.90% (95% CI: 4.33 - 13.99%) among anti-HBc positive BDs, 2.49% (95% CI: 1.2 - 4.81%) among hemodialysis (HD) patients, 4.44% (95% CI: 1.56 - 12.02%) among HIV-positive patients, and 7.76% (95% CI: 4.57 - 12.86%) among HCV-positive patients. No significant trends were observed in OBI prevalence rates among different groups over time (P > 0.05). Conclusions: This review revealed high rates of OBI prevalence among high-risk populations in Iran. It is strongly suggested that occult hepatitis B be investigated among populations with a high chance of its occurrence in our country.
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Datta S, Khillan K, Ranjan V, Wattal C. Nucleic acid amplification test: Bridging the gap in blood safety & re-evaluation of blood screening for cryptic transfusion-transmitted infection among Indian donors. Indian J Med Res 2020; 149:389-395. [PMID: 31249205 PMCID: PMC6607810 DOI: 10.4103/ijmr.ijmr_1340_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background & objectives: Nucleic acid amplification test (NAT) in blood donor screening not only detects window period (WP) donors but also those with chronic occult infections which are negative by routine serological screening. This study was conducted to determine the time trend of NAT positivity and seroprevalence of transfusion-transmitted infections (TTIs) through a period of six years and evaluate the strength of NAT as a supplementary test in identifying the cryptic carriers in blood donor population. Methods: A total of 1,01,411 blood donations were screened between January 2011 and December 2016 by the ELISA and individual donor (ID) NAT Procleix Ultrio Plus Assay. Additional molecular and serological assays were done on the NAT yield samples to differentiate the type of cryptic carriers. Results: NAT yields comprised 0.05 per cent (50/101411) of the total samples tested with a yield rate of 1/2028. Hepatitis B virus (HBV) contributed to 80 per cent of the total NAT yields and the rest 20 per cent due to hepatitis C virus (HCV). Majority of HBV NAT yields (75%) were from chronic occult donors and 25 per cent were WP donors. Both HBV and HCV NAT yields had a wide range of viral count. There was no HIV NAT yield. A significant decline in the prevalence rate of TTIs through the study period of six years was observed. Interpretation & conclusions: The cryptic infections found in blood donors increase the risk of TTIs. Blood screening by both serology and NAT can reduce this threat.
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Affiliation(s)
- Sanghamitra Datta
- Department of Clinical Microbiology & Immunology, Sir Ganga Ram Hospital, New Delhi, India
| | - Kamini Khillan
- Department of Blood Transfusion Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Vivek Ranjan
- Department of Blood Transfusion Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Chand Wattal
- Department of Clinical Microbiology & Immunology, Sir Ganga Ram Hospital, New Delhi, India
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8
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Ghaziasadi A, Fakhari Z, Aghcheli B, Poortahmasebi V, Farahmand M, Norouzi M, Ghalichi L, Soleimani A, Hedayat Yaghoobi M, Ravanshad M, Jazayeri SM. High prevalence of occult hepatitis B infection (OBI) among healthy children and their parents in Alborz province, Iran; Vertical OBI, myth or truth? Liver Int 2020; 40:92-100. [PMID: 31518482 DOI: 10.1111/liv.14252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/23/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Occult hepatitis B infection (OBI) has been described in various clinical settings including after hepatitis B virus (HBV) immunization. The purpose of study was to characterize the prevalence of OBI among immunized children from a subset of general population and the parents of OBI-positive cases. METHODS Sera of 1200 children from general population who have been previously immunized by HBV vaccine were assayed for anti-HBs. 660 were randomly selected for HBV DNA testing by different polymerase chain reaction (PCR) methods and were analysed by direct sequencing on surface genes. RESULTS None of participants were positive for HBsAg and anti-HBc. 549 (45.7%) and 651 (54.3%) cases had anti-HBs > 10 mIU/mL (responders) and < 10 mIU/mL (nonresponders) respectively. Of 660 selected specimens, 91 (16%) of children were positive for OBI. 23 (25.2%) and 68 (74.8%) of HBV DNA positive cases were belonged to responders and nonresponders, respectively, showing significant difference (P < .001). The mean levels of anti-HBs in OBI-positive and OBI-negative groups, showed no considerable variations. The mean viral load for OBI-positive cases showed substantial differences between responders and nonresponders (P = .007). Of 49 parents (98 individuals) of OBI-positive children 11 (22%) and 18 (36%) were positive for anti-HBc and anti-HBs respectively. Molecular testing was positive in 32 subjects (16 couples, 32.6%). In total, 6 mothers and 11 fathers were positive for OBI. CONCLUSION A proportion of OBI-positive vaccinated children could be existed in different populations. This finding could be arisen from vertical HBV transmission or vertical OBI possibly from their parents.
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Affiliation(s)
- Azam Ghaziasadi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences Tehran, Tehran, Iran
| | - Zahra Fakhari
- Department of Virology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Bahman Aghcheli
- Department of Virology, School of Public Health, Tehran University of Medical Sciences Tehran, Tehran, Iran
| | - Vahdat Poortahmasebi
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Farahmand
- Department of Virology, School of Public Health, Tehran University of Medical Sciences Tehran, Tehran, Iran
| | - Mehdi Norouzi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences Tehran, Tehran, Iran.,Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Ghalichi
- Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences Tehran, Tehran, Iran
| | - Alireza Soleimani
- Department of Infectious Disease, Imam Ali Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Mojtaba Hedayat Yaghoobi
- Department of Infectious Disease, Imam Ali Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Mehrdad Ravanshad
- Department of Virology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Seyed Mohammad Jazayeri
- Department of Virology, School of Public Health, Tehran University of Medical Sciences Tehran, Tehran, Iran.,Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran
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Trigo C, do Brasil PEAA, Costa MJM, de Castro L. Occult hepatitis B virus infection: clinical implications in tuberculosis treatment. J Viral Hepat 2016; 23:1027-1035. [PMID: 27624908 DOI: 10.1111/jvh.12583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/16/2016] [Indexed: 02/06/2023]
Abstract
Occult hepatitis B virus infection (OBI) is characterized by the absence of HBsAg and persistence of the virus genome (HBV-DNA) in liver tissue and/or blood. OBI has been reported in several clinical contexts. However, the clinical significance of OBI in tuberculosis (TB) treatment is unknown. We investigated the OBI prevalence and its impact on the risk of drug-induced liver injury (DILI) during TB treatment. This was a prospective cohort study with one hundred patients who were treated for TB from 2008 to 2015. Laboratory, clinical and demographic data of TB patients were extracted from medical records. Based on HBV-DNA testing of serum samples, an OBI prevalence of 12% was established; almost half of these patients had both anti-HBc and anti-HBs serological markers. Low CD4+ cell counts have been shown to be a risk factor for OBI among TB patients co-infected with HIV (P=.036). High DILI incidence was observed in this study. A multivariable Cox proportional hazard model was conducted and identified OBI (HR 2.98, 95% CI 1.30-6.86) as the strongest predictor for DILI when adjusted to CD4+ cell count (HR 0.38, 95% CI 0.17-0.90), ALT before TB treatment (HR 1.37, 95% CI 0.81-2.32) and TB extrapulmonary clinical form (HR 2.91, 95% CI 1.75-7.21). The main aim of this study was to highlight DILI as a clinical outcome during treatment of TB patients with OBI. Therefore, HBV-DNA testing should be considered routinely in monitoring DILI, and also in other clinical implications associated with OBI, reduce morbidity and mortality.
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Affiliation(s)
- C Trigo
- Pharmacogenetics Research Laboratory, Evandro Chagas National Institute of Infectious Diseases (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - P E A A do Brasil
- Intensive Care Clinical Research Laboratory, Evandro Chagas National Institute of Infectious Diseases (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - M J M Costa
- Tuberculosis and Mycobacteria Clinical Research Laboratory, Evandro Chagas National Institute of Infections Diseases (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - L de Castro
- Pharmacogenetics Research Laboratory, Evandro Chagas National Institute of Infectious Diseases (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
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Mohraz M, Jafari R, Poortahmasebi V, Sadeghi A, Hajabdolbaghi M, Rasoolinejad M, Forooghi M, Norouzi M, Poorebrahim M, Khamseh A, Karkhaneh M, Alavian SM, Ebrahimian A, Jazayeri SM. Molecular analysis of occult hepatitis B infection among Iranian HIV-positive patients. Future Virol 2016. [DOI: 10.2217/fvl-2016-0032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aim: The aims of this study were to find out the prevalence of occult hepatitis B infection (OBI) in HIV-1 patients, as well as to analyze the mutational patterns of OBI-positive individuals. Materials & methods: 172 HBsAg-negative, HIV-1-positive patients were selected according to data extracted from questionnaires. HBV serologic and molecular assays were performed. An extensive mutational analysis was applied using direct sequencing on HBsAg. Results: Thirty-one samples (18%) were OBI positive. Among 24 available OBI-positive samples, 17 (71%) contained at least one mutation only within ‘a’ determinant region of HBsAg. A stretch of mutations was found between amino acid positions 121 and 136. The physicochemical properties of individual amino acid substitutions and their potential impacts on 3D structure of ‘a’ determinant mutants were also determined. Conclusion: HBV serologic assays are not reliable markers to exclude occult HBV infection in HIV-positive patients.
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Affiliation(s)
- Minoo Mohraz
- Iranian Research Center for HIV AIDS, High Risk Reduction Institute, Tehran, Iran
| | - Rezvaneh Jafari
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahdat Poortahmasebi
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Sadeghi
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mehrnaz Rasoolinejad
- Iranian Research Center for HIV AIDS, High Risk Reduction Institute, Tehran, Iran
| | - Maryam Forooghi
- Iranian Research Center for HIV AIDS, High Risk Reduction Institute, Tehran, Iran
| | - Mehdi Norouzi
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansour Poorebrahim
- Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Azam Khamseh
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Karkhaneh
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Moayed Alavian
- Middle East Liver Disease (MELD) Center, No 178, Sepahboud Gharanee St. Tehran 1598976516, Iran
| | - Arefeh Ebrahimian
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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11
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Meidani M, Rostami M, Hemmati S, Ashrafi F, Gholamnezhad M, Emadi M, Ghasemian R, Ahmadian M. Screening and evaluation of chronic and occult Hepatitis B in chemo - radiotherapy patients with cancer. Adv Biomed Res 2016; 5:85. [PMID: 27274500 PMCID: PMC4879852 DOI: 10.4103/2277-9175.182216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 08/04/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Hepatitis B virus infection (HBV) and its complications is one of the most serious problems of the health system in many parts of the world. In the present study, we will assess chronic and occult HBV and isolated anti-Hepatitis B core antigen whose screening and evaluation is not routine in different populations. MATERIALS AND METHODS This descriptive analytical study was conducted on 213 patients undergoing chemotherapy - radiotherapy referred to the hematology - oncology clinics of Isfahan, Iran in 2012. In order to determine the serum levels of hepatitis B surface antigen (HbSAg), Hepatitis B Antigen and Antibody (HBCAb), aspartate aminotransferase (AST), alanine transaminase (ALT) and Alkaline phosphatase (ALK.P), venous blood samples were obtained. If the HBCAb sample was positive, another sample of the serum was sent to the laboratory to perform polymerase chain reaction and to determine viral load. RESULTS The mean age of the patients was 47.7 ± 9 years, with an age range of 27 -73 years; 98 (46%) and 115 (54%) cases were male and female, respectively, with mean age of 51.9 ± 8.3 and 44.1 ± 8.1 years, and there was no significant difference (P < 0.001). The mean level of liver enzymes including AST, ALT and ALK.P were 34.2 ± 36.02, 38.9 ± 47.1 and 252.1 ± 234.7, respectively. Two cases were HbSAg positive (0.9%) and six cases were HBCAb positive (2.8%) and HbSAg negative. Three cases had a high viral load at the rate of starting treatment among positive anti-HBC patients. CONCLUSION Because occult hepatitis is investigated less commonly in routine studies, it seems that screening and evaluating its prevalence is useful in the management of patients.
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Affiliation(s)
- Mohsen Meidani
- Department of Infectious Diseases, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mojtaba Rostami
- Department of Infectious Diseases, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Simin Hemmati
- Department of Radiotherapy, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farzaneh Ashrafi
- Department of Hematology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Gholamnezhad
- Department of Infectious Diseases, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Emadi
- Department of Biology, Shahrekord Azad University, Shahrekord, Iran
| | - Rasoul Ghasemian
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Ahmadian
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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12
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Borzooy Z, Jazayeri SM, Mirshafiey A, Khamseh A, Mahmoudie MK, Azimzadeh P, Geravand B, Boroumand MA, Afshar M, Poortahmasebi V, Hosseini M, Streinu-Cercel A. Identification of occult hepatitis B virus (HBV) infection and viral antigens in healthcare workers who presented low to moderate levels of anti-HBs after HBV vaccination. Germs 2015; 5:134-40. [PMID: 26716102 DOI: 10.11599/germs.2015.1081] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Worldwide, healthcare workers (HCWs) show different levels of response to hepatitis B virus (HBV) vaccine. One of the factors associated with vaccine unresponsiveness may be the existence of current or past HBV infection. Regardless of the presence of HBsAg (overt infection), occult HBV infection (OBI, defined as presence of HBV DNA in the absence of HBsAg) might also account for some non- or hypo-response cases. METHODS Sera from 120 HBsAg-negative HCWs with low and moderate levels of anti-HBs, <10 IU/mL (group I) and <100 IU/mL (group II) respectively, were selected and were examined for OBI by sensitive real-time PCR regardless of HBV serological profiles. Direct sequencing on surface genes was carried out in OBI-positive cases. RESULTS Four (3.3%) were positive for OBI. All were negative for anti-HBc. Two of the positive cases had moderate levels of anti-HBs (>10 to <100 IU/mL). No significant differences were found between the two groups in terms of risk factors or serological data. No mutations were found in surface proteins of OBI cases. CONCLUSION OBI in these subjects might be due to other factors rather than presence of "a" determinant mutations. Healthcare workers with inadequate to moderate levels of anti-HBs (<100 IU/mL) following vaccination, regardless of their serological profile for HBV, should be tested for the presence of HBV DNA by sensitive molecular tests. Anti-HBc is not a reliable marker for suspicion of OBI, especially in high-risk group individuals.
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Affiliation(s)
- Zohreh Borzooy
- PhD student, Ms, Department of Infectious Diseases, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Immunology and Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Jazayeri
- MD, PhD, Clinical virologist, Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbass Mirshafiey
- Ms, PhD, Head of the Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Azam Khamseh
- Bs, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Karkhaneh Mahmoudie
- Bs, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Pedram Azimzadeh
- Ms, Gastroenterology and Liver Diseases Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Geravand
- Ms, Ministry of Health and Medical Education, Tehran, Iran
| | - Mohammad Ali Boroumand
- MD, Pathologist, Department of Pathology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Afshar
- Bs, Tehran University of Medical Sciences, Mirza Kouchak Khan Hospital, Tehran, Iran
| | - Vahdat Poortahmasebi
- Ms, PhD student, Virologist, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Hosseini
- Ms, PhD, Department of Epidemiology and Biostatistics School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Adrian Streinu-Cercel
- MD, PhD, Professor, Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; National Institute of Infectious Diseases, "Prof. Dr. Matei Balş", Bucharest, Romania
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13
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Chenari M, Norouzi M, Ghalichi L, Rezaee A, Yari A, Alavian SM, Jazayeri SM. Characterization of overt and occult hepatitis B virus infection among HTLV-1 positive healthy carriers in the Northeast of Iran; AN HTLV-I endemic area. J Med Virol 2014; 86:1861-7. [PMID: 25132488 DOI: 10.1002/jmv.24046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 12/23/2022]
Abstract
To date, no studies have provided data on hepatitis B virus (HBV) prevalence among asymptomatic, healthy human T-lymphotropic virus (HTLV-I) positive carriers. This sero- and molecular epidemiology study was performed on patients in the Northeast of Iran, which is an endemic area for HTLV-I infection. A total of 109 sera were collected from HTLV-I positive healthy carriers who were admitted to Ghaem Hospital, Mashhad City. All were tested for HBV serology and subsequently, real time PCR was carried out on the samples, regardless of the results of the serology. Standard PCR and direct sequencing were applied on positive samples. All cases were negative for HBsAg, Anti-HBc, and anti-HBs were positive in 34 (31.1%), and 35 (32%) individuals, respectively. There were 19 (17.4%) cases that were positive only for anti-HBs, and they had already received HBV vaccine. 16 (15%) were positive for both anti-HBs and anti-HBc, indicating a past-resolved HBV infection. 18 (16.5%) were isolated as anti-HBc, and 56 (51.3%) were negative for all HBV serological markers. Only one subject (0.9%) had detectable HBV DNA (2153 copy/ml), and assigned as being an occult HBV infection. The low prevalence of HBsAg, despite the high percentage of anti-HBc positive cases, might be related to the suppression effect of HTLV-I on surface protein expression. The low prevalence of HBV infection among HTLV-I positive healthy carriers from an endemic region, indicates that the epidemiology of HTLV-I and HBV coinfection is related to the endemicity of HBV in that region, rather than HTLV-I endemicity.
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Affiliation(s)
- Maryam Chenari
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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14
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Taha SE, El-Hady SA, Ahmed TM, Ahmed IZ. Detection of occult HBV infection by nested PCR assay among chronic hepatitis C patients with and without hepatocellular carcinoma. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2013. [DOI: 10.1016/j.ejmhg.2013.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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15
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Prevalence of occult hepatitis B virus infection in a cohort of HIV-positive patients resident in Sicily, Italy. BIOMED RESEARCH INTERNATIONAL 2013; 2013:859583. [PMID: 24063015 PMCID: PMC3770005 DOI: 10.1155/2013/859583] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/12/2013] [Accepted: 07/25/2013] [Indexed: 12/18/2022]
Abstract
Occult hepatitis B virus (OBI) in HIV-infected groups is still debated, as well as the associated risk-factors and clinical significance.
In this paper, we examined a total of 405 HBsAg-negative/HIV-infected patients enrolled from January 2007 to December 2009. Overall, the prevalence of OBI was 5.9% (95% confidence interval (CI95%): 3.8–8.7%); it was more frequently associated with “anti-HBc alone” serological marker (11.3%; adjusted odds ratio = 3.7, CI95%: 1.4–9.8), although it was also detected in the absence of any HBV serological marker (4.9%; CI95%: 2.3–9.1%). A low prevalence of anti-HCV-positive patients with OBI was found (3.1%; CI95%: 0.6–8.7%). HIV RNA plasma levels or other immunological/clinical characteristics were not significantly associated with OBI. All but one occult HBV infections were sustained by genotype D viral strains. OBI is relatively frequent in HIV-infected patients, although it does not seem to exert a relevant clinical impact. Viral genotypes in occult HBV infections reflect those circulating in the Mediterranean area.
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16
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Jutavijittum P, Andernach IE, Yousukh A, Samountry B, Samountry K, Thammavong T, Keokhamphue J, Toriyama K, Muller CP. Occult hepatitis B infections among blood donors in Lao PDR. Vox Sang 2013; 106:31-7. [PMID: 23931585 DOI: 10.1111/vox.12073] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES In Lao People's Democratic Republic, hepatitis B virus is highly endemic. However, blood donations are only screened for HBsAg, leaving a risk of transmission by HBsAg-negative occult infected donors. Here, we characterized first-time blood donors to assess prevalence of hepatitis B virus infections and occult infected donors. MATERIALS AND METHODS Sera were screened for HBsAg, HBeAg and anti-HBs, anti-HBc and anti-HBe antibodies. Occult HBV infections (OBIs) were assessed in HBsAg-negative sera by PCR, and sera of HBsAg positive and occult infected donors were phylogenetically characterized. RESULTS 9·6% of the donors were HBsAg positive, and 45.5% were positive for at least one of the hepatitis B virus serum markers. More than 40% HBsAg carriers were HBeAg positive, with HBeAg seroconversion occurring around 30 years of age. Furthermore, 10·9% of HBsAg-negative, anti-HBc and/or anti-HBs-positive donors were occult infected with hepatitis B virus. Thus, at least 3·9% of blood donations would potentially be unsafe, but hepatitis B virus DNA copy numbers greatly varied between donors. CONCLUSION In Lao People's Democratic Republic, a sizable proportion of HBsAg-negative and anti-HBc antibody-positive blood donations are potentially DNA positive and infective for hepatitis B.
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Affiliation(s)
- P Jutavijittum
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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17
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Martinez JA, Pumarola T. Viriasis nosocomiales. Virus de la hepatitis, herpesvirus y virus de la gripe. Enferm Infecc Microbiol Clin 2013; 31:471-9. [DOI: 10.1016/j.eimc.2013.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/03/2013] [Indexed: 10/26/2022]
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18
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Nishikawa H, Osaki Y. Clinical significance of occult hepatitis B infection in progression of liver disease and carcinogenesis. J Cancer 2013; 4:473-80. [PMID: 23901347 PMCID: PMC3726709 DOI: 10.7150/jca.6609] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 07/05/2013] [Indexed: 01/04/2023] Open
Abstract
Occult hepatitis B infection (OBI) is defined as long-lasting persistence of hepatitis B virus (HBV) DNA in the liver of patients with hepatitis B surface antigen (HBsAg)-negative status, with or without serological markers of previous exposure (antibodies to HBsAg and/or to hepatitis B core antigen). Over the past two decades, significant progress has been made in understanding OBI and its clinical implications. OBI as a cause of chronic liver disease in patients with HBsAg-negative status is becoming an important disease entity. In conditions of immunocompetence, OBI is inoffensive in itself and detection of HBV DNA in the liver does not always indicate active hepatitis. However, when other factors that cause liver damage, such as hepatitis C virus infection, obesity and alcohol abuse are present, the minimal lesions produced by the immunological response to OBI might worsen the clinical course of the underlying liver disease. Several lines of evidence suggest that OBI is associated with progression of liver fibrosis and the development of hepatocellular carcinoma in patients with chronic liver disease. The major interest in OBI is primarily associated with the growing, widely discussed evidence of its clinical impact. The aim of this review is to highlight recent data for OBI, with a major focus on disease progression or carcinogenesis in patients with chronic liver disease.
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Affiliation(s)
- Hiroki Nishikawa
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
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19
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Al-Naamani K, Al-Maqbali A, Al-Sinani S. Characteristics of hepatitis B infection in a sample of omani patients. Sultan Qaboos Univ Med J 2013; 13:380-5. [PMID: 23984022 DOI: 10.12816/0003259] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 01/17/2013] [Accepted: 04/14/2013] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This study aimed to describe the demographic and virological characteristics of chronic hepatitis B virus (HBV) infection in a sample of Omani patients, and indirectly assess the efficacy of hepatitis B vaccination programmes and catch-up strategies. METHODS A retrospective study was undertaken of all patients with chronic HBV infections evaluated and followed-up at the Hepatology Clinic of the Armed Forces Hospital (AFH), Muscat, Oman, between January 2009 and April 2011. RESULTS A total of 154 patients met the inclusion criteria. The mean age of infected patients was 33 years with 72.7% being over 27 years. Females constituted 47.7% of the patients. Half of the cohort was referred either from the AFH's Obstetric Clinic (29.2%) or its Blood Bank (22.1%). A family history of chronic HBV infection was present in 70% of patients. A total of 95% had positive hepatitis B surface antigens, while only 5% had isolated total hepatitis B core antibodies. Most patients (96%) were hepatitis B e-antigen-negative. The majority (77.9%) had low HBV dioribonucleic acid levels of <2,000 IU/ml. Radiological features of liver cirrhosis were observed in 5%. Patients requiring treatment were in the minority (9%). CONCLUSION Almost 50% of the infected patients were female, the majority being of childbearing age. Medical authorities in Oman should consider enforcing a screening policy for all pregnant women using complete hepatitis B serological testing.
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