Quantification of C4d deposition and hepatitis C virus RNA in tissue in cases of graft rejection and hepatitis C recurrence after liver transplantation

Histology is the gold standard for diagnosing acute rejection and hepatitis C recurrence after liver transplantation. However, differential diagnosis between the two can be difficult. We evaluated the role of C4d staining and quantification of hepatitis C virus (HCV) RNA levels in liver tissue. This was a retrospective study of 98 liver biopsy samples divided into four groups by histological diagnosis: acute rejection in patients undergoing liver transplant for hepatitis C (RejHCV+), HCV recurrence in patients undergoing liver transplant for hepatitis C (HCVTx+), acute rejection in patients undergoing liver transplant for reasons other than hepatitis C and chronic hepatitis C not transplanted (HCVTx-). All samples were submitted for immunohistochemical staining for C4d and HCV RNA quantification. Immunoexpression of C4d was observed in the portal vessels and was highest in the HCVTx- group. There was no difference in C4d expression between the RejHCV+ and HCVTx+ groups. However, tissue HCV RNA levels were higher in the HCVTx+ group samples than in the RejHCV+ group samples. Additionally, there was a significant correlation between tissue and serum levels of HCV RNA. The quantification of HCV RNA in liver tissue might prove to be an efficient diagnostic test for the recurrence of HCV infection.

Hepatitis C virus: molecular and epidemiological evidence of male-to-female transmission

INTRODUCTION: There is general consensus that hepatitis C virus is efficiently transmitted by the parenteral route, whereas data on viral transmission by sexual or non-sexual intrafamilial contact are conflicting. OBJECTIVE AND METHOD: The aim of this study was to investigate the transmission of hepatitis C virus in nine heterosexual couples. RESULT: The mean age of the couples was 43.7 years. When interviewed, all of the women denied the presence of risk factors for acquisition of the infection, whereas the cause of infection in the nine husbands could be attributed to blood transfusions in two of them (22.2 percent), use of intravenous and inhaled drugs in six (66.7 percent), acupuncture in one (11.1 percent), and tattooing in one (11.1 percent). All men and none of the women reported sexual relations with sex professionals. The mean homology score (Non Structural 5b-hepatitis C virus) was 98.4 percent. Among the nine couples with matching subtypes, one (11.1 percent) was infected with subtype 1a, three (33.3 percent) with subtype 1b, and five (55.5 percent) with subtype 3a. Shared personal hygiene items showed a much higher correlation with the possible route of transmission and were better supported by the sequence homology data than the other associated risk factors. Three (33.3 percent) couples shared toothbrushes, seven (77.8 percent) shared razor blades, eight (88.8 percent) shared nail clippers, and six (66.7 percent) shared manicure cutters. CONCLUSION: Sharing of personal hygiene items was a confounding factor in the discussion of sexual hepatitis C virus transmission and the hypothesis of male-to-female transmission was supported in this study.

Influência da infecção pregressa pelo vírus da hepatite B na fibrose hepática em portadores de hepatite C crônica: avaliação retrospectiva de uma série de casos / Influence of previous hepatitis B virus infection on liver fibrosis in patients with chronic hepatitis C: a retrospective case series evaluation

INTRODUCÃO: A hepatite C é uma das principais causas de doença hepática em todo mundo. Apresenta um curso evolutivo dinâmico e influenciável por diversos co-fatores. Dentre eles, a infecção pregressa pelo vírus B (anti-HBcAg [+] e HBsAg [-]) tem se associado a pior prognóstico histológico e terapêutico. Este trabalho teve como objetivo analisar a associação entre a infecção pregressa pelo vírus B e fibrose hepática em portadores de hepatite C crônica, de maneira independente. MÉTODOS: Foram revistos retrospectivamente prontuários médicos de pacientes infectados cronicamente pelo vírus C, atendidos consecutivamente durante um ano no ambulatório de Doenças Infecciosas e Parasitárias - HC FMUSP, quanto aos dados epidemiológicos, clínicos, laboratoriais e histológicos. A análise de independência do impacto da infecção pregressa pelo vírus B foi realizada através de modelo estatístico de regressão logística multivariado, considerando a detecção do anti-HBcAg como variável de exposição, sendo o desfecho a alteração estrutural histopatológica graus 3 e 4 (septos com formação de nódulos e cirrose).0 RESULTADOS: 145 indivíduos foram avaliados pelo estudo, 47.2 por cento com anti-HBcAg (+). O fator de risco mais comumente relatado foi transfusão de sangue e hemoderivados (35,9 por cento). Embora necrose em saca-bocado tenha sido encontrada com maior frequência no grupo de infecção pregressa, a sorologia anti-HBcAg (+) não se associou à fibrose hepática avançada. CONCLUSÕES: A infecção pregressa pelo vírus B não parece acentuar a lesão estrutural desencadeada pela hepatite C crônica, após controle estatístico para outros co-fatores sabidamente capazes de influenciar a história natural desta infecção.

INTRODUCTION: Hepatitis C is a major cause of liver disease worldwide. Its evolutionary course is dynamics and may be influenced by several cofactors. Among them, previous hepatitis B virus infection (anti-HBcAg [+] and HBsAg [-]) has been associated with worse histological and therapeutic prognosis. This study had the objective of independently assessing the relationship between previous hepatitis B infection and liver fibrosis in patients with chronic hepatitis C. METHODS: The medical records of patients chronically infected with the hepatitis C virus who had been seen consecutively during a one-year period at the infectious and parasitic diseases outpatient clinic of HC FMUSP were retrospectively reviewed in relation to epidemiological, clinical and histological data. Analysis on the independence of the previous hepatitis B infection was performed using the statistical model of multivariate logistic regression. Detection of anti-HBcAg was taken to be the independent variable. The outcome was taken to be grade 3 and 4 histopathological abnormality (septa with nodule formation and cirrhosis). RESULTS: 145 subjects were evaluated in this study. 47.2 percent of them were anti-HBcAg (+). The main risk factor for infection was blood and blood derivative transfusion (35.9 percent). Findings of anti-HBcAg (+) were not related to advanced liver fibrosis, although piecemeal necrosis has been found frequently in patients with this serological marker. CONCLUSIONS: Previous hepatitis B infection does not seem to increase the structural liver damage triggered by chronic hepatitis C virus infection, after statistical control for other co-factors capable to impact the natural history of this infection.

Hepatitis C: sexual or intrafamilial transmission? Epidemiological and phylogenetic analysis of hepatitis C virus in 24 infected couples / Hepatite C: transmissão sexual ou intrafamiliar? Análise epidemiológica e filogenética do vírus da hepatite C em 24 casais infectados

The role of sexual or intrafamilial transmission of hepatitis C is controversial. A phylogenetic analysis was performed on the non-structural region 5B of the hepatitis C virus (NS5B-HCV). High percentages of homology (mean of 98.3 percent) were shown between the couples. Twenty (83.3 percent) of the 24 men but only two of the women (8.3 percent) reported having had sexually transmitted diseases during their lives. The risk factors for HCV acquisition were blood transfusion (10 couples), use of illegal injected drugs (17), use of inhalants (15), acupuncture (5) and tattoos (5). The shared use of personal hygiene items included toothbrushes between six couples (25 percent), razor blades between 16 (66.7 percent), nail clippers between 21 (87.5 percent) and manicure pliers between 14 (58.3 percent). The high degree of similarity of the hepatitis C virus genome supports the hypothesis of hepatitis C virus transmission between these couples. The shared use of personal hygiene items suggests the possibility of intrafamilial transmission of infection.

O papel da transmissão sexual ou intrafamiliar da hepatite C é controverso. Foi feita análise filogenética, região não estrutural 5B do vírus da hepatite C (NS5B-HCV). Altas percentagens de homologia com média de 98,3 por cento foi revelada entre os casais. Vinte (83,3 por cento) de 24 homens, contra apenas duas (8,3 por cento) mulheres reportaram doença sexualmente transmisível durante suas vidas. Os fatores de risco para aquisição da doença foram: transfusão de sangue para 10 casais, uso de drogas ilícitas injetáveis para 17, inalatórias para 15, acupuntura em 5 e tatuagens para 5. O compartilhamento de utensílios de higiene pessoal incluem: escova de dente para seis (25 por cento) dos casais, lâmina de barbear para 16 (66,7 por cento), cortador de unhas para 21 (87,5 por cento) e alicate de manicure para 14 (58,3 por cento). O alto grau de similaridade genômica entre os vírus da hepatite C suporta a hipótese de transmissão entre os casais. O uso compartilhado de utensílios de higiene pessoal sugere a possibilidade de transmissão intrafamiliar.

Guidelines on management of human infection with the novel virus influenza A (H1N1): a report from the Hospital das Clínicas of the University of São Paulo

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July, 2009. Since then, 9.249 cases were confirmed in Brazil, most of them concentrated in São Paulo. The Hospital das Clínicas of the University of São Paulo is a reference center for H1N1 cases in São Paulo. The purpose of this review is to analyze the evidence concerning diagnosis, prevention, and treatment of novel influenza A (H1N1) infection. In addition, we propose guidelines for the management of this pandemic emphasizing Hospital das Clínicas "bundles" for the control of the pandemic novel influenza A (H1N1).

Epidemiology of human infection with the novel virus influenza A (H1H1) in the Hospital das Clínicas, São Paulo, Brazil - june-september 2009

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July 16, 2009. Since then, 46,810 cases of acute respiratory syndrome have been reported in Brazil, most of them concentrated in São Paulo. Through September 16, we have confirmed 9,249 cases of novel influenza A H1N1in Brazil, including 699 deaths. The mortality rate observed in Brazil is 0.47/100,000 inhabitants and varies according to region. In this period, São Paulo registered 3733 cases (40.3 percent of the total) of novel influenza A (H1N1) infection and 327 deaths, reflecting a mortality rate of 0.79/100,000 inhabitants. The Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC) is a reference center for H1N1 cases in São Paulo. During the winter of 2009, 472 patients in this hospital were diagnosed with H1N1 infection; of these, 210 were admitted, and 16 died. To control this pandemic and to provide adequate care for these patients, the Hospital das Clínicas implemented "bundles" including prevention strategies, an epidemiologic surveillance service, availability of fast diagnosis, antiviral treatment and training of staff. The purpose of this manuscript is to describe the epidemiologic features of novel human influenza A (H1N1) infection in the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo during the winter period of the 2009 pandemic.

Hepatitis C virus detection in the semen of infected patients

Though HCV infection is a serious public health problem, some aspects of its biology are still not well understood, such as its transmission through seminal fluid and sexual transmission. We looked for HCV in the semen of infected patients. Thirteen patients were included. Semen fractions (seminal plasma, leukocytes and spermatozoa) were separated with 45 percent and 90 percent Percoll gradients. The HCV-RNA in blood and semen fractions was extracted using the same protocol (AMPLICOR Roche) and was detected using the qualitative Roche Amplicor test and by agarose gel electrophoresis, with ethidium bromide staining. The mean age of the patients was 40.7 years. Risk factors for the acquisition of HCV included injectable and inhaled drug use in six (42.8 percent), blood transfusion in four (28.6 percent), and no risk factors in four (28.6 percent) patients. Genotype 1 was detected in 62 percent of the patients, followed by genotype 3 in 23 percent and genotype 2 in 15 percent. All blood samples were positive, regardless of the technique used for detection. All semen samples identified by Roche Amplicor and analyzed by agarose gel electrophoresis were negative. Among the 52 semen samples (total and fractions) identified by the Roche Amplicor method, 45 (87 percent) were inhibited. A negative result was recorded for one (1.9 percent) total semen sample, one (1.9 percent) leukocyte and four (7.7 percent) seminal plasma fractions. Only one (1.9 percent) sample of the spermatozoon fraction was positive. The results obtained suggested false-negative reactions for the semen samples.

Clinical and histological characteristics of HIV and hepatitis C virus-co-infected patients in Brazil: a case series study / Características clínicas e histológicas de pacientes co-infectados pelo HIV e vírus da hepatite C no Brasil: estudo de uma série de casos

Hepatitis C virus (HCV) is an important factor contributing to morbidity and mortality in patients co-infected with HIV and HCV. In addition, liver biopsy is an important tool in the clinical management of these patients. Although liver biopsy is controversial, it is recommended for all patients. Data regarding the clinical and histological characteristics of these patients are scarce not only in Brazil but in Latin America as a whole. With the goal of better understanding these characteristics and the benefit of liver biopsy indications in this disease setting, data collected from 234 patients followed from 1996 to 2004 at Casa da AIDS, São Paulo, were analyzed. The following variables were extracted from the patients' medical files at the time of liver biopsy: sex, age, hepatitis C infection risk factors, hepatitis C infection duration, ALT levels, CD4+ T cell counts, history of alcohol abuse, history of antiretroviral therapy, HCV genotype, and liver histological alterations. CONCLUSIONS: 1 - Hepatitis C virus 1 and 3 were the most frequently identified genotypes and were diagnosed in 72 percent and 25.5 percent of cases respectively; 2 - Structural liver alterations were found to be mild or absent in 48.2 percent (113/234) of the analyzed patients; 3 - Fifty-three patients (23 percent) had normal ALT levels and 4 - Significant liver architectural changes (F2-F3) were evident in 22.5 percent of the patients with normal ALT levels.

A infecção causada pelo vírus da hepatite C (VHC) constitui importante causa de morbidade e mortalidade entre pacientes co-infectados pelo HIV e VHC. A indicação da realização de biópsia hepática nesses pacientes é controversa, podendo constituir importante ferramenta no manejo clínico desses pacientes. São escassos os dados relativos às características clínicas e histopatológicas dos pacientes co-infectados no Brasil e em toda a América Latina. Com o objetivo de analisar as características clínicas e histopatológicas em co-infectados e avaliar os benefícios da realização de biópsia hepática nesse grupo de pacientes, analisamos dados relativos a 234 pacientes acompanhados na Casa da AIDS, São Paulo, de 1996 a 2004. A partir de informações obtidas em prontuários, foram analisadas as seguintes variáveis relativas aos pacientes, coletadas à época da realização da biópsia hepática: gênero, idade, fatores de risco para a transmissão da hepatite C, tempo estimado de infecção pelo VHC, níveis séricos de ALT, contagem de células CD4, antecedentes relativos ao uso de álcool, antecedente de uso de terapia antiretroviral, genótipo de VHC e alterações histológicas obtidas através da biópsia hepática. CONCLUSÕES: 1- Os genótipos 1 e 3 foram os mais freqüentes nessa população, representando cerca de 72 por cento e 25,5 por cento dos casos analisados respectivamente; 2- Alterações estruturais hepáticas leves ou ausentes foram observadas em 48,2 por cento dos pacientes (113/234); 3- Cinqüenta e três pacientes (23 por cento) apresentaram níveis de ALT persistentemente normais; 4- Alterações estruturais significativas (F2-F3) foram observadas em 22,5 por cento entre pacientes com níveis de ALT persistentemente dentro da normalidade.

Portal cd4+ and cd8+ t lymphocyte correlate to intensity of interface hepatitis in chronic hepatitis C

BACKGROUND: The pathogenesis of chronic hepatitis C is still a matter of debate. CD4+ and CD8+ T lymphocytes (TL) are typically observed within the portal and periportal spaces of affected livers, but their functional role in hepatitis C progression has not been fully elucidated. METHODS: CD4+ and CD8+ TL were quantified by immunohistochemistry in portal and periportal spaces of 39 liver biopsies from patients with chronic hepatitis C. They were associated to demographic data, histological parameters, laboratory findings of patients and hepatitis C genotypes. RESULTS: There was high numbers of CD4+ and CD8+ TL from which the density of CD4+ T was higher than CD8+ TL in portal and periportal spaces. CD4+ and CD8+ TL were directly correlated to intensity of interface hepatitis. CD8+ TL correlated to serum enzyme levels. CONCLUSION: The high numbers of CD4+ and CD8+ TL in portal and periportal spaces and their correlation to interface hepatitis suggest that hepatitis C evolution depends on the action of intrahepatic T lymphocytes, lending support to the notion of an immune-mediated mechanism in the pathogenesis of chronic hepatitis C.

INTRODUÇÃO: A patogênese da hepatite C crônica ainda está em discussão. Sabe-se que linfócitos T (LT) CD4+ e CD8+ são tipicamente observados no espaço portal e peri-portal de pacientes com hepatite C crônica, mas o conhecimento exato de suas ações no fígado, bem como sua influência na progressão da doença hepática ainda estão em discussão. MÉTODOS: Os LT CD4+ e T CD8+ foram quantificados por imunohistoquímica nos espaços porta e peri-portais em 39 biópsias hepáticas de pacientes cronicamente infectados pelo vírus da hepatite C. Esses dados foram associados com os dados demográficos, as alterações histológicas, os achados laboratoriais dos pacientes com hepatite C e com os genótipos do vírus da hepatite C. RESULTADOS: Houve grande quantidade tanto de LT CD4+ como de CD8+, sendo que houve maior densidade de LTCD4+ do que CD8+ nos espaços portal e peri-portal. Tanto o número de linfócitos T CD4+ como de CD8+ foram diretamente relacionados com a intensidade da hepatite de interface. Os linfócitos T CD8+ foram estatisticamente relacionados às enzimas hepáticas. CONCLUSÃO: O encontro de numerosos linfócitos T CD4+ e linfócitos T CD8+ no espaço-portal e peri-portal e sua correlação com a hepatite de interface sugerem que a evolução da hepatite C dependa da ação dos linfócitos T intra-hepáticos, ou seja, há um mecanismo imuno-mediado na patogênese da hepatite C crônica.

Detection of HCV by PCR in serum and PBMC of patients with hepatitis C after treatment

Although hepatitis C is mainly hepatotropic, some studies suggest that hepatitis C virus (HCV) infects peripheral blood mononuclear cells (PBMC), using them as a reservoir, which might contribute to the development of resistance to treatment. Fifty-four hepatitis-C patients, who had been submitted to treatment, were selected. Blood samples were collected on the same day for the detection of HCV RNA in serum and PBMC by PCR, using the Amplicor HCV 2.0 assay (Roche Diagnostics). HCV genotyping was performed using the INNO-LiPA HCV kit (Versant, Bayer Diagnostics). HCV RNA was detected in both serum and PBMC in 35 (64 percent) patients and no RNA in 16 (29.6 percent). Disagreement between the serum and PBMC results was observed for three patients (5.6 percent), with HCV RNA being detected in PBMC but not in serum. Four months later, new serum and PBMC samples were collected from one of these patients and HCV RNA was detected in both samples, showing that PBMC can reveal signs of a lack of response to treatment. We conclude that the absence of HCV in the serum of patients with chronic hepatitis C by the end of treatment does not mean that there is no circulating virus. HCV in mononuclear cells may be an indicator of the persisting infection.

Hepatitis C treatment: shorter and better?

Herein, we present a synthesis of two publications that evaluate an abbreviated therapeutic approach to treating chronic hepatitis C virus (HCV) infection. Based on those publications, we discuss the use of the early virologic response (EVR) as a tool for the optimized management of patients under treatment, as well as reviewing concepts of HCV viral kinetics. The fourth-week EVR, characterized by HCV RNA dropping to undetectable levels, allows individuals infected with HCV genotype 1 and presenting low baseline viral loads to be treated with the combination of pegylated interferon and ribavirin for 24 weeks, whereas individuals infected with HCV genotypes 2 or 3 can be treated for only 12 weeks. Therefore, by adopting abbreviated treatment regimens optimized through early prediction of sustained viral response, it is possible to increase the number of patients treated without incurring the excess costs related to high rates of treatment failure and management of adverse outcomes, as well as avoiding the risks of unnecessarily exposing patients to drugs that have the potential to be highly toxic.