Sequence characterization of the 5' noncoding region of GB virus C/hepatitis G virus.

The nucleotide sequences of the 5' noncoding region of the GB virus C/hepatitis G virus (GBV-C/HGV) were determined in 18 isolates from the United States. Two genotypes have been classified based on the sequence heterogeneity within the 5' noncoding region of GBV-C/HGV. The most distantly related isolates between the two genotypes were 84.6% identical. Sequence identity of the isolates within a genotype was 95-99%. The 5' noncoding region of this virus contains four highly conserved domains. These conserved elements would facilitate the selection of optimal primers for the sensitive detection of GBV-C/HGV RNA by PCR. In addition, they suggest a crucial role for this region in viral replication and/or gene expression. Detection of genotypic variation among GBV-C/HGV infected individuals may provide further insight into the possible pathogenicity and into the transmission of the virus.

Prevalence of hepatitis G virus in hepatitis C virus (HCV)-infected patients and in HCV-contaminated intravenous immunoglobulin products.

Hepatitis GB virus C/hepatitis G virus (HGV) is an RNA virus, which appears to be transmitted by parenteral exposure to contaminated blood and blood products, and may be associated with clinical hepatitis in humans. The prevalence of HGV was investigated in hepatitis C virus (HCV)-infected patients, and (HCV)-contaminated immune globulin intravenous products (IGIV), manufactured prior to the introduction of viral inactivation processing, and in recipients of these lots. Nested primers, specific for the 5' non-coding region of HGV, were designed and used to test 100 chronic HCV patients, 10 HCV RNA-positive IGIV lots and 36 of the recipients of these products. Hepatitis G virus specificity of the polymerase chain reaction (PCR) products was confirmed by sequencing a number of the amplified products and comparing the results with the published prototype sequence for HGV RNA. HGV RNA was detected in 23 of the 100 (23%) HCV-infected patients. The level of alanine aminotransferase (ALT) was lower in HCV-HGV coinfected patients than those with HCV infection alone. Hence, the severity of HCV infections is not influenced by HGV. Two of the 10 (20%) IGIV lots tested positive for HGV RNA; however, none of the serum samples from recipients of IGIV contained detectable HGV RNA although many were infected with HCV. This suggests that the transmission of HGV RNA from IGIV to the recipients is less efficient than that seen for HCV.

Parvovirus B19 in anemic liver transplant recipients.

Five hundred thirty-three liver transplant recipients were seen for follow-up care over a 6-month period. Of these, 23 (4.3%) had a hemoglobin level of < or = 9 g/dl, with 19 being eligible for inclusion in this study. The median hemoglobin level was 8.7 g/dl. Two patients had iron-deficiency anemia. All of the patients were on therapeutic drugs which can suppress erythropoiesis or shorten the lifespan of mature erythrocytes. Six patients (31.6%) were viremic for human parvovirus B19 but none was B19 immunoglobulin M seropositive. Two patients were immunoglobulin M seropositive for cytomegalovirus. The patients with circulating B19 DNA were not easily distinguished from those without the virus by their laboratory results. The absence of reticulocyte counts for these patients contributed to this inability to differentiate B19 from other causes of anemia, particularly drug myelotoxicity. The high likelihood of making a specific diagnosis with the increasing availability of PCR should spur the search for this virus in the liver transplant population.

Hepatitis C virus infection in a male homosexual cohort: risk factor analysis.

BACKGROUND: Hepatitis C virus (HCV) infection is a major cause of morbidity throughout the world. Parenteral exposure to infected blood accounts for the majority of cases. Sexual transmission is suggested by the higher prevalence of infection in sex workers and homosexual men. Sexual practices which contribute to HCV infection need to be identified. METHODS: The social and medical history, and HCV serostatus of 1058 homosexual men in the Pittsburgh arm of the Multicenter AIDS Cohort Study were analysed. Multivariate analysis was used to determine risk factors for HCV seropositivity. RESULTS: 31 men were HCV seropositive by enzyme immunoassay and recombinant immunoblot assay (2.9%). They were more likely to be HIV seropositive (39%) than the HCV seronegative men (19%). Needle sharing and illegal drug use were the most important risk factors for HCV seropositivity. Statistically significant sexual factors (p < 0.05) included a history of syphilis, rectal gonorrhea, anal insertive intercourse with ejaculation, and douche or enema use before anal receptive intercourse. The number of sexual partners was not a significant risk factor. CONCLUSIONS: HCV infection is associated with specific sexually transmitted diseases (STDs) and sexual practices in the male homosexual population. The evidence of high risk behavior should be incorporated into ongoing educational efforts to decrease the incidence of STDs.

Recurrent hepatitis C virus hepatitis in liver transplant recipients receiving tacrolimus: association with rejection and increased immunosuppression after transplantation.

BACKGROUND: Recurrent hepatitis C virus is associated with significant morbidity and mortality after liver transplantation. However, the risk factors for clinical recurrence including the role of rejection and immunosuppression have not been defined in patients receiving tacrolimus (FK506) as primary immunosuppression. METHODS: Sixty-six consecutive adult liver transplant recipients receiving tacrolimus as primary immunosuppression were monitored; 31 of 66 underwent transplantation for end-stage liver disease caused by hepatitis C virus. Median follow-up for the patients in the study was 3 1/2 years. Recurrent hepatitis C virus hepatitis determined on histopathologic evaluation developed in 58% (18 of 31). A number of clinical variables including rejection and intensity of immunosuppression were assessed for patients with and without recurrence. RESULTS: Rejection episodes preceding recurrence were documented in 72% (13 of 18) of patients with recurrence compared with 23% (3 of 13) in those without recurrence (p=0.007). A total of 33% (5 of 15) of patients with no rejection experienced recurrence versus 83% (5 of 6) with one episode of rejection (p=0.06) and 80% (8 of 10) with more than one episode of rejection (p=0.04). The mean number of steroid boluses for the treatment of rejection was higher for patients with recurrence (2.3 versus 0.77, p=0.01). Overall immunosuppression (as measured by steroids boluses, recycles, OKT3, and azathioprine) was significantly more intense for patients with recurrence (p=0.013). CONCLUSIONS: Greater rejection concurrent with increased immunosuppression was associated with a higher recurrence of hepatitis C in liver transplant recipients.

Prevalence of hepatitis C infection in health care workers affiliated with a liver transplant center.

The risk of hepatitis C to liver transplantation health care workers has not been identified. We compared the occupational risk of hepatitis C in health care workers associated with liver transplantation with risk of health care workers affiliated with the same institutions but not involved in transplantations. Health care workers were recruited from 2 transplant centers. Participation was voluntary; results were confidential. An occupational and health history questionnaire was completed and blood was donated for testing. Health care workers were categorized into 3 groups according to risk for hepatitis C infection: very high, high, and low risk. A total of 241 health care workers were recruited from 2 transplant centers. Fifty-nine percent (142/241) were female; mean age was 38.7 years. Health care workers included: 48.5% (117/241) nurses, 24.9% (60/241) physicians, and 17% (42/241) laboratory personnel. The mean number of years in their occupation was 13.5 years (range < 1 year to 38 years). Twenty-four percent (57/241) were categorized in a very high risk occupation for hepatitis C, 66% (158/241) in a high risk occupation, and 10.8% (26/241) in a low risk occupation. A total of 2.1% (5/241) of health care workers were reactive to hepatitis C by enzyme immunosorbent assay; three of these were positive by polymerase chain reaction testing. Of the 3, none had a history of hepatitis or transfusion. However, 5.3% (3/57) of health care workers involved with liver transplantation were infected, as compared with 0% (0/184) who were not (P = 0.013). We conclude that health care workers associated with liver transplantation may be at a higher risk for hepatitis C when compared with health care workers not associated with transplantation.

Long-term serologic follow-up of hepatitis C virus-seropositive homosexual men.

Hepatitis C virus (HCV) infection may go undiagnosed and continue to present a source of community-acquired or transfusion-associated infection because of shortcomings in sensitivity, specificity, and reproducibility of serologic tests. This project was designed to longitudinally study persons who were HCV seropositive or were at risk for seroconversion to characterize the course of infection. Sequential serum samples obtained semiannually from 617 homosexual male volunteers were available for study from the Pittsburgh site of the Multicenter AIDS Cohort Study. Testing by anti-HCV enzyme immunoassay (EIA) was performed on baseline (1984 to 1985) and most-recent (censor date, August 1992) samples. Selected samples were also assayed for alanine aminotransferase and by recombinant immunoblot (RIBA II) and nested PCR. A total of 17 of 617 (2.8%) men were HCV seropositive at entry. Of the 600 seronegative men, 9 converted to HCV seropositive during the study interval. Parenteral sources of exposure could be identified in 6 of these 26 HCV-seropositive men. Four men were HCV seropositive at baseline and seronegative at their most recent visit. Of the 26 HCV-seropositive men, 12 were also seropositive for human immunodeficiency virus. EIA analysis of 298 longitudinal samples from the 26 men revealed three patterns of HCV seropositivity: persistent, intermittent, and rare. Nine men (35%) showed intermittent or rare seropositivity with periods of over 1 year between some seropositive samples. PCR was positive in 76% of the HCV EIA-positive and 84% of the RIBA-positive samples. Thus, a low but significant number of homosexual men were HCV seropositive with variable positivity over several years of follow-up. A portion of these men become HCV seronegative. Individuals who exhibit intermittent or rare seropositivity are a challenge to diagnosis.

Prostatic sequestration of Cryptococcus neoformans in immunocompromised persons treated for cryptococcal meningoencephalitis.

We report a case of a patient with acquired immune deficiency syndrome who was successfully treated for cryptococcal meningoencephalitis with amphotericin B and 5-flucytosine. He died from other sequelae of acquired immune deficiency syndrome two years later. An autopsy revealed prominent cryptococcal prostatitis. Cryptococci were neither found in the central nervous system nor in other anatomic sites. The autopsy files yielded seven other cases of men with a history of cryptococcal meningoencephalitis. The possibility that the prostate sequesters Cryptococcus neoformans thereby contributing to systemic relapse is explored. The qualify as a sequestration, cyptococci must be cultured from the prostate, or from a midstream voided specimen after prostatic massage, and the prostate must be the only focus of infection.

Sudden unexpected death in a male homosexual cohort.

There has been considerable debate as to the risk of suicide, accidents, and homicide in populations at high risk for HIV infection. The purpose of the present investigation was to determine the incidence of sudden and unexpected deaths in a well-defined cohort of homosexual and bisexual men prospectively studied since 1984. All subjects were enrolled in the Pitt Men's Study, the Pittsburgh, Pennsylvania, component of the Multicenter AIDS Cohort Study. Of this group, 861 were between the ages of 20 and 44, and 35% were seropositive for HIV. There were 70 deaths attributed to AIDS. Five additional deaths were classified as sudden and unexpected, an annual rate of 0.08% (80/100,000). Only one of these was classified by the coroner's office as a suicide; three were due to accidents, and one was a drug overdose of undetermined cause. Only two of the five unexpected deaths were HIV seropositive, and none had the diagnosis of AIDS. The sudden and unexpected death rate in this cohort did not significantly differ from the 0.07% (70/100,000) yearly incidence in the age- and race-matched male population. Thus, in this well-defined male gay cohort, there does not appear to be an increased risk of violent and drug-related deaths in persons at risk for, or with a diagnosis of, AIDS.

The presence of hepatitis C virus (HCV) antibody in human immunodeficiency virus-positive hemophilic men undergoing HCV "seroreversion".

Hepatitis C virus (HCV) is a major cause of transfusion-induced chronic liver disease in hemophiliacs, with 70% to 90% being anti-HCV positive. Seroreversion or loss of antibody response to HCV has been observed in a small proportion of human immunodeficiency virus-positive [HIV(+)] anti-HCV(+) hemophilic men. Despite the seroreversion to an anti-HCV-negative state, such patients continue to show serum alanine aminotransferase (ALT) elevations and biopsy evidence of cirrhosis and/or chronic active hepatitis. To determine the cause for the loss of anti-HCV antibody, we compared first- and second-generation anti-HCV enzyme immunosorbent assay (EIA 1.0 and 2.0), second-generation recombinant immunoblot (RIBA 2.0), and HCV-RNA amplification using polymerase chain reaction (PCR) in 19 "seroreverters" before and after seroreversion. There was no difference between 19 seroreverters and 59 persistently anti-HCV-positive hemophiliacs in mean ALT (1.1 +/- 0.1 XUL v 2.0 +/- 0.2 XUL; chi 2 = 1.80, P > .05), in mean CD4 (188 +/- 36/microL v 232 +/- 28/microL; t = 0.965, P > .05), or in the rate of progression to acquired immunodeficiency syndrome (13 of 19 [68.4%] v 30 of 59 [50.9%]; chi 2 = .987, P > .05, respectively). Before seroreversion, all 19 seroreverters (100%) were positive for EIA 1.0 and 2.0 and PCR, and all but 2 of 19 (89.5%) were RIBA 2.0 positive, whereas, after seroreversion, none were positive for EIA 1.0, 15 of 19 (78.9%) were positive for EIA 2.0, 8 of 18 (44.4%) were positive for RIBA 2.0, and 18 of 19 (94.7%) were positive for PCR. There was a lower CD4 lymphocyte number after seroreversion in those who were RIBA 2.0 negative as compared with those who were RIBA 2.0 positive (32 +/- 10/microL v 171 +/- 52/microL; t = 2.638, P > .05). These results indicate that HIV(+) anti-HCV(+) hemophilic men who undergo "HCV seroreversion" are truly infectious and anti-HCV positive by second-generation tests. Anti-HCV detection in immunosuppressed hosts is significantly improved by second-generation EIA and RIBA assays.

Hemangiomas with localized nodular proliferation of the liver. A suggestion on the pathogenesis of focal nodular hyperplasia.

Multiple cavernous hemangiomas circumscribed by focal regenerative nodules of hepatocytes were incidental findings at the autopsy of two elderly men. Neither patient was on steroids or had venous thrombosis. The lesions were not typical for other nodular proliferations of the liver, such as focal nodular hyperplasia, nodular regenerative hyperplasia, or liver cell adenoma, and they have not been previously reported. We also explore the roles of vascular malformation, oral contraceptives, and thrombosis in the pathogenesis of localized nodular proliferation of the liver.

Lupus anticoagulant associated with specific inhibition of factor VII in a patient with AIDS.

A 37-year-old intravenous drug abuser with acquired immune deficiency syndrome showed elevated activated partial thromboplastin time (APTT) and prothrombin time, normal thrombin time and fibrinogen, and borderline low platelet counts. The patient subsequently had a fracture of the left zygomatic arch, which did not produce uncontrollable bleeding. The coagulogram repeated at this admission showed persistent elevation of APTT. Further coagulation workup showed the presence of a lupus anticoagulant with mild specific inhibition of Factor VII. Platelet aggregation and Factor II levels were normal.

Dendriform pulmonary ossification.

Dendriform pulmonary ossification is a rare entity associated with chronic lung disease that is almost invariably discovered as an incidental finding at autopsy. Antemortem chest roentgenograms of patients with dendriform pulmonary ossification are often interpreted as pulmonary fibrosis and/or bronchiectasis. Radiographic and pathologic findings in two cases are described herein.