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Studies of the “e” Antigen in Acute and Chronic Hepatitis
GASTROENTEROLOGY 71:208-209. 1976 Copyright @ 1976 by The Williama & Wilkin. Co,
VoL 71. No, 2 Printed in U,S.A,
STUDIES OF THE He" ANTIGEN IN ACUTE AND CHRONIC HEPATITIS JOSEPH L. SMITH, M.D., BERT L. MURPHY, M.S., MILES O. AUSLANDER, M.D., JAMES E. MAYNARD, M.D., PH.D., SOLKO S. SCHALM, M.D., WILLIAM H. J. Sm,IMERSKILL, M.D., AND GARY L. GITNICK, M.D.
Phoenix Laboratories Division, Bureau of Epidemiology, Center for Disease Control, Phoenix, Arizona, Department of Medicine. School of Medicine, UCLA Cent~r for the Health Sciences, Los Angeles, California, and Gastroenterology Unit, Mayo Clinic, Rochester, Minnesota
Sera from well individuals, including controls and asymptomatic HB.Ag carriers, post· transfusion hepatitis cases, and chronic active liver disease patients were examined for the presence of "e" antigen and e antibody by rheophoresis. Our data confirm the specific association between the e determinant and hepatitis B infections and indicate that e antigen is closely associated with evidence of chronic hepatic dysfunction, in contrast to the association of e antibody with hepatic normalcy in HB.Ag carriers. However, these correlations are not absolute and, therefore, it should not be inferred that all e antigen·positive individuals will develop chronic hepatitis nor, conversely, that presence of e antibody invariably protects against the development of chronic hepatitis.
Magnius and Espmark l • 2 have recently described a new antigen-antibody system in carriers of hepatitis B surface antigen (HB.Ag), and have designated the new antigenic determinant as "e." Subsequent work has suggested that the presence of e antigen in serum might be a prognostic indicator of severity and duration of hepatic dysfunction in hepatitis B infection.' Recently, Magnius et aI.· have also described an association between the presence of e antigen and abnormal hepatic histology in long term HB.Ag carriers. We have tested sera from selected groups of individuals for the presence of e antigen and its homologous serum antibody (e antibody) to assess the clinical significance of these serological markers in acute and chronic hepatitis, and here present our data. Methods Chosen for study were sera from several groups of individuals, including healthy persons, those with post-transfusion hepatitis, and those with chronic active liver disease (CALD). The well persons included 32 healthy controls who were seronegative for HB.Ag, as well as for antibody against HB.Ag (anti·HB.), and a group of 24 healthy carriers of HB.Ag, initially identified during volunteer blood donation. At time of study, these latter persons had been known to be persistently HB.Ag positive for at least 4 months, were found to be normal on physical examination, and to have repeatedly normal serum glutamic pyruvic transaminase, bilirubin, and alkaline phosphase levels. Liver biopsies obtained on 20 of these 24 individuals revealed no significant morphological alterations. Received November 13. 1975, Accepted February 24. 1976. All commerical names are used for identification only and their mention does not constitute endorsement by the Public HealthService or the United States Department of Health, Education, and Welfare. 208
Patients who developed serum glutamic pyruvic transaminase (SGPr) elevations ~5 times normal level on at least two occasions separated by at least 2 days, 3 weeks to 6 months after infusion of either whole blood or component blood products, and who lacked evidence for other causes of active liver disease were considered as cases of post-transfusion hepatitis. Paired sera were collected during the acute stage of illness .at time of peak transaminase levels and 6 months after acute illness from 38 cases of post·transfusion hepatitis. These cases included 22 individuals with non·B viral hepatitis documented by failure to detect HS.Ag in acute illness phase serum, as well as by failure to develop anti-HB. iri in convalescent phase serum, and 16 cases of post-transfusion. hepatitis B confirmed by either finding HB.Ag in acute illness phase serum or development of anti-HB. in convalescent phase serum. In this study CALD was defined on the basis of liver biopsy abnormalities showing piecemeal necrosis, bridging necrosis, multilobular necrosis, or cirrhosis with active hepatitis. In addition, all such cases had a duration of illness of at least 10 weeks or the presence of cirrhosis on liver biopsy. All had persistent high level SGPT elevations, or moderate elevations in combination with abnormally high levels of serum ,),-globulins.· Of the 50 persons included in the CALD category, 18 had a serologically documented antecedent hepatitis B infection, and 32 were serologically proven to be unrelated to hepatitis B. All sera had been tested for HB.Ag by solid phase radioimmune assay (Ausria II, Abbott Laboratories, North Chicago, Ill.) and anti-HB. by radioimmune assay (AUSAB, Abbott Laboratories), and/or passive hemagglutination (Electro-Nucleonics, Inc., Fairfield, N.J.). Measurement of e antigen and e antibody was performed using rheophoresis plates (Abbott Laboratories) incubated at 27°C in humidified petri dishes (detectable precipitin lines appeared within 24 to 72 hr). The standard e antigen and e antibody reagents were obtained froll1 known HB.Ag-positive donor plasma units. These reagents were verified and typed by Dr. George Le Bouvier, Yale University School of Medicine. The e antigen reagent con-
"e" ANTIGEN IN HB,Ag CARRIERS
August 1976
tained both e, and e. specificities, and the e antibody reagent contained antibody directed against both specificities.'
209
patients whose convalescent phase sera contained e antibodies.
Discussion Results This study, as well as several others, l-f. T-. confirms As shown in table 1, e antigen or e antibody was found only in individuals with serological evidence of past or the specific association of the e antigen-antibody system current hepatitis B virus infection. Moreover, e antigen with hepatitis B infection. Although e antigen has not was detected only in sera positive for HB.Ag, whereas e yet been fully characterized biophysically or immunologantibody was found in both HB.Ag- and anti-HB.-posi- ically, our failure to detect this antigen or its homologous antibody in paired sera from 22 patients with post-transtive sera. When comparing the frequency of e seropositivity in fusion hepatitis of non-B "origin provides further eviasymptomatic HB.Ag carriers and in patients with dence that e 'antigen may be specified by the hepatitis B CALD, two significant patterns became apparent. First, viral genome and not by the host as a general response to e antigen was found in 8 of 15 (53%) HB.Ag-positive hepatic injury. Although our data show a significant association CALD patients, as compared with only 2 of 24 (8%) asymptomatic HB.Ag carriers (P = 0.003, Fisher's exact between presence of e antigen and evidence of chronic test). Second, e antibody was found in 15 of 24 (63%) hepatic dysfunction in contrast to the association of e asymptomatic HB.Ag carriers, as contrasted with 3 of 18 antibod~ with hepatic normalcy in HB.Ag carriers, the (17%) CALD patients with antecedent hepatitis B infec- correlatlOns are not 1 to 1. This is demonstrated by finding e antigen in 2 healthy HB.Ag carriers and e timn (P = 0.003, Fisher's exact test). Both of the e antigen-positive asymptomatic HB.Ag antibody in 3 persons with CALD. Recently, other carriers lacked evidence of significant liver disease. One investigators have also reported finding e antibody in had previously undergone liver biopsy which was inter- sera from patients with chronic liver disease." • Thus, preted as showing minimal nonspecific alterations in although the presence of e antigen in contrast to e several portal tracts. The other person had been an antibody in carriers of HB.Ag may be predictive of asymptomatic carrier for longer than 1 year and at the hepatic outcome in hepatitis B infection, one should time of testing was only weakly e antigen positive. not infer that all e antigen-positive individuals will deSubsequent e antigen testing of sera from those 2 velop chronic hepatitis, nor, conversely, that presence individuals was not performed. Of the 3 anti-e-positive of e antibody invariably protects against the developCALD patients, 2 were anti-HB. positive and 1 was ment of chronic hepatitis. Further studies will be required before the full implications of the e antigenHB.Ag positive. Among the post-transfusion hepatitis cases, we did not antibody system in the course of hepatitis B infection document any seroconversion from positive for e antigen can be completely understood. to positive for e antibody. The 2 patients whose acute REFERENCES phase sera contained e antigen were not the same 2 TABLE
1. Frequency of e antigen and e antibody in well individuals,
cases of post-transfusion hepatitis, and patients with CALlY' Category
Well individuals HBeAg and anti-HB, negative Asymptomatic healthy HB,Ag carriers Post-transfusion hepatitis Hepatitis B origin Acute Convalescent Nonhepatitis B origin Acute Convalescent Chronic active liver disease Prior HBV· infection HB,Ag+ Anti-HB,+ No prior HBV infection
---
• CALn, chronic active liver disease. • HBV, hepatitis B virus.
No. potIitive
No. tested
e antigen
e antibody
32 24
0 2
0 15
16 16
2 0
0
22
22
0 0
0 0
15 3 32
8 0 0
2
2
1
0
1. Magniu8 LO, Espmark JA: A new antigenic complex co-occurring with Australia antigen. Acta Pathol Microbiol Scand [B) 80:335-337, 1972 2. Magnius LO, Espmark JA: New specificities in Australia antigen positive sera distinct from the Le Bouvier determinants. J. lmmunol 160:1017-1021, 1972 3. Nielsen, IO, Dietrichson 0, Juhl E: Incidence and meaning of the "e" determinant among hepatitis-B-antigen positive patients with acute and chronic liver diseases. Lancet 2:913-915, 1974 4. Magnius LO, Lindholm A, Lundin P. et al: A newantigen-antibody system: clinical significance in long-term carriers of hepatitis B surface antigen. JAMA 231:356-359, 1975 5. Soloway RD, Summerskill WHJ, Baggenstoss AH, et al: Clinical, biochemical, and histological remis~ion of severe chronic active liver disease: a controlled study of treatments and early prognosis. Gastroenterology 63:821H!33, 1972 6. Williams A, Le Bouvier G: Heterogeneity and thermolabilityor"e." Bibl Haematol 42:71-74, 1976 7. Maynard, JE, Barrett DH, Murphy BL, et al: Relationship of the e antigen to hepatitis B virus infection in a hyperendemic area. J. Infect Dis 133:339-342, 1976 !to Eleftheriou N, Heatbcote J, Thomas HC, et al: Incidence and clinical significance of e antigen and antibody in acute and chronic liver disease. Lancet 2: 1171-1173, 1975 9. Feinman SV, Beris B, Sinclair JC, et al: e Antigen and anti-e in HBeAg carriers. Lancet 2:1173-1174, 1975
VoL 71. No, 2 Printed in U,S.A,
STUDIES OF THE He" ANTIGEN IN ACUTE AND CHRONIC HEPATITIS JOSEPH L. SMITH, M.D., BERT L. MURPHY, M.S., MILES O. AUSLANDER, M.D., JAMES E. MAYNARD, M.D., PH.D., SOLKO S. SCHALM, M.D., WILLIAM H. J. Sm,IMERSKILL, M.D., AND GARY L. GITNICK, M.D.
Phoenix Laboratories Division, Bureau of Epidemiology, Center for Disease Control, Phoenix, Arizona, Department of Medicine. School of Medicine, UCLA Cent~r for the Health Sciences, Los Angeles, California, and Gastroenterology Unit, Mayo Clinic, Rochester, Minnesota
Sera from well individuals, including controls and asymptomatic HB.Ag carriers, post· transfusion hepatitis cases, and chronic active liver disease patients were examined for the presence of "e" antigen and e antibody by rheophoresis. Our data confirm the specific association between the e determinant and hepatitis B infections and indicate that e antigen is closely associated with evidence of chronic hepatic dysfunction, in contrast to the association of e antibody with hepatic normalcy in HB.Ag carriers. However, these correlations are not absolute and, therefore, it should not be inferred that all e antigen·positive individuals will develop chronic hepatitis nor, conversely, that presence of e antibody invariably protects against the development of chronic hepatitis.
Magnius and Espmark l • 2 have recently described a new antigen-antibody system in carriers of hepatitis B surface antigen (HB.Ag), and have designated the new antigenic determinant as "e." Subsequent work has suggested that the presence of e antigen in serum might be a prognostic indicator of severity and duration of hepatic dysfunction in hepatitis B infection.' Recently, Magnius et aI.· have also described an association between the presence of e antigen and abnormal hepatic histology in long term HB.Ag carriers. We have tested sera from selected groups of individuals for the presence of e antigen and its homologous serum antibody (e antibody) to assess the clinical significance of these serological markers in acute and chronic hepatitis, and here present our data. Methods Chosen for study were sera from several groups of individuals, including healthy persons, those with post-transfusion hepatitis, and those with chronic active liver disease (CALD). The well persons included 32 healthy controls who were seronegative for HB.Ag, as well as for antibody against HB.Ag (anti·HB.), and a group of 24 healthy carriers of HB.Ag, initially identified during volunteer blood donation. At time of study, these latter persons had been known to be persistently HB.Ag positive for at least 4 months, were found to be normal on physical examination, and to have repeatedly normal serum glutamic pyruvic transaminase, bilirubin, and alkaline phosphase levels. Liver biopsies obtained on 20 of these 24 individuals revealed no significant morphological alterations. Received November 13. 1975, Accepted February 24. 1976. All commerical names are used for identification only and their mention does not constitute endorsement by the Public HealthService or the United States Department of Health, Education, and Welfare. 208
Patients who developed serum glutamic pyruvic transaminase (SGPr) elevations ~5 times normal level on at least two occasions separated by at least 2 days, 3 weeks to 6 months after infusion of either whole blood or component blood products, and who lacked evidence for other causes of active liver disease were considered as cases of post-transfusion hepatitis. Paired sera were collected during the acute stage of illness .at time of peak transaminase levels and 6 months after acute illness from 38 cases of post·transfusion hepatitis. These cases included 22 individuals with non·B viral hepatitis documented by failure to detect HS.Ag in acute illness phase serum, as well as by failure to develop anti-HB. iri in convalescent phase serum, and 16 cases of post-transfusion. hepatitis B confirmed by either finding HB.Ag in acute illness phase serum or development of anti-HB. in convalescent phase serum. In this study CALD was defined on the basis of liver biopsy abnormalities showing piecemeal necrosis, bridging necrosis, multilobular necrosis, or cirrhosis with active hepatitis. In addition, all such cases had a duration of illness of at least 10 weeks or the presence of cirrhosis on liver biopsy. All had persistent high level SGPT elevations, or moderate elevations in combination with abnormally high levels of serum ,),-globulins.· Of the 50 persons included in the CALD category, 18 had a serologically documented antecedent hepatitis B infection, and 32 were serologically proven to be unrelated to hepatitis B. All sera had been tested for HB.Ag by solid phase radioimmune assay (Ausria II, Abbott Laboratories, North Chicago, Ill.) and anti-HB. by radioimmune assay (AUSAB, Abbott Laboratories), and/or passive hemagglutination (Electro-Nucleonics, Inc., Fairfield, N.J.). Measurement of e antigen and e antibody was performed using rheophoresis plates (Abbott Laboratories) incubated at 27°C in humidified petri dishes (detectable precipitin lines appeared within 24 to 72 hr). The standard e antigen and e antibody reagents were obtained froll1 known HB.Ag-positive donor plasma units. These reagents were verified and typed by Dr. George Le Bouvier, Yale University School of Medicine. The e antigen reagent con-
"e" ANTIGEN IN HB,Ag CARRIERS
August 1976
tained both e, and e. specificities, and the e antibody reagent contained antibody directed against both specificities.'
209
patients whose convalescent phase sera contained e antibodies.
Discussion Results This study, as well as several others, l-f. T-. confirms As shown in table 1, e antigen or e antibody was found only in individuals with serological evidence of past or the specific association of the e antigen-antibody system current hepatitis B virus infection. Moreover, e antigen with hepatitis B infection. Although e antigen has not was detected only in sera positive for HB.Ag, whereas e yet been fully characterized biophysically or immunologantibody was found in both HB.Ag- and anti-HB.-posi- ically, our failure to detect this antigen or its homologous antibody in paired sera from 22 patients with post-transtive sera. When comparing the frequency of e seropositivity in fusion hepatitis of non-B "origin provides further eviasymptomatic HB.Ag carriers and in patients with dence that e 'antigen may be specified by the hepatitis B CALD, two significant patterns became apparent. First, viral genome and not by the host as a general response to e antigen was found in 8 of 15 (53%) HB.Ag-positive hepatic injury. Although our data show a significant association CALD patients, as compared with only 2 of 24 (8%) asymptomatic HB.Ag carriers (P = 0.003, Fisher's exact between presence of e antigen and evidence of chronic test). Second, e antibody was found in 15 of 24 (63%) hepatic dysfunction in contrast to the association of e asymptomatic HB.Ag carriers, as contrasted with 3 of 18 antibod~ with hepatic normalcy in HB.Ag carriers, the (17%) CALD patients with antecedent hepatitis B infec- correlatlOns are not 1 to 1. This is demonstrated by finding e antigen in 2 healthy HB.Ag carriers and e timn (P = 0.003, Fisher's exact test). Both of the e antigen-positive asymptomatic HB.Ag antibody in 3 persons with CALD. Recently, other carriers lacked evidence of significant liver disease. One investigators have also reported finding e antibody in had previously undergone liver biopsy which was inter- sera from patients with chronic liver disease." • Thus, preted as showing minimal nonspecific alterations in although the presence of e antigen in contrast to e several portal tracts. The other person had been an antibody in carriers of HB.Ag may be predictive of asymptomatic carrier for longer than 1 year and at the hepatic outcome in hepatitis B infection, one should time of testing was only weakly e antigen positive. not infer that all e antigen-positive individuals will deSubsequent e antigen testing of sera from those 2 velop chronic hepatitis, nor, conversely, that presence individuals was not performed. Of the 3 anti-e-positive of e antibody invariably protects against the developCALD patients, 2 were anti-HB. positive and 1 was ment of chronic hepatitis. Further studies will be required before the full implications of the e antigenHB.Ag positive. Among the post-transfusion hepatitis cases, we did not antibody system in the course of hepatitis B infection document any seroconversion from positive for e antigen can be completely understood. to positive for e antibody. The 2 patients whose acute REFERENCES phase sera contained e antigen were not the same 2 TABLE
1. Frequency of e antigen and e antibody in well individuals,
cases of post-transfusion hepatitis, and patients with CALlY' Category
Well individuals HBeAg and anti-HB, negative Asymptomatic healthy HB,Ag carriers Post-transfusion hepatitis Hepatitis B origin Acute Convalescent Nonhepatitis B origin Acute Convalescent Chronic active liver disease Prior HBV· infection HB,Ag+ Anti-HB,+ No prior HBV infection
---
• CALn, chronic active liver disease. • HBV, hepatitis B virus.
No. potIitive
No. tested
e antigen
e antibody
32 24
0 2
0 15
16 16
2 0
0
22
22
0 0
0 0
15 3 32
8 0 0
2
2
1
0
1. Magniu8 LO, Espmark JA: A new antigenic complex co-occurring with Australia antigen. Acta Pathol Microbiol Scand [B) 80:335-337, 1972 2. Magnius LO, Espmark JA: New specificities in Australia antigen positive sera distinct from the Le Bouvier determinants. J. lmmunol 160:1017-1021, 1972 3. Nielsen, IO, Dietrichson 0, Juhl E: Incidence and meaning of the "e" determinant among hepatitis-B-antigen positive patients with acute and chronic liver diseases. Lancet 2:913-915, 1974 4. Magnius LO, Lindholm A, Lundin P. et al: A newantigen-antibody system: clinical significance in long-term carriers of hepatitis B surface antigen. JAMA 231:356-359, 1975 5. Soloway RD, Summerskill WHJ, Baggenstoss AH, et al: Clinical, biochemical, and histological remis~ion of severe chronic active liver disease: a controlled study of treatments and early prognosis. Gastroenterology 63:821H!33, 1972 6. Williams A, Le Bouvier G: Heterogeneity and thermolabilityor"e." Bibl Haematol 42:71-74, 1976 7. Maynard, JE, Barrett DH, Murphy BL, et al: Relationship of the e antigen to hepatitis B virus infection in a hyperendemic area. J. Infect Dis 133:339-342, 1976 !to Eleftheriou N, Heatbcote J, Thomas HC, et al: Incidence and clinical significance of e antigen and antibody in acute and chronic liver disease. Lancet 2: 1171-1173, 1975 9. Feinman SV, Beris B, Sinclair JC, et al: e Antigen and anti-e in HBeAg carriers. Lancet 2:1173-1174, 1975