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476 Reasons for the lack of anti-HBc antibody detection in hepatitis B virus infected patients
05D. Viral Hepatitis'
(d) Hepatitis B
development had amino acid changes in at least one of the 4 open-reading frame of HBV. Conclusions: Infection by different genotypes of HBV (B, Ce, Cs) carries different genomic markers and algorithms for the risk estimation of hepatic carcinogenesis. Future longitudinal studies using these genomic markers are warranted to investigate the relationship of timing of emergence of HBV mutations and the development of HCC.
I•-•
O C C U L T HEPATITIS B VIRUS ( O H B V ) INFECTION WITH A N D W I T H O U T A N T I - H B s A N T I B O D I E S - IMPLICATIONS IN THE D E V E L O P M E N T OF H E P A T O C E L L U L A R CARCINOMA
C.K. Tan1., J.P.E. Chang 1, G.K. Lim 1, Z. Yi 2, L.L. Ooi 3, A. Chung4, E Chow4, W.C. Chow 1. 1Dept of Gastroenterology, 2Dept of Clinical
Research, Singapore General Hospital, Singapore," 3Dept of Surgical Oncology, National Cancer Centre, Singapore," 4Dept of General Surgery, Singapore General Hospital, Singapore
Background: OHBV infection is when HBV DNA is detected in serum or liver tissue of HBsAg-negative patients. Anti-HBc positive cases of OHBV infection can be further differentiated based on anti-HBs antibodies (antiHBsAb). Presence of anti-HBsAb is evidence for immunoclearance of HBsAg and hence an advantage over cases without anti-HBsAb (low grade viraemic carriers). Hepatocellular carcinoma (HCC) uncommonly occurs in OHBV infection. However, it is not known whether extent of tissue HBV integration differs between cases with and without anti-HBsAb. Aim: To study whether extent of HBV integration in tumor and nontumor tissues is influenced by presence of anti-HBsAb in OHBV infection subjects with HCC. Methods: Consecutive HBsAg-negative, anti-HBc positive resected HCC patients in our centre were divided into Group 1 (anti-HBsAb positive) and Group 2 (anti-HBsAb negative). Nested PCR techniques were used to detect HBV "S" and "X" genomes in tumor, non-tumor tissues and serum. Ten HBsAg-positive and 5 seronegative (HBsAg/anti-HBc/anti-HBs/serum HBV DNA) patients with resected HCC served as positive and negative controls respectively. Results: There were 6 patients in Group 1 and 5 in Group 2. Mean antiHBsAb level in Group 1 was 134iu/ml (range 17 564). "S" genome was detected in 5/6(83%) tumor tissue (TT) and 6/6(100%) non-tumor tissue (NT) in Group 1 and 4/5(80%) TT and 3/5(60%) NT in Group 2. "X" genome was detected in 3/6(50%) TT and 6/6(100%) NT in Group 1 and 5/5(100%) TT and 3/5(60%) NT in Group 2. Concordance rates between NT and TT for presence of "S" genome were 83% and 80% for Groups 1 and 2 respectively; for "X" genome 50% and 60% respectively. There were no significant differences between the 2 groups in all the above results. In the sera, "X" genome was not detected in both groups and "S" genome was found in a single case in Group 1. Conclusions: Despite the presence of anti-HBsAb, there is a similar extent of genomic integration of HBV into host liver tissue. This suggests that pathogenesis of HCC is similar in OHBV infection with or without antiHBsAb. Therefore, regardless of anti-HBsAb status, strategies to prevent development of HCC should be similar.
I•-•
R E A S O N S F O R THE L A C K OF A N T I - H B c A N T I B O D Y DETECTION IN HEPATITIS B VIRUS INFECTED PATIENTS
V. Avettand-Fenoel 1, C. Katlama 2, T. Poynard 3, V. Thibault 1. 1 Virology Department, 2Infectious Diseases Department, 3Hepato-GastroEnterology Department, GH Piti&Salpdtri~re, Paris', France Background and Aims: Except during the acute phase, hepatitis B (HB) carriage serologic profile is usually characterized by the concomitant detection of at least HBsAg and anti-HBc antibodies (anti-HBc). However, in few cases an absence of anti-HBc despite persistence of HBsAg is
Clinical Except therapy
S177
observed. The aim of our study was to examine the possible reasons for the lack of anti-HBc detection in some hepatitis B chronic carriers (CHB). Methods: Forty one HB patients who had a confirmed serological profile without anti-HBc were selected among 2169 HB patients with a confirmed HBs Ag carriage. The first line screening assays were based on Axsym (Abbott) serological assays for HBs and HBe Ag and anti-HBc and antiHBe antibodies. The lack of anti-HBc was confirmed using a sandwich ELISA (Monolisa Anti-HBc Plus, Biorad). The precore-core HBV encoding gene of all HB patients lacking anti-HBc was analyzed for specific mutations by direct sequencing. Results: Among 2169 CHB patients, an anti-HBc negative serological profile was observed in 41 (1.89%) patients. All patients had detectable HBV genome using a PCR assay (Cobas, Roche) and all but one were HBe Ag positive. The absence of anti-HBc was confirmed using a second assay in 14/21 (66%) patients, including 2 in an early phase after infection. Genotype distribution was representative of all CHB patients followed in our unit. Direct sequencing of the preC-C gene did not reveal any particular mutations for 13 out of 17 patients. However, 2 patients presented with precore mutations (W37stop or S20T), 1 patient with both a PC mutation and a L64stop in the C ORF and 1 patient with an xI140T change in the X ORE Noteworthy, all but 2 HCV coinfected patients were immunocompromised due to either specific treatments or HIV coinfection. Conclusions: Lack of anti-HBc in CHB patients is rarely seen and is largely explained both by poor sensitivity of some serological assays and by low antibody production in immunocompromised patients. The hypothesis of mutated HBc epitopes was not evidenced in our study. The use of anti-HBc as a marker for HBV carriage should be used with caution in immunocompromised patients.
I•
HIGH RATES OF HEPATITIS B VIRUS REVERSE S E R O C O N V E R S I O N IN A N T I - H B c C A R R I E R S UNDERGOING ALLOGENEIC BONE MARROW TRANSPLANTATION
M. Vigan61 , C. Venel2, D. Soligo 2, F. Lanfranchi 2, G. Lambertenghi Deliliers 2, M. Colombo 1, R Lampertico 1. 1Department of
Gastroenterology and Endocrinology, 2Hematology I Bone Marrow Transplantation Unit, IRCCS Fondazione Ospedale Maggiore and University of Milan, Milan, Italy Background and Aims: To define the risk and the clinical impact of reverse HBsAg seroconversion in HBsAg negative/anti-HBc positive patients after allogeneic hematopoietic stem cell transplantation (HSCT). Patients and Methods. From May 1993 to May 2005, among 216 patients with onco-hematological diseases who underwent allogeneic HSCT, 44 (20%) (31 men, median age 47 years) were HBsAg negative/antiHBc positive. The conditioning regimen consisted of chemotherapy• body irradiation. Graft-versus-host disease (GVHD) prophylaxis included standard-dose cyclosporin-A• or mofetil mycophenolate. Clinical and laboratory examinations were performed weekly for the first two months, monthly, for the first year and every six months thereafter. Results. During 38 months (range:l 148) post-HSCT, 6/44 (14%) patients showed reverse seroconversion; all patients became HBeAg positive with >71og10 copies/ml HBV DNA and 1 36 fold (median 4) ALT increase. Two patients developed jaundice but none developed clinical decompensation. Two patients were placed on lamivudine 100 mg/daily; in one ALT levels and serum HBV-DNA progressively declined whereas the other patient developed lamivudine-resistance, requiring additional treatment with adefovir dipivoxil. The 4 untreated patients maintained persistently high levels of serum HBV-DNA and abnormal ALT throughout the study period. Overall, all these 6 patients developed HBeAg-positive chronic hepatitis B. Nineteen patients (43%) died; causes of death were recurrence of hematological disease (n 6), sepsis (n 6), GVHD (n 6), VOD (n 1). Reverse HBsAg seroconversion occurred in 4 of 18 (22%) patients who developed GVHD as compared to 2/26 (8%) who did not
(d) Hepatitis B
development had amino acid changes in at least one of the 4 open-reading frame of HBV. Conclusions: Infection by different genotypes of HBV (B, Ce, Cs) carries different genomic markers and algorithms for the risk estimation of hepatic carcinogenesis. Future longitudinal studies using these genomic markers are warranted to investigate the relationship of timing of emergence of HBV mutations and the development of HCC.
I•-•
O C C U L T HEPATITIS B VIRUS ( O H B V ) INFECTION WITH A N D W I T H O U T A N T I - H B s A N T I B O D I E S - IMPLICATIONS IN THE D E V E L O P M E N T OF H E P A T O C E L L U L A R CARCINOMA
C.K. Tan1., J.P.E. Chang 1, G.K. Lim 1, Z. Yi 2, L.L. Ooi 3, A. Chung4, E Chow4, W.C. Chow 1. 1Dept of Gastroenterology, 2Dept of Clinical
Research, Singapore General Hospital, Singapore," 3Dept of Surgical Oncology, National Cancer Centre, Singapore," 4Dept of General Surgery, Singapore General Hospital, Singapore
Background: OHBV infection is when HBV DNA is detected in serum or liver tissue of HBsAg-negative patients. Anti-HBc positive cases of OHBV infection can be further differentiated based on anti-HBs antibodies (antiHBsAb). Presence of anti-HBsAb is evidence for immunoclearance of HBsAg and hence an advantage over cases without anti-HBsAb (low grade viraemic carriers). Hepatocellular carcinoma (HCC) uncommonly occurs in OHBV infection. However, it is not known whether extent of tissue HBV integration differs between cases with and without anti-HBsAb. Aim: To study whether extent of HBV integration in tumor and nontumor tissues is influenced by presence of anti-HBsAb in OHBV infection subjects with HCC. Methods: Consecutive HBsAg-negative, anti-HBc positive resected HCC patients in our centre were divided into Group 1 (anti-HBsAb positive) and Group 2 (anti-HBsAb negative). Nested PCR techniques were used to detect HBV "S" and "X" genomes in tumor, non-tumor tissues and serum. Ten HBsAg-positive and 5 seronegative (HBsAg/anti-HBc/anti-HBs/serum HBV DNA) patients with resected HCC served as positive and negative controls respectively. Results: There were 6 patients in Group 1 and 5 in Group 2. Mean antiHBsAb level in Group 1 was 134iu/ml (range 17 564). "S" genome was detected in 5/6(83%) tumor tissue (TT) and 6/6(100%) non-tumor tissue (NT) in Group 1 and 4/5(80%) TT and 3/5(60%) NT in Group 2. "X" genome was detected in 3/6(50%) TT and 6/6(100%) NT in Group 1 and 5/5(100%) TT and 3/5(60%) NT in Group 2. Concordance rates between NT and TT for presence of "S" genome were 83% and 80% for Groups 1 and 2 respectively; for "X" genome 50% and 60% respectively. There were no significant differences between the 2 groups in all the above results. In the sera, "X" genome was not detected in both groups and "S" genome was found in a single case in Group 1. Conclusions: Despite the presence of anti-HBsAb, there is a similar extent of genomic integration of HBV into host liver tissue. This suggests that pathogenesis of HCC is similar in OHBV infection with or without antiHBsAb. Therefore, regardless of anti-HBsAb status, strategies to prevent development of HCC should be similar.
I•-•
R E A S O N S F O R THE L A C K OF A N T I - H B c A N T I B O D Y DETECTION IN HEPATITIS B VIRUS INFECTED PATIENTS
V. Avettand-Fenoel 1, C. Katlama 2, T. Poynard 3, V. Thibault 1. 1 Virology Department, 2Infectious Diseases Department, 3Hepato-GastroEnterology Department, GH Piti&Salpdtri~re, Paris', France Background and Aims: Except during the acute phase, hepatitis B (HB) carriage serologic profile is usually characterized by the concomitant detection of at least HBsAg and anti-HBc antibodies (anti-HBc). However, in few cases an absence of anti-HBc despite persistence of HBsAg is
Clinical Except therapy
S177
observed. The aim of our study was to examine the possible reasons for the lack of anti-HBc detection in some hepatitis B chronic carriers (CHB). Methods: Forty one HB patients who had a confirmed serological profile without anti-HBc were selected among 2169 HB patients with a confirmed HBs Ag carriage. The first line screening assays were based on Axsym (Abbott) serological assays for HBs and HBe Ag and anti-HBc and antiHBe antibodies. The lack of anti-HBc was confirmed using a sandwich ELISA (Monolisa Anti-HBc Plus, Biorad). The precore-core HBV encoding gene of all HB patients lacking anti-HBc was analyzed for specific mutations by direct sequencing. Results: Among 2169 CHB patients, an anti-HBc negative serological profile was observed in 41 (1.89%) patients. All patients had detectable HBV genome using a PCR assay (Cobas, Roche) and all but one were HBe Ag positive. The absence of anti-HBc was confirmed using a second assay in 14/21 (66%) patients, including 2 in an early phase after infection. Genotype distribution was representative of all CHB patients followed in our unit. Direct sequencing of the preC-C gene did not reveal any particular mutations for 13 out of 17 patients. However, 2 patients presented with precore mutations (W37stop or S20T), 1 patient with both a PC mutation and a L64stop in the C ORF and 1 patient with an xI140T change in the X ORE Noteworthy, all but 2 HCV coinfected patients were immunocompromised due to either specific treatments or HIV coinfection. Conclusions: Lack of anti-HBc in CHB patients is rarely seen and is largely explained both by poor sensitivity of some serological assays and by low antibody production in immunocompromised patients. The hypothesis of mutated HBc epitopes was not evidenced in our study. The use of anti-HBc as a marker for HBV carriage should be used with caution in immunocompromised patients.
I•
HIGH RATES OF HEPATITIS B VIRUS REVERSE S E R O C O N V E R S I O N IN A N T I - H B c C A R R I E R S UNDERGOING ALLOGENEIC BONE MARROW TRANSPLANTATION
M. Vigan61 , C. Venel2, D. Soligo 2, F. Lanfranchi 2, G. Lambertenghi Deliliers 2, M. Colombo 1, R Lampertico 1. 1Department of
Gastroenterology and Endocrinology, 2Hematology I Bone Marrow Transplantation Unit, IRCCS Fondazione Ospedale Maggiore and University of Milan, Milan, Italy Background and Aims: To define the risk and the clinical impact of reverse HBsAg seroconversion in HBsAg negative/anti-HBc positive patients after allogeneic hematopoietic stem cell transplantation (HSCT). Patients and Methods. From May 1993 to May 2005, among 216 patients with onco-hematological diseases who underwent allogeneic HSCT, 44 (20%) (31 men, median age 47 years) were HBsAg negative/antiHBc positive. The conditioning regimen consisted of chemotherapy• body irradiation. Graft-versus-host disease (GVHD) prophylaxis included standard-dose cyclosporin-A• or mofetil mycophenolate. Clinical and laboratory examinations were performed weekly for the first two months, monthly, for the first year and every six months thereafter. Results. During 38 months (range:l 148) post-HSCT, 6/44 (14%) patients showed reverse seroconversion; all patients became HBeAg positive with >71og10 copies/ml HBV DNA and 1 36 fold (median 4) ALT increase. Two patients developed jaundice but none developed clinical decompensation. Two patients were placed on lamivudine 100 mg/daily; in one ALT levels and serum HBV-DNA progressively declined whereas the other patient developed lamivudine-resistance, requiring additional treatment with adefovir dipivoxil. The 4 untreated patients maintained persistently high levels of serum HBV-DNA and abnormal ALT throughout the study period. Overall, all these 6 patients developed HBeAg-positive chronic hepatitis B. Nineteen patients (43%) died; causes of death were recurrence of hematological disease (n 6), sepsis (n 6), GVHD (n 6), VOD (n 1). Reverse HBsAg seroconversion occurred in 4 of 18 (22%) patients who developed GVHD as compared to 2/26 (8%) who did not