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A “mini epidemic” of hepatitis A after eating Russian caviar
LETTERS TO THE EDITOR cute: a 45-year-old, anti-HCV-negative female patient died 14 days after the onset of icterus in a liver coma, and a 10-year-old girl died 9 weeks after the onset of the illness. In both cases histological liver examination revealed necrotizing atrophic hepatitis. In two cases we detected an extrahepatic complication - aplastic anemia (2). In 17 patients (47.2%) with a prolonged or chronic course of hepatitis, typical episodic fluctuation of aminotransferases in serum was observed. In all of them liver biopsy and rebiopsy were performed 2-6 years later (Table 1). At the end of our study, 14 patients (38.9%) (10 anti-HCV positive) were shown to have biochemical and histological signs of chronic hepatitis: in six patients (16.7%) chronic active hepatitis (all of them anti-HCV positive) and in eight patients (22.2%) chronic persistent hepatitis, four of them anti-HCV positive. All biopsied anti-HCV negative patients had a histological picture of mild chronic liver inflammation. Three anti-HCV positive patients with chronic active hepatitis have so far been successfully treated with alfa interferon. Prospective studies of acute NANBH in recent years have included approximately 500 patients, over 50% of whom were anti-HCV positive (3-5). As in our study, these authors also established that the development of chronic liver disease was more frequent in antiHCV-positive patients and those with parenteral infection. Anti-
479 HCV-negative patients may have a better prognosis because NANB non-C hepatitis agents cause a more benign disease.
References 1. Le~nifiar G. Preliminary results from the study of acute hepatitis non A, non B (hepatitis C). Zdrav Vestn 1992; 61: 579-85. 2. Le~ni~ar G, Stantir-Pavlini6 M, Andol.~ek D, et al. Aplastic anemia following acute viral hepatitis. Zdrav Vestn 1984; 53: 365-74. 3. Tassopoulos NC, Alikiotis M, Limotirakis F, Nicolakakus, Mela P, Paralogou-Ioanudes M. Acute sporadic non A, non B in Greece. J Med Virol 1988; 26: 71-8. 4. Alter HJ. Chronic consequences of non A, non B hepatitis. V. Serf LB, Lewis JH, eds. Current Perspectives in Hepatology. New York: Plenum Publishing, 1989: 83-97. 5. Wejstal R, Hermodsson S, Norkrans G. Long-term follow up of chronic hepatitis non B, non B with special reference to hepatitis C. Liver 1991; 11: 143-8. Gorazd Le~ni~:ar
Hospital for blfectious Diseases, Celje, SIovenia
A "mini epidemic" of hepatitis A after eating Russian caviar Outbreaks or small epidemics of hepatitis A after eating oysters and insufficiently cooked mussels have been described several times (I,2). Like oysters, caviar is eaten in a relatively untreated condition. The ordinary processing of caviar, after taking it out of the sturgeon, is to rinse it twice in fresh water before packing it in 3-5% brine in glass or tin containers. Certain types of caviar are heat-treated at 60°C for 60 min, while other types are put on sale untreated. Hepatitis A virus (HAV) is inactivated by formalin (1 in 4000 at 37°C for 72 h), chlorine (1 p.p.m, for 30 min) and microwaving, but is relatively resistant to acid, ether or heat (3,4). HAV is inactivated by heating at 85°C for 1 rain, but is only partly inactivated at 60°C for 60 min (3). Transmission of HAV by eating caviar is thus possible. We describe four such cases of hepatitis A. A 42-year-old man was admitted with jaundice, anorexia, fatigue, dark urine and pale stools. Laboratory tests: alanine aminotransferase 3500 U/I (10-40 U/I); bilirubin 135 pmol/1 (<22 pmol/l); alkaline phosphatase 450 U/I (80-270 U/I); prothrombin (combined procoagulant activity of coagulation factors II, VII, X) 0.63 (0.80-1.20); amylase normal. Hepatitis was confirmed by positive IgM antiHAV. The history gave a lead inasmuch as he had taken part 5 weeks earlier in a New Year's lunch, at which six persons were present. It was found that 4-5 weeks after the meal, and within a few days of each other, four of the participants presented clinical signs of hepatitis, later likewise confirmed by positive IgM anti-HAV. One of them, on a tour to Latvia 2 months earlier, had bought, illegally in the street, some Russian caviar. Based on a self-report of what was eaten at the New Year's lunch, the caviar was identified as the only likely cause of the infection. None of those at the lunch had had contact with cases of hepatitis or had otherwise been abroad preceding the outbreak. All four recovered spontaneously, and the laboratory tests returned to normal. Considering the political and economic turmoil in the previous USSR, combined with the increase in tourism to that part of the world, an increase in both the legal and the illegal sale of caviar can be expected. It therefore seems important to be aware of a possible risk of disease transmission by Russian caviar.
The presented cases suggest that the usual processing of Russian caviar does not eliminate the risk of transmission of HAV. A warning is perhaps not out of place, particularly with respect to caviar that is imported illegally, or bought on the black market in Russia or in the Baltic countries, because this caviar is produced without any form of hygienic control. Henning Glerup t, Henrik Tort Sorensen ~, Allan Flyvbjerg ~, Peter Stokvad 2 and Hendrik Vilstrup'
IDepartment of Internal Medich~e V and 2Department of h~ternal Medicine A, Aarhus University Hospital, 8000 Aarhus C, Denmark
References 1. Gaub J, Ranek L. Hepatitis epidemica efter indtagelse af importerede osters (Epidemic of hepatitis after eating imported oysters). Ugeskr Laeger (J Dan Med Assoc) 1973; 135: 345-8. 2. Dienstag JL, Gust DG, Lueas CR, Wong DC, Purcell RH. Mussel-associated viral hepatitis type A: serological confirmation. Lancet 1976; i: 561--4. 3. Mishu B, Hadler SC, Boaz VA, Hutcheson RH, Horan JM, Schaffner W. Foodborne hepatitis A: evidence that microwaving reduces risk? J Infect Dis 1990; 162: 655-8. 4. Sherlock S, Dooley J. Diseases of the Liver and Biliary System, 9th Edn. 1992: 266-9. 5. Lemon SM. Type A viral hepatitis: new developments in an old disease. N Engl J Med 1985; 313: 1059-67. 6. Carl M, Francis DP, Maynard JE. Food-borne hepatitis A: recommendations for control. J Infect Dis 1983; 148:1133-5. 7. Koff RS. Clinical manifestations and diagnosis of hepatitis A virus infection. Vaccine 1992; 10 suppl 1: s15-7. 8. Friedman LS. Hepatitis A: more food for thought. Gastroenterology 1991; 100: 577-8.
479 HCV-negative patients may have a better prognosis because NANB non-C hepatitis agents cause a more benign disease.
References 1. Le~nifiar G. Preliminary results from the study of acute hepatitis non A, non B (hepatitis C). Zdrav Vestn 1992; 61: 579-85. 2. Le~ni~ar G, Stantir-Pavlini6 M, Andol.~ek D, et al. Aplastic anemia following acute viral hepatitis. Zdrav Vestn 1984; 53: 365-74. 3. Tassopoulos NC, Alikiotis M, Limotirakis F, Nicolakakus, Mela P, Paralogou-Ioanudes M. Acute sporadic non A, non B in Greece. J Med Virol 1988; 26: 71-8. 4. Alter HJ. Chronic consequences of non A, non B hepatitis. V. Serf LB, Lewis JH, eds. Current Perspectives in Hepatology. New York: Plenum Publishing, 1989: 83-97. 5. Wejstal R, Hermodsson S, Norkrans G. Long-term follow up of chronic hepatitis non B, non B with special reference to hepatitis C. Liver 1991; 11: 143-8. Gorazd Le~ni~:ar
Hospital for blfectious Diseases, Celje, SIovenia
A "mini epidemic" of hepatitis A after eating Russian caviar Outbreaks or small epidemics of hepatitis A after eating oysters and insufficiently cooked mussels have been described several times (I,2). Like oysters, caviar is eaten in a relatively untreated condition. The ordinary processing of caviar, after taking it out of the sturgeon, is to rinse it twice in fresh water before packing it in 3-5% brine in glass or tin containers. Certain types of caviar are heat-treated at 60°C for 60 min, while other types are put on sale untreated. Hepatitis A virus (HAV) is inactivated by formalin (1 in 4000 at 37°C for 72 h), chlorine (1 p.p.m, for 30 min) and microwaving, but is relatively resistant to acid, ether or heat (3,4). HAV is inactivated by heating at 85°C for 1 rain, but is only partly inactivated at 60°C for 60 min (3). Transmission of HAV by eating caviar is thus possible. We describe four such cases of hepatitis A. A 42-year-old man was admitted with jaundice, anorexia, fatigue, dark urine and pale stools. Laboratory tests: alanine aminotransferase 3500 U/I (10-40 U/I); bilirubin 135 pmol/1 (<22 pmol/l); alkaline phosphatase 450 U/I (80-270 U/I); prothrombin (combined procoagulant activity of coagulation factors II, VII, X) 0.63 (0.80-1.20); amylase normal. Hepatitis was confirmed by positive IgM antiHAV. The history gave a lead inasmuch as he had taken part 5 weeks earlier in a New Year's lunch, at which six persons were present. It was found that 4-5 weeks after the meal, and within a few days of each other, four of the participants presented clinical signs of hepatitis, later likewise confirmed by positive IgM anti-HAV. One of them, on a tour to Latvia 2 months earlier, had bought, illegally in the street, some Russian caviar. Based on a self-report of what was eaten at the New Year's lunch, the caviar was identified as the only likely cause of the infection. None of those at the lunch had had contact with cases of hepatitis or had otherwise been abroad preceding the outbreak. All four recovered spontaneously, and the laboratory tests returned to normal. Considering the political and economic turmoil in the previous USSR, combined with the increase in tourism to that part of the world, an increase in both the legal and the illegal sale of caviar can be expected. It therefore seems important to be aware of a possible risk of disease transmission by Russian caviar.
The presented cases suggest that the usual processing of Russian caviar does not eliminate the risk of transmission of HAV. A warning is perhaps not out of place, particularly with respect to caviar that is imported illegally, or bought on the black market in Russia or in the Baltic countries, because this caviar is produced without any form of hygienic control. Henning Glerup t, Henrik Tort Sorensen ~, Allan Flyvbjerg ~, Peter Stokvad 2 and Hendrik Vilstrup'
IDepartment of Internal Medich~e V and 2Department of h~ternal Medicine A, Aarhus University Hospital, 8000 Aarhus C, Denmark
References 1. Gaub J, Ranek L. Hepatitis epidemica efter indtagelse af importerede osters (Epidemic of hepatitis after eating imported oysters). Ugeskr Laeger (J Dan Med Assoc) 1973; 135: 345-8. 2. Dienstag JL, Gust DG, Lueas CR, Wong DC, Purcell RH. Mussel-associated viral hepatitis type A: serological confirmation. Lancet 1976; i: 561--4. 3. Mishu B, Hadler SC, Boaz VA, Hutcheson RH, Horan JM, Schaffner W. Foodborne hepatitis A: evidence that microwaving reduces risk? J Infect Dis 1990; 162: 655-8. 4. Sherlock S, Dooley J. Diseases of the Liver and Biliary System, 9th Edn. 1992: 266-9. 5. Lemon SM. Type A viral hepatitis: new developments in an old disease. N Engl J Med 1985; 313: 1059-67. 6. Carl M, Francis DP, Maynard JE. Food-borne hepatitis A: recommendations for control. J Infect Dis 1983; 148:1133-5. 7. Koff RS. Clinical manifestations and diagnosis of hepatitis A virus infection. Vaccine 1992; 10 suppl 1: s15-7. 8. Friedman LS. Hepatitis A: more food for thought. Gastroenterology 1991; 100: 577-8.