- Email: [email protected]
Australia Antigen-the Pace Quickens
85
general agreement with the immunofluorescence work of others. 4,5 Probably the intranuclear particles are the core of the DANE particle and Australia antigen is added by incorporation of host-derived material in the cytoplasm of relatively normal hepatocytes.
THE LANCET
Australia Antigen-the Pace Quickens INTENSIVE study of the Australia antigen over the past few years has led clinicians and epidemiologists to revise their views about the clinical features and
methods of spread of hepatitis-virus-B infection. Concern about the problem was justifiable, but sometimes hysterical overtones have proved a nightmare to those organising haemodialysis units, bloodtransfusion services, and laboratories handling blood specimens. Practical considerations apart, Australia
antigen provides an intriguing challenge to virologists and a valuable opportunity for investigation of the immunological factors in host reactions to an infective agent. Although the virus has not yet been cultured, there is increasing evidence based on electronmicroscopic studies of serum that the central core of the large Australia-antigen particle described by DANE and his colleaguesis the virus itself, probably a picornavirus, which is immunologically distinct from its outer coat and the tubular and small spherical forms of the antigen.2Examination of liver tissue for viral particles by electron microscopy and for Australia antigen by immunofluorescence gave apparently contradictory results initially, but a pattern is beginning to emerge which permits tentative conclusions. NOWOSLAWSKI’S groupcompared the distribution of intranuclear 20 nm. particles and immunofluorescence localisation of antigen in postmortem livers from patients with acute viral hepatitis, subacute or chronic hepatitis, and carriers In chronic hepatitis without hepatic disease. nuclear particles and cytoplasmic localisation of antigen were observed, predominantly in the relatively normal tissue, but in adjacent tissue showing the most severe damage only minute amounts of antigen could be demonstrated and no nuclear particles were seen. Furthermore, livers from patients with severe acute hepatitis had no demonstrable antigen or nuclear particles, whereas, at the other end of the spectrum, nuclear particles and nuclear or cytoplasmic antigen were most abundant in patients who were chronic carriers with histologically normal livers. This dissociation between the severity of hepatocyte damage and cytoplasmic localisation of antigen is in 1. Dane, D. S., Cameron, C. H., Briggs, M. Lancet, 1970, i, 695. 2. Almeida, J. D., Rubenstein, D., Stott, E. J. ibid. 1971, ii, 1225. 3. Krawczynski, K., Nazarewicz, T., Brzosko, W. J., Nowoslawski, A. J. infect. Dis. 1972, 126, 372.
While the virulence of different strains of the virus may prove to be important in determining the consequences of infection, there are several indications that the host response to the core particles, or the Australia antigen itself, may be a major factor in determining the severity of the liver disease and in the pathogenesis of extrahepatic lesions such as vasculitis and arthritis. A striking feature of Australia-antigen-containing serum examined under the electron microscope is the presence of large immune complexes, but, despite early evidence that the severity and chronicity of the hepatic damage might depend on antigen or antibody excess,6 no consistent electron microscopic pattern has emerged; large particles and tubular forms are, however, more often present in patients with chronic disease.’ Indirect evidence that immune complexes are formed in the serum is suggested by the high frequency of anticomplementary activity,8 but studies of serumcomplement levels have been conflicting. 9,10 While the role of immune complexes in producing the liver damage remains speculative, by analogy with experimental models the Australia antigen seems to be more convincingly implicated in the pathogenesis of certain extrahepatic lesions. Thus, Australia antigen and complement have been demonstrated in vessel walls in patients with polyarteritis nodosa 11and in the glomeruli in a patient with glomerulonephritis. 12 Furthermore, the finding of low serum-complement levels in patients with arthritis associated with Australia-antigen-positive viral hepatitis suggests that this manifestation of the disease, which resembles serum sickness, may be mediated by immune complexes of the antigen.13,144 An attractive hypothesis implicating a defect of cell-mediated immunity-particularly of thymusderived lymphocytes-in determining the severity of the hepatic damage and the development of chronicity has been put forward by DUDLEY and his associates.15,16 Using phytoharmagglutinin-induced lymphocyte transformation as an index of T 4. 5. 6. 7. 8. 9. 10.
Hadziyannis, S., Vissoulis, C., Moussouros, A., Afroudakis, A. Lancet, 1972, i, 976. Edgington, T. S., Ritt, D. J. J. exp. Med. 1971, 134, 871. Almeida, J. D., Waterson, A. P. Lancet, 1969, ii, 983. Wright, R. Br. med. Bull. 1972, 28, 120. Shulman, N. R., Barker, L. F. Science, 1969, 165, 304. Dudley, F. J., Fox, R. A., Sherlock, S. Lancet, 1971, ii, 1. Kosmidis, J. C., Leader-Williams, L. K. Clin. exp. Immun. 1972, 11, 31.
11. 12.
13.
14. 15. 16.
Gocke, D. J., Hsu, K., Morgan, C., Bombardieri, S., Lockshin, M., Christian, C. L. J. exp. Med. 1971, 134, 330. Combes, B., Stastny, P., Shorey, J., Eigenbrodt, E. H., Barrera, A., Hull, A. R., Carter, N. W. Lancet, 1971, ii, 234. Alpert, E., Isselbacher, K. J., Schur, P. H. New Engl. J. Med. 1971, 285, 185. Onion, D. K., Crumpacker, C. S., Gilliland, B. C. Ann. intern. Med. 1971, 75, 29. Dudley, F. J., Fox, R. A., Sherlock, S. Lancet, 1972, i, 723. Giustino, V., Dudley, F. J., Sherlock, S. ibid. 1972, ii, 850.
86
lymphocyte function, they found that patients who become carriers of the antigen have an impaired response compared with those who clear the antigen rapidly. The numbers of patients studied were, however, few and adequate serial observations from acute to chronic disease were lacking. Impaired lymphocyte transformation in response to phytohsemagglutinin has been observed previously in viral hepatitis, and undoubtedly the carrier state is associated with disorders in which there is impaired cellular immunitysuch as lepromatous leprosy, chronic renal failure, and Down’s syndrome-but the severity of the hepatic damage, if any, in such patients varies widely. 17 These concepts have led POPPER and MACKAY 1g to suggest that hepatitis-B antigens may be responsible for both Australia-antigen-positive chronic active hepatitis and antigen-negative autoimmune " hepatitis; but this view is difficult to sustain in the light of clinical, epidemiological, and immunological distinctions between the two groups.7 Another suggestion is that Australia antigen plays an important role in the aetiology of chronic alcoholic liver disease, based on detection of in-vitro lymphocyte stimulation in response to Australia-antigencontaining serum in patients with this disease’-9; but here, too, the immunological observations run so contrary to clinical findings that much more evidence is required. With purification of the core and coat antigens imminent, rapid advances in our understanding of the pathogenesis of hepatitis-B infection, including both hepatic and extrahepatic manifestations, can be expected. To the virologist and immunologist in search of a human model for a virusinduced immunological disorder the discovery of the Australia antigen may prove to be the realisation of a "
dream.
that the disease already existed in Vietnam, and Djakarta in 1969, but there was no doubt about the epidemic witnessed by ophthalmologists in Java and Singapore in 1970.27,28 Then, in 1971, A.H.C. spread over almost all Asia and the Indian subcontinent : the Indian outbreak started around April 29,30 and the disease reached Japan 31 and South Korea 32 at the end of August or the beginning of September. In Europe there was a small outbreak from September to October in London. The disease was still prevalent in all these areas in 1972, but so far no cases have been observed in North and South America, Australia, or New Zealand. rumour
Bali,
KONO
et
al.33
reported
successful isolation of
a
from conjunctival scrapings of with A.H.C. It had the general characteristics of an enterovirus and was tentatively designated A.H.C. virus. Unlike ordinary enteroviruses, however, it was not found in the intestine but was confined to the conjunctiva in the acute stage of the illness.34 Thus, the main source of infection is probably eye discharge. A.H.C. virus proved to be antigenically distinct from other enteroviruses, and similar agents were isolated in London (Prof. B. R. JONES), Hong Kong,35 and Taiwan (Dr J. C. HIERHOLZER) in one year. At the same time, fourfold or greater rises in antibody against A.H.C. virus were demonstrated in paired sera from .H.c. patients in Singapore (1971) 36 and Djakarta (1972).34 YINMURPHY 37 isolated an antigenically distinct picornavirus in the Singapore outbreak of 1970, and its relation to the 1971 viral isolates remains to be elucidated. The virus was not isolated in Africa until 1971, but Dr. O. G. GAUDIN has lately recovered several strains in Morocco. Comparisons of the Asian and African viruses should show whether a single type is causing the pandemic.
picornavirus Japanese patients new
Another
Acute Haemorrhagic
Conjunctivitis
ACUTE hxmorrhagic conjunctivitis (A.H.c.) broke out in Ghana in June, 1969,20,21 and spread along the west coast of Africa. In 1969 and 1970 it appeared in Nigeria,22, 23 the Ivory Coast, Togo, Liberia, Sierra Leone, Senegal,2 and Gambia, one after the other. Then it was seen on the Mediterranean coast of Africa, outbreaks being reported from Morocco and Tunisia in the early part of 1971.25, 26 There was an unconfirmed 17. Sutnick, A. I., London, W. T., Blumberg, B. S., Gerstley, B. J. S. Am. J. clin. Path. 1972, 57, 2. 18. Popper, H., Mackay, I. R. Lancet, 1972, i, 1161. 19. Pettigrew, N. M., Goudie, R. B., Russell, R. I., Chaudhuri, A. K. R. ibid. 1972, ii, 724. 20. Chatterjee, S., Quarcoopome, C. O., Apenteng, A. Ghana med. J. 1970, 9, 9. 21. Chatterjee, S., Quarcoopome, C. O., Apenteng, A. Br. J. Ophthal. 1970, 54, 626. 22. Akinsete, E. O. J. Nigeria med. Ass. 1970, 7, 46. 23. Parrott, W. F. Practitioner, 1971, 206, 253. 24. Diallo, J., Castets, M., Bassabe, S. Bull. Soc. méd. Afr. noire Lang. fr. 1971, 16, 73. 25. Tarizzo, M. L. Personal communication. 26. W.H.O. Wkly epidem. Rec. 1971, 46, 530.
important problem is the lumbar radiculomyelopathy which sometimes follows the conjunctivitis.38,39 On p. 61 this week Professor KONO and his co-workers report that A.H.c. virus has some degree of neurovirulence in monkeys. Since, no been have however, neurological complications outside is this more work needed on India, reported
aspect. 27. Lim, K. H., Yin-Murphy, M. Singapore med. J. 1970, 12, 249. 28. Mardiono Marsetio, Sardjito, R. Ophthal. indones. (in the press). 29. Pramanik, D. D. Practitioner, 1971, 207, 805. 30. Roy, I. S., Roy, S. N., Ahmed, E. Br. J. Ophthal. 1972, 56, 501. 31. Mitsui, Y., Kajima, M., Matsumura, K., Shiota, H. Jap. J. Ophthal.
1972, 16, 99. 32. Kim, J. H., Shin, I. N., Rhee, S. N., Lee, C. W., Kim, J. D. J. Korean ophthal. Soc. 1972, 13, 17. 33. Kono, R., Sasagawa, A., Ishii, K., Sugiura, S., Ochi, M., Matsumiya, H., Uchida, Y., Kameyama, K., Kaneko, M., Sakurai, N. Lancet,
1972, i, 1191. 34. Kono, R. Unpublished. 35. Chang, W. K. Personal communication. 36. Yin-Murphy, M., Lim, K. H. Lancet, 1972, ii, 857. 37. Yin-Murphy, M. S. East Asian J. trop. Med. publ. Hlth, 1972, 3, 303. 38. Wadia, N. H., Irani, P. F., Katrak, S. M. Lancet, 1972, ii, 970. 39. Bharucha, E. P., Mondkar, V. P. ibid.
general agreement with the immunofluorescence work of others. 4,5 Probably the intranuclear particles are the core of the DANE particle and Australia antigen is added by incorporation of host-derived material in the cytoplasm of relatively normal hepatocytes.
THE LANCET
Australia Antigen-the Pace Quickens INTENSIVE study of the Australia antigen over the past few years has led clinicians and epidemiologists to revise their views about the clinical features and
methods of spread of hepatitis-virus-B infection. Concern about the problem was justifiable, but sometimes hysterical overtones have proved a nightmare to those organising haemodialysis units, bloodtransfusion services, and laboratories handling blood specimens. Practical considerations apart, Australia
antigen provides an intriguing challenge to virologists and a valuable opportunity for investigation of the immunological factors in host reactions to an infective agent. Although the virus has not yet been cultured, there is increasing evidence based on electronmicroscopic studies of serum that the central core of the large Australia-antigen particle described by DANE and his colleaguesis the virus itself, probably a picornavirus, which is immunologically distinct from its outer coat and the tubular and small spherical forms of the antigen.2Examination of liver tissue for viral particles by electron microscopy and for Australia antigen by immunofluorescence gave apparently contradictory results initially, but a pattern is beginning to emerge which permits tentative conclusions. NOWOSLAWSKI’S groupcompared the distribution of intranuclear 20 nm. particles and immunofluorescence localisation of antigen in postmortem livers from patients with acute viral hepatitis, subacute or chronic hepatitis, and carriers In chronic hepatitis without hepatic disease. nuclear particles and cytoplasmic localisation of antigen were observed, predominantly in the relatively normal tissue, but in adjacent tissue showing the most severe damage only minute amounts of antigen could be demonstrated and no nuclear particles were seen. Furthermore, livers from patients with severe acute hepatitis had no demonstrable antigen or nuclear particles, whereas, at the other end of the spectrum, nuclear particles and nuclear or cytoplasmic antigen were most abundant in patients who were chronic carriers with histologically normal livers. This dissociation between the severity of hepatocyte damage and cytoplasmic localisation of antigen is in 1. Dane, D. S., Cameron, C. H., Briggs, M. Lancet, 1970, i, 695. 2. Almeida, J. D., Rubenstein, D., Stott, E. J. ibid. 1971, ii, 1225. 3. Krawczynski, K., Nazarewicz, T., Brzosko, W. J., Nowoslawski, A. J. infect. Dis. 1972, 126, 372.
While the virulence of different strains of the virus may prove to be important in determining the consequences of infection, there are several indications that the host response to the core particles, or the Australia antigen itself, may be a major factor in determining the severity of the liver disease and in the pathogenesis of extrahepatic lesions such as vasculitis and arthritis. A striking feature of Australia-antigen-containing serum examined under the electron microscope is the presence of large immune complexes, but, despite early evidence that the severity and chronicity of the hepatic damage might depend on antigen or antibody excess,6 no consistent electron microscopic pattern has emerged; large particles and tubular forms are, however, more often present in patients with chronic disease.’ Indirect evidence that immune complexes are formed in the serum is suggested by the high frequency of anticomplementary activity,8 but studies of serumcomplement levels have been conflicting. 9,10 While the role of immune complexes in producing the liver damage remains speculative, by analogy with experimental models the Australia antigen seems to be more convincingly implicated in the pathogenesis of certain extrahepatic lesions. Thus, Australia antigen and complement have been demonstrated in vessel walls in patients with polyarteritis nodosa 11and in the glomeruli in a patient with glomerulonephritis. 12 Furthermore, the finding of low serum-complement levels in patients with arthritis associated with Australia-antigen-positive viral hepatitis suggests that this manifestation of the disease, which resembles serum sickness, may be mediated by immune complexes of the antigen.13,144 An attractive hypothesis implicating a defect of cell-mediated immunity-particularly of thymusderived lymphocytes-in determining the severity of the hepatic damage and the development of chronicity has been put forward by DUDLEY and his associates.15,16 Using phytoharmagglutinin-induced lymphocyte transformation as an index of T 4. 5. 6. 7. 8. 9. 10.
Hadziyannis, S., Vissoulis, C., Moussouros, A., Afroudakis, A. Lancet, 1972, i, 976. Edgington, T. S., Ritt, D. J. J. exp. Med. 1971, 134, 871. Almeida, J. D., Waterson, A. P. Lancet, 1969, ii, 983. Wright, R. Br. med. Bull. 1972, 28, 120. Shulman, N. R., Barker, L. F. Science, 1969, 165, 304. Dudley, F. J., Fox, R. A., Sherlock, S. Lancet, 1971, ii, 1. Kosmidis, J. C., Leader-Williams, L. K. Clin. exp. Immun. 1972, 11, 31.
11. 12.
13.
14. 15. 16.
Gocke, D. J., Hsu, K., Morgan, C., Bombardieri, S., Lockshin, M., Christian, C. L. J. exp. Med. 1971, 134, 330. Combes, B., Stastny, P., Shorey, J., Eigenbrodt, E. H., Barrera, A., Hull, A. R., Carter, N. W. Lancet, 1971, ii, 234. Alpert, E., Isselbacher, K. J., Schur, P. H. New Engl. J. Med. 1971, 285, 185. Onion, D. K., Crumpacker, C. S., Gilliland, B. C. Ann. intern. Med. 1971, 75, 29. Dudley, F. J., Fox, R. A., Sherlock, S. Lancet, 1972, i, 723. Giustino, V., Dudley, F. J., Sherlock, S. ibid. 1972, ii, 850.
86
lymphocyte function, they found that patients who become carriers of the antigen have an impaired response compared with those who clear the antigen rapidly. The numbers of patients studied were, however, few and adequate serial observations from acute to chronic disease were lacking. Impaired lymphocyte transformation in response to phytohsemagglutinin has been observed previously in viral hepatitis, and undoubtedly the carrier state is associated with disorders in which there is impaired cellular immunitysuch as lepromatous leprosy, chronic renal failure, and Down’s syndrome-but the severity of the hepatic damage, if any, in such patients varies widely. 17 These concepts have led POPPER and MACKAY 1g to suggest that hepatitis-B antigens may be responsible for both Australia-antigen-positive chronic active hepatitis and antigen-negative autoimmune " hepatitis; but this view is difficult to sustain in the light of clinical, epidemiological, and immunological distinctions between the two groups.7 Another suggestion is that Australia antigen plays an important role in the aetiology of chronic alcoholic liver disease, based on detection of in-vitro lymphocyte stimulation in response to Australia-antigencontaining serum in patients with this disease’-9; but here, too, the immunological observations run so contrary to clinical findings that much more evidence is required. With purification of the core and coat antigens imminent, rapid advances in our understanding of the pathogenesis of hepatitis-B infection, including both hepatic and extrahepatic manifestations, can be expected. To the virologist and immunologist in search of a human model for a virusinduced immunological disorder the discovery of the Australia antigen may prove to be the realisation of a "
dream.
that the disease already existed in Vietnam, and Djakarta in 1969, but there was no doubt about the epidemic witnessed by ophthalmologists in Java and Singapore in 1970.27,28 Then, in 1971, A.H.C. spread over almost all Asia and the Indian subcontinent : the Indian outbreak started around April 29,30 and the disease reached Japan 31 and South Korea 32 at the end of August or the beginning of September. In Europe there was a small outbreak from September to October in London. The disease was still prevalent in all these areas in 1972, but so far no cases have been observed in North and South America, Australia, or New Zealand. rumour
Bali,
KONO
et
al.33
reported
successful isolation of
a
from conjunctival scrapings of with A.H.C. It had the general characteristics of an enterovirus and was tentatively designated A.H.C. virus. Unlike ordinary enteroviruses, however, it was not found in the intestine but was confined to the conjunctiva in the acute stage of the illness.34 Thus, the main source of infection is probably eye discharge. A.H.C. virus proved to be antigenically distinct from other enteroviruses, and similar agents were isolated in London (Prof. B. R. JONES), Hong Kong,35 and Taiwan (Dr J. C. HIERHOLZER) in one year. At the same time, fourfold or greater rises in antibody against A.H.C. virus were demonstrated in paired sera from .H.c. patients in Singapore (1971) 36 and Djakarta (1972).34 YINMURPHY 37 isolated an antigenically distinct picornavirus in the Singapore outbreak of 1970, and its relation to the 1971 viral isolates remains to be elucidated. The virus was not isolated in Africa until 1971, but Dr. O. G. GAUDIN has lately recovered several strains in Morocco. Comparisons of the Asian and African viruses should show whether a single type is causing the pandemic.
picornavirus Japanese patients new
Another
Acute Haemorrhagic
Conjunctivitis
ACUTE hxmorrhagic conjunctivitis (A.H.c.) broke out in Ghana in June, 1969,20,21 and spread along the west coast of Africa. In 1969 and 1970 it appeared in Nigeria,22, 23 the Ivory Coast, Togo, Liberia, Sierra Leone, Senegal,2 and Gambia, one after the other. Then it was seen on the Mediterranean coast of Africa, outbreaks being reported from Morocco and Tunisia in the early part of 1971.25, 26 There was an unconfirmed 17. Sutnick, A. I., London, W. T., Blumberg, B. S., Gerstley, B. J. S. Am. J. clin. Path. 1972, 57, 2. 18. Popper, H., Mackay, I. R. Lancet, 1972, i, 1161. 19. Pettigrew, N. M., Goudie, R. B., Russell, R. I., Chaudhuri, A. K. R. ibid. 1972, ii, 724. 20. Chatterjee, S., Quarcoopome, C. O., Apenteng, A. Ghana med. J. 1970, 9, 9. 21. Chatterjee, S., Quarcoopome, C. O., Apenteng, A. Br. J. Ophthal. 1970, 54, 626. 22. Akinsete, E. O. J. Nigeria med. Ass. 1970, 7, 46. 23. Parrott, W. F. Practitioner, 1971, 206, 253. 24. Diallo, J., Castets, M., Bassabe, S. Bull. Soc. méd. Afr. noire Lang. fr. 1971, 16, 73. 25. Tarizzo, M. L. Personal communication. 26. W.H.O. Wkly epidem. Rec. 1971, 46, 530.
important problem is the lumbar radiculomyelopathy which sometimes follows the conjunctivitis.38,39 On p. 61 this week Professor KONO and his co-workers report that A.H.c. virus has some degree of neurovirulence in monkeys. Since, no been have however, neurological complications outside is this more work needed on India, reported
aspect. 27. Lim, K. H., Yin-Murphy, M. Singapore med. J. 1970, 12, 249. 28. Mardiono Marsetio, Sardjito, R. Ophthal. indones. (in the press). 29. Pramanik, D. D. Practitioner, 1971, 207, 805. 30. Roy, I. S., Roy, S. N., Ahmed, E. Br. J. Ophthal. 1972, 56, 501. 31. Mitsui, Y., Kajima, M., Matsumura, K., Shiota, H. Jap. J. Ophthal.
1972, 16, 99. 32. Kim, J. H., Shin, I. N., Rhee, S. N., Lee, C. W., Kim, J. D. J. Korean ophthal. Soc. 1972, 13, 17. 33. Kono, R., Sasagawa, A., Ishii, K., Sugiura, S., Ochi, M., Matsumiya, H., Uchida, Y., Kameyama, K., Kaneko, M., Sakurai, N. Lancet,
1972, i, 1191. 34. Kono, R. Unpublished. 35. Chang, W. K. Personal communication. 36. Yin-Murphy, M., Lim, K. H. Lancet, 1972, ii, 857. 37. Yin-Murphy, M. S. East Asian J. trop. Med. publ. Hlth, 1972, 3, 303. 38. Wadia, N. H., Irani, P. F., Katrak, S. M. Lancet, 1972, ii, 970. 39. Bharucha, E. P., Mondkar, V. P. ibid.