Prevalence of occult hepatitis C virus infection in beta-thalassemia major patients in Ahvaz, Iran.

Occult hepatitis C virus infection (OCI) is defined by the presence of HCV RNA in peripheral blood mononuclear cells (PBMCs) and liver tissue cells despite the absence of HCV RNA in plasma. Currently, OCI is classified into two types: seropositive OCI (anti-HCV positive and serum HCV RNA negative) and seronegative OCI (anti-HCV and serum HCV RNA negative). Beta-thalassemia is described as a blood disorder that decreases the synthesis of hemoglobin. Repeated blood transfusion is the standard treatment for patients with beta-thalassemia major (BTM), and this increases the risk of exposure to infectious agents. The aim of this study was to investigate the prevalence of OCI among BTM patients. Plasma and PBMCs were collected from 90 BTM patients who were referred to Shafa Hospital in the city of Ahvaz and were screened for HCV antibody using a commercial ELISA kit as the first step. Next, nested RT-PCR was performed on extracts of plasma and PBMCs. HCV RNA from positive PBMCs was sequenced, the sequences were aligned, and a phylogenetic tree was constructed to determine their relationship to reference sequences retrieved from the GenBank database. Seventy-nine out of 90 patients (87.8%) were negative for HCV Ab (seronegative), while 11 patients (12.2%) were seropositive. HCV RNA was found in PBMCs of four patients (66.7%) who were negative for HCV Ab (seronegative) and two patients (33.3%) who were positive for HCV Ab (seropositive). HCV RNA was not detected in plasma samples from these six patients. Six out of 90 BTM patients (6.7%) had OCI. HCV genotyping revealed that all six patients were infected with HCV subtype 3a. We found a high frequency of OCI in BTM patients, which warrants more attention, considering the importance of this infection. Further studies are needed to determine the actual prevalence of OCI in BTM patients in Iran.

Hepatitis E virus prevalence in Egyptian children with transfusion-dependent thalassemia.

Hepatitis E virus (HEV) infection is one of the major public health problems in developing countries. HEV can cause chronic infections in immunocompromised individuals e.g. thalassemic patients with increased risk of morbidity and mortality. In addition there is possibility of HEV transmission through blood transfusion. Therefore, the present study aimed to investigate the seroprevalence and risk factors of HEV infection in ß-thalassemic children. METHODS: This cross-sectional study was conducted on 140 Egyptian children suffering from ß-thalassemia, attending the hematology outpatient clinic from April to October 2016. Serum samples from patients were collected and anti-HEV antibodies; Immunoglobulin G (IgG) and Immunoglobulin M (IgM) were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: The seroprevalence of HEV in ß-thalassemic chidren was relatively high (27.15%). Anti-HEV IgG prevalence was 24.29% while that of IgM was 2.86%. There was significant association between HEV infection and age, residence, liver enzymes and amount of blood transfusion per year. CONCLUSIONS: Thalasemic patients are vulnerable to chronicity and increased risk of morbidity and mortality from HEV infection. Frequent assessment of liver enzymes in thalassemic patients to monitor subclinical HEV is recommended. Close monitoring and HEV screening of blood donations should be taken in consideration. Public awareness about HEV endemicity, modes of transmission, and risk hazards especially in high risk group should be done to reduce the disease burden.

Hepatitis E virus prevalence in Egyptian children with transfusion-dependent thalassemia

ABSTRACT Hepatitis E virus (HEV) infection is one of the major public health problems in developing countries. HEV can cause chronic infections in immunocompromised individuals e.g. thalassemic patients with increased risk of morbidity and mortality. In addition there is possibility of HEV transmission through blood transfusion. Therefore, the present study aimed to investigate the seroprevalence and risk factors of HEV infection in β-thalassemic children. Methods: This cross-sectional study was conducted on 140 Egyptian children suffering from β-thalassemia, attending the hematology outpatient clinic from April to October 2016. Serum samples from patients were collected and anti-HEV antibodies; Immunoglobulin G (IgG) and Immunoglobulin M (IgM)were measured by enzyme-linked immunosorbent assay (ELISA). Results: The seroprevalence of HEV in β-thalassemic chidren was relatively high (27.15%). Anti-HEV IgG prevalence was 24.29% while that of IgM was 2.86%. There was significant association between HEV infection and age, residence, liver enzymes and amount of blood transfusion per year. Conclusions: Thalasemic patients are vulnerable to chronicity and increased risk of morbidity and mortality from HEV infection. Frequent assessment of liver enzymes in thalassemic patients to monitor subclinical HEV is recommended. Close monitoring and HEV screening of blood donations should be taken in consideration. Public awareness about HEV endemicity, modes of transmission, and risk hazards especially in high risk group should be done to reduce the disease burden.

The effectiveness of sofosbuvir and daclatasvir in the treatment of hepatitis C in thalassaemia major patients and their effect on haematological factors.

Context: Patients with thalassaemia are at risk of infections such as hepatitis C virus (HCV) due to their repeated blood transfusions; meanwhile, the treatment of thalassaemia patients who had developed HCV infection is a controversial issue. Aims: Although the effectiveness of direct-acting antivirals on HCV infection has been confirmed, their side-effects as well as effects on haematological factors due to the resultant need for blood transfusion remain to be further understood. Materials and Methods: In this study, 61 patients with major beta thalassaemia and HCV infection, and who had a history of interferon treatment failure were examined. The patients underwent a 24-week treatment with sofosbuvir (SOF) and daclatasvir (DAC). Sustained virological response 12 was used to assess response to treatment. At the end of the study, the need for blood transfusion and serum ferritin was evaluated. Results: About 98.4% of the patients responded to the treatment, and only one patient with genotype 1b did not respond positively. No significant complications necessitating treatment cessation were observed, and all the patients tolerated the treatment well. The level of liver enzymes showed a significant reduction 12 weeks after the treatment. The need for blood transfusions in patients before treatment was averagely 1.595 ± 0.65 bag per month, in which 1.593 ± 0.64 bags were received after treatment (P = 0.9). This regimen did not affect the amount of anaemia in patients and did not differentiate the need for blood transfusions. The rate of haemoglobin before treatment was 9.5 ± 1.42 g/dl, which reached 9.6 ± 1.6 g/dl after treatment (P = 0.54). Ferritin levels decreased significantly (from 1948.08 ± 1539.54 to 1315.73 ± 1207.67 ng/ml) (P = 0.001) in the patients after the treatment. Conclusion: Combination of SOF and DAC is an effective and tolerable treatment regimen without affect on the amount of anaemia in patients and did not differentiate the need for blood transfusions.

Efficacy and Safety of Direct Acting Antiviral Therapy for Chronic Hepatitis C in Thalassemic Children.

OBJECTIVES: There is limited data on the efficacy and safety of directly acting antiviral therapy (DAA) for chronic hepatitis C in pediatric population. The aim was to assess the efficacy and safety of DAA in chronic hepatitis C ß-thalassemic major pediatric patients. METHODS: Prospective study was conducted from September 2015 to January 2017. All ß-thalassemic major chronic hepatitis C pediatric patients with age between 5 and 14 years were included in this study. Data related to demography, laboratory parameters, hepatitis C viral load, genotype and outcome of antiviral therapy was analyzed. DAA was planned according to EASL guidelines 2015 for chronic hepatitis C therapy in adults. OBSERVATIONS: Fourteen ß-thalassemic major patients (median age was 9.5 y, 12 male) were studied. All patients were of genotype 3, received DAA (sofosbuvir 400 mg+daclatasvir 80 mg) for 12 weeks. The median viral load was 2.5×10 IU/mL. End of treatment response and sustained virological response at 12 weeks was achieved in all the patients. Serum alanine aminotransferase, aspartate aminotransferase, ferritin, and albumin significantly reduced after DAA. CONCLUSIONS: DAA in adult dosage are safe and effective for treatment of chronic hepatitis C (genotype 3) in pediatric ß-thalassemic major population.

Dual therapy with peg-interferon and ribavirin in thalassemia major patients with chronic HCV infection: Is there still an indication?

BACKGROUND: Iron overload and hepatitis C virus (HCV) infection together can lead to chronic liver damage in thalassemia major (TM) patients. AIMS: We investigated viral, genetic, and disease factors influencing sustained virological response (SVR) after peg-interferon and ribavirin therapy in TM patients with HCV infection. METHODS: We analyzed 230 TM patients with HCV infection (mean age 36.0±6.3 years; 59.1% genotype 1; 32.2% genotype 2; 3.4% genotype 3; and 5.3% genotype 4; 28.7% carried CC allele of rs12979860 in IL28B locus; 79.6% had chronic hepatitis and 20.4% cirrhosis; 63.5% naive and 36.5% previously treated with interferon alone) treated in 14 Italian centers. RESULTS: By multivariate regression analysis SVR was independently associated with CC allele of IL28B SNP (OR 2.98; CI 95% 1.29-6.86; p=0.010) and rapid virologic response (OR 11.82; CI 95% 3.83-36.54; p<0.001) in 136 genotype 1 patients. Combining favorable variables the probability of SVR ranged from 31% to 93%. In genotype 2 patients, only RVR (OR 8.61; CI 95% 2.85-26.01; p<0.001) was associated with SVR higher than 80%. In 3 patients with cirrhosis a decompensation of liver or heart disease were observed. Over 50% of patients increased blood transfusions. CONCLUSION: Dual therapy in TM patients with chronic HCV infection is efficacious in patients with the best virological, genetic and clinical predictors. Patients with cirrhosis have an increased risk of worsening liver or heart disease.

No evidence of xenotropic murine leukemia virus-related virus infection in Brazilian multiply transfused patients with sickle cell disease and beta-thalassemia major.

Although xenotropic murine leukemia virus-related virus (XMRV) has been regarded as a laboratory contaminant, it remains one of the most controversial viruses. The objective of the study was to determine if XMRV is present in 44 patients with beta-thalassemia major, 48 with sickle cell disease, and 89 volunteer blood donors. After RNA/ DNA extraction from plasma/buffy coat the samples were screened for XMRV sequences by conserved nested GAG primers. None of the RNA samples showed a positive result. Surprisingly, four DNA samples obtained from blood donors were positive for XMRV provirus. The subsequent phylogenetic analysis revealed that these sequences are identical to the positive control (murine leukemia retrovirus) and are probably consistent with laboratory contamination. XMRV infection (provirus and viral RNA) was absent in multiply transfused patients and volunteer blood donors. The positive result obtained from some blood donors probably reflects laboratory contamination. We believe that XMRV does not pose risk to blood transfusion.

Prevalence of HBV and HCV among the multi-transfused beta thalassemic major patients in a day care centre of blood transfusion department of Mymensingh Medical College Hospital.

Though regular blood transfusion improves the overall survival of patients with ß-thalassemia which is one of the most common genetic diseases in the world, carries a definite risk of infection with blood-borne viruses. It is a major health problem, brings much morbidity, early mortality and a great deal of misery for a family both financially and emotionally. World Health Organization (WHO) reported that there is about 3% beta thalassemia carrier and more than two thousand thalassemic children are born every year in Bangladesh. We carried out this study to provide epidemiologic data on hepatitis B virus (HBV) & hepatitis C virus (HCV) infection among ß-thalassemic patients. Moreover, HBV & HCV infection-associated risk factors were investigated in this study. Two hundred patients with ß-thalassemia major were enrolled in this study. Using Rapid Immuno-chromatographic Test and their sera were tested for HBsAg and HCVAb. The positive HBsAg & HCVAb results were confirmed by ELISA. The study sample 200 consisted of 165 males (82.5%) and 35 females (17.5%), with a mean±SD age of 5.9±9.0 years. Four (2%) patients were HCV-Ab positive; 13(6.5%) were HBsAg positive. Univariate analysis showed that (P=0.01), older age (P=0.001), longer transfusion duration (P=0.000), HBsAg seropositivity (P=0.03), and higher serum ferritin level (P=0.002) were significantly associated with a higher prevalence of HCV. Using multivariate analysis, age (P<0.001), serum ferritin level (P< 0.001) were independent factors associated with HCV infection. Improvement of the people's knowledge about TTI risk factors, blood screening strategies and HBV vaccination have led to a dramatically decrease in prevalence of TTIs particularly HBV during the last decades in Bangladesh.However, post-transfusion transmission of HCV has still remained a major health concern in multi-transfused patients. As the prevalence of HCV infection is much higher among ß-thalassemic patients as compared with HBV infections routine screening of donated blood for HCV is highly recommended by ELISA.

Exacerbation of microcytic anemia associated with cessation of anti-retroviral therapy in an HIV-1-infected patient with beta thalassemia.

We report a patient with Japanese minor ß thalassemia and HIV-1 infection. The patient showed prolonged anemia, which was originally attributed to chronic parvovirus B19 infection. Twelve years later, the patient presented with exacerbation of microcytic anemia following cessation of anti-retroviral therapy; the exacerbation resolved when anti-retroviral therapy was resumed. Sequencing of the ß globin gene revealed heterozygosity for a four-nucleotides deletion at codon 41/42 and minor ß thalassemia was confirmed. Because HIV-1-infected patients frequently show anemia due to nutritional deficiencies, opportunistic infections, AIDS-related malignancies, drug treatment and a direct effect of HIV-1 on the bone marrow, it is likely to overlook other causes of anemia. Thalassemia should be considered in the differential diagnosis of anemia even in HIV-1 infected patients, when microcytic anemia without iron deficiency is observed. Our case suggested that active HIV infection may have worsened ß thalassemia, and early introduction of anti-retroviral therapy is beneficial for the recovery of anemia.

Natural history of hepatitis C in thalassemia major: a long-term prospective study.

BACKGROUND: Transfusion-acquired hepatitis C virus (HCV) remains an important problem among patients with thalassemia. In this study, we evaluated the natural history of post-transfusional hepatitis C in thalassemia major, paying special attention to spontaneous viral clearance, to factors influencing the chronicity rate and fibrosis progression. DESIGN AND METHODS: A prospective study to evaluate the incidence and etiology of transfusion-related hepatitis was started in 1980. In patients who developed hepatitis C, HCV RNA, ALT, and ferritin were measured over time. The correlation between interleukin-28B gene polymorphisms and viral clearance was also analyzed. RESULTS: Seventy-three of 135 patients (62.2%) acquired HCV. An extended follow-up (22 to 30 yr) with HCV RNA assessment was available in 52 patients. Of them, 23 (44.2%) cleared the virus. The proportion of IL-28B genotypes was different between the subjects who cleared the virus and the subjects who did not. Fibrosis progression was similar in HCV RNA-positive and HCV RNA-negative patients. Liver iron was the only factor associated with the fibrosis. CONCLUSIONS: In thalassemia patients with HCV infection, liver iron does not play a major role in influencing the chronicity rate, whereas it is significantly associated with the fibrosis.

Prevalence of hepatitis C infection among children with ß-thalassaemia major in Mid Delta, Egypt: a single centre study.

BACKGROUND: Transfusion dependant patients are at a higher risk of acquiring bloodborne infections even under conditions of safe transfusion. This study was designed to determine sero-prevalence of hepatitis C infection and possible associated risk factors in thalassaemic children. METHODS: One hundred and twenty five children with ß thalassaemia major (ß-TM) were recruited from the Haematology/Oncology Unit, Paediatric Department, Tanta University Hospital, Egypt, between April 2010 and October 2011. Patients underwent history taking, full clinical examination, routine investigations and venous blood sampling. Serum was stored at -20°C till tested for hepatitis C (HCV Ab) and B (HBsAg) by ELISA. HCV Ab positive cases were confirmed by PCR. RESULTS: All patients were HBsAg negative. HCV Ab ELISA was positive in 76%, negative in 20% and equivocal in 4%. Fifty patients (40%) had positive PCR for HCV. PCR showed low viraemia in 78%, moderate viraemia in 20% and high viraemia in 2%. A positive family history of HCV, history of minor operative intervention and/or dental procedures were significantly associated with higher frequency of HCV infection in thalassaemic children, while amount and frequency of transfused blood, age at transfusion and chelation state were not. CONCLUSION: HCV infection is highly prevalent in children with ß-TM in Egypt despite strict pre-transfusion blood testing. This should arouse the attention for environmental and community acquired factors. Quality management to insure infection control in minor operative procedures and adding more sensitive tests for blood screening are recommended.

Seropositivity of hepatitis C, hepatitis B and HIV in chronically transfused ß-thalassaemia major patients.

The purpose of this study was to determine the frequency and trend of transfusion transmitted infections (TTI) in chronically transfused ß-thalassaemia major (TM) patients with reference to the duration of transfusions. A cross-sectional study was done on 160 ß-TM patients and 5517 healthy blood donors to find out the prevalence of HCV, HBV and HIV infections. Out of 160 patients, 21 cases (13.1%) were anti-HCV positive, 2 (1.25%) were HBsAg positive. HIV antibodies were not detected in any sample. However, 109 (1.9%) and 104 (1.8%) of 5517 blood donors were positive for HCV and HBV respectively. No donor showed HIV antibodies. Anti-HCV was positive in 9/111(8.4%) thalassaemics (< 10 years of age) while 11/49 (22%) [> 10 years of age] showing significant difference (p = 0.005) among the two groups. For the past 10 - 12 years the screening of blood has reduced the magnitude of the disease significantly as shown by the trend in two age groups. Further improvements need to be done to implement uniform screening throughout the country.

[Impact of cytomegalovirus infections on T lymphocyte subsets in children with ß-thalassemia major early after allogeneic hematopoietic stem cell transplantation].

OBJECTIVE: To investigate the effect of human cytomegalovirus (HCMV) infection on T lymphocyte subsets in children with ß-thalassemia major (TM) during the initial 6 months after allogeneic hematopoietic stem cell transplantation (Allo-HSCT). METHODS: From January, 2010 to January, 2011, 35 children with TM underwent Allo-HSCT. Peripheral blood samples were obtained from the children 6 month after the transplantation to examine the changes of T lymphocytes subsets in relation to HCMV seropositivity. RESULTS: Thirteen children were found seropositive and 22 were seronegative for HCMV. The HCMV-seropositive children had a higher CD8⁺ cell percentage but a lower CD4⁺ cell percentage than those without HCMV infection. Compared with those seronegative for HCMV, the children with HCMV seropositivity showed increased percentages of CD8⁺ cells and CD8⁺CD28⁻ cells with a decreased percentage of CD8⁺CD28⁺ cells. A positive linear correlation was found between the percentages of CD8⁺CD28⁻ cells and CD8⁺ cells. CONCLUSION: HCMV infection can lead to the accumulation of CD8⁺CD28 cells to cause increased CD8⁺ T cells in the peripheral blood in TM children after Allo-HSCT. The percentages of CD8⁺CD28⁻ cells has a positive linear correlation to that of CD8⁺ cells.

Genotyping of Human parvovirus B19 among Brazilian patients with hemoglobinopathies.

Human parvovirus B19 (B19V) infection can be a life-threatening condition among patients with hereditary (chronic) hemolytic anemias. Our objective was to characterize the infection molecularly among patients with sickle cell disease and thalassemia. Forty-seven patients (37 with sickle cell disease, and 10 with ß-thalassemia major) as well as 47 healthy blood donors were examined for B19V infection by anti-B19V IgG enzyme immunoassay, quantitative PCR, which detects all B19V genotypes, and DNA sequencing. B19V viremia was documented in nine patients (19.1%) as two displayed acute infection and the rest had a low titre viremia (mean 3.4 × 10(4) copies/mL). All donors were negative for B19V DNA. Anti-B19V IgG was detected in 55.3% of the patients and 57.4% among the donors. Based on partial NS1 fragments, all patient isolates were classified as genotype 1 and subgenotype 1A. The evolutionary events of the examined partial NS1 gene sequence were associated with a lack of positive selection. The quantification of all B19V genotypes by a single hydrolytic probe is a technically useful method, but it is difficult to establish relationships between B19V sequence characteristics and infection outcome.

Distribution of hepatitis C virus genotypes amongst the beta-thalassemia patients in North of Iran.

Beta-thalassemia patients have high prevalence for HCV infection. In developing countries, HCV antibody is reported to be high in this group of patients. This study carried out to determine the distribution of HCV genotypes amongst the beta-thalassemia patients in North of Iran. The present study has been carried out between February and March 2010 amongst a group of 245 beta-thalassemia patients (125 male and 120 female) referred to the hospitals Mazandaran and Guilan provinces for a blood transfusion. Qualitative analysis of these samples using ELISA and PCR. The PCR positive samples were subjected to genotyping by RFLP method. Of total 245 beta-thalassemia patients who were the subjects of this study, 28 of these patients were diagnosed through PCR test to have RNA virus. For this reason, the prevalence of this illness in this study group was estimated as 11.42%. By using the RFLP technique, the above genotyping were identified and the prevalence of three genotypes, including 3a, 1a and 1b were proved. The genotype 3a was most prevalent. Out of 28 positive samples, 18 (64.3%) samples had this genotype. After that, genotype 1a with 9 positive occurrences (32.1%) and genotype 1b with only 1 positive occurrence (3.6%) were most prevalent. This study demonstrated that the main reason the beta-thalassemia patients became infected with the genotype of the virus was due to receiving infected blood that entered into Iran during the past two decades.

IL28B polymorphisms influence stage of fibrosis and spontaneous or interferon-induced viral clearance in thalassemia patients with hepatitis C virus infection.

BACKGROUND: Polymorphisms in the interleukin-28B are important determinants in the spontaneous and drug-induced control of hepatitis C virus infection. DESIGN AND METHODS: We assessed the association of rs8099917 and rs12979860 polymorphisms with spontaneous viral clearance, severity of liver fibrosis, and response to interferon-monotherapy in 245 thalassemia major patients with hepatitis C virus infection. RESULTS: Ninety-eight patients (40%) had a spontaneous viral clearance while 147 patients (60%) developed a chronic infection. Spontaneous viral clearance was more frequent among patients with the T/T genotype of rs8099917 polymorphism (OR 2.130; P = 0.008) or C/C genotype of rs12979860 polymorphism (OR 2.425; P = 0.001). During observation, 131 patients with chronic infection underwent a liver biopsy; age (OR 1.058; P = 0.01) G/T or G/G genotypes of rs8099917 polymorphism (OR 3.962; P = 0.001), and C/T or T/T genotypes of rs12979860 polymorphism (OR 3.494; P = 0.005) were associated with severe liver fibrosis, independent of liver iron concentration. Finally, T/T genotype of rs8099917 polymorphism (OR 3.014; P = 0.03) or C/C genotype of rs12979860 polymorphism (OR 3.285; P = 0.01), age (OR 0.902; P = 0.001), female gender (OR 3.418; P = 0.01) and 2 or 3 virus C genotypes (OR 4.700; P=0.007) were independently associated with sustained virological response in 114 patients treated with alpha-interferon. Conclusions Polymorphisms in the interleukin-28B are associated with the control of hepatitis C virus infection in thalassemia major patients, and understanding allelic patterns has an important role in determining prognosis and therapeutic management.