Course of hepatitis C virus (HCV) RNA and HCV core antigen testing are predictors for reaching sustained virologic response in liver transplant recipients undergoing sofosbuvir treatment in a real-life setting.

BACKGROUND: Hepatitis C virus (HCV) infection is associated with reduced graft survival in orthotopic liver transplant recipients. Treatment with the new direct-acting antivirals (DAAs) is safe and efficient, but no reliable predictive factors for sustained virologic response (SVR) have been identified so far. The HCV core antigen assay (HCV-core-Ag) is a new, inexpensive, and efficient method to detect viral antigens, but the value of this technique to predict treatment response in orthotopic liver transplantation (OLT) patients is still unclear. METHODS: All OLT patients who were treated with a sofosbuvir-based antiviral regimen at our center between March 2014 and August 2014 were included in the analysis (n = 20). HCV-core-Ag and HCV RNA (polymerase chain reaction [PCR]) were determined at each visit. Primary endpoints of this study were SVR at 4 or 12 weeks after end of treatment (SVR 4 and SVR 12). RESULTS: HCV-core-Ag tested negative after a median of 2 weeks (range 1-16 weeks) while PCR tests became negative after a median of 4 weeks (range 2-12 weeks). Time until PCR negativity and until HCV-core-Ag negativity showed a good correlation (R = 0.711, P < 0.001, Fig. ). Seventeen of 20 patients (85%) achieved SVR 12. SVR 12 was associated with a short time interval between treatment start and HCV PCR negativity (P = 0.005) or HCV-core-Ag negativity (P = 0.003, Mann-Whitney test). No severe side effects were observed. CONCLUSIONS: DAA treatment is safe and well tolerated in OLT. The time points of HCV-core-Ag loss and PCR negativity were predictors of SVR 12.

Efficacy and safety of sofosbuvir/ledipasvir for the treatment of patients with hepatitis C virus re-infection after liver transplantation.

BACKGROUND: Hepatitis C virus (HCV) infection is associated with a particularly poor outcome after liver transplantation. In December 2014, sofosbuvir/ledipasvir (SOF/LDV) fixed-dose combination (FDC) was approved for HCV genotype 1 and 4 in Europe. In orthotopic liver transplantation (OLT) recipients, the interferon-free treatment of HCV re-infection with novel direct-acting antivirals has been demonstrated to be safe and effective in clinical trials, but real-world data are missing. The aim of this study was to investigate the safety and efficacy of SOF/LDV FDC in OLT recipients in the real-life setting. METHODS: All consecutive OLT patients started on SOF/LDV FDC for 12 or 24 weeks at the University Medical Center Hamburg-Eppendorf and Medical School Hannover between October 2014 and August 2015 were retrospectively analyzed (n = 30). The primary efficacy endpoint was sustained virological response (SVR), i.e., absence of viremia 12 weeks after end of treatment (SVR 12). Liver function tests, creatinine, blood count, and HCV RNA (by polymerase chain reaction assay) were determined at each visit. RESULTS: SVR was achieved in 29/30 patients (96.67%) treated with SOF/LDV ± ribavirin (RBV) for 12 (n = 4) or 24 weeks (n = 25). Twenty-five patients (86.2%) received RBV. However, in 15 of the 25 patients, RBV administration had to be discontinued because of severe anemia (57.7%). One RBV-treated patient died of a myocardial infarction during antiviral therapy; this event was most likely not directly related to SOF/LDV. Aside from RBV-associated anemia, no severe side effects of the antiviral regimen were observed. CONCLUSION: Antiviral treatment with SOF/LDV is highly effective, safe, and well tolerated in OLT recipients. The addition of RBV often results in severe anemia, requiring dose reduction or discontinuation.

Relevance of chronic hepatitis E in liver transplant recipients: a real-life setting.

The chronic course of hepatitis E virus (HEV) infections in orthotopic liver transplant (OLT) recipients has been described previously, but prospectively collected data are rare. We aimed to study the role of chronic hepatitis E in OLT in a real-life setting. Therefore, 287 adult OLT recipients (169 male [59%], median age 56 years) were prospectively tested by HEV polymerase chain reaction assay (lower level of detection = 10 IU/mL), irrespective of their level of liver enzymes. In 4 patients (1.4%), chronic HEV infection was diagnosed. All 4 patients were male, and their age (median 48.5 years), the time since transplantation (median 45.5 months), and bilirubin level (median 0.6 mg/dL) did not differ significantly from the total cohort. However, alanine transaminase and aspartame transaminase levels were significantly higher in HEV-infected patients (75-646 U/L, median 216 U/L and 68-317 U/L, median 108 U/L) than in non-infected patients (6-617 U/L, median 41 and 6-355 U/L, median 36; P = 0.004 and 0.040, Mann-Whitney test). In 3 patients, liver biopsy was performed and revealed signs of inflammation and chronic liver disease, as enlarged densely infiltrated portal tracts with mild-to-moderate interface hepatitis. All infected patients were treated with ribavirin with the starting dose adjusted to renal function (400-800 mg/day). In 2 patients, dose reduction was necessary. Transaminases normalized in all 4 patients, and all patients cleared their infection within 3 months of ribavirin treatment. However, 1 patient experienced viral relapse 12 weeks after discontinuation. Ribavirin medication was re-started and viral clearance occurred within 8 weeks and persisted. Sequence analysis of the HEV genome of this patient revealed that he was infected with an HEV variant, which recently has been shown to have a reduced response to ribavirin in cell culture. The risk of chronic HEV infections in OLT recipients in low-endemic countries should not be overestimated. No case of chronic hepatitis E was observed in patients with normal liver enzymes, indicating that general screening of all OLT recipients is not necessary. However, if chronic hepatitis E develops, it can be treated efficiently with ribavirin.

Comparison of autochthonous and imported cases of hepatitis A or hepatitis E.

BACKGROUND: Hepatitis A and hepatitis E are not limited to tropical countries but are also present in industrialized countries. Both infections share similar clinical features. There is no comparative study evaluating the clinical parameters of autochthonous and imported hepatitis A virus and hepatitis E virus infections. AIMS: The aim of this study was to determine differences between autochthonous and imported hepatitis A virus (HAV) and hepatitis E virus (HEV) infections. METHODS: Medical charts of all patients at our center with acute HAV and HEV infections were analyzed retrospectively (n = 50, study period 01/2009 - 08/2013). RESULTS: Peak bilirubin (median 8.6 vs. 4.4 mg/dL, p = 0.008) and ALT levels (median 2998 vs. 1666 IU/mL, p = 0.04) were higher in patients with hepatitis A compared to hepatitis E. In comparison to autochthones hepatitis E cases, patients with imported infections had significantly higher peak values for AST, ALT, bilirubin and INR (p = 0.009, p = 0.002, p = 0.04 and p = 0.049, respectively). In HAV infection, AST levels tended to be higher in imported infections (p = 0.08). CONCLUSIONS: (i) It is not possible to differentiate certainly between acute HAV and HEV infections by clinical or biochemical parameters, however, HAV infections might be associated with more cholestasis and higher ALT values. (ii) Imported HEV infections are associated with higher transaminases, INR and bilirubin levels compared to autochthonous cases and (iii) imported HAV infections tend to be associated with higher transaminases in comparison to autochthonous cases.

Improved detection of bacterial central nervous system infections by use of a broad-range PCR assay.

A universal PCR assay for bacteria and fungi detected meningitis pathogens in 65% of 20 cerebrospinal fluid (CSF) samples from patients with suspected central nervous system (CNS) infections compared to a 35% detection rate by culture and/or microscopy methods. Thus, the PCR assay can improve the diagnosis rate of infective meningitis when standard methods provide a negative result.

Is rapid hepatitis C virus testing from corpses a screening option for index persons who have died after mass-casualty incidents in high-prevalence settings in the field?

INTRODUCTION: We tested a commercially available rapid hepatitis C virus (HCV) test assay for its potential use for analyses of corpses as a screening option for index persons who have died after mass-casualty incidents in high-prevalence settings in the field. MATERIALS AND METHODS: 50 blood samples were drawn from 16 recently deceased confirmed HCV-positive patients whose corpses were stored at 4°C in the mortuary and were analysed at admission and up to 48 h post mortem by rapid serological testing using the ImmunoFlow HCV test (Core Diagnostics, Birmingham, UK) in comparison with automated serological assays and PCR. Samples from 50 HCV-negative corpses were also analysed. RESULTS: The blood of only four of the 16 HCV-positive corpses reacted clearly with the ImmunoFlow HCV test, while in five cases the result was only weakly reactive and three cases showed very weak reactivity. Four of the infected corpses showed initially negative results, three of which became very weakly reactive 48 h post mortem. 49 out of 50 samples (98%) from HCV-negative corpses tested negative. DISCUSSION: The rapid test system we investigated showed insufficient sensitivity regarding the identification of HCV positivity. Automated serological testing or PCR should be preferred if it is realistically available in the deployed military setting.

From IEDs to AIDS? Detection of HIV in human corpses by rapid screening tests after suspected intentional transmission in terrorist attacks.

OBJECTIVES: We evaluated the feasibility of intentional transmission of HIV by means of suicide bombing and rape as a terrorist tactic in asymmetric conflicts by evaluating the recognised optimum conditions for biological warfare. We also estimated the suitability of a fourth-generation rapid test for HIV detection in the blood of dead terrorists killed in the completion of their mission. METHODS: The feasibility of deliberate transmission of HIV for terroristic ends was evaluated on the basis of published experience from passive biological warfare research. In addition, blood from four recently deceased HIV-positive patients and four HIV-negative control corpses, stored at 4°C in a mortuary, was analysed at 12, 24, 36 and 48 h postmortem by rapid serological testing. RESULTS: The feasibility of HIV infection for terroristic purposes was established. The fourth-generation HIV rapid test we evaluated identified all HIV-positive samples and was negative for all HIV-negative samples. CONCLUSIONS: Rapid HIV testing from the remains of dead terrorists in the deployed military environment is possible. Samples should be acquired quickly, basic sample preparation is advisable and consequent decisions concerning postexposure prophylaxis should take into account the diagnostic gap in early infections.

Persisting hepatitis E virus infection leading to liver cirrhosis despite recovery of the immune system in an HIV-infected patient.

Chronic hepatitis E has been described several times in strongly immunosuppressed HIV-patients. We describe the persistence of HEV-infection in an HIV-patient despite a restored immune response. This case demonstrates that HEV-infection can persist in formerly immunosuppressed individuals irrespective of the current immune status. Persisting HEV-infection can lead to chronic inflammation and liver cirrhosis. Physicians should be aware of the possibility of chronic hepatitis E even in patients that are not any longer immunocompromised. However, ribavirin is an efficient treatment option.

High rate of chronicity in HCV infection determined by antibody confirmatory assay and PCR in 4110 patients during long-term follow-up.

BACKGROUND: It is still unclear how many patients with hepatitis C virus (HCV) antibodies have viremia and hence are infectious. OBJECTIVES: To determine the chronicity of HCV infection by correlation of HCV antibodies with presence of viremia in long-term follow-up. STUDY DESIGN: In a longitudinal study sera of 4110 patients were analyzed with second generation HCV-enzyme immunoassay (EIA) and polymerase chain reaction (PCR). Only those patients were included in this study in whom sequential serum samples over a period of 2 years were available. To avoid preanalytical and analytical failures, we used a transport solution to prevent RNA degradation and a four-antigen recombinant immunoblot assay, established in our laboratory, for confirmation of antibody reactivity. RESULTS: Of 2815 patients with confirmed HCV antibodies 2784 (98.9%) were also positive in HCV-PCR assay. False reactive EIA results were detected in 177 (13.7%) individuals as shown by confirmatory assay and PCR. Only one patient (0.04%) spontaneously lost detectable HCV viremia and subsequently HCV-specific antibodies. CONCLUSIONS: Our study clearly demonstrates that presence of confirmed HCV-specific antibodies correlates significantly (98.9%; P < 0.001) with HCV viremia, and that spontaneous loss of viremia is a very rare event in HCV infection. We also found that elimination of HCV infection is not sufficiently predicted by the loss of detectable viremia in PCR, but can be concluded from the disappearance of virus-specific antibodies.

Diagnostic evaluation of a new combined HIV p24 antigen and anti-HIV1/2/O screening assay.

To evaluate a new fourth generation assay for simultaneous detection of antibodies to the human immunodeficiency virus (HIV) 1 and 2 and HIV p24 antigen in daily routine we tested 675 sera obtained from 673 patients and compared the results to conventional antibody tests. In 546 uninfected patients the rate of unspecific reactivities was slightly higher in the new screening assay as compared to conventional antibody assays (1.1% vs. 0.4%). All 121 sera derived from patients with known HIV infection were detected correctly. In six patients from whom sera were obtained during early seroconversion the fourth generation ELISA was positive in three cases, while conventional third generation tests still were negative. In patients negative for HIV antibodies and low amounts of p24 antigen less than 100 pg/ml also the fourth generation ELISA remained negative. Thus, this new assay permits earlier detection of HIV infection and reduces the diagnostic window. It is a reliable tool for routine diagnosis of HIV, especially in blood donors and patients with high risk behavior.

Prognostic significance of the hepatitis B virus-DNA concentration in patients after orthotopic liver transplantation.

Hepatitis B virus-DNA was detected by polymerase chain reaction in 9 out of 10 patients after orthotopic liver transplantation. Three of these patients were at the same time positive for hepatitis B virus-DNA by dot-blot hybridization (hepatitis B virus-DNA > 1.5 pg/ml). In these three patients HBs-antigen (HBsAg) reappeared within a mean time of 12 weeks after orthotopic liver transplantation (range 7-18 weeks). Only two of the six polymerase chain reaction-positive and dot-blot-negative patients (hepatitis B virus-DNA between 0.4 fg/ml and 1.5 pg/ml) had recurrence of HBsAg within a mean time of 54 weeks (range 52-56 weeks). Passive immunoprophylaxis with anti-HBs antibodies (serum titers > 100 IU/l) did not prevent infection of the graft in the five reinfected patients. We conclude that a low concentration of serum hepatitis B virus-DNA after orthotopic liver transplantation, which is detectable only by polymerase chain reaction, indicates a delayed infection of the graft.

Die vertikale Übertragung des Hepatitis-C-Virus von infizierten Müttern auf ihre Kinder Das Risiko der HCV-Übertragung durch Muttermilch ist gering : Das Risiko der HCV-Übertragung durch Muttermilch ist gering.

Children of mothers chronically infected with hepatitis-C-virus (HCV) during pregnancy and delivery were prospectively followed. 90 children born to 85 infected mothers were included in our study; nine of the mothers were known to be co-infected with HIV-1. These 90 children were first tested within 60 days after birth and followed for at least three months. Three of the 90 children became infected perinatally with HCV as shown by persistence of antibodies after 2 years of life and a positive result in the RT-PCR. One of these 3 children has evidence of ongoing hepatitis as shown by slightly elevated alanine aminotransferase values, but is otherwise clinically well, likewise the other 2 infected children. 54 of the 87 uninfected children were followed until they lost maternal antibodies after an average of one year.In another part of the study we tested 76 breast milk samples from 73 chronically HCV-infected mothers for the presence of HCV-RNA. None of the samples was positive. One of the 76 children of these mothers became HCV-infected; the course of infection in this case favours an HCV-transmission during pregnancy or delivery and not by breast feeding. These data show that maternal HCV-infection should not be a contraindication for breast feeding.

Hepatitis C virus antibodies among different groups at risk and patients with suspected non-A, non-B hepatitis.

4000 sera were tested for antibodies against hepatitis C virus (HCV) by means of an ELISA using the C100-3 antigen. 38.9% of patients with non-A, non-B hepatitis following blood transfusion (n = 108) had HCV antibodies. Among patients with chronic liver damage of unknown origin (n = 316) 30.4% were anti-HCV positive, and in 2,506 patients with transitional or chronic elevation of transaminases 14.8% showed HCV antibodies. Haemophiliacs (n = 26) with 65.4% anti-HCV positives and drug addicts (n = 46) with 56.5% anti-HCV positives had the highest prevalence among high risk groups. Addicts dying from drug abuse (n = 216) and HIV 1 positives (n = 127) were anti-HCV positive in 37.5% and 26.0%, respectively. Patients on haemodialysis (n = 331) had antibodies against HCV in 12.4%. Health care workers (n = 217) appear to be at a comparably low risk with only 2.8% anti-HCV positives. Up to now we could not find a single case of intrafamilial spread of HCV in 46 examined cases. We suggest that HCV infectivity of contaminated body fluids and blood is lower than that of hepatitis B virus or human immunodeficiency virus type 1 carriers. In suspected non-A, non-B hepatitis negative test results should be confirmed in a second sample because it may take three to six months after infection before HCV antibodies occur. However, about 10% of chronic HCV infections are not detectable with the presently available test. This may change when new tests become available using HCV specific antigens other than C100-3.

[Evaluation of the efficacy of a recombinant hepatitis B vaccine]. / Erfahrungen mit der Wirksamkeit eines gentechnologisch hergestellten Hepatitis-B-Impfstoffes.

A recombinant vaccine against hepatitis B derived from yeast cells (Gen-HB-Vax, Co. MSD/Behring) has been evaluated in 59 healthy young volunteers (37 men, 22 women) with an average age of 24.4 years. The seroconversion rate was 100%, and no major side effects were observed. During a follow-up period of 24 months concentrations of antibodies against HBsAg were shown to decline to one tenth within 16 to 17 months. Triple vaccination led to protective antibody titres for about 27 months on average. Based on these findings we suggest the following recommendations concerning revaccination: an anti-HBs titre of more than 10,000 mIU/ml four weeks after third vaccination should be reassessed 3-5 years later, and titres between 1000 and 10,000 mIU/ml after 2-3 years. A control of the antibody titre should be performed after 1-2 years if the titre is 200-1000 mIU/ml after the third vaccination, and after 6-12 months if it is 100-200 mIU/ml. Antibody titres between 10 and 100 mIU/ml should already be reassessed about 3-6 months later. We recommend an immediate revaccination for persons with anti-HBs titres below 10 mIU/ml. This corresponds to the course of antibody concentrations which could be seen in former studies with the conventional serum-derived vaccine. Maximum anti-HBs titres are slightly below those observed with the serum-derived vaccine.

Hepatitis C virus infection in pregnancy and the risk of mother-to-child transmission.

The risk of vertical transmission of the hepatitis C virus (HCV) from infected mothers to their children during pregnancy and delivery was determined in 120 children born to HCV-positive mothers. Methods included enzyme immunoassay and immunoblot for detection of HCV antibodies and reverse transcription polymerase chain reaction (RT-PCR) for detection of viral RNA. Six (5%) children were perinatally infected with HCV as shown by RT-PCR. None of the infected children had clinical signs of hepatitis. None of the pregnancies was complicated by abortion, stillbirth, premature birth, or malformation of the child. Special concern was given to the possibility of HCV transmission via breast milk. In no breast milk sample obtained from 34 HCV-infected mothers was HCV RNA detected. These observations indicate that HCV infection is not necessarily a contraindication for breast-feeding.

Study on reliability of commercially available hepatitis C virus antibody tests.

The serodiagnosis of hepatitis C virus (HCV) infection was analyzed by a recombinant immunoblot assay (RIBA) with recombinant proteins encoded by the viral RNA isolated from our patients in Hamburg, Germany. The HCV RNA was amplified by PCR, and proteins encoded by the viral core and the NS3, NS4, and NS5 regions were expressed subsequently in Escherichia coli. The results obtained with our UKE RIBA were compared with the results of the Abbott HCV second-generation enzyme immunoassay (EIA). Serum samples from 270 patients, which were sent to us on the suspicion of HCV hepatitis and which were negative for hepatitis A virus and hepatitis B virus antibodies, were examined. In 227 cases (84.1%), there were identical positive (204 cases, 75.6%) or negative (23 cases, 8.5%) results in both tests. In 32 cases (11.9%), the reactive Abbott second-generation HCV EIA results could not be confirmed by the UKE RIBA and the HCV PCR. In follow-up studies conducted over 1 year, these results did not change. In three cases (1.1%), the UKE RIBA presented a positive result while the Abbott second-generation HCV EIA was negative. All three cases were positive in the HCV PCR and showed seroconversion in an HCV EIA 4 to 6 weeks later. In addition, 33 patient serum samples were examined by UKE RIBA in parallel with the Ortho RIBA 2.0. In three cases (9.1%), a positive Ortho RIBA 2.0 result could not be confirmed by the UKE RIBA and the HCV PCR. All three patients were free of complaints. The UKE RIBA showed also a smaller number of indeterminate results (3.0%) than the Ortho RIBA 2.0 (24.2%). This comparison study demonstrates that the commercially available HCV antibody tests should be further improved.