Hepatitis Monthly
Year:2011 | Volume:11 | Issue:1 (30)|Papers Count:18

Implication for Health policy/practice/research/medical education: This editorial has been written to aware about the drawbacks of the liver granuloma and the importance of brucellosis as one of the most common zoonotic diseases. Reading this article is recommended especially to pathologists, infectious diseases specialists and gastroenterologists in the viewpoint of differential diagnosis of liver granuloma. Prevention of this infection should be considered more by authorized people in the health system.

Halothane was introduced as an anesthetic in the 1950s and was considered a revolutionary agent in the field of anesthesia. Soon after, halothane-induced hepatitis became a concern, leading to the development of less toxic gases that induced a lower incidence of side effects. Two types of halothane-related hepatotoxicity have been described: type 1, or mild hepatitis, is associated with elevated transaminase levels and self-limiting symptoms, and type 2, or severe hepatotoxicity, is associated with acute fatal liver failure and is fatal in most cases. Hepatotoxicity is most likely to be immune related, based on much evidence. Free radicals that are produced by the metabolism of halothane in the liver can modify cellular proteins and introduce neo-antigens to the immune system. Sensitization to these neo-antigens induces a more severe response after multiple exposures; most cases of type 2 hepatitis occur after repeated contact. New halogenated anesthetics such as enflurane, sevoflurane, and desflurane, are not metabolized in the liver, causing few cases of sensitization. Compared with halothane, these anesthetics are expensive. As a result, replacement of halothane with new halogenated anesthetics requires a precise cost-benefit analysis, especially in developing countries that have low health care budgets.

Human immunodeficiency virus (HIV)- infected patients are at risk of acquiring viral hepatitis, due to common routes of transmission. As the introduction of highly active antiretroviral therapy (HAART) reduced the frequency of opportunistic infections and improved survival, viral hepatitis emerged as an important cause of morbidity and mortality in HIV-infected cases. Occult hepatitis B virus (HBV) infection is characterized by presence of HBV infection without detectable hepatitis B surface antigen (HBsAg). There are conflicting reports on the impact of occult HBV infection on the natural history of HIV disease. In this review, we described the findings of studies on HIV and hepatitis B co-infection with focus on the prevalence of occult HBV infection. The results of this review demonstrated the importance of prevention, diagnosis and treatment of occult HBV infection in HIV-positive patients.

Background: Nucleic acid amplification testing is recommended for screening blood donations; however, they are not widely available in developing countries such as Iranian. Confidential unit exclusion (CUE) gives blood donors the opportunity to confidentially indicate whether their blood is or is not suitable for transfusion to others. Hoewever, its effectiveness in improving blood safety has recently been questioned by the blood banking community.Objectives: The purpose of this study was to determine the efficacy of CUEin Iran. Patients and Methods: Data on transfusion-transmitted disease markers (HBsAg, HCVAb, HN Ab, RPR) were extracted from a database of voluntary. blood donations in 2006 at the Tehran Blood Transfusion Center. The prevalence of markers were compared between CUE-positive ("should not use") and CUE-negative ("can be used") donations. Results: CUE-positive donations had significantly higher risk of HBVand HCVmarkers (odds ratio (95%confidence interval): 7.5 (5.4-10.5) and 53 (2.5-11.3) respectively). No HN or syphilis markers were detected in either group.Conclusions: CUEis an effective option for identifying donors with increased risk of HBVand HCV markers.

Background: Hepatitis B virus (HBV) genotypes and mutations are gaining importance in determining the clinical course of chronic liver disease.Objectives: To determine and compare the distribution of HBV genotypes and genomic variations in Pakistan to other parts of the world. Patients and Methods: We conducted a prospective study at Aga Khan University Hospital from December 2006 to December 2008. HBV genotype was determined in 257 HBV DNA-positive patients. Patients were divided into two groups according to HBeAg positivity. Mutations in the pre-core and core promoter regions of HBV were determined in HBeAg-negative patients by line probe INNOLIPA assay.Results: The mean±SD age of patients was 28±5 years; there were 201 (78%) men. HBeAg was positive in 219 (85%) patients and negative in 38 (15%). HBeAg-positive patients were younger than HBeAgnegative patients (95% vs 21% in£30 years, p<0.001). HBV genotype D found in 247 (96.2 %) patients followed by a combined infection with HBV genotype B+D in 9 (3.3%) and 1 (0.5%) with genotype A. The mutations identified in 38 HBeAg-negative patients were T1762/A1764 in 21 (55.2%), PC mutant in7 18.4, (%T1762/A1764/PC mutant in 2 (5%) and T1762/A1764/PC wild mutation in 1 (2%); no mutation identified in 7 (18.4%). Phylogenetic analysis did not show any significant differences between HBV genotype D isolated from Pakistan and those isolated from other parts of the world. Conclusions: HBV genotype D is predominant in Pakistan, irrespective of HBeAg status. PC and BCP mutations were found in significant numbers of patients infected with genotype D. The HBV genotype D isolates from Pakistan are identical to the sequences isolated from other parts of the world.

Background: There is a strong association between hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection which are mainly transmitted by contamination with blood via intravenous drug abuse (IVDU) or sexual contact.Objectives: To determine the prevalence of these infections and the risk factors associated with them among prisoner and non-prisoner IVDUs in Tehran, Iran.Patients and Methods: This cross-sectional study was performed in two jails and three drug rehabilitation centers between 2001 and 2002 in Tehran. HBsAg and HBcAb were checked using highly specific third generation enzyme immunoassays (DIA. PRO, Italy, specificity >99%, and Radim, Italy, specificity, 99.7% respectively). HCVAb was detected using ELISA (DIA.PRO, Italy) with both sensitivity and specificity >98%. HIVAb test (DRG Diagnostics kit, Germany) was performed for 459 of the 468 IDU subjects. Results: 392 prisoners and 135 individual attending drug rehabilitation centers were approached. Of the 518 subjects studied, 464 (89.5%) were male, 386 (74.5%) were prisoners and 132 (25.5%) were nonprisoners. In this study, HBsAg, HCVAb and HIVAb were positive in 19 (3.7%), 359 (69.5%) and 70 (15.5%) of subjects, respectively. These tests were positive in 17 (4.5%), 311 (80.5%) and 63 (17%) among prisoners and 2 (1.5%), 48 (36.5%) and 7 (7.8%) in non-prisoners, respectively. Multiple logistic regression analysis revealed that independent factors related to co-infection of HCV and HIV infection were imprisonment (p<0.001. OR: 7.5) and using common syringe (p=0.03, OR: 4.5).Conclusions: Our findings strongly suggest that drug injection inside prison carries is a risk for HIV infection and that HIV infection among IDUs is likely to be bridged to the broader population through sexual contact without using effective prevention programs.

Background: Occult hepatitis B infection (OBI) is a form of hepatitis in which there is an absence of detectable HBsAg, despite the presence of HBV-DNA in the peripheral blood of patients. It seems that non-effective or attenuated immune system responses against HBV lead to the development of OBI. Previous studies showed that the Fas/Fas ligand (FasL) system is an important death signaling pathway that is used by cytotoxic T lymphocytes to eradicate HBV from the liver.Objectives: To investigate polymorphisms in the -670 region of the Fas gene in those with OBI. Patients and Methods: The plasma samples from 3700 blood donors were tested for HBsAg and anti- HBs by ELISA. The HBsAg-/anti-HBc+ samples were selected and screened for HBV-DNA by PCR. Those with HBV-DNA were diagnosed as OBI and PCR-RFLP technique was performed to examine polymorphisms within their Fas gene.Results: 352 (9.5%) of 3700 blood samples were HBsAg-/anti-HBc+. HBV-DNA was detected in 57 (16.1%) of 352 HBsAg-/anti-HBc+ samples. Therefore, 57 HBsAg-/anti-HBc+/HBV-DNA+ patients were diagnosed as OBI. Patient and control groups had no significant differences in terms of the studied polymorphisms. onclusions: The functional polymorphisms in the promoter region of Fas gene are not associated with OBI. Therefore, it may be concluded that polymorphisms at the-670 position of the Fas gene do not have any critical effects on the immune response against HBV in OBI.

Background: The reduction of hepatitis B virus replication to minimal levels is emerging as key therapeutic goal in chronic hepatitis B (CHB). Objectives: This study aimed to evaluate and compare the efficacies of adefovir (ADV) and entecavir (ETV) in CHB. Patients and Methods: In this prospective study, 100 naïve patients were assigned to treatment with ADV (33 HBeAg-positive and 19 HBeAg-negative patients) or ETV (32 HBeAg-positive and 16 HBeAgnegative patients). The primary efficacy outcome was ALT normalization, reduction in HBV DNA, and seroconversion of HBeAg. Second efficacy outcomes included resistance and safety. Comparisons of quantitative and qualitative variables between groups were analyzed by student t-test and chi-square test (or Fisher’s exact test), respectively.Results: Among HBeAg-positive patients, ETV was superior to ADV with respect to mean reduction in HBV DNA (-7.5 versus -6.3, respectively, at Month 24, p=0.003) and the percentage of those with HBV DNA<103 copies/mL at Month 24 [96.9% (31/32) vs. 69.7% (23/33), respectively, p=0.002] and <300 copies/mL at Month 24 [84.4% (27/32) vs. 54.5% (18/33), respectively, p=0.004]. But, the rates of ALT normalization and HBeAg seroconversion between the groups were similar [87.9% (29/33) vs. 96.9% (31/32), respectively, p=0.355; and 24.2% (8/33) vs. 25.0% (8/32), respectively, p=0.943]. In HBeAg-negative patients who received ETV or ADV, the reduction in HBV DNA (-6.8 versus -5.9, respectively, p=0.192), percentage of ALT normalization [100% (16/16) vs. 78.9% (15/19), respectively, p=0.109], HBV DNA<103 copies/mL [100% (16/16) vs. 89.5% (17/19), respectively, p=0.489], and HBV DNA <300 copies/mL [100% (16/16) vs. 84.2% (16/19), respectively, p=0.234] were similar. No ETV- or ADV-associated mutations were observed, and both agents were well tolerated.Conclusions: ETV and ADV are effective therapies for CHB. In HBeAg-positive patients, the efficacy of ETV is significantly superior to that of ADV, and in HBeAg-negative patients, the agents effect similar biochemical and virological responses.

Background: Hepatitis B is the major cause of chronic hepatitis and cirrhosis in Iran. Sanitation and immunization is one of the most effective measures for prevention of the disease which is now widely used in developing countries. However, the immune response to the vaccine varies by age.Objectives: To determine the effect of zinc sulfate on immune response to hepatitis-B vaccine in elderly. Patients and Methods: In a clinical trial on 140 subjects aged³40 years with a body mass index (BMI) <30 kg/m2, and without any co-morbid disease were recruited. Those who had negative hepatitis B core antibody (102 persons) were randomly allocated to two groups. The trial group received hepatitis B vaccine plus 200 mg zinc sulfate daily for 30 days and the control group received vaccine plus placebo.Results: 52 of 102 people were female (51%). The two studied groups were comparable in terms of age, gender, and smoking habits. The mean antibody production in the intervention and control groups was 116.93 and 157.37 mIU/mL, respectively (p=0.22). No statistical differences were observed between the two groups in terms of proportion of people who were protected after vaccination (26.0% and 36.5% in people with and without zinc, respectively).Conclusions: This study revealed that zinc sulfate has no effect in level of immunity among elderly.

Thalassemic patients are at high risk for developing hepatitis C virus (HCV) infection. Interferons (alpha, peg) are the treatment of choice for treating HCV infection. Pancytopenia though is an uncommon side effect of interferon therapy, may occur in thalassemics for the nature of the disease. Herein, we report an HCV-infected 23-year-old man with thalassemia intermedia referred to our clinic with pancytopenia following interferon therapy (alpha interferon, 3 injection / wk ; no Ribaverin). The drug was discontinued, but his condition got worse over time and he did not response to any supportive treatment such as Oxymethalone and GSCF and he died 17 months after his first presentation with the picture of pancytopenia and septicemia. Although pancytopenia is a rare side effect in non-thalassemic patients treated with interferon, in thalassemics, it is more frequent.

The recent paper from Leonardi and La Rosa (2010) aimed to establish the prevalence of celiac disease (CD) in patients with chronic hepatitis B (HBV) infection (1). Previous studies suggest that chronic hepatitis C (HCV) could trigger immunological gluten intolerance in susceptible patients (2). This hypothesis, however, is not yet supported by sufficient scientific evidence. Similarly, the possible induction of CD in patients treated with interferon (IFN) therapy is supported in literature only by case reports (3). Moreover, CD affects as much as 1% of the general population (4). and it is possible that the association described in some papers is the result of incidental findings in a population most studied for the underlying disease. Although the study by Leonardi and La Rosa (2010) was unable to disclose any association between CD and HBV infection, it represents an interesting starting point...

In their retrospective study, Leonardi and La Rosa (2010) did not find any instances of celiac disease (CD) among hepatitis Bvirus carrier patients (1). CD is an inflammatory, immune-mediated intestinal disorder triggered by ingested wheat gluten in genetically susceptible individuals (2). Leonardi and La Rosa (2010) found CD antibodies (immunoglobulin A and G antigliadin( in 11.6% of the cases, but no patient had immunoglobulin A antiendomysium or immunoglobulin A antitissue transglutaminase; consequently, a diagnosis of CD was ruled out...

We have read with interest the article on “Knowledge, Attitude and Practice of Iranian Medical Specialists regarding Hepatitis B and C” by Kabir and colleagues (1). Although the authors have previously published several papers on the same issue, this recent survey has revealed several important findings we wish to emphasize (2). In this study the overall knowledge of physicians regarding preventive measures of viral hepatitis is shown to be relatively low. Interestingly, physicians’ knowledge of viral hepatitis C was significantly lower than viral hepatitis B. Despite the growing epidemic of viral hepatitis C and the decreasing burden of viral hepatitis B, it seems that the medical community and health-care workers (HCWs), are not familiar with this changing epidemiology of viral hepatitis (3-5)...

I read enthusiastically the thoughtful comments by Lankarani about our recent paper (1) and I am in agreement with most of the issues discussed. However, I want to emphasize some points that require more explanation. It is important to note that physicians’ knowledge of viral hepatitis C was significantly lower than viral hepatitis B with respect to the seroconversion rate but not for the prevalence rate. Physicians had better knowledge of the seroconversion rate of HCV than HBV, but this difference was not significant (14.3 vs. 11.8, P=NS). Physicians had less knowledge of HCV than HBV prevalence in the general population, and this difference was significant (47.2 vs. 66.9, P<0.05)...

Celiac disease (CD) is an autoimmune disorder characterized by small intestinal mucosal injury and nutrient malabsorption that affects patients with a specific genetic predisposition (HLADR3-DQ2 and HLA DR4-DQ8) who are exposed to gluten, the major storage protein of wheat and similar grains (1, 2). Abnormal immune response to gliadin, genetic factors, and environmental factors play a role in the pathogenesis of CD. Infectious agents have been implicated in the pathogenesis of many autoimmune disorders. Transient infections or increased permeability of the mucosa may facilitate disease onset induced by the uptake of gluten peptides into a microenvironmental milieu in the small intestinal mucosa (3)...

Regarding the article of Leonardi and La Rosa: "Are hepatitis B virus and celiac disease linked?", published in the 2010 issue of Hepatitis Monthly (1), we believe that there is no relationship between the hepatitis B virus (HBV) and celiac disease (CD). None of the study’s patients tested positive for immunoglobulin A anti-endomysium or immunoglobulin A anti-tissue transglutaminase antibodies, nor did they exhibit symptoms of CD...

We read with interest the article by Leonardi and La Rosa (2010) that deals with the hypothesis that nonintestinal inflam-matory diseases, such as hepatitis B virus (HBV), may trigger immunologic gluten intolerance in susceptible people (1). A recent study indicated that a high frequency of rotavirus infections may increase the risk of celiac disease (CD) autoimmunity in genetically predisposed individuals (2). Although we recognize the relevance of this controversial field of study, we cannot accept that a sample size of 60 patients is sufficient to explain this epidemiological link.