extrahepatic manifestations of hcv
TRANSCRIPT
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Management of Extrahepatic Manifestations of Chronic Hepatitis C
Mario U. Mondelli
Department of Infectious Diseases,University of Pavia, Fondazione IRCCS Policlinico San Matteo
Kasr Al-Aini International Post Graduate Course of Hepatology, Cairo University, 10-12 October 2009
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Chronic Hepatitis C VirusExtrahepatic Manifestations
• Non organ-specific antibodies• Mixed cryoglobulinaemia (Types II & III):
– Purpura (Leukocytoclastic vasculitis)– Glomerulonephritis– Peripheral neuropathy
• Non-Hodgkin’s lymphoma: low grade, MZ• Autoimmune thyroiditis (up to 36% anti-TPO prevalence,
CD81 on thyrocytes, ↑ IL-8)
• Porphyria cutanea tarda (Metanalysis showed OR 274.78)
• Diabetes mellitus (defects in insulin signalling)
• Lichen planus• Sicca (non-Sjögren’s syndrome) (SS-A, SS-B neg.; no xerophtalmia)
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Chronic Hepatitis C VirusAutoantibodies
HCV % Control %
Rheumatoid factor 70 8
Cryoglobulins >50 <1
ANA
• > 1:40
• > 1:180
21
13
10
2
Antismooth muscle (SMA)
• > 1:40
• > 1:180
21
7
2
<1
Anti–liver-kidney microsome (LKM) 5 <1
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Autoantibodies Are Frequent in Both Hepatitis B and C
SMA ANA
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Liver Kidney
LKM1 Is Seen Only in Hepatitis C Virus Infection
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DELLTEHRMTWDPAQ CYP2D6252-66
HCV310-24PGHITGHRMAWDMMM
Similarity with E1 region of HCV
Molecular Mimicry
Vergani D, 2006
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DELLTEHRMTWDPAQ CYP2D6252-66
HCV310-24PGHITGHRMAWDMMM
Similarity with E1 region of HCV
Molecular Mimicry
Vergani D, 2006
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CRYOGLOBULIN
• Immunoglobulin which undergoes reversible temperature-induced insolubilization
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Cacoub P, et al. Curr Opin Rheumatol. 2002;14:29-35.
CryoglobulinaemiasClassification
Immunoglobulin Classification
IMonoclonalNo rheumatoid factor
Primary
IIPolyclonal IgGMonoclonal IgMRheumatoid factor
Secondary mixedHCV infection
IIIPolyclonal IgGPolyclonal IgM
Secondary mixedInfectionsAutoimmune disordersLymphoproliferative diseases
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HCV and Mixed Cryoglobulinaemic Syndrome (MCS) Clinical Manifestations
• Minor:– Purpura– Fatigue– Arthralgias– Sensitive neuropathy
• Major:– Glomerulonephritis– Motor neuropathy– Hyperviscosity syndrome– Systemic vasculitis
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HCV and CryoglobulinaemiaPurpura, Vasculitis
• Occurs in dependent areas
• Deposition of cryoglobulins in small capillaries
• Pruritic
• Ulcerations may develop
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Criteria Major MinorSerological • Mixed cryoglobulinaemia
• Low C4• Rheumatoid factor• HCV or HBV infection
Pathological • Leukocytoclastic vasculitis • Mono-oligoclonal B-cell infiltrate in liver or BM
Clinical • Purpura • Membranous-proliferative glomerulonephritis• Peripheral neuropathy• Cutaneous ulcers
Ferri C, Zignego AL, Pileri SA. J Clin Pathol 2002; 55: 4 – 13.
Diagnostic Criteria of Mixed Cryoglobulinaemia
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How to Combine Diagnostic Criteria
• Confirmed MCS:– Serological MCS (± low C4) + purpura + leukocytoclastic vasculitis.– Serological MCS (± low C4) + 2 minor symptoms + 2 minor
serological/pathological findings.
• Incomplete or possible MCS: – Serological MCS or low C4 + 1 minor symptom + 1 minor
serological finding ± compatible pathological findings.– Purpura and/or leukocytoclastic vasculitis + 1 minor symptom +
1 minor serological finding ± compatible pathological findings– 2 minor symptoms + 2 serological findings ± compatible
pathological findings
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Immune Manifestations of HCVPathogenesis
Monoclonal IgM RF
Cryoglobulin traps HCV
HCV evades theimmune response
Chronic B-cell stimulation by
HCV antigen (E2 ?)
Polyclonal IgG
Y
Y
Y
YGenetic and
environmentalfactors
Y Y
Y
YY
Y
Y
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• Are specific viral protein sequence changes or recurrent amino acid motifs responsible for aberrant polyclonal B cell stimulation in chronic HCV infection ?
• Is polyclonal B cell activation a general feature of chronic HCV infection and what are the mechanisms responsible for initiation and maintenance of this phenomenon ?
Questions
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HCV Sequence Changes Found in Cryoglobulinaemic patients
• Insertion at position 385 (HVR1) detected in 5 (24%) of 21 patients with cryoglobulinaemia and in none of controls (Gerotto et al., Blood 2001;98:2657-63).
• Two HVR1 positions (389 and 398) and 3 HVR2/CD81-binding site positions (474, 493, 497) associated with cryoglobulinaemia (Hofmann et al., Blood 2004;104:1228-9).
• No specific HVR1 motifs associated with cryoglobulinaemia (Rigolet et al., Leukemia 2005; 19:1070-1076)
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AA Insertions within HVR1 in Patients with and without Cryoglobulins
Patient ID Insertion Position No. of clones with changes
Cryo + (6.2%) 117 (1b) TR 387 1/20
171 (1b) ?? ?? ??
28 (2a/c) GLSL
GLTL
404
404
9/11
1/11
169 (2a/c) ASSSM
SSPTA
SSPMA
384
385
385
8/12
3/12
1/12
193 (2a/c) GAG
GTV
385
385
9/10
1/10
Controls (9.1%) 17 (1b) GPG
ELG
385
385
4/12
2/12
191 (2a/c) ARY
TRQ
ARQ
TRR
*
385
385
385
385
6/11
1/11
3/11
1/11
183 (2a/c) RTV
RKT
RTA
384
384
384
2/10
1/10
Bianchettin G et al., J Virol 2007;81:4564-71 .
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Weblogo of the Positions Highlighted by the PCA Analysis of 548 HVR1 Sequences.
The higher the letter, the higher the frequency of the amino acid in that position.
384 386 388 391 395 396 397 398 399 405
384 386 388 391 395 396 397 398 399 405
pos
neg
384 386 388 391 395 396 397 398 399 405
384 386 388 391 395 396 397 398 399 405
384 386 388 391 395 396 397 398 399 405384 386 388 391 395 396 397 398 399 405
384 386 388 391 395 396 397 398 399 405384 386 388 391 395 396 397 398 399 405
Cryo +
Controls
Bianchettin G et al., J Virol 2007;81:4564-71 .
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% C
D69 B
cells
% C
D183 B
cells
% C
D86 B
cells
0
20
40
60
80
100
0
20
40
60
80
100
0
20
40
60
80
100
0
20
40
60
80
100
CD27-Total CD27+ CD27-Total CD27+
% C
D71 B
cells
Healthy controls (n=36) HCV+ patients (n=50)
p=0.0002 p=0.0007 p=0.0031 p=0.0002
p=0.0001 p<0.0001 p=0.032 p=0.0004 p=0.021 p=0.0019
Proportions of Activated Memory (CD27+) and Naïve (CD27-) B-Cells in Patients with Chronic HCV Infection and Healthy Controls
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MW. 50bp DNA Ladder, 10 water, 11 Neg. ctrl, 12 Pos. ctrl 1. B.A. 2. C.E. 6. B.A 3. F.R. 7. C.E 4. M.T. 8. M.T. 5. F.I. 9. F.I.
CD19+/CD69+ CD19+/CD69-
Genomic HCV RNA
1 2 3 4 5 6 7 128 9 10 11MW
100bp
Minus-strand HCV RNA
160bp
1 2 3 4 5 6 7 128 9 10 11MW
160bp
1/4
Full
Pugnale, Negro, Mondelli, unpublished
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One Signal is Sufficient to Activate
Human Memory B Cells
CD40
Innate immunity derived signalsTLR
Bystander T cell help / CytokinesProliferation
Differentiation
Bernasconi et al Science 2002
OR
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SF
C/1
05 P
BM
CS
FC
/105
PB
MC
Media CD40L CD40L+IL10
Healthy Controls (n=44)
HCV Patients (n=56)
p = 0.0227
Media CpG CpG+IL2
p = 0.0128
p = 0.0006
N. of IgG-Producing Cells in Patients with Chronic HCV Infection and Healthy Controls after Stimulation with CD40L ± IL10 or CpG ± IL2
0
450
900
0
750
1500
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CD81
CD19
CD21
E2E2B CellBCR (Ig)
Polyclonal B cell activation
LymphoproliferaLymphoproliferative Diseasetive Disease
B cell clonal expansion
Putative Mechanisms of B-Cell Activation
in HCV Infection
AutoimmunityAutoimmunity
Activation threshold
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CryoglobulinaemiaTherapeutic Strategies
Rationale Strategy
Eradicate aetiological agent
• PEG-IFN + Ribavirin
Reduce inflammation • Steroids
Remove CIC • Cyclophosphamide• Plasmapheresis
Promote CIC clearance by RES
• Lac diet
Eliminate B lymphocytes • Rituximab
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Rituximab
• Murine IgG1 humanised mAb • Binds CD20 on mature B cells• Acts by:
– Complement-mediated cytotoxicity– ADCC– Opsonization and clearance by RES– Pro-apoptotic ?
• Approved for treatment of NHL
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Rituximab: Clinical Studies beyond NHL
• RA (only FDA approved condition)• SLE• ITP• Autoimmune haemolytic anaemia• Pemphigus• Waldenstrom’s macroglobulinaemia• Wegener’s granulomatosis• MCS
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Clinical Response to Rituximab 375 mg/m2
for 4 Weeks in HCV+ Patients with MCSA Systematic Review of 13 Studies
Clinical Features
N. of Cases Complete Response N. (%)
Purpura 33 24 (73)
Arthralgia 30 16 (53)
Neuropathy 25 9 (36)
Glomerulonephritis 13 9 (70)
Cryocrit 15 11(73)
Cacoub, P et al. Ann Rheum Dis 2008;67:283-7
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Phase 2 Single-Arm Study on Low-Dose Rituximab for Symptomatic, Refractory Mixed Cryoglobulinaemia
(AIFA Protocol FARM6KMZFY)
• 250 mg/m2 x 2
• 1-year follow-up
• Objectives:– Reduce treatment costs– Reduce side effects ( HCV RNA, infections)
(Fiorilli, Mondelli, Zignego, Pozzato, Co-PI’s)
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Reactivation of HBV with Rituximab Administration
• Anti-HBs titers dropped precipitously after rituximab administration in vaccinated patients – Median titers 80 IU/mL before administration dropped to 38 IU/mL after
administration (P < .05)
• 3 of 20 patients with inactive HBV had detectable HBV DNA at Days 92, 146, 320 after 2-3 doses of rituximab
Metzler F, et al. AASLD 2008. Abstract 848.
25020015010050
10080604020
0 100 200 300
400
300
200
100
0
108
106
104
102
-200 0 200 400
30
20
10
00 500 1000
108
106
104
102
Patient 1 Patient 2 Patient 3
Ant
i-HB
s (I
U/m
L)S
erum
ALT
(U
/L)
HB
V D
NA
(IU
/mL)
1st r
ituxi
mab
dos
e
Days Days Days
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Patients
Rituximab 250 mg/m2 2 one week apart (n = 36)
Wk 12interim analysis Wk 52
Phase 2 Single-Arm Study on Low-Dose Rituximab for Symptomatic, Refractory Mixed Cryoglobulinaemia
(AIFA Protocol FARM6KMZFY)
Follow-upRituximab 250 mg/mRituximab 250 mg/m22 2 2 one week apart one week apart (n = 16)(n = 16)
50% reduction in BVAS & cryocrit
Size of initial group 16 patientsSize of second group 36 patientsCriterion for stopping on a negative finding at 1st stage 5 or less respondersCriterion for positive finding at 2nd stage: 27 or more respondersSignificance level 0.03Expected number of patients under null hypothesis 46Power 0.85 (expected response rate 60 ± 15%)Expected number of patients under alternative hypothesis 50
(Fiorilli, Mondelli, Zignego, Pozzato, Co-PI’s)
5 or less responders5 or less respondersSTOPSTOP
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BASELINE RITUXIMAB (after 2 infusions)
0.16
0.03 0.13 3.14
4 WEEKS 8 WEEKS 12 WEEKS
6.81
16 WEEKS
CD19 FITC
5.29
CD19 FITC CD19 FITC
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% B
Lym
ph
ocy
tes
(CD
19+
)
Rituximab
Rituximab
Rituximab
Rituximab
#1 #2
#3 #4
Time (weeks)
B Lymphocyte Count after RITUXIMAB Treatment
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Rituximab
• Excellent results on vasculitic ulcers and severe renal involvement.
• No effect on peripheral neuropathy
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Clinical, Immunological, and Virological Efficacy of Rituximab ± PEG-IFN2b and Ribavirin
Complete Response Rituximab/PEG–IFN/RBV
(n=20)
Rituximab only
(n=12)
Clinical 80% 58%
Immunological 67% 46%
Virological 55% 0%
Terrier et al. Arthritis Rheum 2009;60:2531-40.
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CryoglobulinaemiaTherapeutic Strategies
Clinical Symptoms Treatment
Asymptomatic Monitor
Mild-moderate Low-dose steroids ± Lac diet
Moderate-Severe PEG-IFN + RBV, Low-dose steroids
Severe, rapidly progressive Plasmapheresis + steroids + Cyclophosphamide;
Rituximab + PEG-IFN + RBV
Chronic hepatitis +
mild cryoglobulinaemia
Peg-IFN + RBV ± Rituximab
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Acknowledgements
Lab Team:• Gabriella Bianchettin • Antonella Cerino• Stefania Varchetta• Barbara Oliviero• Enrica Paudice
Clinical Team:• Serena Ludovisi• Giuseppe Michelone • Marco Zaramella
Area di Ricerca Infettivologica Fondazione IRCCS Policlinico San Matteo and
University of Pavia
Collaborators:• Franco Negro, Dept.of Gastroenterology, University of Geneva• Anna Tramontano, Dept. of Biochemistry, University of Rome La Sapienza• Milvia Casato, Dept. of Medicine, University of Rome La Sapienza• Giampaolo Merlini, Centre for Amyloidosis, University of Pavia
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Chronic Hepatitis C Virus Autoantibodies (cont’d)
• No relationship between presence of autoantibodies and
– Severity of chronic HCV
– HCV genotype
• Correlation between rheumatoid factor titre and
– Cryoglobulinaemia
– But not symptomatic cryoglobulinaemia
• Circulating autoantibodies from autoimmune disorders may result in
– False positive anti-HCV
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HCV Prevalence and Crude and Adjusted O.R. in Patients with B-NHL vs. Controls
Total # HCV+ % HCV+ Crude O.R. (95% C.I.)
Adjusted O.R. (95% C.I.)
Controls 396 22 5.6 1 1
Patients with B-NHL
400 70 17.5 3.6 (2.2-6.0) 3.1 (1.8-5.2)
Mele A, et al. Blood. 2003;102:996-999
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ANTI-THYROID ANTIBODIES IN PATIENTS WITH VIRAL CHRONIC HEPATITIS
(Preziati et al, 1995)
CH-HCV (n=78)
positiveTiter (KU/l)
CH-HBV (n=49)
positiveTiter (KU/l)
36%(17 – 1190)
0
16%(57 – 836)
10%(64 – 282)
TPO-Ab Tg-Ab
Anti-Thyroid AutoAb
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Extrahepatic Effects of HCVPorphyria Cutanea Tarda
2 case series3 uncontrolled series280 patientsAlcohol: 36%-77%
Fargion (1992)
De Castro (1993)
Criber (1995)
Stolzel (1995)
Kondo (1997)
0
20406080100
PCT
0 5 10 15 20
Control
Combined meta-analysis of 7 studies: OR 274.78, CI 104.12-725.13
(Gisbert et al., J Hepatol 2003;39:620-7.)
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CharacteristicHCV
Sialadenitis
Primary
Sjögren’s Syndrome
SS-A, SS-B Negative Positive
Lymphocytic capillaritis
Mild
Pericapillary
Mostly CD8 cells
Severe
Periductal
Mostly CD4 cells
Sicca syndrome:• Xerophthalmia• Xerostomia
Absent
8%-36%
Present
Present
Extrahepatic Effects of HCVLymphocytic Sialadenitis
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Nagao Y, et al. J Gastroenterol Hepatol. 2004;19:1101-1113.
Extrahepatic Effects of HCVLichen Planus
• Occurs in < 1% of the general population• 10%-30% of patients with chronic HCV• Appearance
– Flat topped, violaceous, pruritic papules– Throughout body – Oral mucosa
• Histology– Dense infiltration of dermis with T lymphocytes
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Meta-Analysis of Case-Control Studies Comparing the Prevalence of HCV Infection in Patients with PCT and in Healthy Controls.
Gisbert et al., J Hepatol 2003;39:620-7.
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Extrahepatic Effects of HCVB-Cell Lymphoma
8 case series1754 pts evaluated
Ferri (1994)
Mazzaro (1996)
Silvestri (1996)
Izumi (1996)
McColl (1996)
Zignego (1997)
DeRosa (1997)
Zuckerman (1997)
0102030
B Cell Lymphoma
0 10 20 30
Controls
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Three Signals Are Required to Activate Human Naïve B Cells
CD40
p-MHC
(1) Ag
(3) Innate immunity derived signals
tlr(2) Cognate T cell help
(1’) Costimulation
Ag
ProliferationSurvival
Ruprecht & Lanzavecchia, Eur J Immunol 2006;36:810-6
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DELLTEHRMTWDPAQPPRDL
CYP2D6252-71: Major epitope of LKM1
271252
Molecular Mimicry
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Protein Database Search
EHRMTWDPAQPPRDL
DRLSPRPPAQPPRRR IE 175 HSV-1
CYP2D6257-271
E1 HCVGHRMAWDMMMNWSPT
QLPPPAAPAQPPPGV EBNA-2 Epstein-Barr
PMIAAAPPAQPPSQP IE63 H. Cytomegalovirus
AARTAPAPAQPPSPA J1L H. Cytomegalovirus
Multiple Hits Hypothesis
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Chronic HCV infection is associated with extrahepatic manifestations including autoantibody production and abnormal B-cell proliferation
Background
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Functional Studies on Memory B-Cells in Chronic HCV Infection
PBMC500-3,000/w
Anti-CD40+IL10
7 d 6 d
Ig producing-cells (ELISPOT)
CpG 2006 IL2
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CYP2D6 shares an amino acid
sequence with HCV
LKM-1 targets CYP2D6
LKM-1 may arise through a
mechanism of molecular mimicry
Molecular Mimicry
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Prevalence of HVR1 Insertions in Patients with and without
Cryoglobulinaemia
113 Patients
80 Cryo + 33 Controls
5 (6.25%) with insertions
3 (9.1%)with insertions
3/46 (6.5%) genotype 2a/c
2/34 (5.9%) genotype 1b
2/17 (11.8%)genotype 2a/c
1/16 (6.25%)genotype 1b
Bianchettin G et al., J Virol 2007;81:4564-71 .
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Human Mature B Cell Phenotype
B cell areas of lymph nodes and spleen
IgMhi,IgDhi
CD19,CD20,CD21hi
CD38lo, ABCB1(?)
IgM, IgG, IgA, IgDlo
CD19,CD20,CD27
CD38CD126CD138
Bone marrow andinflamed tissues
MemoryBlood Naïve Plasmacell
AbPlasmablast
CD19lo,CD20lo
IgG,CD69,CD86…
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0
10
20
30
0
25
50
75
100
Healthy controls (n=36) HCV+ patients (n=50) HBV+ patients (n=22)
% C
D1
9+
cells
Controls HCV HBV
% C
D2
7+
& C
D2
7-
B c
ells
CD27+ CD27-
Proportions of Total and Memory (CD27+) and Naïve B Cells in Healthy Controls and
Patients with Chronic HCV or HBV Infection
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Eradication of HCV Infection Associates with a Decreased Expression of Activation Markers and
CXCR3
Rosa et al., PNAS 2005;102:18544-9
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Stimulation with CpG Oligonucleotides Is Sufficient for Optimal Expansion of
Memory B Cells
CD19+/CD27+ CD19+/CD27-CD19+
Me
dia
Cp
G
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Reactivation of HBV With Rituximab Administration
• Retrospective analysis of patients who received 1 course of rituximab at single center: 2005-2007
• 180 of 258 patients (70%) treated with rituximab tested for HBV – Vaccinated: 46% – Negative: 39% – Anti-HBc/anti-HBs positive: 11% – HBV DNA positive: < 1%
Metzler F, et al. AASLD 2008. Abstract 848.
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INCIDENCE OF THYROID DYSFUNCTION IN HCV PATIENTSTREATED WITH IFN
248677
1043439598246
3251
21 (8.5%)18 (2.7%)69 (6.6%)17 (3.9%)60 (10%)
9 (3.6%)
194 (6.0%)
Marcellin ’95Okanoue ’96Koh ’97Kakizaki ‘’99Dumolin ’99Wong ’02
Total
Treated Thyroid dysfunctionAuthor
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RISK FACTORS FOR DEVELOPMENT OF THYROIDDYSFUNCTION DURING IFN THERAPY
11761774
38428
15353
823
SexFemalesMales
TPO-AbPositiveNegative
Treated Thyroid dysf.Risk factors
4.4 (3.2 – 5.9)
3.9 (1.9 – 8.1)
R.R. (C.I.)
Marazuela ’96; Fernandez-Soto ’98; Hsieh ’00; Vial ’95;Okanoue ’96; Koh ’97;Kakizaki ’99; Deutsch ’97; Roti ‘96
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Chronic Hepatitis C Virus Autoantibodies (cont’d)
• No relationship between presence of autoantibodies and
– Severity of chronic HCV
– HCV genotype
• Correlation between rheumatoid factor titre and
– Cryoglobulinaemia
– But not symptomatic cryoglobulinaemia
• Circulating autoantibodies from autoimmune disorders may result in
– False positive anti-HCV
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Zein CO, et al. Am J Gastroenterol. 2005;100:48-55.
Chronic HCV and Diabetes MellitusCase Prevalence
• N = 179 with chronic HCV• Prevalence of diabetes
mellitus and insulin resistance noted
• Compared with expected rate based on NHANES III study after adjusting for– Age– Sex– Race
• Prevalence of DM or insulin resistance higher in those with chronic HCV
0
4
8
12
16
20
Females Males
Nu
mb
er o
f C
ases
ObservedExpected
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Pathogenetic Mechanisms Responsible for Development of Type 2 Diabetes in HCV Infection
Early Defects in Upstream Insulin Signalling
Components (IRS-1, PI3-kinase, Akt)
Increased Insulin Resistance
Type 2 Diabetes Mellitus
Aytung et al., Hepatology 2003;38:1384-92
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Enlarged Pericapsular Lymph Node in a Patient with Chronic HCV Infection
>CD20+ B cells
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CD27-
% C
D69 B
cells
% C
D86 B
cells
% C
D71 B
cells
0
20
40
60
80
100
0
20
40
60
80
100
0
20
40
60
80
100
0
20
40
60
80
100
% C
D183 B
cells
Total TotalCD27+ CD27+ CD27-
Healthy controls (n=36) HCV+ patients (n=50) HBV+ patients (n=22)
p=0.0013
p=0.0002
p=0.0009
p=0.0007p=0.0031
p=0.0078
p=0.0002
p=0.0152p=0.001
p=0.0001 p=0.012p<0.0001 p<0.0001 p=0.032
p=0.0004 p=0.021 p=0.0019
Proportions of Activated Memory (CD27+) and Naïve (CD27-) B-Cells in Patients with Chronic HBV or HCV Infection and Healthy Controls
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TOT TOT CD27+ CD27+ CD27- CD27-0
20
40
60
80
100
CTRLS HCV+ PTS
%C
D18
3 B
cel
ls
p < 0.0001p < 0.0001
Proportions of CXCR3+ Memory (CD27+) and Naïve (CD27-)
B-Cells in Patients with Chronic HCV Infection and Healthy Controls
n=33 n=29
Cerino et al., in preparation
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Correlation between Serum HCV RNA and CD183 (CXCR3) Expression on B cells
0
25
50
75
100
0
25
50
75
100
% C
D183/C
D19+
cells
% C
D183/C
D19+
27+
cells
HCV RNA (IU/ml x 106)
0 1 2 3 4 5
15 16
0 1 2 3 4 5
15 16
Speaman r=0.408
p=0.012
Speaman r=0.59
p=0.0001
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N. of IPC-Producing Cells in Patients with Chronic HCV Infection and Healthy Controls Following Stimulation with CD40L ± IL10
HCV Patients (n=33)Healthy Controls (n=31)
0
450
900
CD40L+IL10
p=0.0128
p=0.0193
IgG
CD40L
0
450
900
SF
C/1
05 P
BC
IgA
Media
Media0
450
900
Media CD40L CD40L+IL10
IgM
CD40L CD40L+IL10
SF
C/1
05 P
BC
SF
C/1
05 P
BC
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N. of IPC-Producing Cells in Patients with Chronic HCV Infection and Healthy Controls Following Stimulation with CpG ± IL2
0
1000
2000
Healthy Controls (n=41) HCV Patients (n=49)
Media CpG CpG+IL2
IgA
0
1000
2000 IgG
Media CpG CpG+IL2
p=0.0202
0
1000
2000
Media CpG CpG+IL2
IgM
SF
C/1
05 P
BC
SF
C/1
05 P
BC
SF
C/1
05 P
BC
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TOT TOT CD27+ CD27+ CD27- CD27-0
20
40
60
80
100
CTRLS HCV+ PTS
%C
D69
B c
ells
p= 0.0004p= 0.0049
Proportions of Activated Memory (CD27+) and Naïve (CD27-) B-Cells in Patients with Chronic HCV Infection and
Healthy Controls
n=33 n=29
Cerino et al., in preparation
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…an autoimmune disease is a viral disease
in which the virus is unknown.
Rolf Zinkernagel - Immunol Rev. 1996;152:21-45