Case Report: A rare pediatric case of hepatitis B virus infection with acute disseminated encephalomyelitis/Guillain–Barré syndrome spectrum diseases

Reactivation of HBV replication in HIV-HBV infected patients

New-Onset Right-Sided Weakness and Unsteady Gait in a 10-year-old Boy.

Management of encephalitis, which can be fatal, requires understanding of a broad range of causative agents, pathophysiologic mechanisms, clinical syndromes, and outcomes.After completing this article, readers should be able to:The broad definition of the term "encephalitis," that is, inflammation of the brain, necessitates acknowledgment of the enormous inclusivity of the topic. The most common interpretation of the term implies a direct invasion of the brain by an infectious pathogen, most commonly, viral, fungal, or parasitic. The topic also includes examples of meningitis mediated by bacteria or other agents, which can produce extrameningeal symptoms such as lethargy or seizures, in which case, the combined term "meningoencephalitis" is used.There are also many examples of encephalitis not due to direct central nervous system (CNS) infections. Inflammatory processes due to an acute or chronic illness can result in an acute immune-mediated encephalitis, such as acute disseminated encephalomyelitis (ADEM), lupus cerebritis, and paraneoplastic syndromes. Agents or conditions that produce slowly progressive CNS symptoms, such as tertiary syphilis or "slow viruses" (the prion protein encephalopathies), also are considered examples of encephalitis. Table 1 lists only a limited number of the many pathogens and pathologic conditions that can cause either acute or subacute encephalitis. In this discussion, we will mainly address examples of acute encephalitis related to direct CNS infection and para-infectious processes involving the CNS. These examples embrace the major portion of the spectrum of disease presentation, course, and recovery, as well as mechanisms of cerebral injury.In addition to the taxonomic classification in Table 1, causes of infectious encephalitis often are grouped according to the most common methods of transmission. "Arboviruses" are those spread by insect vectors, such as West Nile virus (WNV) and the equine encephalitis group (both by mosquitoes). Zoonotic causes of encephalitis not spread by intermediary insect vectors include many of the parasitic infections (larva migrans) and rabies. Community-acquired encephalitides, such as enterovirus, adenovirus, and late-childhood herpesvirus infections, generally are spread by person-to-person contact. Vertically transmitted pathogens include neonatal herpes simplex (HSV), rubella virus, and cytomegalovirus, and likely many other viral agents. Vertical, symptomatic transmission of WNV has been well documented. Finally, sexual transmission is the major mechanism of infection for adult herpes simplex type 2 virus and HIV (which can produce an acute, often transient, meningoencephalitis in the absence of opportunistic infection).Iconic examples of parainfectious encephalitis in children include ADEM and acute cerebellar ataxia. Variants of these conditions, such as acute hemorrhagic leukoencephalitis and Bickerstaff brainstem encephalitis, are reported primarily in adult and older adult populations. Parainfectious syndromes are differentiated in practice from acute infectious encephalitis based upon clinical history and a lack of supporting evidence for direct CNS invasion. In the case of ADEM, there is usually an antecedent illness or immunization, followed 2 to 30 days later by various focal neurologic symptoms, possibly accompanied by signs of meningeal irritation. The early presentation may be confused with acute infectious encephalitis, and some instances of each phenomenon may be categorized incorrectly. Lumbar puncture findings can be variable, ranging from normal to a mild or moderate lymphocytic pleocytosis with an elevated protein concentration. Acute cerebellar ataxia follows a similar course of antecedent illness, but with symptoms limited to the cerebellum (ataxia, nystagmus, and cerebellar dysarthria).Infectious, parainfectious, and primary inflammatory causes of encephalitis are typically considered mutually exclusive. However, the example of Mycoplasma-related encephalitis illustrates some difficulty in differentiating direct versus indirect mechanisms of CNS disease, and the magnitude of the topic. Although widely regarded as a parainfectious phenomenon with variable pathology, up to 2% of these patients have Mycoplasma polymerase chain reaction (PCR)-positive cerebrospinal fluid (CSF), which might indicate some direct CNS invasion. Mycoplasma is a prevalent pediatric illness and cause of encephalitis. One hundred and eleven of 1988 patients referred to the California Encephalitis Project (CEP) tested positive for Mycoplasma pneumoniae; 76% of those affected were pediatric patients. (1)(2)Epidemiological data on encephalitis is organized according to identified agent. The CEP was initiated in 1998 for the collection of epidemiological data and is the most comprehensive database to date. It includes all referred immunocompetent individuals over 6 months of age and all clinical presentations, including chronic and slowly progressive encephalitis. Criteria for inclusion include encephalopathy or ataxia, plus at least one clinical finding (fever, seizures, focal neurologic deficits, CSF pleocytosis, abnormal neuroimaging, or abnormal EEG). By using a combination of CSF PCR, nasopharyngeal/throat specimen viral isolation, and acute and convalescent paired sera, all patients receive testing for herpesviruses, arboviruses, enteroviruses, respiratory viruses, measles virus, Chlamydia species, and M pneumoniae. Between 1998 and 2005, 1,570 patients were enrolled. A confirmed or probable causative agent was identified in only 16% of cases. Of identifiable causes, 69% were viral, 20% bacterial, 8% noninfectious (ie, autoimmune disease), 7% prion protein, 3% parasitic, and 1% fungal. Extensive testing procedures still revealed no identifiable cause in 63% of patients. (3) Among the more prominent causes of viral encephalitis, HSV accounted for only 2.5% of the CEP cases; in contrast, HSV was identified in 5% of 322 pediatric patients with acute encephalitis seen in one series between 1994 and 2005. (4)Epidemics of infectious encephalitis have always attracted much media attention, such as the WNV outbreak first seen in the United States in New York City in 1999. Between 1999 and 2007, 1,478 pediatric cases of confirmed WNV infection occurred in the United States, of which 443 (30%) had neurologic involvement. Of those with neurologic symptoms, there were three fatalities. Overall, children accounted for only 4% of reported WNV infection cases, with an estimated median annual incidence of 0.07 per 100,000. The pediatric fatality rate contrasts favorably with the 12% mortality rate from the 1999 epidemic, in which the majority of symptomatic cases were elderly people. WNV is now an epidemiological risk factor throughout the contiguous United States and the Caribbean. (5) Although WNV remains the most commonly encountered arboviral encephalitis agent, California encephalitis viruses have the greatest proportion of pediatric symptomatic infections (88% of cases), and eastern equine encephalitis has the highest overall mortality rate of 42%.The importance of local epidemiological information and seasonality cannot be ignored. Many cases of viral encephalitis either occur in epidemics, display a clear seasonal predilection, or both. For example, enteroviruses are most often seen in spring and summer; arthropod-borne illnesses, in the summer and fall. Respiratory virus-mediated cases often are specific to fall and winter. These elements of conventional epidemiological wisdom, however, should be subordinate to locally observed trends, such as cases of H1N1 influenza encephalitis observed during an out-of-season epidemic.In contrast, ADEM tends to be more sporadically observed than many infectious causes, although population data in the United States have supported a winter-spring predilection for the condition. Recent data from Canada, however, failed to show this seasonality. (6) The inclusion criteria for ADEM strongly influences reported incidence, producing wide variations, with a range of 0.2 to 0.8 per 100,000 children in the United States and Canada, and 0.07 per 100,000 in Germany. Antecedent infectious illness or vaccination typically is identified in 50% to 75% of patients. Presenting symptoms are highly variable, as the range of reported incidences of any one neurologic symptom in pooled study data suggest. Outcomes statistics are similarly scattered, with a 57% to 89% reported rate of full recovery.Infectious agents and parainfectious processes are presumed to mediate their acute symptoms through any combination of postulated mechanisms listed in Table 2. Evidence is best for the causes of fatal cases, in which wholesale parenchymal destruction is usually identifiable at necropsy, including direct neuronal and glial invasion with apoptosis, neuronophagia, vascular occlusion leading to infarction, and secondary effects of cerebral edema.Evidence supporting largely immune-mediated mechanisms of injury (cytotoxic antibodies, cytokine effects, etc) is less direct, and more evident in parainfectious/inflammatory causes of encephalitis. In ADEM fatalities, perivenular lymphocytic infiltration with local myelinolysis is a hallmark finding on pathology specimens. (12) Evidence supporting the concept of antibody-mediated mechanisms derives mainly from the clinical efficacy of intravenous immune globulin (IVIG) and plasmapheresis in the treatment of ADEM. Demonstration of antibody targeting precise CNS molecules in human ADEM and other demyelinating disease cases is scarce, with poor concordance, even between individuals who have similar syndromes. Existing knowledge of autoantibodies targeting specific CNS molecules is derived mainly from experience with paraneoplastic syndromes in adults, eg, anti-Yo, anti-Hu, and anti-Purkinje cell antibodies. These mechanisms, however, produce subacute encephalitis or cerebellitis distinct from typical pediatric ADEM. Even in children with classic postinfectious cerebellitis, fewer than half display anti-Purkinje cell antibodies.The lack of routinely detectable autoantibody in parainfectious CNS disease is likely attributable to both the large number of causative infectious agents and the multiplicity of possible targeting mechanisms. The latter may include both molecular mimicry and abnormal handling of normally occurring cellular antigens. For example, an invading virus may manufacture proteins that share epitopes with normal human myelin (mimicry), or may produce enzymes that cleave or misfold normal host proteins into immunologically unrecognized forms. For example, vaccinia virus core protein kinase cleaves myelin basic protein.Even more difficult is the isolation of cytokine effects in producing CNS injury. Interleukins 6 and 8, interferon γ, and tumor necrosis factor α seem to be among those cytokines most commonly identified as correlating with severity of disease course or outcomes across multiple causes of encephalitis, both infectious and noninfectious (eg, lupus cerebritis), but with high variability between specific agents. High concentrations of interleukins 6 and 8 can be found in the CSF of patients with Mycoplasma encephalitis and Japanese encephalitis. Higher titers in a small number of Japanese encephalitis patients seemingly correlated with a lower survival rate. It is unclear if cytokines are causative of further CNS injury or are active markers of disease severity.The typical presentation of acute encephalitis consists of any combination of altered mental status, seizures, other behavioral changes, weakness, sensory disturbances, or nonepileptic movement disorders, in the absence of an identifiable external cause, such as intoxication, traumatic brain injury, or psychosocial stressors. In the younger child or infant, symptoms may be even less distinct, and can include uncharacteristic somnolence, disinterest in feeding, weak suck, irritability, loss of head control, or abnormal eye movements. Further clinical clues may include the presence of fever (either acutely or in the 1–4 week interval before the onset of symptoms), or meningeal irritation (Table 3). However, these supporting clues may not be apparent upon first presentation. Because the clinical symptoms of encephalitis include a very broad range in both scope and severity, suspicion should be high in the approach to any child presenting with uncharacteristic behavior that is persistent and disproportionate to environmental and situational factors.Upon identification of a suspected case of encephalitis, a relatively short but critical series of steps should be executed, as summarized in Table 4. Additional facts to consider in the initial evaluation of the patient include seasonal presentation, history of immunosuppression, travel history, recent local epidemiological information, and presence of focal neurologic symptoms or deficits. Table 5 lists additional specific testing that should be routinely considered based upon protocols developed for the CEP and specific clinical settings. Table 6 lists, according to clinical clues, other viral causes of encephalitis that would require agent-specific testing if suspected.In patients in whom a parainfectious process is suspected, acute testing for demyelinating inflammatory conditions is increasingly popular. This testing is motivated by the increasing recognition of pediatric multiple sclerosis (MS) and other demyelinating conditions, eg, neuromyelitis optica (Devic disease), which may be mistaken initially for ADEM. Signs that increase suspicion for MS-related conditions include the presence of exclusively white matter abnormalities on MRI (especially if monolesional), optic neuritis, isolated myelitis, a recurrent or polyphasic disease course, or postadolescent age. In these cases, standard lumbar puncture studies also include myelin basic protein assay and measurement of CSF immunoglobulins with oligoclonal banding, and concomitant serum protein electrophoresis. Although the presence of disproportionate oligoclonal antibody production within the CSF is more suggestive of idiopathic demyelination (eg, MS), this finding is not sufficiently specific to prove a diagnosis of MS because ADEM and other CNS inflammatory conditions, including CNS infection, can produce similar results. The neuromyelitis optica antibody often is present in cases having optic neuritis associated with spinal cord symptoms. Documented neuromyelitis optica antibody-positive patients also have presented with optic neuritis only.In following the standard evaluation of patients with symptoms of encephalitis, the diagnostic testing results most commonly encountered include either unremarkable or variable leukocytosis or lymphocytosis. Comprehensive metabolic panels often fail to demonstrate specific abnormalities. Some enteroviral infections can produce a sepsislike syndrome with more remarkable hematologic abnormalities. Neonatal HSV infections sometimes produce hepatic function abnormalities and disseminated intravascular coagulation. Inappropriate secretion of antidiuretic hormone can be seen in almost any encephalitic process, but is reported more commonly in St Louis encephalitis (primarily a disease of the elderly population) and WNV infections.Understanding clinical-anatomic correlations may be helpful in refining the differential diagnosis, because some causes of encephalitis display tropism for specific CNS tissues. Table 3 describes the cardinal symptoms of infection or inflammation in major anatomic subdivisions, as well as commonly used clinical terms. Although the anatomic localization is an important part of initial symptom recognition, neuroimaging plays an indispensable role, whether or not localizing clinical symptoms are present. In the very young child, clinically based neuroanatomic localization also can be notoriously difficult. Table 7 describes some classically cited agent-specific localization-related findings, identifiable by symptoms, neuroimaging, or both. However, a high degree of variability in clinical presentations mandates that the search for an etiologic agent cannot be confined strictly to those agents classically injurious to specific CNS locations.Neuroimaging, including MRI, early in the course of disease may sometimes yield false-negative results. For purposes other than identifying substantial cerebral edema, midline shift or hemorrhage, computed tomography imaging generally is not sufficient for the diagnostic workup of encephalitis.The lumbar puncture is the single most utilized test for the diagnosis of encephalitis. The primary results, however, generally lack specificity, and can be normal early in the course of the disease. In those patients displaying abnormal CSF results, the most characteristic findings are increased opening pressure, normal or elevated protein concentration, normal glucose level, and pleocytosis, which often begins with polymorphonuclear leukocytes and then converts to lymphocytic, or sometimes monocytic, predominance with progression of the disease. Although there are reported variations on this theme with certain etiologic agents, such as hemorrhagic pleocytosis with HSV, atypical lymphocytes with Epstein-Barr virus, or mononuclear leukocytes with echovirus or varicella-zoster infection, there are no pathognomonic CSF findings that help to differentiate infectious cases of encephalitis.The ability to obtain PCR amplification of viral DNA fortunately has added new usefulness to the lumbar puncture in encephalitis. This modality, however, requires clinical suspicion of a specific diagnostic entity, and is not available as a broad "battery" of testing. Additionally, viral DNA often is not recovered in certain stages of illness. For example, 5% to 10% of adult cases of HSV meningitis have negative PCR results upon the first lumber puncture. Furthermore, results often are not immediately available, and can take from 1 to 7 days or longer to be available. Hence, the decision to use specific antibiotic or antiviral treatments, such as acyclovir for suspected HSV meningitis, is still largely predicated upon clinical suspicion.Parainfectious encephalitis such as ADEM or acute cerebellar ataxia may manifest many of the same CSF findings as infectious encephalitis. However, pleocytosis tends to be less dramatic in most, but not all, parainfectious cases. When pathogen genomic material can be isolated from the CSF, the likelihood of a parainfectious or purely inflammatory etiology becomes remote.The most reliable standard for demonstrating causation of acute infectious encephalitis remains the pairing of acute and convalescent serum titers. A fourfold rise in titer, especially immune globulin M, against a suspected agent is most often considered diagnostic. This method is limited by the adequacy of follow-up and the accuracy of testing selection. Many patients are discharged and lost to close follow-up long before convalescent titers are obtainable. Of those tested, the causative agent may be missed by clinical suspicion-guided testing targeting other organisms erroneously.The priority in the treatment of acute encephalitis is the duality of clinical stabilization and containment of potentially damaging inflammatory processes. Because many patients present with any combination of seizures, delirium, autonomic instability, and respiratory irregularities, treatment of these acute symptoms often takes priority. This stabilization should not, however, delay addressing the suspicion of either an infectious or parainfectious condition and initiating appropriate treatment. Commonly, such patients are empirically treated with intravenous acyclovir while waiting for lumbar puncture, or while waiting for laboratory results, including HSV PCR. Either because of delays in obtaining these results, or because of the known false-negative rate of PCR testing of acute CSF specimens, many will complete the required 21-day course of acyclovir without a firmly established laboratory diagnosis.The emphasis on prompt treatment of possible HSV encephalitis should not overshadow a thorough search for clues to other causative agents. Table 5 lists some alternative considerations in the diagnosis of acute infectious encephalitis that might affect treatment options.Beyond the primary infectious considerations, ADEM ranks as the most likely cause of an acute encephalitis. The constellation of a temporally separate infectious illness or an immunization before the onset of symptoms, multiple encephalitic symptoms, and multifocal MRI abnormalities in both gray and white matter are highly suggestive (but not pathognomonic) for the diagnosis of ADEM. Treatment varies substantially from the approach to acute infectious encephalitis in that high-dose corticosteroids are a first-line treatment, followed by IVIG or plasmapheresis in cases refractory to corticosteroid treatment. The use of both IVIG and plasmapheresis remains unsupported by clinical trials; but IVIG has received wider acceptance as an alternative treatment at this time.The use of corticosteroids in the setting of nonherpetic infectious encephalitis remains controversial. Outside of single case reports, the only available supportive evidence for their use derives from the treatment of progressive multifocal leukoencephalopathy, a subacute/chronic encephalitis caused by polyomavirus JC that primarily in of cerebral as or over 2 of is a critical in infectious encephalitis. is a variable finding in encephalitis. by is an important of treatment. In a series of children with meningitis or of patients with 3 of with at symptomatic and fluid are the most is used on a limited as case and small series However, the of use is limited by the of with of the and the possible of active agents into the This may result in the of cerebral more fail and is isolated and small series to the use of for treatment of symptomatic often becomes a of in patients with encephalitis. In the of patients Of patients developed or This group of patients a mortality with an overall mortality rate for the agent known has been used in the treatment of patients with acute symptomatic agents most are available in intravenous and include agents and The typical approach begins with upon recognition of either recurrent or followed by of a more with to in some are still most commonly used but agents such as or are either high or fail to of or agent as the most likely treatment, including the use of or this of treatment, usually is motivated both by the of in the patient and the to a as a of the adequacy of other are added to the treatment either as intravenous or or other direct during the of the with and agents. The use of is to both more as well as a more the of the agent without However, metabolic can to obtain of any or all agents in often are used as a treatment of use of or has limited results as In the longer the of the the for full and outcomes of both infectious and inflammatory encephalitis range from full to The of clinical remains can be identified that strongly the for of the infectious agent or process, age of the of primary cerebral and spinal cord presence of cerebral edema, of cerebral and vascular injury, presence of other system disease and and to treatment The importance of the of infectious disease in should not be This is especially in neonatal encephalitis accompanied by sepsislike syndromes, infectious or which may produce mortality Even among older disease especially as in the epidemics, in which the survival rate was among those in the acute of illness. of is for of encephalitis In to this much upon the causative agent. a agents that produce more cerebral necrosis (especially if or brainstem injury is or vascular disease have available statistics in The specific etiologic agent some for example, of patients who have HSV encephalitis some identifiable neurologic in some among children affected by had no detectable the encephalitis. for more even in cases there are no deficits, remains a topic. For example, of children 3 to 7 meningitis or encephalitis, 20% symptoms, with only 3% of The incidence of similar neurologic in other causes of encephalitis remains largely at this

BACKGROUNDChronic hepatitis B virus (HBV) infection is often associated with increased lipid deposition in hepatocytes. However, when combined with non-alcoholic fatty liver disease or hyperlipidemia, it tends to have a lower HBV deoxyribonucleic acid (DNA) load. The relationship between lipid metabolism and HBV DNA replication and its underlying mechanisms are not well understood.AIMTo investigate the relationship between lipid metabolism and HBV DNA replication and its underlying mechanisms.METHODS1603 HBsAg-seropositive patients were included in the study. We first explored the relationship between patients' lipid levels, hepatic steatosis, and HBV DNA load. Also, we constructed an HBV infection combined with a hepatic steatosis cell model in vitro by fatty acid stimulation of HepG2.2.15 cells to validate the effect of lipid metabolism on HBV DNA replication in vitro. By knocking down and overexpressing Plin2, we observed whether Plin2 regulates autophagy and HBV replication. By inhibiting both Plin2 and cellular autophagy under high lipid stimulation, we examined whether the Plin2-autophagy pathway regulates HBV replication.RESULTSThe results revealed that serum triglyceride levels, high-density lipoprotein levels, and hepatic steatosis ratio were significantly lower in the HBV-DNA high load group. Logistic regression analysis indicated that hepatic steatosis and serum triglyceride levels were negatively correlated with HBV-DNA load. Stratified analysis by HBeAg showed significant negative correlations between HBV-DNA load and hepatic steatosis ratio in both HBeAg-positive and HBeAg-negative groups. An in vitro cell model was developed by stimulating HepG2.2.15 cells with palmitic acid and oleic acid to study the relationship between HBV-DNA load and lipid metabolism. The results of the in vitro experiments suggested that fatty acid treatment increased lipid droplet deposition and decreased the expression of cell supernatant HBsAg, HBeAg, and HBV DNA load. Western blot and polymerase chain reaction analysis showed that fatty acid stimulation significantly induced Plin2 protein expression and inhibited the expression of hepatocyte autophagy proteins. Inhibition of Plin2 protein expression under fatty acid stimulation reversed the reduction in HBsAg and HBeAg expression and HBV DNA load induced by fatty acid stimulation and the inhibition of cellular autophagy. Knocking down Plin2 and blocking autophagy with 3-methyladenine (3-MA) inhibited HBV DNA replication.CONCLUSIONIn conclusion, lipid metabolism is a significant factor affecting HBV load in patients with HBV infection. The in vitro experiments established that fatty acid stimulation inhibits HBV replication via the Plin2-autophagy pathway.

Detection of HBV DNA and antigens in HBsAg-positive patients with primary hepatocellular carcinoma

hepatitis B virus (HBV) reactivation (HBVr) after inhibition of hepatitis C virus (HCV) in HBsAg-negative/anti–HBc-positive patients is a rare event and, recently, it was described belatedly after therapy with direct-acting antiviral(s) (DAAs) in a liver transplant (LT) recipient.1 We describe 2 cases of LT recipients who developed HBVr after DAA, off-therapy, and after HCV ribonucleic acid (RNA) inhibition with Interferon (IFN), on-therapy. Neither case had risk factors for de novo hepatitis B virus (HBV) infection. CASE 1 A 57-year-old man underwent LT for HCV-related cirrhosis, genotype 1b, in 2011; before surgery, he was anti–HBc-positive and HBV deoxyribonucleic acid (DNA)-negative. The donor was negative for all the HBV markers. After LT, the patient was treated with tacrolimus without evidence of rejection. In 2015, a liver biopsy detected HCV-related cirrhosis evolution and a 24-week cycle of DAA (sofosbuvir/ledipasvir) and ribavirin (RBV) was started obtaining sustained virological response. During the half-yearly monitoring and before DAA treatment HBsAg and HBV DNA were negative. Sixteen months after the end of DAA treatment, in the absence of variations of the immunosuppressive regimen, he developed a hepatitis flare with HBVr (HBsAg positive and HBV DNA 6.9 × 106 IU/mL). Thus, immunosuppression was reduced and Entecavir introduced with a progressive normalization of liver function tests and undetectable HBV-DNA (Figure 1).FIGURE 1: HBV reactivation after DAA (case 1) or IFN (case 2)-based therapy of recurrent hepatitis C in 2 anti–HBc-positive LT recipients.CASE 2 A 58-year-old man underwent LT for HCV-related cirrhosis, genotype 1b in 2010. At that time, he was HBsAg-negative, HBV DNA-negative and anti–HBc-positive. The donor was negative for HBV markers. Three unsuccessful attempts of IFN-based therapy were performed before LT. After LT and during the anti-HCV treatment, the patient was treated with cyclosporine without evidence of rejection. Hepatitis C virus recurrence was diagnosed 3 months after LT, and 1 year later, he was newly treated with IFN and RBV. Hepatitis C virus RNA became negative after 3 months but therapy was stopped 2 months later because of HBVr (HBsAg positive and HBV DNA 2,746 IU/mL). Entecavir was introduced with subsequent HBsAg and HBV DNA negativization, whereas HCV RNA relapsed. In 2014, he was treated with DAA (sofosbuvir) and RBV for 24 weeks achieving sustained virological response (Figure 1). DISCUSSION In many coinfected patients, HCV prevails on HBV. Inhibition of HCV can change this balance inducing HBVr, defined as HBsAg reappearance in anti-HBc positive and/or an increase in HBV replication and hepatitis in HBsAg-positive patients.2 Considering the past experience with IFN, owing to the dual action of the drug on both HCV and HBV replication, HBVr has been observed in only small numbers of patients. In contrast to IFN, DAA do not have any anti-HBV properties, and the risk of reactivation seems higher, particularly in HBsAg-positive patients. Moreover, HBVr can occur during treatment (more often within 4 to 8 weeks) or after the end of therapy.3 To date in the LT setting, only 1 case of HBVr has been described after treatment with DAA in 1 anti–HBc-positive recipient who received an HBV-negative liver allograft. This virological condition is commonly considered at a very low risk of reactivation (<10%), and anti-HBV prophylaxis is not recommended. The mechanisms of HBVr in anti–HBc-positive patients remain debated with 2 possible explanations in LT recipients treated with DAA: (a) a very low inoculum associated with a prolonged incubation period after the DAA therapy, as recently proposed4; (b) immunosuppression due to the antirejection therapy and to the decrease of neutralizing antibodies (anti-HBs), as recently described.3 The clinical consequence could be on the one hand a lower risk of HBVr, minor clinical relevance (only HBsAg-reappearance) and early timing (on-therapy) with IFN, on the other hand, a higher risk of HBVr, greater clinical relevance (hepatitis flare) and late timing (off-therapy) with DAA. Therefore, considering the lack of similar reports of HBVr in large cohorts of anti–HBc-positive LT patients treated for HCV recurrence, clinicians should be aware of this rare phenomenon and evaluate patients with alanine aminotransferase flare for HBVr even in the long term after DAA treatment.

To investigate the relationship between hepatitis B virus (HBV) deoxyribonucleic acid (DNA) and HBV covalently closed circular DNA (cccDNA) in the ovary and HBV intrauterine infection. HBV DNA and HBV cccDNA were assayed in the ovaries of 33 pregnant women who were positive for HBV DNA, tested by Fluorescent quantitative polymerase chain reaction (FQ-PCR). The level of HBV mark (HBVM) and the content of HBV DNA in peripheral blood of infants were measured by chemoluminescence and FQ-PCR methods respectively. The overall positive rate for both HBV DNA and HBV cccDNA in ovarian samples was 51.52% (17/33). The rate on intrauterine infection among infants was 12.12% (4/33) and all the 4 infected infants were delivered from mothers with normal hepatic function. When HBV DNA and HBV cccDNA were both positive, the rate of intrauterine infection in infants was significantly higher than those who were with both negative results (P < 0.05). Levels of HBV cccDNA and the rate of positive samples were significantly higher in mothers with infants who appeared to have had intrauterine infection than those did not (P < 0.01 and < 0.05, respectively). HBV infection could be discovered in the human ovary and might be transmitted to the filial generation via ovum.

Background:Cytokines play an important role in occurrence and recovery of hepatitis B virus (HBV) infection. The aim of this study was to investigate the changes of cytokines concentration and its correlation to alanine aminotransferase (ALT), HBV deoxyribonucleic acid (HBV-DNA), hepatitis B envelope antigen (HBeAg), and HBV surface antigen (HBsAg) in the development of chronic hepatitis B (CHB).Methods:Thirteen healthy individuals (HI), 30 chronic HBV-infected patients in immune tolerant (IT) phase, and 55 CHB patients were enrolled between August 2015 and May 2017. The peripheral blood samples were collected from all individuals. The levels of interferon (IFN)-α2, interleukin (IL)-10, transforming growth factor (TGF)-β1, HBV-DNA, HBsAg, and HBeAg and liver function were measured. The quantitative determinations of cytokines levels, including IFN-α2, IL-10, and TGF-β1 were performed using Luminex multiplex technology. The correlation of cytokines to ALT, HBV-DNA, HBsAg, and HBeAg was analyzed by linear regression analysis.Results:IFN-α2 levels were similar between HI and IT groups (15.35 [5.70, 67.65] pg/ml vs. 15.24 [4.07, 30.73] pg/ml, Z = −0.610, P = 0.542), while it elevated significantly in CHB group (35.29 [15.94, 70.15] pg/ml vs. 15.24 [4.07, 30.73] pg/ml; Z = −2.522, P = 0.012). Compared with HI group (3.73 [2.98, 11.92] pg/ml), IL-10 concentrations in IT group (5.02 [2.98, 10.11] pg/ml), and CHB group (7.48 [3.10, 18.00] pg/ml) slightly increased (χ2= 2.015, P = 0.365), and there was no significant difference between IT and CHB group (Z = −1.419, P = 0.156). The TGF-β1 levels among HI (3.59 ± 0.20 pg/ml), IT (3.62 ± 0.55 pg/ml), and CHB groups (3.64 ± 0.30 pg/ml) were similar (χ2= 2.739, P = 0.254). In all chronic HBV-infected patients (including patients in IT and CHB groups), the elevation of IFN-α2 level was significantly associated with ALT level (β= 0.389, t = 2.423, P = 0.018), and was also negatively correlated to HBV-DNA load (β = −0.358, t = −2.308, P = 0.024), HBsAg (β = −0.359, t = −2.288, P = 0.025), and HBeAg contents (β = −0.355, t = −2.258, P = 0.027). However, when both ALT level and cytokines were included as independent variable, HBV-DNA load, HBsAg, and HBeAg contents were only correlated to ALT level (β = −0.459, t = −4.225, P = 0.000; β = −0.616, t = −6.334, P = 0.000; and β = −0.290, t = −2.433, P = 0.018; respectively).Conclusions:IFN-α2 elevation was associated with ALT level in patients with chronic HBV infection. However, in CHB patients, only ALT level was correlated to HBV-DNA, HBsAg and HBeAg contents.

Viral encephalitis.

Previous studies reported that hepatitis B virus (HBV) deoxyribonucleic acid (DNA) can be detected in livers of patients who received transplants for hepatitis B despite the absence of serological markers of HBV recurrence. Quantification of HBV DNA was not performed and presence of covalently closed circular (ccc) DNA was not analyzed in most studies. We aimed to quantify total and ccc HBV DNA in explant liver and post-orthotopic liver transplantation (OLT) biopsies and to correlate the values with HBV recurrence post-OLT. Frozen liver tissue from 34 patients (9 with explant liver only, 9 with explant liver and post-OLT liver biopsies, and 16 with post-OLT biopsies only) in the National Institutes of Health HBV-OLT study was examined using real-time polymerase chain reaction (PCR). Among the 18 patients with explant liver, 7 were hepatitis B e antigen (HBeAg)-positive, 8 had detectable serum HBV DNA, and 10 received antiviral therapy prior to OLT. Total and ccc HBV DNA was detected in explant livers of 17 and 16 patients, respectively. Of the 10 patients who received antiviral therapy pre-OLT, serum HBV DNA was undetectable in 8 at transplantation but 7 had detectable total and ccc HBV DNA in their explant liver. Of the 25 patients with post-OLT biopsies, total HBV DNA was detected in 83% and ccc DNA in 17% of 47 biopsies, although only 2 patients had HBV recurrence. In conclusion, total and ccc HBV DNA could be detected in explant livers of most patients despite antiviral therapy pre-OLT. Total but not ccc HBV DNA could be detected in post-OLT liver biopsies of most patients despite undetectable serum HBV DNA and hepatitis B surface antigen (HBsAg). Our findings suggest that occult HBV reinfection occurs in most HBV patients after OLT and continued administration of appropriate prophylactic therapy is important in preventing overt HBV recurrence.

Occult hepatitis B virus (HBV) infection is defined as the detection of HBV deoxyribonucleic acid (DNA) in the serum or liver tissue of individuals who test negative for hepatitis B surface antigen (HBsAg). We undertook a prospective study to evaluate the significance and course of occult HBV in patients with hepatitis C virus (HCV) cirrhosis undergoing orthotopic liver transplantation (OLT). A sensitive real-time polymerase chain reaction assay was utilized to test for serum HBV DNA at enrollment and for hepatic HBV DNA within the explant liver. Patients were followed with serum HBsAg and HBV DNA post-OLT. A total of 56 patients with HCV cirrhosis were enrolled between October 2002 and July 2004; of these, 44 underwent OLT. The overall prevalence of occult HBV based on positive serum HBV DNA was 16 of 56 (28%), and based on positive hepatic HBV DNA ("occult HBV liver") was 22 of 44 (50%). The presence of serum hepatitis B core antibody (anti-HBc) and a past history of injection drug use correlated with occult HBV.Explant-proven hepatocellular carcinoma (HCC) was found in 13 of 22 (59%) patients with occult HBV liver compared to 8 of 22 (36%) patients without occult HBV liver (P ¼ 0.36, odds ratio 2.5; confidence interval 0.76–8.54 [corrected]. Post-OLT, no cases of HBV reactivation were noted, and there was no significant association between occult HBV and recurrent HCV. In conclusion, occult HBV is far more prevalent in patients with end-stage HCV than would be expected from its prevalence in the general population. Occult HBV infection is strongly associated with the presence of anti-HBc, history of injection drug use, and explant-proven HCC.

Acute encephalomyelitis in children refers to an insult of cortical white matter leading to acute disseminated encephalomyelitis, insult of the spinal cord leading to multifocal myelopathy, or a combined form of encephalomyelitis. We report here the clinical presentations and outcome of 16 children with severe acute encephalomyelitis analyzing the effect of high-dose methylprednisolone or intravenous immunoglobulins, administered separately or in combination. Five children developed acute disseminated encephalomyelitis alone, eight developed severe multifocal myelopathy accompanied in two of them by radiculoneuropathy, and three developed the most severe form of combined encephalomyeloradiculoneuropathy. The indications for treatment with either high-dose methylprednisolone, intravenous immunoglobulin, or a combination of the two were severe acute disseminated encephalomyelitis, visual loss, or severe flaccid weakness accompanied by bladder and bowel incontinence. Overall, 10 children had remarkably responded to high-dose methylprednisolone alone and recovered within 10 days. One patient with severe myelopath, developing paraplegia, who failed oral corticosteroids completely recovered following intravenous immunoglobulin. Of the isolated acute disseminated encephalomyelitis group, all patients were initially treated with high-dose intravenous methylprednisolone and recovered within 10 days, including visual remission in the child with severe optic neuritis. All six children with solitary severe multifocal myelopathy were treated with high-dose methylprednisolone alone and recovered within the first week. Two patients had severe myeloradiculoneuropathy and were therefore treated with combined high-dose methylprednisolone and intravenous immunoglobulin: one remains paraplegic, whereas the second was ventilated for 3 weeks and recovered after 2 months. The three children with the most severe form of encephalomyeloradiculoneuropathy were treated with combined high-dose methylprednisolone and intravenous immununoglobulin; two remain severely handicapped, of whom one is paraplegic, and the third unexpectedly recovered within 3 months. Therefore, our experience indicates that either high-dose methylprednisolone or intravenous immunoglobulin, given separately or combined, may be efficacious in severe debilitating pediatric-onset acute encephalomyelitis. In children with the most severe form of encephalomyeloradiculoneuropathy, we suggest initially administering high-dose methylprednisolone and intravenous immunoglobulin combined, given the poorer outcome of our patients with combined severe central and peripheral demyelination.

Hepatitis B Virus Seropositivity in Chronic Myeloid Leukemia Patients Receiving Tyrosine Kinase Inhibitors: Preliminary Results of a Single-Center Cross-Sectional Study

Guillain–Barre syndrome (GBS) is an acute onset, usually monophasic immune-mediated disorder of the peripheral nervous system. The term GBS is often considered to be synonymous with acute inflammatory demyelinating polyradiculoneuropathy (AIDP), but with the increasing recognition of variants over the past few decades, the number of diseases that fall under the rubric GBS have grown to include axonal variants and more restricted variants, such as Miller Fisher syndrome (MFS) [Table 1].[1] Table 1 Guillain–Barre syndrome—clinical variants Epidemiology The reported incidence rates for GBS are 1–2 per 100,000 population.[2–4] The lifetime likelihood of any individual acquiring GBS is 1:1000.[5] The subtypes of GBS have different incidence rates in different parts of the world. In Europe and North America AIDP is dominant contributing to 90% of the cases. In contrast in China and Japan AMAN being the most common subtype.[6,7] The picture is intermediate when we look at other population. In Indian series the incidence of AIDP and AMAN are virtually equal although AMAN is more common in younger patients.[8] There seems to be a slight preponderance of AIDP in studies by Gupta et al[9] and by Meena et al (unpublished data from NIMS, Hyderabad). Available Indian literature indicates a peak incidence between June–July and Sept–October.[10] In western countries, GBS is common in the 5th decade,[11] but in India it occurs more commonly at a younger age.[10,12] GBS is equally common in men and women and can occur at any age. There is a male preponderance among the hospitalized population.[10,12]

Real-time monitoring of serum hepatitis B virus (HBV) levels is essential for the management of patients with chronic HBV infection in clinical practice, including monitoring the resistance of anti-HBV nucleotide analog or the detection of HBV reactivation. In this context, serum HBV deoxyribonucleic acid (DNA) quantification should be rapidly measured. A rapid HBV DNA quantification assay was established on the Fully Automated Genetic Analyzer, μTASWako g1. The assay performs automated sample preparation and DNA extraction, followed by the amplification and detection of quantitative polymerase chain reaction (PCR) combined with capillary electrophoresis (qPCR-CE) on integrated microfluidic chip. This study aimed to evaluate the analytical and clinical performance of HBV DNA assay on the μTASWako g1 platform in human serum and EDTA-plasma. The HBV DNA assay has a linear quantitative range from 20 to 108 IU/mL of HBV DNA with standard deviation (SD) of ≤0.14 log10 IU/mL. The limits of detection of the assay were 4.18 for the serum and 4.35 for EDTA-plasma. The HBV assay demonstrated the equivalent performance in both human serum and EDTA-plasma matrices. The HBV genotypes A to H were detected with an accuracy of ±0.34 log10 IU/mL. In quantification range, the HBV DNA assay was correlated with Roche cobas AmpliPrep/cobas TaqMan Ver2.0 (CAP/CTM v2) (r = 0.964). The mean difference (μTASWako g1-CAP/CTM v2) of the reported HBV DNA was -0.01 log10 IU/mL. Overall, the sensitivity, accuracy, and precision of the μTASWako g1 HBV assay were comparable to the existing commercial HBV DNA assay, and the assay can be completed within 110 min. This evaluation suggests that the HBV DNA assay on the μTASWako g1 is potentially applied for alternative method of the HBV viral load test, in particular with the advantage of the HBV DNA result availability within 2 h, improving the HBV infection management.