HBV HCV Research Articles

Management of hepatitis C in HIV and/or HBV co-infected patients

Co-infection with either HIV or HBV in chronic hepatitis C patients is common, since all these viruses share transmission routes and geographical distribution. Interaction between these viruses generally amplifies liver damage, increasing the risk of developing end-stage liver disease and hepatocellular carcinoma. HIV–HCV co-infection is associated with poorer response to antiviral therapy. New antivirals against HCV are eagerly awaited for this population. HBV–HCV dual infections are less common. The principles guiding indication of therapy in monoinfected patients should be followed considering which virus replicates in persons with serological markers of dual HBV–HCV infection. Although there is growing evidence supporting the use of direct acting antivirals (DAA) in dually infected patients with active HCV replication, prospective trials should be conducted to demonstrate their benefit, assessing carefully the rate and clinical consequences of HBV rebounds.

The cobas P 630 instrument: A dedicated pre-analytic solution to optimize COBAS® AmpliPrep/COBAS® TaqMan® system workflow and turn-around-time

The cobas p 630, a fully automated pre-analytical instrument for primary tube handling recently introduced to complete the Cobas(®) TaqMan systems portfolio, was evaluated in conjunction with: the COBAS(®) AmpliPrep/COBAS(®) TaqMan HBV Test, v2.0, COBAS(®) AmpliPrep/COBAS(®) TaqMan HCV Test, v1.0 and COBAS(®) AmpliPrep/COBAS(®) TaqMan HIV Test, v2.0. The instrument performance in transferring samples from primary to secondary tubes, its impact in improving COBAS(®) AmpliPrep/COBAS(®) TaqMan workflow and hands-on reduction and the risk of possible cross-contamination were assessed. Samples from 42 HBsAg positive, 42 HCV and 42 HIV antibody (Ab) positive patients as well as 21 healthy blood donors were processed with or without automated primary tubes. HIV, HCV and HBsAg positive samples showed a correlation index of 0.999, 0.987 and of 0.994, respectively. To assess for cross-contamination, high titer HBV DNA positive samples, HCV RNA and HIV RNA positive samples were distributed in the cobas p 630 in alternate tube positions, adjacent to negative control samples within the same rack. None of the healthy donor samples showed any reactivity. Based on these results, the cobas p 630 can improve workflow and sample tracing in laboratories performing molecular tests, and reduce turnaround time, errors, and risks.

Occult hepatitis B infection in different high risk patients

Dear Editor, We read with great interest the article “epidemiology of occult hepatitis B infection among thalassemia, hemophilia and hemodialysis patients” by Arababadi et al. [1]. because of our common field of interest in investigation of occult hepatitis B infection (OBI) in high risk patients such as HIV infected cases and hemodialysis patients. OBI is defined as the presence of HBV-DNA in the liver tissue or serum without detectable hepatitis B surface antigen (HBsAg) [2]. About 20 % of OBI cases are negative for all HBV markers except HBV-DNA, 50 % are positive for hepatitis B core antibody (anti-HBc) and 35 % are positive for hepatitis B surface antibody (anti-HBs) [3]. We investigated OBI in HIV positive patients [10][11]. OBI is an important issue in these patients because HIV/HBV co-infected individuals are at increased risk of chronic hepatitis, cirrhosis, and hepatocellular carcinoma [4]. In the published reports, the prevalence of occult HBV infection in HIV infected patients ranged between 0-10 % using standard PCR methods [5][6][7] and 35- 89 % using more sensitive assays [8][9] . In our study, out of 106 enrolled HIV infected patients, 20.75 % had isolated anti-HBc (HBsAg negative, anti-HBs negative and anti-HBc positive). HBV-DNA was detected in 13.6 % of patients with isolated anti-HBc. We divided these patients based on their HCV status. Out Of 63 anti-HCV positive cases, 28.6 % had isolated anti-HBc and 16.7 % of the latter group had OBI. But we did not find any OBI in HIV patients without HCV infection [10][11]. We also conducted the same study in hemodialysis patients [12]. The prevalence of occult HBV infection in dialysis patients was reported with a range between 0 to 58 % in published studies [13][14][15][16]. We found that 6.2 % of 289 enrolled patients had isolated anti-HBc and OBI was detected in 50 % of these patients. Only one of our patients with occult HBV was co-infected with HCV, so a conclusion cannot be reached regarding the association of occult HBV infection and HCV in this study [12]. Overall, the rate of OBI detection can be affected by sensitivity of the HBV-DNA assay, the sample size, power of the study and composition of the study populations. In conclusion we agree with Arababadi et al. [1]. Suggestions indicating that OBI is relatively common in high risk cases such as hemodialysis and HIV infected patients. Therefore, the risk of HBV transmission is probable in these groups and screening of high risk groups is recommended.

PMO-170 Prevalence of hepatitis E in New York among HIV negative chronic liver disease population “is it an innocent bystander”

IntroductionHepatitis E is essentially an oral fecal infection with high prevalence in developing countries. There is limited data available on its prevalence in Urban US. The study evaluates the prevalence...

Occult hepatitis B and occult hepatitis C viremia in patients with hematologic malignancies.

e17016 Background: Occult Hepatitis B (OHB)and Hepatitis C (OHC) in patients with hematological malignancies (HM) are understudied, mainly because biopsies to identify these viruses in the liver are often not performed due to an associated risk of complications (e.g., bleeding). We describe our retrospective experience of patients with HM tested for OHB and OHC. Methods: Between 09/09 and 11/10, 18 unselected consecutive patients with an abnormal liver panel were tested for both OHB and OHC which was defined as detectable viremia in the absence of HBsAg and anti-HCV, respectively. Severe liver dysfunction was defined as ALT >10 times the upper limit of normal (>560 IU/L) and/or a total bilirubin >6 mg/dL. Plasma samples were tested for HBV DNA and HCV RNA by using real-time PCR (Cobas Taqman HBV and HCV Tests-Roche Molecular Systems). Results: Most patients (12 or 67%) had leukemia, followed by lymphoma (5 patients or 28%). Two patients (11%) had OHB, and none had OHC.The 2 patients with OHB were born in areas with an intermediate to high prevalence of HBV; both had only low grade viremia (<29 IU/mL). At the time HBV DNA testing was performed, peak ALT levels in these 2 patients were 843 IU/L and 6,047 IU/L compared to a median peak ALT of 302 IU/L (range, 84-1,320 IU/L) among those without OHB (P=0.03). Severe liver dysfunction occurred in the 2 (100%) patients with OHB compared to 6 (38%) of the non-OHB cases (P=0.1). Durations of ALT elevation were 12 and 17 days in patients with OHB, compared to a median duration of 13 days (range, 5-73 days) in non-OHB patients. Co-infections were identified in 1 patient with OHB and in 10 (63%) without OHB. The 2 patients with OHB and 8 (50%) patients without OHB died within 6 months after HBV DNA testing. Conclusions: Although our data are limited, in a group of cancer patients in whom a liver biopsy is not available, detection of HBV DNA or HCV RNA in serum in the absence of HBsAg or anti-HCV identifies a subset of patients with occult viral hepatitis, a phenomenon of unclear clinical significance.

Sequential immunological analysis of HBV/HCV co-infected patients during Peg-IFN/RBV therapy

The immunopathogenesis of dual chronic infection with hepatitis B virus and hepatitis C virus (HBV/HCV) remains unclear. The in vivo suppressive effects of each virus on the other have been reported. In this study we aimed to analyze the virological and immunological parameters of HBV/HCV coinfected patients during pegylated interferon/ribavirin (Peg-IFN/RBV) therapy. One patient with high HBV-DNA and high HCV-RNA titers (HBV-high/HCV-high) and 5 patients with low HBV-DNA and high HCV-RNA titers (HBV-low/HCV-high) were enrolled. Twenty patients monoinfected with HBV and 10 patients monoinfected with HCV were enrolled as control subjects.. In vitro cultures of Huh 7 cells with HBV/HCV dual infection were used to analyze the direct interaction of HBV/HCV. Direct interaction of HBV clones and HCV could not be detected in the Huh-7 cells. In the HBV-high/HCV-high-patient, the HCV-RNA level gradually declined and HBV-DNA gradually increased during Peg-IFN/RBV therapy. Activated CD4- and CD8-positive T cells were increased at 1 month of Peg-IFN/RBV-therapy, but HBV-specific IFN-γ-secreting cells were not increased and HBV-specific interleukin (IL)-10 secreting cells were increased. The level of HBV- and HCV-specific IFN-γ-secreting cells in the HBV-high/HCV-high-patient was low in comparison to that in the HBV- or HCV-monoinfected patients. In the HBV-low/HCV-high-patient, HCV-RNA and HBV-DNA rapidly declined during Peg-IFN/RBV therapy. Activated CD4- and CD8-positive T cells were increased, and HBV- and HCV-specific IFN-γ-secreting cells were also increased during Peg-IFN/RBV-therapy. The immunological responses of the HBV-high/HCV-high patient were low in comparison to the responses in HBV and HCV monoinfected patients. Moreover, the response of immune cells in the HBV-high/HCV-high patient during Peg-IFN/RBV therapy was insufficient to suppress HBV and HCV.

Mo1910 Prevalence of Hepatitis E in New York Among HIV Negative Chronic Liver Disease Population “Is it an Innocent Bystander”

Introduction Hepatitis E is essentially an oral fecal infection with high prevalence in developing countries. There is limited data available on its prevalence in Urban US. The study evaluates the prevalence of hepatitis E antibody IgG and IgM in New York in patients with chronic liver disease. Methods 440 (n=440) were divided into two groups: group A; control 140 patients without any stigmata of liver disease. Group B, 300 patients with history of liver disease including hepatitis B 125/300 (41%), Chronic hepatitis C 60/300 (20%), fatty liver 70/300 (23%), Alcoholic liver disease 29/300 (10%), HBV HCV co infection 9/300 (3%), auto immune hepatitis 2/300 (0.6%), PBC /PSC 5/300 (2%). HEV antibody IGM and IGG were measured with HEV genotyping. 22/300 (7%) patients were liver transplant recipients, 6/300 (2%) patients were kidney transplant recipients. 43/300 (14%) patients were Intra venous Drug Abuser. 20/300 (7%) received Blood products. Results History and genotypic characteristics Conclusion Results : Group (A) HEV IgG positive 13% (18/140), Group B HEV IgG positive 40.6% (122/300) including 3.7% (4/122) having both IgM and IgG positive. The prevalence of HEV IgG was 54% (12/22) in the liver transplant recipient group and 33% (2/6%) kidney transplant recipient group. The study demonstrates the prevalence of hepatitis E infection in New York and HEV antibody in CLD. Including transplant donors and recipients. Question remains the impact and progression of acute or chronic liver disease with concomitant HEV in pre, peri, and post liver transplant recipient. Larger study needs to validate. Competing interests None declared.

HIV and other co-infections among drug users attending the Integrated Counselling & Testing Centre (ICTC) at Agra, India

BackgroundThe present study was carried over a period of 2 years, from January, 2009 to December, 2010. Material and methodsThree hundred and seventy (370) drug users attending an Integrated Counselling & Testing Centre (ICTC) at Agra were screened for HIV-1/2, HBV, HCV and syphilis infections.The socio-demographic features and addiction profile of the drug users were studied. ResultsSeroprevalence of HIV infection is 4.86% (18/370), HBV was found to be 0.81% (3/370), HCV is 5.67% (21/370) and VDRL is 25.94% (96/370) among the drug users. Of these, 2 (0.54%) each were co-infected with HIV–HBV, HBV–HCV and HCV–Syphilis whereas 15 (4.05%) were co-infected with HIV–HCV and 25 (6.75%) with HIV–VDRL infections. HIV-1/2 co-infection was found in only 2 (0.54%) of the drug users. The diagnosis of co-infections was confirmed based on laboratory testing and correlated clinically, at the time of testing. The drugs most commonly used were a combination of Lupigesic, Avil and Diazepam. ConclusionThe easy availability of drugs, curiosity and peer approval were the common reasons for initiation of drug abuse among those tested at this Centre. This is the first report of the HIV, HBV, HCV and VDRL screening among drug users in Agra in this region of the country.

Prospective Study on the Survival of HCC Patients Treated with Transcatheter Arterial Lipiodol Chemoembolization

Tanscatheter arterial embolization irrespective of with or without an anticancer agent and lipiodol has been controversial with regard to survival benefit. Therefore, we conducted a prospective study to analyze the effect of transcatheter arterial lipiodol chemoembolization (TACE) on the survival of HCC. A prospective study was conducted, and a total of 326 patients with primary liver cancer who were newly diagnosed were collected from January 2004 to January 2005 in Zhejiang Provincial People's Hospital of China. A univariate Cox's regression analysis was used to assess the survival of the HCC cases receiving TACE. The duration of follow-up for the HCC patients treated with TACE ranged from 3 months to 60 months. For the overall patients, survival rate at 5 years was 42%. Both HBV Ag and HCV Ab positive patients showed significantly low survival rate at 5 years. The multivariate analysis revealed The IV TNM stage was related to an heavy increased risk of death of HCC patients, and Child C grade group showed a significant moderate increased risk. Our study showed TACE is associated with a better prognosis of HCC patients, and the HBV infection, TNM stage, Child-Pugh grade and number of TACE may influence the survival probability. Further TACE studies should be assess the quality of life of HCC patients, so as to provide more information for treatment of HCC.

Historical study of acute hepatitis B in subjects with or without hepatitis C infection

BackgroundThe epidemiological pattern of hepatitis B virus infection in Italy has greatly changed over the past decades. The aim of the study was to evaluate during time the epidemiological features of acute hepatitis B cases referred to an Infectious Disease Unit in North-East of Italy between 1978 and 1995. Patients and methodsStored sera of 183 cases were tested for HBV markers, HBV genotypes, anti-Delta and anti-HCV. ResultsAnti-HBcIgM was positive in all cases. Mean age increased from 30.2years in 1978 to 37.5 in 1995 (P<0.01). Significant increase was observed in proportion of cases reporting intravenous drug use from 11.5% to 29.6% (P<0.03). Chronicity rate was as low as 1.1%. Mean days of hospitalization significantly decreased. HBV genotype determination showed that majority of cases was infected by genotype D, but its prevalence decreased from 88.2% in 1978 to 75.0% in 1995. Delta coinfection was present in 8.2%. The prevalence of HCV in patients with acute HBV was 35.0%; it fluctuated from 26.2% to 44.2%, mostly related (53.1%) to intravenous drug use. Dual infection did not lead to a more severe course of disease. ConclusionsFrom this retrospective study, remarkable fluctuations in the prevalence of dual HBV–HCV infection before the implementation of HBV vaccination were observed. Presence of anti-HCV did not affect the course of acute HBV.

Determination of Hepatitis Delta Virus Genotype among HBV Carriers in Southwest of Iran

Background and Aims: HDV is a defective satellite virus and classified in genus Deltavirus. Its disease is related and limited to HBV-infected patients. Acute infection of delta agent occurs in two different patterns; simultaneous infection with both HBV & HDV or super infection of chronically HBV infected patients that lead to more sever type of hepatitis. According to genetic diversity of genomic RNA of HDV, 8 clades have been classified. The aim of this study was to determine the delta virus genotype among the HBV & HDV infected patients in Ahvaz city. Materials and Methods: Sera sample collected from 31 seropositive HDV patients including 21 male and 9 female mean age 46±13.5 suffering from chronic hepatitis and 1 male patient with acute hepatitis. The encoding region for C terminal half of the Delta anti gene of the HDV’s genomic RNA reverse transcribed and then amplified by nested PCR. The HDV PCR positive samples were sequenced, and the sequences were compared with reference sequences on GenBank. All samples were tested for HBV DNA, HCV RNA and HCV anti body. Results: Only 15(48%) out of 31 anti HDV seropositive patients were positive for HDV RNA by nested RT-PCR. Alignment and phylogenic analysis of the present HDV sequences revealed that all sequences belong to clade 1. Only 1 HDV RNA positive patient was positive for HBV DNA by nested PCR. Conclusion: According to previous studies the clade 1 (genotype 1) is the predominant clade of HDV in our country. However some (2-HDV-R, 4-HDV-R &11-HDV-R) of our isolates show extensive differences from the two previously isolated HDVs from Iran. Most of the our isolates were closely related to the Iranian HDVs, but Egyptian HDV still remains the most relevant foreign isolate. Suppression of HBV replication by delta virus is common but mutual suppression of HDV and HCV remains unclear.

Sustained HCV Clearance by Interferon-Based Therapy Reduces Hepatocellular Carcinoma in Hepatitis B and C Dually-Infected Patients

Recent studies have indicated that interferon (IFN) or pegylated interferon (PEG-IFN) plus ribavirin therapy can achieve sustained virological response (SVR) against HCV equally in dual HBV-HCV infection and in HCV monoinfection. Whether these therapies can reduce hepatocellular carcinoma (HCC) development in dual HBV-HCV infection remains unclear. A total of 135 dually-infected patients with active hepatitis C receiving IFN or PEG-IFN plus ribavirin therapy were enrolled. The cumulative incidence of HCC was compared to that in 1,470 HCV-monoinfected patients. Based on the Cox proportional hazards model, dual infection was an independent factor for HCC development in all 1,605 chronic hepatitis C patients with or without positive hepatitis B surface antigen receiving IFN or PEG-IFN plus ribavirin (hazard ratio (HR)=1.864, 95% CI 1.052-3.303; P=0.033). In dually-infected patients, HCC developed in 4 of 96 with HCV SVR and 11 of 39 without HCV SVR (P < 0.001) after a median follow-up of 4.6 years. Age (HR=1.175, 95% CI 1.070-1.291; P=0.001) and non-HCV-SVR (HR=7.874, 95% CI 2.375-26.32; P=0.001) were independent factors for HCC development. Subgroup analysis showed that HCC occurrence was lower in patients with HCV SVR and HBV DNA levels < 2,000 IU/ml at the end of treatment or follow-up compared to those with HCV SVR and HBV DNA levels ≥ 2,000 IU/ml (P=0.034) and those without HCV SVR (P<0.001). Sustained HCV clearance by IFN or PEG-IFN plus ribavirin therapy may significantly reduce HCC in HBV-HCV dually-infected patients, whereas persistence or reactivation of HBV decreases the benefit of HCV SVR.

A cross-sectional survey of occult hepatitis B virus infection in HIV-infected patients in acquired immune deficiency syndrome area

To assess the prevalence of occult HBV infection in HIV-infected patients inacquired immune deficiency syndrome area. Serum samples were obtained from 97 HIV-infected patients who transmitted by paid blood donation. ELISA was used to detect HBV erologic markers (HBsAg, Anti-HBs, HBeAg, anti-HBe and anti-HBc) and HCV antibody. Flow Cytometry were used to detect CD4+ T cell count. Nested PCR was used to amplify surface protein region of HBV DNA. Ninety two patients were HBsAg negative in the 97 HIV-infected patients (94.85%). Twenty seven patients were co-infected with occult hepatitis B virus infection in the 92 HBsAg negative patients (29.35%). Seventy three patients were co-infected with HCV in the 92 HBsAg negative patients(79.35%). CD4 cell count of subjects with occult HBV infection were significantly lower (212.11 +/- 133.1 cells/mm3 versus 318.9 +/- 172.2 cells/mm3, respectively, P < 0.01). A significantly higher prevalence of isolated anti-HBc was observed in HIV-infected subjects co-infectioned with occult HBV infection [62.96% (13 of 27) versus 18.46% (15 of 65), P < 0.01]. No statistical significant association could be established between the age, sex and whether co-infected with HCV. It is found that occult HBV infection did occurs in HIV-infected patients. Individuals co-infected with HIV and occult HBV infection are more likely to have isolated anti-HBc than subjects with HIV alone. Co-infection with HIV and occult HBV is more likely to occue in subjects with lower CD4.

Polymorphisms of UGT1A7 and XRCC1 are associated with an increased risk of hepatocellular carcinoma in Northeast China

Hepatocellular carcinoma (HCC) is a complex disease which associates with both environmental and genetic factors. The purpose of this study was to investigate whether the genetic polymorphisms of UDP-glucuronosyltransferase (UGT1A7), an important phase II biotransformation enzyme, and X-ray repair cross-complementing group 1(XRCC1), a pivotal DNA-repair gene, were related to the risk of HCC in Northeast China. One hundred and thirty six HCC patients and one hundred and thirty six frequency-matched controls were included in this hospital-based case-control study. Genotypes of UGT1A7 and XRCC1 were determined using allele-specific polymerase chain reaction (AS-PCR) and PCR-restriction fragment length polymorphism (RFLP), and for which the odds ratio (OR) with 95% confidence interval (95% CI) were calculated. The proportion of UGT1A7 low enzymatic allele (*2 or *3) was higher in HCC patients than those in controls. The UGT1A7*1/*2 and *3/*3 genotypes were associated with higher HCC risk (OR=2.09, 95%CI: 1.10–3.97; OR=5.67, 95%CI: 1.76–18.30, respectively). The XRCC1 codon 399 Arg/Gln genotype could also elevate HCC risk (OR=2.16, 95% CI 1.29–3.61). In addition to polymorphisms of UGT1A7 and XRCC1, multivariate logistic regression analysis demonstrated that other significant independent factors associated with HCC were HBV infection (OR=68.07, 95%CI: 28.03–165.26), HCV infection (OR=30.97, 95%CI: 8.06–118.94) and family history of HCC (OR=10.62, 95%CI: 2.22–50.77). The study shows that the polymorphisms of UGT1A7 and XRCC1 are associated with HCC risk. Determination of the polymorphisms of UGT1A7 and XRCC1 may provide an important clue to preventive measure against HCC.

Late hepatitis B virus relapse in patients co-infected with hepatitis B virus and hepatitis C virus after antiviral treatment with pegylated interferon-a2b and ribavirin

HBV DNA and HCV RNA viremia levels may fluctuate over time in HBV-HCV-coinfected patients. Long-term follow-up data of more than 6 months after PEG-IFNa + ribavirin treatment of HBV/HCV co-infection are lacking. We here report that HBV may reactivate, even after a period of years, in HBV- and HCV-co-infected patients if HCV is cleared by antiviral therapy. In contrast, a sustained response concerning HCV is durable. We recommend long-term monitoring of HBV/HCV-co-infected patients after IFN a-based therapies.

A 1:1 matched case-control study on the interaction between HBV, HCV infection and DNA repair gene XPC Ala499Val, Lys939Gln for primary hepatocellular carcinoma

To evaluate the interaction between environmental factors, HBV/HCV infections and DNA repair gene XPC exon 8 Ala499Val, exon 15 Lys939Gln on related risks to primary hepatocellular carcinoma (PHC). A 1:1 matched case-control study was conducted in Shunde city, Guangdong province. The genotypes of Ala499Val and Lys939Gln were detected by polymerase chain reaction restrictive fragment length polymorphism (PCR-RFLP) analysis, and gene-environment interactions were analyzed by conditional logistic regression. Among people infected by HBV with non- or at least one mutant gene of Ala499Val carriers, the risk of PHC significantly increased, with ORs as 3.768 (95%CI: 1.137 - 12.485) and 3.667(95%CI: 1.122 - 11.981) respectively. With non- or at least one mutant gene of Lys939Gln, the risk was increasing with ORs as 6.778 (95%CI: 2.025 - 22.688) and 3.152 (95%CI: 1.062 - 9.351) respectively. In those with HCV infection, non- or at least one mutant gene of Ala499Val might increase the risk with ORs as 2.955 (95%CI: 0.587 - 14.869), 1.085(95%CI: 0.307 - 3.839) respectively. However, when compared to the ones with no mutant gene of Lys939Gln among the same research subjects, those carrying at least one gene may decrease the risk, with OR lowered from 4.197 (95%CI: 0.870 - 20.243) to 0.887 (95%CI: 0.228 - 3.448). But the interactions between HBV infection, HCV infection and XPC genes were not statistically significant. Among people infected by HCV, the mutant gene of Ala499Val had the tendency to lower the risk of PHC, and the mutant gene of Lys939Gln also appeared the same in the population with either HBV infection or HCV infection in Shunde, Guangdong. Another study with large samples should be performed to analyze the interactions among environments-genes.

PVI-24 QCMD external quality assessment results of Turkish participants for HBV DNA and HCV RNA panels

PVI-24 QCMD external quality assessment results of Turkish participants for HBV DNA and HCV RNA panels

Longitudinal evaluation of viral interactions in treated HIV-hepatitis B co-infected patients with additional hepatitis C and D virus

Virological interactions of hepatitis B (HBV), hepatitis C (HCV) and hepatitis D (HDV) viruses in HIV-infected patients have been poorly characterized especially under treatment influences. Undetection rates of hepatitis viruses were longitudinally analyzed in a 3-year cohort of 308 HIV-HBV co-infected patients and compared using Generalized Estimating Equation models adjusted for age, HIV-RNA, CD4 cell-count and antiviral treatment. Chronic hepatitis co-infection in HIV-infected patients (age years, SD) was: 265 HBV (40.7, 8.2); 19 HBV-HCV (39.7, 4.1); 12 HBV-HDV (35.2, 9.9); 12 HBV-HCV-HDV (39.2, 5.2). At inclusion, treatment with lamivudine/tenofovir was not significantly different between co-infection groups. HBV suppression was significantly associated with HDV (aOR = 3.85, 95%CI 1.13-13.10, P = 0.03) and HCV tri-infection (aOR = 2.65, 95%CI 1.03-6.81, P = 0.04), but marginally associated with HIV-HBV-HCV-HDV (aOR = 2.32, 95%CI 0.94-5.74, P = 0.07). In quad-infection, lower HDV-undetectability (vs HIV-HBV-HDV, P = 0.2) and higher HCV-undetectability (vs HIV-HBV-HCV, P = 0.1) were demonstrated. The degree of HBV suppression varied between visits and co-infection groups [range of aOR during follow-up (vs HIV-HBV co-infection): HIV-HBV-HCV = 2.23-5.67, HIV-HBV-HDV = 1.53-15.17]. In treated co-infected patients, HDV expressed continuous suppression over HCV- and HBV-replications. Peaks and rebounds from undetectable hepatitis B, C and/or D viremia warrant closer follow-up in this patient population. HDV-replication was uncontrolled even with antiviral treatment.

Dyspepsia Due to Metastatic Breast Cancer

Purpose: Introduction: Metastatic spread of breast cancer to the upper gastrointestinal tract has been infrequently reported in the literature (1). The common sites of spread include bones, lung and liver. We report a rare case of metastatic lobular breast cancer to stomach. Methods: Case: A 51 year-old African-american woman presented with complaints of dyspepsia and weight loss. She denied any melena, hematochezia or vomiting. Lab work revealed HB 7.6%; AST 129; ALT 125; Alk P 360; Direct/Total Bilirubin 1.3/2.5; Albumin/Protein 2.3/5.8; BUN/Creatinine 11/1.4; Amylase 102; Lipase 82; HAV and HBV immune and HCV negative. Contrast CT abdomen showed double duct sign with pancreatic head fullness, which were confirmed by MRCP. Bone scan revealed diffuse metastatic bone disease. Two years prior to this presentation, she underwent modified radical mastectomy with adjuvant chemotherapy and radiotherapy for Stage IIIa (ER/PR +ve HER 2 NEU −ve) invasive lobular carcinoma of the left breast. She subsequently was taking Tamoxifen and till recently remained symptom-free. Results: EUS during this presentation revealed 12 mm antral mass which was biopsied; pancreatic head fullness which unfortunately could not be sampled due to technical difficulties. Antral biopsy immunohistochemistry demonstrated staining for AE1/AE3; cytokeratin 7 +ve/ cytokeratin 20 −ve. This immunoprofile pattern confirmed a metastatic breast carcinoma. Conclusion: Discussion: Despite improvement in treatment of breast cancer, distant metastatic disease continues to occur. The incidence of breast cancer metastasis to the stomach, especially lobular cancer is higher then other variants including ductal cancers (2). A high index of suspicion for metastatic disease to the stomach of previous breast cancer should be maintained when new gastrointestinal symptoms develop. 1. Menuck LS, Amberg JR. Metastatic disease involving the stomach. Am J Dig Dis. 1975;20:903–13. 2. Taal BG, den Hartog Jager FC, Steinmetz R, Peterse H. The spectrum of gastrointestinal metastases of breast carcinoma, I: stomach. Gastrointest Endosc. 1992;38:130–135.Figure: H&E staining of metastatic breast carcinoma to stomach

Hepatitis B or hepatitis C coinfection in HIV‐infected pregnant women in Europe

The aim of the study was to investigate the prevalence of and risk factors for hepatitis C or B virus (HCV or HBV) coinfection among HIV-infected pregnant women, and to investigate their immunological and virological characteristics and antiretroviral therapy use. Information on HBV surface antigen (HBsAg) positivity and HCV antibody (anti-HCV) was collected retrospectively from the antenatal records of HIV-infected women enrolled in the European Collaborative Study and linked to prospectively collected data. Of 1050 women, 4.9% [95% confidence interval (CI) 3.6-6.3] were HBsAg positive and 12.3% (95% CI 10.4-14.4) had anti-HCV antibody. Women with an injecting drug use(r) (IDU) history had the highest HCV-seropositivity prevalence (28%; 95% CI 22.8-35.7). Risk factors for HCV seropositivity included IDU history [adjusted odds ratio (AOR) 2.92; 95% CI 1.86-4.58], age (for > or =35 years vs. <25 years, AOR 3.45; 95% CI 1.66-7.20) and HBsAg carriage (AOR 5.80; 95% CI 2.78-12.1). HBsAg positivity was associated with African origin (AOR 2.74; 95% CI 1.20-6.26) and HCV seropositivity (AOR 6.44; 95% CI 3.08-13.5). Highly active antiretroviral therapy (HAART) use was less likely in HIV/HCV-seropositive than in HIV-monoinfected women (AOR 0.34; 95% CI 0.20-0.58). HCV seropositivity was associated with a higher adjusted HIV RNA level (+0.28 log(10) HIV-1 RNA copies/mL vs. HIV-monoinfected women; P=0.03). HIV/HCV-seropositive women were twice as likely to have detectable HIV in the third trimester/delivery as HIV-monoinfected women (AOR 1.95; P=0.049). Although HCV serostatus impacted on HAART use, the association between HCV seropositivity and uncontrolled HIV viraemia in late pregnancy was independent of HAART.