823
transfusion,’ and happened at 5 weeks in our patient. We conclude that acute HCV infection mav
cause acute
urticaria.
Department of Dermatology, School of Medicine, University of California, Davis, Sacramento, California 95816, USA
MARTIN REICHEL THEODORA M. MAURO
1. Alter HJ, Purcell RH, Shih HW, et al. Detection of antibody to hepatitis C virus in prospectively followed transfusion recipients with acute and chronic non-A, non-B hepatitis. N Engl J Med 1989; 321: 1494-500.
Anti-HCV testing in autoimmune hepatitis and primary biliary cirrhosis SiR.—The Chiron/Ortho ELISA to detect antibody to a nonstructural peptide of hepatitis C virus (HCV), when applied to autoimmune chronic hepatitis, has been reported positive in 40-60% of sera.!-3 In LKMl autoimmune hepatitis (type 2) more than 80% of cases were positive.4 If validated such rates would suggest that HCV is responsible for a proportion of cases of autoimmune hepatitis, a development of both diagnostic and therapeutic relevance. A different assay, the recombinant immunoblotting assay (RIBA), detects antibodies to two recombinant HCV peptides (the antigen used in the ELISA and a subsequence) and incorporates superoxide dismutase (SOD) as a control antigen. Although strictly speaking the RIBA is not a confirmatory test of the ELISA (the same antigenic preparation being used) it does allow control of the specificity of an ELISA positive reaction. We have applied the HCV RIBA to LKMl positive sera from patients with autoimmune hepatitis type 2 to verify the specificity of HCV ELI SA. As controls we tested patients with primary biliary cirrhosis (PBC), an immune-mediated chronic liver disease for which the reported seroprevalence of anti-HCV is 0% to 27% by ELISA.5,6 Sera from 48 patients with LKMl chronic hepatitis were studied.’ Sera were tested both by ELISA and RIBA at dilutions of 1 in 10 and 1 in 50, respectively. ELISA-positive sera were titrated end point. Both qualitative and semiquantitative (from negative 3+ or more) RIBA evaluations were recorded. Sera from 55 patients with PBC were tested by ELISA and positive sera were then checked by RIBA, as were ELISA negative sera. 8 LKMl positive sera (4 ELISA positive/RIBA negative and 4 ELISA-RIBA negative) and 9 PBC sera (5 ELISA positive/RIBA negative and 3 ELISA-RIBA negative) were retested by RIBA at a serum dilution of 1 in 10. 41 (85%) of the 48 LKM1 sera from patients with chronic hepatitis were positive for anti-HCV by ELISA, and 32 of these were positive by RIBA. ELISA titres were over 2000 in 11 of the positive sera. The prevalence of RIBA anti-HCV in LKMchronic hepatitis was thus 67% (32/48). None of the 7 ELISA anti-HCV negative sera was positive by RIBA. Most sera with low ELISA titres turned out to be RIBA negative: of the 9 ELISA positive sera with a titre of 10 or 50 only 1 was positive by RIBA while only 1 of the 32 ELISA positive sera with a titre of 100 or more was negative by RIBA. 3 of the 4 ELISA positive/RIBA negative sera turned out to be positive by RIBA, when retested at 1 in 10 dilution. ELISA titres of the 3 sera were 10, 50, and 100, while the titre of the negative one was 10. The 4 ELISA negative sera were negative by RIBA at 1 in 10. 19 (35%) PBC cases were positive for anti-HCV by ELISA, with a median titre of 10 (range 10-50), significantly lower than that of LKMI positive sera (p < 0001, Wilcoxon rank-sum test). ELISA anti-HCV specificity was confirmed by RIBA in 3 of the 19 cases (16%), so RIBA anti-HCV prevalence in PBC was 5% (3/55). None of the 16 sera with ELI SA titres lower than 100 was positive by RIBA and none of 36 ELISA negative sera was positive by
to
to
RIBA. None of the 5 ELISA positive PBC sera (titres 10, 10, 10, 50, and 50) that were RIBA negative at 1 in 50 and none of the 4 ELISA
negative sera were reactive when retested by RIBA at 1 in 10. Positive reactions with SOD protein were not detected in the 103 at either
dilution. Our previous finding of a high prevalence of ELI SA anti-HCV in LKM1 autoimmune hepatitis is confirmed here by RIBA. The
ELISA titre seemed predictive of the RIBA result: in the results for LKMl hepatitis and for PBC sera only 1 sample of the 25 that were ELISA positive with a titre lower than 100 was RIBA positive and only 1 of 35 ELISA positive sera with titres equal to 100 or more was negative by RIBA. Retesting by RIBA at the dilution used in the ELISA (1 in 10) suggested a difference between LKMl hepatitis and PBC sera: a clear-cut RIBA positivity at 1 in 10 dilution was found in 3 of the 4 LKM1sera but in none of the 5 PBC sera with similar ELISA-RIBA reactivities. This indicates that false-positive results can be obtained by the anti-HCV ELISA, at least for PBC sera.
Positive anti-HCV results in type 1 autoimmune hepatitis have been questioned on the basis that "sticky" globulins or IgG make these sera unsuitable for testing by ELISAbut we have not been able to confirm this observation in type 1 or type 2 autoimmune hepatitis (unpublished). It has also been claimed that ELISA anti-HCV positivity could be due to antibodies to SODbut we have never seen antibodies to SOD in tests with RIBA. We did not attempt to distinguish recent from remote HCV infection by the urea wash8 because no relevant clinical or biochemical changes had occurred in our patients. False-positive ELISA anti-HCV results have been reported in patients with monoclonal gammopathy9 but this abnormality is uncommon in chronic liver disease and was not proven in our patients. Department of Diagnostic Medicine, Institute of General Clinical Medicine and Therapeutics, University of Bologna, and Central Laboratory, Policlinico S. Orsola, via Massoronti 9, 40138 Bologna, Italy
M. FUSCONI M. LENZI G. BALLARDINI RITA MINIERO F. CASSANI DANIELA ZAULI F. B. BIANCHI
JI, Esteban R, Viladomiu L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989; ii: 294-96. 2. Cassani F, Ballardini G, Fusconi M, Lenzi M, Zauli D, Bianchi FB. Autoimmune chronic hepatitis and anti HCV: an intriguing overlap. Ital J Gastroenterol 1990; 22: 154. 3. McFarlane IG, Smith HM, Johnson PJ, Bray GP, Bergani D, Williams R. Hepatitis C virus antibodies in chronic active hepatitis: pathogenetic factor or false-positive result? Lancet 1990; 335: 754-57. 4. Lenzi M, Ballardini G, Fusconi M, et al. Type 2 autoimmune hepatitis and hepatitis C virus infection. Lancet 1990; 335: 258-59. 5. Chiaramonte M, Floreani A, Giacomini A, et al. Anti HCV in primary biliary cirrhosis. Gut 1990; 31: A626. 6. Ebling F, Naukkarien R, Liikola J. Recombinant immunoblotting assay for hepatitis C virus as predictor of infectivity. Lancet 1990; 335: 982-83. 7. Ikeda J, Toda G, Hashimoto N, Kurokawa K. Antibody to superoxide dismutase, autoimmune hepatitis, and antibody tests for hepatitis C virus. Lancet 1990; 335: 1345-46. 8. Wreghitt TG, Gray JI, Aloyisius S, Contreras M, Barbara JAJ. Antibody avidity test for recent infection with hepatitis C virus. Lancet 1990; 335: 789. 9. Boudart D, Lucas JC, Muller JY, Le Carrer D, Planchon B, Harousseau JL. False positive hepatitis C virus antibody tests in paraproteinaemia. Lancet 1990; 336: 63. 1. Esteban
Periodic
gammaglobulin to prevent hepatitis
C in at-risk sexual partners SIR,-Hepatitis C virus (HCV) infection can be transmitted sexually,’-3 so how should one advise an HCV seronegative partner of an anti-HCV-positive man or woman? In the absence of a vaccine, the only way to avoid infection, in our view, is the periodic administration of human gammaglobulin to the uninfected partner. Intramuscular gammaglobulin prevents post-transfusion non-A, non-B hepatitis.4,5 The partners (mean age 20 years, range 17-24) of seven men and four women who were positive for HCV antibody (Ortho ELISA, confirmed by the Chiron recombinant immunoblot assay) took part in this study, after giving informed consent. The seropositive men and women all had raised aminotransferase levels, ranging from 2 to 5 times the upper limit of normal. Eight had histologically proven chronic active hepatitis. Seven subjects had received blood transfusions. All eleven couples reported that they had started an unprotected sexual relationship not more than 60 days before beginning this study. All the anti-HCV negative partners had normal liver-function tests. We gave 4 ml normal human gammaglobulin intramuscularly to the anti-HCV negative partners every 2 months and monitored
transfusion,’ and happened at 5 weeks in our patient. We conclude that acute HCV infection mav
cause acute
urticaria.
Department of Dermatology, School of Medicine, University of California, Davis, Sacramento, California 95816, USA
MARTIN REICHEL THEODORA M. MAURO
1. Alter HJ, Purcell RH, Shih HW, et al. Detection of antibody to hepatitis C virus in prospectively followed transfusion recipients with acute and chronic non-A, non-B hepatitis. N Engl J Med 1989; 321: 1494-500.
Anti-HCV testing in autoimmune hepatitis and primary biliary cirrhosis SiR.—The Chiron/Ortho ELISA to detect antibody to a nonstructural peptide of hepatitis C virus (HCV), when applied to autoimmune chronic hepatitis, has been reported positive in 40-60% of sera.!-3 In LKMl autoimmune hepatitis (type 2) more than 80% of cases were positive.4 If validated such rates would suggest that HCV is responsible for a proportion of cases of autoimmune hepatitis, a development of both diagnostic and therapeutic relevance. A different assay, the recombinant immunoblotting assay (RIBA), detects antibodies to two recombinant HCV peptides (the antigen used in the ELISA and a subsequence) and incorporates superoxide dismutase (SOD) as a control antigen. Although strictly speaking the RIBA is not a confirmatory test of the ELISA (the same antigenic preparation being used) it does allow control of the specificity of an ELISA positive reaction. We have applied the HCV RIBA to LKMl positive sera from patients with autoimmune hepatitis type 2 to verify the specificity of HCV ELI SA. As controls we tested patients with primary biliary cirrhosis (PBC), an immune-mediated chronic liver disease for which the reported seroprevalence of anti-HCV is 0% to 27% by ELISA.5,6 Sera from 48 patients with LKMl chronic hepatitis were studied.’ Sera were tested both by ELISA and RIBA at dilutions of 1 in 10 and 1 in 50, respectively. ELISA-positive sera were titrated end point. Both qualitative and semiquantitative (from negative 3+ or more) RIBA evaluations were recorded. Sera from 55 patients with PBC were tested by ELISA and positive sera were then checked by RIBA, as were ELISA negative sera. 8 LKMl positive sera (4 ELISA positive/RIBA negative and 4 ELISA-RIBA negative) and 9 PBC sera (5 ELISA positive/RIBA negative and 3 ELISA-RIBA negative) were retested by RIBA at a serum dilution of 1 in 10. 41 (85%) of the 48 LKM1 sera from patients with chronic hepatitis were positive for anti-HCV by ELISA, and 32 of these were positive by RIBA. ELISA titres were over 2000 in 11 of the positive sera. The prevalence of RIBA anti-HCV in LKMchronic hepatitis was thus 67% (32/48). None of the 7 ELISA anti-HCV negative sera was positive by RIBA. Most sera with low ELISA titres turned out to be RIBA negative: of the 9 ELISA positive sera with a titre of 10 or 50 only 1 was positive by RIBA while only 1 of the 32 ELISA positive sera with a titre of 100 or more was negative by RIBA. 3 of the 4 ELISA positive/RIBA negative sera turned out to be positive by RIBA, when retested at 1 in 10 dilution. ELISA titres of the 3 sera were 10, 50, and 100, while the titre of the negative one was 10. The 4 ELISA negative sera were negative by RIBA at 1 in 10. 19 (35%) PBC cases were positive for anti-HCV by ELISA, with a median titre of 10 (range 10-50), significantly lower than that of LKMI positive sera (p < 0001, Wilcoxon rank-sum test). ELISA anti-HCV specificity was confirmed by RIBA in 3 of the 19 cases (16%), so RIBA anti-HCV prevalence in PBC was 5% (3/55). None of the 16 sera with ELI SA titres lower than 100 was positive by RIBA and none of 36 ELISA negative sera was positive by
to
to
RIBA. None of the 5 ELISA positive PBC sera (titres 10, 10, 10, 50, and 50) that were RIBA negative at 1 in 50 and none of the 4 ELISA
negative sera were reactive when retested by RIBA at 1 in 10. Positive reactions with SOD protein were not detected in the 103 at either
dilution. Our previous finding of a high prevalence of ELI SA anti-HCV in LKM1 autoimmune hepatitis is confirmed here by RIBA. The
ELISA titre seemed predictive of the RIBA result: in the results for LKMl hepatitis and for PBC sera only 1 sample of the 25 that were ELISA positive with a titre lower than 100 was RIBA positive and only 1 of 35 ELISA positive sera with titres equal to 100 or more was negative by RIBA. Retesting by RIBA at the dilution used in the ELISA (1 in 10) suggested a difference between LKMl hepatitis and PBC sera: a clear-cut RIBA positivity at 1 in 10 dilution was found in 3 of the 4 LKM1sera but in none of the 5 PBC sera with similar ELISA-RIBA reactivities. This indicates that false-positive results can be obtained by the anti-HCV ELISA, at least for PBC sera.
Positive anti-HCV results in type 1 autoimmune hepatitis have been questioned on the basis that "sticky" globulins or IgG make these sera unsuitable for testing by ELISAbut we have not been able to confirm this observation in type 1 or type 2 autoimmune hepatitis (unpublished). It has also been claimed that ELISA anti-HCV positivity could be due to antibodies to SODbut we have never seen antibodies to SOD in tests with RIBA. We did not attempt to distinguish recent from remote HCV infection by the urea wash8 because no relevant clinical or biochemical changes had occurred in our patients. False-positive ELISA anti-HCV results have been reported in patients with monoclonal gammopathy9 but this abnormality is uncommon in chronic liver disease and was not proven in our patients. Department of Diagnostic Medicine, Institute of General Clinical Medicine and Therapeutics, University of Bologna, and Central Laboratory, Policlinico S. Orsola, via Massoronti 9, 40138 Bologna, Italy
M. FUSCONI M. LENZI G. BALLARDINI RITA MINIERO F. CASSANI DANIELA ZAULI F. B. BIANCHI
JI, Esteban R, Viladomiu L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989; ii: 294-96. 2. Cassani F, Ballardini G, Fusconi M, Lenzi M, Zauli D, Bianchi FB. Autoimmune chronic hepatitis and anti HCV: an intriguing overlap. Ital J Gastroenterol 1990; 22: 154. 3. McFarlane IG, Smith HM, Johnson PJ, Bray GP, Bergani D, Williams R. Hepatitis C virus antibodies in chronic active hepatitis: pathogenetic factor or false-positive result? Lancet 1990; 335: 754-57. 4. Lenzi M, Ballardini G, Fusconi M, et al. Type 2 autoimmune hepatitis and hepatitis C virus infection. Lancet 1990; 335: 258-59. 5. Chiaramonte M, Floreani A, Giacomini A, et al. Anti HCV in primary biliary cirrhosis. Gut 1990; 31: A626. 6. Ebling F, Naukkarien R, Liikola J. Recombinant immunoblotting assay for hepatitis C virus as predictor of infectivity. Lancet 1990; 335: 982-83. 7. Ikeda J, Toda G, Hashimoto N, Kurokawa K. Antibody to superoxide dismutase, autoimmune hepatitis, and antibody tests for hepatitis C virus. Lancet 1990; 335: 1345-46. 8. Wreghitt TG, Gray JI, Aloyisius S, Contreras M, Barbara JAJ. Antibody avidity test for recent infection with hepatitis C virus. Lancet 1990; 335: 789. 9. Boudart D, Lucas JC, Muller JY, Le Carrer D, Planchon B, Harousseau JL. False positive hepatitis C virus antibody tests in paraproteinaemia. Lancet 1990; 336: 63. 1. Esteban
Periodic
gammaglobulin to prevent hepatitis
C in at-risk sexual partners SIR,-Hepatitis C virus (HCV) infection can be transmitted sexually,’-3 so how should one advise an HCV seronegative partner of an anti-HCV-positive man or woman? In the absence of a vaccine, the only way to avoid infection, in our view, is the periodic administration of human gammaglobulin to the uninfected partner. Intramuscular gammaglobulin prevents post-transfusion non-A, non-B hepatitis.4,5 The partners (mean age 20 years, range 17-24) of seven men and four women who were positive for HCV antibody (Ortho ELISA, confirmed by the Chiron recombinant immunoblot assay) took part in this study, after giving informed consent. The seropositive men and women all had raised aminotransferase levels, ranging from 2 to 5 times the upper limit of normal. Eight had histologically proven chronic active hepatitis. Seven subjects had received blood transfusions. All eleven couples reported that they had started an unprotected sexual relationship not more than 60 days before beginning this study. All the anti-HCV negative partners had normal liver-function tests. We gave 4 ml normal human gammaglobulin intramuscularly to the anti-HCV negative partners every 2 months and monitored
