A. Pdr, K. Barna, G. Baflai, M. Baldzs, A. Patakfalvi, ~ . G6gl
Chronic Active Hepatitis in Patients with and without
Hepatitis B Surface Antigenemia Summary: This study was designed to compare the clinical and immunological characteristics of the hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative (cryptogenic) forms of chronic active hepatitis. The data of 48 patients with chronic active hepatitis, 24 with persistent HBs anfigenemia and 24 without HBsAg, were analysed. HB~Ag was detected by counterimmunoelectrophoresis and radioimmunoassay,Theclinical features, biochemical liver function tests, immunoglobulins, complement C3, autoantibodies, and cell-mediated immunoreactivity of the two forms of the disease were compared. Cirrhosis was found to occur more frequently at the time of diagnosis in the HBsAg-negative group, and the serum alkaline phosphatase level was raised significantly compared to the HBsAg-positive form. The elevation of the IgG level was greater in the cryptogenie form, but the difference was not statistically significant compared to the HB~Ag-positive patients. There was a marked difference in the frequency of the mitochondriat antibodies, but not of the antinuctear factor and other autoantibody-like serum factors. Lymphoblastic transformation revealed a similar diminution in response to phytohaemagglutinin stimulation in both groups of patients compared to the normal controls. An increase of the aH-thymidine incorporation was seen after stimulation with human liver mitochondriat antigen, and leukocyte migration inhibition could be observed with this antigen in both forms of chronic active hepatitis.
Zusammenfassung: Aktive chronisehe Hepatitis in Patienten m# und ohne Hepatitis-B-Oberfliichenantigeniimie - ein klinischer und immunologischer Vergleieh. Das Studium wurde durchgeftihrt, mn klinische und immunologische Charakteristika des HepatitisB-Oberfl~ichen-Antigens(HB~Ag)-positiveund -negative (kryptogene Form) Befunde der chronischen aktiven Hepatitis zu vergleichen. Die Angaben yon 48 Patienten mit chronischer aktiver Hepatitis, davon 24 mit persistierender HBs-Antigen/imie und 24 ohne HB-Befund, wurden analysiert. Die HBs-Antigen~imie wurde mit Hilfe yon Gegenstromelektrophorese und Radioimmunassay nachgewiesen. Das klinische Bild sowie die Laborbefunde (Leberfunktionsteste, ImmunugIobuline, KomplementC3, Autoantik6rper und zellul/ir ausgel6ste Immunantwort der beiden Krankheitsformen) wurden verglichen. Es wurde gefunden, dab eine Zirrhose h/iufiger in der HB s-negativen Gruppe auftrat und der alkalische Serumphosphatase-Spiegel signifikant anstieg. Die Werte des IgG-Spiegel lagen be/ den kryptogenen Formen h6her, ohne einen statistisch signifikanten Unterschied im Vergleich zu den HBs-positiven Patienten zu ergeben. Es bestand ein deutlicher Unterschied im Auftreten yon mitochondrialen Antik/Srper, Dies galt jedoch nicht fiJr Antinuklearfaktoren und andere Antik6rper ~thnlicher Serumfaktoren. Die Lymphoblastentransformation ergab in beiden Gruppen eine ~ihnliche Reaktionseinschdinkung gegentiber der Phytoh~imagglutininStimulierung in beiden Patientengruppen, verglichen mit normalen Kontrollen. Ein Anstieg der 3H-Thymidin-Inkorporation wurde nach einer Stimulierung mit humanem mitochondrialen Antigen der Leber beobachtet. Das gleiche galt auch ffir beiden Formen der chronischen aktiven Hepatitis mit demselben Antigen fiJr die Hemmung der Leukozytenmigration.
Introduction
active hepatitis for a period of six years. Using the data obtained we attempted to compare the clinical, biochemical and immunological features of the two main types of chronic active hepatitis, namely HB~Ag-positive and HB~Agnegative. We wished to determine the similarities and differences of these two types of disease. Similarities suggest that there is a similar pathomechanism in both forms, while differences might be due either to different etiology or to a different reaction of the host organism.
Chronic active hepatitis can be regarded as a polyetiological disease, in which progressive hepatoceUular injury is due to a peculiar reaction of the host organism. Etiologically at least three main forms of the disease can be distinguished: 1. cryptogenic autoimmune chronic hepatitis (1); 2. hepatitis B surface antigen-associated (HB~Ag-positive) chronic active hepatitis (2); and 3. drug-induced forms of chronic active hepatitis (3). There have been several reports concerning these different forms of chronic active hepatitis, but there is some contradiction in their characterization. Some authors have emphasized the immunserological differences between HBsAgPositive and HBsAg-negative chronic hepatitis, opposing thereby the viral etiology with an autoimmune pathogenesis (4, 5, 6). However, it has also been suggested that an etiopathogenetic relationship might exist between infection with the hepatitis B virus and an autoimmune reaction in the development of chronic hepatitis (7, 8, 9), even in patients without detectable HBs antigenemia (10). We followed up more than fifty patients with chronic
152
Infection 5 (1977) Nr. 3
Patients and Methods The data of 24 patients with HBsAg-positive chronic active hepatitis and of 24 patients without HBsantigenemia (HBsAgnegative chronic active hepatitis) were analysed. The diagnosis Dr. A. Pdr, Dr. M. Baldzs, Dr. A. Patakfalvi, Dr..4". G6gl, First Department of Medicine, University Medical School POcs, Ifjus~ig 31, H-7643 P6cs, Hungary; Dr. K. Barna, Department of Infectious Disease, County Hospital, Rfik6czi 2, H-7621 P6cs, Hungary; Dr. G. Bajmi, Regional Blood Transfusion Centre, Dischka 7, H-7621 P6cs, Hungary.
A. Pdr, K. Barna, G. Ba]tai, M. Baldzs, A. Patakfalvi, z{. GdgI: Chronic Hepatitis and HBsAg of chronic active hepatitis was made on clinical, biochemical and histological grounds. The clinical features of the patients are shown in Tables t and 2. Table 1 : Sex and age of the patients and duration of the disease in the two forms of chronic active hepatitis. Patients Patients with HBsAg without HBsAg (n = 24) (n = 24) Females Males
10 14
18 6
Mean age (years) at the time of diagnosis Range
44.5 16-70
45.6 12-65
Mean duration of the disease (years): from onset of symptoms till the diagnosis from the diagnosis till May 1974
Results 1.3
1.7
2.7
3.7
Table 2: Clinicalfeatures Patients Patients with HBsAg without t-IBsAg (n = 24) (n = 24) History of viral hepatitis-like disease
16
11
Type of onset: abrupt insidious
14 10
10 t4
Systemic symptoms or associated diseases: arthralgia pleuritis ache diabetes metlitus purpura Raynaud's phenomenon histamine refracter } achlorhydr. -k hypothyroidism -k ulcerative colitis membranoproliferative nephritis retinitis immunocytopenia Splenomegaly Cirrhosis of liver
serum complement C3 (BetalC globulin) quantitation was carried out using Hyland immunoplates. Autoantibodies (antinuclear, anti-smooth muscle and antimitochondrial antibodies) were detected by indirect immunofluorescence (13). Autoimmune complement fixation reactions were also carried out with aUogenous liver cell subcellular components, and nuclear, mitochondriaI, microsomal and supernatant fractions prepared by ultracentrifugation on sucrose (14). Antigammaglobutin-factor (rheuma-factor) was determined by the Rose Waaler test and latex agglutination. Cell-mediated immunoreactivity was evaluated by phytohaemagglutinin (PHA)-stimulated lymphoblastic transformation, measuring the 3H-thymidine incorporation (15). Cellular immune response against human liver mitochondrial antigen was investigated by lymphoblastic transformation as well as by the leukocyte migration inhibition test (16) using the same material as specific antigen.
15 6 2 3 3 -1
16 5 2 1 4 1 --
--
1
1 1 9
--
13
16
9
15
10
HBsAg was detected by counterimmunoetectrophoresis (11) and solid-phase radioimmunoassay (12) using Abbott Ausria II 125 kits. Biochemical liver function tests were performed using standard techniques. (Serum bilirubin was measured by an automated color±metric method, transaminases and alkaline phosphatase were determined by a kinetic method in opt±mated system.) Immunoglobulin serum levels were determined by the single radial immunodiffusion method of Mancini, using monovalent antisera provided by the "Human" Institute (Budapest), and
Table 1 shows the sex and age distribution o f patients, as well as the duration of disease in the two groups. A predominance o f females can be noted in the HB~Ag-negative group. As shown in Table 2 the HB~Ag-positive group tended to have an abrupt onset, and the HB~Ag-negative group an insidious onset. Systemic manifestations and associated diseases occurred with similar frequency in both groups, while the occurrence of cirrhosis-present at the time of diagnosis-seemed to be m o r e frequent in the H B ~Ag-negative cases. TaMe 3: Haematological, biochemical and immunochemical indexes in the two groups of patients with chronic active hepatitis. HBsAgpositive group (n = 24) (mean ± ESR(Westergreen) (mm/hr) 25 ± 4 Red blood cellcount (108/mm~) 4.1± 0.1 White blood cell count 6.0± 0.3 Platelet count (lO~/mm ~) 149 ± 16 Serum total bilirubin (rag/100 ml) GOT (IU) GPT (1U) ALP (iU) BSP retention (per cent after 45 min) Prothrombin activity (per cent of norm) Serum total protein (g/100 ml) albumin (g/100 ml) globulin (g/100 hal)
3.6 ± 91 56 65 t9
0.8
± 13 ± 9 ± 6 ± 4
79 ± 7.8 ± 3.7 ± 4.1 ±
3 0.3 0.1 0.2
lgG (mg/100 ml) 2.292± 157 IgA 356 ± 29 IgM 276 ± 37 BetalC globulin 110 ± 11 (Complement C 3) * =
HBsAgnegative group (n = 2 4 ) S.E.M.)
30 ± 3.9± 5.1 _+ 160 ±
5 0.I 0.4* 16
3.8±
0.8
150 ± 32 93 ± 25 1 2 6 + 21 ** 19 ± 3 76 ± 7.9± 3.7± 4.2±
4 0.3 0.1 0.2
2.926±230 * 374 _+ 37 234 + 29 124 ± 13
p
Chronic Active Hepatitis in Patients with and without
Hepatitis B Surface Antigenemia Summary: This study was designed to compare the clinical and immunological characteristics of the hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative (cryptogenic) forms of chronic active hepatitis. The data of 48 patients with chronic active hepatitis, 24 with persistent HBs anfigenemia and 24 without HBsAg, were analysed. HB~Ag was detected by counterimmunoelectrophoresis and radioimmunoassay,Theclinical features, biochemical liver function tests, immunoglobulins, complement C3, autoantibodies, and cell-mediated immunoreactivity of the two forms of the disease were compared. Cirrhosis was found to occur more frequently at the time of diagnosis in the HBsAg-negative group, and the serum alkaline phosphatase level was raised significantly compared to the HBsAg-positive form. The elevation of the IgG level was greater in the cryptogenie form, but the difference was not statistically significant compared to the HB~Ag-positive patients. There was a marked difference in the frequency of the mitochondriat antibodies, but not of the antinuctear factor and other autoantibody-like serum factors. Lymphoblastic transformation revealed a similar diminution in response to phytohaemagglutinin stimulation in both groups of patients compared to the normal controls. An increase of the aH-thymidine incorporation was seen after stimulation with human liver mitochondriat antigen, and leukocyte migration inhibition could be observed with this antigen in both forms of chronic active hepatitis.
Zusammenfassung: Aktive chronisehe Hepatitis in Patienten m# und ohne Hepatitis-B-Oberfliichenantigeniimie - ein klinischer und immunologischer Vergleieh. Das Studium wurde durchgeftihrt, mn klinische und immunologische Charakteristika des HepatitisB-Oberfl~ichen-Antigens(HB~Ag)-positiveund -negative (kryptogene Form) Befunde der chronischen aktiven Hepatitis zu vergleichen. Die Angaben yon 48 Patienten mit chronischer aktiver Hepatitis, davon 24 mit persistierender HBs-Antigen/imie und 24 ohne HB-Befund, wurden analysiert. Die HBs-Antigen~imie wurde mit Hilfe yon Gegenstromelektrophorese und Radioimmunassay nachgewiesen. Das klinische Bild sowie die Laborbefunde (Leberfunktionsteste, ImmunugIobuline, KomplementC3, Autoantik6rper und zellul/ir ausgel6ste Immunantwort der beiden Krankheitsformen) wurden verglichen. Es wurde gefunden, dab eine Zirrhose h/iufiger in der HB s-negativen Gruppe auftrat und der alkalische Serumphosphatase-Spiegel signifikant anstieg. Die Werte des IgG-Spiegel lagen be/ den kryptogenen Formen h6her, ohne einen statistisch signifikanten Unterschied im Vergleich zu den HBs-positiven Patienten zu ergeben. Es bestand ein deutlicher Unterschied im Auftreten yon mitochondrialen Antik/Srper, Dies galt jedoch nicht fiJr Antinuklearfaktoren und andere Antik6rper ~thnlicher Serumfaktoren. Die Lymphoblastentransformation ergab in beiden Gruppen eine ~ihnliche Reaktionseinschdinkung gegentiber der Phytoh~imagglutininStimulierung in beiden Patientengruppen, verglichen mit normalen Kontrollen. Ein Anstieg der 3H-Thymidin-Inkorporation wurde nach einer Stimulierung mit humanem mitochondrialen Antigen der Leber beobachtet. Das gleiche galt auch ffir beiden Formen der chronischen aktiven Hepatitis mit demselben Antigen fiJr die Hemmung der Leukozytenmigration.
Introduction
active hepatitis for a period of six years. Using the data obtained we attempted to compare the clinical, biochemical and immunological features of the two main types of chronic active hepatitis, namely HB~Ag-positive and HB~Agnegative. We wished to determine the similarities and differences of these two types of disease. Similarities suggest that there is a similar pathomechanism in both forms, while differences might be due either to different etiology or to a different reaction of the host organism.
Chronic active hepatitis can be regarded as a polyetiological disease, in which progressive hepatoceUular injury is due to a peculiar reaction of the host organism. Etiologically at least three main forms of the disease can be distinguished: 1. cryptogenic autoimmune chronic hepatitis (1); 2. hepatitis B surface antigen-associated (HB~Ag-positive) chronic active hepatitis (2); and 3. drug-induced forms of chronic active hepatitis (3). There have been several reports concerning these different forms of chronic active hepatitis, but there is some contradiction in their characterization. Some authors have emphasized the immunserological differences between HBsAgPositive and HBsAg-negative chronic hepatitis, opposing thereby the viral etiology with an autoimmune pathogenesis (4, 5, 6). However, it has also been suggested that an etiopathogenetic relationship might exist between infection with the hepatitis B virus and an autoimmune reaction in the development of chronic hepatitis (7, 8, 9), even in patients without detectable HBs antigenemia (10). We followed up more than fifty patients with chronic
152
Infection 5 (1977) Nr. 3
Patients and Methods The data of 24 patients with HBsAg-positive chronic active hepatitis and of 24 patients without HBsantigenemia (HBsAgnegative chronic active hepatitis) were analysed. The diagnosis Dr. A. Pdr, Dr. M. Baldzs, Dr. A. Patakfalvi, Dr..4". G6gl, First Department of Medicine, University Medical School POcs, Ifjus~ig 31, H-7643 P6cs, Hungary; Dr. K. Barna, Department of Infectious Disease, County Hospital, Rfik6czi 2, H-7621 P6cs, Hungary; Dr. G. Bajmi, Regional Blood Transfusion Centre, Dischka 7, H-7621 P6cs, Hungary.
A. Pdr, K. Barna, G. Ba]tai, M. Baldzs, A. Patakfalvi, z{. GdgI: Chronic Hepatitis and HBsAg of chronic active hepatitis was made on clinical, biochemical and histological grounds. The clinical features of the patients are shown in Tables t and 2. Table 1 : Sex and age of the patients and duration of the disease in the two forms of chronic active hepatitis. Patients Patients with HBsAg without HBsAg (n = 24) (n = 24) Females Males
10 14
18 6
Mean age (years) at the time of diagnosis Range
44.5 16-70
45.6 12-65
Mean duration of the disease (years): from onset of symptoms till the diagnosis from the diagnosis till May 1974
Results 1.3
1.7
2.7
3.7
Table 2: Clinicalfeatures Patients Patients with HBsAg without t-IBsAg (n = 24) (n = 24) History of viral hepatitis-like disease
16
11
Type of onset: abrupt insidious
14 10
10 t4
Systemic symptoms or associated diseases: arthralgia pleuritis ache diabetes metlitus purpura Raynaud's phenomenon histamine refracter } achlorhydr. -k hypothyroidism -k ulcerative colitis membranoproliferative nephritis retinitis immunocytopenia Splenomegaly Cirrhosis of liver
serum complement C3 (BetalC globulin) quantitation was carried out using Hyland immunoplates. Autoantibodies (antinuclear, anti-smooth muscle and antimitochondrial antibodies) were detected by indirect immunofluorescence (13). Autoimmune complement fixation reactions were also carried out with aUogenous liver cell subcellular components, and nuclear, mitochondriaI, microsomal and supernatant fractions prepared by ultracentrifugation on sucrose (14). Antigammaglobutin-factor (rheuma-factor) was determined by the Rose Waaler test and latex agglutination. Cell-mediated immunoreactivity was evaluated by phytohaemagglutinin (PHA)-stimulated lymphoblastic transformation, measuring the 3H-thymidine incorporation (15). Cellular immune response against human liver mitochondrial antigen was investigated by lymphoblastic transformation as well as by the leukocyte migration inhibition test (16) using the same material as specific antigen.
15 6 2 3 3 -1
16 5 2 1 4 1 --
--
1
1 1 9
--
13
16
9
15
10
HBsAg was detected by counterimmunoetectrophoresis (11) and solid-phase radioimmunoassay (12) using Abbott Ausria II 125 kits. Biochemical liver function tests were performed using standard techniques. (Serum bilirubin was measured by an automated color±metric method, transaminases and alkaline phosphatase were determined by a kinetic method in opt±mated system.) Immunoglobulin serum levels were determined by the single radial immunodiffusion method of Mancini, using monovalent antisera provided by the "Human" Institute (Budapest), and
Table 1 shows the sex and age distribution o f patients, as well as the duration of disease in the two groups. A predominance o f females can be noted in the HB~Ag-negative group. As shown in Table 2 the HB~Ag-positive group tended to have an abrupt onset, and the HB~Ag-negative group an insidious onset. Systemic manifestations and associated diseases occurred with similar frequency in both groups, while the occurrence of cirrhosis-present at the time of diagnosis-seemed to be m o r e frequent in the H B ~Ag-negative cases. TaMe 3: Haematological, biochemical and immunochemical indexes in the two groups of patients with chronic active hepatitis. HBsAgpositive group (n = 24) (mean ± ESR(Westergreen) (mm/hr) 25 ± 4 Red blood cellcount (108/mm~) 4.1± 0.1 White blood cell count 6.0± 0.3 Platelet count (lO~/mm ~) 149 ± 16 Serum total bilirubin (rag/100 ml) GOT (IU) GPT (1U) ALP (iU) BSP retention (per cent after 45 min) Prothrombin activity (per cent of norm) Serum total protein (g/100 ml) albumin (g/100 ml) globulin (g/100 hal)
3.6 ± 91 56 65 t9
0.8
± 13 ± 9 ± 6 ± 4
79 ± 7.8 ± 3.7 ± 4.1 ±
3 0.3 0.1 0.2
lgG (mg/100 ml) 2.292± 157 IgA 356 ± 29 IgM 276 ± 37 BetalC globulin 110 ± 11 (Complement C 3) * =
HBsAgnegative group (n = 2 4 ) S.E.M.)
30 ± 3.9± 5.1 _+ 160 ±
5 0.I 0.4* 16
3.8±
0.8
150 ± 32 93 ± 25 1 2 6 + 21 ** 19 ± 3 76 ± 7.9± 3.7± 4.2±
4 0.3 0.1 0.2
2.926±230 * 374 _+ 37 234 + 29 124 ± 13
p
