Journal of Clinical Virology 60 (2014) 105–111
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Depression and neuroticism in patients with chronic hepatitis C: Correlation with peripheral blood mononuclear cells activation Tomasz Pawlowski a , Marek Radkowski b , Krzysztof Małyszczak a , Małgorzata Inglot c , Małgorzata Zalewska c , Joanna Jablonska d , Tomasz Laskus b,∗ a
Division of Psychotherapy and Psychosomatic Medicine, Wrocław Medical University, Wrocław, Poland Department of Immunopathology, Medical University of Warsaw, Warsaw, Poland c Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Wrocław Medical University, Wrocław, Poland d Department of Hepatology and Acquired Immunodeficiency Syndrome, Medical University of Warsaw, Warsaw, Poland b
a r t i c l e
i n f o
Article history: Received 1 August 2013 Received in revised form 20 February 2014 Accepted 5 March 2014 Keywords: HCV Depression Immune activation Cognitive Neuroticism
a b s t r a c t Background: Hepatitis C virus (HCV) infection is commonly associated with cognitive dysfunction and depression, which could be related to direct brain infection. Viral sequences and proteins were found in brain macrophage/microglia cells and these cells were reported to be activated. Since blood leukocytes cross blood–brain barrier, activation state of peripheral blood mononuclear cells (PBMC) could reflect the state of brain immune cells. Objective: The aim of the study was to determine whether depression and neuroticism in chronic HCV infection correlates with the expression of key cytokines and chemokines in PBMC. Design: We studied 24 HCV-positive patients undergoing treatment with interferon and ribavirin. Patients were tested for depression using Beck Depression Inventory (BDI) and Montgomery Åsberg Depression Rating Scale (MADRS), while neuroticism was assessed by the Revised Eysenck Personality Inventory (N/EPO-R). Transcripts representing 28 various cytokines and chemokines were measured by real-time quantitative PCR in PBMC. Results: Prior to therapy BDI and MADRS positively correlated with viral load while neuroticism correlated with IL-3, IL-8 and M-CSF transcription levels. Six months after therapy there was positive correlation between depression and/or neuroticism scores and the levels of proinflammatory cytokines TNF-␣ and IL-12 transcripts, as well as IL-8, IL-10, IL-16, MCP-1, MCP-2, MIP-1-alpha, MIP-1-beta, and TGF-beta, and IFN- transcripts. Conclusion: Activation of PBMC, as measured by the level of cytokine and chemokine transcripts, correlates with depression and neuroticism scores. These findings suggest a pivotal role of immune cells activation in depression and possibly neurocognitive dysfunction among chronic hepatitis C patients. © 2014 Elsevier B.V. All rights reserved.
1. Background Patients with chronic hepatitis C virus (HCV) infection were reported to suffer from depression and cognitive dysfunction [1–3]. The reasons behind this phenomenon were largely unclear, but it was suspected that they could be related to the psychological burden of chronic illness and/or liver dysfunction. However, Forton
Abbreviations: HCV, hepatitis C virus; PBMC, peripheral blood mononuclear cells; BDI, Beck Depression Inventory; MADRS, Montgomery Åsberg Depression Rating Scale; N/EPO-R, Revised Eysenck Personality Inventory. ∗ Corresponding author at: Medical University of Warsaw, Pawinskiego 7C, 02-106 Warsaw, Poland. Tel.: +48 22 862 4649; fax: +48 22 883 1360. E-mail address: [email protected] (T. Laskus). http://dx.doi.org/10.1016/j.jcv.2014.03.004 1386-6532/© 2014 Elsevier B.V. All rights reserved.
and colleagues demonstrated elevations of choline/creatine ratios in basal ganglia and white matter in patients with hepatitis C by proton magnetic-resonance spectroscopy (1 H MRS) thus providing evidence for the likely biological basis of HCV-related brain effects. Such changes were not present either in healthy volunteers or patients with hepatitis of other etiology [2,4] and were clearly different from those seen in hepatic encephalopathy, where the choline ratios are depressed [5]. Notably, they are similar to findings reported in patients with HIV infection, where virus replicates in the central nervous system [6,7]. The original findings reported by Forton were since confirmed by other groups [8,9]. The results of the above studies raised the possibility that HCV could be neurotropic. Indeed, negative-strand HCV RNA, which is viral replicative intermediate, was subsequently detected in autopsy brain tissue [10] and two other studies demonstrated the
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T. Pawlowski et al. / Journal of Clinical Virology 60 (2014) 105–111
Fig. 1. Neuroticism and Depression in patients with chronic HCV infection treated with Interferon and Ribavirin. Neuroticism was assessed by the Revised Eysenck Personality test, while depression was measured by Back Depression Index (BDI) and Montgomery Åsberg Depression Rating Scale (MADRS). Twelve patients were sustained virological responders (treatment success) and 12 remained HCV RNA positive (treatment failure). Psychological evaluation was done right before (pre-Tx) and 6 months after the end of treatment (post-Tx). Data were compared using the nonparametric Wilcoxon matched pairs test (NS).
presence of HCV proteins in brain tissue by Western blotting and/or immunostaining [11,12]. Furthermore, brain-derived HCV variants were found to be distinct from those circulating in blood, thus suggesting the presence of separate CNS compartment [10,13]. The cells harboring HCV in the brain were identified by two independent groups as astrocytes and macrophages/microglia cells [11,12]. It has been established that all basic groups of leukocytes: T-cells, B-cells, macrophage/monocytes and NK-cells, have the ability to enter the brain under certain conditions [14] and some monocyte family members are constantly being replaced as part of normal physiology [15,16]. Thus it could be speculated that the activation state of lymphoid cells circulating in the blood could reflect the activation of those in the brain.
2. Objectives The aim of the study was to determine whether depression and neuroticism in chronic HCV infection correlates with the expression of key cytokines and chemokines in PBMC. 3. Study design 3.1. Patients The current study was nested within a larger study analyzing the effect of interferon treatment on neuroticism and depression in patients with chronic hepatitis C (study still in progress).
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thereafter. Enrolled patients undergo psychological testing before and 6 months after therapy and biological samples, including sera and PBMC, are collected at the same time points. The current analysis includes 24 patients who were the first to finish the full course of therapy and reach the point of 6 months follow up. At that point 12 patients were found to be HCV RNA negative and were considered to have achieved sustained virological response (SVR), and 12 were considered treatment failures, since they remained HCV RNA positive in serum. There were 11 women (46%) and 13 men (54%), their median age was 51 years (range 26–68 years). The predominant HCV genotype was 1b (16; 67%), followed by 3a (6; 25%), and 4 (2; 8%). Median pretreatment HCV viral load was 4.75 × 106 IU/ml (range 1.4 × 105 –5.0 × 107 ). All patients had raised ALT activity in serum (median 106 IU/l) and all were HIV-negative and had no serological markers of HBV infection. Liver biopsy was done within 2 months preceding commencement of therapy and liver histopathology was read in a blinded fashion as to the clinical data by a trained pathologist using Hepatitis Activity Index scoring system proposed by Knodell et al. [17]. All patients were receiving pegylated interferon alfa-2a 180 g once weekly (Pegasys; Hoffmann-LaRoche, Basel, Switzerland) combined with ribavirin (Schering-Plough Corp.) in the dose of 1000 mg/day if their body weight was
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Depression and neuroticism in patients with chronic hepatitis C: Correlation with peripheral blood mononuclear cells activation Tomasz Pawlowski a , Marek Radkowski b , Krzysztof Małyszczak a , Małgorzata Inglot c , Małgorzata Zalewska c , Joanna Jablonska d , Tomasz Laskus b,∗ a
Division of Psychotherapy and Psychosomatic Medicine, Wrocław Medical University, Wrocław, Poland Department of Immunopathology, Medical University of Warsaw, Warsaw, Poland c Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Wrocław Medical University, Wrocław, Poland d Department of Hepatology and Acquired Immunodeficiency Syndrome, Medical University of Warsaw, Warsaw, Poland b
a r t i c l e
i n f o
Article history: Received 1 August 2013 Received in revised form 20 February 2014 Accepted 5 March 2014 Keywords: HCV Depression Immune activation Cognitive Neuroticism
a b s t r a c t Background: Hepatitis C virus (HCV) infection is commonly associated with cognitive dysfunction and depression, which could be related to direct brain infection. Viral sequences and proteins were found in brain macrophage/microglia cells and these cells were reported to be activated. Since blood leukocytes cross blood–brain barrier, activation state of peripheral blood mononuclear cells (PBMC) could reflect the state of brain immune cells. Objective: The aim of the study was to determine whether depression and neuroticism in chronic HCV infection correlates with the expression of key cytokines and chemokines in PBMC. Design: We studied 24 HCV-positive patients undergoing treatment with interferon and ribavirin. Patients were tested for depression using Beck Depression Inventory (BDI) and Montgomery Åsberg Depression Rating Scale (MADRS), while neuroticism was assessed by the Revised Eysenck Personality Inventory (N/EPO-R). Transcripts representing 28 various cytokines and chemokines were measured by real-time quantitative PCR in PBMC. Results: Prior to therapy BDI and MADRS positively correlated with viral load while neuroticism correlated with IL-3, IL-8 and M-CSF transcription levels. Six months after therapy there was positive correlation between depression and/or neuroticism scores and the levels of proinflammatory cytokines TNF-␣ and IL-12 transcripts, as well as IL-8, IL-10, IL-16, MCP-1, MCP-2, MIP-1-alpha, MIP-1-beta, and TGF-beta, and IFN- transcripts. Conclusion: Activation of PBMC, as measured by the level of cytokine and chemokine transcripts, correlates with depression and neuroticism scores. These findings suggest a pivotal role of immune cells activation in depression and possibly neurocognitive dysfunction among chronic hepatitis C patients. © 2014 Elsevier B.V. All rights reserved.
1. Background Patients with chronic hepatitis C virus (HCV) infection were reported to suffer from depression and cognitive dysfunction [1–3]. The reasons behind this phenomenon were largely unclear, but it was suspected that they could be related to the psychological burden of chronic illness and/or liver dysfunction. However, Forton
Abbreviations: HCV, hepatitis C virus; PBMC, peripheral blood mononuclear cells; BDI, Beck Depression Inventory; MADRS, Montgomery Åsberg Depression Rating Scale; N/EPO-R, Revised Eysenck Personality Inventory. ∗ Corresponding author at: Medical University of Warsaw, Pawinskiego 7C, 02-106 Warsaw, Poland. Tel.: +48 22 862 4649; fax: +48 22 883 1360. E-mail address: [email protected] (T. Laskus). http://dx.doi.org/10.1016/j.jcv.2014.03.004 1386-6532/© 2014 Elsevier B.V. All rights reserved.
and colleagues demonstrated elevations of choline/creatine ratios in basal ganglia and white matter in patients with hepatitis C by proton magnetic-resonance spectroscopy (1 H MRS) thus providing evidence for the likely biological basis of HCV-related brain effects. Such changes were not present either in healthy volunteers or patients with hepatitis of other etiology [2,4] and were clearly different from those seen in hepatic encephalopathy, where the choline ratios are depressed [5]. Notably, they are similar to findings reported in patients with HIV infection, where virus replicates in the central nervous system [6,7]. The original findings reported by Forton were since confirmed by other groups [8,9]. The results of the above studies raised the possibility that HCV could be neurotropic. Indeed, negative-strand HCV RNA, which is viral replicative intermediate, was subsequently detected in autopsy brain tissue [10] and two other studies demonstrated the
106
T. Pawlowski et al. / Journal of Clinical Virology 60 (2014) 105–111
Fig. 1. Neuroticism and Depression in patients with chronic HCV infection treated with Interferon and Ribavirin. Neuroticism was assessed by the Revised Eysenck Personality test, while depression was measured by Back Depression Index (BDI) and Montgomery Åsberg Depression Rating Scale (MADRS). Twelve patients were sustained virological responders (treatment success) and 12 remained HCV RNA positive (treatment failure). Psychological evaluation was done right before (pre-Tx) and 6 months after the end of treatment (post-Tx). Data were compared using the nonparametric Wilcoxon matched pairs test (NS).
presence of HCV proteins in brain tissue by Western blotting and/or immunostaining [11,12]. Furthermore, brain-derived HCV variants were found to be distinct from those circulating in blood, thus suggesting the presence of separate CNS compartment [10,13]. The cells harboring HCV in the brain were identified by two independent groups as astrocytes and macrophages/microglia cells [11,12]. It has been established that all basic groups of leukocytes: T-cells, B-cells, macrophage/monocytes and NK-cells, have the ability to enter the brain under certain conditions [14] and some monocyte family members are constantly being replaced as part of normal physiology [15,16]. Thus it could be speculated that the activation state of lymphoid cells circulating in the blood could reflect the activation of those in the brain.
2. Objectives The aim of the study was to determine whether depression and neuroticism in chronic HCV infection correlates with the expression of key cytokines and chemokines in PBMC. 3. Study design 3.1. Patients The current study was nested within a larger study analyzing the effect of interferon treatment on neuroticism and depression in patients with chronic hepatitis C (study still in progress).
T. Pawlowski et al. / Journal of Clinical Virology 60 (2014) 105–111
107
thereafter. Enrolled patients undergo psychological testing before and 6 months after therapy and biological samples, including sera and PBMC, are collected at the same time points. The current analysis includes 24 patients who were the first to finish the full course of therapy and reach the point of 6 months follow up. At that point 12 patients were found to be HCV RNA negative and were considered to have achieved sustained virological response (SVR), and 12 were considered treatment failures, since they remained HCV RNA positive in serum. There were 11 women (46%) and 13 men (54%), their median age was 51 years (range 26–68 years). The predominant HCV genotype was 1b (16; 67%), followed by 3a (6; 25%), and 4 (2; 8%). Median pretreatment HCV viral load was 4.75 × 106 IU/ml (range 1.4 × 105 –5.0 × 107 ). All patients had raised ALT activity in serum (median 106 IU/l) and all were HIV-negative and had no serological markers of HBV infection. Liver biopsy was done within 2 months preceding commencement of therapy and liver histopathology was read in a blinded fashion as to the clinical data by a trained pathologist using Hepatitis Activity Index scoring system proposed by Knodell et al. [17]. All patients were receiving pegylated interferon alfa-2a 180 g once weekly (Pegasys; Hoffmann-LaRoche, Basel, Switzerland) combined with ribavirin (Schering-Plough Corp.) in the dose of 1000 mg/day if their body weight was
