Tohoku University Health Center, Sendai 980, *the First Department of Internal Medicine, Tohoku University School of Medicine, Sendai 980, f Hikarigaoka Spellman Hospital, Sendai 980, $Sendai Red Cross Hospital, Sendai 980, and §Jusendo General Hospital, Koriyama 963 NAKAMURA, S., TAKEZAWA, Y., SATO,T., IVIAEDA, T., NAKAMURA, M. and KERA,K. Hepatitis B Antigens and Antibodies in Asymptomatic Carriers and in Chronic Liver Diseases. Tohoku J. exp. Med., 1979, 128 (1), 81-87 88% of asymptomatic hepatitis B surface antigen (HBsAg) carriers and 97% of HBsAg positive patients with chronic hepatitis or non-alcoholicliver cirrhosisshowed high titers of antibody to hepatitis B core antigen (anti-HBc). A high titer of antiHBc, thus suggested to be an indicator of persistent hepatitis B virus infection, was found rarely in seronegative patients with chronic hepatitis, non-alcoholic cirrhosis, or alcoholic liver diseases. It was not revealed in idiopathic portal hypertension or Budd-Chiari syndrome. In asymptomatic HBsAg carriers of 2029 years of age, hepatitis B e-antigen (HBeAg) was significantly more frequently found in males than in females. There were differences in sex ratio, age, and history of blood transfusion between B type and non-B type of chronic hepatitis and non-alcoholic liver cirrhosis. antibody to hepatitis B core antigen; hepatitis B e-antigen; hepatitis B surface antigen carrier; liver disease; sex difference
Determination of hepatitis B antigens and antibodies, namely, hepatitis B surface antigen (HBsAg), its antibody (anti-HBs), antibody to hepatitis B core antigen (anti-HBc), hepatitis B e-antigen (HBeAg), and its antibody (anti-HBe), provides useful diagnostic markers. In addition to the continuous presence of HBsAg in the blood, a high titer of anti-HBc is suggested to be a reliable indicator of persistent hepatitis B virus infection (Kojima et al. 1977). The latter may be useful, especially in seronegative cases. The presence of HBeAg is associated not only with infectivity (Okada et al. 1976) but also with activity of chronic liver disease (Sheikh et al. 1975). In this paper report is made on measurement of hepatitis B antigens and antibodies in asymptomatic HBsAg carriers and in patients with chronic liver diseases in our hospitals located in the north-eastern district of Japan. In order to know the presence of persistent hepatitis B virus infection also in seronegative cases. determinations were carried out not only in asymptornatic HBsAg carriers, Received
29, 1978. 81
and non-alcoholic hypertension,
to be related,
but also in alcoholic syndrome
MATERIALS AND METHODS The 195 subjects examined consisted of 58 asymptomatic HBsAg carriers, 70 cases of chronic hepatitis, 27 of non-alcoholic liver cirrhosis, 33 of alcoholic liver diseases including 16 of alcoholic liver cirrhosis, 5 of idiopathic portal hypertension, and 2 of Budd-Chiari syndrome. Alcoholic liver diseases were diagnosed when patients with liver diseases drank 88 g or more of alcohol (4 go or more of sake daily). In a few patients, even though the alcoholic intake was less than 88 g, alcoholic liver diseases were diagnosed when liver biopsy showed definite histological proof such as alcoholic hyaline or pericellular fibrosis. The subjects were tested for HBsAg, anti-HBs, and anti-HBc in the blood. When HBs Ag was positive, HBaAg and anti-HBe in the blood were also tested. HBsAg was determined by the reversed passive hemagglutination method, anti-HBs by the passive hemagglutination method, anti-HBc by the immune adherence hemagglutination method (Tsuda et al. 1975), and HBaAg and anti-HBe by immunodiffusion. RESULTS Asymptomatic
Anti-HBs was positive in 3 (5%) of the 58 carriers (Table 1). Immune adherence hemagglutination titer of anti-HBc was 211or more in 51 subjects (88%) , 21 _10in 5 (9%) , and 27 or less in 2 (3%) (Table 1). HBeAg was positive in 12 (21%) of the 58 carriers , and anti-HBe in 22 (31%), TABLE 1.
HBsAg, in chronic
anti-HBs, and anti-HBc liver diseases
Hepatitis TABLE 2.
* The difference is statistically
and Antibodies in asymptomatic
_??_ n asymptomatic HBsAg carriers of 20-29 years of age, HBeAg was positive in 7 44%) of 16 males and in 3 (12%) of 25 females (Table 2). The sex difference of _??_ BeAg was statistically significant (p=0.03). On the other hand, anti-HBe was _??_ ositive in 2 males (12%) and in 10 females (40%). The sex difference of anti-HBe _??_ s not a significant (p=0.06). Sex difference was not clear in carriers of 30 'ears or more of age. There was no significant difference in incidence of HBeAg or _??_ nti-HBe between the third decade and the older age group (Table 2). Titer of _??_ BsAg was significantly higher in carriers with HBeAg than in those without _??_ BeAg. _??_ hronic hepatitis and non-alcoholic liver cirrhosis HBsAg was positive in 28 (40%) of the 70 patients with chronic hepatitis and a 7 (26%) of the 27 patients with non-alcoholic liver cirrhosis (Table 1). Of the 6 HBsAg positive patients with chronic hepatitis or non-alcoholic liver cirrhosis, Lone showed anti-HBs, and titer of anti-HBc was 211 or more in 34 patients 97%). Of the 35 patients with HBs-antigenemia, 8 (23%) showed HBeAg, and 4 (11%) _??_ nti-HBe. In HBsAg positive chronic hepatitis, glutamic pyruvic transaminase GPT) over 200 Karmen units was found in 50% of patients with HBeAg, in 16% ,f those without HBeAg and anti-HBe, and in none of patients with anti-HBe Table 3). However, the difference was not statistically significant. Thymol _??_ urbidity test (TTT) over 4 units was observed in none of patients with HBeAg, in ,3% of patients without HBeAg and anti-HBe, and in 33% of patients with antiMe (Table 3). The difference of TTT abnormality between HBeAg positive and _??_egative groups was not significant (p>0.05). TABLE 3. Liverfunction testsin chronichepatitisB
Of the 62 HBsAg negative and remained the same at least of anti-HBc
patient was excluded After this correction, chronic
2.2: 1 in chronic the other hand,
patients, one showed anti-HBc titer of 211 or more for 8 months. Since such a continuously high titer to show
, this from non-B type group and included into B type group. comparisons were made between B type and non-B type of
In B type,
male to female
hepatitis and 2.5: 1 in non-alcoholic cirrhosis. the sex ratio was 1.05 and 1.5, respectively.
In chronic hepatitis, the average age was 33.6 years in B type and 48.6 years in non-B type. The difference was statistically significant (p0 .05). There was no significant difference in GPT or TTT . The differences in GOT, GPT , and b TTT etween B type and non-B type of chronic hepatitis were not significant . Alcoholic
None of the 33 patients with alcoholic liver diseases showed HBsAg . Anti-HB c titer of 211or more was found only in one patient with alcoholic liver ci rrhosis (Table 1). Idiopathic
None of the 5 patients with idiopathic portal hypertension a nd of the 2 patients with Budd-Chiari syndrome revealed HBsAg or anti-HBc titer of 211or more (Table 1).
The present observation that most of asymptomatic HBsA and HBsAg seropositi ve patients with chronic hepatitis or non -alcoholicg carriers liver cirrhosis had high titers of anti-HBc is in accord with previo us reports (Suzuki and Mitamura 1975; T suda and Mayumi 1976). According to Kojima et al . (1977), a high titer of anti-HB c ranging from 211to 216 by the imm une adherence hemagglutination method was revealed in all the cirrhotic patients with circulating and/or liver hepatitis B antigens. Therefore , a high titer of anti-HBc is suggested to be a reliable indicator
of persistent hepatitis B virus infection. From this viewpoint, the results of antiHBc in HBsAg seronegative patients are interesting. In the present investigation, anti-HBc with
of 211 or more hepatitis diseases.
or non-alcoholic It
only in one of the 62 seronegative cirrhosis observed
and in one of the 33 patients in the
As for HBsAg seronegative patients with chronic hepatitis or non-alcoholic cirrhosis, none of the patients but one showed a high titer of anti-HBc, or is con sidered to be associated with persistent hepatitis B virus infection. This con clusion disagrees with recent report of Bories et al. (1978), because only a high titer of anti-HBc is thought to indicate persistent hepatitis B virus infection in the present investigation whereas all anti-HBc-positive patients were thought to be consequence of chronic infection with hepatitis B virus in the study of Bories et al. (1978). As shown in our results of the HBsAg seropositive patients with chronic hepatitis or non-alcoholic cirrhosis, persistent hepatitis B virus infection is usually accompanied with high titers of anti-HBc and rarely with low titers of anti-HBc. There are papers which associate hepatitis B virus infection with alcoholic or other liver diseases. According to Hirose et al. (1977), HBsAg was detected in the livers of 5 of 19 alcoholic patients with liver cirrhosis. The high titers of antiHBc and presence of HBsAg in the blood were not rarely observed in alcoholic patients with liver cirrhosis (Nagata et al. 1977). The difference between these studies and the present investigation seems to be ascribed to the criteria of alcoholics. In the above-mentioned reports, patients were diagnosed as alcoholic when the patients drank 3 go or more of sake daily. In the present investigation, on the other hand, most of the alcoholic patients drank 4 go or more of sake (88 g or more of alcohol), and only a few patients who drank 3-4 go of sake daily were considered to be alcoholic when they showed definite histological evidence such as alcoholic hyaline or pericellular fibrosis. 3 go of sake are too low as a general lower limit of alcoholics. If a limit of 4 go of sake is applied to Hirose's series, none of the alcoholic patients with cirrhosis has HBsAg in the liver. Liver cells were orcein-positive in 9.5% of patients with idiopathic portal hypertension (Shikata et al. 1976). HBsAg was found in the blood of 6.9% of pa tients with idiopathic portal hypertension (Ichihara and Sugiura 1977). Therefore, it is clear that a part of patients with idiopathic portal hypertension is associated with persistent hepatitis B virus infection. However, the absence of high titer of anti-HBc in the 5 patients in the present study shows that such association is present only in a few patients with idiopathic portal hypertension. Budd-Chiari syndrome which is found not rarely in Japan is mostly caused by membraneous obliteration of the inferior vena cava in the hepatic portion (Nakamura et al. 1968). Therefore, it is likely to be due to a congenital defect. Though a HBs Ag seropositive case of Budd-Chiari syndrome is reported (Sugimoto et al. 1976), our result of anti-HBc is in the negative as to association between Budd-Chiari
In 3 asymptomatic HBsAg carriers, HBsAg and anti-HBs were simultaneously detactable. Though it seems likely that the chronic carriers became secondarily infected by hepatitis B virus of different subtypes (Sasaki et al. 1976), it was not confirmed since the titer of anti-HBs was low and its subtypes could not be determined. In asymptomatic HBsAg carriers of 20-29 years of age, HBeAg was significantly more frequently found in males than in females. Thus, there seems to be sex difference in the incidence of HBeAg in asymptomatic HBsAg carriers. Though such a tendency has hitherto not been reported, it is not unlikely. Nakamura (1977) pointed out that anti-HBe was significantly more frequently seen in female students with HBs-antigenemia than in male students. In comparison of chronic hepatitis and non-alcoholic liver cirrhosis between B type and non-B type which were corrected by the results of anti-HBc, there were differences in sex ratio, age, and history of blood transfusion. It is to be noted that half of the patients with non-B type of chronic hepatitis (chronic non-A non-B hepatitis) or non-alcoholic liver cirrhosis seemed to be caused by blood transfusion. Acknowledgment We wish Meteropolitan and anti-HBe.
to thank Institute
Dr. F. Tsuda and Dr. M. Mayumi, Hepatitis Division of Medical Science, for the determinaton of anti-HBc,
of Tokyo HBeAg,
Bories, P., Coursaget, P., Goudeau, A., Degott, C., Maupas, P. & Benhamou, J.P . (1978) Antibody to hepatitis B core antigen in chronic active hepatitis. Brit. Med. J., 1, 396-397. 2) Hirose, S., Ohta, G. & Yoshizawa, H. (1977) A morphological modification of the liver cirrhosis with the presence of intrahepatic HBsAg in steady drinkers in autopsy cases. Acta hepatol. jap., 18, 625-633. (Japanese) 3) Ichihara, S. & Sugiura, M. (1977) Idiopathic portal hypertension. Medico, 8, 33143318. (Japanese) 4) Kojima, M., Udo, K., Takahashi, Y., Yoshizawa, H., Tsuda, F., Itch, Y., Miyakawa, Y. & Mayumi, M. (1977) Correlation between titer of antibody to hepatitis B core antigen and presence of viral antigens in the liver. Gastroenterology, 73, 664-667. 5) Nagata, A., Furuta, S., Kiyosawa, K., Koike, Y., Sahara, T., Akahane, Y. , Furukawa, K., Iijima, Y., Yamamura, S., Komatsu, H., Kawahara, K., Tominaga , J. & Oda, M. (1977) Studies on the implication of HBV infection in liver diseases of chronic alcoholics, with special reference to an autopsy case with acute alcoholic hepatitis positive for intrahepatitic HBsAg. Jap. J. Gastroent., 74, 1021-1029. (Japanese) 6) Nakamura, S. (1977) Chronic hepatitis B and hepatitis B surface antigen carriers in university students. Tohoku J. exp. Med., 124, 391-392. 7) Nakamura, T., Nakamura, S., Aikawa, T., Suzuki, 0., Onodera, A. & Karoji, N. (1968) Obstruction of the inferior vena cava in the hepatic portion and the hepatic veins. Angiology, 19, 479-498. 8) Okada, K., Kamiyama, I., Inomata, M., Imai , M., Miyakawa, Y. & Mayumi, M. (1976) e Antigen and anti-e in the serum of asymptomatic carrier mothers as indicators of positive and negative transmission of hepatitis B virus to their infants. New Eng. J. Med., 294, 746-749.
13) 14) 15)
Sasaki, T., Ohkubo, Y., Yamashita, Y., Imai, M., Miyakawa, Y. & Mayumi, M. (1976) Co-occurrence of hepatitis B surface antigen of a particular subtype and antibody to a heterogous subtypic specificity in the same serum. J. Immunol., 117, 2258-2259. Sheikh, N.E., Woolf, I.L., Galbraith, R.M., Eddleston, A.L.W.F., Dymock, I.W. & Williams, R. (1975) e Antigen-antibody system as indicator of liver damage in patients with hepatitis-B antigen. Brit. med. J., 4, 252-253. Shikata, T., Uzawa, T. & Yamazaki, S. (1976) Causal genesis of liver fibrosis ac companied with portal hypertension. Acta hepatol. jap., 17, 417-424. (Japanese) Sugimoto, T., Morita, N., Mizuki, M., Kobayashi, K. & Annen, Y. (1976) A case of hepatocellular carcinoma, associated with an occluson of inferior vena cava caused by fibrous membrane. Acta hepatol. jap. 17., 472-477. (Japanese). Suzuki, H. & Mitamura, K. (1975) HBs antibody and HBc antibody in the blood. Sogo Rinsho, 24, 2358-2364. (Japanese). Tsuda, F. & Mayumi, M. (1976) Antibodies to HBs and HBc antigens. Naika, 37,10131016. (Japanese) Tsuda, F., Takahashi, T., Takahashi, K., Miyakawa, Y. & Mayumi, M. (1975) Determination of antibody of hepatitis B core antigen by means of immune adherence hemagglutination. J. Immunol., 115, 834-838.