Women and HCV

by Liz Highleyman, Contributing Editor

In the past decade, chronic hepatitis C has become a widespread health concern, and this is true for women as well as for men. The U.S. federal government estimates that about four million Americans are infected with hepatitis C. More men than women have the disease; most experts believe this is because men are more likely to have risk factors for exposure to the hepatitis C virus (HCV), not because they are more susceptible than women to infection. In the U.S., African-Americans and Latinos have higher hepatitis C rates than whites.

Many people remain unaware that they have HCV. Before 1992, people often contracted HCV through blood transfusions. In 1992, an accurate test for donated blood came into wide use, and today transfusions are considered safe. In the 1970s and 1980s, before HCV was identified, women often received blood transfusions when they underwent Cesarean delivery (C-section); some of these women remain unaware that they received donated blood. Some experts suggest that women who had a C-section before 1992 should be tested for HCV.

HCV Risk Factors

The risk factors for contracting HCV are similar for women and men. Sharing needles for injection drug use is a major risk, and most studies show that a majority of people who have injected drugs are HCV-positive. Nurses and others who work in healthcare settings may contract HCV when they come into contact with blood, for example through accidental needlesticks. Other methods of transmission include shared equipment used for non-injection drugs (for example, cocaine straws and crack pipes); re-use of needles for acupuncture, tattooing, or body piercing; and shared personal items such as razors, manicure tools, and toothbrushes. Be sure to cover any cuts or sores to prevent contact with blood, and properly dispose of used tampons and sanitary napkins. Hepatitis C is not spread through casual contact such as sneezing, coughing, hugging, or sharing drinking glasses. For as many as 10% of people with HCV, no specific risk factors can be identified.

Sexual Transmission of HCV

Sexual transmission of HCV is uncommon. Most studies show that only a small percentage of people – estimated at 0-3% -- contract HCV through unprotected heterosexual intercourse with a steady, monogamous HCV-positive partner. People who have multiple sex partners have a higher risk of contracting HCV. According to the National Institutes of Health (NIH), people in long-term, monogamous relationships do not need to change their current sexual practices, although they should discuss safer sex if either partner is concerned about transmission. The NIH recommends that people who have multiple sexual partners should practice safer sex, in particular using latex condoms. There are no known cases of HCV being transmitted through oral sex on a woman (cunnilingus) or on a man (fellatio); however, it is theoretically possible that the virus could be transmitted this way if a person has mouth sores, bleeding gums, or a throat infection. Some studies indicate that sexual transmission from men to women is more efficient than transmission from women to men, as is also the case with HIV. As with HIV, HCV may be more efficiently transmitted through anal sex than through vaginal intercourse. The risk of HCV transmission through woman-to-woman sexual activity has not been studied. Because HCV is spread through blood, it is more likely to be sexually transmitted when a woman is having her menstrual period.

HCV Progression & Symptoms in Women

Various studies have shown that hepatitis C progression is slower and liver damage tends to be less severe in women than in men. For one thing, it appears that women are more likely to completely clear HCV from their bodies after infection and never develop chronic disease. It is usually estimated that 80-85% of all people infected with HCV will go on to develop chronic hepatitis C, but the rate is lower for women. A German study of 1,018 young women infected with HCV in 1978-9 through contaminated immunoglobulin transfusions found that after 20 years, about 45% had cleared the virus. Researchers do not know why the HCV clearance rate is higher in women than men.

Women who do have chronic hepatitis C (that is, they still have HCV after six months) tend not to develop liver cirrhosis (scarring), liver cancer, or liver failure as rapidly as men. For all people with chronic HCV, disease progression is usually slow. A majority of people with chronic hepatitis C never develop serious liver damage. Among those who do, the process usually takes years or even decades; the usual estimate is 10-40 years, and may be longer for women. In the German study, only four of the 1,018 women had developed cirrhosis after 20 years. Some experts believe that the female hormone estrogen protects women from liver damage; if this is the case, the protective effect may diminish after menopause, as women’s bodies produce less of the hormone.

Many people with HCV have no symptoms and lead normal lives. Those who do develop symptoms may experience prolonged fatigue (tiredness), fever, headache, loss of appetite, nausea, pain in the abdomen, or pain in the muscles or joints. The types of symptoms are similar in women and men, but women may develop symptoms later or may experience more mild effects.

Several autoimmune conditions, in which the immune system attacks the body’s own tissue, are associated with HCV (for example, cryoglobulinemia, glomerulonephritis, and Sjogren’s syndrome). Because women in general are much more likely than men to have autoimmune conditions, it is not surprising that women with HCV seem to be at greater risk than HCV-infected men for developing these conditions. However, according to Norah Terrault, MD, MPH, of the University of California at San Francisco Division of Gastroenterology, while women with HCV may be more predisposed than men to autoimmune conditions, this does not necessarily mean that these conditions are directly associated with HCV; women may simply be more likely to have co-existing autoimmune conditions that may not be caused by HCV. More study is needed in this area.

HCV Diagnosis & Monitoring

Doctors use various tests to determine if a person has hepatitis C. One type of test measures antibodies in the blood, indicating that a person been exposed to HCV; the two most common antibody tests are called ELISA and RIBA. Viral load tests measure how much HCV genetic material is present in the blood; the two most common viral load tests are called PCR and bDNA. There are several different types of hepatitis C virus called genotypes. Genotype tests can help determine how well HCV treatment might work. Genotypes 1a and 1b, which are most common in the U.S., are more difficult to treat. Current research does not indicate that women are likely to have different HCV genotypes than men.

Liver function tests, which measure levels of liver enzymes and other substances in the blood, indicate how well the liver is working. Changes in liver enzyme levels can help to determine whether the liver is damaged and whether HCV treatment is working. People with chronic hepatitis C often have increased levels of two liver enzymes called ALT and AST. Women tend to have lower ALT levels than men. However, this does not necessarily means that their liver disease is less severe. According to Terrault, ALT is “not a perfect reflection” of liver damage, and screening tests based on ALT levels alone may miss some women with liver disease.

HCV Treatment in Women

Not everyone with hepatitis C needs treatment. Doctors determine whether treatment is appropriate based on various factors including HCV genotype, viral load, liver enzyme levels, and extent of liver damage. Since women tend to have less severe liver damage that develops more slowly, they may be less likely than men to need treatment. However, treatment recommendations should not be based solely on ALT levels, which are typically lower in women.

Today, the current standard treatment for chronic hepatitis C is a combination of two medications, interferon and ribavirin. Interferon is a manufactured version of a natural substance produced by the body's immune system. Ribavirin (brand name Rebetol) is an antiretroviral drug that kills certain types of viruses. Combination treatment with interferon plus ribavirin was approved by the Food and Drug Administration (FDA) in 1998. Studies have shown that the combination works better than treatment with interferon alone (monotherapy). But interferon monotherapy does appear to work well for some people with mild hepatitis who have minimal liver damage. Recent studies have shown that a new type of interferon -- called pegylated interferon -- works better with ribavirin than standard interferon. Pegylated interferon lasts longer in the body and does not have to be injected as often. This August, the FDA approved the combination of pegylated interferon plus ribavirin for the treatment of chronic hepatitis C. The standard treatment regimen for HCV is the same for women and men.

Since HCV treatment works best in people with milder liver damage, women tend to benefit more from therapy than men. According to Terrault, this is true “across the board” for different types of HCV therapy, although the gender difference is “less striking” with pegylated interferon compared to standard interferon. A couple of studies have found that interferon therapy worked better in pre-menopausal women than in men of the same age or postmenopausal women, suggesting again that estrogen may play some role in protecting women’s livers. Some research indicates that treatment does not work as well in African-Americans as it does in whites; more study is needed to determine how these race and gender effects interact in black women.

The drugs used to treat HCV cause side effects in some people. The most common side effects of interferon include headache, nausea, fatigue, loss of appetite, muscle and joint pain, and mental depression or anxiety. The most serious side effects of ribavirin are low levels of certain types of blood cells (anemia, neutropenia, and thrombocytopenia). In the population as a whole, women have higher rates of depression than men, and so may be more likely to experience this side effect; interferon is typically not recommended for people who are already experiencing major depression or other psychiatric illnesses. Interferon may worsen autoimmune conditions; the relationship between interferon and autoimmune conditions in women with HCV is an area for further study. Also, because women lose blood each month through menstruation, they are more likely than men to develop anemia (a low red blood cell count). Women taking ribavirin should have their blood cell levels monitored regularly.

Because women tend to weigh less than men, treatment dosage has been a concern. Standard interferon therapy is based on a fixed dose, and lighter-weight women may receive more of the drug than is necessary to control their HCV. Higher doses are associated with more severe side effects. Pegylated interferon, however, is dosed based on weight. People who weigh less received a lower dose, thus reducing the possibility of “overtreatment.”

HCV and Pregnancy

Many women with HCV are concerned about the risk of transmitting the virus to their babies during pregnancy or birth. Studies consistently show that the rate of perinatal or vertical transmission is low, about 5% or 1 in 20. Vertical transmission is most likely to happen when the mother has a high HCV viral load; several studies have shown that no transmission occurred when women had undetectable viral loads. Studies also show that women who are co-infected with both HCV and HIV have a higher risk (15-35%) of transmitting HCV to their infants. One British study has suggested that the risk of vertical HCV transmission may be reduced through Cesarean delivery; however, according to the Society of Obstetricians and Gynecologists of Canada, “routine Cesarean section is not recommended as a specific measure to reduce the risk of vertical transmission of HCV.”

Although HCV has been detected in breast milk in some studies, there is no indication that breastfeeding transmits the virus. Most experts do not discourage HCV-positive women from breastfeeding. But women may wish to exercise caution if their nipples are cracked or bleeding. HCV is not transmitted from mothers to children through normal household contact.

According to Terrault, who treats many women with HCV, being pregnant does not adversely affect the progression of hepatitis C. Likewise, women with HCV do not have a higher rate of pregnancy or birth complications compared to uninfected women. However, women with severe, advanced liver disease may experience difficulties during pregnancy.

Universal prenatal screening of women for HCV is not currently recommended. Babies of HCV-positive women should be tested for HCV after 12-18 months. According to the Centers for Disease Control and Prevention, most infants infected with HCV at birth have no symptoms and do well during childhood. Studies suggest that infants are more likely than adults to completely clear the virus from their bodies. HCV treatment has not been well studied in infants and children.

Ribavirin is known to cause miscarriages and birth defects, so pregnant women should not take this drug. In addition, both women of childbearing potential and men taking ribavirin should use two reliable forms of birth control during treatment and for six months after treatment ends. Most doctors also recommend that interferon should not be taken during pregnancy, because its effects on the human fetus is not well known.

Hormones and HCV

Because hormones are processed by the liver, traditionally some doctors have recommended that women with HCV should not take hormone replacement therapy (HRT) or hormonal contraceptives such as the pill. But according to Terrault, hormone doses used to be much higher than they are now, and this belief is outdated. She says that HRT should not be withheld from women with HCV if it is indicated for their overall health. Likewise, the risks of hormonal contraceptives, Terrault says, are “very low.” Some early studies suggested that women who used combined estrogen plus progesterone contraceptive pills were at higher risk for liver cancer, but a more recent study of women using newer, lower-dose pills did not find an association. Nevertheless, some doctors still recommend progesterone-based rather than estrogen-based birth control pills for women with HCV.

After menopause, when their bodies produce less estrogen, many women develop osteoporosis, or brittle bones. It is known that thinning of the bones occurs in people with liver damage. Treatment with ribavirin has also been associated with bone loss. Therefore, taking estrogen to prevent bone loss may be beneficial to women with HCV. Moderate exercise can also help maintain healthy bones, and is recommended for women with HCV unless they are feeling very ill. Avoid high dose supplements of vitamin D, which can harm the liver.

Terrault emphasizes that the effect of menopause on women with HCV should be better studied. Some women with hepatitis C and other chronic diseases have reported early menopause, and at least one study has found that liver cirrhosis is associated with reduced fertility. Terrault notes that some of her patients find it difficult to tell whether symptoms such as fatigue and depression are due to menopause or HCV. How menopause affects HCV progression and treatment is not well known, and more research is clearly needed.

Take Care of Yourself

Living with a chronic disease can be stressful. Rates of HCV are high in women who use drugs, economically disadvantaged women, and women in prison. Many women with hepatitis C face issues such as lack of access to quality health care, lack of health insurance, stigma, and discrimination.

There are several measures you can take to improve the health of your liver and your overall quality of life. Good nutrition is important for people with hepatitis C. A healthy diet is low in fat, salt, and sugar, and high in carbohydrates and fiber. Processed foods often have chemical additives, so eat less canned or frozen foods, and more fresh fruits and vegetables. Avoid high dose vitamin and mineral supplements. Some doctors recommend that people with hepatitis should drink less coffee, eat less chocolate, and avoid raw or undercooked shellfish. Avoid alcohol, which can be very harmful to the liver. The NIH recommends that people with HCV drink no more than one alcoholic beverage per day. Certain illegal or recreational drugs, prescription drugs, over-the-counter (non-prescription) medications, and herbal remedies can also damage the liver. Tell your doctor about all drugs and herbs you are taking. Because other types of viral hepatitis can be much worse in people who already have hepatitis C, anyone with HCV should ask their doctor about getting the hepatitis A and B vaccines (there is no vaccine for hepatitis C). See your doctor regularly and get checkups to monitor your liver health.

Many women with hepatitis C experience chronic fatigue and depression. Try to plan activities in advance and make realistic schedules. Pace your activities, and don’t forget to take time out for relaxation or naps. Try to maintain a realistic picture of your health. Learn to say ‘no’ to those who have unrealistic expectations of your energy level, and don’t be afraid to ask family and friends for the help you need. Meditation can be a useful tool to help reduce stress. Many people find that peer support groups with other HCV-positive people can help them cope with their disease and overcome feelings of isolation. Support groups can provide a safe space to share information and discuss the emotional issues surrounding chronic hepatitis C.

Women often put the care of their families above their own needs and neglect their own health. If you have chronic hepatitis C, don’t forget to take care of yourself!"

http://www.hcvadvocate.org/Articles/wmnlong.cfm

HCV affects more then just our liver

Liz Webb is the author of the monthly online magazine

Please visit her Web Site, she also takes questions in her Shared Voices section

www.askemilyss.com:

Over the past six years, similar questions have been posed to me by hepatitis C patients thousands of times. Too often, their doctors tell them their symptoms and other medical conditions are not related to hepatitis C, which causes frustration and confusion for patients. The fact that so many patients report similar symptoms and that a multitude of research has shown a remarkable number of HCV patients with other conditions, makes it clear that there is more to the relation between these conditions than just coincidence.

In her book Hepatitis C - A Personal Guide To Good Health, Beth Ann Petro Roybal writes, "Certain symptoms, such as itchy skin and jaundice, are directly caused by liver damage brought on by HCV. ... Symptoms such as chronic fatigue may not be caused by liver damage per se, but may be a result of HCV’s assault on the immune system. ... Some people with hepatitis C also develop other conditions as a result of their damaged immune system. Some of these conditions include mixed cryoglobulinemia, rheumatoid arthritis, lichen planus and glomerulonephritis (kidney disease)."

Matthew Dolan, citing several studies in his book The Hepatitis C Handbook, backs up this claim. Dolan points to a study by Christian Stassburg and Michael Manns in Viral Hepatitis Review that noted: "Chronic hepatitis C infection has been found to be associated with an array of autoimmune diseases including … autoimmune thyroid disease, autoimmune hepatitis, porphyria cutanea tarda, Sjögren’s syndrome, etc. This means that immune stimulants such as interferon may cause more problems in patients with autoimmune symptoms."

With the many studies and papers associating autoimmune diseases in patients with HCV, why has it been so difficult to be diagnosed and treated for such illnesses? Dolan writes, "Patients will find that they are experiencing symptoms that specialists would not normally expect given a particular set of liver function test results. ... Patients who present without clear signs of liver disease and with low or undetectable virus can experience (diagnostic and treatment) problems; doctors may often be unwilling to accept that such patients are experiencing debilitating symptoms."

With hepatitis C’s reputation of being only a liver disease, these overlapping autoimmune conditions may complicate the potential treatments of HCV, Strassburg and Manns noted, and cause confusion for the patient as well as their doctor.

The Lymphatic Connection

The lymphatic system — a major component of our overall immune system — is key in aiding our bodies to fight off viruses and infections. A subsystem of the circulatory system consisting of a complex network of vessels, tissues and organs, the lymphatic system helps defend the body against infection by supplying disease-fighting cells called lymphocytes. The lymphatic system also helps maintain fluid balance in the body by collecting excess fluid and particulate matter from tissues and depositing them in the bloodstream. So how does the lymphatic system get itself involved with a virus that affects the liver?

Dolan points to several studies that indicate HCV lives and replicates within the lymphatic system as well as the liver causing immune system malfunction. Dolan details how the virus is able to mutate and avoid the immune system’s attack. Addition-ally, he describes how the virus can trick the immune system into attacking the body’s own tissues. This understanding of HCV as a systemic disease — a disease that affects several bodily systems at once — may explain why some people with high viral loads have little damage or inflammation in the liver, yet they experience severe symptoms very similar to the flu.

"Some people with chronic HCV experience a range of symptoms usually classified as autoimmune," Dolan states. "This occurrence may owe at least as much to the presence of HCV in the lymphatic system as to the liver." Due to the autoimmune-related nature of these conditions, they may not be seen in other forms of hepatitis, which makes it difficult for liver specialists to recognize them let alone relate them to hepatitis C.

Until recently, hepatitis C has been perceived by the medical community to be a localized infection of the liver. Researchers have found that hepatitis C is not just a liver disease but a disease that affects many bodily systems at once, causing the immune system to malfunction and lose the ability to differentiate between HCV particles and human cells.

This overlapping nature of hepatitis C as a liver and immune system disease, notes Dr. Parveen Kumar and Dr. Michael Clark, editors of Clinical Medicine, can lead to an autoimmune disease. "An autoimmune disease occurs when the immune system fails to recognize the body’s own tissues as self and mounts an attack on them. Illnesses are divided into those that affect just one organ (organ-specific) and those that affect many systems (systemic)."

Diagnosis and Treatment Challenge

"For the last five or six months, I’ve woken up every morning with extreme pain in my back. I think it’s in the kidney area, just below my ribs. I also have chronic joint pain, constant fatigue; I have had blood tests and a biopsy but nothing has ever been explained ..."

HCV Patient

Many HCV patients describe how their lives have become a vicious cycle as they try to get recognition and treatment for their various symptoms and conditions that are not specific to liver disease. Their autoimmune-related symptoms are difficult to diagnose as often their lab tests are below diagnostic levels or they do not fully develop all of the clinical diagnostic symptoms linked to a particular disease.

Dr. Ben Cecil, a hepatologist experienced with HCV patients who present with overlapping autoimmune diseases, confirms the findings: "I have several patients with cryoglobulinemia and one with renal failure and malignant hypertension. Many of my patients have pains in their muscles and joints which is probably related to HCV."

Cecil said he recognizes the potential contradictions of lab results and symptoms, and comments that the low titers of antinuclear antibody and other autoimmune disease markers are nonspecific. He suggests that your doctor should consult with a rheumatologist if there is suspicion of overlapping disease processes. He also suggests potential autoimmune tests such as the rheumatoid factor for rheumatoid arthritis, cryoglobulins for cryoglobulinemia as well as the erythrocyte sedimentation rate for evidence of general inflammation. Depending on your symptoms and your doctor’s advice, additional tests to detect kidney disease, thyroid dysfunction and diabetes may also be required.

Take Charge of Your Care

"For the past two years, I have been in pain, almost flu like in nature, achy bones, etc. This past spring the pain became very intense, and I developed swollen feet and ankles on both legs. Blood tests show no sign of autoimmune disease, and my liver counts were fine. The liver doctor has written me off saying my symptoms have no connection to the hep C. I am becoming very frustrated!"

HCV Patient

With stories like these coming to me nearly everyday, it is clear that diagnostic medicine, which considers hepatitis C to be only a liver disease and relies wholly on laboratory measures, is failing to help hepatitis C patients who suffer from HCV-related, autoimmune disorders. It is important to keep in mind that intuition and interpretation on the part of the physician is of utmost importance, and the possible existence of autoimmune diseases should not be ruled out simply because the early lab reports are negative for diagnostic markers.

The American Liver Foundation has stated, "First, we need to intensify efforts to educate primary care physicians and patients. Physicians must be armed with state-of-the-art information about diagnostic testing and optimal care. Physicians and patients must be empowered to make informed decisions about treatment."

Doctors and patients may benefit from standard evaluation guidelines which list tests for related conditions and how to interpret them, since as mentioned, many of these conditions do not always fit the known diagnostic criteria. Such an approach could provide the doctor with an opportunity to design a carefully planned treatment protocol that could then help to protect the patient from having the underlying conditions worsen.

If you feel you are suffering from possible HCV-related autoimmune diseases, the best thing you can do is to find a doctor who is aware of the connections with HCV, one who is willing to listen to you, and provide you with appropriate treatment and symptomatic relief. If you find yourself being dismissed, look for another doctor and keep looking until you find the one right for you. hep

Liz Webb is the author of the monthly online magazine on her Web site.

www.askemilyss.com:

FAQ on Autoimmunity

What is autoimmunity?

One of the functions of the immune system is to protect the body by responding to invading microorganisms, such as viruses or bacteria, by producing antibodies or sensitized lymphocytes (types of white blood cells). Under normal conditions, an immune response cannot be triggered against the cells of one's own body. In certain cases, however, immune cells make a mistake and attack the very cells that they are meant to protect. This can lead to a variety of autoimmune diseases. They encompass a broad category of related diseases in which the person's immune system attacks his or her own tissue.

What causes autoimmunity?

The immune system normally can distinguish "self" from "non-self." Some lymphocytes are capable of reacting against self, resulting in an autoimmune reaction. Ordinarily these lymphocytes are suppressed. Autoimmunity occurs naturally in everyone to some degree; and in most people, it does not result in diseases. Autoimmune diseases occur when there is some interruption of the usual control process, allowing lymphocytes to avoid suppression, or when there is an alteration in some body tissue so that it is no longer recognized as "self" and is thus attacked. The exact mechanisms causing these changes are not completely understood; but bacteria, viruses, toxins, and some drugs may play a role in triggering an autoimmune process in someone who already has a genetic (inherited) predisposition to develop such a disorder. It is theorized that the inflammation initiated by these agents, toxic or infectious, somehow provokes in the body a "sensitization" (autoimmune reaction) in the involved tissues.
 

What are the types of autoimmunity?

Particular autoimmune disorders are frequently classified into organ-specific disorders and non-organ-specific types. Autoimmune processes can have various results, for example, slow destruction of a specific type of cells or tissue, stimulation of an organ into excessive growth, or interference in its function. Organs and tissues frequently affected include the endocrine gland, such as thyroid, pancreas, and adrenal glands; components of the blood, such as red blood cells; and the connective tissues, skin, muscles, and joints. Some autoimmune diseases fall between the two types. Patients may experience several organ-specific diseases at the same time. There is, however little overlap between the two ends of the spectrum.

In organ-specific disorders, the autoimmune process is directed mostly against one organ. Examples, with the organ affected, include Hashimoto's thyroiditis (thyroid gland), pernicious anemia (stomach), Addison's disease (adrenal glands), and insulin-dependent diabetes mellitus (pancreas).

In non-organ-specific disorders, autoimmune activity is widely spread throughout the body. Examples include rheumatoid arthritis, systemic lupus erythematosus (SLE or lupus), and dermatomyositis.
 

What are some of the treatments for autoimmune diseases?

Of first importance in treating any autoimmune disease is the correction of any major deficiencies. An example would be replacing hormones that are not being produced by the gland, such as thyroxin in autoimmune thyroid disease or insulin in type one diabetes. In autoimmune blood disorders, treatment may involve replacing components of the blood by transfusion.

Second in importance is the diminishing of the activity of the immune system. This necessitates a delicate balance, controlling the disorder while maintaining the body's ability to fight disease in general. The drugs most commonly used are corticosteroid drugs. More severe disorders can be treated with other more powerful immunosuppressant drugs, such as methotrexate, cyclophosphamide, and azathioprine. All of these drugs, however, can damage rapidly dividing tissues, such as the bone marrow, and so are used with caution. Intravenous immunoglobulin therapy is used in the treatment of various autoimmune diseases to reduce circulating immune complexes. Some mild forms of rheumatic autoimmune diseases are treated by relieving the symptoms with nonsteroidal anti-inflammatory medications. Drugs that act more specifically on the immune system, for example, by blocking a particular hypersensitivity reaction, are being researched.
 

What is the family connection in autoimmune diseases?

The ability to develop an autoimmune disease is determined by a dominant genetic trait that is very common (20 percent of the population) that may present in families as different autoimmune diseases within the same family. The genetic predisposition alone does not cause the development of autoimmune diseases. It seems that other factors need to be present as well in order to initiate the disease process. It is important for families with members who have an autoimmune disease to mention this fact when another member of the family is experiencing medical problems that appear to be difficult to diagnose.

The above questions and answers are intended to provide basic information about autoimmunity and are not intended to take the place of a physician's adivice.
 

Does HCV Replicate Outside The Liver and It's Significance?

http://www.natap.org/

Some individuals with HCV report experiencing fatigue, emotional distress, and cognitive impairment. Objective testing has found HCV can be associated with these symptoms. Some doctors believe these symptoms may be associated with causes other than HCV, such as prior alcohol or drug use, or other psychiatric disturbances; and some studies suggest HCV can enter the CSF and the brain. In HIV, it has been established that HIV can reside and replicate in the brain. Another way in which HIV or HCV may affect the brain is by disturbances caused to the immune system, disruptions in cytokine balance. Disruptions in the immune system can affect the brain and other organs. So, can HCV reside and replicate in other organs other than the liver? This question is the subject of previously reported and ongoing studies. This article reports on previous study findings and tries to put these questions in perspective.

Two studies reported at AASLD (Nov 2002) discuss HCV and it's possible presence in the brain suggesting implications for the presence of HCV extra-hepatically, outside the liver. Results from study in England suggests HCV replicates in the brain (abstract 185, Forton et al). Researchers at the Mayo Clinic reported finding HCV in the cerebrospinal fluid and in PBMCs of patients with HCV in serum, suggesting the PBMCs may carry HCV into the neurologic system; this study is detailed at www.natap.org/2002/AASLD/day15.htm

So, does HCV replicate and is it found outside the liver? Results are mixed from various studies conducted over recent years, and some of these studies are reported below. Apparently, this question has not been answered and whether HCV exists outside the liver is not resolved. In fact, there are enough reasons to think HCV may not reside in reservoirs outside the liver as there are to think there are reservoirs outside the liver. The first article below talks about extrahepatic manifestations of HCV. It is clear that patients with HCV experience skin, renal, hematologic, and arthritic disorders, and having these disorders is associated with having HCV. The study is one of many supporting this and it is well accepted that HCV is associated with these extrahepatic dosorders. However, it is distinctly possible that this is due to HCV causing cytokine disruptions, dysregulation in the immune system, which may in turn lead to these disorders; rather thah due to HCV replicating in cells and organs outside the liver. Apparently, the studies that have found HCV in cells and organs outside the liver use lab testing methods and techniques which are not yet refined enough to be completely accepted by researchers. It appears researchers feel these test methods need further evaluation and confirmation.

In the end, it appears unresolved whether HCV can replicate or exists outside the liver. In addition, it may be irrelevant even if it does replicate and exist outside the liver. In HIV, reservoirs have been identified in patients who achieve and sustain undetectable HIV viral load (<50 copies/ml of HIV viral load). In addition, these patients can sustain undetectability and maintain good health for many years despite these reservoirs. It remains unanswered whether these patients will see their HIV viral load rebound due to the existence of reservoirs. So, does the existence of HCV reservoirs matter, if they do exist? Perhaps not. Studies of patients with HCV who have sustained viral responses for as long as 11 years have found no HCV in the blood or liver. Presumably, if HCV reservoirs persist these individuals would have reservoirs. Yet these patients remained undetectable. If HCV reservoirs do in fact exist, perhaps achieving sustained response eradicates HCV in these reservoirs. Perhaps patients who relapse after achieving end-of-treatment responses from IFN/RBV do so because there are reservoirs. These questions remained unanswered. But, ultimately what appears to matter is whether or not a patient can achieve and sustain a sustained viral response. If they can, studies show no HCV in the blood and liver. Of course, we do in fact need long term and larger studies to confirm that SVRs are sustainable and to evaluate the long term health outcomes for patients who sustain the SVR.

Extrahepatic manifestations of hepatitis C among United States male veterans

Hepatitis C virus (HCV) has been associated with several extrahepatic conditions. To date, most studies assessing these associations involved small numbers of patients and lacked a control group. Using the computerized databases of the Department of Veterans Affairs, we carried out a hospital-based case-control study that examined all cases of HCV-infected patients hospitalized during 1992 to 1999 (n = 34,204) and randomly chosen control subjects without HCV (n = 136,816) matched with cases on the year of admission. The inpatient and outpatient files were searched for several disorders involving the skin (porphyria cutanea tarda [PCT], vitiligo, and lichen planus); renal (membranous glomerulonephritis [GN] and membranoproliferative glomerulonephritis); hematologic (cryoglobulin, Hodgkin's and non-Hodgkin's lymphoma [NHL]); endocrine (diabetes, thyroiditis); and rheumatologic (Sjšgren's syndrome). The association between HCV and these disorders was examined in multivariate analyses that controlled for age, gender, ethnicity, and period of military service. Patients in the case group were younger in age (45 vs. 57 years), were more frequently nonwhite (39.6% vs. 26.3%), and were more frequently male (98.1% vs. 97.0%). A significantly greater proportion of HCV-infected patients had PCT, vitiligo, lichen planus, and cryoglobulinemia. There was a greater prevalence of membranoproliferative GN among patients with HCV but not membranous GN. There was no significant difference in the prevalence of thyroiditis, Sjšgren's syndrome, or Hodgkin's or NHL. However, NHL became significant after age adjustment. Diabetes was more prevalent in controls than cases, but no statistically significant association was found after adjustment for age. In conclusion, we found a significant association between HCV infection and PCT, lichen planus, vitiligo, cryoglobulinemia, membranoproliferative GN, and NHL. Patients presenting with these disorders should be tested for HCV infection. (HEPATOLOGY 2002;36:1439-1445.)

Search for Hepatitis C Virus Extrahepatic Replication Sites in Patients With Acquired Immunodeficiency Syndrome: Specific Detection of Negative-Strand Viral RNA in Various Tissues

The existence of extrahepatic reservoirs of hepatitis C virus (HCV) replication remains highly controversial. We searched for the presence of HCV-RNA negative strand in various tissues from eight HCV-infected patients who died of acquired immunodeficiency syndrome (AIDS)-related complications. Negative-strand RNA was detected by a Tth-based reverse-transcriptase polymerase chain reaction (RT-PCR), which was optimized for sensitivity and strand specificity on synthetic RNA templates. This assay was capable of detecting about 102 genomic Eq molecules of the correct strand while unspecifically detecting ³108 genomic Eq molecules of the incorrect strand. Negative-strand viral RNA was detected in all but one liver, in lymph nodes (5 cases), in pancreas (5 cases), in adrenal gland (2 cases), in thyroid (2 cases), in bone marrow (1 case), and in spleen (1 case). These data suggest a possible presence of HCV replication sites outside the liver, at least in AIDS patients. Whether these findings relate to various extrahepatic manifestations of HCV infection remains to be determined. (Hepatology 1998;28:1398-1401.)

The existence of extrahepatic reservoirs of hepatitis C virus (HCV) replication remains highly controversial. Several groups have reported the detection of HCV-RNA negative strand, a viral replicative intermediate, in peripheral blood mononuclear cells (PBMCs); however, the validity of these studies has been recently questioned, because it was demonstrated that reverse-transcriptase polymerase chain reaction (RT-PCR) used for the detection of HCV RNA is not strand-specific. Thus, subsequent studies using assays optimized for strand specificity either failed to demonstrate the presence of viral negative strand in PBMCs or found it to be a very rare event.

Even less is known about HCV replication in other extrahepatic sites, because studies using strand-specific assays are few; Landford et al. failed to detect HCV-RNA negative strand in multiple organs from a chronically infected chimpanzee, while Lerat et al. did not detect any evidence of viral replication in fresh bone marrow cells from six patients with chronic hepatitis. However, both studies have serious limitations: the former was conducted on a single ape that had a low level of HCV replication in the first place, while in the latter study, no tissues other than bone marrow were examined. Obviously, the existence of extrahepatic HCV replication sites would have broad implications for antiviral treatment and our understanding of multiple extrahepatic manifestations of HCV infection, the pathogenesis of which is currently obscure.

The major obstacle to a study of extrahepatic HCV replication is the availability of multiple tissues from infected individuals. Apparently, such samples could be obtained only during autopsy of patients with chronic infection. We reasoned that such an investigation could be conducted on postmortem tissues from intravenous drug addicts dying from acquired immunodeficiency syndrome (AIDS), because HCV infection in this group is almost uniform, and viral titers in human immunodeficiency virus (HIV)-infected subjects are usually elevated.

In the current study, we searched for the presence of HCV-RNA negative strand in various tissues from eight HCV-positive drug addicts who died of AIDS-related complications. To avoid mispriming events during RT-PCR, cDNA synthesis was conducted at a high temperature with the thermostable enzyme, Tth. We have recently used such a Tth-based RT-PCR for the identification of hepatitis G replication sites. The sensitivity and specificity of our assay was determined using synthetic RNA templates.

We studied tissue samples from eight HIV-1-infected drug addicts who died from AIDS-related complications between March and June 1997. All eight patients were anti-HCV-positive and hepatitis G virus (HGV) RNA-negative in serum; their CD4 count at the time of admission was below 200 cells per cubic millimeter. Tissue samples were obtained during routine autopsy conducted within 48 hours of death and stored at -80¡C until analysis. The study was conducted in accordance with institutional IRB requirements.

Samples of the following tissues were collected postmortem from each patient: liver, bone marrow, mediastinal lymph node, pancreas, thyroid, adrenal gland, kidney, lung, skeletal muscle, spleen, and spinal cord. Serum samples were drawn within the last week of the patient's life; however, in two cases (patients 1 and 5), they were collected a few hours before death, and in one subject (patient 4), serum was collected at death. In addition, in four cases (patients 2, 3, 6, and 7), an additional serum sample was collected at autopsy.

We studied tissue samples from eight HIV-1-infected drug addicts who died from AIDS-related complications between March and June 1997. All eight patients were anti-HCV-positive and hepatitis G virus (HGV) RNA-negative in serum; their CD4 count at the time of admission was below 200 cells per cubic millimeter. Tissue samples were obtained during routine autopsy conducted within 48 hours of death and stored at -80¡C until analysis. The study was conducted in accordance with institutional IRB requirements.

Samples of the following tissues were collected postmortem from each patient: liver, bone marrow, mediastinal lymph node, pancreas, thyroid, adrenal gland, kidney, lung, skeletal muscle, spleen, and spinal cord. Serum samples were drawn within the last week of the patient's life; however, in two cases (patients 1 and 5), they were collected a few hours before death, and in one subject (patient 4), serum was collected at death. In addition, in four cases (patients 2, 3, 6, and 7), an additional serum sample was collected at autopsy.

RESULTS

All analyzed samples were positive for the presence of HCV RNA when tested with the MMLV RT-based assay, although the actual titer varied widely from tissue to tissue, being the highest in the liver, and at least two logs lower at other sites.

Using a Tth-based strand-specific assay, the presence of HCV-RNA negative strand was documented in all but one liver sample in titers that were one to two logs lower than the titers of the positive strand. In two patients (patients 7 and 8), all extrahepatic tissue samples were negative, while in the remaining six patients, HCV-RNA negative strand was detected in at least one tissue. RNA negative strand was most commonly present in lymph node and pancreas tissue (five patients), followed by adrenal gland tissue (two patients), thyroid (two patients), bone marrow (one patient), and spleen (one patient). All serum samples, including those collected at autopsy, tested negative for the presence of HCV-RNA negative strand. These results were confirmed in two independent experiments using two separate extraction procedures.

The present work is currently the only extensive study on extrahepatic HCV replication sites in humans. Because the tissue samples were collected at the time of autopsy, some RNA might have been degraded, and low-level replication at various organs could have been missed; however, the presence of HCV-RNA negative strand was commonly demonstrated in lymph nodes and pancreas, and occasionally in adrenal gland, bone marrow, thyroid tissue, and spleen. These results cannot be simply explained by contamination with liver-derived HCV-RNA negative strand, because the latter was not detected in any of pre- or postmortem serum samples. Although limited to AIDS patients, our study provides evidence that HCV is not strictly hepatotropic.

However, we cannot exclude the possibility of low-level viral replication at other sites as well. Because RNA negative strands seem to be present at a level that is one to two logs lower than the level of the positive strand, in some instances, replication could be below the sensitivity level of our Tth-based strand-specific assay.

In a recent study, we used a similar group of patients to search for possible replication sites of HGV.11 In striking contrast to HCV infection, in which high titers of negative-strand viral RNA were almost uniformly detected in liver tissue, HGV-RNA negative strand was rarely present in liver samples. However, it was detected in bone marrow and spleen, but not in any of the other analyzed tissues. Thus, although the specific cellular site of replication within the positive tissues was not identified, HGV is likely to have a different tissue tropism than HCV.

HCV has been suggested to be a lymphotropic virus; though its replication is rarely if ever detected in PBMCs from human subjects, it has been reported to infect lymphocyte cell lines in vitro,12 and some recent studies on chimpanzees suggest the existence of strains with particular affinity for lymphocytes. The common presence of severe lymphopenia prevented the collection of PBMCs in our patients. However, it is the prevailing opinion that in AIDS patients, the study of lymph nodes is far superior to the study of PBMCs.14 In the current investigation, we found the presence of negative-strand viral RNA in lymph nodes from 5 of 8 patients, but it is unclear which cells were infected. Nevertheless, because lymph nodes in AIDS are depleted of dendritic and T cells, it is likely that HCV replicated in the cells of the monocyte/macrophage lineage or even in B cells. The latter possibility is particularly intriguing, because chronic HCV infection was credibly associated with B-cell lymphoproliferative disorders such as mixed cryoglobulinemia and B-cell non-Hodgkin's lymphoma. Interestingly, it was recently shown that HCV core protein has broad trans-acting properties, including the activation of some known oncogenes.

In our previous study,6 we did not detect HCV-RNA negative strand in PBMCs from HIV-negative patients with chronic hepatitis C, which is in agreement with the results published by two other groups. However, considering the expected low level of viral replication at extrahepatic sites and the fact that strand-specific assays are relatively insensitiveÑin several studies, they were found to be at least one log less sensitive than standard RT-PCR4-7Ñreplication could have been below the limit of detection. Thus, detection of HCV-RNA negative strand in lymphoid tissue in AIDS patients could be related to enhanced viral replication in the presence of severe immunodeficiency. Alternatively, HCV replication could be more efficient in activated cells, and/or weakened immune pressure against HCV could lead to the development of lymphotropic viral strains. However, it should be emphasized that the types and ratios of cells in the lymph nodes of AIDS patients are not representative of the typical PBMC composition in HIV-negative subjects.

Equally intriguing is the finding of HCV-replicative intermediates in thyroid and pancreas. The correlation between various forms of thyroid dysfunction and HCV infection is long known and was initially attributed solely to the effects of treatment with interferon. However, it was soon realized that thyroid abnormalities are commonly present in patients even before the actual treatment is started. A similar association was recently reported between HCV infection and the development of diabetes mellitus. Nevertheless, it remains unclear what cell lineage supports replication at extrahepatic sites. Interestingly, thyroid, pancreas, and adrenal glands were reported to be commonly involved in disseminated cytomegalovirus infection in AIDS patients.

There remains the important question of whether the ratio of infected cells in the extrahepatic tissues would be high enough to sustain infection and to be of clinical relevance......However, the actual number of infected cells at the extrahepatic sites could be higher because part of the viral RNA could have degraded between the time of the patient's death and autopsy.

In summary, using highly strand-specific Tth-based RT-PCR, we detected the common presence of negative-strand HCV RNA in lymph nodes and pancreas, and occasionally in thyroid, adrenal gland, spleen, and bone marrow from HCV-infected patients with AIDS. Because the study was conducted on severely ill and immunocompromised patients, the significance of our findings for HIV-negative patients is still uncertain. However, they could possibly relate to the various extrahepatic manifestations of HCV infection.

Hepatitis C virus negative strand RNA is not detected in peripheral blood mononuclear cells and viral sequences are identical to those in serum: a case against extrahepatic replication

Peripheral blood mononuclear cells (PBMCs) from 27 hepatitis C virus (HCV)-infected patients were analysed for the presence of HCV negative strand RNA with strand-specific Tth-based RT-PCR. No negative strand RNA was detected in any sample, and positive strand HCV sequences amplified from PBMCs were identical to those found in serum. These findings suggest that HCV does not replicate in PBMCs, and the presence of HCV sequences at this site is compatible with passive virus adsorption and/or contamination by circulating virus. J Gen Virol 1997 Nov;78 ( Pt 11):2747-50

Specific detection of hepatitis C virus minus strand RNA in hematopoietic cells

The presence of hepatitis C virus (HCV) negative strand RNA in extrahepatic compartments based on PCR detection assays has been suggested in many reports with a very heterologous detection rate (from 0 to 100%). In this study, we have analyzed the presence of HCV negative strand in hepatic (liver biopsies, n = 20) and extrahepatic (sera, n = 32; PBMC, n = 26 and fresh bone marrow cells, n = 8) compartments from infected patients with three different reverse transcriptase (RT)-PCR-based assays using primers located in the 5' noncoding region, with or without a tag selected to display different viral loads (10(5)-3 x 10(7) genomic equivalent/ml or gram) and viral genotypes (n = 5). Using synthetic as well as biological templates, we could document extensive artifactual detection of negative strand RNA, due to self priming and mispriming events, even either 5' noncoding region primer pair was used, whereas both artifacts were dramatically reduced (mispriming) or eliminated (selfpriming) using CAP-based RT-PCR assay. Mispriming artifacts were directly correlated to the titer of positive strand RNA present in the sample. Using the CAP-PCR assay, the presence of HCV negative strand RNA was found in 75% of livers (16:20) and only 8% of PBMC, independent of the genotype involved, but could not be documented in sera (0:32) and fresh bone marrow cells (0:6). These findings suggest that caution regarding the type of RT-PCR assay used and the level of HCV positive strand RNA present in the biological sample analyzed has to be taken to avoid false identification of viral reservoirs. The findings suggest that hematopoietic peripheral cells can support HCV replication, although in a very limited number of carriers. J Clin Invest 1996 Feb 1;97(3):845-51

EDITORIAL in Hepatology by Negro and Levrero

Although HCV infection of hepatocytes has been demon-strated convincingly by in situ hybridization and immunohis-tochemistry, the localization of HCV in both peripheral blood mononuclear cells (PBMC) and bone marrow cells has repeatedly been questioned, although similar techniques, as well as the strand-specific reverse-transcriptase polymerase chain reaction (RT-PCR) amplification, have been used.......

......The presence of the replicative intermediate of HCV-negative strand RNA in PBMC and in vitro infected lymphoblastoid cells was reported soon after the discovery of HCV; however, the strand specificity of these early RT-PCR procedures was questioned in subsequent work based on the

......Suitably modified assays resulted in a more highly specific detection of the negative-strand RNA; however, increased specificity may have adversely affected sensitivity, possibly explaining why different authors who studied the HCV tropism for cells of the hematopoietic lineage reported conflicting results. In fact, one likely explanation may be that HCV replicates in PBMC but only at very low levels, which makes its detection difficult and inconsistent. Furthermore, another explanation suggests that extrahepatic sites may contribute little to the total plasma level of HCV; that is an idea that seems to be confirmed by indirect data on serum HCV RNA kinetics in the liver transplantation model. It should be noted that in this same model, some authors have made claims that the reinfection of the grafted liver can take place only via the existence of an extrahepatic reservoir of HCV replication... (editorial note: and this post-transplant reinfection appears to occur only in patients who were not able to achieve SVR, suggesting that once an SVR is achieved extrahepatic HCV reservoirs, if there are any, are eradicated or are irrelevant).

......The infection of PBMC by HCV has also been reported using in situ hybridization, with conflicting results. Oddly enough, the proportion of infected cells does not correlate with the sensitivity of the assay. However, if the RT-PCR data are to be believed, the proportion of PBMC infected by HCV must be very low.... Two in situ hybridization studies provided an estimate of 1 to 3 cells per 10,000 34 and 0.15% to 4%, respectively. A more sensitive in situ PCR analysis, using fluorescent primers, increased the percentage up to a maximum of 8.1% of the total number of cells. Also mononuclear cells infiltrating the liver have reportedly been infected by HCV, but these data are contradicted by most other groups who have applied similar techniques....

...The presence of HCV has been evaluated in several other extrahepatic compartments. Analogous to other flaviviruses, HCV has been sought in the bone marrow. HCV RNA of both strands and HCV antigens have been detected by nonradioisotopic in situ hybridization and immunofluores-cence, respectively, in a low percentage of bone marrow mononuclear cells derived from 54% of patients with chronic hepatitis C. RT-PCR-based studies seemed to confirm the presence of HCV replicative forms in the bone marrow, especially in the presence of cryoglobulinemia. However, using a more strand-specific RT-PCR, Lerat et al. Questioned these findings, as did others looking for HCV-negative strand in bone marrow and other extrahepatic organs (PBMC, spleen, muscle, lymph nodes, pancreas, and kidney) taken from a chimpanzee at autopsy. Data which suggest that the presence of HCV in bone marrow preparations should also be interpreted with caution owing to the varying degree of contamination with peripheral blood cells. In situ staining of HCV has been demonstrated in both salivary gland epithelium and keratinocytes at the site of cryoglobulinemia-associated vasculitis. Again, however, contradictory data have been reported: immunohistochemistry has failed to stain non-structural HCV proteins in the skin of cryoglobulinemic, chronic hepatitis C patients, and a careful RT-PCR study has suggested the absence of HCV RNA in salivary gland epithelial cells. Finally, the presence of HCV in the brain has only been anecdotally reported and awaits confirmation...

....In light of these conflicting reports, new data concerning the extrahepatic replication of HCV is expected to elicit skepticism....The paper by Bronowicki et al......presents new evidence favoring the persistent replication of HCV in hematopoietic cells. The authors used the elegant model of mice with severe combined immunodeficiency. These severe combined immunodeficiency mice lack both humoral and cellular immunity caused ......Although this model will be used infrequently to study the pathobiology of HCV, it has provided convincing evidence for HCV replication in hematopoietic cells...

...HCV may directly affect the function of immune cells by interfering with their capability to eliminate HCV-infected hepatocytes. HCV-infected lymphocytes may be crippled in their ability either to undergo activation in response to proper stimulation or to exert effector functions. These considerations remain purely speculative without specific studies, which have been hampered by the lack of a reproducible in vitro infection system and by the lack of an easy ex vivo access to adequate samples of infected lymphoid cells. Alternatively, HCV-infected cells, either lymphoid or epithelial cells, may become resistant to the induction of programmed cell death....

...The functional implications of this finding await clarification. Defects in the control of immune system homeostasis by apoptosis are important for the pathogenesis of both autoimmune and lymphoproliferative disorders. Indeed, malignancies of the hematopoietic lineage have been associated with HCV infection, especially non-Hodgkin's lymphoma; one study suggests that other extrahepatic malignancies may be more frequent among HCV-infected patients than in the general population...HCV may directly transform infected cells, including cells of lymphoid origin...B-cell non-Hodgkin's lymphoma is often associated with HCV infection, and a primary extranodal localization (espe-cially liver, stomach, and salivary glands) is more frequently observed in HCV-positive than in HCV-negative indi-viduals. However, it is interesting to note that the non-Hodgkin's lymphomatous tissue does not seem to support HCV replication. Moreover, the weight of evidence of HCV infection with hematopoietic malignancies is epidemiologic and does not provide insight into the mechanism of this association. The paper by Bronowicki et al. does not resolve that issue...

...this syndrome share the same cross-idiotype. Thus, the mechanisms leading to the development of a fully malignant form of B-cell non-Hodgkin's lymphoma may involve local factors, including cytokine secretion, or factors independent of HCV, such as Helicobacter pylori. The presence of a clear geographical heterogeneity in the prevalence of HCV- positive non-Hodgkin lymphomas indicates that other genetic and environmental cofactors must be sought to explain the pathogenesis of these lymphoproliferative disor-ders. In the absence of clear evidence that the transformed lymphocytes are infected by HCV, the pathogenesis of HCV-associated lymphomas is uncertain. Despite the potential ability of the virus to affect crucial regulatory mechanisms in the cell, its role seems to be that of an infectious cofactor in a multi-step process which relies on the accumulation of several as yet unidentified genetic alterations.