Occult hepatitis B virus infections Dieter Glebe Institute for - - PowerPoint PPT Presentation

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Occult hepatitis B virus infections Dieter Glebe Institute for - - PowerPoint PPT Presentation

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AREVIR-Meeting, 23th April 2009 Stiftung Caesar, Bonn Occult hepatitis B virus infections Dieter Glebe Institute for Medical Virology, Justus-Liebig Universitt Gieen German Consulting Laboratory for Hepatitis B Entry of hepatitis

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Occult hepatitis B virus infections

AREVIR-Meeting, 23th April 2009 Stiftung Caesar, Bonn

Dieter Glebe

Institute for Medical Virology, Justus-Liebig Universität Gießen German Consulting Laboratory for Hepatitis B

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SLIDE 2

Entry

  • f hepatitis

virus, start of replication

immunity slow replication inapparent transient infection immune defence

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SLIDE 3

Entry

  • f hepatitis

virus, start of replication

acute fulminant immunity recovery slow replication strong replication inapparent transient infection Delayed, vigorous immune response immune defence

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SLIDE 4

Entry

  • f hepatitis

B virus, start of replication

incomplete response efficient inefficient acute fulminant immunity chronic hepatitis recovery slow replication strong replication cirrhosis carcinoma inapparent transient infection immunotolerance, inapparent, chronic Delayed, vigorous immune response immune defence HBsAg carrier

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SLIDE 5

Entry

  • f hepatitis

B virus

incomplete response efficient inefficient acute fulminant immunity chronic hepatitis recovery slow replication strong replication cirrhosis carcinoma inapparent transient infection immunotolerance, inapparent, chronic Delayed, vigorous immune response immune defence HBsAg carrier

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HBsAg HBcAg HBV DNA HBsAg

1000 fold excess

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Anti-HBs HBsAg

HBV DNA PCR

Anti-HBc

Acute resolving hepatitis B

disease months Recovery

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Definition of occult HBV infection (OBI): HBsAg non-reactive, but infected

  • Definition (true OBI):

– Presence of HBV DNA in the liver, – With detectable or undetectable HBV DNA in serum – HBsAg tested negative by current assays – HBV DNA in serum very low (<200 IU/ml)

  • False OBI

– Infection by HBV variants with SHBs mutations (escape mutants), not detectable by HBsAg tests

Taormina expert meeting on occult hepatitis B virus infections. J.Hepatol 49 (2008) 652-657

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Anti-HBs HBsAg

HBV DNA PCR

Anti-HBc

Acute resolving hepatitis B

disease months Recovery Low level persistance

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Entry of hepatitis B virus, start of replication

acute fulminant immunity recovery weak replication strong replication inapparent infection Delayed, vigorous immune response immune defence Occult intrahepatic infection Infectious blood and organ donations Continuous selection

  • f

HBV mutants

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HBV transmissions by HBsAg negative, anti-HBc positive blood donors with

  • ccult

HBV infection

  • 5 donors

– HBV DNA <10 – 240 ge/mL, no anti-HBs – In 4 donors several mutations

  • f the

HBsAg loop – 1 donor had wildtype HBsAg

  • 55 recipients, 68% anti-HBc

pos. – 10 possible transmissions, asymptomatic – 22 probable transmissions, asymptomatic – 3 fatal hepatitis B cases

  • 2 with

proven transmission

  • cofactors: sepsis, immunosuppression

– no normal acute hepatitis B after transfusion

Summary

  • f data

from Germany and Denmark 2004 - 2005

  • W. Gerlich et al. J Med Virol 2007; 79:S32-S36
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Definition of occult HBV infection (OBI): HBsAg non-reactive, but infected

  • Definition (true OBI):

– Presence of HBV DNA in the liver, – With detectable or undetectable HBV DNA in serum – HBsAg tested negative by current assays – HBV DNA in serum very low (<200 IU/ml)

  • False OBI

– Infection by HBV variants with SHBs mutations (escape mutants), not detectable by HBsAg tests

Taormina expert meeting on occult hepatitis B virus infections. J.Hepatol 49 (2008) 652-657

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Transient occult HBV infection with unusual high HBV DNA levels

  • Blood

donor positive in Ultrio NAT – HBV DNA 90 000 ge/ml (15,500 IU/ml) – no anti-HBs, no anti-HBc – Normal ALT

  • 32 days

later – HBV DNA + – Anti-HBc and anti-HBs positive – Elevated ALT

  • 57 days

later – HBV DNA negative, – Anti-HBc and anti-HBs positive – ALT normal

Bremer et al. Transfusion, in press

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Transient occult HBV infection with unusual high HBV DNA levels

  • HBV DNA 90 000 ge/ml, but

no HBsAg detectable

– Escape mutations in HBsAg? – Altered epitopes for HBsAg ELISA? Cloning and sequencing of the whole genome

  • No mutations

in the HBsAg loop

  • No „diagnostic

escape“, true OBI

  • but:
  • Frameshift

in the preS domain, Possibly low secretion of subviral particles

Bremer et al. Transfusion, in press

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Transient occult HBV infection with unusual high HBV DNA levels

  • HBV DNA 90 000 ge/ml, but

no HBsAg detectable

– HBsAg and virions covered with anti-HBs? – Immune complexes? Precipitation with Polyethyleneglycol (PEG)

Bremer et al. Transfusion, in press + addition of anti-HBs

?

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Transient occult HBV infection with unusual high HBV DNA levels

  • HBV DNA 90 000 ge/ml, but

no HBsAg detectable

– HBsAg and virions covered with anti-HBs? – Immune complexes? Precipitation with Polyethyleneglycol (PEG) Immune-precipitation with anti-human antibodies Bremer et al. Transfusion, in press + addition of anti-HBs No immune complexes present

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Transient occult HBV infection with unusual high HBV DNA levels

  • HBV DNA 90 000 ge/ml, but

no HBsAg detectable

– Altered topology

  • f HBsAg on virions?

– Virions without HBsAg? Immune-precipitation with anti-preS1 and anti-SHBs antibodies

correct topology of LHBs and SHBs Bremer et al. Transfusion, in press

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Transient occult HBV infection with unusual high HBV DNA levels

CsCl gradient

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Transient occult HBV infection with unusual high HBV DNA levels

CsCl gradient

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Transient occult HBV infection with unusual high HBV DNA levels

CsCl gradient

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Transient occult HBV infection with unusual high HBV DNA levels

Unusual viral density profile

Association with plasma proteins possible CsCl gradient

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Definition of occult HBV infection (OBI): HBsAg non-reactive, but infected

  • Definition (true OBI):

– Presence of HBV DNA in the liver, – With detectable or undetectable HBV DNA in serum – HBsAg tested negative by current assays – HBV DNA in serum very low (<200 IU/ml) – Could be up to 15,500 IU/ml ! False OBI – Infection by HBV variants with SHBs mutations (escape mutants), not detectable by HBsAg tests

Taormina expert meeting on occult hepatitis B virus infections. J.Hepatol 49 (2008) 652-657

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Persistance of hepatitis B virus

acute fulminant immunity recovery weak replication

strong replication

inapparent infection Delayed, vigorous immune response immune defence

Occult intrahepatic infection Immunosuppression Reactivation

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Persistance of hepatitis B virus

acute fulminant immunity recovery weak replication

strong replication

inapparent infection Delayed, vigorous immune response immune defence

Occult intrahepatic infection Immunosuppression Reactivation

Continuous selection

  • f

HBV mutants Growth of escape- variants

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HBV Reactivation

  • Induced

by immunosuppression

  • Frequent

in inactive HBsAg carriers

  • Possible

in anti-HBc and/or anti-HBs positive persons

– Rare in kidney transplantation – Frequent in bone marrow/stem cell transplantation and lymphoma therapy

  • Asymptomatic

replication to high viremia

– under immunosuppression

  • Hepatitis starts

with immune reconstitution

– May be fatal, but can be prevented

  • Pretesting

for anti-HBc/s necessary

  • Monitoring

with sensitive HBV DNA assays

  • Early or

pre-emptive therapy necessary

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Institut for Medical Virology, Giessen, Germany Corinna M. Bremer Mona Saniewski Ulrike C. Wend Wolfram H. Gerlich Dieter Glebe

supported by DFG Collaborative Research Center SFB 535

Chiron, Novartis Vaccines and Diagnostics, Suresnes, France Nico Lelie

Acknowledgements

Centro de Transfusión de la Comunidad de Madrid, Spain Pilar Torres

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Transmission of HBV by anti-HBc

  • nly

blood : donor related look back

  • Genotype A2 adw2, dynamic

quasispecies – Many mutations in the RT-domain: – Conserved: V112I, N118H, R120S, L140I, Y151F – In donation 2: rtA181T sW172stop – Occurs during during lamivudine, adefovir, telbivudine and clevudine therapy. – sW172stop mutation confers defect in HBsAg secretion and dominant negative effect

  • n virion secretion

(Warner et al., Hepatology 2008). – reduction

  • f viral

breakthrough during anti-viral therapy. Genotypic profiling of HBV during reactivation

A. Lattermann, Lahn-Dill-Klinik Wetzlar, S. Wienzek, et al., Institute of Clinical Immunology and Transfusion Medicine, Giessen, Germany

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I H

Model of the HBsAg loop IV

Q F

Model of the HBsAg loop : escape (?) mutations in an anti-HBs negative blood donor IV

V