Fibrosing cholestatic hepatitis possibly related to persistent parvovirus B19 infection in a renal transplant recipient

Yan-Shen Shan1, Po-Chang Lee1,, Jen-Ren Wang2, Huey-Pin Tsai3, Chunne-Ming Sung4 and Ying-Tai Jin3

Departments of 1 Surgery, 2 Medical Technology, 3 Pathology and 4 Nephrology, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Keywords: fibrosing cholestatic hepatitis; intravenous immunoglobulin; parvovirus B19; polymerase chain reaction; renal transplantation



   Introduction
 Top
 Introduction
 Case
 Discussion
 References
 
Fibrosing cholestatic hepatitis (FCH) is characterized by ballooning degeneration of hepatocytes with periportal fibrosis and abundant accumulation of viral antigen in the cytoplasm [1,2]. In recipients of solid-organ transplants, FCH may result in rapidly progressive liver failure with mild abnormalities of serum aminotransferase levels. Clinically, most reported cases of FCH in transplant recipients are related to hepatitis B (HBV) or hepatitis C (HCV) infections, but its association with other hepatotoxic viruses has not previously been described [3,4].

With a respiratory route of transmission parvovirus B19 (B19) is the only member of the family Parvoviridae known to be a common cause of human infections worldwide. In healthy adults and children, B19 infections can cause erythema infectiosum and polyarthropathy syndromes [5]. It may also induce aplastic anaemia and liver dysfunction, which may range from mild biochemical abnormalities to liver failure [68]. We previously described a case of B19-related acute hepatitis in an immunosuppressed patient with a renal transplant [9]. The pathologic changes in hepatic infections by B19, however, have not been well described. In the normal host, B19 is eliminated following production of specific IgG and IgM antibodies, which coincides with the disappearance of the virus from circulation. In renal transplant recipients, persistent B19 infections can be found along with serum positive for viral DNA even after intravenous immunoglobulin (IVIG) treatment [1012]. We report here the first case of FCH possibly related to a persistent B19 infection in a renal transplant recipient undergoing immunosuppressive therapy.



   Case
 Top
 Introduction
 Case
 Discussion
 References
 
The patient was a 15-year-old male with IgA-induced nephropathy and end-stage renal failure who had required dialysis during the preceding 2 years. Before dialysis, the patient had on one occasion, in June 1997, suffered from fever (up to 39°C), an unexplained anaemia (Hb 5.9 g/dl), and thrombocytopenia (40 000/mm3), but he had normal ferritin levels. At that time his serologic studies were positive for hepatitis B surface antigen (HBsAg) and there were trace levels of hepatitis B surface antibody (HBsAb), but HIV-Ab and HCV-Ab were negative. A bone marrow examination was not performed. Following that episode, the patient received daily continuous ambulatory peritoneal dialysis, an occasional transfusion of packed red blood cells, and weekly erythropoietin (Epo) (4000 units). One year later, in September 1998, the patient received a cadaveric renal transplant. His postoperative course was uneventful and the patient was maintained on an immunosuppressive regimen of cyclosporin A (CsA) (8 mg/kg/day), mycophenolate mofetil (MMF) (1.5 g/day), and prednisolone (10 mg/day). Serum creatinine levels stabilized at around 90 µmol/l. One month postoperatively, high fever (up to 40°C) with profound anaemia (Hb 5.2 g/dl) developed associated with normal liver aminotransferase levels—aspartate aminotransferase (AST) 17 U/l (normal <40), alanine aminotransferase (ALT) 24 U/l (normal <55). Ferritin and Epo levels were within normal limits. As we suspected a B19 infection, we tested for serum B19 DNA using a nested polymerase chain reaction (PCR) assay. The patient's serum samples were positive for B19 IgM antibody but negative for B19 IgG antibody. Retrospective PCR analysis of sera stored prior to transplantation gave positive results for B19 DNA and negative results for both B19 IgM and IgG antibodies. IVIG (400 mg/kg/day) was administered intravenously for 1 week, and resulted in prompt recovery from the anaemia (Hb 14.6–15.4 g/dl), but serum B19 DNA remained positive with low titres of B19 IgG and IgM antibodies. During the follow-up period, the patient's liver function tests remained within normal limits. We maintained serum levels of CsA at around 250 ng/ml.

Six months later, despite normal renal function, mild jaundice developed (bilirubin 3.2 mg/dl) and abnormal liver enzyme levels (AST 340 U/l, ALT 616 U/l) were found. The patient was admitted with a presumptive diagnosis of B19 hepatitis based on persistent positive results for B19 DNA PCR and low titres of serum IgM and IgG antibody. IVIG was administered for 1 week (400 mg/kg/day). He was discharged when his serum bilirubin level decreased to 2.7 mg/dl, but with recovery of mild liver function tests (AST 195 U/l, ALT 383 U/l). One month later he was readmitted with an elevated bilirubin level (5.6 mg/dl) and persistent abnormal liver function tests (AST 166 U/l, ALT 199 U/l, ALK-P 217 U/l, GGT 308 U/l). Serum HBV-DNA, HBsAg, HBeAg, HBcAb, and B19 DNA were positive, while HBcAg, HBsAb, HBcIgM, HBeAb, and HCVAb were negative. There was no serologic evidence of cytomegalovirus, herpes simplex, varicella, HGV, or Epstein–Barr virus infections. With a provisional diagnosis of chronic, active HBV infection, we started lamivudine 100 mg/day. We also reduced the doses of immunosuppressive agents—CsA to 2 mg/kg/day, MMF to 0.5 g/day, and prednisolone to 5 mg/day over 2 weeks. Twenty-one days after starting lamivudine therapy, a rapid deterioration of liver function and aplastic anaemia occurred (bilirubin 13.5 mg/dl, AST 200–300 U/l, ALT 200–250 U/l, Hb 7.2 g/dl, WBC 2400/cmm, platelet 76000/cmm, appearance of 42% nucleated RBC). The patient expired as a result of liver failure. Liver necropsy showed the presence of marked portal and periportal fibrosis with bile duct proliferation, balloon degeneration of most hepatocytes, canalicular and cellular cholestasis with near-absence of necro-inflammatory hepatocyte reaction, marked architectural damage, and incomplete septum formation. The histopathologic findings were compatible with FCH.

The suspicion of B19-induced FCH then led us to perform a liver tissue PCR for B19 DNA. The test result was strongly positive (Figure 1Go). To confirm the infection, immunohistochemical stains for HBV were performed next. HBsAg was not present in the cytoplasm of hepatocytes and HBcAg was detected in the nucleus of some hepatocytes. HBV pre-core and core region mutation tests for pre-S1, which participates in regulating the expression of the HBsAg, allowing export of the virus, were performed with negative results. Further in situ hybridization was performed on a sample of the liver tissue with a B19-specific probe, which demonstrated massive accumulation of B19 antigens in the nucleus and cytoplasm of the ballooning hepatocytes. This gave support to the idea that FCH might be related to over-replication of B19 in hepatocytes.



View larger version (86K):
[in this window]
[in a new window]
 
Fig. 1. Parvovirus B19 DNA PCR liver tissue product. Lane M, 100 bp size marker; lane L, liver tissue; lane PC, positive control; lane NC, negative control.

 



   Discussion
 Top
 Introduction
 Case
 Discussion
 References
 
FCH is a nightmarish development for transplant recipients with HBV or HCV infection. High concentrations of viral antigens accumulating within cytoplasms of hepatocytes result in their death, an aetiology suggested by models of HBV transinfected in transgenic mice [1]. Based on the histopathology for this patient's liver, hepatic failure secondary to FCH occurred without immunochemical evidence of HBsAg accumulation in the cytoplasm of the degenerated hepatocytes. Given the presence of positive serum HBeAg, HBsAg, HBcAb, and HBV-DNA, and of negative serum HBcIgM, chronic active hepatitis was suspected in this patient. The elevation of aminotransferase levels to greater than five times the upper limit of normal led to the initiation of 100 mg/day lamivudine therapy. From the results of the Asian Hepatitis Lamivudine Trial [13], HBeAg seroconversion and decreases in HBV-DNA load may occur within as little as 4 weeks time. Brind et al. [14] also reported a case of FCH caused by HBV where serum HBV-DNA levels rapidly decreased from 100 to 2.8 pg/ml within a week of lamivudine therapy. Not withstanding the treatment, widespread accumulation of HBsAg and HBcAg in the degenerated hepatocytes persisted, and in most cases HBsAg accumulated in the cytoplasm with pre-core/core mutation. This indicates that lamivudine can quickly halt viral replication but that previously over-replicated and unsecreted viral antigens within hepatocytes can still cause injury. In our patient, immunohistochemistry showed HBcAg only in some nuclei of the degenerated hepatocytes without cytoplasmic HBsAg accumulation. This indicates that the accumulation of HBV antigens in the degenerated hepatocytes, secondary to export defects or over-replication of virus, was not to blame, especially given the preceding 3 weeks of lamivudine treatment and the fact that no mutation in the pre-core region was found. It also points to a non-HBV-related FCH despite one attack of chronic hepatitis as evidenced by positive serum HBsAg and anti-HBc antibodies and liver tissue positive for HBcAg.

IVIG therapy after an episode of B19 infection may result in a chronic B19 infection with persistent low titres of serum B19 IgM and IgG antibodies and positive B19 PCR tests, associated with improvement of liver function tests. Chronic active hepatitis developed in our patient and led us to direct our therapeutic efforts at HBV-related FCH in his last hospital admission. Lamivudine therapy was given to control HBV replication, but the patient died because of FCH. The strongly positive B19 PCR results and detection of massive B19 antigen accumulation in the nuclei and cytoplasms of the balloon degenerated hepatocytes noted on in situ hybridization suggest that the FCH was possibly related to B19 replication rather than to HBV or HCV.

In the immunocompromised host, B19 may not be fully eradicated and can result in a persistent infection. Following immunosuppressive therapy, increased viral replication in the presence of persistent B19 infection further aggravates an aplastic anaemia and a hepatic failure secondary to FCH, as they did in our patient. In conclusion, despite immunohistochemical assays showing reactivation of HBV, particles of B19, rather than HBV antigens, accumulate in the cytoplasm of the ballooning hepatocytes. Persistent B19 infection may be responsible for FCH in renal transplant patients as suggested by our present observation. Given the high prevalence of B19 infections, B19-infection-induced FCH should be kept in mind in the differential diagnosis of unexplained anaemia associated with progressive hepatic failure in immunocompromised renal transplant recipients.



   Notes
 
Correspondence and offprint requests to: Po-Chang Lee, MD, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan, Taiwan 704. Back



   References
 Top
 Introduction
 Case
 Discussion
 References
 

  1. Chisari FV, Filippi P, Buras J et al. Structural and pathological effects of synthesis of hepatitis B virus large envelope polypeptide in transgenic mice. Proc Natl Acad Sci USA1987; 84: 6909–6913[Abstract]
  2. Lau YN, Bain VG, Davies SE et al. High level expression of hepatitis B virus (HBV) antigens in fibrosing cholestatic hepatitis. Evidence that HBV may be cytopathic in liver grafts. Gastroenterology1992; 102: 956–962[ISI][Medline]
  3. Mason AL, Wick M, White HM et al. Increased hepatocyte expression of hepatitis B virus transcription in patients with features of fibrosing cholestatic hepatitis. Gastroenterology1993; 105: 237–244[ISI][Medline]
  4. Zylberberg H, Carnot F, Mawzer MF, Blancho G, Legendre C, Pol S. Hepatitis C virus-related fibrosing cholestatic hepatitis after renal transplantation. Transplantation1997; 63: 158–160[ISI][Medline]
  5. Brown KE, Young NS. Parvovirus B19 in human disease. Annu Rev Med1997; 48: 59–67[ISI][Medline]
  6. Tsuda H. Liver dysfunction caused by parvovirus B19. Am J Gastroenterol1993; 88: 1463[ISI][Medline]
  7. Pardi DS, Romero Y, Mertz LE, Douglas DD. Hepatitis-associated aplastic anemia and acute parvovirus B19 infection: a report of two cases and a review of the literature. Am J Gastroenterol1998; 93: 468–470[ISI][Medline]
  8. Langnas AN, Markin RS, Cattral MS, Naides SJ. Parvovirus B19 as a possible causative agent of fulminant liver failure and associated aplastic anemia. Hepatology1995; 22: 1661–1665[ISI][Medline]
  9. Lee PC, Hung CJ, Lei HY, Chang TT, Wang JR, Jan MS. Parvovirus B19-related hepatitis in an immunosuppressed kidney transplant. Nephrol Dial Transplant2000; 15: 1486–1488[Free Full Text]
  10. Musiani M, Zerbini M, Gentilomi G et al. Persistent B19 parvovirus infections in haemophilic HIV-1 infected patients. J Med Virol1995; 46: 103–108[ISI][Medline]
  11. Moudgil A, Shidban H, Nast CC et al. Parvovirus B19 infection-related complications in renal transplant recipients. Treatment with intravenous immunoglobulin. Transplantation1997; 64: 1847–1850[ISI][Medline]
  12. Frichhofen N, Abkowitz JL, Sufford M et al. Persistent B19 parvovirus infection in patients infected with human immunodeficiency virus typeI (HIV-I): a treatable cause of anemia in AIDS. Ann Intern Med1990; 113: 926–933[ISI][Medline]
  13. Chien RN, Liaw YF, Atkins M. Pretherapy alanine transaminase level as a determinant for hepatitis B e antigen seroconversion during Lamivudine therapy in patients with chronic hepatitis B. Asian Hepatitis Lamivudine Trial Group. Hepatology1999; 30: 770–774[ISI][Medline]
  14. Brind AM, Bennett MK, Bassendine MF. Nucloside analogue therapy in fibrosing cholestatic hepatitis—a case report in an HBsAg positive renal transplat recipient. Liver1998; 18: 134–139[ISI][Medline]
Received for publication: 23.12.00
Revision received 22. 5.01.