Journal of Medical Virology 38191-194 (1992)
Persistent Delta Antigenaemia in Chronic Delta Hepatitis and Its Relation With Human Immunodeficiency Virus Infection Philippe Roingeard, Frederic Dubois, Patrick Marcellin, Jacques Bernuau, Sylvie Bonduelle, Jean-Pierre Benhamou, and Alain Goudeau Laboratoire de Virologie, URA CNRS 1334, Hbpital Bretonneau, Tours (P.R., F.D., S.B., A.G.), and Service d'Hepatologie, INSERM U 24, Hhpital Beaujon, Clichy (P.M., J.B., J.-P.B.), France The prevalence of persistent hepatitis delta (HD) antigenaemia and associated factors in patients with chronic infection with the hepatitis delta virus (HDV) were investigated. Among 157 consecutive patients known t o be carriers of hepatitis B surface antigen (HBsAg), 36 (23%) had one serum marker of HDV infection (anti-HD and/or HDAg). Nine of the patients with an HDV marker were HDAg positive, including three w h o were anti-HD negative. A follow-up over a mean period of 13 months showed that five of five patients had a persistent HD antigenaemia. This serological profile was associated with the presence of antibody to the human immunodeficiency virus (anti-HIV) (P < 0.01), serum HIV antigen (HlVAg) ( P < 0.21, and the female sex (P < 0.05). Persistent HD antigenaemia could be the consequence of the suppression of T cell cytotoxic activity against hepatocytes expressing HDAg, a lower humoral response, and/or hormonal factors. o 1992 Wiley-Liss, Inc.
tion of immune complexes with anti-HD [Di Bisceglie and Negro, 1989; Buti et al., 19891. Western blotting, a technique that denatures immune complexes, is the only satisfactory method for the detection of complexed HDAg, but it is technically difficult [Buti et al., 19891. The diagnosis of chronic HDV infection is, therefore, usually based on the detection of anti-HD [Di Bisceglie and Negro, 19891. The occurrence of a persistent HD antigenaemia detected by RIA or EIA has been reported in three patients, all of whom were infected by the human immunodeficiency virus (HIV) [Grippon et al., 1987; Shattock et al., 19871. There have been no assessments to date of the prevalence of HD antigenaemia in populations of chronic HDV carriers, either infected by, or free of HIV. One hundred and fifty-seven unselected consecutive HBsAg carriers were studied to estimate the prevalence of persistent HD antigenaemia and to identify associated factors.
PATIENTS AND METHODS One hundred and fifty-seven patients (123 men, 34 women; mean age 37) known to be HBsAg carriers (RIA; Abbott Laboratories, Chicago, IL) were included KEY WORDS: hepatitis B virus, hepatitis delta in this prospective study. They were all negative for virus, hepatitis delta antigen antibody to the hepatitis B core antigen of the IgM class (IgM anti-HBc, RIA, Abbott), and none displayed clinical or biological signs of acute hepatitis. Histological INTRODUCTION diagnosis based on a liver biopsy was carried out in 130 Chronic infection with the hepatitis B virus (HBV) is patients: 15 (12%) had chronic persistent hepatitis a major cause of chronic liver disease. In some patients, (CPH), 77 (59%) had chronic active hepatitis (CAH), 18 chronic liver disease may also be aggravated by super- (14%) had liver cirrhosis (LC), 17 (13%)had CAH and infection with hepatitis delta virus (HDV), a viroid-like LC, and 3 (2%) had hepatocellular carcinomas (HCC). The risk factors for chronic HBsAg carriage were: agent requiring hepatitis B surface antigen (HBsAg) for its propagation [Hoofnagel, 1989; Taylor, 19901. intravenous (IV) drug abuse in 25 cases (16%); sexual During the acute phase of HDV infection, hepatitis contact in 27 cases (17%), of whom 23 were male homodelta antigen (HDAg) may be detected in the sera of sexuals; medical occupation in 18 cases (11%); blood patients using radioimmunoassay (RIA) or enzyme- product injection in 10 cases (6%);immigration from (or linked immunoassay (EIA) [Dubois and Goudeau, 1988; a stay in) a n HBV endemic area in 60 cases (38%). Buti et al., 1988; Shattock and Morris, 19911. During chronic HDV infection, patients develop high titres of Accepted for publication April 24, 1992. anti-HD, frequently associated with IgM anti-HD [Di Address reprint requests t o Dr. Philippe Roingeard, LaboraBisceglie and Negro, 19891, and serum HDAg is not toire de Virologie, URA CNRS 1334, HBpital Bretonneau, 2 Boudetected by RIA or EIA, probably because of the forma- levard Tonnelle, 37044 Tours Cedex, France. 0 1992 WILEY-LISS, INC.
192
Roingeard et al. TABLE I. Serological Features of 157 Consecutive Cases of Known Chronic HBsAg Carriers
Mean age Female IV drug abuse Anti-HIV+ HIVAg +
HDAg+
HDV positive" Anti-HD+/HDAg-
Total with HDV markers
HDV negative
gb (6%')
27' (17%)
36 (23%)
121 (77%)
33 t 12 3 (11%) 14 (52%) 7 (26%)) 015
32 k 12 8 (22%) 21 (58%)P < 0.001 14 (39%)P < 0.001 3110
39 -t 13 26 (21%') 4 (3%) 6 (5%) 016
31 k 12 5 (56%)P < 0.05 7 (78%)ns 7 (78%)P < 0.01 315 (60%)P < 0.2
"Anti-HD and/or HDAg positive. b6/9also anti-HD positive, including 2 IgM anti-HD. '21 IgM anti-HD positive.
HDVAg and total anti-HD were tested by Hepanostika delta (Organon Teknika, Boxtel, The Netherlands), which detects HDAg or anti-HD as previously described [Dubois and Goudeau, 1988; Pol et al., 19891. IgM anti-HD was detected with Hepanostika anti-delta IgM (Organon Teknika). Anti-HIV was detected by Western Blot (Dupont, Rockville, MD) and the positive sera were tested for HIVAg by EIA (Abbott).Fifty-eight patients were followed for a period ranging from 3 to 29 months. The chi-square test and its Yates's correction (for populations s 5 samples) were used for statistical comparisons (degree of freedom = 1).
RESULTS Thirty-six patients (23%)had a t least one serological marker of HDV infection: anti-HD and/or HDAg (Table I).They were younger (32 2 12)than the HDV negative patients (39 ? 13). Among the 36 HDV positive patients, 21 (58%)were IV drug abusers, compared to only 4 (3%')among the 121 HDV negative cases ( P < 0.001). The distributions of other risk factors were not significantly different between the HDV positive and the HDV negative patients. Anti-HIV was more frequently found among the HDV positive patients: 14/36 (39%)vs. 61121 (5%) among the HDV negative patients ( P < 0.001 1. CAH and/or LC were found by liver histology in 31/33 (94%~) of the HDV positive patients and 85/97 (88%) of the HDV negative patients (not significant). The sera of 9 patients were positive for HDAg (6%)of the study population, 25% of the HDV positive patients), including 6 who were also anti-HD positive (Table I). Five of the 9 (56%)were female patients, vs. 3127 (11%)in the HDAg negative/anti-HD positive group ( P < 0.05). IgM anti-HD was detected in 219 (22%) HDAg positive patients and in 21/27 (78%) HDAg negativeianti-HD positive patients ( P < 0.01 j. AntiHIV was found in 719 (78%)HDAg positive patients and in 7/27 (26%)HDAg negativeianti-HD positive patients ( P < 0.01).Sixteen of the 20 anti-HIV positive patients were tested for serum HIVAg: 3 of the 5 HDAg positive patients were HIVAg positive, but none of the 5 HDAg negativeianti-HD positives ( P < 0.2) and none of the 6 HDV negatives were HIVAg positive. CAH and/or LC were found by analysis of liver histology in 8J8 HDAg
positive patients and 23/25 HDAg negativeianti-HD positive patients. Five serum HDAg positive patients were followed up for 4-29 months (mean 13 months). All five patients had persistent HD antigenaemia. Of the 36 sera collected from these 5 HDAg positive patients, 34 were HDAg positive. The profiles of two patients are presented in Figure 1. One patient became serum HDAg negative on two consecutive samples but HDAg was detected in the subsequent samples (patient Ha in Fig. 1 ) . During the follow-up of these five patients, one anti-HD negative subject developed anti-HD and a second developed IgM anti-HD. Twelve HDAg negativeianti-HD positive patients were followed up for 7-18 months (mean 11 months): anti-HD persisted in all cases, IgM anti-HD persisted in 9/10 patients, and all remained HDAg negative. Fortyone HDV negative patients, followed up for 3-15 months (mean 10 months), remained HDV negative (HDAg or anti-HD negative).
DISCUSSION This study provides the first estimate of the prevalence of persistent HD antigenaemia in a n unselected population of HBsAg positive chronic liver diseases. Among 36 HDV positive HBsAg carriers, 9 (25% were found to be HDAg positive. The five patients for whom follow-up was possible remained HDAg positive, indicating that this profile is much more common than previously thought. Three of the nine HDAg positive patients were anti-HD negative: in these cases, a serological investigation based only on anti-HD detection would have misinterpreted the aetiology of the underlying chronic liver disease. Optical density values given by EIAs with sequential sera showed fluctuating levels of serum HDAg and anti-HD, including periods of negativity. Moreover, the levels of HDAg and anti-HD appeared to be inversely correlated, suggesting the need of these complementary EIAs for accurate diagnosis of chronic HDV infection. IV drug abuse was the only risk factor differentiating HDV positive from HDV negative patients. The high prevalence of HDV infection in IV drug abusers compared to other groups at risk of acquiring HBV infection (male homosexuals, medical care workers) has
-
Persistent Hepatitis Delta Antigenaemia
10
9 8 7
193
Patient Fo (HDAg) Patient Ha (HDAg)
6
5 4
3 2 1
0
6 8 1012141618202224262830Months
0 2 4 1,6 1
1
l
0
'
l
2
'
4
l
'
6
i
'
l
~
l
~
l
~
l
~
l
~
l
'
l
'
l
'
l
'
l
'
l
'
~
8 1012141618202224262830Months
Fig. 1. Hepatitis delta antigen (HDAg)and antibody (anti-HD)semiquantified by EIA on sequential serum samples from two chronic HBsAg carriers (patients Ha and Fo). The value is calculated as the optical density divided by the cutoff value. HDAg was detected by a sandwich EIA, giving a value directly proportional to the HDAg level. Anti-HD was detected by a sandwich-inhibition EIA, giving a value inversely proportional to the antibody level.
been previously reported but the reasons remain unclear [Hoofnagel, 19891. The higher prevalence of HIV infection among the HDV positive patients (P< 0.001) was the consequence of the IV drug abuse factor in this population. However, HD antigenaemia was correlated with coincident HIV infection ( P < 0.01) but not with IV drug abuse. HIVAg was found in three of five antiHIV/HDAg positive patients, and in none of five antiHIVianti-HD positive patients, suggesting that persistent HD antigenaemia may correlate with severe immunodeficiency [Pedersen et al., 19871. Suppression
of cytotoxic T lymphocyte activity against hepatocytes expressing HDAg could explain the persistence of HD antigenaemia; this mechanism has been previously suggested for hepatitis B e antigen (HBe Ag, a HBV core-associated antigen) in chronic HBV infection [Goldin e t al., 19901. Alternatively, HD antigenaemia could be due to a n overall lowering of the hurnoral response against HDAg, as suggested by the lack of IgM anti-HD in 7/9 HDAg positive patients vs. 6/27 in HDAg negativeianti-HD positive patients ( P < 0.01). A combination of these two mechanisms may also be possible.
Roingeard et al.
194
Curiously, HDAg positive patients were more frequently female than male ( P < 0.05). It is speculated that hormonal factors are involved in the regulation of HDV replication. This hypothesis deserves to be investigated in vitro, using the recently developed HDV culture system [Wu et al., 19911.
ACKNOWLEDGMENTS This work was supported by grant 900702 from INSERM, France, and by a grant from the Ministere de 1'Education Nationale, France. REFERENCES Buti M, Esteban R, Roggendorf M, Fernandez J, Jardi R, Rashofer R, Allende H, Genesca J (1988):Hepatitis D virus RNA in acute delta infection: Serological profile and correlation with other markers of hepatitis D virus infection. Hepatology 81125-1129. Buti M, Esteban R,Jardi R, Rodriguez-Frias F, Casacuberta J , Esteban J I , Allende E, Guardia J (1989): Chronic delta hepatitis: Detection of hepatitis delta virus antigen in serum by immunoblot and correlation with other markers of delta virus replication. Hepatology 10:907-910. Di Bisceglie AM, Negro F (1989):Diagnosis of hepatitis delta virus infection. Hepatology 10:1014-1016. Dubois F, Goudeau A (1988):Kinetics of delta antigen and delta antibody in acute delta hepatitis: Evaluation with different enzyme immunoassays. Journal of Clinical Microbiology 7:1339-1342.
Goldin RD, Fish DE, Hay A, Waters JA, McGarvey MJ, Main J , Thomas HC (1990): Histological and immunohistochemical study of hepatitis B virus in human immunodeficiency virus infection. Journal of Clinical Pathology 43:203-205. Grippon P, Ribiere 0, Cadranel JF, Pelletier S, Karkouche B, Pillot B, Emerit J , Opolon P (1987):Long-term delta antigenaemia without appearance of delta antibody in two immunodeficient patients. Lancet 1:1021. Hoofnagel J H (1989): Type D (delta) hepatitis. Journal of the American Medical Association 261:1321-1325. Pedersen C, Neilsen C, Vestergaard B, Gerstoft J, Krogsgaard K, Nielsen J O (1987):Temporal relation of antigenaemia and loss and antibodies to core antigens to development of clinical disease in HIV infection. British Medical Journal 295567-569. Pol S, Dubois F, Roingeard P, Zignedo L, Housset C, Brechot C, Goudeau A, Berthelot P (1989):Hepatitis delta virus infection in french male HBsAg positive homosexuals. Hepatology 10:342-345. Shattock AG, Morris MC (1991): Evaluation of commercial enzyme immunoassays for detection of hepatitis delta antigen and antihepatitis delta virus (HDV) and immunoglobulin M anti-HDV antibodies. Journal of Clinical Microbiology 29:1873-1876. Shattock AG, Finlay H, Hillary IB (1987): Possible reactivation of hepatitis D with chronic 6 antigenaemia by human immunodeficiency virus. British Medical Journal 294:16561657. Taylor JM (1990): Hepatitis delta virus: cis and trans functions required for replication. Cell 61:371-373. Wu J-C, Chen P-J, Kuo MYP, Lee S-D, Chen D-S, Ting L-P (1991): Production of hepatitis delta virus and suppression of helper hepatitis B virus in a human hepatoma cell line. Journal of Virology 65:1099-1104.
Persistent Delta Antigenaemia in Chronic Delta Hepatitis and Its Relation With Human Immunodeficiency Virus Infection Philippe Roingeard, Frederic Dubois, Patrick Marcellin, Jacques Bernuau, Sylvie Bonduelle, Jean-Pierre Benhamou, and Alain Goudeau Laboratoire de Virologie, URA CNRS 1334, Hbpital Bretonneau, Tours (P.R., F.D., S.B., A.G.), and Service d'Hepatologie, INSERM U 24, Hhpital Beaujon, Clichy (P.M., J.B., J.-P.B.), France The prevalence of persistent hepatitis delta (HD) antigenaemia and associated factors in patients with chronic infection with the hepatitis delta virus (HDV) were investigated. Among 157 consecutive patients known t o be carriers of hepatitis B surface antigen (HBsAg), 36 (23%) had one serum marker of HDV infection (anti-HD and/or HDAg). Nine of the patients with an HDV marker were HDAg positive, including three w h o were anti-HD negative. A follow-up over a mean period of 13 months showed that five of five patients had a persistent HD antigenaemia. This serological profile was associated with the presence of antibody to the human immunodeficiency virus (anti-HIV) (P < 0.01), serum HIV antigen (HlVAg) ( P < 0.21, and the female sex (P < 0.05). Persistent HD antigenaemia could be the consequence of the suppression of T cell cytotoxic activity against hepatocytes expressing HDAg, a lower humoral response, and/or hormonal factors. o 1992 Wiley-Liss, Inc.
tion of immune complexes with anti-HD [Di Bisceglie and Negro, 1989; Buti et al., 19891. Western blotting, a technique that denatures immune complexes, is the only satisfactory method for the detection of complexed HDAg, but it is technically difficult [Buti et al., 19891. The diagnosis of chronic HDV infection is, therefore, usually based on the detection of anti-HD [Di Bisceglie and Negro, 19891. The occurrence of a persistent HD antigenaemia detected by RIA or EIA has been reported in three patients, all of whom were infected by the human immunodeficiency virus (HIV) [Grippon et al., 1987; Shattock et al., 19871. There have been no assessments to date of the prevalence of HD antigenaemia in populations of chronic HDV carriers, either infected by, or free of HIV. One hundred and fifty-seven unselected consecutive HBsAg carriers were studied to estimate the prevalence of persistent HD antigenaemia and to identify associated factors.
PATIENTS AND METHODS One hundred and fifty-seven patients (123 men, 34 women; mean age 37) known to be HBsAg carriers (RIA; Abbott Laboratories, Chicago, IL) were included KEY WORDS: hepatitis B virus, hepatitis delta in this prospective study. They were all negative for virus, hepatitis delta antigen antibody to the hepatitis B core antigen of the IgM class (IgM anti-HBc, RIA, Abbott), and none displayed clinical or biological signs of acute hepatitis. Histological INTRODUCTION diagnosis based on a liver biopsy was carried out in 130 Chronic infection with the hepatitis B virus (HBV) is patients: 15 (12%) had chronic persistent hepatitis a major cause of chronic liver disease. In some patients, (CPH), 77 (59%) had chronic active hepatitis (CAH), 18 chronic liver disease may also be aggravated by super- (14%) had liver cirrhosis (LC), 17 (13%)had CAH and infection with hepatitis delta virus (HDV), a viroid-like LC, and 3 (2%) had hepatocellular carcinomas (HCC). The risk factors for chronic HBsAg carriage were: agent requiring hepatitis B surface antigen (HBsAg) for its propagation [Hoofnagel, 1989; Taylor, 19901. intravenous (IV) drug abuse in 25 cases (16%); sexual During the acute phase of HDV infection, hepatitis contact in 27 cases (17%), of whom 23 were male homodelta antigen (HDAg) may be detected in the sera of sexuals; medical occupation in 18 cases (11%); blood patients using radioimmunoassay (RIA) or enzyme- product injection in 10 cases (6%);immigration from (or linked immunoassay (EIA) [Dubois and Goudeau, 1988; a stay in) a n HBV endemic area in 60 cases (38%). Buti et al., 1988; Shattock and Morris, 19911. During chronic HDV infection, patients develop high titres of Accepted for publication April 24, 1992. anti-HD, frequently associated with IgM anti-HD [Di Address reprint requests t o Dr. Philippe Roingeard, LaboraBisceglie and Negro, 19891, and serum HDAg is not toire de Virologie, URA CNRS 1334, HBpital Bretonneau, 2 Boudetected by RIA or EIA, probably because of the forma- levard Tonnelle, 37044 Tours Cedex, France. 0 1992 WILEY-LISS, INC.
192
Roingeard et al. TABLE I. Serological Features of 157 Consecutive Cases of Known Chronic HBsAg Carriers
Mean age Female IV drug abuse Anti-HIV+ HIVAg +
HDAg+
HDV positive" Anti-HD+/HDAg-
Total with HDV markers
HDV negative
gb (6%')
27' (17%)
36 (23%)
121 (77%)
33 t 12 3 (11%) 14 (52%) 7 (26%)) 015
32 k 12 8 (22%) 21 (58%)P < 0.001 14 (39%)P < 0.001 3110
39 -t 13 26 (21%') 4 (3%) 6 (5%) 016
31 k 12 5 (56%)P < 0.05 7 (78%)ns 7 (78%)P < 0.01 315 (60%)P < 0.2
"Anti-HD and/or HDAg positive. b6/9also anti-HD positive, including 2 IgM anti-HD. '21 IgM anti-HD positive.
HDVAg and total anti-HD were tested by Hepanostika delta (Organon Teknika, Boxtel, The Netherlands), which detects HDAg or anti-HD as previously described [Dubois and Goudeau, 1988; Pol et al., 19891. IgM anti-HD was detected with Hepanostika anti-delta IgM (Organon Teknika). Anti-HIV was detected by Western Blot (Dupont, Rockville, MD) and the positive sera were tested for HIVAg by EIA (Abbott).Fifty-eight patients were followed for a period ranging from 3 to 29 months. The chi-square test and its Yates's correction (for populations s 5 samples) were used for statistical comparisons (degree of freedom = 1).
RESULTS Thirty-six patients (23%)had a t least one serological marker of HDV infection: anti-HD and/or HDAg (Table I).They were younger (32 2 12)than the HDV negative patients (39 ? 13). Among the 36 HDV positive patients, 21 (58%)were IV drug abusers, compared to only 4 (3%')among the 121 HDV negative cases ( P < 0.001). The distributions of other risk factors were not significantly different between the HDV positive and the HDV negative patients. Anti-HIV was more frequently found among the HDV positive patients: 14/36 (39%)vs. 61121 (5%) among the HDV negative patients ( P < 0.001 1. CAH and/or LC were found by liver histology in 31/33 (94%~) of the HDV positive patients and 85/97 (88%) of the HDV negative patients (not significant). The sera of 9 patients were positive for HDAg (6%)of the study population, 25% of the HDV positive patients), including 6 who were also anti-HD positive (Table I). Five of the 9 (56%)were female patients, vs. 3127 (11%)in the HDAg negative/anti-HD positive group ( P < 0.05). IgM anti-HD was detected in 219 (22%) HDAg positive patients and in 21/27 (78%) HDAg negativeianti-HD positive patients ( P < 0.01 j. AntiHIV was found in 719 (78%)HDAg positive patients and in 7/27 (26%)HDAg negativeianti-HD positive patients ( P < 0.01).Sixteen of the 20 anti-HIV positive patients were tested for serum HIVAg: 3 of the 5 HDAg positive patients were HIVAg positive, but none of the 5 HDAg negativeianti-HD positives ( P < 0.2) and none of the 6 HDV negatives were HIVAg positive. CAH and/or LC were found by analysis of liver histology in 8J8 HDAg
positive patients and 23/25 HDAg negativeianti-HD positive patients. Five serum HDAg positive patients were followed up for 4-29 months (mean 13 months). All five patients had persistent HD antigenaemia. Of the 36 sera collected from these 5 HDAg positive patients, 34 were HDAg positive. The profiles of two patients are presented in Figure 1. One patient became serum HDAg negative on two consecutive samples but HDAg was detected in the subsequent samples (patient Ha in Fig. 1 ) . During the follow-up of these five patients, one anti-HD negative subject developed anti-HD and a second developed IgM anti-HD. Twelve HDAg negativeianti-HD positive patients were followed up for 7-18 months (mean 11 months): anti-HD persisted in all cases, IgM anti-HD persisted in 9/10 patients, and all remained HDAg negative. Fortyone HDV negative patients, followed up for 3-15 months (mean 10 months), remained HDV negative (HDAg or anti-HD negative).
DISCUSSION This study provides the first estimate of the prevalence of persistent HD antigenaemia in a n unselected population of HBsAg positive chronic liver diseases. Among 36 HDV positive HBsAg carriers, 9 (25% were found to be HDAg positive. The five patients for whom follow-up was possible remained HDAg positive, indicating that this profile is much more common than previously thought. Three of the nine HDAg positive patients were anti-HD negative: in these cases, a serological investigation based only on anti-HD detection would have misinterpreted the aetiology of the underlying chronic liver disease. Optical density values given by EIAs with sequential sera showed fluctuating levels of serum HDAg and anti-HD, including periods of negativity. Moreover, the levels of HDAg and anti-HD appeared to be inversely correlated, suggesting the need of these complementary EIAs for accurate diagnosis of chronic HDV infection. IV drug abuse was the only risk factor differentiating HDV positive from HDV negative patients. The high prevalence of HDV infection in IV drug abusers compared to other groups at risk of acquiring HBV infection (male homosexuals, medical care workers) has
-
Persistent Hepatitis Delta Antigenaemia
10
9 8 7
193
Patient Fo (HDAg) Patient Ha (HDAg)
6
5 4
3 2 1
0
6 8 1012141618202224262830Months
0 2 4 1,6 1
1
l
0
'
l
2
'
4
l
'
6
i
'
l
~
l
~
l
~
l
~
l
~
l
'
l
'
l
'
l
'
l
'
l
'
~
8 1012141618202224262830Months
Fig. 1. Hepatitis delta antigen (HDAg)and antibody (anti-HD)semiquantified by EIA on sequential serum samples from two chronic HBsAg carriers (patients Ha and Fo). The value is calculated as the optical density divided by the cutoff value. HDAg was detected by a sandwich EIA, giving a value directly proportional to the HDAg level. Anti-HD was detected by a sandwich-inhibition EIA, giving a value inversely proportional to the antibody level.
been previously reported but the reasons remain unclear [Hoofnagel, 19891. The higher prevalence of HIV infection among the HDV positive patients (P< 0.001) was the consequence of the IV drug abuse factor in this population. However, HD antigenaemia was correlated with coincident HIV infection ( P < 0.01) but not with IV drug abuse. HIVAg was found in three of five antiHIV/HDAg positive patients, and in none of five antiHIVianti-HD positive patients, suggesting that persistent HD antigenaemia may correlate with severe immunodeficiency [Pedersen et al., 19871. Suppression
of cytotoxic T lymphocyte activity against hepatocytes expressing HDAg could explain the persistence of HD antigenaemia; this mechanism has been previously suggested for hepatitis B e antigen (HBe Ag, a HBV core-associated antigen) in chronic HBV infection [Goldin e t al., 19901. Alternatively, HD antigenaemia could be due to a n overall lowering of the hurnoral response against HDAg, as suggested by the lack of IgM anti-HD in 7/9 HDAg positive patients vs. 6/27 in HDAg negativeianti-HD positive patients ( P < 0.01). A combination of these two mechanisms may also be possible.
Roingeard et al.
194
Curiously, HDAg positive patients were more frequently female than male ( P < 0.05). It is speculated that hormonal factors are involved in the regulation of HDV replication. This hypothesis deserves to be investigated in vitro, using the recently developed HDV culture system [Wu et al., 19911.
ACKNOWLEDGMENTS This work was supported by grant 900702 from INSERM, France, and by a grant from the Ministere de 1'Education Nationale, France. REFERENCES Buti M, Esteban R, Roggendorf M, Fernandez J, Jardi R, Rashofer R, Allende H, Genesca J (1988):Hepatitis D virus RNA in acute delta infection: Serological profile and correlation with other markers of hepatitis D virus infection. Hepatology 81125-1129. Buti M, Esteban R,Jardi R, Rodriguez-Frias F, Casacuberta J , Esteban J I , Allende E, Guardia J (1989): Chronic delta hepatitis: Detection of hepatitis delta virus antigen in serum by immunoblot and correlation with other markers of delta virus replication. Hepatology 10:907-910. Di Bisceglie AM, Negro F (1989):Diagnosis of hepatitis delta virus infection. Hepatology 10:1014-1016. Dubois F, Goudeau A (1988):Kinetics of delta antigen and delta antibody in acute delta hepatitis: Evaluation with different enzyme immunoassays. Journal of Clinical Microbiology 7:1339-1342.
Goldin RD, Fish DE, Hay A, Waters JA, McGarvey MJ, Main J , Thomas HC (1990): Histological and immunohistochemical study of hepatitis B virus in human immunodeficiency virus infection. Journal of Clinical Pathology 43:203-205. Grippon P, Ribiere 0, Cadranel JF, Pelletier S, Karkouche B, Pillot B, Emerit J , Opolon P (1987):Long-term delta antigenaemia without appearance of delta antibody in two immunodeficient patients. Lancet 1:1021. Hoofnagel J H (1989): Type D (delta) hepatitis. Journal of the American Medical Association 261:1321-1325. Pedersen C, Neilsen C, Vestergaard B, Gerstoft J, Krogsgaard K, Nielsen J O (1987):Temporal relation of antigenaemia and loss and antibodies to core antigens to development of clinical disease in HIV infection. British Medical Journal 295567-569. Pol S, Dubois F, Roingeard P, Zignedo L, Housset C, Brechot C, Goudeau A, Berthelot P (1989):Hepatitis delta virus infection in french male HBsAg positive homosexuals. Hepatology 10:342-345. Shattock AG, Morris MC (1991): Evaluation of commercial enzyme immunoassays for detection of hepatitis delta antigen and antihepatitis delta virus (HDV) and immunoglobulin M anti-HDV antibodies. Journal of Clinical Microbiology 29:1873-1876. Shattock AG, Finlay H, Hillary IB (1987): Possible reactivation of hepatitis D with chronic 6 antigenaemia by human immunodeficiency virus. British Medical Journal 294:16561657. Taylor JM (1990): Hepatitis delta virus: cis and trans functions required for replication. Cell 61:371-373. Wu J-C, Chen P-J, Kuo MYP, Lee S-D, Chen D-S, Ting L-P (1991): Production of hepatitis delta virus and suppression of helper hepatitis B virus in a human hepatoma cell line. Journal of Virology 65:1099-1104.
