w w w . r e u m a t o l o g i a . c o m . b r
REVISTA
BRASILEIRA
DE
REUMATOLOGIA
Original
article
Hepatitis
C
virus
antibodies
in
high
risk
juvenile
onset
systemic
lupus
erythematosus
Nádia
E.
Aikawa
a,b,∗,
Ana
P.
Nascimento
a,
André
L.S.
Hayata
a,
Eloisa
Bonfá
a,
Cláudia
Goldenstein-Schainberg
aaDivisionofRheumatology,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil
bPediatricRheumatologyUnit,HospitaldaCrianc¸a,HospitaldasClínicas,SchoolofMedicine,UniversidadedeSãoPaulo,
SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received22October2014 Accepted27October2015 Availableonline19March2016
Keywords:
HepatitisCvirus Anti-HCV
Juvenilesystemiclupus erythematosus
a
b
s
t
r
a
c
t
Objective:ToevaluatetheprevalenceofhepatitisCvirus(HCV)infectioninhighriskjuvenile systemiclupuserythematosus(JSLE).
Studydesign:FortylowincomeJSLEpatients(6M:34F;meanage19±4.4yrs;meandisease duration6±3.2yrs)werestudied.Twentyhealthychildrenandadolescentsmatchedfor socialeconomicallevelwereincludedascontrols.Anti-HCVtestswereperformedusing athirdgenerationmicroparticleenzymeimmunoassay.Inclusioncriterionwaslowsocial economicallevel.
Results:Thefrequenciesofanti-HCVantibodywerelowandcomparablebetweenJSLEand controlgroup(2.5%vs.0,p=1.0).JSLEpatientshadsignificantlymoreriskfactorsforHCV infectioncomparedtothecontrolgroup,includingimmunosuppressivetreatment(90%vs. 0,p<0.0001),hospitalization(50%vs.12.5%,p=0.0006)andinvasiveprocedures(47.5%vs. 12.5%,p=0.001).
Conclusions: Theobservedlowfrequencyofanti-HCVantibodiesinhighriskJSLEsuggests thatthisvirusdoesnotseemtohavearelevantroleinthepathogenesisofthisdisease.
©2016ElsevierEditoraLtda.Allrightsreserved.
Anticorpos
contra
o
vírus
da
hepatite
C
em
pacientes
de
alto
risco
com
lúpus
eritematoso
sistêmico
de
início
juvenil
Palavras-chave:
VíruscontraahepatiteC Anti-VHC
Lúpuseritematososistêmico deiníciojuvenil
r
e
s
u
m
o
Objetivo:Avaliaraprevalênciadeinfecc¸ãopelovírusdahepatiteC(VHC)empacientesde altoriscocomlúpuseritematososistêmicodeiníciojuvenil(LESJ).
Desenhodoestudo:Foramestudados40pacientesdebaixarendacomLESJ(6H:34M,com médiade19±4,4anos;durac¸ãomédiadadoenc¸ade6±3,2anos).Incluíram-senogrupo controle20crianc¸aseadolescentessaudáveispareadospornívelsocioeconômico. Fizeram-setestesanti-VHCcomumensaioimunoenzimáticodemicropartículasdeterceiragerac¸ão. Ocritériodeinclusãofoiobaixonívelsocioeconômico.
∗ Correspondingauthor.
E-mail:[email protected](N.E.Aikawa). http://dx.doi.org/10.1016/j.rbre.2016.02.011
Resultados: Asfrequênciasdeanticorposanti-VHCforambaixasecomparáveisentreos gruposLESJecontrole(2,5%versus0,p=1).OspacientescomLESJtinham significativa-mentemaisfatoresderiscoparainfecc¸ãoporVHCemcomparac¸ãocomogrupocontrole, incluindotratamentoimunossupressor(90%versus0,p<0,0001),internac¸ão(50%versus 12,5%,p=0,0006)eprocedimentosinvasivos(47,5%versus12,5%,p=0,001).
Conclusões:Abaixafrequênciadeanticorposanti-VHCobservadanospacientesdealtorisco comLESJsugerequeessevírusnãopareceterumpapelrelevantenapatogênesedessa doenc¸a.
©2016ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Systemic lupus erythematosus (SLE) is a complex autoim-mune disease,characterizedbya wide spectrum of multi-organ involvement and laboratorial abnormalities. The diseaseischaracterizedbyseveralimmunoregulatory alter-ations that culminate to an exacerbated production of autoantibodies.ThepathogenesisofSLEisstillunclearbut someinfectiousagents,includinghepatitisCvirus(HCV),may beinvolvedaspossibletriggeringagents.1,2
HCVisalinearsinglestrandedRNAvirusofthe Flaviviri-daefamily,whichhasanextensivegenomicvariability.3Itis
wellknownthatHCVinfection isoneofthemostcommon causesofchronicviralhepatitis.3Furthermore,several
extra-hepaticimmunologicalmanifestationshavebeenassociated toHCV.4–6
In fact, HCV is an important inductor of autoantibody productionsuchasantinuclearantibodies (ANA),6
rheuma-toid factors and cryoglobulins7 and a possible association
ofthisvirus withautoimmunerheumatic diseases, includ-ing Sjögren’ssyndrome and vasculitis has been previously described.8,9InadultSLEpatientssomereportspointoutto
ahigherprevalenceofanti-HCVantibodies(3–13%)thanthe expectedforthe generalpopulation1,10,11 raising the
possi-bilitythatexposuretothisinfectionagentmaycontributeto diseaseexpression.
Thereare,however,nodataregardingtheassociationof HCVinjuvenileSLE(JSLE).Therefore,the aimofthisstudy wastoinvestigatetheprevalenceofseraanti-HCVantibodies inhighriskJSLEpatients.
Patients
and
methods
Fiftyconsecutivelowincomesubjectswhofulfilledthe Ameri-canCollegeofRheumatology(ACR)classificationcriteria12for
JSLEfollowedatourPediatricRheumatologyUnitwereinitially selected.Tenofthemwereexcludedduetoincompletecharts andirregularfollow-up.Theremainingfortyeligiblepatients wereincludedinthestudy.Twentyhealthysubjectsmatched bysocioeconomicstatus(accordingtoastandardized ques-tionnaireofAssociac¸ãoBrasileira dos Institutosde Pesquisade Mercados)wereselectedforthecontrolgroup.13
HighHCVriskfactorwasdefinedbylowincome[lowest Braziliansocio-economicclasses(C,DorE)]andpresenceof oneormoreriskfactors:hospitalizations,invasivediagnostic
or therapeutic procedures (intravenous medications, biop-siesorendoscopicdiagnosticmethods),immunosuppressive drugs,bloodproductstransfusions,intravenousdrugsuseand promiscuoussexualactivity(≥3sexualpartnersperyear).14
ThisstudywasapprovedbytheLocalEthicalCommitteeof ourUniversityHospital.
ForJSLEpatients,clinicalmanifestationsatdisease diag-nosis and atthe moment ofthe study were searched.SLE disease activityatstudyentrywasrecordedforallpatients usingtheSLEDiseaseActivityIndex(SLEDAI)score15andan
indexgreaterthan8wasconsideredasactiveJSLE.
Asystematicphysicalexaminationwasperformedtofind signs ofhepaticimpairment,including cutaneousstigmata, liverenlargement,ascitesand/orjaundice.
Detectionofanti-HCVantibodies
Testingforanti-HCVantibodieswasperformedinserafromall JSLEpatientsandcontrolsusingathirdgeneration immunen-zymeassaywithMEIA–microparticleenzymeimmunoassay (ELISA-3; Axsym System version 3.0; Abbott, Abbott Park, IL). TheMEIAtest isa variationofthe standardized enzy-matic immunoabsorbancy assay (EIA) developed to detect specificantibodiesagainststructuralandnon-structural pro-teins of virus genome. Thismethod uses plate containing recombinant HCV antigens Hcr43, c200, c100-3, pL33c and NS5.
Laboratoryautoimmuneandhepaticprofile
Allsubjectswerescreenedforanti-nuclearantibodies(ANA) byindirectimmunofluorescenceusingHEp-2cellsassubstrate and anti-dsDNA antibody by indirect immunofluorescence usingCrithidialuciliae.Furtherserologicevaluationincluded testing for Ro and La autoantibodies by countercurrent immunoelectrophoresis,anti-Smandanti-ENAantibodiesby hemmaglutination, IgM and IgG anti-cardiolipin by ELISA and rheumatoid factor by latex fixation and Waaler–Rose tests. In addition, protein electrophoresis, cryoglobulins (by cryoprecipitation) and total complement CH100 (by immunohemolysis)including C3and C4fractions(byradial immunodiffusion)wereinvestigated.
Table1–DemographicdataandriskfactorsforHCVinfectionin40JSLEpatientsand20controls.
JSLEpatient Controls p-Value
n=40 n=20
n(%)
Demographicdata
Femalegender,n(%) 34(85) 16(80) 0.72
Meandiseaseduration,years 6±3.2 –
Caucasianrace,n(%) 36(90) 14(70) 0.07
Riskfactor
Bloodandbloodcomponentstransfusion 0 0 1.0
Sexualpromiscuity 0 0 1.0
Drugaddiction 0 0 1.0
Lowincome 40(100) 20(100) 1.0
Immunosuppressivedrug 36(90) 0 <0.0001
Previoushospitalization 20(50) 2(10) 0.004
Numberofinvasiveprocedures 19(47.5) 3(15) 0.022
JSLE,juvenilesystemiclupuserythematosus;HCV,hepatitisCvirus.
Statisticalanalysis
Resultsare presentedasthe mean±standard deviationfor continuousvariablesandnumber(%)forcategoricalvariables. Differencesbetweencategoricalvariables were assessedby Fisher’sexacttest.Inallstatisticaltestssignificancewas con-sideredwithapvalue<0.05.
Results
Thirtyfour(85%)JSLEpatientsand16(80%)controlsubjects werefemale withameanageof19±4.4years and17±3.9 yearsrespectively(p>0.05).Themeandiseasedurationwas 6±3.2years.
Frequenciesofpositiveserumanti-HCVwerelowand com-parable in JSLE and control group (2.5% vs. 0, p=1.0). JSLE patientshadsignificantlymoreriskfactorsforHCVinfection comparedtothecontrolgroup,including immunosuppress-ivetreatment(90%vs.0,p<0.0001),hospitalization(50%vs. 12.5%,p=0.0006)and invasive procedures (47.5%vs. 12.5%, p=0.001)(Table 1). None of them had history of contami-natedbloodproducttransfusionorsexualrelationwithaHCV individual.
All47JSLEpatients ´hospitalizationswereduetoeither bac-terialinfections or to disease relapses and forthe control group,the5hospitalizationswereduetoinvasiveprocedures. The only JSLE patient with detectable anti-HCV was a 23 year-oldfemale patientwithnormal liverultrasound in spiteofslightly elevatedtransaminaseslevels (AST61IU/L, ALT58IU/L)andhypergammaglobulinemia.Hercomplement levelswere normal,ANA waspositive (1/200)and all other autoantibodiesincludingantiliverantibodiesand cryoglobu-linswerepersistentlynegative.Atthemomentofthestudy, she had a mild malar rash, photosensitivity and arthri-tis with a SLEDAI <8 in spite of taking low dose GC and chloroquine.
TheanalysisofJSLEclinicalmanifestationsdemonstrated: 40(100%)cutaneousandjoints,18(46%)renal,18(46%) hema-tologicaland15(38%)neurological.MorethanonethirdofJSLE
patients(15/39;38%)hadactivedisease(SLEDAI≥8).Halfof themwereonhighdosesofglucocorticoid(GC),varyingfrom 0.5to1.0mg/kg/day,and90%wereunderimmunosuppressive treatmentforameanperiodof1.5±0.5years[azathioprinein 22(56%),methotrexatein2(5%)andcyclophosphamidein12 (31%);4wereonmonthlyGCpulsetherapy].
Further laboratory analysis revealed that ten (26%) JSLE childrenhadhypergammaglobulinemiaand12(31%)hadlow complement levels comparedtonone inthe controlgroup (p<0.05).CryoglobulinswerenegativeinserafromallJSLEand controls.ANA, anti-dsDNA,anti-Smandanti-Rowere posi-tiveinserafrom100%,50%,27.5%and17.5%ofJSLEpatients, respectively.Autoantibodieswereuniformlynegativein con-trolgroup.
Discussion
Toourknowledge,thisisthefirststudytodemonstratealow frequencyofanti-HCVserologyinapopulationofhighrisk JSLEpatientsfromatertiaryUniversityHospital.
A limitation of the present study is that nowadays all adolescentsandyoungadultsareunderriskofsexually trans-mitted diseases,including hepatitisC.This isaworldwide problem,andthisissueisimportantnotonlytolowerincome families but to all families. Moreover, the low number of subjectsinthecontrolgrouphereinhampersdefinitive con-clusionsregardingHCVinhealthysubjects.
The prevalence of HCV infection among blood donors varies in different Braziliangeographic areas from 0.8%in smallercitiessuchasCuritiba,Paranáto4.78%inourlargest city SãoPaulo.16,17 Data regardingHCVinfection inhealthy
children and adolescents are however worldwide scarce. A study conducted by Martins18 in Goiânia, Middle West
of Brazil, revealed a prevalence of anti-HCV antibodies in this age bracket varying from 0.2to 3%, similarly to chil-dren from a tertiary pediatric center in London, England (1.97%).19
had low social levels and at least one additional known riskfactorforHCVtransmissionsuchas immunosuppress-ivedrugsuse,hospitalizationsandinvasiveinterventions.18,20
Thislowprevalencemay bepartiallyexplainedbythefact that patients were predominantly female and the virus seems to be influenced by genderbeing more frequent in men.4 Accordingly, Karakoc et al. reported a frequency of
2.6% of anti-HCV by ELISA in a cohort of 38 SLE female patients, similar to the control population of the same region.21 Moreover, in our Rheumatology outpatientclinic,
JSLEpatientsareroutinelyorientedregardingsexualactivity andprotectionagainstsexuallytransmitteddiseases, there-fore the low frequency of anti-HCV serology observed in the JSLE groupcan be relatedto abetter education ofthe patients.
Ontheotherhand,themethodologyemployeddoesnot seemtoaccountforthenearlyabsenceofthisreactivityin thepresent studysincemicroparticlesare usedtoincrease the reactantsurfaceallowing highlevels ofsensitivityand specificity.22Infact,noneofour15patientswithactivedisease
(elevatedSLEDAIindex)revealedapositivetestforanti-HCV inspiteofpreviousreportoffalsepositiveanti-HCVserology relatedtolupusactivity.5,11,23
Additionally, HCV has also been associated to a high varietyof extrahepatic manifestationsincluding membra-noproliferativeglomerulonephritis,porphyriacutaneatarda, lychenplanusandthyroiditis.4–9ThenotablecapacityofHCV
to induce autoantibodies has aroused particular interests in the possible association between SLE and HCV chronic hepatitis.6 In fact, lupus patients concurrently infected by
HCV were reported toexpress distinct featureswith lower frequencyof cutaneousinvolvement and anti-dsDNA anti-bodies titers and higher frequency of liver injuries,24 a
pattern also observed in the only patient with this con-dition reported in the present study. Cryoglobulins are alsofrequently found in HCV positivecontrasting to HCV-negative SLE patients,25 although not observed in our
patient.
Inconclusion,thisstudysuggeststhatHCVdoesnotseem torepresentanimportantcomplicationinJSLE.Thepossible relevanceofthisvirusinlupusmanifestationsremainstobe determined.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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