Section 3 -

Compound Disease Occurrence and Overlap Syndromes Neil Theise, M.D. Romil Saxena, M.D.

Case 3A 56 year old man. Hepatitis C positive; liver biopsy for grading and staging Diagnosis: Chronic hepatitis with moderate interface activity and at least portal fibrosis, clinically hepatitis C Steatosis, moderate with extensive steatofibrosis. Comment: Hepatitis C infection and non- alcoholic fatty liver disease are two of the commonest causes of chronic liver disease in the US; therefore it is not unlikely that these 2 conditions may co-exist in the same patient. However, this simple fact is complicated by experimental evidence that implicates HCV as an etiologic factor in the development of steatosis. In transgenic mouse models, the hepatitis C core protein has been shown to lead to hepatic steatosis, and correlate with the grade of steatosis. The HCV core protein has also been found within fat droplets in hepatocytes, and has been shown to inhibit microsomal transfer protein which may lead to an accumulation of triglycerides in hepatocytes. The original descriptions of the histological features of HCV described mild macrovesicular steatosis, in addition to portal lymphoid follicles and bile duct damage, as one of the 3 cardinal features of HCV. It has become clear over the years however that the association of fatty liver and hepatitis C infection is not a simple one, especially in populations predisposed to fatty liver disease. Several studies have shown an independent association of steatosis with infection by genotype 3, but not with genotype 1. Sharma et al found steatosis in all patients with genotype 3; however in infection with genotype 1, the grade of steatosis correlated with BMI. Similarly, Hofer et al found correlation of BMI with steatosis in patients with genotype 1 infection, but not with genotype 3 infection. Monto reported that when patients with risk factors for NASH were excluded, only genotype 3 remained an independent predictor of steatosis. Additionally, a correlation has been demonstrated between viral load and development of steatosis in HCV genotype 3 infection. Thus, it appears that mild steatosis seen in non-3 genotype infection is a manifestation of NAFLD; whereas steatosis in patients with genotype 3 infection is the result of viral infection. Sharma et al and Hofer et al have shown lower cholesterol levels in patients with genotype 3. This lipid abnormality is reversed with viral eradication, but fails to normalize in non-responders. A direct relationship between cholesterol levels and hepatic steatosis was however not apparent. Other studies have shown lower beta-lipoprotein levels in patients with genotype 3 HCV, and this finding was associated with the presence of steatosis. Furthermore, a correlation has been demonstrated between hepatic viral load and apoprotein B levels. This raises the intriguing possibility that the hepatitis C virus may interfere with lipid metabolism. Several studies have shown the relationship and role of hepatic steatosis, body weight, visceral obesity and degree of fibrosis in HCV. An additional consequence of the presence of steatosis in association with hepatitis C infection is poor virological response of these patients to anti-HCV therapy. This may be particularly important in the context of increasing incidence of obesity; in other words, we may be required to treat more HCV patients with associated NAFLD. Case 3B 40 year old woman with elevated alkaline phosphatase (500-700 I.U.) and positive anti-mitochondrial antibodies, 1:640. ALT/AST also elevated in 100 - 200 I.U. range. Diagnosis: Primary biliary cirrhosis - autoimmune hepatitis overlap syndrome Comment: The term overlap syndrome has been applied to 2 distinct situations. The first is the crossover patient, who has characteristics mainly of one autoimmune disease, associated with one or two features of another: For e.g., a patient with distinctive features of PBC who also has positivity for autoimmune markers other than AMA. This is an erroneous definition of overlap autoimmune syndromes because there is considerable overlap in the clinical, biochemical and serological and even histological features in the classic presentations of the hepatic autoimmune diseases. The true overlap syndromes should by definition, show majority of the clinical, biochemical, serologic and histologic characteristics of 2 autoimmune diseases. The considerable overlap of clinical, serological, biochemical and histological features that occurs between the various autoimmune hepatic diseases makes diagnosis of the true overlap syndromes particularly challenging. This is evident in literature where several studies fervently claim the existence of overlap syndromes, and an equal number dispute their occurrence with comparable vigor. Thus the existence of a PBC-AIH overlap syndrome is a matter of intense debate, since PBC may be AMA negative, may have aberrant markers of autoimmunity, or may show considerable portal and lobular inflammation. Titers of AMA in PBC can fluctuate, becoming either positive or negative over the course of the disease. Up to 50% of PBC patients have low titers of ASMA and 70% are positive for ANA. Conversely, low AMA titers have been found in approximately 20% of patients with AIH. Some patients even have antibodies specifically against the PDC -E2 complex. Histologically, some degree of hepatitis-like parenchymal injury is almost universal in PBC. Using a set of strict criteria that required diagnosing each disease separately by the presence of at least 2 of 3 criteria for each disease, the incidence of PBC-AIH overlap was found to be 9% among a series of unselected PBC patients. At least 2 of 3 of the following criteria were required for the diagnosis of PBC: 1) serum alkaline phosphatase levels at least 2 times the normal level or GGT levels at least 5 times normal, (2) positive AMA and (3) a liver biopsy specimen showing florid duct lesion. The diagnosis of AIH required at least 2 of the following 3 criteria: (1) ALT levels 5 times normal, (2) serum IgG 2 times the normal level or a positive ASMA, and (3) liver biopsy with moderate or severe interface hepatitis and no other disease except PBC (Chazouilleres, 1998). A separate study defined PBC-AIH overlap syndrome as all patients who had an aggregate score of 10 or greater on the IAHG scoring system for AIH, and seropositivity for AMA. These patients had lower levels of IgG, higher levels of IgM and lower occurrence of ASMA than classical AIH. These patients entered remission with steroids as commonly as patients with classical autoimmune hepatitis (Czaja, 1998). The 2 components of PBC-AIH overlap syndrome may occur either simultaneously at presentation, or sequentially during the course of their illness. Alternatively, PBC-AIH may appear simultaneously but may switch to one disease or another during the course of the disease. Patients may show flares of AIH either spontaneously or under UDCA therapy and require steroids in addition to UDCA, which can be tapered off once normalization of transaminase levels has been achieved Additional confusion is caused by the terms autoimmune cholangitis and autoimmune cholangiopathy, which are used for patients who have typical features of PBC but are AMA negative. This group of patients constituted 32% of 200 patients diagnosed with PBC at the AFIP; this incidence is probably skewed due to the consultation nature of the practice at AFIP (Goodman, 1995). A series of 597 patients at the Mayo Clinic found 5.8% of PBC patients to be negative for AMA by immunofluorescence (Lacerda, 1995). However, negativity for AMA depends on the technique used for its detection and many cases that are negative by immunofluorescence may show positivity by ELISA or immunoblotting. Additionally, PDC-E2 reactivity may be positive in biliary epithelial cells, even in the absence of AMA. In a study of 200 cases of histologically characteristic PBC, Goodman et al studied the serological profile with respect to presence of AMA and ANA by separating them into 4 serological groups: AMA+ / ANA - (31%), AMA+ / ANA+ (37%), AMA - / ANA + (20%) and AMA - / ANA - (12%). The authors found no difference in clinical, laboratory or histologic features between these 4 groups, concluding that the antibodies are merely paraphenomena of the autoimmune disease processes, and not pathogenetically important. Subtle differences have been found between the AMA negative and AMA positive groups. AMA negative PBC patients have been found to have positive SMA and ANA more often than AMA positive patients; lower IgM and AST, and higher IgG than the AMA positive group. The titers for ANA tend to be higher in AMA negative PBC. However, the preponderance of evidence suggests that autoimmune cholangitis/ autoimmune cholangiopathy is merely a subset of PBC that is AMA negative. Suggested Reading: Case 3A Adinolfi LE, Gambardella M, Andreana A et al. Steatosis accelerates the progression of liver damage of chronic hepatitis C patients and correlates with specific HCV genotype and visceral obesity. Hepatology 2001; 33: 1358-1364. Adinolfi LE, Utili R, Andreana A et al. Serum HCV RNA levels correlate with histological liver damage and concur with steatosis in progression to chronic hepatitis C. Dig Dis Sci 2001; 46: 1677-1683. Hofer H, Bankl HC, Wrba F et al. Hepatocellular fat accumulation and low serum cholesterol in patients infected with HCV-3a. Am J Gastroenterol 2002; 97: 2880-2885. Hourigan LF, MacDonald GA, Purdie D et al. fibrosis in chronic hepatitis C correlates significantly with body mass index and steatosis. Hepatology 1999; 29: 1215-1219. Monto A. Hepatitis C and steatosis. Seminars Gastrointestinal Disease 2002; 13: 40-46. Moriya K, Yotsuyanagi H, Shintani Y et al. Hepatitis C virus core protein induces hepatic steatosis in transgenic mice. J Gen Virol 1997; 78: 1527-1531. Petit JM, Benichou M, Duvillard L et al. Hepatitis C virus-associated hypobetalipoproteinemia is correlated with plasma viral load, steatosis and liver fibrosis. Am J Gastroenterol 2003; 98: 1150-1154. Ratziu V, Trabut J, Poynard T. Fat, diabetes, and liver injury in chronic hepatitis C/ Current Gastroenterol Reports 2004; 6: 22-29. Rubbia-Brandt L, Quadri R, Abid K et al. Hepatocyte steatosis is a cytopathic effect of hepatitis C genotype 3. J Hepatol 2000; 33: 106-115. Sanyal AJ, Contos MJ, Sterling RK et al. Nonalcoholic fatty liver disease in patients with hepatitis C is associated with features of metabolic syndrome. AM J GAstroenterol 2003; 98: 2064-2071 Serfaty L, Andreani T, Giral P et al. Hepatitis C virus induced hypobetalipoproteinemia: A possible mechanism for steatosis in chronic hepatitis C. J Hepatol 2001; 34: 428-434. Sharma P, Balan V, Hernandez J et al. Hepatic steatosis in hepatitis C virus genotype 3 infection: does it correlate with body mass index, fibrosis, and HCV risk factors? Dig Dis Sci 2004; 49: 25-29. Younossi ZM, McCullough AJ, Ong JP et al. Obesity and non-alcoholic fatty liver disease in chronic hepatitis C. J Clin Gastroenterol 2004; 38: 705-709. Case 3B: Angulo P, El-Amin O, Carpenter HA et al. Development of autoimmune hepatitis in the setting of long-standing primary biliary cirrhosis. Am J Gastroenterol 2001; 96: 3021-3027. Bogdanos D, Vergani D, Mieli-Vergani G. Overlap syndromes from pediatrics to adulthood. J Gastroenterol Hepatol 2004; 19 (S): S284-286. Chazouillères O, Wendum D, Serfaty L et al. Primary biliary cirrhosis - Autoimmune hepatitis overlap syndrome: Clinical features and response to therapy. Hepatology 1998; 28: 296-301. Czaja AJ. Frequency and nature of the variant syndromes of autoimmune liver disease. Hepatology 1998; 28: 360-365. Goodman ZD, McNally PR, Davis DR et al. Autoimmune Cholangitis: A variant of primary biliary cirrhosis. Clinicopathologic and serologic correlations in 200 cases. Dig Dis Sci 1995; 40: 1232-1242. Lacerda MA, Ludwig J, Dickson E et al. Antimitochondrial antibody-negative primary biliary cirrhosis. Am J Gastroenterol 1995; 90: 247-249. Woodward J, Neuberger J. Autoimmune overlap syndromes. Hepatology 2001; 33: 994-1002.