Blood, Vol. 92 No. 9 (November 1), 1998:
pp. 3486-3488
CORRESPONDENCE
Hepatitis C Virus (HCV) Infection: Serum Rheumatoid Factor
Activity and HCV Genotype Correlate With Cryoglobulin Clonality
 |
LETTER |
To the Editor:
Chronic hepatitis C virus (HCV) infection has only recently been
recognized as the leading cause of mixed
cryoglobulinemia.1,2 Rheumatoid factor B cells are part of
the normal repertoire and significant titers of rheumatoid factors (RF)
are induced during normal antiviral or antibacterial immune responses.
Under the pressure of chronic antigen stimulation, RF repertoire is
remodeled, and progressively includes monospecific, somatically mutated
RF similar to those observed in chronic autoimmune diseases such as
rheumatoid arthritis (RA).3 HCV-related proteins, genomic HCV sequences, and ongoing viral replication have been identified in
peripheral blood mononuclear cells and lymph node cells from patients
with type II mixed cryoglobulinemia and neoplastic
lymphoproliferation.4,5 The emergence of non-Hodgkin's
lymphoma has been associated to chronic HCV infection,6,7
an observation that remains controversial. Here we examine whether RF
activity and HCV genotype may be related to cryoglobulin clonality.
Among 965 patient sera positive for anti-HCV antibodies (Cobas Core
anti-HCV EIA; Roche Diagnostic System, Basel, Switzerland), RF activity
was >100 IU/mL in 60 (6.3%) (HCV group 1). As assessed by
two-dimensional polyacrylamide gel electrophoresis
(2D-PAGE),8 cryoglobulins (>0.04 g/L) were present in 36 patients from group 1 (median protein concentration 0.12 g/L) and in 8 of 59 randomly selected patients with RF activity <100 IU/mL (HCV
group 2, median protein concentration 0.06 g/L, group 1 v
group 2 P < .0001). HCV reverse transcriptase-polymerase
chain reaction (RT-PCR) (Amplicor-HCV; Roche Molecular Systems,
Branchburg, NJ) was positive in 56 patients (93.3%) from group 1, and
in 46 (78%) from group 2. These results indicated that RF activity
>100 IU/mL closely correlated with positive RT-PCR and was a
good indicator of the probability to isolate a cryoglobulin. However,
there was no strict correlation between absolute RF activity and
the amount of cryoglobulin isolated from individual samples.
Among 82 patients with chronic hepatitis B virus (HBV)
infection (Cobas Core EIA; Roche Diagnostic System), RF activity was >100 IU/mL in 11 (13.4%). Cryoglobulins were found positive in only
two of these sera (18.2%), a strikingly lower proportion than in HCV
patients from group 1 (60%, P = .019). This did not reflect a lower RF activity in HBV patients because median RF activity
was 165 IU/mL versus 161 IU/mL in HCV group 1. The association of a
cryoglobulin with HCV rather than with HBV infection was thus clearly
confirmed9 and suggested that HCV itself and/or the
immune response to HCV may play a critical role in the generation of
cryoglobulins.
According to Brouet's classification (modified as
described8), among 36 cryoglobulins from HCV sera group 1 (RF activity > 100 IU/mL), 4 belonged to type II (monoclonal), 10 to type II-III (oligoclonal), and 22 to type III (polyclonal) (Table
1 and Fig 1).
There was no significant difference in median protein concentration between cryoglobulins type II/II-III and type III (0.15 g/L
v 0.11 g/L, P = .28). Cryoprecipitates (<0.04
g/L) isolated from cryoglobulin-negative HCV sera were all type III. In
contrast to cryoglobulins isolated from patients with chronic HBV
infection or with rheumatoid arthritis (RA) with RF activity >100
IU/mL, or from HCV group 2 patients (RF activity <100 IU/mL),
analysis of cryoglobulins from group 1 HCV patients indicated a strong trend toward cryoglobulins with monoclonal (type II) or oligoclonal (type II-III) IgM component (HCV sera RF > 100 v
RF < 100: Fisher's exact test, two-sided P
value = .0022).
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| Fig 1.
Representative examples of type III (a and b), type
II-III (c), and type II cryoglobulins (d and e). Type II and II-III
cryoglobulins are characterized by a dominant clonal IgM component
(arrows).
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HCV genotypes (Inno-LiPA HCV II; Innogenetics, Zwijndrecht, Belgium)
were determined in sera with cryoglobulins from group 1 and compared
with HCV genotype of cryoglobulin negative sera. Genotype 1b (15 of 36 cases, 41.7%) predominated in sera with cryoglobulins and was present
in only 6 of 24 cryoglobulin-negative sera (25%), although without
reaching significance (Table 2). Conversely, genotype 3a was predominant in cryoglobulin-negative sera
(41.2%). There was no selection bias because global HCV genotype distribution in group 1 compared with that of an unselected group of
patients from the same area (n = 263) was similar (genotype 1b:
35%v 29.7%, genotype 2a: 33% v
34%10). Moreover, whereas type III cryoglobulins were
associated with genotype 3a, genotype 1b was significantly more
frequently found in cryoglobulins with a monoclonal or oligoclonal IgM
component (type II or II-III) (Fisher's exact test, two-sided
P value = .02).
Taken together, we here confirm the strong association between
cryoglobulins and chronic HCV infection.1 Furthermore, our results support an association between high RF activity, HCV viral replication, and selection of monoclonal or oligoclonal RF secreting B
cells, observations that may be representative of enhanced
and/or long duration immune pressure in response to chronic HCV
infection with subsequent selection of RF secreting B
cells.3 Prospective studies with longitudinal cryoglobulin
analysis will be necessary to ensure this hypothesis. Genotype 1b was
overrepresented in HCV group 1 cryoglobulins. This did not result
from a selection bias because the overall distribution of HCV
genotypes in group 1 patients was very close to the prevalence of HCV
genotypes in an unselected and contemporary group of patients with HCV
infection from the same area.10 Furthermore, HCV genotype
1b was associated with monoclonal or oligoclonal cryoglobulin types
(P = .02), whereas genotype 3a (the most
frequent genotype in cryoglobulin negative sera from group 1) was
associated with type III cryoglobulins. Our findings are not in
agreement with those of a study in which an association between
cryoglobulins and genotype 2a/III was found,11 nor with
those of another study in which an association between cryoglobulins,
type of cryoglobulins, and HCV genotype was lacking.12 These discrepancies may be related to a geographical heterogeneity possibly related to genetic and environmental cofactors. However, in an
unselected series of HCV patients, genotype 1 (1a and 1b) was shown to predominate (75%) in sera associated with blood
transmitted HCV infection and a longer duration of
infection.13 In our patients there was no particular
selection bias in favor of blood-transmitted infection, which may
explain the predominance of type 1b HCV in cryoglobulins. In contrast,
the association of type 1 HCV with long duration of infection may be a
factor favoring immune selection of oligoclonal or monoclonal
RF.3 The respective role of immune response and HCV itself
in their potential link to non-Hodgkin's lymphoma will have to be
further analyzed.
Cristian Antonescu
Claude Mayerat
Alain Mantegani
Philippe C. Frei
François Spertini
Division
of Immunology and Allergy
Centre Hospitalier Universitaire
Vaudois
Lausanne, Switzerland
Jean-Daniel Tissot
Centre de Transfusion Sanguine
Swiss Red
Cross
Lausanne, Switzerland
| |
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