|Year : 2017 | Volume
| Issue : 1 | Page : 19-30
Multicentre study of hepatitis C virus status in Egyptian patients with B-cell non-Hodgkin’s lymphoma with assessment of patients’ immunological state
Mohamed O Azzazi1, Mohamed A.M. Mohamed2, Mohamed M Mousa1, Rasha M Mohammed1, Salma S Eldin Youssef MSc Clinical Hematology 3
1 Department of Internal Medicine & Clinical Hematology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Department of Gastroenterology and Hepatology, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
3 Department of Clinical Hematology, Egypt Air Hospital, Cairo, Egypt
|Date of Submission||12-Dec-2016|
|Date of Acceptance||22-Dec-2016|
|Date of Web Publication||18-May-2017|
Salma S Eldin Youssef
Faculty of Medicine, Ain Shams University, 4 B Madinet Nasr Elgedida Buildings, Hassas Elmaamoun Street Extension, Madinet Nasr 11765, Cairo
Source of Support: None, Conflict of Interest: None
Background Hepatitis C virus (HCV) is both hepatotropic and lymphotropic and is estimated to affect over 180 million individuals worldwide. Chronic HCV infection has been associated with B-cell indolent lymphomas, especially marginal zone lymphoma.
Objectives Our study aimed to study the relation between HCV infection in B-cell non-Hodgkin’s lymphoma (NHL) patients and the patients’ immunological state, and to study the characteristics of different histological forms of NHL in HCV-positive patients in relation to HCV genotypes and to viral load.
Patients and methods This study was carried out on 100 B-cell non-Hodgkin’s lymphoma (B-NHL) patients and three control groups including 50 patients with various solid malignancies, 50 patients with non-HCV hepatic affection, and 50 control healthy participants, respectively. All patients were subjected to laboratory investigations including complete blood count, erythrocyte sedimentation rate, C-reactive protein, liver profile, renal profile, serum lactate dehydrogenase (LDH), serum β2 microglobulin, serum cryoglobulins, serum immunoglobulins, HCV antibody detection by enzyme immunoassay, quantification of HCV RNA by RT-PCR, and identification of HCV genotype by LiPA.
Results Our results showed that the most prevalent histopathologic subtype of B-NHL among HCV-positive patients was mucosa associated lymphoid tissue lymphoma (±SD 71.4%). The prevalence of HCV infection among B-NHL patients was found to be 43% and all HCV-positive patients had genotype 4. Viral load was positively correlated with serum LDH, serum β2 microglobulin, and serum IgM levels, and inversely correlated with platelet count and prothrombin concentration in HCV-positive patients of B-NHL and solid malignancies groups. Serum cryoglobulinemia was identified in HCV-positive patients of both B-NHL (74.4%) and control solid malignancies groups (66.6%).
Conclusion From these results, we can conclude that the prevalence of HCV infection among B-NHL Egyptian patients is ∼43%, with detection of serum cryoglobulins and elevation of serum levels of immunoglobulins IgG, IgM, LDH, and β2 microglobulin in HCV-positive patients.
Keywords: B-cell non-Hodgkin’s lymphoma, hepatitis C virus, hepatitis C virus-genotype 4, mixed cryoglobulinemia, role of hepatitis C virus in lymphomagenesis
|How to cite this article:|
Azzazi MO, Mohamed MA, Mousa MM, Mohammed RM, Eldin Youssef SS. Multicentre study of hepatitis C virus status in Egyptian patients with B-cell non-Hodgkin’s lymphoma with assessment of patients’ immunological state. Egypt J Haematol 2017;42:19-30
|How to cite this URL:|
Azzazi MO, Mohamed MA, Mousa MM, Mohammed RM, Eldin Youssef SS. Multicentre study of hepatitis C virus status in Egyptian patients with B-cell non-Hodgkin’s lymphoma with assessment of patients’ immunological state. Egypt J Haematol [serial online] 2017 [cited 2018 Apr 23];42:19-30. Available from: http://www.ehj.eg.net/text.asp?2017/42/1/19/206435
| Introduction|| |
Lymphomas encompass a group of lymphoproliferative malignant diseases that originate from T and B cells in the lymphatic system. Traditionally, lymphomas have been subcategorized into two groups: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma (NHL) .
NHL involves a heterogeneous group of over 40 lymphoproliferative malignancies with diverse patterns of behaviors and responses to treatment .
The relation between developing NHL and infective agents, particularly viral agents, has been suggested .
Epidemiological studies have demonstrated an increased risk for developing B-cell lymphomas in patients with chronic hepatitis C virus (HCV) infection. However, the strength of the association shows great geographic discrepancies, with higher relative risk in countries with high HCV prevalence. It remains unclear whether additional environmental genetic factors are involved or whether the international variability is simply a consequence of the variable infection prevalence .
HCV is a small (55–65 nm in size), enveloped, positive-sense, single-stranded RNA virus of the family Flaviviridae. HCV is the cause of liver diseases in humans .
HCV is further classified into at least seven major genotypes that differ by about 30% in their nucleotide sequence. These genotypes (1, 2, 3, 4, 5, 6, 7) show differences based on their worldwide distribution, transmission, and disease progression . Genotype 4 is most common in central Africa, Egypt, and the Middle East. It is noteworthy that genotype 4 is quasi exclusive (91%) in Egypt .
HCV infection is a major public health problem with more than 170 million people infected worldwide. This figure represented nearly 3% of the world’s total population according to the estimation of the WHO, with two to three million new cases per year .
Figures from epidemiological studies in different regions of the world show wide variance in HCV prevalence patterns, though it is clearly evident that the incidence of HCV is higher among less developed nations, reaching as high as 14.5% in certain localities in Egypt .
HCV is both hepatotropic and lymphotropic. HCV infection becomes chronic in most cases, and over time, people are at an increased risk for developing liver cirrhosis and its complications such as hepatocellular carcinoma .
However, several extrahepatic manifestations involving other organ systems have been reported in association with chronic HCV infection, including immune-mediated rheumatic disorders, endocrine disorders, renal complications, and neoplastic disorders .
Hematological manifestations such as monoclonal gammopathy of uncertain significance, mixed cryoglobulinemia (MC), and B-cell non-Hodgkin’s lymphoma (B-NHL) have been not only associated with HCV infection but also a causal relationship has been suggested .
Several authors described an intriguing association between HCV infection and ‘essential’ MC, an immune complex-mediated vasculitis involving small vessels, with some geographic differences . This incidence of HCV infection in MC ranges from 40 to 90%, whereas HCV-negative MC accounts for about 5–10% of total cases .
The most straightforward demonstration of an oncogenic role of HCV in NHL comes from trials showing that antiviral therapy, based mostly on peg–interferon and ribavirin, resulted in complete or partial remission of lymphoma in HCV-positive and not in HCV-negative NHL patients .
Although clinical responses to antiviral therapy strongly support a role for HCV in lymphomagenesis, they do not inform about the mechanism linking HCV to NHL induction. Evidence from experimental studies suggests that there are more than three different mechanisms whereby HCV might contribute to NHL induction.
The first of these mechanisms is chronic antigenic stimulation. The first observation that lends support to this mechanism is the histological presentation of many, but not all, HCV-associated hematologic malignancies, which are typically of germinal centres and post-germinal centres B cells .
This suggests that lymphomagenesis occurs when B cells proliferate in response to antigen. Further evidence comes from the antibody response and Ig variable (V) gene usage in patients with chronic HCV infection and HCV-associated NHL. The HCV-E2 protein is the primary target of antibody responses against HCV .
Monoclonal antibodies derived from HCV-infected patients use a restricted IgV gene repertoire, with a strong bias for Vh 1–69 (also known as 51 p1) and Vk 3-A27 (also known as KV 325) .
In addition, the monoclonal IgM component of type II MC is often encoded by the same set of V region gene, Vh 1–69 and Vk 3-A27. In fact, many of the monoclonal rheumatoid factors from patients with type II MC express WaCRIs, which is often associated with light and heavy chain CRIs characteristic for V regions encoded by Vh 1–69 and Vk 3-A27 . Eventually, these genes are expressed also by most HCV-associated NHLs .
These data suggested that HCV-associated NHLs derive from B cells activated during HCV infection, with some of these B cells being specific for HCV-E2, representing the malignant counterpart of type II MC.
A second potentially lymphomagenic mechanism of HCV infection derives from the high affinity interaction between HCV-E2 and one of its receptors, the tetraspanin CD81 .
Multimeric engagement of CD81 on human B cells by a combination of HCV-E2 and anti-CD81 antibodies led to polyclonal activation of naive, CD 27 negative B cells .
In addition to direct effects on B cells, engagement of CD81 on T cells lowered the threshold for interleukin-2 production, resulting in response to suboptimal stimuli and bystander activation of B cells. Altogether, these results suggest that CD81 engagement on B and T cells may lead to direct or indirect activation and, possibly, chronic proliferation of B cells .
Chronic B-cell proliferation in response to antigenic stimulation or polyclonal activation may predispose to genetic aberrations such as translocation or overexpression or both of the antiapoptotic protein Bcl-2. Bcl-2 overexpression is especially frequent in follicular lymphoma. It has been found also in B cells of patients with MC and even in HCV-positive cases without cryoglobulins .
Moreover, interaction between HCV-E2 and CD81 on B cells has been shown to trigger the enhanced expression of activated cytosine deaminase and to induce double-strand DNA breaks in the IgVH gene locus, thereby further contributing to generation of a mutator phenotype conductive to malignant transformation .
The third tumorigenic mechanism of HCV that has been proposed is direct infection of B cells. The reason for this mechanism to be acceptable is the demonstration that HCV is indeed able to infect and replicate in B cells. Thus, although HCV-infected patients with MC, only in a minority of cases also RNA negative strands, the HCV replicative intermediates suggestive of viral replication were detected in the cells . Detection of RNA negative strands by PCR, however, may give rise to false positive results.
HCV may infect and replicate only a relatively rare subset of B cells, such as CD5-positive B cells. These cells have been shown to express high levels of CD81 and expand in HCV-infected liver cells .
It is proposed also that integration of two or more oncogenic signals is required for lymphoma formation to occur, which may be still be relatively small, but nevertheless, they may now give rise to supraliminal oncogenic signals that results in a statistically greater incidence of lymphoma formation in HCV-infected than in noninfection person. This would explain the relatively modest increase in the risk for NHL in HCV-positive persons .
Many different histopathologic types of NHL have been linked to HCV acquisition, namely, indolent lymphomas, especially marginal zone lymphoma (MZL), and aggressive lymphomas, mainly diffuse large B-cell lymphoma (DLBCL). In Western countries, DLBCL is the most common lymphoma subtype associated with HCV infection .
| Patients and methods|| |
The present study was carried out on 100 patients with B-NHLs, 50 patients with various malignant solid malignancies, and 50 patients with hepatic affection other than HCV infection who were recruited from Ain-Shams University Hospital, Hematology Department, and National Cancer Institute from the period between April 2013 and August 2015. A total of 50 healthy participants were included to comprise a control group.
The studied groups
The studied patient group included 100 patients with B-NHLs. There were 79 men and 21 women, with ages ranging from 28 to 83 years. According to histopathologic subtypes, there were eight patients with splenic marginal zone lymphoma (SMZL), five patients with nodal MZL, 22 patients with lymphoplasmacytic lymphoma, 15 patients with follicular lymphoma, 14 patients with mucosa associated lymphoid tissue lymphoma, 13 patients with mantle cell lymphoma, 10 patients with DLBCL, and 13 patients with small lymphocytic lymphoma/chronic lymphocytic leukemia (CLL).
There were three control groups (A, B, and C).
It included 50 patients with various malignant solid tumors. There were 30 men and 20 women, their ages ranging from 36 to 83 years. According to the solid malignancy site, there were 10 patients with gastrointestinal malignancies (cancer colon or cancer stomach), nine patients with breast cancer, seven patients with hepatobiliary malignancies (hepatocellular carcinoma or cholangiocarcinoma), nine patients with respiratory system malignancies (bronchogenic carcinoma or mesothelioma), four patients with cancer pancreas, and six patients with urinary tract malignancies (urinary bladder cancer or prostatic cancer) and female genital tract malignancies (cancer ovary or endometrial carcinoma).
It included 50 patients with hepatic affection with conditions other than hepatitis C infection. There were 31 men and 19 women, their ages ranging from 26 to 80 years. According to the type of hepatic affection, there were 28 patients with liver cirrhosis, 17 patients with liver fibrosis, and five patients with hepatitis B virus infection.
It included 50 healthy participants. There were 33 men and 17 women, their ages ranging from 23 to 62 years.
The patient and control groups were investigated by routine laboratory work-up [complete blood count (CBC), erythrocyte sedimentation rate, C-reactive protein, lactate dehydrogenase (LDH), alanine aminotransferase, aspartate aminotransferase, serum albumin, serum bilirubin, prothrombin concentration, blood urea, serum creatinine, serum uric acid]; serum β2 microglobulin, HCV antibody detection by enzyme immunoassay; HCV RNA quantitative assay by RT-PCR; HCV genotype determination by LiPA (Siemens Versant HCV Genotype 2.0 Assay, Germany); serum cryoglobulin; serum immunoglobulins IgM, IgG, and IgA levels; bone marrow aspirate and trephine biopsy (if indicated); histopathological examination and immunohistochemical staining of bone marrow; lymph node biopsy and spleen for pan B-cell and pan T-cell markers; immunophenotyping of peripheral blood for patients having lymphocytosis; abdominal ultrasound; and computed tomography neck, chest, abdomen, and pelvis.
Data management and analysis
The collected data was revised, coded, tabulated, and fed into a PC with statistical package for social science (15.0.1 for Windows, 2001; SPSS Inc., Chicago, Illinois, USA). Data were presented and suitable analyses were carried out according to the type of data obtained for each parameter.
- Parametric numerical data were presented as mean±SD, and range, whereas nonparametric data were presented as median and interquartile range.
- Non-numerical data were presented as frequency and percentage.
The following tests were used:
- Student’s t-test.
- Mann–Whitney U-test.
- Analysis of variance test.
- Correlation analysis (using Spearman’s method).
- The χ2-test.
- Fisher’s exact test.
- The Kruskal–Wallis test.
P-value: level of significance:
- P>0.05: nonsignificant.
- P<0.05: significant.
- P<0.01: highly significant.
| Results|| |
[Table 1] shows the descriptive data of NHL cases (patient group) according to age, sex, viral load, histopathologic subtypes, and HCV infection status. The most prevalent histopathologic subtype among B-NHL patients was SMZL and the least prevalent was CLL, with 43% of patients HCV-positive and 57% of patients HCV-negative.
|Table 1 Description of personal and medical data of B-cell NHL cases (Patient group).|
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[Table 2] shows the descriptive data of solid malignancies group (control group A) according to age, sex, viral load, type of solid malignancy, and HCV infection status. Overall, 36% of solid malignancies patients were HCV-positive and 64% of patients were HCV-negative.
|Table 2 Description of personal and medical data of solid malignancies cases (Control group A).|
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[Table 3] shows descriptive data of hepatic affection other than HCV patients (control group B) according to age, sex, type of liver disease, and HCV infection status.
|Table 3 Description of personal and medical data of cases with hepatic affection other than HCV infection (Control group B).|
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[Table 4] shows the comparison between NHL patients and solid malignancy patients (control group A) as regards age, sex, viral load, and HCV infection status, with a highly significant difference between NHL and control group A patients as regards sex (P=0.01), whereas a nonsignificant difference between both groups as regards age, HCV infection status, and viral load (P=0.260, 0.411, and 0.212, respectively).
|Table 4 Comparison between B-cell NHL cases and solid malignancies cases as regard personal and medical data.|
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[Table 5] shows the relation between age, sex, and histopathology of NHL patients with HCV infection, with a nonsignificant difference between HCV-positive and negative cases as regards age (P=0.419) or sex (P=0.203).
|Table 5 Relation between each of age, sex, histopathology of B-cell NHL and HCV infection status.|
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[Table 6] shows the relation between sex and histopathology of NHL and viral load as the viral load did not statistically differ according to sex (P=0.886) or histopathology of NHL (P=0.619).
|Table 6 Relation between each of sex, histopathology of B-cell NHL and viral load.|
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[Table 7] shows the relation between age, sex, and histopathology of solid malignancies of HCV infection in the control group A, with a nonsignificant correlation between age (P=0.523), sex (P=0.470), histopathology of solid tumors (P=0.994), and HCV status among control group A patients, with the highest percentage of HCV-positive cases (44.4%) in respiratory tract malignancies patients and the least percentage in cancer pancreas patients (25%).
|Table 7 Relation between each of age, sex, histopathology of solid malignancies and viral load.|
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[Table 8] shows the comparison between the patient group and control groups A and B as regards laboratory data with the following findings.
|Table 8 Comparison between patient group, control group A and control group B as regard lab data.|
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[Table 9] shows the comparison between the NHL group and control groups A and B as regards serum cryoglobulin status, with a highly significant (P=0.009) increase in serum cryoglobulin positivity in NHL and solid malignancy patients compared with non-HCV liver disease patients.
|Table 9 Compariso between patient group, control group A and control group B as regard serum cryoglobulin status.|
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[Table 10] shows the correlations between viral load and CBC among NHL cases, with a highly significant negative inverse correlation between viral load by PCR and platelet count (P=0.0001), whereas there was a nonsignificant correlation between viral load and both white blood cell (WBC) count and hemoglobin (Hb) level (P=0.295 and 0.564, respectively).
|Table 10 Correlation between viral load and CBC counts among B-cell NHL cases.|
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[Table 11] shows the correlations between viral load and liver functions among NHL cases, with a highly significant inverse correlation between viral load and prothrombin concentration (P=0.001), whereas there was a nonsignificant correlation between viral load and each of serum albumin, serum bilirubin, and serum LDH (P=0.174, 0.450, and 0.487, respectively).
|Table 11 Correlation between viral load and liver function tests among B-cell NHL cases.|
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[Table 12] shows the correlations between viral load and immunoglobulin among NHL cases, with a highly significant positive correlation between viral load and serum β2 microglobulin (P=0.0001), significant correlation with serum IgM (P=0.043), and nonsignificant correlation with each of serum cryoglobulin, serum IgG, and serum IgA (P=0.072, 0.332, and 0.660, respectively).
|Table 12 Correlation between viral load, S.beta 2 microglobulin, S.cryoglobulin and serum immunoglobulins among B-cell NHL cases.|
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[Table 13] shows the correlations between viral load and CBC in the control group A (solid malignancies), with a nonsignificant correlation between viral load and each of WBC count, Hb level, and platelet count (P=0.433, 0.376, and, 0.651, respectively).
|Table 13 Correlation between viral load and CBC counts among solid malignancies cases.|
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[Table 14] shows the comparison between HCV-positive and HCV-negative cases of the NHL patient group as regards laboratory data, with a highly significant decrease in platelet count, prothrombin concentration (P=0.005 and 0.001, respectively), a highly significant increase in serum bilirubin, serum LDH (P=0.009 and 0.001, respectively), and a significant increase in serum IgM (P=0.035) in HCV-positive patients compared with HCV-negative patients with NHL, whereas there was a nonsignificant difference between HCV-positive and HCV-negative patients as regards WBC count, Hb level, serum albumin, serum β2 microglobulin, serum IgG, and serum IgA.
|Table 14 Comparison between HCV+ve and HCV-ve cases of B-cell NHL patient group as regard lab data.|
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[Table 15] shows the comparison between HCV-positive and negative patients of the control group A (solid malignancies) as regards laboratory data, with a highly significant increase in serum bilirubin level in HCV-positive patients of the control group A (solid malignancies) compared with HCV-negative patients (P=0.009), a highly significant decrease in prothrombin concentration in HCV-positive patients compared with HCV-negative patients (P=0.001), a significant increase in the serum LDH level in HCV-positive patients compared with HCV-negative patients (P=0.034), and a nonsignificant difference between HCV-positive and HCV-negative patients as regards WBC count, Hb level, platelet count, serum albumin, serum β2 microglobulin, serum IgM, serum IgG, and serum IgA.
|Table 15 Comparison between HCV+ve and HCV-ve cases of solid malignancies group as regard lab data.|
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[Table 16] shows the comparison between HCV-positive and HCV-negative patients of the NHL group as regards serum cryoglobulin status, with a highly significant increase in serum cryoglobulin positivity in HCV-positive patients of the NHL group compared with HCV-negative patients (P=0.001).
|Table 16 Comparison between HCV+ve and HCV-ve cases of B-cell NHL patient group as regard serum cryoglobulin status.|
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[Table 17] shows the comparison between HCV-positive and HCV-negative patients of the control group A (solid malignancies) as regards serum cryoglobulin status, with a highly significant increase in serum cryoglobulin positivity in HCV-positive patients of the control group A compared with HCV-negative patients (P=0.001).
|Table 17 Comparison between HCV+ve and HCV-ve cases of solid malignancies group as regard serum cryoglobulin status.|
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| Discussion|| |
In our study the prevalence of HCV infection among B-NHL patients was found to be 43%, followed by 36% in patients with solid tumors. However, comparison between the two groups showed a nonsignificant difference (P=0.411).
Approximately similar results were detected in a study by Abo-Taleb et al. , which was conducted on 57 patients with B-NHL, and in which the prevalence of HCV infection among those patients was 42%. On the other hand, a much lesser prevalence rate was observed in a number of studies. In a study conducted in Brazil in 2002, the presence of HCV in patients with NHL was reviewed, and an association rate of 9% was reported with NHL . The prevalence of HCV in solid tumor patients was found to be 1.3% in a study conducted by Brasseur et al. . This study included 450 patients with solid tumors. More than half (63.7%) had a gastrointestinal cancer.
In our study, all HCV-positive patients had genotype 4 of HCV. This result confirms the data reported by Miller et al. , as they stated that the highest prevalence of antibodies to HCV in the world was reported in Egypt, where HCV genotype 4 predominates.
Regarding viral load, there was no significant difference between B-NHL and solid tumors (P=0.212).
In the present study, the most prevalent histopathologic subtype of B-NHL found among HCV-positive patients was mucosa associated lymphoid tissue lymphoma (±SD 71.4%), followed by SMZL (±SD 50.0%), follicular lymphoma (±SD 45.5%), nodal MZL, DLCL (±SD 40.0%), CLL (±SD 38.5%), lymphoplasmacytic lymphoma (±SD 33.3%), and then mantle cell lymphoma (±SD 23.1%). These results were in agreement with the those previously reported by Arcaini et al. ; they found that HCV is associated with B-NHL, especially with indolent lymphomas such as MZL, lymphoplasmacytic lymphoma, follicular lymphoma, chronic lymphocytic leukemia, and small lymphocytic lymphoma. However, several studies reported an association of high grade lymphomas such as DLBCL.
Results of our study showed a nonsignificant difference in the incidence of anemia (P=0.057) in HCV-positive patients compared with HCV-negative patients of the B-NHL group, and similarly, a nonsignificant difference (P=0.783) in the incidence of anemia between HCV-positive and HCV-negative patients was found in the control group A. In addition, a nonsignificant difference (P=0.76) in the incidence of anemia was found when comparing the B-NHL group (collectively including HCV-positive and HCV-negative patients) with both control patient groups A and B. In addition, our results revealed a nonsignificant correlation between the viral load and Hb level in both B-NHL patient group (P=0.564) and control group A (P=0.376). The findings of Sulkowski et al.  were in agreement with our results when they stated that, anemia associated with HCV infection is often related to peg-interferon and ribavirin use in the treatment of HCV infection and not to the infection itself.
In the current study, a highly significant increased incidence of thrombocytopenia (P=0.005) was found in HCV-positive when compared with HCV-negative patients of the B-NHL patient group, whereas a nonsignificant incidence of thrombocytopenia (P=0.251) was found in HCV-positive patients when compared with HCV-negative patients of the control group A. We also found that the incidence of thrombocytopenia was highly significant in the B-NHL patient group collectively (HCV-positive and HCV-negative) (P=0.001) when compared with both control patient groups A and B, whereas a nonsignificant difference in the incidence of thrombocytopenia was found when comparing both control patient groups with each other. We also found that the platelet count showed a highly significant negative correlation (P=0.0001) with HCV viral load in the B-NHL patient group, whereas a nonsignificant correlation (P=0.651) was found in the control patient group A. Similar results were reported by Louie et al. ; they reported that thrombocytopenia is a major problem in HCV-infected patients and the most common hematological manifestation. A recent systematic review of 27 studies reported a 24% prevalence of thrombocytopenia in chronic HCV-infected patients in more than half of the studies.
As regards WBC count, our study concluded that there is a nonsignificant incidence of leukopenia in HCV-positive patients when compared with HCV-negative patients in both B-NHL patient group (P=0.476) and solid tumors control patient group (P=0.914). In the current study, a highly significant increased incidence of leukopenia (P=0.001) was found in B-NHL patients collectively (HCV-positive and HCV-negative) when compared with both control patient groups (solid tumors group and hepatic affection other than HCV infection group). However, comparison between both control patient groups showed nonsignificant difference. A nonsignificant correlation was found between the WBC count and HCV viral load in both B-NHL patient group (P=0.295) and solid tumors control patient group (P=0.433). Many authors supported our results as they published that apart from being a side effect of antiviral therapy, leukopenia or neutropenia could be the result of hypersplenism , autoimmune neutropenia, direct bone marrow involvement, and activation of caspase 10 and increased neutrophil apoptosis . In addition to bone marrow , peripheral blood neutrophils have also been shown to be the replication site for HCV; however, its potential role in causing neutropenia is unclear .
In our study, we found a highly significant increase in the serum bilirubin level in HCV-positive patients when compared with HCV-negative patients in both B-NHL patient group and solid malignancies patient control group (P=0.009 and 0.009, respectively). However, a nonsignificant difference (P=0.28) was found on comparing the three groups with each other (B-NHL patients collectively (HCV-positive and HCV-negative) and both control patient groups A and B also collectively).
In addition to that we also found a highly significant decline in prothrombin concentration in HCV-positive patients when compared with HCV-negative patients in both B-NHL patient group and solid malignancies patient control group (P=0.001 and 0.001, respectively). However, a nonsignificant difference (P=0.19) was found on comparing the three groups with each other (B-NHL patients collectively and both control patient groups A and B).
Regarding serum albumin level, there was a nonsignificant difference between HCV-positive and HCV-negative patients in both B-NHL patient group and patient control group A (P=0.211 and 0.619, respectively). Similarly, a nonsignificant difference in the serum albumin level was found when comparing B-NHL patients collectively with control group A, also collectively, whereas a highly significant decrease in serum albumin was found in B-NHL patients compared with the control group B.
In the present study, a nonsignificant correlation was found between viral load and each of serum albumin and serum bilirubin in the B-NHL group (P=0.174 and 0.450, respectively) and control patient group A (P=0.344 and 0.447, respectively).
In this study a significantly high serum LDH was found in HCV-positive patients in comparison with HCV-positive ones in both patient B-NHL group and control patient group A (P=0.001 and 0.034, respectively). However, a nonsignificant difference in the serum LDH was found on comparing the B-NHL with the control group A collectively (HCV-positive and HCV-negative), whereas a significantly high level was found in the B-NHL patient group on comparing it with control group B (P=0.04) and in control group A compared with control group B (collectively). Moreover, a nonsignificant correlation between viral load and serum LDH was found in both B-NHL group (P=0.487) and control group A (P=0.195). Similar results were obtained in a study performed in Egypt by Elgawad et al. , carried out on 120 HCV-positive patients. Overall, 13.3% had monoclonal B lymphocytes (MBL) and 15% had polyclonal B lymphocytes (PCBL). They found that patients having MBL and PCBL had significantly higher levels of serum LDH (P=0.04 and 0.016, respectively) compared with patients negative for MBL and PCBL. In contrast, a nonsignificant difference in the serum LDH level was found on comparing HCV-positive/B-NHL and HCV-negative/B-NHL patients in a study performed in Egypt by Abo-Taleb et al. , conducted on 57 patients with B-NHL; in total, 24 patients were HCV-positive and 33 patients were HCV-negative.
Our study results also revealed a nonsignificant difference in β2 microglobulin level between HCV-positive and HCV-negative patients in both B-NHL group (P=0.355) and control group A (P=0.618). Moreover, a nonsignificant difference was found between both groups collectively (HCV-positive and negative patients). However, a significantly higher levels of β2 microglobulin were found in B-NHL patients compared with control group B patients (P=0.001), and in control group A patients compared with control group B patients (P=0.001). In addition, we found a highly significant (P=0.0001) positive correlation between viral load and β2 microglobulin level in the B-NHL patient group, whereas a nonsignificant (P=0.268) correlation between them was found in control group A.
These findings go in agreement with those of Marilyn et al. ; they conducted a study on altered expression of peripheral immune factors associated with neuropsychiatric symptom severity in adults with and without HCV infection, and found that β2 microglobulin levels were higher in adults with HCV (n=39) than those without (n=40) (P<0.001).
In our study, serum cryoglobulinemia was significantly identified in HCV-positive patients than in HCV-negative patients in both B-NHL group (74.4%) (P=0.001) and control patient group A (66.6%) (P=0.001), with IgG being the most predominant Ig subtype, followed by IgM and IgA in B-NHL patient group and control group A. A positive significant (P=0.043) correlation between viral load and serum IgM level selectively was found in the B-NHL patient group. Our results were in agreement with those of Jacobson et al. , as they stated that type I cryoglobulinemia consists of isolated monoclonal immunoglobulin IgM and most commonly occurs in association with lymphoproliferative disorders. Type II cryoglobulinemia consists of mixed immune complexes, typically monoclonal IgM and polyclonal IgG. Type II cryoglobulinemia was the most common type of cryoglobulinemia seen in HCV-infected patients. Type III cryoglobulinemia consists of mixed immune complexes, typically formed by polyclonal IgM. In a study conducted by the MULTIVIRC group, involving 1083 patients with chronic HCV infection, a cryoglobulin prevalence of 40% was reported, and, interestingly, all cryoglobulins positive patients had either type II (65%) or type III (35%) MC .
| Conclusion|| |
By reviewing the results of our study, we can conclude that the prevalence of HCV infection among B-NHL Egyptian patients can be approximately estimated as 43% with altered immunological status of the sera of HCV-positive patients in the form of abnormal detection of serum cryoglobulins and elevation of serum immunoglobulins IgG and IgM, as well as the elevation of serum levels of the biological markers LDH and β2 microglobulin.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Marcus R, Sweetenham JW, Williams ME. Lymphoma: pathology, diagnosis, and treatment
. New York, NY: Cambridge University Press 2007.
Harris NL, Jaffe ES, Stein H et al.
A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood
Suarez F, Lortholary O, Hermine O, Lecuit M. Infection associated lymphomas derived from marginal zone B cells: a model of antigen-driven lymphoproliferation. Blood
Zaltron S, Spinetti A, Biasi L, Baiguera C, Castelli F. Chronic HCV infection: epidemiological and clinical relevance. BMC Infect Dis
Kapoor A, Simmonds P, Gerold G, Qaisar N, Jain K, Henriquez JA et al.
Characterization of a canine homolog of hepatitis C virus. Proc Natl Acad Sci USA
Kuiken C, Simmonds P. Nomenclature and numbering of the hepatitis C virus. Methods Mol Biol
Sievert W, Altraif I, Razavi HA, Abdo A, Ahmed EA, Alomair A et al.
A systematic review of hepatitis C virus epidemiology in Asia, Australia and Egypt. Liver Int
|8.| World Health Organization. Hepatitis C infection
. Geneva, Switzerland: World Health Organization; 2014.
Flaxman AD, Vos T, Lim S, Murray CJL. Integrated meta-regression framework for descriptive epidemiology
. Seattle, WA: University of Washington; 2013.
Lee MH, Yang HI, Yuan Y, L’Italien G, Chen CJ. Epidemiology and natural history of hepatitis C virus infection. World J Gastroenterol
Jacobson IM, Cacoub P, Dal Maso L, Harrison SA, Younossi ZM. Manifestations of chronic hepatitis C virus infection beyond the liver. Clin Gastroenterol Hepatol
Zignego AL, Giannini C, Ferri C. Hepatitis C virus-related lymphoproliferative disorders: an overview. World J Gastroenterol
Dammacco F, Sansonno D. Antibodies to hepatitis C virus in essential mixed cryoglobulinaemia. Clin Exp Immunol
Sansonno D, Tucci FA, Lauletta G et al.
Hepatitis C virus productive infection in mononuclear cells from patients with cryoglobulinaemia. Clin Exp Immunol
Vallisa D, Bernuzzi P, Arcaini L et al.
Role of anti-hepatitis C virus (HCV) treatment in HCV-related, low-grade, B-cell, non-Hodgkin’s lymphoma: a multicenter Italian experience. J Clin Oncol
De Re V, de Vita S, Marzotto A et al.
Pre-malignant and malignant lymphoproliferations in an HCV-infected type II mixed cryoglobulinemic patient are sequential phases of an antigen-driven pathological process. Int J Cancer
Ishii K, Rosa D, Watanabe Y et al.
High titers of antibodies inhibiting the binding of envelope to human cells correlate with natural resolution of chronic hepatitis C. Hepatology
Chan CH, Hadlock KG, Foung SK, Levy S V(H)1-69 gene is preferentially used by hepatitis C virus-associated B cell lymphomas and by normal B cells responding to the E2 viral antigen. Blood
Gorevic PD, Frangione B. Mixed cryoglobulinemia cross-reactive idiotypes: implications for the relationship of MC to rheumatic and lymphoproliferative diseases. Semin Hematol
Ivanovski M, Silvestri F, Pozzato G et al.
Somatic hypermutation, Clonal diversity, and preferential expression of the VH 51p1/VL kv325 immunoglobulin gene combination in hepatitis C virus-associated immunocytomas. Blood
Pileri P, Uematsu Y, Campagnoli S et al.
Binding of hepatitis C virus to CD81. Science
Rosa D, Saletti G, de Gregorio E et al.
Activation of naive B lymphocytes via CD81, a pathogenic mechanism for hepatitis C virus-associated B lymphocyte disorders. Proc Natl Acad Sci USA
Wack A, Soldaini E, Tseng CTK, Nuti S, Klimpel GR, Abrignani S. Binding of the hepatitis C virus envelope protein E2 to CD81 provides a costimulatory signal for human T cells. Eur J Immunol
Poetsch M, Weber-Matthiesen K, Plendl HJ et al.
Detection of the t(14:18) chromosomal translocation by interphase cytogenetics with yeast-artificial-chromosome probe in follicular lymphoma and nonneoplastic lymphoproliferation. J Clin Oncol
Machida K, Cheng KT, Pavio N, Sung VM, Lai MM. Hepatitis C virus E2-CD81 interaction induces hypermutation of the immunoglobulin gene in B cells. J Virol
Inokuchi M, Ito T, Uchikoshi M et al.
Infection of B cells with hepatitis C virus for the development of lymphoproliferative disorders in patients with chronic hepatitis C. J Med Virol
Curry MP, Golden-Mason L, Doherty DG, Deignan T, Norris S, Duffy M et al.
Expansion of innate CD5pos B cells expressing high levels of CD81 in hepatitis C virus infected liver. J Hepatol
De Re V, Caggiari L, Simula MP, de Vita S, Sansonno D, Dolcetti R. B-cell lymphomas associated with HCV infection. Gastroenterology
Abo-Taleb FM, El-Hefeni AM, Kotb A, El-Gohary TA Efficacy of ribavirin to prevent hepatitis reactivation in hepatitis C virus-infected patients treated for non-Hodgkin lymphoma. Afro-Egypt J Infect Endem Dis
Chindamo MC, Spector N, Segadas JA, Pimenta G, Vanderborght B, Morais JC et al.
Prevalence of hepatitis C infection in patients with non-Hodgkin lymphomas. Oncol Rep
Brasseur M, Heurgué-Berlot A, Barbe C, Brami C, Rey JB et al.
Prevalence of hepatitis B and C and sensibility of a selective screening questionnaire in patients receiving chemotherapy for solid tumors. BMC Cancer
Miller FD, Abu-Raddad LJ. Evidence of intense ongoing endemic transmission of hepatitis C virus in Egypt. Proc Natl Acad Sci USA
Arcaini L, Merli M, Volpetti S, Rattotti S, Gotti M, Zaja F. Indolent B-cell lymphomas associated with HCV infection: clinical and virological features and role of antiviral therapy. Clin Dev Immunol
Sulkowski MS, Shiffman ML, Afdhal NH, Reddy KR, McCone J, Lee WM et al.
Hepatitis C virus treatment-related anemia is associated with higher sustained virologic response rate. Gastroenterology
Louie KS, Micallef JM, Pimenta JM, Forssen UM. Prevalence of thrombocytopenia among patients with chronic hepatitis C: a systematic review. J Viral Hepat
Kedia S, Goyal R, Mangla V, Kumar A, Solivan S, Das P et al.
Splenectomy in cirrhosis with hypersplenism: improvement in cytopenias, child’s status and institution of specific treatment for hepatitis C with success. Ann Hepatol
Akhtari M, Curtis B, Waller EK. Autoimmune neutropenia in adults. Autoimmun Rev
Abou El Azm AR, El-Bate H, Abo-Ali L, Mansour N, Ghoraba H, Salem ML. Correlation of viral load with bone marrow and hematological changes in pale patients with chronic hepatitis C virus. Arch Virol
Crovatto M, Pozzato G, Zorat F, Pussini E, Nascimben F, Baracetti S et al.
Peripheral blood neutrophils from hepatitis C virus-infected patients are replication sites of the virus. Haematologica
Elgawad MA, El Gezawy EM, El-Deen Mohammed HS. Chronic hepatitis C virus infection and B-cell clonality. Life Sci J
Marilyn H, Fuller BE, Olavarria H et al.
Altered expression of peripheral immune factors is associated with neuro-psychiatric symptom severity in adults with and without chronic hepatitis C virus infection. Brain Behav
Cacoub P, Saadoun D, Limal N, Sene D, Lidove O, Piette JC. PEGylated interferon alfa-2b and ribavirin treatment in patients with hepatitis C virus-related systemic vasculitis. Arthritis Rheum
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17]