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HCV Found in Autopsy Brain Tissue

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  • claudine intexas
    HCV Found in Autopsy Brain Tissue- Emerging evidence of hepatitis C virus neuroinvasion AIDS: Volume 19 Suppl 3 October 2005 p S140-S144 Laskus, Tomasza,c;
    Message 1 of 7 , Nov 9, 2005
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      HCV Found in Autopsy Brain Tissue-
      Emerging evidence of hepatitis C virus neuroinvasion

      AIDS: Volume 19 Suppl 3 October 2005 p S140-S144

      Laskus, Tomasza,c; Radkowski, Mareka,b; Adair, Debra Ma; Wilkinson, Jeffreya; Scheck, Adrienne Cc; Rakela, Jorgea

      >From the aDepartment of Medicine, Mayo Clinic Scottsdale, Scottsdale, Arizona 85259
      bInstitute of Infectious Diseases, Warsaw Medical Academy, Poland
      cBarrow Neurological Institute, Phoenix, Arizona.

      Abstract
      It has been reported that hepatitis C virus (HCV) infection is associated with cognitive dysfunction, fatigue and depression, which do not correlate with the severity of liver disease and cannot be accounted for by hepatic encephalopathy or drug abuse. There is also emerging evidence that HCV infection can have negative neurocognitive effects in HIV-infected cohorts. Magnetic resonance spectroscopy has suggested the likely existence of a biological basis for these effects. HCV replicative forms have recently been detected in autopsy brain tissue and the infected cells have been identified as CD68-positive (macrophages/microglia). These findings raise the possibility that HCV infection of the brain could be directly related to the reported neuropsychological and cognitive changes. HCV is not strictly hepatotropic, as it can also replicate in leukocytes, including monocytes/macrophages. The latter cells could provide access of HCV into the central nervous system ('Trojan horse'
      mechanism) in a process similar to that postulated for HIV-1. In support of this hypothetical mechanism come reports showing a close relationship between HCV sequences present in the brain and cerebrospinal fluid and sequences found in lymph nodes and peripheral blood mononuclear cells. However, despite some similarities there is a fundamental difference between HIV-1 and HCV infection as the latter does not progress into AIDS-type dementia.

      Introduction

      Hepatitis C virus (HCV) is an important etiological factor of chronic hepatitis, cirrhosis, and hepatocellular carcinoma [1,2]. The prevalence of chronic HCV infection ranges between 0.3 and 4% for most parts of the world [3], whereas the prevalence of antibodies to HCV in the United States is 1.8%, and approximately 2.7 million Americans carry the virus [4].

      Hepatitis C virus infection in HIV-1-positive patients

      HCV infection is common among HIV-positive patients as both pathogens share similar routes of transmission. In the United States and Europe, 13-43% of HIV-infected individuals are also infected with HCV [5]. Moreover, HIV co-infection may facilitate mother-to-infant [6] and horizontal [7] transmission of HCV. It has been reported that HIV accelerates the development of severe liver disease in HCV-infected patients [8,9], and a recent reduction in mortality and morbidity among HIV-infected patients could have contributed to the emergence of HCV as a significant pathogen in this population. These negative effects of HIV on liver disease could be a result of the enhancement of HCV replication in the setting of immunodeficiency. However, there is also evidence that HCV replication may be directly enhanced by the presence of HIV, as HIV seroconversion in HCV-positive patients was associated with an immediate increase in serum HCV-RNA levels [10].

      HCV infection may also negatively affect the course of HIV disease. In particular, a report from the Swiss cohort study [11], which included over 2000 subjects, demonstrated that HIV/HCV-co-infected patients were more likely to develop AIDS-defining opportunistic infections than those only infected with HIV. Similar findings were reported in a large Italian study [12] and from The Women's Interagency HIV-1 Study [13]. However, Sulkowski et al. [14] did not find evidence that HCV infection substantially alters the risk of dying, developing AIDS, or responding immunologically to highly active antiretroviral therapy. These discrepancies are difficult to sort out, particularly as the cohorts and their respective controls varied in demographics and epidemiological background.

      Extrahepatic replication of hepatitis C virus

      HCV is not strictly hepatotropic, as it can also replicate in peripheral blood mononuclear cells (PBMC). Several groups of researchers have detected HCV-RNA negative strand, which is a viral replicative intermediate, within PBMC, and it was also demonstrated that viral genomic sequences present in PBMC are often different from those found in serum and the liver [15-18]. HCV RNA has also been detected in PBMC and hematopoietic progenitor cells by in situ hybridization [19]. Furthermore, the same minor quasispecies variants of strain H77, which were selected in lymphoblastoid cells in vitro, were found to be replicating in vivo in PBMC of chimpanzees inoculated with the same parent strain [20]. Within the population of PBMC, the cells harboring replicating virus have been identified primary as monocytes/macrophages and B cells, although T cells can also be infected, particularly in long-lasting infection [21-23]. The above cells may manifest functional changes in chronic hepatitis C
      patients, although it is unclear whether this is directly caused by HCV infection. B-cell dysfunction is thus characterized by low-titer and delayed onset antibody response and an increased frequency of naive B cells [24,25], whereas monocyte-derived dendritic cells demonstrate impaired allostimulatory function [21,26]. It was recently shown that primary human macrophages can be infected by HCV in vitro, as evidenced by the detection of viral replicative forms, an occasional evolution of viral sequences during cell culture, and positive staining of infected cells for viral non-structural protein 3 (NS3) [27,28]. Moreover, HCV infection of macrophages in vitro may induce TNF-α and IL-8 [29].

      Interestingly, there is emerging evidence that HIV could facilitate HCV replication not only in the liver, but also at extrahepatic sites [22,28]. The mechanisms by which HIV could enhance extrahepatic HCV infection are still speculative, one possibility being that this effect is related to general immunosuppression. Accordingly, in one small study viral negative strand was more common in PBMC from patients after liver transplantation than in patients before liver transplantation [30], and the presence of HCV replication was documented in hematopoietic cells inoculated into severe combined immunodeficiency mice [31]. An increase in extrahepatic HCV replication could also be related to HIV-induced cell activation. In support of such a possibility come observations that the addition of pokeweed and phytohemagglutinin mitogens to PBMC cultures may significantly enhance HCV replication [22,32]. However, HIV infection could also facilitate extrahepatic replication of HCV more directly.
      For example, the HIV tat protein is a strong transactivator, and a putative tat-binding motif was found in the NS4 region of HCV [33]. We have recently shown that the same cell could harbor both pathogens, which could facilitate close viral-viral interactions [28].

      Interestingly, in a recent study encompassing 75 HCV-infected women, 62 of whom were co-infected with HIV-1, local HIV viremia and the presence of HCV RNA in serum were the only independent predictors of HCV RNA in genital tract secretions. Significant (> 600 IU/ml) HCV viremia in cervical lavage samples was present in 28% of HIV-co-infected women and in none of the HIV-negative women [34]. Local interactions and possible co-infection of the same cells could perhaps explain the co-transmission of HIV with HCV reported in earlier mother-to-child transmission studies conducted before the introduction of highly active antiretroviral therapy [35]. The co-transmission of both pathogens was also reported in sexual partners of HIV/HCV-co-infected hemophiliac individuals [7]. Extrahepatic sites of HCV replication may play a major role in viral persistence: it was recently demonstrated that the virus may linger for years at extrahepatic sites after ostensible successful treatment-induced or
      spontaneous clearance [32,36]. Furthermore, extrahepatic variants were demonstrated to have a low rate of non-synonymous mutations in the hypervariable envelope region, which may suggest low immunological pressure or low replication turnover, both of which could be conducive to viral persistence [23].

      Hepatitis C virus effect on central nervous system

      There is growing evidence that patients with chronic hepatitis C are more likely to have significant changes in their physical and mental wellbeing, such as fatigue and depression, than patients with liver disease of other etiology [37,38]. These symptoms are unrelated to the mode of acquisition of the infection or to the severity of liver disease but often remit after antiviral therapy [37,39]. Two recently published studies have shown that HCV infection is associated with cognitive dysfunction [40,41]. Forton et al. [40] found that patients with chronic hepatitis C were impaired on cognitive tasks. Moreover, impairments in power of concentration and speed of working memory were independent of a history of injection drug use, depression or fatigue. The same researchers used proton magnetic resonance spectroscopy and demonstrated elevations in basal ganglia and white matter of choline/creatine ratios in patients with mild hepatitis C, which were not present either in healthy
      volunteers or patients with hepatitis B [40,42]. These changes were unrelated to either hepatic encephalopathy or a history of injection drug use, and were more pronounced in patients with cognitive impairment. It is of note that similar proton magnetic resonance spectroscopy abnormalities were found in patients with HIV infection, which suggests some similarities between both pathogens with respect to central nervous system (CNS) involvement [43,44]. Findings suggestive of neurocognitive impairment were also reported by Kramer et al. [45], who used P300 event-related potentials in a large cohort of patients with chronic HCV infection. HCV infection was also associated with reduced white matter N-acetyl aspartate in abstinent methamphetamine users, suggesting that the infection may worsen methamphetamine-associated neuronal injury [46]. Additional evidence of a likely biological basis of cognitive dysfunction is provided by a recent report showing multiple gene _expression
      differences in brain tissue between HCV-positive and HCV-negative patients [47].

      Some studies have indicated an impact of HCV on CNS function among HIV-infected cohorts. In one small sample, co-infected patients were more likely to show overall cognitive impairment than patients with exclusive HIV infection [48]. Distinct negative neurocognitive effects of HCV co-infection were recently documented in an advanced HIV cohort [49]. The latter two studies point to the necessity of future studies in HIV/HCV-co-infected patients, in whom cognitive impairment is generally attributed only to HIV infection.

      Results of the above studies raise the possibility of direct HCV infection of the CNS. HCV belongs to the flaviviridae family, which includes well-known neurotropic viruses (e.g. yellow fever, dengue, tick-borne encephalitis viruses), and several reports have implicated HCV as an occasional cause of CNS and peripheral nervous system pathologies [50-52]. Viral sequences were also amplified directly from brain tissue from a patient diagnosed with progressive encephalomyelitis [50]. However, the presence of viral sequences in brain tissue could be the result of blood contamination and cannot be regarded as evidence of local HCV replication. In a recent study, we detected negative-strand HCV RNA, which is a viral replicative intermediary, in autopsy brain tissue of three out of six HCV-infected patients, and in two of these patients there was evidence of viral brain compartmentalization as viral sequences amplified from the brain differed from those circulating in serum. Importantly,
      brain-derived HCV variants were found to be more closely related to the virus present in the lymphoid system than to the virus circulating in serum, as based on sequence analysis of two different viral regions [53]. A close relationship between the HCV variants present in brain tissue and those present in lymph nodes was recently reported by another group of researchers [54]. Moreover, CNS-derived 5′-untranslated region sequences were reported to have reduced translation efficiency compared with virus present in the serum and liver. The latter finding is compatible with a slow replication rate of brain HCV strains and could perhaps favor viral latency.

      We have recently identified the brain cells harboring HCV as macrophages/microglia [47]. In that study, basic brain cell types (macrophages/microglia, neurons, astrocytes, oligodendrocytes) were separated by laser capture microscopy from autopsy brain tissue from two HCV-positive patients. HCV-RNA positive and negative strands were consistently detected only in CD68-positive cells (macrophage/microglia). In a different approach, brain tissue was stained with anti-NS3 monoclonal antibodies, NS3-positive cells were separated by laser capture microscopy and phenotyped by the amplification of cell-specific transcripts. Again, the evidence pointed to CD68-positive cells as the being infected by HCV.

      The hypothetical route for CNS infection could be provided by infected macrophages/monocytes, and perhaps also by B cells and T cells ('Trojan horse' mechanism). Although it was long believed that circulating leukocytes are excluded from the CNS, it is now known that all basic groups of leukocytes, T cells, B cells, macrophage/monocytes and natural killer cells, have the ability to enter the brain under certain conditions [55]. Importantly, certain monocyte family members are constantly being replaced as part of normal physiology [56,57], whereas the entry of T cells and B cells appears to be dependent only on the activation state of the leukocyte and not on CNS factors [58,59]. In support of this hypothetical mechanism come observations on the presence of HCV in the cerebrospinal fluid (CSF) from both HIV-positive and HIV-negative patients [60,61]. In a more recent study [62], we found HCV RNA in the cellular fraction of CSF (eight out of 13 patients), but viral sequences were
      rarely present in supernatants (two out of 13 patients). Importantly, in half of the patients in whom viral sequences were amplified, the CSF-derived virus was closer to that found in PBMC, than to that circulating in serum, which suggested that it was of lymphoid origin. In two of the latter patients sequences recovered from CSF and serum were classified as belonging to different genotypes. However, they were compatible with the genotype present in PBMC. These findings strongly suggest that the virus found in CSF was derived from peripheral blood leukocytes, and not serum. The presence of differing viral genotypes in serum and lymphoid compartments was also reported by others [23].

      The still hypothetical scenario connecting HCV infection and functional CNS changes could be summarized as follows. HCV can infect PBMC, particularly macrophages, and this process is likely to be facilitated by concomitant HIV co-infection. Infected leukocytes could cross the blood-brain barrier ('Trojan horse' phenomenon) in a process similar to that postulated for HIV-1 infection [63,64]. Subsequently, there could be a secondary spread of HCV to permissive cells within the brain. The primary targets are brain microglia cells, which are essentially tissue-resident macrophages of blood monocytic origin [65]. Infected macrophages and microglia cells could release proinflammatory cytokines, such as TNF-α, IL-1, and IL-6, neurotoxins such as nitric oxide, and viral proteins, which could induce an alteration in brain function leading in turn to neurocognitive dysfunction and depression [66,67]. A similar chain of events seems to be operational in HIV-1 infection [68,69]. However,
      despite some similarities there is a fundamental difference between HIV-1 and HCV infections, as the latter does not progress into AIDS-type dementia. This is perhaps due to the fact that HCV replication in macrophages is low level and is confined to a limited number of cells [28].


      References
      1. Alter MJ, Margolis HS, Krawczynski K, Judson FN, Mares A, Alexander WJ, et al. The natural history of community-acquired hepatitis C in the United States. The Sentinel Counties Chronic non-A, non-B Hepatitis Study Team. N Engl J Med 1992; 327:1899-1905.
      2. Simonetti RG, Camma C, Fiorello F, Cottone M, Rapicetta M, Marino L, et al. Hepatitis C virus infection as a risk factor for hepatocellular carcinoma in patients with cirrhosis. A case-control study. Ann Intern Med 1992; 116:97-102.
      3. Nishioka K. Epidemiological studies on hepatitis C virus infection: detection, prevalence, exposure and prevention. Intervirology 1994; 37:58-67.
      4. Alter MJ, Kruszon-Moran D, Nainan OV, McQuillan GM, Gao F, Moyer LA, et al. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med 1999; 341:556-562.
      5. Winnock M, Salmon-Ceron D, Dabis F, Chene G. Interaction between HIV-1 and HCV infections: towards a new entity? J Antimicrob Chemother 2004; 53:936-946.
      6. Zanetti AR, Tanzi E, Paccagnini S, Principi N, Pizzocolo G, Caccamo ML, et al. Mother-to-infant transmission of hepatitis C virus. Lombardy Study Group on Vertical HCV Transmission [see Comments]. Lancet 1995; 345:289-291.
      7. Eyster ME, Alter HJ, Aledort LM, Quan S, Hatzakis A, Goedert JJ. Heterosexual co-transmission of hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Ann Intern Med 1991; 115:764-768.
      8. Eyster ME, Diamondstone LS, Lien JM, Ehmann WC, Quan S, Goedert JJ. Natural history of hepatitis C virus infection in multitransfused hemophiliacs: effect of coinfection with human immunodeficiency virus. The Multicenter Hemophilia Cohort Study. J Acquir Immune Defic Syndr 1993; 6:602-610.
      9. Hanley JP, Jarvis LM, Andrews J, Dennis R, Lee R, Simmonds P, et al. Investigation of chronic hepatitis C infection in individuals with haemophilia: assessment of invasive and non-invasive methods. Br J Haematol 1996; 94:159-165.
      10. Beld M, Penning M, Lukashov V, McMorrow M, Roos M, Pakker N, et al. Evidence that both HIV and HIV-induced immunodeficiency enhance HCV replication among HCV seroconverters. Virology 1998; 244:504-512.
      11. Greub G, Ledergerber B, Battegay M, Grob P, Perrin L, Furrer H, et al. Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study. Lancet 2000; 356:1800-1805.
      12. De Luca A, Bugarini R, Lepri AC, Puoti M, Girardi E, Antinori A, et al. Coinfection with hepatitis viruses and outcome of initial antiretroviral regimens in previously naive HIV-infected subjects. Arch Intern Med 2002; 162:2125-2132.
      13. Kovacs A, Du W, DeGiacomo M, Shahidyazdani T, Wright D, Nowicki J. Impact of HCV viremia on HIV disease progression in women. In: 15th International AIDS Conference. Bangkok, Thailand, 11-16 July 2004 [Abstract MoPeB3343].
      14. Sulkowski MS, Moore RD, Mehta SH, Chaisson RE, Thomas DL. Hepatitis C and progression of HIV disease. JAMA 2002; 288:199-206.
      15. Laskus T, Radkowski M, Wang LF, Jang SJ, Vargas H, Rakela J. Hepatitis C virus quasispecies in patients infected with HIV-1: correlation with extrahepatic viral replication. Virology 1998; 248:164-171.
      16. Laskus T, Radkowski M, Wang LF, Nowicki M, Rakela J. Uneven distribution of hepatitis C virus quasispecies in tissues from subjects with end-stage liver disease: confounding effect of viral adsorption and mounting evidence for the presence of low-level extrahepatic replication. J Virol 2000; 74:1014-1017.
      17. Lerat H, Rumin S, Habersetzer F, Berby F, Trabaud MA, Trépo C, et al. In vivo tropism of hepatitis C virus genomic sequences in hematopoietic cells: influence of viral load, viral genotype, and cell phenotype. Blood 1998; 91:3841-3849.
      18. Navas S, Martin J, Quiroga JA, Castillo I, Carreno V. Genetic diversity and tissue compartmentalization of the hepatitis C virus genome in blood mononuclear cells, liver, and serum from chronic hepatitis C patients. J Virol 1998; 72:1640-1646.
      19. Sansonno D, Iacobelli AR, Cornacchiulo V, Iodice G, Dammacco F. Detection of hepatitis C virus (HCV) proteins by immunofluorescence and HCV RNA genomic sequences by non-isotopic in situ hybridization in bone marrow and peripheral blood mononuclear cells of chronically HCV- infected patients. Clin Exp Immunol 1996; 103:414-421.
      20. Shimizu YK, Igarashi H, Kanematu T, Fujiwara K, Wong DC, Purcell RH, et al. Sequence analysis of the hepatitis C virus genome recovered from serum, liver, and peripheral blood mononuclear cells of infected chimpanzees. J Virol 1997; 71:5769-5773.
      21. Bain C, Fatmi A, Zoulim F, Zarski JP, Trepo C, Inchauspe G. Impaired allostimulatory function of dendritic cells in chronic hepatitis C infection. Gastroenterology 2001; 120:512-524.
      22. Laskus T, Radkowski M, Piasek A, Nowicki M, Horban A, Cianciara J, et al. Hepatitis C virus in lymphoid cells of patients coinfected with human immunodeficiency virus type 1: evidence of active replication in monocytes/macrophages and lymphocytes. J Infect Dis 2000; 181:442-448.
      23. Ducoulombier D, Roque-Afonso AM, Di Liberto G, Penin F, Kara F, Richard Y, et al. Frequent compartmentalization of hepatitis C virus variants in circulating B cells and monocytes. Hepatology 2004; 39:817-825.
      24. Chen M, Sallberg M, Sönnerborg A, Weiland O, Mattsson L, Jin L, et al. Limited humoral immunity in hepatitis C virus infection. Gastroenterology 1999; 116:135-143.
      25. Ni J, Hembrador E, Di Bisceglie AM, Jacobson IM, Talal AH, Butera D, et al. Accumulation of B lymphocytes with a naive, resting phenotype in a subset of hepatitis C patients. J Immunol 2003; 170:3429-3439.
      26. Auffermann-Gretzinger S, Keeffe EB, Levy S. Impaired dendritic cell maturation in patients with chronic, but not resolved, hepatitis C virus infection. Blood 2001; 97:3171-3176.
      27. Caussin-Schwemling C, Schmitt C, Stoll-Keller F. Study of the infection of human blood derived monocyte/macrophages with hepatitis C virus in vitro. J Med Virol 2001; 65:14-22.
      28. Laskus T, Radkowski M, Jablonska J, Kibler K, Wilkinson J, Adair D, et al. Human immunodeficiency virus facilitates infection/replication of hepatitis C virus in native human macrophages. Blood 2004; 103:3854-3859.
      29. Radkowski M, Bednarska A, Horban A, Stanczak J, Wilkinson J, Adair DM, et al. Infection of primary human macrophages with hepatitis C virus in vitro: induction of tumour necrosis factor-alpha and interleukin 8. J Gen Virol 2004; 85:47-59.
      30. Radkowski M, Wang LF, Vargas HE, Rakela J, Laskus T. Detection of hepatitis C virus replication in peripheral blood mononuclear cells after orthotopic liver transplantation. Transplantation 1998; 66:664-666.
      31. Bronowicki JP, Loriot MA, Thiers V, Grignon Y, Zignego AL, Brechot C. Hepatitis C virus persistence in human hematopoietic cells injected into SCID mice. Hepatology 1998; 28:211-218.
      32. Pham TN, MacParland SA, Mulrooney PM, Cooksley H, Naoumov NV, Michalak TI. Hepatitis C virus persistence after spontaneous or treatment-induced resolution of hepatitis C. J Virol 2004; 78:5867-5874.
      33. Ferbeyre G, Bourdeau V, Cedergren R. Does HIV tat protein also regulate genes of other viruses present in HIV infection? [Letter]. Trends Biochem Sci 1997; 22:115-116.
      34. Rakela J, Radkowski M, Laskus T, Wilkinson J, Adair D, Kovacs A, et al. HCV presence in genital secretions in HIV/HCV coinfected women. Hepatology 2003; 38:184A.
      35. Papaevangelou V, Pollack H, Rochford G, Kokka R, Hou Z, Chernoff D, et al. Increased transmission of vertical hepatitis C virus (HCV) infection to human immunodeficiency virus (HIV)-infected infants of HIV- and HCV-coinfected women. J Infect Dis 1998; 178:1047-1052.
      36. Radkowski M, Gallegos-Orozco JF, Jablonska J, Colby TF, Walewska-Zielecka B, Kubicka J, et al. Persistence of hepatitis C virus in patients successfully treated for chronic hepatitis C. Hepatology 2004; 41:106-114.
      37. Foster GR. Hepatitis C virus infection: quality of life and side effects of treatment. J Hepatol 1999; 31:250-254.
      38. Singh N, Gayowski T, Wagener MM, Marino IR. Quality of life, functional status, and depression in male liver transplant recipients with recurrent viral hepatitis C. Transplantation 1999; 67:69-72.
      39. Bonkovsky HL, Woolley JM. Reduction of health-related quality of life in chronic hepatitis C and improvement with interferon therapy. The Consensus Interferon Study Group [see Comments]. Hepatology 1999; 29:264-270.
      40. Forton DM, Thomas HC, Murphy CA, Allsop JM, Foster GR, Main J, et al. Hepatitis C and cognitive impairment in a cohort of patients with mild liver disease. Hepatology 2002; 35:433-439.
      [Medline Link] [CrossRef] [Context Link]
      41. Hilsabeck RC, Perry W, Hassanein TI. Neuropsychological impairment in patients with chronic hepatitis C. Hepatology 2002; 35:440-446.
      42. Forton DM, Allsop JM, Main J, Foster GR, Thomas HC, Taylor-Robinson SD. Evidence for a cerebral effect of the hepatitis C virus. Lancet 2001; 358:38-39.
      43. Marcus CD, Taylor-Robinson SD, Sargentoni J, Ainsworth JG, Frize G, Easterbrook PJ, et al. 1H MR spectroscopy of the brain in HIV-1-seropositive subjects: evidence for diffuse metabolic abnormalities. Metab Brain Dis 1998; 13:123-136.
      44. Meyerhoff DJ, Bloomer C, Cardenas V, Norman D, Weiner MW, Fein G. Elevated subcortical choline metabolites in cognitively and clinically asymptomatic HIV+ patients. Neurology 1999; 52:995-1003.
      45. Kramer L, Bauer E, Funk G, Hofer H, Jessner W, Steindl-Munda P, et al. Subclinical impairment of brain function in chronic hepatitis C infection. J Hepatol 2002; 37:349-354.
      46. Taylor MJ, Letendre SL, Schweinsburg BC, Alhassoon OM, Brown GG, Gongvatana A, et al. Hepatitis C virus infection is associated with reduced white matter N-acetylaspartate in abstinent methamphetamine users. J Int Neuropsychol Soc 2004; 10:110-113.
      47. Adair D, Wilkinson J, Scheck A, Radkowski M, Rakela J, Laskus T. Differential display and microarray analysis show differentially expressed genes in central nervous system in HCV infected patients and laser capture microscopy points to brain microglia as cells harboring HCV. Hepatology 2004; 40:433A.
      48. Letendre SL, Cherner M, Ellis R, Grant I. Individuals coinfected with hepatitis C (HCV) and HIV are more cognitively impaired than those infected with either virus alone [Abstract]. J Neurovirol 2002; 8:27-28.
      49. Ryan EL, Morgello S, Isaacs K, Naseer M, Gerits P. Neuropsychiatric impact of hepatitis C on advanced HIV. Neurology 2004; 62:957-962.
      50. Bolay H, Soylemezoglu F, Nurlu G, Tuncer S, Varli K. PCR detected hepatitis C virus genome in the brain of a case with progressive encephalomyelitis with rigidity. Clin Neurol Neurosurg 1996; 98:305-308.
      51. Heckmann JG, Kayser C, Heuss D, Manger B, Blum HE, Neundorfer B. Neurological manifestations of chronic hepatitis C. J Neurol 1999; 246:486-491.
      52. Origgi L, Vanoli M, Carbone A, Grasso M, Scorza R. Central nervous system involvement in patients with HCV-related cryoglobulinemia. Am J Med Sci 1998; 315:208-210.
      53. Radkowski M, Wilkinson J, Nowicki M, Adair D, Vargas H, Ingui C, et al. Search for hepatitis C virus negative-strand RNA sequences and analysis of viral sequences in the central nervous system: evidence of replication. J Virol 2002; 76:600-608.
      54. Forton DM, Karayiannis P, Mahmud N, Taylor-Robinson SD, Thomas HC. Identification of unique hepatitis C virus quasispecies in the central nervous system and comparative analysis of internal translational efficiency of brain, liver, and serum variants. J Virol 2004; 78:5170-5183.
      55. Hickey WF. Leukocyte traffic in the central nervous system: the participants and their roles. Semin Immunol 1999; 11:125-137.
      56. Hickey WF, Vass K, Lassmann H. Bone marrow-derived elements in the central nervous system: an immunohistochemical and ultrastructural survey of rat chimeras. J Neuropathol Exp Neurol 1992; 51:246-256.
      57. Unger ER, Sung JH, Manivel JC, Chenggis ML, Blazar BR, Krivit W. Male donor-derived cells in the brains of female sex-mismatched bone marrow transplant recipients: a Y-chromosome specific in situ hybridization study. J Neuropathol Exp Neurol 1993; 52:460-470.
      58. Hickey WF, Hsu BL, Kimura H. T-lymphocyte entry into the central nervous system. J Neurosci Res 1991; 28:254-260.
      59. Knopf PM, Harling-Berg CJ, Cserr HF, Basu D, Sirulnick EJ, Nolan SC, et al. Antigen-dependent intrathecal antibody synthesis in the normal rat brain: tissue entry and local retention of antigen-specific B cells. J Immunol 1998; 161:692-701.
      60. Maggi F, Giorgi M, Fornai C, Morrica A, Vatteroni ML, Pistello M, et al. Detection and quasispecies analysis of hepatitis C virus in the cerebrospinal fluid of infected patients. J Neurovirol 1999; 5:319-323.
      61. Morsica G, Bernardi MT, Novati R, Uberti Foppa C, Castagna A, Lazzarin A. Detection of hepatitis C virus genomic sequences in the cerebrospinal fluid of HIV-infected patients. J Med Virol 1997; 53:252-254.
      62. Laskus T, Radkowski M, Bednarska A, Wilkinson J, Adair D, Nowicki M, et al. Detection and analysis of hepatitis C virus sequences in cerebrospinal fluid. J Virol 2002; 76:10064-10068.
      63. Price RW, Sidtis J, Rosenblum M. The AIDS dementia complex: some current questions. Ann Neurol 1988; 23(Suppl.):S27-S33.
      64. Zheng J, Gendelman HE. The HIV-1 associated dementia complex: a metabolic encephalopathy fueled by viral replication in mononuclear phagocytes. Curr Opin Neurol 1997; 10:319-325.
      65. Davis EJ, Foster TD, Thomas WE. Cellular forms and functions of brain microglia. Brain Res Bull 1994; 34:73-78.
      66. Capuron L, Dantzer R. Cytokines and depression: the need for a new paradigm. Brain Behav Immun 2003; 17(Suppl. 1):S119-S124.
      [Medline Link] [Context Link]
      67. Wilson CJ, Finch CE, Cohen HJ. Cytokines and cognition - the case for a head-to-toe inflammatory paradigm. J Am Geriatr Soc 2002; 50:2041-2056.
      68. Kolson DL, Lavi E, Gonzalez-Scarano F. The effects of human immunodeficiency virus in the central nervous system. Adv Virus Res 1998; 50:1-47.
      69. Pulliam L, Herndier BG, Tang NM, McGrath MS. Human immunodeficiency virus-infected macrophages produce soluble factors that cause histological and neurochemical alterations in cultured human brains. J Clin Invest 1991; 87:503-512.


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    • avansi7465
      It s a blood borne pathogen. Where there s blood there will also be HCV. Nice to know I don t have alzheimer s though. Sorry for the sarcasm. I m having
      Message 2 of 7 , Nov 10, 2005
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        It's a blood borne pathogen. Where there's blood there will also be HCV. Nice to know I don't have alzheimer's though. Sorry for the sarcasm. I'm having one of my days. Anne

        -----Original Message-----
        From: claudine intexas <claudineintexas@...>
        Sent: Nov 9, 2005 11:18 PM
        To: giworld-hepatitis@yahoogroups.com, Web Warriors <HepCWebWarriors@yahoogroups.com>
        Subject: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue

        HCV Found in Autopsy Brain Tissue-
        Emerging evidence of hepatitis C virus neuroinvasion

        AIDS: Volume 19 Suppl 3 October 2005 p S140-S144

        Laskus, Tomasza,c; Radkowski, Mareka,b; Adair, Debra Ma; Wilkinson, Jeffreya; Scheck, Adrienne Cc; Rakela, Jorgea

        >From the aDepartment of Medicine, Mayo Clinic Scottsdale, Scottsdale, Arizona 85259
        bInstitute of Infectious Diseases, Warsaw Medical Academy, Poland
        cBarrow Neurological Institute, Phoenix, Arizona.

        Abstract
        It has been reported that hepatitis C virus (HCV) infection is associated with cognitive dysfunction, fatigue and depression, which do not correlate with the severity of liver disease and cannot be accounted for by hepatic encephalopathy or drug abuse. There is also emerging evidence that HCV infection can have negative neurocognitive effects in HIV-infected cohorts. Magnetic resonance spectroscopy has suggested the likely existence of a biological basis for these effects. HCV replicative forms have recently been detected in autopsy brain tissue and the infected cells have been identified as CD68-positive (macrophages/microglia). These findings raise the possibility that HCV infection of the brain could be directly related to the reported neuropsychological and cognitive changes. HCV is not strictly hepatotropic, as it can also replicate in leukocytes, including monocytes/macrophages. The latter cells could provide access of HCV into the central nervous system ('Trojan horse'
        mechanism) in a process similar to that postulated for HIV-1. In support of this hypothetical mechanism come reports showing a close relationship between HCV sequences present in the brain and cerebrospinal fluid and sequences found in lymph nodes and peripheral blood mononuclear cells. However, despite some similarities there is a fundamental difference between HIV-1 and HCV infection as the latter does not progress into AIDS-type dementia.

        Introduction

        Hepatitis C virus (HCV) is an important etiological factor of chronic hepatitis, cirrhosis, and hepatocellular carcinoma [1,2]. The prevalence of chronic HCV infection ranges between 0.3 and 4% for most parts of the world [3], whereas the prevalence of antibodies to HCV in the United States is 1.8%, and approximately 2.7 million Americans carry the virus [4].

        Hepatitis C virus infection in HIV-1-positive patients

        HCV infection is common among HIV-positive patients as both pathogens share similar routes of transmission. In the United States and Europe, 13-43% of HIV-infected individuals are also infected with HCV [5]. Moreover, HIV co-infection may facilitate mother-to-infant [6] and horizontal [7] transmission of HCV. It has been reported that HIV accelerates the development of severe liver disease in HCV-infected patients [8,9], and a recent reduction in mortality and morbidity among HIV-infected patients could have contributed to the emergence of HCV as a significant pathogen in this population. These negative effects of HIV on liver disease could be a result of the enhancement of HCV replication in the setting of immunodeficiency. However, there is also evidence that HCV replication may be directly enhanced by the presence of HIV, as HIV seroconversion in HCV-positive patients was associated with an immediate increase in serum HCV-RNA levels [10].

        HCV infection may also negatively affect the course of HIV disease. In particular, a report from the Swiss cohort study [11], which included over 2000 subjects, demonstrated that HIV/HCV-co-infected patients were more likely to develop AIDS-defining opportunistic infections than those only infected with HIV. Similar findings were reported in a large Italian study [12] and from The Women's Interagency HIV-1 Study [13]. However, Sulkowski et al. [14] did not find evidence that HCV infection substantially alters the risk of dying, developing AIDS, or responding immunologically to highly active antiretroviral therapy. These discrepancies are difficult to sort out, particularly as the cohorts and their respective controls varied in demographics and epidemiological background.

        Extrahepatic replication of hepatitis C virus

        HCV is not strictly hepatotropic, as it can also replicate in peripheral blood mononuclear cells (PBMC). Several groups of researchers have detected HCV-RNA negative strand, which is a viral replicative intermediate, within PBMC, and it was also demonstrated that viral genomic sequences present in PBMC are often different from those found in serum and the liver [15-18]. HCV RNA has also been detected in PBMC and hematopoietic progenitor cells by in situ hybridization [19]. Furthermore, the same minor quasispecies variants of strain H77, which were selected in lymphoblastoid cells in vitro, were found to be replicating in vivo in PBMC of chimpanzees inoculated with the same parent strain [20]. Within the population of PBMC, the cells harboring replicating virus have been identified primary as monocytes/macrophages and B cells, although T cells can also be infected, particularly in long-lasting infection [21-23]. The above cells may manifest functional changes in chronic hepatitis C
        patients, although it is unclear whether this is directly caused by HCV infection. B-cell dysfunction is thus characterized by low-titer and delayed onset antibody response and an increased frequency of naive B cells [24,25], whereas monocyte-derived dendritic cells demonstrate impaired allostimulatory function [21,26]. It was recently shown that primary human macrophages can be infected by HCV in vitro, as evidenced by the detection of viral replicative forms, an occasional evolution of viral sequences during cell culture, and positive staining of infected cells for viral non-structural protein 3 (NS3) [27,28]. Moreover, HCV infection of macrophages in vitro may induce TNF-α and IL-8 [29].

        Interestingly, there is emerging evidence that HIV could facilitate HCV replication not only in the liver, but also at extrahepatic sites [22,28]. The mechanisms by which HIV could enhance extrahepatic HCV infection are still speculative, one possibility being that this effect is related to general immunosuppression. Accordingly, in one small study viral negative strand was more common in PBMC from patients after liver transplantation than in patients before liver transplantation [30], and the presence of HCV replication was documented in hematopoietic cells inoculated into severe combined immunodeficiency mice [31]. An increase in extrahepatic HCV replication could also be related to HIV-induced cell activation. In support of such a possibility come observations that the addition of pokeweed and phytohemagglutinin mitogens to PBMC cultures may significantly enhance HCV replication [22,32]. However, HIV infection could also facilitate extrahepatic replication of HCV more directly.
        For example, the HIV tat protein is a strong transactivator, and a putative tat-binding motif was found in the NS4 region of HCV [33]. We have recently shown that the same cell could harbor both pathogens, which could facilitate close viral-viral interactions [28].

        Interestingly, in a recent study encompassing 75 HCV-infected women, 62 of whom were co-infected with HIV-1, local HIV viremia and the presence of HCV RNA in serum were the only independent predictors of HCV RNA in genital tract secretions. Significant (> 600 IU/ml) HCV viremia in cervical lavage samples was present in 28% of HIV-co-infected women and in none of the HIV-negative women [34]. Local interactions and possible co-infection of the same cells could perhaps explain the co-transmission of HIV with HCV reported in earlier mother-to-child transmission studies conducted before the introduction of highly active antiretroviral therapy [35]. The co-transmission of both pathogens was also reported in sexual partners of HIV/HCV-co-infected hemophiliac individuals [7]. Extrahepatic sites of HCV replication may play a major role in viral persistence: it was recently demonstrated that the virus may linger for years at extrahepatic sites after ostensible successful treatment-induced or
        spontaneous clearance [32,36]. Furthermore, extrahepatic variants were demonstrated to have a low rate of non-synonymous mutations in the hypervariable envelope region, which may suggest low immunological pressure or low replication turnover, both of which could be conducive to viral persistence [23].

        Hepatitis C virus effect on central nervous system

        There is growing evidence that patients with chronic hepatitis C are more likely to have significant changes in their physical and mental wellbeing, such as fatigue and depression, than patients with liver disease of other etiology [37,38]. These symptoms are unrelated to the mode of acquisition of the infection or to the severity of liver disease but often remit after antiviral therapy [37,39]. Two recently published studies have shown that HCV infection is associated with cognitive dysfunction [40,41]. Forton et al. [40] found that patients with chronic hepatitis C were impaired on cognitive tasks. Moreover, impairments in power of concentration and speed of working memory were independent of a history of injection drug use, depression or fatigue. The same researchers used proton magnetic resonance spectroscopy and demonstrated elevations in basal ganglia and white matter of choline/creatine ratios in patients with mild hepatitis C, which were not present either in healthy
        volunteers or patients with hepatitis B [40,42]. These changes were unrelated to either hepatic encephalopathy or a history of injection drug use, and were more pronounced in patients with cognitive impairment. It is of note that similar proton magnetic resonance spectroscopy abnormalities were found in patients with HIV infection, which suggests some similarities between both pathogens with respect to central nervous system (CNS) involvement [43,44]. Findings suggestive of neurocognitive impairment were also reported by Kramer et al. [45], who used P300 event-related potentials in a large cohort of patients with chronic HCV infection. HCV infection was also associated with reduced white matter N-acetyl aspartate in abstinent methamphetamine users, suggesting that the infection may worsen methamphetamine-associated neuronal injury [46]. Additional evidence of a likely biological basis of cognitive dysfunction is provided by a recent report showing multiple gene _expression
        differences in brain tissue between HCV-positive and HCV-negative patients [47].

        Some studies have indicated an impact of HCV on CNS function among HIV-infected cohorts. In one small sample, co-infected patients were more likely to show overall cognitive impairment than patients with exclusive HIV infection [48]. Distinct negative neurocognitive effects of HCV co-infection were recently documented in an advanced HIV cohort [49]. The latter two studies point to the necessity of future studies in HIV/HCV-co-infected patients, in whom cognitive impairment is generally attributed only to HIV infection.

        Results of the above studies raise the possibility of direct HCV infection of the CNS. HCV belongs to the flaviviridae family, which includes well-known neurotropic viruses (e.g. yellow fever, dengue, tick-borne encephalitis viruses), and several reports have implicated HCV as an occasional cause of CNS and peripheral nervous system pathologies [50-52]. Viral sequences were also amplified directly from brain tissue from a patient diagnosed with progressive encephalomyelitis [50]. However, the presence of viral sequences in brain tissue could be the result of blood contamination and cannot be regarded as evidence of local HCV replication. In a recent study, we detected negative-strand HCV RNA, which is a viral replicative intermediary, in autopsy brain tissue of three out of six HCV-infected patients, and in two of these patients there was evidence of viral brain compartmentalization as viral sequences amplified from the brain differed from those circulating in serum. Importantly,
        brain-derived HCV variants were found to be more closely related to the virus present in the lymphoid system than to the virus circulating in serum, as based on sequence analysis of two different viral regions [53]. A close relationship between the HCV variants present in brain tissue and those present in lymph nodes was recently reported by another group of researchers [54]. Moreover, CNS-derived 5′-untranslated region sequences were reported to have reduced translation efficiency compared with virus present in the serum and liver. The latter finding is compatible with a slow replication rate of brain HCV strains and could perhaps favor viral latency.

        We have recently identified the brain cells harboring HCV as macrophages/microglia [47]. In that study, basic brain cell types (macrophages/microglia, neurons, astrocytes, oligodendrocytes) were separated by laser capture microscopy from autopsy brain tissue from two HCV-positive patients. HCV-RNA positive and negative strands were consistently detected only in CD68-positive cells (macrophage/microglia). In a different approach, brain tissue was stained with anti-NS3 monoclonal antibodies, NS3-positive cells were separated by laser capture microscopy and phenotyped by the amplification of cell-specific transcripts. Again, the evidence pointed to CD68-positive cells as the being infected by HCV.

        The hypothetical route for CNS infection could be provided by infected macrophages/monocytes, and perhaps also by B cells and T cells ('Trojan horse' mechanism). Although it was long believed that circulating leukocytes are excluded from the CNS, it is now known that all basic groups of leukocytes, T cells, B cells, macrophage/monocytes and natural killer cells, have the ability to enter the brain under certain conditions [55]. Importantly, certain monocyte family members are constantly being replaced as part of normal physiology [56,57], whereas the entry of T cells and B cells appears to be dependent only on the activation state of the leukocyte and not on CNS factors [58,59]. In support of this hypothetical mechanism come observations on the presence of HCV in the cerebrospinal fluid (CSF) from both HIV-positive and HIV-negative patients [60,61]. In a more recent study [62], we found HCV RNA in the cellular fraction of CSF (eight out of 13 patients), but viral sequences were
        rarely present in supernatants (two out of 13 patients). Importantly, in half of the patients in whom viral sequences were amplified, the CSF-derived virus was closer to that found in PBMC, than to that circulating in serum, which suggested that it was of lymphoid origin. In two of the latter patients sequences recovered from CSF and serum were classified as belonging to different genotypes. However, they were compatible with the genotype present in PBMC. These findings strongly suggest that the virus found in CSF was derived from peripheral blood leukocytes, and not serum. The presence of differing viral genotypes in serum and lymphoid compartments was also reported by others [23].

        The still hypothetical scenario connecting HCV infection and functional CNS changes could be summarized as follows. HCV can infect PBMC, particularly macrophages, and this process is likely to be facilitated by concomitant HIV co-infection. Infected leukocytes could cross the blood-brain barrier ('Trojan horse' phenomenon) in a process similar to that postulated for HIV-1 infection [63,64]. Subsequently, there could be a secondary spread of HCV to permissive cells within the brain. The primary targets are brain microglia cells, which are essentially tissue-resident macrophages of blood monocytic origin [65]. Infected macrophages and microglia cells could release proinflammatory cytokines, such as TNF-α, IL-1, and IL-6, neurotoxins such as nitric oxide, and viral proteins, which could induce an alteration in brain function leading in turn to neurocognitive dysfunction and depression [66,67]. A similar chain of events seems to be operational in HIV-1 infection [68,69]. However,
        despite some similarities there is a fundamental difference between HIV-1 and HCV infections, as the latter does not progress into AIDS-type dementia. This is perhaps due to the fact that HCV replication in macrophages is low level and is confined to a limited number of cells [28].


        References
        1. Alter MJ, Margolis HS, Krawczynski K, Judson FN, Mares A, Alexander WJ, et al. The natural history of community-acquired hepatitis C in the United States. The Sentinel Counties Chronic non-A, non-B Hepatitis Study Team. N Engl J Med 1992; 327:1899-1905.
        2. Simonetti RG, Camma C, Fiorello F, Cottone M, Rapicetta M, Marino L, et al. Hepatitis C virus infection as a risk factor for hepatocellular carcinoma in patients with cirrhosis. A case-control study. Ann Intern Med 1992; 116:97-102.
        3. Nishioka K. Epidemiological studies on hepatitis C virus infection: detection, prevalence, exposure and prevention. Intervirology 1994; 37:58-67.
        4. Alter MJ, Kruszon-Moran D, Nainan OV, McQuillan GM, Gao F, Moyer LA, et al. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med 1999; 341:556-562.
        5. Winnock M, Salmon-Ceron D, Dabis F, Chene G. Interaction between HIV-1 and HCV infections: towards a new entity? J Antimicrob Chemother 2004; 53:936-946.
        6. Zanetti AR, Tanzi E, Paccagnini S, Principi N, Pizzocolo G, Caccamo ML, et al. Mother-to-infant transmission of hepatitis C virus. Lombardy Study Group on Vertical HCV Transmission [see Comments]. Lancet 1995; 345:289-291.
        7. Eyster ME, Alter HJ, Aledort LM, Quan S, Hatzakis A, Goedert JJ. Heterosexual co-transmission of hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Ann Intern Med 1991; 115:764-768.
        8. Eyster ME, Diamondstone LS, Lien JM, Ehmann WC, Quan S, Goedert JJ. Natural history of hepatitis C virus infection in multitransfused hemophiliacs: effect of coinfection with human immunodeficiency virus. The Multicenter Hemophilia Cohort Study. J Acquir Immune Defic Syndr 1993; 6:602-610.
        9. Hanley JP, Jarvis LM, Andrews J, Dennis R, Lee R, Simmonds P, et al. Investigation of chronic hepatitis C infection in individuals with haemophilia: assessment of invasive and non-invasive methods. Br J Haematol 1996; 94:159-165.
        10. Beld M, Penning M, Lukashov V, McMorrow M, Roos M, Pakker N, et al. Evidence that both HIV and HIV-induced immunodeficiency enhance HCV replication among HCV seroconverters. Virology 1998; 244:504-512.
        11. Greub G, Ledergerber B, Battegay M, Grob P, Perrin L, Furrer H, et al. Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study. Lancet 2000; 356:1800-1805.
        12. De Luca A, Bugarini R, Lepri AC, Puoti M, Girardi E, Antinori A, et al. Coinfection with hepatitis viruses and outcome of initial antiretroviral regimens in previously naive HIV-infected subjects. Arch Intern Med 2002; 162:2125-2132.
        13. Kovacs A, Du W, DeGiacomo M, Shahidyazdani T, Wright D, Nowicki J. Impact of HCV viremia on HIV disease progression in women. In: 15th International AIDS Conference. Bangkok, Thailand, 11-16 July 2004 [Abstract MoPeB3343].
        14. Sulkowski MS, Moore RD, Mehta SH, Chaisson RE, Thomas DL. Hepatitis C and progression of HIV disease. JAMA 2002; 288:199-206.
        15. Laskus T, Radkowski M, Wang LF, Jang SJ, Vargas H, Rakela J. Hepatitis C virus quasispecies in patients infected with HIV-1: correlation with extrahepatic viral replication. Virology 1998; 248:164-171.
        16. Laskus T, Radkowski M, Wang LF, Nowicki M, Rakela J. Uneven distribution of hepatitis C virus quasispecies in tissues from subjects with end-stage liver disease: confounding effect of viral adsorption and mounting evidence for the presence of low-level extrahepatic replication. J Virol 2000; 74:1014-1017.
        17. Lerat H, Rumin S, Habersetzer F, Berby F, Trabaud MA, Trépo C, et al. In vivo tropism of hepatitis C virus genomic sequences in hematopoietic cells: influence of viral load, viral genotype, and cell phenotype. Blood 1998; 91:3841-3849.
        18. Navas S, Martin J, Quiroga JA, Castillo I, Carreno V. Genetic diversity and tissue compartmentalization of the hepatitis C virus genome in blood mononuclear cells, liver, and serum from chronic hepatitis C patients. J Virol 1998; 72:1640-1646.
        19. Sansonno D, Iacobelli AR, Cornacchiulo V, Iodice G, Dammacco F. Detection of hepatitis C virus (HCV) proteins by immunofluorescence and HCV RNA genomic sequences by non-isotopic in situ hybridization in bone marrow and peripheral blood mononuclear cells of chronically HCV- infected patients. Clin Exp Immunol 1996; 103:414-421.
        20. Shimizu YK, Igarashi H, Kanematu T, Fujiwara K, Wong DC, Purcell RH, et al. Sequence analysis of the hepatitis C virus genome recovered from serum, liver, and peripheral blood mononuclear cells of infected chimpanzees. J Virol 1997; 71:5769-5773.
        21. Bain C, Fatmi A, Zoulim F, Zarski JP, Trepo C, Inchauspe G. Impaired allostimulatory function of dendritic cells in chronic hepatitis C infection. Gastroenterology 2001; 120:512-524.
        22. Laskus T, Radkowski M, Piasek A, Nowicki M, Horban A, Cianciara J, et al. Hepatitis C virus in lymphoid cells of patients coinfected with human immunodeficiency virus type 1: evidence of active replication in monocytes/macrophages and lymphocytes. J Infect Dis 2000; 181:442-448.
        23. Ducoulombier D, Roque-Afonso AM, Di Liberto G, Penin F, Kara F, Richard Y, et al. Frequent compartmentalization of hepatitis C virus variants in circulating B cells and monocytes. Hepatology 2004; 39:817-825.
        24. Chen M, Sallberg M, Sönnerborg A, Weiland O, Mattsson L, Jin L, et al. Limited humoral immunity in hepatitis C virus infection. Gastroenterology 1999; 116:135-143.
        25. Ni J, Hembrador E, Di Bisceglie AM, Jacobson IM, Talal AH, Butera D, et al. Accumulation of B lymphocytes with a naive, resting phenotype in a subset of hepatitis C patients. J Immunol 2003; 170:3429-3439.
        26. Auffermann-Gretzinger S, Keeffe EB, Levy S. Impaired dendritic cell maturation in patients with chronic, but not resolved, hepatitis C virus infection. Blood 2001; 97:3171-3176.
        27. Caussin-Schwemling C, Schmitt C, Stoll-Keller F. Study of the infection of human blood derived monocyte/macrophages with hepatitis C virus in vitro. J Med Virol 2001; 65:14-22.
        28. Laskus T, Radkowski M, Jablonska J, Kibler K, Wilkinson J, Adair D, et al. Human immunodeficiency virus facilitates infection/replication of hepatitis C virus in native human macrophages. Blood 2004; 103:3854-3859.
        29. Radkowski M, Bednarska A, Horban A, Stanczak J, Wilkinson J, Adair DM, et al. Infection of primary human macrophages with hepatitis C virus in vitro: induction of tumour necrosis factor-alpha and interleukin 8. J Gen Virol 2004; 85:47-59.
        30. Radkowski M, Wang LF, Vargas HE, Rakela J, Laskus T. Detection of hepatitis C virus replication in peripheral blood mononuclear cells after orthotopic liver transplantation. Transplantation 1998; 66:664-666.
        31. Bronowicki JP, Loriot MA, Thiers V, Grignon Y, Zignego AL, Brechot C. Hepatitis C virus persistence in human hematopoietic cells injected into SCID mice. Hepatology 1998; 28:211-218.
        32. Pham TN, MacParland SA, Mulrooney PM, Cooksley H, Naoumov NV, Michalak TI. Hepatitis C virus persistence after spontaneous or treatment-induced resolution of hepatitis C. J Virol 2004; 78:5867-5874.
        33. Ferbeyre G, Bourdeau V, Cedergren R. Does HIV tat protein also regulate genes of other viruses present in HIV infection? [Letter]. Trends Biochem Sci 1997; 22:115-116.
        34. Rakela J, Radkowski M, Laskus T, Wilkinson J, Adair D, Kovacs A, et al. HCV presence in genital secretions in HIV/HCV coinfected women. Hepatology 2003; 38:184A.
        35. Papaevangelou V, Pollack H, Rochford G, Kokka R, Hou Z, Chernoff D, et al. Increased transmission of vertical hepatitis C virus (HCV) infection to human immunodeficiency virus (HIV)-infected infants of HIV- and HCV-coinfected women. J Infect Dis 1998; 178:1047-1052.
        36. Radkowski M, Gallegos-Orozco JF, Jablonska J, Colby TF, Walewska-Zielecka B, Kubicka J, et al. Persistence of hepatitis C virus in patients successfully treated for chronic hepatitis C. Hepatology 2004; 41:106-114.
        37. Foster GR. Hepatitis C virus infection: quality of life and side effects of treatment. J Hepatol 1999; 31:250-254.
        38. Singh N, Gayowski T, Wagener MM, Marino IR. Quality of life, functional status, and depression in male liver transplant recipients with recurrent viral hepatitis C. Transplantation 1999; 67:69-72.
        39. Bonkovsky HL, Woolley JM. Reduction of health-related quality of life in chronic hepatitis C and improvement with interferon therapy. The Consensus Interferon Study Group [see Comments]. Hepatology 1999; 29:264-270.
        40. Forton DM, Thomas HC, Murphy CA, Allsop JM, Foster GR, Main J, et al. Hepatitis C and cognitive impairment in a cohort of patients with mild liver disease. Hepatology 2002; 35:433-439.
        [Medline Link] [CrossRef] [Context Link]
        41. Hilsabeck RC, Perry W, Hassanein TI. Neuropsychological impairment in patients with chronic hepatitis C. Hepatology 2002; 35:440-446.
        42. Forton DM, Allsop JM, Main J, Foster GR, Thomas HC, Taylor-Robinson SD. Evidence for a cerebral effect of the hepatitis C virus. Lancet 2001; 358:38-39.
        43. Marcus CD, Taylor-Robinson SD, Sargentoni J, Ainsworth JG, Frize G, Easterbrook PJ, et al. 1H MR spectroscopy of the brain in HIV-1-seropositive subjects: evidence for diffuse metabolic abnormalities. Metab Brain Dis 1998; 13:123-136.
        44. Meyerhoff DJ, Bloomer C, Cardenas V, Norman D, Weiner MW, Fein G. Elevated subcortical choline metabolites in cognitively and clinically asymptomatic HIV+ patients. Neurology 1999; 52:995-1003.
        45. Kramer L, Bauer E, Funk G, Hofer H, Jessner W, Steindl-Munda P, et al. Subclinical impairment of brain function in chronic hepatitis C infection. J Hepatol 2002; 37:349-354.
        46. Taylor MJ, Letendre SL, Schweinsburg BC, Alhassoon OM, Brown GG, Gongvatana A, et al. Hepatitis C virus infection is associated with reduced white matter N-acetylaspartate in abstinent methamphetamine users. J Int Neuropsychol Soc 2004; 10:110-113.
        47. Adair D, Wilkinson J, Scheck A, Radkowski M, Rakela J, Laskus T. Differential display and microarray analysis show differentially expressed genes in central nervous system in HCV infected patients and laser capture microscopy points to brain microglia as cells harboring HCV. Hepatology 2004; 40:433A.
        48. Letendre SL, Cherner M, Ellis R, Grant I. Individuals coinfected with hepatitis C (HCV) and HIV are more cognitively impaired than those infected with either virus alone [Abstract]. J Neurovirol 2002; 8:27-28.
        49. Ryan EL, Morgello S, Isaacs K, Naseer M, Gerits P. Neuropsychiatric impact of hepatitis C on advanced HIV. Neurology 2004; 62:957-962.
        50. Bolay H, Soylemezoglu F, Nurlu G, Tuncer S, Varli K. PCR detected hepatitis C virus genome in the brain of a case with progressive encephalomyelitis with rigidity. Clin Neurol Neurosurg 1996; 98:305-308.
        51. Heckmann JG, Kayser C, Heuss D, Manger B, Blum HE, Neundorfer B. Neurological manifestations of chronic hepatitis C. J Neurol 1999; 246:486-491.
        52. Origgi L, Vanoli M, Carbone A, Grasso M, Scorza R. Central nervous system involvement in patients with HCV-related cryoglobulinemia. Am J Med Sci 1998; 315:208-210.
        53. Radkowski M, Wilkinson J, Nowicki M, Adair D, Vargas H, Ingui C, et al. Search for hepatitis C virus negative-strand RNA sequences and analysis of viral sequences in the central nervous system: evidence of replication. J Virol 2002; 76:600-608.
        54. Forton DM, Karayiannis P, Mahmud N, Taylor-Robinson SD, Thomas HC. Identification of unique hepatitis C virus quasispecies in the central nervous system and comparative analysis of internal translational efficiency of brain, liver, and serum variants. J Virol 2004; 78:5170-5183.
        55. Hickey WF. Leukocyte traffic in the central nervous system: the participants and their roles. Semin Immunol 1999; 11:125-137.
        56. Hickey WF, Vass K, Lassmann H. Bone marrow-derived elements in the central nervous system: an immunohistochemical and ultrastructural survey of rat chimeras. J Neuropathol Exp Neurol 1992; 51:246-256.
        57. Unger ER, Sung JH, Manivel JC, Chenggis ML, Blazar BR, Krivit W. Male donor-derived cells in the brains of female sex-mismatched bone marrow transplant recipients: a Y-chromosome specific in situ hybridization study. J Neuropathol Exp Neurol 1993; 52:460-470.
        58. Hickey WF, Hsu BL, Kimura H. T-lymphocyte entry into the central nervous system. J Neurosci Res 1991; 28:254-260.
        59. Knopf PM, Harling-Berg CJ, Cserr HF, Basu D, Sirulnick EJ, Nolan SC, et al. Antigen-dependent intrathecal antibody synthesis in the normal rat brain: tissue entry and local retention of antigen-specific B cells. J Immunol 1998; 161:692-701.
        60. Maggi F, Giorgi M, Fornai C, Morrica A, Vatteroni ML, Pistello M, et al. Detection and quasispecies analysis of hepatitis C virus in the cerebrospinal fluid of infected patients. J Neurovirol 1999; 5:319-323.
        61. Morsica G, Bernardi MT, Novati R, Uberti Foppa C, Castagna A, Lazzarin A. Detection of hepatitis C virus genomic sequences in the cerebrospinal fluid of HIV-infected patients. J Med Virol 1997; 53:252-254.
        62. Laskus T, Radkowski M, Bednarska A, Wilkinson J, Adair D, Nowicki M, et al. Detection and analysis of hepatitis C virus sequences in cerebrospinal fluid. J Virol 2002; 76:10064-10068.
        63. Price RW, Sidtis J, Rosenblum M. The AIDS dementia complex: some current questions. Ann Neurol 1988; 23(Suppl.):S27-S33.
        64. Zheng J, Gendelman HE. The HIV-1 associated dementia complex: a metabolic encephalopathy fueled by viral replication in mononuclear phagocytes. Curr Opin Neurol 1997; 10:319-325.
        65. Davis EJ, Foster TD, Thomas WE. Cellular forms and functions of brain microglia. Brain Res Bull 1994; 34:73-78.
        66. Capuron L, Dantzer R. Cytokines and depression: the need for a new paradigm. Brain Behav Immun 2003; 17(Suppl. 1):S119-S124.
        [Medline Link] [Context Link]
        67. Wilson CJ, Finch CE, Cohen HJ. Cytokines and cognition - the case for a head-to-toe inflammatory paradigm. J Am Geriatr Soc 2002; 50:2041-2056.
        68. Kolson DL, Lavi E, Gonzalez-Scarano F. The effects of human immunodeficiency virus in the central nervous system. Adv Virus Res 1998; 50:1-47.
        69. Pulliam L, Herndier BG, Tang NM, McGrath MS. Human immunodeficiency virus-infected macrophages produce soluble factors that cause histological and neurochemical alterations in cultured human brains. J Clin Invest 1991; 87:503-512.


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      • alleypat@comcast.net
        Anne, I know how you feel. I ve been cursing my HCV for days now. It s kept me out of a gene threrapy study for malignant melanoma. So now I have to do chemo.
        Message 3 of 7 , Nov 11, 2005
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          Anne, I know how you feel.

          I've been cursing my HCV for days now. It's kept me out of a gene threrapy study for malignant melanoma. So now I have to do chemo. My liver is NOT gonna like that. sigh

          Sometimes I think God just doesn't like me.

          Maybe next week will be better.

          Alley

          [Non-text portions of this message have been removed]
        • avansi7465
          Alley, I missed something along the way. I thought the melanoma was a past issue and no longer a problem. What kind of chemo? Prayers just started. And
          Message 4 of 7 , Nov 12, 2005
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            Alley,

            I missed something along the way. I thought the melanoma was a past issue and no longer a problem. What kind of chemo? Prayers just started. And next week will be better.

            Anne

            -----Original Message-----
            From: alleypat@...
            Sent: Nov 11, 2005 11:44 PM
            To: GIWorld-Hepatitis@yahoogroups.com
            Subject: Re: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue

            Anne, I know how you feel.

            I've been cursing my HCV for days now. It's kept me out of a gene threrapy study for malignant melanoma. So now I have to do chemo. My liver is NOT gonna like that. sigh

            Sometimes I think God just doesn't like me.

            Maybe next week will be better.

            Alley

            [Non-text portions of this message have been removed]




            Welcome to GIHepWorld

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          • alleypat@comcast.net
            Thanks Anne. No, the melanoma was removed and some lymph nodes several years ago. It was present in one lymph node then. In July I had another melanoma in the
            Message 5 of 7 , Nov 15, 2005
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              Thanks Anne. No, the melanoma was removed and some lymph nodes several years ago. It was present in one lymph node then. In July I had another melanoma in the same area so had all the lymph nodes removed there (well all they can get). Then I went to apply for a melanoma vaccine trial and the CT scans revealed it had spread to my lungs. I applied to a gene trial (trying to avoid toxic crap) but didn't qualify due to my active HCV. So now I'm looking at other trials iwth different types of medications (chemo). The doctor says without treatment, I'll live 6 to 9 months. That's a little hard to take in LOL. A lot depends on how fast it grows and all that rot. I'm not looking forward to treatment, but I am looking forward to living :).

              Alley
              -------------- Original message --------------
              Alley,

              I missed something along the way. I thought the melanoma was a past issue and no longer a problem. What kind of chemo? Prayers just started. And next week will be better.

              Anne

              -----Original Message-----
              From: alleypat@...
              Sent: Nov 11, 2005 11:44 PM
              To: GIWorld-Hepatitis@yahoogroups.com
              Subject: Re: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue

              Anne, I know how you feel.

              I've been cursing my HCV for days now. It's kept me out of a gene threrapy study for malignant melanoma. So now I have to do chemo. My liver is NOT gonna like that. sigh

              Sometimes I think God just doesn't like me.

              Maybe next week will be better.

              Alley

              [Non-text portions of this message have been removed]




              Welcome to GIHepWorld

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              [Non-text portions of this message have been removed]
            • avansi7465
              Dear Alley, I had to read this a few times before I could stop crying long enough to respond. If this were a perfect world, whatever you decide (chemo-wise)
              Message 6 of 7 , Nov 17, 2005
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                Dear Alley,

                I had to read this a few times before I could stop crying long enough to respond. If this were a perfect world, whatever you decide (chemo-wise) to take for this would also kill the HCV. Of course, if this were a perfect world, none of us would have HCV or melanomas in the first place.

                We've been through the squamous cell several times, but never the melanoma....and it was always caught before it metastasized Please know that our thoughts and prayers are with you. We're too far away to cook and clean or baby sit the grandchildren, but we'd like to help in anyway we can.

                Of course this is your decision, but I'd do the treatment.

                Please keep me posted.

                Prayers, Hugs, and energy,
                Anne

                -----Original Message-----
                From: alleypat@...
                Sent: Nov 15, 2005 11:45 AM
                To: GIWorld-Hepatitis@yahoogroups.com
                Subject: Re: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue

                Thanks Anne. No, the melanoma was removed and some lymph nodes several years ago. It was present in one lymph node then. In July I had another melanoma in the same area so had all the lymph nodes removed there (well all they can get). Then I went to apply for a melanoma vaccine trial and the CT scans revealed it had spread to my lungs. I applied to a gene trial (trying to avoid toxic crap) but didn't qualify due to my active HCV. So now I'm looking at other trials iwth different types of medications (chemo). The doctor says without treatment, I'll live 6 to 9 months. That's a little hard to take in LOL. A lot depends on how fast it grows and all that rot. I'm not looking forward to treatment, but I am looking forward to living :).

                Alley
                -------------- Original message --------------
                Alley,

                I missed something along the way. I thought the melanoma was a past issue and no longer a problem. What kind of chemo? Prayers just started. And next week will be better.

                Anne

                -----Original Message-----
                From: alleypat@...
                Sent: Nov 11, 2005 11:44 PM
                To: GIWorld-Hepatitis@yahoogroups.com
                Subject: Re: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue

                Anne, I know how you feel.

                I've been cursing my HCV for days now. It's kept me out of a gene threrapy study for malignant melanoma. So now I have to do chemo. My liver is NOT gonna like that. sigh

                Sometimes I think God just doesn't like me.

                Maybe next week will be better.

                Alley

                [Non-text portions of this message have been removed]




                Welcome to GIHepWorld

                Post message: GIWorld-Hepatitis@yahoogroups.com
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              • w.landstra
                HI Alley.Just read yr mail.Don.t know what to say.I.am not good at those things.I don.t believe in God,because if I was God I would cure you right now so I
                Message 7 of 7 , Nov 18, 2005
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                  HI Alley.Just read yr mail.Don.t know what to say.I.am not good at those things.I don.t believe in God,because if I was God I would cure you right now so I can.t pray for you I believe in positive thoughts and if enough people hve positive thoughts there.s power there(mabye that.s God,who knows).So I.am thinking positive about you and that you.ll find a solution.Courage Willem.
                  ----- Original Message -----
                  From: avansi7465
                  To: GIWorld-Hepatitis@yahoogroups.com
                  Sent: Friday, November 18, 2005 4:59 AM
                  Subject: Re: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue


                  Dear Alley,

                  I had to read this a few times before I could stop crying long enough to respond. If this were a perfect world, whatever you decide (chemo-wise) to take for this would also kill the HCV. Of course, if this were a perfect world, none of us would have HCV or melanomas in the first place.

                  We've been through the squamous cell several times, but never the melanoma....and it was always caught before it metastasized Please know that our thoughts and prayers are with you. We're too far away to cook and clean or baby sit the grandchildren, but we'd like to help in anyway we can.

                  Of course this is your decision, but I'd do the treatment.

                  Please keep me posted.

                  Prayers, Hugs, and energy,
                  Anne

                  -----Original Message-----
                  From: alleypat@...
                  Sent: Nov 15, 2005 11:45 AM
                  To: GIWorld-Hepatitis@yahoogroups.com
                  Subject: Re: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue

                  Thanks Anne. No, the melanoma was removed and some lymph nodes several years ago. It was present in one lymph node then. In July I had another melanoma in the same area so had all the lymph nodes removed there (well all they can get). Then I went to apply for a melanoma vaccine trial and the CT scans revealed it had spread to my lungs. I applied to a gene trial (trying to avoid toxic crap) but didn't qualify due to my active HCV. So now I'm looking at other trials iwth different types of medications (chemo). The doctor says without treatment, I'll live 6 to 9 months. That's a little hard to take in LOL. A lot depends on how fast it grows and all that rot. I'm not looking forward to treatment, but I am looking forward to living :).

                  Alley
                  -------------- Original message --------------
                  Alley,

                  I missed something along the way. I thought the melanoma was a past issue and no longer a problem. What kind of chemo? Prayers just started. And next week will be better.

                  Anne

                  -----Original Message-----
                  From: alleypat@...
                  Sent: Nov 11, 2005 11:44 PM
                  To: GIWorld-Hepatitis@yahoogroups.com
                  Subject: Re: [GIWorld-Hepatitis] HCV Found in Autopsy Brain Tissue

                  Anne, I know how you feel.

                  I've been cursing my HCV for days now. It's kept me out of a gene threrapy study for malignant melanoma. So now I have to do chemo. My liver is NOT gonna like that. sigh

                  Sometimes I think God just doesn't like me.

                  Maybe next week will be better.

                  Alley

                  [Non-text portions of this message have been removed]




                  Welcome to GIHepWorld

                  Post message: GIWorld-Hepatitis@yahoogroups.com
                  Subscribe: GIWorld-Hepatitis-subscribe@yahoogroups.com
                  Unsubscribe: GIWorld-Hepatitis-unsubscribe@yahoogroups.com
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                  Welcome to GIHepWorld

                  Post message: GIWorld-Hepatitis@yahoogroups.com
                  Subscribe: GIWorld-Hepatitis-subscribe@yahoogroups.com
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                  Visit your group "GIWorld-Hepatitis" on the web.

                  To unsubscribe from this group, send an email to:
                  GIWorld-Hepatitis-unsubscribe@yahoogroups.com

                  Your use of Yahoo! Groups is subject to the Yahoo! Terms of Service.

                  [Non-text portions of this message have been removed]




                  Welcome to GIHepWorld

                  Post message: GIWorld-Hepatitis@yahoogroups.com
                  Subscribe: GIWorld-Hepatitis-subscribe@yahoogroups.com
                  Unsubscribe: GIWorld-Hepatitis-unsubscribe@yahoogroups.com
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                  Welcome to GIHepWorld

                  Post message: GIWorld-Hepatitis@yahoogroups.com
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