1. Management of Extrahepatic
Manifestations of Chronic
Hepatitis C
Mario U. Mondelli
Department of Infectious Diseases,
University of Pavia,
Fondazione IRCCS Policlinico San Matteo
Kasr Al-Aini International Post Graduate Course of Hepatology, Cairo University, 10-12 October 2009

2. Chronic Hepatitis C Virus
Extrahepatic Manifestations
• Non organ-specific antibodies
• Mixed cryoglobulinaemia (Types II & III):
– Purpura (Leukocytoclastic vasculitis)
– Glomerulonephritis
– Peripheral neuropathy
• Non-Hodgkin’s lymphoma: low grade, MZ
• Autoimmune thyroiditis (up to 36% anti-TPO prevalence,
CD81 on thyrocytes, ↑ IL-8)
•
•
•
•
Porphyria cutanea tarda (Metanalysis showed OR 274.78)
Diabetes mellitus (defects in insulin signalling)
Lichen planus
Sicca (non-Sjögren’s syndrome) (SS-A, SS-B neg.; no xerophtalmia)

3. Chronic Hepatitis C Virus
Autoantibodies
HCV %
Control %
Rheumatoid factor
70
8
Cryoglobulins
>50
<1
ANA
• > 1:40
• > 1:180
21
13
10
2
Antismooth muscle (SMA)
• > 1:40
• > 1:180
21
7
2
<1
Anti–liver-kidney microsome (LKM)
5
<1

4. Autoantibodies Are Frequent in
Both Hepatitis B and C
SMA
ANA

5. LKM1 Is Seen Only in Hepatitis C Virus Infection
Liver
Kidney

6. Molecular Mimicry
Similarity with E1 region of HCV
PGHITGHRMAWDMMM
HCV310-24
DELLTEHRMTWDPAQ
CYP2D6252-66
Vergani D, 2006

7. Molecular Mimicry
Similarity with E1 region of HCV
PGHITGHRMAWDMMM
HCV310-24
DELLTEHRMTWDPAQ
CYP2D6252-66
Vergani D, 2006

8. CRYOGLOBULIN
•
Immunoglobulin which undergoes
reversible temperature-induced
insolubilization

9. Cryoglobulinaemias
Classification
Immunoglobulin Classification
I
II
Monoclonal
No rheumatoid factor
Polyclonal IgG
Monoclonal IgMκ
Rheumatoid factor
Polyclonal IgG
III
Polyclonal IgM
Cacoub P, et al. Curr Opin Rheumatol. 2002;14:29-35.
Primary
Secondary mixed
HCV infection
Secondary mixed
Infections
Autoimmune disorders
Lymphoproliferative diseases

10. HCV and Mixed Cryoglobulinaemic Syndrome (MCS)
Clinical Manifestations
• Minor:
–
–
–
–
Purpura
Fatigue
Arthralgias
Sensitive neuropathy
• Major:
–
–
–
–
Glomerulonephritis
Motor neuropathy
Hyperviscosity syndrome
Systemic vasculitis

11. HCV and Cryoglobulinaemia
Purpura, Vasculitis
• Occurs in dependent
areas
• Deposition of
cryoglobulins in
small capillaries
• Pruritic
• Ulcerations may
develop

12. Diagnostic Criteria of Mixed Cryoglobulinaemia
Criteria
Major
Minor
Serological
• Mixed cryoglobulinaemia
• Low C4
• Rheumatoid factor
• HCV or HBV infection
Pathological
• Leukocytoclastic vasculitis • Mono-oligoclonal B-cell
infiltrate in liver or BM
Clinical
• Purpura
• Membranous-proliferative
glomerulonephritis
• Peripheral neuropathy
• Cutaneous ulcers
Ferri C, Zignego AL, Pileri SA. J Clin Pathol 2002; 55: 4 – 13.

13. How to Combine Diagnostic Criteria
• Confirmed MCS:
– Serological MCS (± low C4) + purpura + leukocytoclastic
vasculitis.
– Serological MCS (± low C4) + 2 minor symptoms + 2 minor
serological/pathological findings.
• Incomplete or possible MCS:
– Serological MCS or low C4 + 1 minor symptom + 1 minor
serological finding ± compatible pathological findings.
– Purpura and/or leukocytoclastic vasculitis + 1 minor symptom +
1 minor serological finding ± compatible pathological findings
– 2 minor symptoms + 2 serological findings ± compatible
pathological findings

14. Immune Manifestations of HCV
Pathogenesis
HCV evades the
immune response
Chronic B-cell
stimulation by
HCV antigen (E2 ?)
Y
Y
Y
Y
Polyclonal IgG
Y
Y
Y
Y
Y
Y
Y
Cryoglobulin
traps HCV
Monoclonal IgM RF
Genetic and
environmental
factors

15. Questions
• Are specific viral protein sequence changes or
recurrent amino acid motifs responsible for
aberrant polyclonal B cell stimulation in chronic
HCV infection ?
• Is polyclonal B cell activation a general feature of
chronic HCV infection and what are the mechanisms
responsible for initiation and maintenance of this
phenomenon ?

16. HCV Sequence Changes Found in
Cryoglobulinaemic patients
• Insertion at position 385 (HVR1) detected in 5 (24%) of 21
patients with cryoglobulinaemia and in none of controls
(Gerotto et al., Blood 2001;98:2657-63).
• Two HVR1 positions (389 and 398) and 3 HVR2/CD81binding site positions (474, 493, 497) associated with
cryoglobulinaemia (Hofmann et al., Blood 2004;104:1228-9).
• No specific HVR1 motifs associated with
cryoglobulinaemia (Rigolet et al., Leukemia 2005; 19:1070-1076)

17. AA Insertions within HVR1 in Patients with and without Cryoglobulins
Patient ID
No. of clones with changes
117 (1b)
TR
387
1/20
??
??
??
28 (2a/c)
GLSL
GLTL
404
404
9/11
1/11
169 (2a/c)
ASSSM
SSPTA
SSPMA
384
385
385
8/12
3/12
1/12
193 (2a/c)
Controls (9.1%)
Position
171 (1b)
Cryo + (6.2%)
Insertion
GAG
GTV
385
385
9/10
1/10
17 (1b)
GPG
ELG
385
385
4/12
2/12
191 (2a/c)
ARY
TRQ
ARQ
TRR
*
385
385
385
385
6/11
1/11
3/11
1/11
183 (2a/c)
RTV
RKT
RTA
384
384
384
2/10
1/10
Bianchettin G et al., J Virol 2007;81:4564-71 .

18. Weblogo of the Positions Highlighted by the PCA Analysis
of 548 HVR1 Sequences.
The higher the letter, the higher the frequency of the amino acid in that position.
Cryo
pos +
384 386 388 391 395 396396 397 398 405
386 388 391 395
397 398 399 405
Controls
neg
384
386 388 391 395 396396 397 398
386 388 391 395
397 398 399
399
405
405
Bianchettin G et al., J Virol 2007;81:4564-71 .

19. Proportions of Activated Memory (CD27+) and Naïve (CD27-) B-Cells in Patients with
Chronic HCV Infection and Healthy Controls
p=0.0002
p=0.0007
100
% CD86 B cells
% CD69 B cells
100
80
60
40
20
p=0.0002
80
60
40
20
0
0
100
p=0.0001
p<0.0001
p=0.03
2
80
60
40
20
100
% CD71 B cells
% CD183 B cells
p=0.0031
p=0.0004
p=0.021
p=0.0019
80
60
40
20
0
0
Total
CD27+
CD27-
Healthy controls (n=36)
Total
CD27+
HCV+ patients (n=50)
CD27-

20. MW
1
2
3
4
5
6
7
8
9
10
11
12
100bp
Genomic HCV RNA
MW
1
2
3
4
5
6
7
8
9
10
11
12
1/4
160bp
Full
160bp
Minus-strand HCV RNA
MW. 50bp DNA Ladder, 10 water, 11 Neg. ctrl, 12 Pos. ctrl
1. B.A.
2. C.E.
3. F.R.
4. M.T.
5. F.I.
CD19+/CD69+
6. B.A
7. C.E
8. M.T.
9. F.I.
CD19+/CD69Pugnale, Negro, Mondelli, unpublished

21. One Signal is Sufficient to Activate
Human Memory B Cells
Bystander T cell help / Cytokines
Proliferation
Differentiation
CD40
OR
TLR
Innate immunity derived signals
Bernasconi et al Science 2002

22. N. of IgG-Producing Cells in Patients with Chronic HCV Infection and
Healthy Controls after Stimulation with CD40L ± IL10 or CpG ± IL2
p = 0.0227
SFC/105 PBMC
1500
750
0
Media
CpG
Healthy Controls (n=44)
HCV Patients (n=56)
900
SFC/105 PBMC
CpG+IL2
p = 0.0006
450
p = 0.0128
0
Media
CD40L
CD40L+IL10

23. Putative Mechanisms of B-Cell Activation
in HCV Infection
B Cell
CD
81
E2
BCR (Ig)
CD21
↓ Activation threshold
CD19
Polyclonal B cell activation
B cell clonal expansion
Lymphoproliferative
Disease
Autoimmunity

24. Cryoglobulinaemia
Therapeutic Strategies
Rationale
Strategy
Eradicate aetiological
agent
• PEG-IFNα + Ribavirin
Reduce inflammation
• Steroids
Remove CIC
• Cyclophosphamide
• Plasmapheresis
Promote CIC clearance by
RES
• Lac diet
Eliminate B lymphocytes
• Rituximab

25. Rituximab
• Murine IgG1κ humanised mAb
• Binds CD20 on mature B cells
• Acts by:
–
–
–
–
Complement-mediated cytotoxicity
ADCC
Opsonization and clearance by RES
Pro-apoptotic ?
• Approved for treatment of NHL

26. Rituximab: Clinical Studies
beyond NHL
•
•
•
•
•
•
•
•
RA (only FDA approved condition)
SLE
ITP
Autoimmune haemolytic anaemia
Pemphigus
Waldenstrom’s macroglobulinaemia
Wegener’s granulomatosis
MCS

27. Clinical Response to Rituximab 375 mg/m 2
for 4 Weeks in HCV+ Patients with MCS
A Systematic Review of 13 Studies
Clinical
Features
N. of Cases
Complete Response
N. (%)
Purpura
33
24 (73)
Arthralgia
30
16 (53)
Neuropathy
25
9 (36)
Glomerulonephritis
13
9 (70)
Cryocrit
15
11(73)
Cacoub, P et al. Ann Rheum Dis 2008;67:283-7

28. Phase 2 Single-Arm Study on Low-Dose Rituximab for
Symptomatic, Refractory Mixed Cryoglobulinaemia
(AIFA Protocol FARM6KMZFY)
• 250 mg/m2 x 2
• 1-year follow-up
• Objectives:
– Reduce treatment costs
– Reduce side effects (↑ HCV RNA, infections)
(Fiorilli, Mondelli, Zignego, Pozzato, Co-PI’s)

29. Reactivation of HBV with
Rituximab Administration
• Anti-HBs titers dropped precipitously after rituximab
administration in vaccinated patients
– Median titers 80 IU/mL before administration dropped to 38 IU/mL after
administration (P < .05)
• 3 of 20 patients with inactive HBV had detectable HBV DNA at
Patient 1
100
80
60
40
20
250
200
150
100
50
0 100 200 300
Days
Metzler F, et al. AASLD 2008. Abstract 848.
400
300
200
100
0
-200
Patient 2
Patient 3
108
30
106
20
106
104
10
104
102
0 200 400
Days
0
102
0
500 1000
Days
108
HBV DNA (IU/mL)
1st rituximab dose
Anti-HBs (IU/mL)
Serum ALT (U/L)
Days 92, 146, 320 after 2-3 doses of rituximab

30. Phase 2 Single-Arm Study on Low-Dose Rituximab for
Symptomatic, Refractory Mixed Cryoglobulinaemia
(AIFA Protocol FARM6KMZFY)
5 or less responders
STOP
Patients
Wk 12
interim analysis
Rituximab 250 mg/m2 × 2
one week apart (n = 16)
50% reduction in BVAS & cryocrit
Wk 52
Follow-up
Rituximab 250 mg/m2 × 2
one week apart (n = 36)
Size of initial group 16 patients
Size of second group 36 patients
Criterion for stopping on a negative finding at 1st stage 5 or less responders
Criterion for positive finding at 2nd stage: 27 or more responders
Significance level 0.03
Expected number of patients under null hypothesis 46
Power 0.85 (expected response rate 60 ± 15%)
Expected number of patients under alternative hypothesis 50
(Fiorilli, Mondelli, Zignego, Pozzato, Co-PI’s)

31. BASELINE
RITUXIMAB (after 2 infusions)
5.29
0.16
CD19 FITC
CD19 FITC
4 WEEKS
8 WEEKS
12 WEEKS
0.03
0.13
3.14
CD19 FITC
16 WEEKS
6.81

32. B Lymphocyte Count after RITUXIMAB Treatment
#1
#2
% B Lymphocytes (CD19+)
Rituximab
Rituximab
#3
#4
Rituximab
Rituximab
Time (weeks)

33. Rituximab
• Excellent results on vasculitic ulcers and severe
renal involvement.
• No effect on peripheral neuropathy

34. Clinical, Immunological, and Virological Efficacy
of Rituximab ± PEG-IFNα2b and Ribavirin
Complete Response Rituximab/PEG–IFN/RBV
(n=20)
Rituximab only
(n=12)
Clinical
80%
58%
Immunological
67%
46%
Virological
55%
0%
Terrier et al. Arthritis Rheum 2009;60:2531-40.

35. Cryoglobulinaemia
Therapeutic Strategies
Clinical Symptoms
Treatment
Asymptomatic
Monitor
Mild-moderate
Low-dose steroids ± Lac diet
Moderate-Severe
PEG-IFN + RBV, Low-dose
steroids
Severe, rapidly progressive Plasmapheresis + steroids +
Cyclophosphamide;
Rituximab + PEG-IFN + RBV
Chronic hepatitis +
mild cryoglobulinaemia
Peg-IFN + RBV ± Rituximab

36. Acknowledgements
Area di Ricerca Infettivologica
Fondazione IRCCS Policlinico San Matteo and University of Pavia
Lab Team:
• Gabriella Bianchettin
• Antonella Cerino
• Stefania Varchetta
• Barbara Oliviero
• Enrica Paudice
Clinical Team:
• Serena Ludovisi
• Giuseppe Michelone
• Marco Zaramella
Collaborators:
• Franco Negro, Dept.of Gastroenterology, University of Geneva
• Anna Tramontano, Dept. of Biochemistry, University of Rome La Sapienza
• Milvia Casato, Dept. of Medicine, University of Rome La Sapienza
• Giampaolo Merlini, Centre for Amyloidosis, University of Pavia

37. Chronic Hepatitis C Virus
Autoantibodies (cont’d)
• No relationship between presence of autoantibodies and
– Severity of chronic HCV
– HCV genotype
• Correlation between rheumatoid factor titre and
– Cryoglobulinaemia
– But not symptomatic cryoglobulinaemia
• Circulating autoantibodies from autoimmune disorders
may result in
– False positive anti-HCV

38. HCV Prevalence and Crude and Adjusted
O.R. in Patients with B-NHL vs. Controls
Total
# HCV+ % HCV+ Crude O.R.
(95% C.I.)
Adjusted O.R.
(95% C.I.)
Controls
396
22
5.6
1
1
Patients with
B-NHL
400
70
17.5
3.6 (2.2-6.0)
3.1 (1.8-5.2)
Mele A, et al. Blood. 2003;102:996-999

39. ANTI-THYROID ANTIBODIES IN PATIENTS WITH
VIRAL CHRONIC HEPATITIS
(Preziati et al, 1995)
Anti-Thyroid AutoAb
TPO-Ab Tg-Ab
CH-HCV (n=78)
positive
Titer (KU/l)
CH-HBV (n=49)
positive
Titer (KU/l)
36%
16%
(17 – 1190) (57 – 836)
0
−
10%
(64 – 282)

40. Extrahepatic Effects of HCV
Porphyria Cutanea Tarda
Fargion (1992)
De Castro (1993)
Criber (1995)
2 case series
3 uncontrolled series
280 patients
Alcohol: 36%-77%
Stolzel (1995)
Kondo (1997)
100 80
60
40
PCT
20
0
0
5
10
15
20
Control
Combined meta-analysis of 7 studies: OR 274.78, CI 104.12-725.13
(Gisbert et al., J Hepatol 2003;39:620-7.)

41. Extrahepatic Effects of HCV
Lymphocytic Sialadenitis
HCV
Sialadenitis
Primary
Sjögren’s
Syndrome
SS-A, SS-B
Negative
Positive
Lymphocytic
capillaritis
Mild
Pericapillary
Mostly CD8 cells
Severe
Periductal
Mostly CD4 cells
Absent
8%-36%
Present
Present
Characteristic
Sicca syndrome:
• Xerophthalmia
• Xerostomia

42. Extrahepatic Effects of HCV
Lichen Planus
• Occurs in < 1% of the general population
• 10%-30% of patients with chronic HCV
• Appearance
– Flat topped, violaceous, pruritic papules
– Throughout body
– Oral mucosa
• Histology
– Dense infiltration of dermis with T lymphocytes
Nagao Y, et al. J Gastroenterol Hepatol. 2004;19:1101-1113.

43. Meta-Analysis of Case-Control Studies Comparing the Prevalence
of HCV Infection in Patients with PCT and in Healthy Controls.
Gisbert et al., J Hepatol 2003;39:620-7.

44. Extrahepatic Effects of HCV
B-Cell Lymphoma
Ferri (1994)
8 case series
1754 pts evaluated
Mazzaro (1996)
Silvestri (1996)
Izumi (1996)
McColl (1996)
Zignego (1997)
DeRosa (1997)
Zuckerman (1997)
30
20
10
0
B Cell Lymphoma
10
20
Controls
30

45. Three Signals Are Required to Activate
Human Naïve B Cells
(1) Ag
(1’) Costimulation
p-MHC
Ag
tlr
(2) Cognate T cell help
CD40
Proliferation
Survival
(3) Innate immunity derived signals
Ruprecht & Lanzavecchia, Eur J Immunol 2006;36:810-6

46. Molecular Mimicry
CYP2D6252-71: Major epitope of LKM1
DELLTEHRMTWDPAQPPRDL
252
271

47. Multiple Hits Hypothesis
Protein Database Search
DRLSPRPPAQPPRRR
IE 175 HSV-1
EHRMTWDPAQPPRDL
CYP2D6257-271
E1 HCV
EBNA-2 Epstein-Barr
GHRMAWDMMMNWSPT
QLPPPAAPAQPPPGV
PMIAAAPPAQPPSQP
AARTAPAPAQPPSPA
IE63 H. Cytomegalovirus
J1L H. Cytomegalovirus

48. Background
 Chronic HCV infection is associated with
extrahepatic manifestations including
autoantibody production and abnormal
B-cell proliferation

49. Functional Studies on Memory B-Cells in
Chronic HCV Infection
PBMC
500-3,000/w
Anti-CD40+IL10
CpG
2006
7 d
± IL2
6 d
Ig producing-cells (ELISPOT)

50. Molecular Mimicry
 LKM-1 targets CYP2D6
 CYP2D6 shares an amino acid
sequence with HCV
 LKM-1 may arise through a
mechanism of molecular mimicry

51. Prevalence of HVR1 Insertions in Patients
with and without Cryoglobulinaemia
113 Patients
80 Cryo +
33 Controls
5 (6.25%)
with insertions
3 (9.1%)
with insertions
3/46 (6.5%)
genotype 2a/c
2/17 (11.8%)
genotype 2a/c
2/34 (5.9%)
genotype 1b
1/16 (6.25%)
genotype 1b
Bianchettin G et al., J Virol 2007;81:4564-71 .

52. Human Mature B Cell Phenotype
B cell areas of lymph nodes and spleen
IgMhi,IgDhi
CD19,CD20,CD21hi
CD38lo, ABCB1(?)
Blood
Naïve
IgM, IgG, IgA, IgDlo
CD19,CD20,CD27
CD38
CD126
CD138
Memory
Plasmacell
CD19lo,CD20lo
Plasmablast
IgG,CD69,
CD86…
Ab
Bone marrow and
inflamed tissues

53. % CD27+ & CD27B cells
Proportions of Total and Memory (CD27+) and Naïve
B Cells in Healthy Controls and Patients with Chronic
HCV or HBV Infection
100
% CD19+ cells
30
20
10
0
Controls
HCV
Healthy controls (n=36)
75
50
25
0
CD27+
HBV
HCV+ patients (n=50)
CD27-
HBV+ patients (n=22)

54. Eradication of HCV Infection Associates with a Decreased
Expression of Activation Markers and CXCR3
Rosa et al., PNAS 2005;102:18544-

55. Stimulation with CpG Oligonucleotides Is Sufficient
for Optimal Expansion of Memory B Cells
CpG
Media
CD19+
CD19+/CD27+
CD19+/CD27-

56. Reactivation of HBV With Rituximab
Administration
• Retrospective analysis of patients who received
≥ 1 course of rituximab at single center: 2005-2007
• 180 of 258 patients (70%) treated with rituximab tested
for HBV
– Vaccinated: 46%
– Negative: 39%
– Anti-HBc/anti-HBs positive: 11%
– HBV DNA positive: < 1%
Metzler F, et al. AASLD 2008. Abstract 848.

57. CIDENCE OF THYROID DYSFUNCTION IN HCV PATIENT
TREATED WITH IFNα
Author
Treated
Thyroid dysfunction
Marcellin ’95
Okanoue ’96
Koh ’97
Kakizaki ‘’99
Dumolin ’99
Wong ’02
248
677
1043
439
598
246
21 (8.5%)
18 (2.7%)
69 (6.6%)
17 (3.9%)
60 (10%)
9 (3.6%)
Total
3251
194 (6.0%)

58. RISK FACTORS FOR DEVELOPMENT OF THYROID
DYSFUNCTION DURING IFNα THERAPY
Risk factors Treated Thyroid dysf.
R.R. (C.I.)
Sex
Females
Males
1176
1774
153
53
4.4 (3.2 – 5.9)
TPO-Ab
Positive
Negative
38
428
8
23
3.9 (1.9 – 8.1)
Marazuela ’96; Fernandez-Soto ’98; Hsieh ’00; Vial ’95;Okanoue ’96; Koh ’97;
Kakizaki ’99; Deutsch ’97; Roti ‘96

59. Chronic Hepatitis C Virus
Autoantibodies (cont’d)
• No relationship between presence of autoantibodies and
– Severity of chronic HCV
– HCV genotype
• Correlation between rheumatoid factor titre and
– Cryoglobulinaemia
– But not symptomatic cryoglobulinaemia
• Circulating autoantibodies from autoimmune disorders
may result in
– False positive anti-HCV

60. Chronic HCV and Diabetes Mellitus
Case Prevalence
20
Observed
Expected
•
Number of Cases
16
•
•
12
8
4
•
0
Females
Males
Zein CO, et al. Am J Gastroenterol. 2005;100:48-55.
N = 179 with chronic HCV
Prevalence of diabetes
mellitus and insulin resistance
noted
Compared with expected rate
based on NHANES III study
after adjusting for
– Age
– Sex
– Race
Prevalence of DM or insulin
resistance higher in those with
chronic HCV

61. Pathogenetic Mechanisms Responsible for Development of
Type 2 Diabetes in HCV Infection
Early Defects in Upstream Insulin
Signalling Components (IRS-1,
PI3-kinase, Akt)
Increased Insulin Resistance
Type 2 Diabetes Mellitus
Aytung et al., Hepatology 2003;38:1384-92

62. Enlarged Pericapsular Lymph Node in a Patient
with Chronic HCV Infection
>CD20+ B cells

63. Proportions of Activated Memory (CD27+) and Naïve (CD27-) B-Cells in Patients with
Chronic HBV or HCV Infection and Healthy Controls
p=0.0013
p=0.0002
80
60
40
20
0
p=0.0152
p=0.0031
80
p=0.0002
60
40
20
0
p=0.001
p<0.0001 p<0.0001
p=0.032
100
% CD71 B cells
% CD183 B cells
100
p=0.0001 p=0.012
p=0.0078
100
p=0.0007
% CD86 B cells
% CD69 B cells
100
p=0.0009
80
60
40
20
80
p=0.0004
p=0.021
p=0.0019
60
40
20
0
0
Total
CD27+
Healthy controls (n=36)
CD27HCV+ patients (n=50)
Total
CD27+
HBV+ patients (n=22)
CD27-

64. Proportions of CXCR3+ Memory (CD27+) and Naïve (CD27-)
B-Cells in Patients with Chronic HCV Infection and
Healthy Controls
p < 0.0001
p < 0.0001
%CD183 B cells
100
80
60
40
20
0
TOT
TOT
CD27+
CD27+
CD27-
CTRLS
HCV+ PTS
n=33
CD27-
n=29
Cerino et al., in preparation

65. % CD183/CD19+ cells
Correlation between Serum HCV RNA and CD183
(CXCR3) Expression on B cells
100
Speaman r=0.408
75
p=0.012
50
25
0
0
1
2
3
4
15
5
16
% CD183/CD19+27+
cells
100
Speaman r=0.59
75
p=0.0001
50
25
0
0
1
2
3
4
5
HCV RNA (IU/ml x 10 6 )
15
16

66. N. of IPC-Producing Cells in Patients with Chronic HCV Infection
and Healthy Controls Following Stimulation with CD40L ± IL10
900
IgG
SFC/105 PBC
p=0.0193
450
p=0.0128
0
Media
CD40L+IL10
900
IgA
SFC/105 PBC
SFC/105 PBC
900
CD40L
450
IgM
450
0
0
Media
CD40L
CD40L+IL10
Healthy Controls (n=31)
Media
HCV Patients (n=33)
CD40L
CD40L+IL10

67. N. of IPC-Producing Cells in Patients with Chronic HCV Infection
and Healthy Controls Following Stimulation with CpG ± IL2
2000
IgG
SFC/105 PBC
p=0.0202
1000
0
Media
1000
0
Media
CpG+IL2
2000
IgA
SFC/105 PBC
SFC/105 PBC
2000
CpG
CpG
CpG+IL2
Healthy Controls (n=41)
IgM
1000
0
Media
HCV Patients (n=49)
CpG
CpG+IL2

68. Proportions of Activated Memory (CD27+) and Naïve (CD27-)
B-Cells in Patients with Chronic HCV Infection and
Healthy Controls
p= 0.0049
p= 0.0004
%CD69 B cells
100
80
60
40
20
0
TOT
TOT
CD27+
CTRLS
n=33
CD27+
CD27-
CD27-
HCV+ PTS
n=29
Cerino et al., in preparation

69. …an autoimmune disease
is a viral disease
in which the virus is unknown.
Rolf Zinkernagel - Immunol Rev. 1996;152:21-45