Documente Academic
Documente Profesional
Documente Cultură
1.
2.
3.
4.
Introducere
Epidemilogia VHC
Istoria natural a virusului hepatitic C
Biologia moleculara a VHC
4.1. Proteinele structurale ale VHC
4.2. Proteinele non structurale
4.3. Genotipurile VHC
5. Ciclul viral al virusului hepatitic C
6. Micro-ARN ca markeri ai Infeciei cu VHC
7. Decelarea VHC n fluide ale cavitii bucale
8. Patogenia infeciei cu VHC
*As. Dr. UMF Carol Davila, Bucureti
**Cercet. 1 Dr. Instit.Virusologie tefan S. Nicolau
14
TABLE OF CONTENTS
1. Introduction
2. HCV Epidemiology
3. Natural History of Hepatitis C Virus
4. Molecular Biology of HCV
4.1. HCV Structural Proteins
4.2. Nonstructural proteins
4.3. HCV Genotypes
5. HCV Lifecycle
6. MicroRNAs as HCV Infection Markers
7. HCV Detection in Mouth Fluids
8. HCV Infection Pathogenesis
15.2.Sampling
16. Bibliography
INTRODUCTION
Hepatitis C virus has become a global epidemic,
causing chronic infection in almost over 170 million
people worldwide. 1 This means about 5 times as
many people as are infected with HIV. Incomplete
epidemiologic data make that only in the United States
the number of people who might be infected with this
virus is twice higher that the estimated number.2
In the developed countries, blood screening was
introduced, which significantly decreased the risk of
post-transfusion infection. However, the new occurring
cases may be explained by that infection is mainly spread
by intravenous drug use and less frequently via other
ways of exposure.
In most cases, HCV infection leads to chronic
hepatitis, which is a major indication for liver transplant.
Even after two decades since its discovery, HCV
(hepatitis C virus) continues to be a public health
concern, and WHO estimates that a minimum of 3%
of the worlds population is chronically infected with
this virus.3, 4
In Romania, HCV infection is a major cause of
concern and its prevalence in the general population
15
16
17
EPIDEMILOGIA VHC
Cele mai recente rapoarte WHO estimez prevalena
infeciei HCV la 3% din populaia globului, prin
complicaiile produse fiind cauza principal a
recomandrilor de transplant hepatic.12 CDC estimeaz
ca aproape 4 milioane de americani au fost expui
virusului hepatitic C, peste jumtate dintre aceti
prezentnd infecii cronice. Mai mult, se raporteaz
anual circa 26000 de noi cazuri iar 12000 de persoane
decedeaz ca urmare a cirozei sau carcinomului
hepatocelular. 13 Dei VHC este endemic la nivel
global, distribuia sa nregistreaz o mare variabilitate
geografic, rile africane i asiatice avnd prevalena cea
mai mare. Comparativ, n tarile vest i nord- europene, n
America de Nord i Australia se raporteaz o prevalen
sczut.14, 15 n afara diferenelor geografice exist i
diferene temporale n patternurile de infecie cu VHC.
Spre exemplu, dei n SUA, Australia, Spania prevalena
infeciei este similar, (1.0%-1.9%), n SUA prevalena
cea mai mare a persoanelor infectate se nregistreaz
ntre 30-49 ani (circa 2/3 dintre cei infectai) ceea ce
indic faptul c transmiterea a aprut n ultimii 20-40
de ani la tineri.16
Factorii de risc care au fost asociai infeciei cu VHC
sunt transfuziile cu snge netestat, utilizarea drogurilor
injectabile sau a unor proceduri asociate actului medical
(chirurgicale). n rile n curs de dezvoltare, n care
seroprevalena crescut este corelat cu vrsta, se
consider ca actul medical necorespunztor (transfuzii,
injecii) a fost factorul major de transmitere a VHC17
i de meninere a unor arii hiperendemice izolate.18
Reutilizarea seringilor de sticl n cursul campaniei de
tratare a schisostomiasei n Egipt pare a fi responsabil
de transmiterea iatrogenic pe scara larg a acestui
patogen19. Comportamentul sexual este uneori asociat
cu cresterea riscului de infecie dar fr existena unor
dovezi clare.20 Transmiterea sexual pare a fi mai puin
incriminat, dar nu se poate preciza cauza: fie ncrcarea
virala n fluidele i esutul genital este mic fie celulele
tractului genital nu constituie o int viral.21 Cu toate
acestea, exist date care incrimineaz practicile sexuale
ca mijloc de transmitere a infeciei, procentele varind
ntre 2 i 22%.22 Asociaia American pentru Studiul
18
HCV EPIDEMILOGY
The most recent WHO reports estimate a 3%
prevalence rate of HCV infection in the worlds
population, the complications occurred being the leading
cause of recommendations of liver transplantation.12
CDC estimates that almost 4 million Americans have
been exposed to the Hepatitis C virus, and half of them
are chronically infected. Furthermore, almost 26000
new cases are reported each year and 12000 people
die from cirrhosis or cirrhosis and hepatocellular
carcinoma.13 Although HCV is endemic worldwide,
there is a large degree of geographic variability in its
distribution, the African and Asian countries having the
highest prevalence rates. Comparatively, the Western
and North-European countries, the North-American
countries and Australia report a low prevalence.14, 15
There are both geographic and temporal differencesin
the patterns of HCV infection. For example, although in
the United States, Australia, Spain similar prevalence of
HCV infection (1.0%-1.9%) are reported, in the Unites
States prevalence is highest among persons 30-49 years
old (almost two-thirds of those infected), which indicates
that transmission occurred during the last 20-40 years
among young adults.16
The risk factors related to HCV infection are
unscreened blood transfusions, injectable drug use or
medical (surgical) associated procedures. In developing
countries, where high seroprevalenceis age-dependant,
unsafe medical procedures (transfusions, injections)
were a major risk factor for HCV transmission17 and
persistence in isolated hyperendemic areas.18 In Egypt,
glass syringes reused in the schistosomiasis treatment
campaign seem to be responsible for the large-scale
iatrogenic transmission of this pathogen.19 Sexual
behavior is sometimes associated to the high risk of
infection but without having any clear evidence.20
Sexual transmission seems to be less incriminated,
but no cause can be identified: either the viral load in
fluids and genital tissue is low or the genital duct cells
are not targeted by the virus.21 However, there is data
incriminating sexual practices as means of transmission
of the infection, with rates varying between 2 and
22%.22 The American Association for the Study of Liver
20
hemodializa
tatuaje efectuate
utilizarea de droguri
multiplii parteneri sexuali
nepturi sau expuneri mucozale (ca factor de risc
pentru personalul medical)
transplant de organe efectuat inainte de 1992
sex cu persoane infectate cu VHC
tratament pentru hemofilie efectuat nainte de 1987
n unele cazuri ns, factorii de risc nu au putut fi
identificai.
Dup cum afirma Douglas L. Senecal, PA-C; Joseph
Morelli n articolul Hepatitis C virus infection: A current
review , OCTOBER 2007 20(10) www.jaapa.com
JAAPA, istoria natural a virusului ghideaz informarea
pacientului i decizia unei terapii. Se arat c procentul
pacienilor infectai cu VHC cu vindecare spontan este
cuprins ntre 10 i 20%, n timp ce cronicizarea este de
80 pn la 90%; infectarea cronica conduce la ciroz
(pe parcrsul unei perioade ce 20-30 de ani) n cazul a
20-30% dintre cazurile clinice.
Faptul c ncrcarea viral poate s varieze
considerabil pe parcursul diferitelor momente ale zilei,
precum i faptul c nu indic evoluia hepatitei, fac ca
acest marker viral s nu fie eficient n monitorizarea
infeciei.
Evoluia pacienilor cu ciroza datorat infeciei VHC
este sever, n sensul c riscul de decompensare este de
aproape 4% pe an; acesteia i se asociaz sngerari ale
varicelor, encefalopatie hepatic, disfuncii pulmonare
sau renale, icter, hidroperitoneu. Se estimeaz c,
din fericire, numai un procent de 25% din numrul
pacienilor cu ciroz hepatic se decompenseaz
ajungnd s necesite transplant.
O corelaie ntre viremie i inflamaia lobular a
fost realizat folosind testul bDNA pentru msurarea
cantitii de ARN VHC30.
History of tattoos
History of cocaine use
Multiple sexual partners
Needlestick or mucosal exposure (in a health care
worker)
Organ transplant before 1992
Sex with an HCV-infected patient
Treatment for hemophilia before 1987
however, in some cases, the risk factors remained
unidentified.
According to Douglas L. Senecal, PA-C; Joseph
Morelli in article Hepatitis C virus infection: A current
review, OCTOBER 2007 20(10) www.jaapa.com
JAAPA, the natural history of HCV infection guides
patient education and the decision of whether a patient
should undergo therapy. It shows that in patients infected
with HCV, 10% to 20% will have spontaneous clearance
and chronic infection will develop in the other 80% to
90%; the chronic infection will lead to cirrhosis(over
a period of 20 to 30 years), in 20% to 30% of patients.
The fact that it can significantly fluctuate throughout
the course of a day and that it is not an indication
of progression to hepatitis makes this viral marker
inefficient in infection monitoring.
The history of patients with HCV-induced cirrhosis
is alarming in that there is a 4% risk per year that
decompensation will occur; this is accompanied
by bleeding from varices, hepatic encephalopathy,
pulmonary or renal dysfunction, jaundice, ascites.
Fortunately, only 20% of all patients with cirrhosis will
ever decompensate and require transplantation.
A correlation between viremia and lobular
inflammation was made using the bDNA test to measure
the HCV RNA load. 30
21
FIG 1. Structura VHC: proteina core (miez) interacioneaz cu genomul ARN viral pentru a forma nucleocpsid. Doua glicoproteine asociate anvelopei (E1 i E2) sunt nvelite de o anvelop lipidic derivat de la celula gazd ( Sharma, 2010).
FIG 1. HCV structure: The core protein interacts with viral genomic RNA to form the nucleocapsid.
Two membrane-associated envelope glycoproteins (E1 and E2) are embedded in a lipid envelope
which is derived from the host (Sharma, 2010).
22
24
25
26
GENOTIPURILE VHC
HCV GENOTYPES
27
28
29
30
32
33
34
35
ANUL GINGIVAL
Spaiul situat ntre gingie i dinte, pn la epiteliul
joncional, cu o adncime normal ntre 1 i 3 mm, avnd
un perete intern (dentar), unul extern (gingival), care se
ntlnesc n zona denumit baza anului, poart numele
de ant gingival.
LICHIDUL ANULUI GINGIVAL
Provine din venulele corionului gingival situat mai
apical de epiteliul sulcular. Este secretat continuu, n
cantiti mici.
Prin studii fcute pe animale s-a evidentiat ca
fluoresceina injectat intravenos apare n lichidul
crevicular dupa numai 3 minute.67
Rolul vizibil al lichidului crevicular este acela de
a ndeprta mecanic resturile mici alimentare sau alte
particule strine ce ar putea ajunge n antul ginival,
contribuind la sntatea local, precum i de a ajuta
36
GINGIVAL SULCUS
The space located between the gingiva and the tooth,
up to the junctional epithelium, with a normal depth
from 1 to 3 mm, having an internal (dental) wall, and an
external (gingival) wall, which meet in the area called
the base of the sulcus, bears the name of gingival sulcus.
GINGIVAL CREVICULAR FLUID
It comes from the venules of the gingival chorion,
located more apically from the sulcular epithelium. It is
continuously secreted, in small quantities.
Studies conducted on animals have shown that
the fluorescein intravenously injected appears in the
crevicular fluid after only 3 minutes.67
The visible role of the crevicular fluid is of
mechanically removing the small food leftovers or other
alien particles which could reach the gingival sulcus,
contributing to the local health, as well as helping to
37
38
39
OBIECTIVE
OBJECTIVES
PREZENTAREA STUDIULUI
DATE CARE SUSIN STUDIUL
1
1. Montebugnoli L, Dolci G, Anti-HCV antibodies
are detectable in the gingival crevicular fluid of HCV
positive subjects, Minerva Stomatol. 2000 Jan-Feb 62
Autorii arat c testele ELISA realizate pe probe
de snge au decelat anticorpii virali specifici n 100%
din cazuri n timp ce anticorpii n saliv nu s-au putut
decela iar n lichidul antului gingival au fost detectai
n aproximativ 80% din cazurile clinice cunoscute
ca infectate; acest fapt se constituie ntr-un indicator
important: VHC ptrunde n cavitatea bucal pe calea
lichidului crevicular i de aici se rspndete mai departe
n saliv i apoi n afara cavitii bucale.
Studiul arat c lichidul crevicular reprezint o
alternativ viabil pentru detectarea anticorpilor anti
VHC. Mai mult dac se folosesc teste rapide ar fi posibil
o testare pe scar larg n cadrul cabinetelor de medicin
dentar.
1
2. Suzuki T, Omata K, Satoh T, Miyasaka T, Arai
C, Maeda M, Matsuno T, Miyamura T Quantitative
detection of hepatitis C virus (HCV) RNA in saliva and
40
1
1. Montebugnoli L, Dolci G, Anti-HCV antibodies
are detectable in the gingival crevicular fluid of HCV
positive subjects, Minerva Stomatol. 2000 Jan-Feb 62
The authors have shown that the ELISA tests on
blood samples have detected specific viral antibodies
in 100% of the cases, while antibodies could not be
detected in the saliva, and in the gingival crevicular
fluid antibodies were detected in approximately 80%
of the clinical cases known as infected; that is an
important indicator: HVC enters the mouth in the
crevicular fluid and from there spreads into the saliva
and then outside the mouth via the saliva.
The study has shown that the crevicular fluid is
a valid alternative for the detection of anti HVC
antibodies. Moreover, if rapid tests are used, this
may be a useful routine procedure for use in dental
practices.
1
2. Suzuki T, Omata K, Satoh T, Miyasaka T, Arai
C, Maeda M, Matsuno T, Miyamura T Quantitative
detection of hepatitis C virus (HCV) RNA in saliva and
3. Gkhan Akgz, Murat nan Cengiz, lker Keskiner, ereften Akgz, Murat Can, and Aydan Akgz,
Correlation of Hepatitis C Antibody Levels in Gingival
Crevicular Fluid and Saliva of Hepatitis C Seropositive
Hemodialysis Patients, International Journal of Dentistry, Volume 2009 (2009), Article ID 247121 63.
That study compared the prevalence of HCV antibody levels in saliva, and gingival crevicular fluid
of HCV seropositive hemodialysis patients, the study
including 39 clinical cases. The ELISA Ortho HCV 3.0
SAVe test was used for antibody analysis. A statistic
comparison was made between the anti HVC antibody
levels in the 2 oral fluids and the seric levels, with the
following results:
antibodies in serum 100%
antibodies in crevicular fluid and saliva 15,4%
The study concludes that the crevicular fluid is a
source of HVC entering the mouth.
41
42
43
44
ACORD INFORMAT
INFORMED CONSENT
- Your acceptance related to the investigation of some markers of hepatitis C virus by blood,
47
Chestionar
Prin ntrebrile care urmeaz se ncearc estimarea prevalenei factorilor de risc pentru infecia HCV,
la pacienii care solicit asistena medical la clinica noastr. Pentru factorii de risc declarai/depistai
n acest interviu, esenial este s se estimeze data primei expuneri. Pentru aceste obiective, dac este
necesar utilizai liber reversul fiei notnd numrul rndului.
Date personale ale pacientului
Nume familie: _________________ Prenume : __________________Vrsta____ Sex (M/F): __
Locul naterii: ___________________________ Etnie: Roman Alta (numii): _______________
Status marital: Cstorit Necstorit Vduv Divorat
Copil
Tel: ______________________Mediu (U/R):____
Ocupaie i loc de munc: ______________________________________________________
Educaie pacient: (coli terminate): Universitar Liceal Scoal gimnazial
Venit (# main, cas n familia pacientului):_______________ Pacientul consum alcool (Da/Nu): ____
Mrime familie (# persoane care servesc masa simultan cu pacientul): ____#Aduli ____ #Copii ___
Instituie
Evenimente n experiena pacientului:
1. Transfuzie de snge ? (Da/Nu):___ Dac Da data (luna/an) efectuarii:___/____ [Verso > 1]
2. Transplant organe/esuturi ? (Da/Nu):___ Dac Da data (luna/an) efectuare:___/___ [Verso > 1]
3. Primete factori de coagulare ? (Da/Nu):___ Dac Da de cnd (luna/an) face tratament: ___/____
4. Dializ renal ? (Da/Nu):___ Dac dializ unic cnd: ___/___ Dac cronic dializat, de cnd: ___/___
5. Intervenie chirurgical ? (Da/Nu): ___ Dac mai multe cte ? ___minore(1)/majore(2) ___Vrsta prima__
6. Tratamente stomatologice ?Nu__(<5): ___ (<10)____(>10)_____ (luna/an) ultimul: ___/___
7. Multiple ((5) tratam. injectabile Nu__(<5): ___ (<10)____(>10)_____ (luna/an) ultimul: ___/___
Comportamente i riscuri
8. Droguri pe cale IV ? (Da/Nu):___Dac Da cnd a nceput (luna/an)? ___/___ [Clarific risc transmit!]
9. Nr. parteneri sexuali n anul 2012 (adult): __ Boli sex transm antecedente____care?______________
10. Lucreaz cu bolnavi sau n laborator serologie (Da/Nu): ____ [Dac Da clarific natura muncii riscul!]
11. Are tatuaje ? (Da/Nu): ___ [Dac Da clarific cnd i cum au fost facute]
12. Are cercei sau guri pentru cercei? (Da/Nu)____ [Dac Da clarific cnd i cum au fost fcute]
13. Utilizeaz frecvent servicii comerciale pentru manichiur, pedichiur sau brbierit (Da/Nu): ___
[Clarificai]
14. n familie utilizeaz n comun peria de dini sau/i aparatul de ras, (Da/Nu): ___ [Clarificai]
15. Alte boli hepatice__________Contact familial/profesional cu hep.virale________________
48
Data:
Semntura:
Questionnaire
The following questions attempt to estimate the prevalence of risk factors for HCV infection in patients
asking for healthcare in our clinic. For the risk factors stated/detected in this interview, an estimation of
the first exposure date is essential. For these objectives, you are required to use freely the overleaf, and
note down the row number.
Patients Personal Data
Last name: __________________ First name: _____________________Age____ Sex (M/F): __
Date of birth: ______________ Ethnic group: Romanian Other (to be specified): ____________
Marital status: Married Unmarried Widow(er) Divorced
Children
Tel.: ______________________Environment (U/R):____
Profession and place of work: ___________________________________________________
Patients education: (graduated schools): University High School Secondary School
Income (# car, house in the patients family):_____________ The patient drinks alcohol daily (Yes/No): __
Family members (# members eating at the same time with the patient): ____#Adults ____
#Children___ Institution
Events in the patients history:
1. Blood transfusion? (Yes/No):___ If Yes date (month/year):___/____ [Verso > 1]
2. Organ/tissue transplant? (Yes/No):___ If Yes date (month/year):___/____ [Verso > 1]
3. Does the patient receive clotting factors? (Yes/No):___ If Yes since when (month/year): ___/____
4. Renal dialysis? (Yes/No):___ If single dialysis, when: ___/___ If chronically dialyzed, since when: ___/___
5. Surgery? (Yes/No): ___ If several, how many? ___minor(1)/major(2) ___Age on the first surgery__
6. Dental treatments? No__(<5): ___ (<10)____(>10)_____ (month/year) last treatment: ___/___
7. Multiple ((5) injectable treatments No__(<5): ___ (<10)____(>10)_____ (month/year) last treatment: ___/___
Behaviors and risks
8. Injectable drugs? (Yes/No):___If Yes since when (month/year)? ___/___ [Clarify the transmission risk!]
9. No. of sexual partners in 2012 (adult): __
Sexually transmitted disease history ____which one? ______________
10. Does patient works with patients or in the serology lab? (Yes/No): ____
[If Yes clarify the nature of the work risk!]
11. Does she/he have any tattoos? (Yes/No): ___ [If Yes clarify when and how they were made]
12. Does the patient have pierces or wear earrings? (Yes/No)____
[If Yes clarify when and how they were made]
13. Does the patient use frequently commercial services such as manicure, pedicure or shaving (Yes/
No): ___ [ Clarify]
14. Does the patient share his/her toothbrush and/or razor with the other family members?
(Yes/No): ___ [ Clarify]
15. Other hepatic diseases __________ Family/professional contact with viral hepatitis________________
Date:
Signature:
49
Metode:
Methods:
Bibliografie
1. Ploss A, Dubuisson J, New advances in the molecular
50
379, 2010
2007 october
2005
51
7(9):745-748, 2006
infection 1993
44. Jones CT, Murray CL, Eastman DK, Tassello J, Rice CM,
45. Hahm B, Han DS, Back SH, Song OK, Cho MJ, Kim CJ,
380-92, 2005
2006; 80 : 6013-23
280 : 36417-28.
52
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Cancer 9: 306
Februerie 2000
38: 15531557
6625
28: 35263536
Septembrie 2005
90: 17271736
53
C?, http://www.hepatitis-central.com/mt/archives/2007/03/
can_saliva_tran.html, 8 Martie 2007
, Dental
, Journal of
2012
Februarie 2005
Hepatitis B And C
In Dentistry,
Papers), 2008
54
Hepatology 1993
Gasteroenterology, 1990
Gasteroenterology, 1994
55