Reactivation of hepatitis B virus with immune-escape mutations after ocrelizumab treatment for multiple sclerosis

Ocrelizumab is an anti-CD20 monoclonal antibody for the treatment of multiple sclerosis (MS) that is closely related to rituximab. We describe a case of hepatitis B virus (HBV) reactivation in an MS patient with resolved HBV infection receiving ocrelizumab. HBV reactivation was monitored with HBV-DNA and HBV surface antigen periodic assessment. Anti-HBV treatment with entecavir was started after HBV-DNA detection. Ocrelizumab can reactivate viral replication in patients with resolved HBV infection. HBV reactivation monitoring seems an effective and safe option for the management of these patients. More studies are needed to assess the optimal management of HBV reactivation in MS patients on ocrelizumab treatment

Reactivation of hepatitis B virus with immune-escape mutations after ocrelizumab treatment for multiple sclerosis

Ocrelizumab is an anti-CD20 monoclonal antibody for the treatment of multiple sclerosis (MS) that is closely related to rituximab. We describe a case of hepatitis B virus (HBV) reactivation in an MS patient with resolved HBV infection receiving ocrelizumab. HBV reactivation was monitored with HBV-DNA and HBV surface antigen periodic assessment. Anti-HBV treatment with entecavir was started after HBV-DNA detection. Ocrelizumab can reactivate viral replication in patients with resolved HBV infection. HBV reactivation monitoring seems an effective and safe option for the management of these patients. More studies are needed to assess the optimal management of HBV reactivation in MS patients on ocrelizumab treatment

Genetic determinants in a critical domain of ns5a correlate with hepatocellular carcinoma in cirrhotic patients infected with hcv genotype 1b

HCV is an important cause of hepatocellular carcinoma (HCC). HCV NS5A domain‐1 interacts with cellular proteins inducing pro‐oncogenic pathways. Thus, we explore genetic variations in NS5A domain‐1 and their association with HCC, by analyzing 188 NS5A sequences from HCV genotype‐1b infected DAA‐naïve cirrhotic patients: 34 with HCC and 154 without HCC. Specific NS5A mutations significantly correlate with HCC: S3T (8.8% vs. 1.3%, p = 0.01), T122M (8.8% vs. 0.0%, p < 0.001), M133I (20.6% vs. 3.9%, p < 0.001), and Q181E (11.8% vs. 0.6%, p < 0.001). By multivariable analysis, the presence of >1 of them independently correlates with HCC (OR (95%CI): 21.8 (5.7–82.3); p < 0.001). Focusing on HCC‐group, the presence of these mutations correlates with higher viremia (median (IQR): 5.7 (5.4–6.2) log IU/mL vs. 5.3 (4.4–5.6) log IU/mL, p = 0.02) and lower ALT (35 (30–71) vs. 83 (48–108) U/L, p = 0.004), suggesting a role in enhancing viral fitness without affecting necroinflammation. Notably, these mutations reside in NS5A regions known to interact with cellular proteins crucial for cell‐cycle regulation (p53, p85‐PIK3, and β‐ catenin), and introduce additional phosphorylation sites, a phenomenon known to ameliorate NS5A interaction with cellular proteins. Overall, these results provide a focus for further investigations on molecular bases of HCV‐mediated oncogenesis. The role of these NS5A domain‐1 mutations in triggering pro‐oncogenic stimuli that can persist also despite achievement of sustained virological response deserves further investigation

DECLINE OF PREVALENCE OF RESISTANCE ASSOCIATED SUBSTITUTIONS TO NS3 AND NS5A INHIBITORS AT DAA- FAILURE IN HEPATITIS C VIRUS IN ITALY OVER THE YEARS 2015 TO 2018

Background: A minority of patients fails to eliminate HCV and resistance-associated substitutions (RASs) are commonly detected at failure of interferon-free DAA regimens . Methods: Within the Italian network VIRONET-C, the prevalence of NS3/NS5A/NS5B RASs was retrospectively evaluated in patients who failed an EASL recommended DAA-regimen in 2015-2018 . The geno2pheno system and Sorbo MC et al. Drug Resistance Updates 2018 were used to infer HCV- genotype/subtype and predict drug resistance . The changes in prevalence of RASs over time were evaluated by chi-square test for trend, predictors of RASs at failure were analysed by logistic regression . Results: We included 386 HCV infected patients: 75% males, median age was 56 years (IQR 52-61), metavir fibrosis stage F4 in 76%; 106 (28%) were treatment- experienced: 91 (86%) with IFN-based treatments, 26 (25%) with DAAs. Patients with HIV and HBV coinfection were 10% (33/317) and 8% (6/72), respectively. HCV genotype was 1b in 122 pts (32%), 3 in 109 (28%), 1a in 97 (25%), 4 in 37 (10%), 2 in 21 (5%). DAA regimens were: LDV/SOF in 115 (30%), DCV/SOF in 103 (27%), 3D in 83 (21%), EBR/GRZ in 32 (8%), VEL/SOF in 29 (7%), GLE/PIB in 18 (5%) and 2D in 6 (2%); ribavirin was administered in 123 (32%) . The NS5A fasta-sequence was available for all patients, NS5B for 361 (94%), NS3 for 365 (95%) . According to the DAA failed the prevalence of any RASs was 90%, namely 80/135 (59%) in NS3, 313/359 (87%) in NS5A, 114/286 (40%) in NS5B . The prevalence of any RASs significantly declined from 2015 to 2018 (93% vs 70%, p=0.004): NS5A RASs from 90% to 72% (p=0 .29), NS3 RASs from 74% to 18% (p<0 .001), while NS5B RASs remained stable . Independent predictors of any RASs included advanced fibrosis (AOR 6.1, CI 95% 1.8-20.3, p=0 .004) and genotype (G2 vs G1a AOR 0 .03, CI 95% 0 .002- 0 .31, p=0 .004; G3 vs G1a AOR 0 .08, CI 95% 0 .01-0 .62, p=0 .02; G4 vs G1a AOR 0 .05, CI 95% 0 .006-0 .46, p=0 .008), after adjusting for age, previous HCV treatment and year of genotype . Notably, full activity was predicted for GLE/PIB in 75% of cases and for at least two components of VEL/SOF/VOX in 53% of cases, no case with full-resistance to either regimen was found . Conclusion: Despite decreasing prevalence over the years, RASs remain common at virological failure of DAA treatment, particularly in patients with the highest grade of liver fibrosis. The identification of RASs after failure could play a crucial role in optimizing retreatment strategies

HCV very late relapse following an atypical viral kinetics in a HIV patient treated for hepatitis C with direct-acting antivirals

Direct-acting antivirals (DAAs) for the treatment of HCV have dramatically increased the rate of sustained virological response: patients not achieving sustained virological response represent a challenge and rates of late recurrent viremia are very low. We describe here the first case of a very late HCV relapse, following an atypical kinetics (characterized by a spontaneous but transient HCV clearance after an early virological relapse), in a HIV co-infected patient treated with DAAs. Optimal adherence to the therapy was well documented and a phylogenetic analysis ruled out a possible reinfection from a different HCV strain. In conclusion, our case underlines the importance of a long follow-up (> 48 weeks) after DAAs therapies in HCV\u2013HIV co-infected patients who might benefit the most from a very rigorous virological surveillance

Founder effect of NS3 variant Q80K in HCV1a infected patients in Italy

Background: Italy is characterized by a high HCV burden, with higher prevalence rates in Southern and Insular areas compared to Central and Northern regions. Despite 95% success rates reported for all HCV genotypes with direct-acting antivirals (DAAs), eradication is hampered by the impact of natural resistance-associated variants (RAVs), especially in case of retreatment after DAA failure. This study aimed to investigate HCV1a variability within Italy, as well as the association of clusters with epidemiological factors and NS3 RAVs. Materials and methods: Between 2011 and 2015, 183 baseline NS3 sequences from serum samples of HCV1a infected patients were obtained with Sanger sequencing. Individuals were sampled in seven Italian regions (Abruzzo, Apulia, Emilia-Romagna, Lazio, Liguria, Lombardy and Sardinia). HCV1a control strains coding for protein NS3 and sequenced worldwide, were gathered from Genbank. A total dataset of 1084 sequences was obtained after subtyping, quality control and alignment. Sequences were annotated with RAVs using Geno2pheno, with year and country, and when available with gender, age, therapy status, transmission route and viral co-infection. Phylogenetic reconstruction was performed using RAxML, with GTR model and supported by 1000 bootstrap replicates. Clustering of sequences was identified with Cluster Picker, using 70% bootstrap support as threshold. Phylogenetic and temporal signal were determined with TreePuzzle and Path-O-Gen, after which clusters were confirmed using Bayesian phylogeny with BEAST. Results: Median age of the 183 HCV1a positive patients was 55 years (IQR: 50-66), with the majority being male (80.9%) and DAA naïve (89.1%). Transmission route was available for 61/183 patients (33%) and only 12/183 patients (7%) were co-infected with HIV. Based on a maximum-likelihood and Bayesian phylogenetic tree of the whole dataset, we identified two clusters, which included 3 patients from our cohort in total. The first cluster consisted of two DAA-naïve HCV mono-infected patients from Abruzzo (PP = 1). Both patients were male with one infected through intravenous drug use. For the second cluster (PP > 0.97), an HIV/HCV co-infected patient from Lazio clustered with an Italian control sequence, with for the latter lacking information for viral co-infections. Both sequences were derived from DAA-naïve patients with unknown transmission route. Remarkably, both clusters included patients all harbouring RAV Q80K. In depth-analysis showed a dispersion of the Italian sequences across the whole phylogenetic tree and a distinction of the tree into two major clades, with one consisting of all, except for one, sequences harbouring variant Q80K (n=96). Due to low support for the two separate clades, downsampling to 20% of the tree was performed multiple times, and this confirmed each time the existence of a founder effect for RAV Q80K. Conclusions: Phylogeny of HCV1a NS3 sequences identified two clusters among DAA-naïve Italian patients each harbouring RAV Q80K. All HCV1a sequences could be assigned to one of two major clusters, one with and one without Q80K. This founder effect of Q80K has implications for treatment of HCV1a cirrhotic patients with simeprevir and sofosbuvir, since Q80K is associated with lower success rates. Phylogenetic cluster analysis may aid in predicting treatment response and assessing viral evolution under DAA selective pressure.status: accepte

Impact of HCV1a migration patterns on the public health policy regarding genotyping of the Q80K resistanceassociated variant in Italy

Introduction: Viral factors can impair the efficacy of direct-acting antiviral (DAA) based therapies for the hepatitis C virus (HCV). An important example is the naturally occurring and highly prevalent Q80K variant in the NS3 gene, which can interfere with the action of simeprevir. Aims: Italy has a comparatively high HCV prevalence among Western European countries, such that the public health impact of the Q80K variant may be more pronounced. This motivated us to initiate a study relating the Italian HCV1a epidemic with that in other countries, with the emphasis on the migration patterns of the Q80K variant. Material and Methods: Newly generated NS3 sequence data from 183 HCV1a Italian patients were complemented with publicly available time and geo-referenced virus genetic data from around the world. An integrated Bayesian inference approach was used to elucidate the population level transmission patterns through time and space using a model that allows for different migration rates depending on the direction of movement. Results: The NS3 polymorphism Q80K revealed to be highly abundant in one of the two clades in which HCV1a segregates, but is rarely observed in the other clade. The high Q80K prevalence in this clade can be traced to a single origin in the United States. From there it spread globally, including to several European countries. This variant was introduced in Italy around 1960. Phylogeographic reconstructions also show that seeding into Italy was initially dominated by the US, but its relative importance declined in favour of introductions with an European continental origin. Italy also acted as a hub for the onward HCV1a dissemination within Europe, which can involve Q80K strains. An exploration of the within-country migration patterns revealed mixing of strains between North, Central and South Italy, which suggests that the Italian epidemic is quite uniform and does not evolve in local subepidemics. Conclusions: We find indications that immigration and national circulation, both in complex patterns, fuel the Italian HCV1a epidemic. This precludes a clear differentiation between HCV1a patients at risk to acquire the NS3 variant Q80K. In turn, this implies that genotyping should not target specific groups, but that it may be cost-effective to test all HCV1a patients eligible for therapy with simeprevir for the absence of the Q80K polymorphism.status: Published onlin