Clinical, laboratory, and virological characteristics of patients with positive hepatitis B surface antigen in Upper Egypt

Aim The aim of the study was to determine the clinical, laboratory, and virological characteristics of patients with chronic HBV infection in Upper Egypt. Patients and methods This descriptive, cross-sectional study included 252 patients with positive hepatitis B surface antigen (HBsAg). It was conducted in the Tropical Medicine and Gastroenterology Department and Outpatient Clinic, Assiut University Hospital (Egypt), from May 2012 to May 2014. All patients underwent clinical evaluation, were administered a questionnaire about risk factors for transmission of HBV, underwent liver function tests, abdominal ultrasonographic examination, and complete blood count, evaluation of serological markers of HBV, and quantitative detection of HBV-DNA. Results Of the 252 patients included, 88.5% were male with a mean age of 35.4 years. Arthralgia was the most common complaint (15.5%) and hepatomegaly was the most common finding (8.3%). As regards imaging results (ultrasonographic) the following were found: normal liver in 83.3%, coarse liver in 11.9%, hepatomegaly in 7.5%, splenomegaly in 6.3%, and cirrhosis in 5.9%. As regards laboratory results normal alanine aminotransferase was found in 79.8%, normal aspartate aminotransferase in 85.7%, reduced serum albumin in 4.4%, and low platelet count in 9.9%. The majority of patients (91.7%) were hepatitis B envelope antigen negative; 65.9% of patients were positive for HBV on PCR. No significant differences were found between positive HBV-DNA status (by PCR) and negative HBV-DNA status as regards clinical, imaging, and laboratory characteristics of patients. Conclusion Most of the patients had normal liver on ultrasonographic examination and normal liver function tests. No significant difference was found between positive HBV-DNA status (by PCR) and negative HBV-DNA status as regards clinical, imaging, and laboratory characteristics of patients.


Introduction
Hepatitis B virus (HBV) belongs to Hepadnaviridae, a family of enveloped viruses with an incomplete double-stranded DNA genome of 3.2 kb. HBV can be classified into at least eight genotypes (A-H) based on a divergence in the entire nucleotide sequence greater than 8% [1,2]. Infection with HBV is a major public health problem [3]. Chronic HBV infection is a major underlying etiology in liver cirrhosis and hepatocellular carcinoma (HCC) [4].
In countries with high HBV endemicity (prevalence >8%), the main source of infection is through perinatal transmission from the chronically infected mother or through infection during early childhood [5,6]. Vertical (mother to infant) transmission occurs worldwide and is mainly related to transplacental transmission of HBV in utero, perinatal infection through contact with infectious blood or body fluids from the infected mother at the time of delivery, or postnatal transmission during care or through breast milk [6].
In areas of low HBV endemicity, most infections are acquired by horizontal transmission in early adult life, through intravenous drug use, or through unprotected sexual activities [7]. Other risk factors include working in a healthcare setting, blood transfusions, dialysis, sharing razors or toothbrushes with an infected person, travelling in countries where the infection rate is high, and living in an institution [8,9]. Tattooing and acupuncture led to a significant number of cases in the 1980s; however, this has become less common with improved sterility [9]. Chronic HBV infection in Egypt is an important medical problem. The prevalence of hepatitis B surface antigen (HBsAg) in Egypt is intermediate (2-7%) [10,11].

Clinical, laboratory, and virological characteristics of patients with positive hepatitis B surface antigen in Upper Egypt
The infection may be entirely asymptomatic and may go unrecognized [12]. Chronic infection with HBV may be asymptomatic and may progress to liver cirrhosis and HCC [13].
HBsAg is most frequently used to screen for the presence of HBV infection. Most hepatitis B diagnostic panels contain HBsAg and total anti-hepatitis B core (anti-HBc) (both IgM and IgG). Shortly after the appearance of HBsAg, hepatitis B envelope antigen (HBeAg) will appear [14]. During the natural course of an infection, the HBeAg may be cleared, and antibodies to the 'e' antigen (anti-HBe) will arise immediately after. This conversion is usually associated with a marked decline in viral replication [14].
The aim of the current study was to determine the clinical, laboratory, and virological characteristics of patients with chronic HBV infection in Upper Egypt.

Type of the study
(1) Study design: cross-sectional analytic study. Exclusion criteria included other identifiable causes of chronic liver diseases, a history of antiviral therapy, and acute hepatitis B infection.

Study population
The following were performed: ( HBV-DNA was quantified by real-time PCR using a 7500 fast real-time PCR system (Applied PCR System; Biosystems, Life Technologies, Grand Island, New York, USA), using ready-to-use PCR kits supplied by Artus HBV PCR kit (version 1, Catalog #4506163; Qiagen GmbH) [15].

Ethical considerations
Before enrollment all participants signed a consent certificate after a detailed discussion about the study subject and study aim. Participants were clearly informed that refusal to participate would not prevent them from getting full benefit of the available medical service and treatment. Data were collected by means of personal interviews with participants after ensuring data confidentiality. The study was approved by the Faculty of Medicine Ethical Committee, Assiut University. The procedures followed were in accordance with the ethical standards (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

Statistic analysis
Statistical analysis was performed using statistical package for the social sciences (SPSS, version 17; SPSS Inc., Chicago, Illinois, USA). All data were expressed as mean ± SD or as frequencies. Continuous variables were compared through Student's t-test and proportions were compared with c 2 -test. Results were presented as mean ± SD. P values less than 0.05 were considered significant.

Results
The study included 252 patients, of whom 88.5% were male. Their median age was 35 years (mean 35.4 ± 10.2 years). All patients were native residents of Egypt. The possible risk factors for HBV infection are summarized in Table 1.
Arthralgia was the most common complaint (15.5%) and hepatomegaly was the most common finding (8.3%), as shown in Table 2.
As regards laboratory data elevated ALT more than two-fold was found in 4.8% of patients, elevated AST more than two-fold in 1.2%, reduced serum albumin in 4.4%, and low platelet count in 9.9%, as shown in Table 3. The majority of patients (91.7%) were negative for HBeAg, and 65.9% of patients were positive for HBV on PCR, as shown in Table 4.
No significant difference was seen between positive HBV-DNA status (by PCR) and negative HBV-DNA status in terms of clinical, imaging, and laboratory characteristics of patients, as shown in Table 5.

Discussion
Our study disclosed some important observations. First, dental manipulations, surgical operations, previous blood transfusion, HBV infection in the family, and tattooing were the possible risk factors for HBV infection in our patients. Second, arthralgias, fatigue, and abdominal pain were the main clinical manifestations of chronic HBV infection. Third, most of the patients had normal liver on ultrasonographic examination and normal liver function tests. Fourth, the majority of patients with chronic HBV infection were negative HBeAg and about two-thirds had positive PCR. Fifth, no significant difference was found in clinical, imaging, and laboratory characteristics between patients with positive HBV-DNA status (by PCR) and negative HBV-DNA status.
The results of this study are similar to a previous study by O'Connell et al. [16] and to a study by Allwright et al. [17]. They reported that HBV was found in all body secretions and excretions, but only blood, body fluids containing visible blood, semen, and vaginal secretions represented a risk of transmission. HBV is transmitted by percutaneous and mucosal exposure to infective blood or body fluids. The main modes of HBV transmission include sexual or close household contact with an infected person, perinatal mother to infant transmission, injecting drug use, and nosocomial exposure. Grogan et al. [18] reported that HBV can be transmitted by transfusion of infected blood or blood products, sharing unsterilized injection needles for intravenous drug use, hemodialysis, acupuncture, tattooing,  and injuries from contaminated sharp instruments sustained by hospital personnel.
Our present study bears some similarities with previous reports by Liaw et al. [14], who found that the main clinical manifestations of chronic HBV infection were fatigue, vague abdominal discomfort, nausea and vomiting, anorexia, sometimes arthralgia and rash, followed by bleeding gums. Studies by Tosti et al. [19] also reported the same findings.
In the present study, our results also showed that the majority of patients had normal liver on ultrasonographic examination (83.3%) and normal liver function tests: normal ALT levels (79.8%), normal AST levels (85.7%), normal total bilirubin (93.3%), normal   serum albumin (95.6%), and normal Prothrombin time (92%). Our study has some similarities with previous reports by Lok et al. [20], who reported that most of the patients with chronic HBV infection had normal liver and normal liver function tests.
The replicative phase of chronic HBV infection is characterized by the presence of HBeAg and HBV-DNA. The nonreplicative phase is characterized by the absence of HBeAg and HBV-DNA. Several HBeAg-negative patients have persistent high HBV replication associated with liver inflammation and ongoing fibrosis [3]. HBeAg-negative chronic HBV infection is mostly associated with mutations in the precore and basal core promoter regions that result in prevention or reduction of HBeAg synthesis without affecting the replicative ability of the virus [3,21]. Several studies have shown a strong relationship between HBV genotypes and mutations in the precore and core promoter regions that abolish or diminish the production of HBeAg [21][22][23].
In the present study, we demonstrated that most of the patients (91.7%) were HBeAg negative (presumably indicating precore or core promoter mutation). Studies by Sitnik et al. [23] reported similar findings. Zaky et al. [24] mentioned that in Upper Egypt 94% of hepatitis B-infected persons were HBeAg negative and 41% had positive HBV-DNA on PCR. However, in the study by Zahran et al. [25], only 72% of hepatitis B-infected patients were HBeAg negative.
Most chronic HBV infections are characterized by high HBV-DNA levels (>20 000 IU/ml). Lower HBV-DNA values (2000-20 000 IU/ml) are common in HBeAg-negative chronic infection, which is associated with a low likelihood of spontaneous disease remission [26]. Detection of HBV-DNA level is a criterion for determining the state of infection, the risk of progression toward cirrhosis and HCC, identification of patients who need antiviral therapy, determining response to therapy, and identifying the emergence of drug resistance [27]. Chu et al. [27] and Ledesma et al. [28] confirmed the relationship between viral load level and liver damage in patients negative for HBeAg, whereas Alam et al. [29] reported that low-level viral load is not always an indication of improved conditions and in some patients it indicates advanced disease. In an Iranian study by Taghavi et al. [30], it was reported that there was no statistically significant difference between patients with positive and those with negative HBV-DNA in terms of age, sex, clinical manifestations, and liver enzyme levels.
Our results are in agreement with these studies as it showed that there was no significant difference in clinical, imaging, and laboratory characteristics between patients with positive HBV-DNA status and those with negative HBV-DNA status.

Conclusion
The main clinical manifestations of chronic HBV infection were arthralgias, fatigue, and abdominal pain, followed by bleeding gums. Most of the patients had normal liver on ultrasonographic examination and normal liver function tests. The majority of patients with chronic HBV infection were HBeAg negative. There was no significant difference in clinical, imaging, and laboratory characteristics between patients with positive HBV-DNA status (by PCR) and those with negative HBV-DNA status.