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From www.bloodjournal.org by guest on August 3, 2017. For personal use only. A Prospective Study of Transfusion-Transmitted GB Virus C Infection: Similar Frequency but Different Clinical Presentation Compared With Hepatitis C Virus By Jin-Town Wang, Feng-Chiao Tsai, Cha-Ze Lee, Pei-Jer Chen, Jin-Chuan Sheu, Teh-Hong Wang, and Ding-Shinn Chen To study the incidence and outcome of GB virus C (GBV-C) infection in blood recipients. Serum samples collected in a prospectivestudy were examinedforGBV-CRNA by a nested polymerasechainreactionassay.Among the 400 adults who underwent cardiac surgery,40 were positive for GBV-C RNA, including six whose pretransfusion sera were already positive and seven coinfected with hepatitis C virus (HCV) during transfusion.The risk of transmission was estimated to be -0.46% per donor. GBV-C viremiawas detectable 1 week after transfusion and could persist for 8 years. However, no evident symptomsor signs were noted in the 25 patients infected by GBV-C alone, and the average peak serum alanine aminotransferase activity was 31 IU/L only (range, 12 to 123). with persistently normal levels in 20 patients. In the seven patients coinfectedwith HCV, the clinical courses of posttransfusion hepatitis were similar to those infected by HCV alone. In eight patientswith posttransfusion non-A-E hepatitis, only one was positive for GBV-C RNA. Sixty samples were chosen to test hepatitis G virus (HGV) sequences, 26 of the 30 GBV-C positives were positive for HGVRNA in contrast to noneof the 30 GBV-Cnegative samples. In conclusion, GBV-C canbe transmitted by transfusion in -9% of patients who underwent cardiac surgery. Nevertheless,this virus doesnot seem to cause classic hepatitis in most instances. 0 1996 by The American Societyof Hematology. M transaminase (ALT) during this 6-month period were followed every month for 1 year and then every 3 months for as long as possible. Blood samples were obtained during each visit and kept frozen at -80°C until tested. Additional samples beside the follow-up schedule were obtained in some patients who were checked for blood tests due to their underlying disease. The samples were carefully handled and aliquoted to avoid contamination and degradation of viral nucleic acid.’’ As of June 1994, a total of 1,038 patients were enrolled. Of them, 910 recipients completed the 6-month follow-up, while128 patients were lost to follow-up at the 6-month period. Among the 910 recipients, 665 received transfusion when anti-HCV was not screened in blood donors, and 245 patients were transfused after anti-HCV screening that was initiated on July 1, 1992. Most of the blood recipients were patients receiving cardiac surgery and had a mean donor number of 18.6 2 14.6 (range, 1 to 97). For the GBV-C study, 400 recipients were enrolled. They included the first 250 consecutive patients transfused since 1987 and before anti-HCV screening was implemented in blood donors and the first 150 patients transfused after the anti-HCV screening. Of the 400 recipients tested for GBV-C, 24 were infected by HCV and eight were diagnosed as posttransfusion non-A-E hepatitis by serologic assays and PCR for hepatitis B and C viruses as previously described.” All the 24 HCV infections were detected before anti-HCV screening. After testing of GBV-C RNA, 30 GBV-C positive recipients and 30 GBV-C negative recipients were selected and tested for HGV RNA by PCR including: (1) the pretransfusion sample and two posttransfusion samples of all the eight non-A-E hepatitis patients (24 samples, OLECULAR CLONING of the hepatitis viruses and rapid progress in serologic assays have enabled us to diagnose the etiology in the majority of posttransfusion hepatitis (PTH) cases. However, after screening for the antibody to hepatitis C virus (anti-HCV) in blood donors, there are still 2%to 3% of patients whose posttransfusion hepatitis cannot be attributed to hepatitis A, B, C, D, or E viruses.’.2 Among the candidate non-A-E hepatitis viruses, a wellknown one that has been characterized extensively in animal models, is the GB hepatitis agent.3Recently two GB hepatitis agent-like viruses, GBV-A and GBV-B, have been identified and isolated from the inoculated tamarins, butboth seem absent in human^.^.^ After further study, novel GBV-like sequences, designated GBV-C, were isolated from serum samples of some non-A-E hepatitis patients in western Africa and North A m e r i ~ aPreliminary .~ data have shown viremia in humans. However, the modes of transmission and the clinical significance of GBV-C infection remain ~ n k n o w n . ~ As we have conducted a prospective study of posttransfusion hepatitis in Taiwan since 1987,’ the serial serum samples collected from these prospectively followed recipients can be used to study the risk of GBV-C transmission through blood transfusion, as well as the clinical course of those who are infected. Accordingly, we investigated the presence of GBV-C genome in these recipients by using a nested polymerase chain reaction (PCR) assay, and the clinical correlation of hepatitis was analyzed. After testings of GBV-C RNA were completed in our study, a closely related agent, hepatitis G virus (HGV) was identified.’ We, therefore, also tested HGV RNA in some of our samples. MATERIALSANDMETHODS Blood recipients. From June 1987, we conducted a prospective study of posttransfusion hepatitis in the National Taiwan University Hospital.’ Interim results for hepatitis viruses infection and human T-cell lymphotropic virustype I (HTLV-I) have been reported in detail before.”.” Briefly, patients who received blood transfusion and met the following criteria were recruited: normal liver function tests before transfusion; no transfusion in the past year; no previous history of liver diseases, alcoholism, drug addiction, or exposure to hepatotoxic drugs. After transfusion, the recipients were followedup every 2 to 4 weeks for 6 months. Patients with elevated alanine Blood, Vol 88, No 5 (September l), 1996:pp 1881-1886 Fromthe Departments of Bacteriology and Intern1 Medicine, School of Medicine, College of Medicine, National Taiwan University: Taipei; andthe Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan. Submitted March 8, 1996, accepted April 22, 1996. Supported by grants from the Department of Health and the National Science Council, Executive Yuan, Taiwan, Republic of China. Address reprint requests to Ding-Shinn Chen, MD, Hepatitis Research Center, National Taiwan University Hospital, I , Chang-Te St, Taipei, Taiwan 10016. The publication costs of this article were defrayed in part by page charge payment. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. section 1734 solely to indicate this fact. 0 1996 by The American Society of Hematology. 0006-4971/96/8805-00IO$3.00/0 1881 From www.bloodjournal.org by guest on August 3, 2017. For personal use only. 1882 two of them were GBV-C RNA positive), (2) two posttransfusion samples of 18 randomly selected patients without hepatitis (36 samples; 28 of them were GBV-C RNA positive). Donors. The blood or blood components used were donated by volunteers negative for hepatitis B surface antigen, antibody to human immunodeficiency virus, and with serum ALT activities <4S I U L (normal, <31 IUL). Antibody to HCV by a second generation assay was added to the screening list in July 1992. Plasma samples of donors were also collected from transfused fresh frozen plasma or whole blood before transfusion as completely as possible. PCR assay. To screen GBV-C viral RNA, the pretransfusion, and the 6-month posttransfusion serum samples from these 400 recipients were tested by a nested PCR. We had tested GBV-C in 104 patients in both first and 6-month posttransfusion samples. Of them, seven were positive at both first and 6-month posttransfusion samples, three were positive at 6 months, and one was positive at the first posttransfusion samples only. Therefore, to avoid including recipients with carry-over rather than true infection and to save the resources and time of so manyPCR experiments, we tested the 6-month posttransfusion sample in the subsequent patients. Serial posttransfusion samples of a given recipient were tested if the 6month posttransfusion sample was positive and the pretransfusion sample was negative. Plasma samples from 200 volunteer blood donors unrelated to this study were tested as controls. The initial PCR screening was done by pooling 10 to 15 pL of serum specimens from seven to 10 patients. The outer primer pair was GBV-C-SI and GBV-C-al, inner primers were GBV-C.4-s1 and GBV-C.4-al, or GBV-C.5-sl andGBV-C.5-al.’ Nucleic acidwas extracted from 100 pL of serum, reverse transcribed, and subjected to a nested PCR, as described previously.” Ten microliters of the PCR products were electrophoresed in a 2% agarose gel and stained with ethidium bromide. Positive samples were then broken down by testing GBVC RNA in each individual sample by the same method. Negative samples were tested again by adding a GBV-C RNA positive serum sample to exclude the presence of reaction inhibitor. The PCR assay has been proven tobe specific for detecting serum GBV-C RNA after sequencing the PCR products from more than 10 patients. For each PCR assay, a weak positive serum sample, which was positive only after nested PCR by both inner primers, was used as positive control. Serum samples from healthy subjects that were collected during a routine physical check-up and were proven to be negative for GBV-C RNA with all of the above-mentioned GBV-C primers (they also tested negative for HGV RNA after HGV sequences were available) were used as negative controls. For each experiment, a negative serum sample, as well as regents without template, were used as negative control. To detect HGV RNA by PCR, two primer pairs from the HGV genome were used: the outer primer pair was HGV-F1 S‘aggtgtcttcaaagaccggaagg;HGV-R1 S’tcagaggccagagcgtatagctc; the inner primer pair was HGV-F2 S‘ggacttccggatagctgaaaagct; HGV-R2 5‘gcgccacacagatggcgca? The procedures were the same as those for GBV-C RNA. DNAsequencing. DNA sequences were determined in PCR products from recipients positive for GBV-C RNA to confirm the specificity. For sequencing reaction, 40 mL of the specific biotinylated amplification product (amplified by primer GBV-4sl and 4al or GBV-5sl and 5al) were used to generate single-stranded template for sequencing by Dynabeads M280 streptavidin (Dynal AS, Oslo, Norway). The single-stranded, biotinylated PCR products were directly sequenced using a cycle sequencing protocol and reagents supplied with the Taq Dye Terminator Cycle Sequencing Kit (ABI, Foster City, CA). The thermal cycling condition of GBV-C sequencing were 35 cycles at 94°C for SO seconds 60°C for 50 seconds and 72°C for SO seconds after the initial denaturation step at 94°C for S minutes. After PCR, the reaction mixtures were extracted with phenoUchloroform (4: 1) twice and precipitated with 95% (vol/vol) etha- WANG ET AL nol and 3 m o a sodium acetate, pH 5.2. Following centrtfugation for 25 minutes, each pellet was dried in a speed-Vac (Savant, NY) and stored at -20°C until electrophoresis. Dried pellets were resuspendedin 4 mL of loading buffer [S:1 (vollvol) deionized formamide/SO rnmol/L EDTA pH 8.01 and were heated at 95°C for 3 minutes to loading onto a 6% (wthol) polyacrylamide gel containing 7 molL urea. Electrophoresis was performed on an AB1 373 automated sequencer (ABI). Southern blot. To further confirm the specificity of thenested PCR, 30 random samples were checked by southern blot. The PCR products from a sequenced sample amplified by primer pair GBV4al and 4sl were purifiedandusedas the probe. The probe was labeled using a enhanced chemiluminescence kit (Amersham, Buckinghamshire, UK) according to the manufacturer’s instructions. Southern hybridization was performed as previously described.” Briefly, the PCR products were electrophoresed and transferred to a nylon membrane (Oncor, Gaithersburg, MD). The filterswere prehybridized with a rapid hybridization buffer (Amersham) at 65°C for 1 to 2 hours and hybridized with the probe at 65°C for 2 hours. Filters were then washed with 0.1% sodium dodecyl sulfate (SDS) and 0.Sx SSC (1 X SSC is 0.1S m o a NaCl plus 0.015 mol/L sodium citrate) at 42°C for 20 minutes twice and then washed with 0 . 1 8 SDS and 0.1 X SSC for 20 minutes. The film was exposed for I minute after treating with the substrate. Statisticalmethods. Student’s t-test and Chi-square testwere used for statistical analysis. RESULTS None of the pooled negative samples showed reaction inhibitor after repeat testing. On repeat testings for each individual after initial screening, 39 of the posttransfusion samples (39 of 400 = 8.6%, 95% confidence intervals = 6.8 to 12.7), six of the pretransfusion samples of the 400 recipients (6 of 400 = I S % , 95% confidence intervals = 0.3 to 2.7)and four of the 200 donors were positive for serum GBV-C RNA, respectively. All six pretransfusion samples and 34 of the posttransfusion samples were positive for both primers (Fig 1A). All of the samples checked by Southern blot specifically hybridized to the probe (Fig 1B). Four of the five patients were positive by GBV-SsUSal primer, while one was positive by GBV-4s1/4al only. Samples positive for only one primer pair were considered positive if more than two of the serial samples were positive. Two of these samples were sequenced and confirmed to be GBV-C RNA by a homology of 85% and 87% in 82 nucleotides with the reported sequences,’ respectively. Five of the six patients positive for GBV-C RNA in pretransfusion samples were still positive on the posttransfusion samples. Therefore, 40 recipients were positive on either pre- or posttransfusion samples. The positive rates for the recipients and donors were 40 of 400 and 4 of 200, respectively. Of the 34 recipients (34 of 394 = 8.6%, 95% confidence intervals = 5.8 to 11.4) with new posttransfusion GBV-C viremia, 22 (8.8%) were transfused before, while 12 (8.0%) were transfused after anti-HCV screening (22 of 250 v 12 of 150, P > . l ). Seven (20.6%) of the 34 recipients were coinfected with HCV during blood transfusion. The number of donors in these 34 patients wassignificantly higher than those not infected with GBV-C (24.2v 17.6, P < .01). Two recipients, each carrying HCV and HTLV-I, were superinfected by GBV-C during transfusion. Therefore, 25 recipients were From www.bloodjournal.org by guest on August 3, 2017. For personal use only. TRANSFUSION-TRANSMITTED ! A B 1 2 3 4 5 1 2 3 4 5 Fig 1. PCR products of a patient infected with GBV-C. Lane 1, marker: 11x174 DNA digested with Haelll; lane 2, PCR products amplified with primer GBV-C 5.q.. and 5.,; lane 3, PCR products amplified with primer GBV-C 4,, and 4.,; lane 4, a negative control; and lane 5, marker 100 bp ladder. (A) Gel electrophoresis. (B) Southern blot: infected by GBV-C alone. These 25 recipients had a mean peak serum ALT of 3 1 IU/L (Table 1 ), 20 did not have any ALT elevation during the 6-month follow-up (Fig 2A), three had mild ALT elevation (less than twofold the upper limit of normal), and two were found to have elevated ALT levels more than twofold the upper limit (peak ALT value 101 and 123 IU/L, respectively). Among these five recipients with elevated serumALT activities, the elevation was so mild that only one fit the criteria of posttransfusion hepatitis." Except for those coinfected withHCV, all the GBV-C infected subjects were asymptomatic during the acute stage. In the follow-up period of 1 to 8 years, they appeared clinically well, and there was no evidence of hepatitis or other systemic diseases. The clinical course and laboratory data in the seven HCV coinfected recipients was similar to those infected byHCV only (Table l). All seven patients developed chronic hepatitis, two of them died6 years after transfusion due to underlying heart disease, and another patient was foundto have unexplained iron deficiency anemia (Hb = 9.2 to 9.8 gm/dL) 7 years after transfusion. The results of serial testings showed that GBV-C viremia appeared as early Table 1. Clinical Data of Patients With Posttransfusion GBV-C Infection Compared With HCV Infection GBV-C Alone n = 25 Mean age Sex (male:female) Mean donor number* Mean peak ALT, IU/L Chronicity rate Jaundice 44.1 169 21.2 31 38% (5/13) 0 With HCV Coinfection n = 7 55.6 3:4 28.4 442 100% (7/7)t 28% (2/7) HCV Alone n = 17 46.2 11:6 20.4 501 88% (15/17)t 35% (6/17) Excluding one HCV carrier and one HTLV-1 carrier, both had mild ALT elevation. Significantly larger than recipients without GBV-C infection ( P < .01, Student's t-test). t For HCV infection. as 1 week after transfusion and remained detectable for as long as 8 years. In three patients coinfected by GBV-C and HCV, HCV RNA could be detected in most of their serial serum samples, while GBV-C RNA was detectable intermittently during the follow-up period (Fig 2B). Of 22 patients (13 GBV-Cinfected alone, seven with HCV coinfection, one HCV carrier, and one HTLV-l carrier) whohadtwo or moreserum samples available 6 months after transfusion. eight had GBV-C RNA detectable. The number of samples tested for persistent infection in each patient was 5.6 (range 2 to 20) and the time of sampling ranged from 9 months to 8 years after transfusion. Therefore, if defined by the presence of GBV-C RNA for >6 months after infection, the persistent infection rate of acute GBV-C infection acquired after blood transfusion was estimated to be 36% (8 of 22). In the eight patients with posttransfusion non-A-E hepatitis, only one ( I 2.5%) had serum GBV-C RNA. The patient with acute non-A-E PTH became GBV-C positive 1 month after transfusion (Fig 2C). The GBV-C viremia persisted for 2 years, while ALT became normal 3 months after transfusion. In the 30 GBV-C positive samples, 26 were positive for HGV, while none of the 30 GBV-C negative samples were positive for HGV sequences. The patient with acute non-AE PTH and GBV-C positivity was positive for HGV sequences. DISCUSSION Blood transfusion is a vital therapeutic intervention in daily clinical practice, but it always carries the risk of bloodtransmitted viral infections, including human hepatitis viruses and retroviruses.'".'' The recently cloned human GBhepatitis like virus, GBV-C,' promptedour concern. Because GBV-C viremia has been demonstrated in man, it maybe transmitted through blood-borne infection and studying recipients of blood transfusion is the most likely way to document this possibility. From www.bloodjournal.org by guest on August 3, 2017. For personal use only. 1884 WANG ET AL The recently cloned HGV is closely related to GBV-C by the high nucleotide and amino acid homologybetween these two viruses.' In the same series of serum samples, our data alsoshowed a high consistency of viremia of thesetwo A 62 - - + + + + o ' , , , , OM + + 3M 6M B " , , , , 3Y I 1 7Y Time after trclarlhsion I ;;; B 1 700 - -+- ++++++ - i 600500 "_ + - 100 0 OM 3M 6M 5Y 6Y 4YI 3Y Y 2Y 3Y 4Y Time after transfusion c RNA - - + ++ + 1241 0 Iwk 4wk viruses in different patients. These results suggested GBVC and HGV are probably identical. When clinicalpresentations of posttransfusion GBV-C infection were compared with those of HCV, GBV-C seemed not to cause evident hepatitis as that by HCV. The majority (20 of 25, 80%) of posttransfusion GBV-C infected recipients had persistently normal levels of serum ALT, and most (7 of 8, 87.5%) patientswhohaddocumented non-A-E hepatitis in our posttransfusion hepatitis study were negative In the one patientwithnon-Afor serum GBV-C RNA. E hepatitis and posttransfusion GBV-C/HGV infection, the hepatitis was mild, and ALT didnot elevate duringa followup period of 2 years. Taken together, the results suggested that GBV-C/HGV may not be a classic hepatotropic agent, like hepatitis viruses A-E. However, caution must be taken in interpreting these data because the casesinfected by GBVC/HGV in our series were limited in number, and GBV-C/ HGV may cause severe hepatitis in only a small proportion ofinfectedpatients,as was shown in arecent study that this virus has been claimed to be associated with fulminant hepatitis of unknown etiology.'' Another important implication of the low GBV-C/HGV positivity rate in posttransfusion non-A-E hepatitis is that perhaps there exists another non-A-E, non-GBV-C/HGV hepatitis agent(s) that can be transmitted through blood transfusion. In our study, we found a prevalence of GBV-C viremia in 10% of the blood recipients. Because currently no serologictests are available, emergence of GBV-C viremiais the only clue for acuteinfection of this virus. Although there could be subjects with chronic intermittent viremia as shown in the case depicted in Fig 2B and thus ostensibly fulfilled the criterion, the low PCR positivity rate before transfusion (1 S% v 9.8% posttransfusion, P < .O I ) suggested that most of them were indeed infected through blood transfusion. On the other hand,defining acute GBV-C infection by screening the 6-month posttransfusion samples could miss some patients whose viremia were cleared within this short period. However, theproportion seemed small as shown by our preliminary results, and detection of viremia atan early stage couldincludeGBV-CRNA carried overfrom the donor without true infection in the recipients. Taken together, the infection rate in our study should be close to the real incidence, although serological testing is necessary to clarify it in the future. In those with posttransfusion GBV-C infection, the viral genome was detected in the first serum sample 1 week posttransfusion and couldthenpersist for as longas 8 years. 3M 4M hM Time aRer transfusion + + Fig 2. Viremia and serum ALT levels of three patients with post0, pretransfusion. (A) A 43-year-old transfusionGBV-Cinfection. woman infectedwith GBV-C afterblood transfusion. Note thepersistently normal ALT levels (<31 IUIL) deeppite GBV-C viremia for up to 7 years. (B1 A 68-year-old woman coinfected with GBV-C and HCV after blood transfusion. Note the intermittent GBV-C viremia and persistent HCV viremia. The serum ALT levels are similar to those infected by HCValone showing biphasicpeaks. (C) A49-year-old male with non-A-E hepatitis and GBV-C infaction alone. Note the transient mild ALT elevations of serum ALT levels that decrease to normal range despite persistent GBV-C viremia. From www.bloodjournal.org by guest on August 3, 2017. For personal use only. TRANSFUSION-TRANSMITTED GBV-C INFECTION This indicates that GBV-C may cause a chronic infection. The chronicity rate was estimated to be 36% by the presence of viremia for more than 6 months. However, the actual rate might be lower if seroconversion instead of viremia at the 6-month sample after transfusion was adopted to diagnose acute infection. The only risk factor associated with GBVC infection in our study was the number of blood donors. Screening of anti-HCV inblood donors did not seem to reduce the risk of GBV-C infection (8.8% v 8.0%, P > .l), although many were coinfected by HCV and GBV-C before the anti-HCV screening. We also found a 1.5% and 2% GBV-C prevalence rate of viremia in the pretransfusion samples of the recipients and volunteer blood donors, respectively. The prevalence of GBV-C carriage in the Taiwanese adult population should be close to this range. The risk of transfusion-associated transmission in Taiwan was estimated tobe approximately 0.46% per donor [34/(400 X 18.6) = 0.00461. However, because there could be a recipient receiving blood or its products from multiple GBV-C viremic donors, the actual risk could have been higher than this estimate. Because only donors from transfused plasmaand whole blood were collected and the PCR assay might be more sensitive than in vivo infectivity,” we did not calculate the risk of transmission from the prevalence rate of viremic donors. The inapparent clinical symptoms and signs in the acute GBV-C infected patients did not preclude the necessity for further screening for this virus, as serious sequelae could happen only in a small proportion of patients with chronic viral infections. For example, the risk of anemia happened in only some of those infected with parvovirus B19.l8 The risk of the development of a tropical spastic paraparesis/ HTLV-I-associated myelopathy and adult T-cell leukemia has been well documented in patients with HTLV-I infection, yet onlya small proportion of those with long-standing infection had these complications.’9-23 In summary, we have documented the transmission of GBV-CMGV through blood transfusion. Although we could not find definite associations of this viral infection with hepatitis, we have shown chronicity of transfusion-acquired acute GBV-CMGV infections. Some might develop significant sequelae after prolonged carriage of the virus. Therefore, a longer follow-up in more GBV-CMGV infected subjects is warranted. On the other hand, GBV-C/HGV infection in patients with different hepatic and nonhepatic diseases should also be studied to clarify other possible clinical implications of this infection. In the meantime, serologic assays for markers of GBV-CMGV infection should also be developed to ravel the true frequencies of GBV-CMGV infection, as well as for clinical diagnosis and, perhaps, also for donor screening in the future. REFERENCES 1. Japanese Red Cross Non-A, Non-B Hepatitis Research Group: Effect of screening for hepatitis C virus antibody and hepatitis B virus core antibody on incidence of posttransfusion hepatitis. Lancet 338:1040, 1991 2. Donahue JG, Munoz A, Ness PM, Brown DE Jr, Yawn DH, McAllister HA Jr, Reitz BA, Nelson KE: The declining risk of 1885 posttransfusion hepatitis C virus infection. N Engl J Med 327:369, 1992 3. Deinhardt F, Holmes AW, Capps, R B , Popper H: Studies on the transmission of disease of human viral hepatitis to marmoset monkeys. I. Transmission of disease, serial passages and description of liver lesions. J Exp Med 125:673, 1967 4. Simons JN, Pilot-Matias TJ, Leary TP, Dawson GJ, Desai SM, Schlauder GG, Muerhoff AS, Erker JC, Bujik SI, Chalmers ML, VanSant CL, Mushahwar IK: Identification of two flavivirus-like genomes in the GBhepatitis agent. Proc Natl AcadSci USA 92:3401, 1995 5. Schlauder GG, Dawson GJ, Simons JN, Pilot-Matias TJ, Gutierrez RA, Heynen CA, Knigge MF, Kurpiewski GS, Bujik SL, Leary TP, Muerhoff AS, Desai SM, Mushahwar IK: Molecular and serologic analysis in the transmission of the GB hepatitis agents. J MedVirol46231, 1995 6. Muerhoff AS, Leary TP, Simons JN, Pilot-Matias TJ, Dawson GI, Erker JC, Chalmers ML, Schlauder GG, Desai SM, Mushahwar IK: Genomic organization of GB viruses A and B: Two new members of the Flaviviridae associated with GB agent hepatitis. J Virol 69:5621, 1995 7. Simons JN, Leary TP, Dawson GJ, Pilot-Matias TJ, Muerhoff AS, Schlauder GG, Desai SM, Mushahwar IK: Isolation of novel virus-like sequences associated with human hepatitis. Nature Med 1:564, 1995 8. 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Wylie BR: Transfusion transmitted infection: viral and exotic disease. Anaesth Intensive Care 21:24, 1993 16. Yoshiba M, Okamoto H, Mishiro S: Detection of the GBVC hepatitis virus genome inserum from patients with fulminant hepatitis of unknown aetiology. Lancet 346:1131, 1995 17. Ulrich PP, Bhat RA, Seto B, Mack D, Sninsky J, Vyas GN: Enzymatic amplication of hepatitis B virus DNA inserum compared with infectivity testing in chimpanzees. J Infect Dis 160:37, 1989 18. Brown KE, Green SW, Antunez de Mayolo J, Bellanti JA, From www.bloodjournal.org by guest on August 3, 2017. For personal use only. 1886 S m i t h SD, Smith TJ, Young NS: Congenital anaemia after transplacental B19 parvovirus infection. Lancet 343:895, 1994 19. Tokudome S , Tokunaga 0, Shimamoto Y, Miyamoto Y, Sumida I, Kikuchi M, Takeshita M, Ikeda T, Fujiwara K, Yoshihara M: Incidence of adult T-cell leukernidlymphoma among human Tlymphotrophic virus type I carriers in Saga, Japan. Cancer Res 49:226, 1989 20. Hjelle B: Human T-cell leukemidlymphoma viruses. Life cycle, pathogenecity, epidemiology, and diagnosis. Arch Pathol Lab Med 115:440, 1991 21. Manns A, Blattner WA: The epidemiology of the human T- WANG ET AL cell lymphotropic virus type I and type 11: Etiologic role in human disease. Transfusion 31 :67, 1991 22.Gout 0, Baulac M,Gessain A, Semah F, Saal F,Peries J, Cabrol C, Foucault-Fretz C, LaplaneD,Sigaux F, deTheG:Rapid development of myelopathy afterHTLV-I infection acquiredby transfusion during cardiac transplantation. N Engl J Med 322:383, 1990 23. Kaplan JE, Litchfield B, Rouault C, Lairmore MD, Luo CC, Williams L, BrewBJ, Price RW, Janssen R, Stoneburner R, Ou CY, Folks T, De B: HTLV-I-associated myelopathy associated with blood transfusion in the United States: Epidemiologic and molecular evidence linking donor and recipient. Neurology 41:192, 1991 From www.bloodjournal.org by guest on August 3, 2017. For personal use only. 1996 88: 1881-1886 A prospective study of transfusion-transmitted GB virus C infection: similar frequency but different clinical presentation compared with hepatitis C virus JT Wang, FC Tsai, CZ Lee, PJ Chen, JC Sheu, TH Wang and DS Chen Updated information and services can be found at: http://www.bloodjournal.org/content/88/5/1881.full.html Articles on similar topics can be found in the following Blood collections Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036. 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