Download Vertical transmission of HCV: first case report in Lahore, Pakistan

Vertical transmission of HCV: first case report in Lahore, Pakistan
Breera Wahid (M.Phil)1*, Sajjad Ullah (PhD)1, Manzoor Hussain (M.Phil)1, Khansa Wahid
(M.Phil)1, Rukhsana Parveen (M.Phil)1, Muhammad Idrees(PhD)1, Nadeem Sheikh(PhD)1
Centre for Applied Molecular Biology, 87-West Canal Bank Road Thokar Niaz Baig, University
of the Punjab, Lahore, Pakistan
*Corresponding author
Division of Molecular Virology, Centre for Applied Molecular Biology, University of the
Punjab, Lahore-53700, Pakistan Tel: +92-42-5293141; Fax: +92-42-5293149; Email: MI:
[email protected]
Summary
Hepatitis C is an infection of liver and it is an important factor in the etiology of hepatocellular
carcinoma, cirrhosis, fibrosis, and liver damage. Currently, perinatal transmission of HCV during
pregnancy is a major global health concern. In the literature there is no evidence of vertical
transmission of HCV from Lahore, therefore, we report the first case of mother-to-child
transmission of HCV infection. A pregnant female with HCV infection gave birth to a baby who
was also HCV positive and the results led to the conclusion that vertical transmission is the
primary transmission route among newborns.
Keywords: HCV, perinatal transmission, pregnant, liver cirrhosis.
Introduction
The burden of HCV in pregnant women and neonates is not accurately documented. Literature
suggests that worldwide prevalence of HCV infection ranges between 3-10%. Vertical
transmission is the leading cause of pediatric HCV infection and associated liver diseases [1].
Meta-analysis of studies show that the incidence of HCV infection is higher in infants born to
mothers co-infected with HIV infection [2]. Several other factors such as amniocentesis, high
maternal HCV viral load, preterm labor, mode of delivery, and intravenous drug use increase the
risk of transmission of HCV from mother to child. HCV positive newborns should be referred to
a specialist and the infected child probably develop hepatitis C antibodies during the first 12 to
18 months of life whereas, FDA has approved the treatment of children above 3 year of age with
interferon and ribaivirin regimen. Presently, there is no HCV vaccine but the children infected
with HCV should be vaccinated against HAV and HBV [3]. Both intrapartum and intrauterine
transmission of HCV have been reported. Positive PCR during the first 3 days of life indicates
that in utero transmission that occurs in one third of children whereas, late intrauterine or
intrapartum transmission occurs in half of children. Accumulating evidence suggest the perinatal
and postnatal transmission with significant rise in HCV RNA several weeks after birth [4, 5].
Here, we report the mother-to-infant transmission of HCV because the cases of vertical
transmission of HCV are under-reported.
Case presentation
A 28-year old woman, resident of Lahore, Pakistan married with HCV positive male sought
Akhtar Hospital Lahore for clinical assessment at 28th week of gestation with history of fever,
fatigue, loss of appetite, jaundice, and gastrointestinal issues. Moderate elevation in aspartate
aminotransferase (AST) 51 U/L (reference range < 37 U/L), and albumin 38g/L (normal range:
35 to 45g/L) and alanine aminotransferase (ALAT) 97 U/L (reference range < 42 U/L) was
observed in liver function test. Complete Blood Count Test revealed normal white blood cell, red
blood cell and platelet counts. Serum level of bilirubin, urea nitrogen, creatine, glucose, and
electrolytes were all in normal range. Blood sample of patient was sent to Genome Center for
Molecular-based Diagnostics & Research, Lahore Pakistan for detection of HCV. Hepatitis C
virus–polymerase chain reaction (HCV–PCR) was positive with viral load of 3,76,380 IU/mL.
The patient was infected with HCV genotype 1b. Abdominal ultrasound indicated no changes in
the size and appearance of liver and other internal organs. The patient was treated with
complementary and alternative medicine because of anticipated birth defects associated with
anti-viral therapy. About 2 months later, low birthweight baby boy of 4.5 pounds was born by
vaginal delivery. Newborn was not breastfed and HCV genotype 1b was confirmed by PCR
analysis performed on day 4 of life.
Discussion
Vertical transmission is the leading cause of HCV infection in children. Every year about 40,000
children are born to HCV positive pregnant women of which 4,000 children are perinatally
infected with HCV. Approximately 1% to 11% of newborns born to HCV positive women
develop chronic infection [6, 7]. Benova L. et al demonstrated that 1 in every 20 children born to
HCV positive women acquire HCV infection. approximately 5.8% to 10.8% of newborns acquire
HCV infection because of maternal HIV coinfection [2, 8]. Risk of vertical transmission of HCV
infection is 1.97 and 2.82 times higher in HCV positive women co-infected with HIV [9]. HCV
infection of the peripheral blood monocytes increases the rate of vertical transmission [10]. An
increase in ALT (alanine transferase) enzyme during pregnancy and after pregnancy is associated
with an increased risk of vertical transmission [11]. Likewise, an increase in the level of HCV
RNA is also present in breastmilk but it usually gets inactivated in the digestive tract of infant
[12, 13]. Several studies suggested that C-section delivery decreased the rate of transmission but
according to recent evidences mode of delivery doesn’t affect maternal fetus transmission of
HCV infection [14, 15]. HCV viral load and HCV specific T cell responses vary during
pregnancy. Several studies show increase in HCV RNA second and third trimesters of
pregnancy. It is thought that maternal immune system activates in the postpartum period that
results in viral clearance [16, 17] and spontaneous clearance of HCV is noticed in about 25-30%
of children [18]. No clinical interventions to curb the vertical transmission have been
demonstrated.
Conclusion
Newborns easily acquire HCV during delivery because of exposure with infected maternal
blood. Women should receive blood screening for HCV prior to pregnancy. There are no primary
preventive measures and medical interventions currently available to mitigate the risk of HCV
infection among neonates. A more in-depth research is needed to understand the changes in
immune mechanism of mother against HCV and the use of DAA (direct anti-viral) drugs during
pregnancy because prenatal screening is not routine and there are no proven medical
countermeasures to prevent vertical transmission.
Acknowledgments
We wish to thank all employees of Genome Center for Molecular-based Diagnostics & Research,
Lahore Pakistan and Molecular Diagnostics Section, Centre for Applied Molecular Biology for
their excellent technical assistance.
Conflict of Interest
Authors declare no conflict of interest.
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