Chronic liver disease in the Alexandria governorate, Egypt: Contribution of schistosomiasis and hepatitis virus infections

Background/Aims: In Egypt chronic liver disease is customarily attributed to Schistosoma mansoni infection, Anti-HCV antibodies are highly prevalent among Egyptian blood donors, yet little is known about the risk factors, pathogenicity and virological features of HCV and its association with schistosomiasis, We studied 135 adult patients with chronic liver disease living in the Alexandria governorate, mostly in rural areas of the Nile Delta. Methods: Evaluation included abdominal ultrasonography; detection of anti-HCV antibodies and markers of HBV and HDV infection; HCV-RNA assay by 5' untranslated region nested polymerase-chain-reaction and HCV genotyping by a line probe assay; serologic (anti-soluble egg antigen, anti-SEA) and parasitological examinations for Schistosoma mansoni infection; and liver biopsy if not contraindicated. Results: Ninety-one (67%) patients had anti-HCV and 107 (85%) anti-SEA, 32 (30%) of whom excreted schistosomal eggs in stools, In addition, 21 (16%) patients had HBsAg, 86 (64%) anti-HBc and four (3%) anti-delta, Thus, many patients had evidence of multiple infections, double in 66% (anti-HCV and anti-SEA), triple in 33% (anti-HCV HBsAg and anti-SEA), Based on our diagnostic criteria, 25 (19%) patients had schistosomal portal fibrosis (anti-HCV positive in eight), 24 (18%) chronic hepatitis (anti-HCV positive in 19), 76 (56%) cirrhosis (anti-HCV positive in 58) and 10 hepatic tumors (anti-HCV positive in six), At multivariate analysis, the presence of anti-HCV was independently associated with previous parenteral anti-schistosomal therapy, a history of hematemesis and seropositivity for anti-HBc. Fifty (55%) of 91 anti-HCV positive sera had HCV-RNA, in 41 cases classified as genotype 4a. Detection of HCV-RNA was associated with a more severe liver disease and occurred less frequently in patients with a history of schistosomiasis. Conclusions: HCV infection with genotype 4a is the main cause of severe chronic liver disease in Egypt, where it is highly associated with schistosomiasis.