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* Department of Internal Medicine I, University of Ulm, Ulm, Germany;
Institute of Hepatology and
Division of Infection and Immunity, University College London, London, United Kingdom; and
Institut National de la Recherche et de la Médicale Unité 580, Institut Necker, Paris, France
| Abstract |
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| Introduction |
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350 million people worldwide and is a major cause of liver disease and hepatocellular carcinoma. Current antiviral treatments are disappointing, as only 30% of treated patients are able to maintain stable control of HBV replication (3). Because T cells play a major role in controlling HBV infection (4), different vaccine formulations have been used in chronically infected patients in an attempt to elicit HBV-specific T cell responses that can control HBV replication. However, therapeutic vaccinations have been so far disappointing. This may be due to the preferential use of vaccination procedures designed to elicit a prophylactic humoral response in healthy subjects (5). Furthermore, fundamental characteristics of the HBV-specific T cell response present during chronic HBV infection (6, 7, 8) may limit vaccination efficacy as HBV-specific CD4 and CD8 T cells are mostly deleted or functionally impaired in hepatitis B patients with high levels of viremia. An alternative strategy to elicit HBV-specific T cell responses in patients with chronic hepatitis may be the use of variant epitopes of HBV to induce "new" specific T cell responses that cross-react with epitopes derived from the infecting virus. Natural variability within HBV proteins exists, particularly among the different HBV isolates from the genotypes AG (with >8% divergence between them) (9, 10). These genotypes have diverse geographical distributions, and their variability seems to influence the clinical course of the disease (11, 12). Sequence differences between HBV genotypes may lead to differences in virus replication and translation but can also result in differences in the immunogenicity of the viral proteins, particularly for T cells. We previously reported (13, 14) that CD8 T cell responses to natural variants of a Kb-restricted epitope of the hepatitis B surface Ag (HBsAg) can specifically break tolerance in HBsAg-transgenic mice. In this study, we follow up on these studies by analyzing murine cross-reactive CD8 T cell responses to variants of Dd- and HLA-A*0201-restricted HBsAg epitopes and human CD8 T cell responses to variants of the HLA-A*0201-restricted S208216 epitope of HBsAg.
We focus on the HBV small envelope protein (HBsAg) in this study (15). MHC class I-binding determinants that specifically stimulate CD8 T cells from humans and mice have been identified in the small HBsAg protein. The natural sequence variability of HBV Ags is 510% (10, 16). This limited variability (1518 residue exchanges in a 226-aa protein) allows us to analyze differences in the immunogenicity and cross-reactivity between MHC class I-binding determinants with single residue exchanges. In this study, we used nontransgenic and HBsAg-transgenic mice to study the specific and cross-reactive CD8 T cell responses to natural variants of the Dd-binding S201209 epitope of the HBsAg. In addition, we identified cross-reactive CD8 T cells from HLA-A*0201-transgenic mice that recognize natural variants of the HLA-A*0201-binding S185194 and S208216 epitopes. Finally, we asked whether CD8 T cells preferentially stimulated by particular natural variants of the HLA-A*0201-binding S208216 epitope are found during natural HBV infection in patients.
| Materials and Methods |
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Ld H-2dm2 BALB/c (dm2) mice, HLA-A*0201-transgenic HHB (A2-tg) mice (17), H-2b C57BL/6JBom (B6) mice, (dm2 x B6)F1 mice, C57BL/6J-TgN(Alb1HBV)44Bri-transgenic (pAlb-HBs) mice (18), and (dm2 x pAlb-HBs)F1 mice were bred and kept under standard pathogen-free conditions in the animal colony of Ulm University (Ulm, Germany). Male and female mice were used at 1216 wk of age.
Cells
The H-2d mastocytoma cell line P815 was obtained from the American Type Culture Collection (TIB64). The generation of stable P815/S transfectants has been described elsewhere (19). The chicken hepatoma cell line LMH was obtained from Dr. H.-J. Schlicht (University of Ulm, Department of Virology, Ulm, Germany). The human lymphoblastoid cell line C1R and the stable Kd- and Dd-expressing transfectants derived from this line were a generous gift from Dr. P. van Endert (Institut National de la Sante et de la Recherche Medicale J580, Paris, France).
HBsAg vaccines
We selected for this study three sequences encoding the complete, small HBsAg protein of genotype A, C, and D listed in Table I. These sequences were cloned into the pCI expression vector (catalog no. E1731; Promega) to generate the expression plasmids pCI/S-A, pCI/S-C, and pCI/S-D. All three vectors expressed comparable amounts of HBsAg after transient transfection of these DNAs into LMH cells (13).
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Intramuscular nucleic acid immunization was achieved by injecting 50 µg (1 µg/µl) plasmid DNA into each tibialis muscle (i.e., 100 µg plasmid DNA/mouse) as described previously (20). Mice were usually vaccinated only once. Where indicated, mice were boosted twice at days 28 and 52 after priming.
Synthetic peptides
The synthetic, HBsAg variant-specific peptides used are listed in Table II and were obtained from JPT Peptide Technologies. Peptides were dissolved in DMSO at a concentration of 110 mg/ml and diluted with culture medium before use.
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Spleen cells (1 x 107 ml) were incubated for 1 h in RPMI 1640 medium either with the indicated amounts of the HBsAg peptides or with C1R/Dd cells prepulsed with the indicated amounts of the HBsAg peptides (106 ml). Thereafter, brefeldin A (catalog no. 15870; Sigma-Aldrich) was added to a final concentration of 5 µg/ml and the cultures were incubated for another 4 h. Cells were harvested, washed, and surface stained with PE-conjugated anti-CD8 mAb (catalog no. 01045B; BD Pharmingen). Surface-stained cells were fixed with 2% paraformaldehyde in PBS. Fixed cells were resuspended in permeabilization buffer (HBSS, 0.5% BSA, 0.5% saponin, and 0.05% sodium azide) and incubated with FITC-conjugated anti-IFN-
mAb (catalog no. 55441; BD Pharmingen) or FITC-conjugated anti-TNF mAb (catalog no. 554418; BD Pharmingen) for 30 min at room temperature and washed twice in permeabilization buffer. Stained cells were resuspended in PBS/0.3% w/v BSA supplemented with 0.1% w/v sodium azide. We determined the frequencies of CD8+IFN-
+ T cells by flow cytometry analyses. The mean number of CD8+IFN-
+ T cells or CD8+ TNF-
+ T cells per 105 CD8+ spleen cells of three to five individual mice (±SEM) is shown.
IFN-
detection by ELISA
IFN-
was measured in cell culture supernatants by double-sandwich ELISA (catalog no. 550582; BD Pharmingen).
Chromium release assays
Single-cell suspensions were prepared from spleens of mice in Clicks RPMI 1640 tissue culture medium supplemented with 10 mM HEPES buffer, 5 x 105 M 2-ME, antibiotics, and 10% v/v FCS (PAA Laboratories). A selected batch of Con A-stimulated rat spleen cell supernatant (2% v/v) was added to the culture medium. Three x 107 responder cells were cocultured with 1 x 106 irradiated P815 cells prepulsed for 4 h with 100 µg/ml of the relevant MHC class I-binding peptide. The coculture was performed in 10 ml of medium in upright 25-cm2 tissue culture flasks in a humidified atmosphere/5% CO2 at 37°C. After 5 days of culture, CTL were harvested, washed, and assayed for specific cytolytic reactivity. Serial dilutions of effector cells were cultured with 2 x 103 51Cr-labeled targets in 200-µl round-bottom wells. Specific cytolytic activity of cells was tested in short-term 51Cr release assays against HBsAg-expressing or nonexpressing P815 transfectants. After a 4-h incubation at 37°C, 50 µl of supernatant was collected for gamma radiation counting. The percentage of specific release was calculated as ((experimental release spontaneous release)/(total release spontaneous release)) x 100. Total counts were measured by resuspending target cells. Spontaneously released counts were always <15% of the total counts. Data shown are the mean of triplicate cultures. The SEM of triplicate data was always <20% of the mean.
Patients
Eighteen HLA-A2-positive adult subjects who resolved acute hepatitis B infection were studied. All subjects were anti-HBc and anti-HBs Ab positive and negative for Abs to hepatitis C virus,
-virus, or HIV-1,-2.
In vitro expansion of human HBV-specific CD8 cells
PBMC were placed in 96-well plates at 2 x 106 ml and stimulated with HBV peptides at 1 µM final concentration. rIL-2 was added on day 4 of culture (20 U/ml). Cell lines were tested on day 10 by immunological assays (IFN-
production and CD107 expression) to detect peptide-specific CD8 T cells or further expanded for selection of S208216-specific CTL clones. Briefly, the IFN-
capture assay (Miltenyi Biotec) was used to select peptide-specific CD8 T cells. Selected cells were seeded at different concentrations (1, 5, and 10 cell/well) in 96-well plates with 105 irradiated (3000 rad) allogeneic PBMC and PHA (0.5 µg/ml)/well. Cells were restimulated every 2 wk with allogeneic-irradiated PBMC, and growing cell lines were expanded with A-AIM medium (Invitrogen Life Technologies) supplemented with IL-2 (20 U/ml), IL-7 (10 ng/ml), and IL-15 (10 ng/ml). Lines were tested for peptide specificity, and cell lines showing >90% of peptide-specific CD8 cells were maintained and further expanded.
CD107 assay
PBMC-derived lines were stimulated with indicated concentrations of peptides in the presence of FITC-labeled anti-CD107 Abs (BD Pharmingen) (21). After 4 h of stimulation at 37°C in a CO2 incubator, cells were washed once with PBS/0.3% w/v BSA supplemented with 0.1% w/v sodium azide, resuspended in supplemented PBS and PE-labeled anti-CD8 Ab added to the wells. After 20 min of incubation at 4°C, cells were washed twice. The frequency of CD8+CD107+ T cells was analyzed by flow cytometry analyses.
| Results |
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We cloned the complete sequences of three natural variants of the small HBsAg of the HBV genotype A, C, and D (Table I) into the expression plasmid pCI to construct the DNA vaccines pCI/S-A, pCI/S-C, and pCI/S-D. Ld-deficient dm2 mice were immunized with the pCI/S-A, pCI/S-C, or pCI/S-D DNA vaccines. dm2 mice were used to eliminate suppression of CD8 T cell responses to the Dd-restricted S201209 epitope by CD8 T cells specific for the dominant, Ld-restricted S2839 epitope (22, 23, 24).
Variant S201209 peptides C and D have consensus anchor residues at P2, P3, and P9 but differ at P7 where an asparagine (N) is exchanged for a serine (S) (Table II). Vaccination of dm2 mice with pCI/S-C- or pCI/S-D-primed CD8 T cells that preferentially recognized the priming epitope, but also cross-reacted with the D or C variant, respectively (Fig. 1). Variant A of the S201209 epitope has a valine (V) at the anchor P9 residue where variant D has the consensus leucine (L) residue (25, 26) (Table II). dm2 mice vaccinated with pCI/S-A did not develop CD8 T cells specific for the priming epitope (Fig. 2A). Variant A-specific CD8 T cells could not be detected after repeated immunizations of dm2 mice with the pCI/S-A DNA vaccine, nor after repeated in vitro restimulation of CD8 T cells from immunized mice with one to three antigenic S201209 peptides (data not shown). Stimulating spleen cells from pCI/S-D-primed mice with titrated amounts of each variant of the antigenic S201209 peptide revealed that the variant D peptide restimulated CD8 T cells more efficiently than variant A peptide (Fig. 2B). This was confirmed by restimulating pCI/S-D-primed, S201209-specific short-term CD8 T cell lines with P815 cells pulsed with titrated doses of the Dd-binding S201209 peptide variants and measuring IFN-
release (Fig. 2B). Dd-restricted S201209-specific CD8 T cells are thus primed by variant D but not variant A, and CD8 T cells primed by variant D showed relatively low cross-reactive recognition of the variant A epitope. To determine whether the inability to prime variant A-specific CD8 T cells could be due to an Ag-processing and/or presentation defect, P815 transfectants were generated that express comparable levels of the A or D variant of HBsAg (Fig. 3A). In specific cytolytic or cytokine release assays, pCI/S-D-primed CD8 T cells responded to transfectants expressing variant D but not transfectants expressing variant A. These results strongly suggest that the loss of the consensus P9 anchor residue reduces processing/presentation efficacy of the A variant peptide.
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Priming of cross-reactive CD8 T cells to the C (WGPSLYNIL) or D (WGPSLYSIL) variant of the Dd-restricted HBsAg determinant in pCI/S-C- or pCI/S-D-vaccinated dm2 mice was observed when their immune spleen cells were restimulated for 4 h ex vivo with high doses of the respective antigenic peptide (Fig. 1A). Titration of the restimulating antigenic peptide revealed that pCI/S-D-primed CD8 T cells were stimulated more efficiently by the variant D S201209 peptide WGPSLYSIL but showed cross-reactivity to the variant C WGPSLYNIL peptide (Fig. 1B). This pattern was observed with IFN-
+CD8+ or TNF-
+CD8+ T cells (Fig. 1B). Similarly, pCI/S-C-primed CD8 T cells were stimulated efficiently by variant C peptide but cross-reacted to variant D peptide (Fig. 1B). Thus, pCI/S-C and pCI/S-D vaccines prime CD8 T cell responses to the S201209 epitope of HBsAg; the primed CD8 T cell populations show a preferential specific reactivity to the immunizing variant but also cross-reactivity to the alternative variant.
CD8 T cells primed to the variant C (WGPSLYNIL) epitope recognized the variant D epitope naturally processed by transfected P815/S-D cells (Fig. 3B). Thus, a natural epitope variant of HBsAg with a single residue exchange (WGPSLYNIL vs WGPSLYSIL) primes cross-reactive CD8 T cell immunity to a naturally processed variant of the epitope. As expected, transfectants expressing variant A did not present this epitope to immune CD8 T cells (Fig. 3B).
Recognition of the tested variant S201209 peptides is Dd restricted
To confirm that all variant S201209 peptides tested were presented in the context of the Dd class I molecule, C1R transfectants were pulsed with peptides and used to restimulate immune spleen cells primed by pCI/S-C. The variant S201209 peptides were presented by peptide-pulsed Dd- but not Kd-expressing C1R cells (Fig. 4). Similar data were obtained when immune spleen cells primed by pCI/S-D were restimulated ex vivo by peptide-pulsed C1R transfectants (data not shown). A change in the presenting restriction element thus does not underlie variant-specific recognition of the S201209 epitope.
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pAlb-HBs mice express the HBsAg D variant from a transgene in the liver (18, 24, 27). Due to the transgenic nature of the HBsAg, pAlb-HBs mice are immunologically tolerant to the D variant S201209 epitope. We examined whether CD8 T cells specific for variant C can be primed in these transgenic mice and, if so, whether the primed CD8 T cells are able to cross-react with the variant D epitope of HBsAg constitutively produced by these animals. Transgenic F1 mice were generated by crossing pAlb-HBs B6 mice with dm2 mice and selecting for HBsAg+ progeny. Transgenic (HBsAg+) and nontransgenic (HBsAg) F1 mice were repeatedly vaccinated with the pCI/S-C or pCI/S-D DNA vaccines encoding the C or D variants of HBsAg. As expected, the pCI/S-D vaccine primed a CD8 T cell response to the variant D S201209 epitope in nontransgenic but not transgenic F1 mice (Fig. 5, group 2) (28). In contrast, vaccination of transgenic F1 mice with the pCI/S-C vaccine induced a CD8 T cell response to variant C of the S201209 epitope (Fig. 5B, group 4). Although these CD8 T cells preferentially recognized the variant C epitope, they showed cross-reactivity to the variant D epitope (Fig. 5B, group 4). This response was lower than that elicited by the pCI/S-C vaccine in nontransgenic F1 mice (Fig. 5A, group 4). Thus, a natural epitope variant of HBsAg with a single residue exchange (WGPSLYNIL vs WGPSLYSIL) can prime cross-reactive CD8 T cell immunity in a mouse tolerant to one variant of the epitope.
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We primed CD8 T cell responses to HBsAg variants in HLA A*0201-transgenic (A2-tg) mice to test whether residue exchanges within A2-restricted epitopes of natural HBsAg variants change its immunogenicity and/or cross-reactivity. We selected for this study the A and D variants of the HLA A2-restricted S185194 (29) and S208216 (30) epitopes because they contain residue exchanges within the antigenic determinant.
Similar to the A variant Dd-restricted epitope, the A variant S185194 epitope has a modified C-terminal anchor residue (exchange of a valine V in variant D/C into an alanine A in variant A) (Table II). A2-tg mice were vaccinated with the pCI/S-A or the pCI/S-D vaccine. The pCI/S-D vaccine primed CD8 T cells to the S185194 epitope that were restimulated ex vivo efficiently by the variant D GLSPTVWLSV peptide but inefficiently by variant A GLSPTVWLSA peptide (Fig. 6). No S185194-specific CD8 T cell response was primed by the pCI/S-A vaccine (Fig. 6). Thus, similar to priming the Dd-restricted S201209-specific response to HBsAg in dm2 mice, a residue exchange in an anchor position strikingly reduced the immunogenicity of this HLA A2-restricted epitope in vivo and its antigenicity in vitro (cf Figs. 2 and 6).
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Having demonstrated that natural variants of the HLA-A2-restricted S208216 epitope can induce cross-reactive CD8 T cells in A2-transgenic mice, we investigated whether similar cross-reactive CD8 T cells are induced in natural HBV infection. We initially tested whether the two S208216 variant peptides (variant D/C ILSPFLPLL and variant AIVSPFIPLL) can expand S208216-specific CD8 T cells from HBV-infected patients. The incidence of the S208216-specific CD8 response in A2+ patients who resolved HBV infection was low (2 of 18 subjects tested positive). However, in both S208216-responsive subjects, restimulation with the variant A and the variant D S208216 peptide specifically activated CD8 T cells (Fig. 8A), indicating that S208216 (cross-)-reactive CD8 cells can be induced by natural HBV infection. Interestingly, the S208216-A variant elicited stronger CD8 T cell expansion than the S208216-D variant peptide in both patients. Because the S208216-A variant peptide is derived from the HBV genotype A, the more common genotype present in our geographical area (North Europe) (9, 10), it is likely that the immunogenic difference of the two variant peptides reflects the initial infection with genotype A.
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. Fig. 8B shows that variant D of S208216 was able to activate S208216 variant A-specific CD107+ CD8 T cells (left panel) or IFN-
+ CD8 T cells (right panel), directly demonstrating cross-reactivity of CD8 T cells induced by a natural HBV infection. | Discussion |
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Generation of variant epitopes of Ags during a virus infection is widespread although the extent of this variability differs greatly among viruses. An immune response against a variant epitope may be generated either by eliciting a polyclonal primary response comprising (possibly infrequent and subdominant) cross-reactive specificities recognizing the variant determinant, or by de novo priming of a variant-specific response when the variant arises. An example for the former has been published in the influenza system (31). The polyclonal CD8 T cell population specific for an influenza A nucleoprotein epitope contains infrequent cross-reactive T cells that expand from the original memory population upon challenge with a variant virus to produce T cells productively recognizing both the parental and the mutant epitope. Polyclonal memory T cell populations can thus provide protection against a range of antigenic variants. This may not hold true for chronic virus infection where the relevant cross-reactive T cells are eliminated. Under these conditions, the alternative approach of eliciting a new and strong, variant-specific response with cross-reactivity toward the infecting variant may be more promising. As demonstrated in the present study, this approach can even break tolerance, supporting a potential therapeutic value of this strategy.
MHC molecules show a broad specificity for peptide binding. Consensus anchor residues that mediate peptide binding to MHC molecules are required to make peptides antigenic. This is confirmed in the present study for Dd- and HLA A2-binding HBsAg peptide; eliminating one of their consensus anchors eliminates their antigenicity. The fine specificity of Ag recognition resides in TCR contact residues that project from the peptide-binding cleft of the MHC molecules. Restricted TCR recognition of MHC molecule plus peptide displays exquisite specificity but also degeneracy. This has become apparent especially by studies on T cell clones that can show unexpected degeneracy as well as fine specificity. For example, the C2 TCR clone recognizes at least 12 antigenic peptides in the context of three restricting MHC proteins (Kb, Ld, and H-2r), but also displays exquisite specificity by discriminating between very similar epitopes (32). As described by the "altered peptide ligand" concept, stimulation of T cells by their cognate peptide into which single, conservative residue exchanges have been introduced often results in only partial activation, changes in phenotype and/or anergy triggered by qualitatively different signal transduction events (33). Variant peptides can, therefore, trigger responses in cross-reactive T cells that are not necessarily protective. It seems furthermore important to consider how many different T cell clones are specifically activated in a T cell response to an epitope. This would give information on the repertoire of clonotypes from which cross-reactive T cells to particular variants of an epitope can be recruited. Published data (34) (involving single-cell PCR analyses of the TCR of specific cells) suggest that only few clones are present at the peak of the primary response to an individual epitope, and these clones also predominate in the subsequent memory response. But this may vary substantially between individual Ags. In vivo, rather few clones with a specificity of unknown degeneracy are thus expected to be primed by an epitope, some of which have the chance to become eliminated because they only partially activate a T cell.
The emergence of residue exchanges within an epitope would be expected to have many alternative outcomes: 1) primed T cell clones cross-react to the new variant epitope and are fully activated; 2) primed clones cross-react to the variant epitope but are only partially activated or eliminated; 3) previously, only partially activated clones become fully activated; 4) the variant is not immunogenic; or 5) new T cell clones are primed. Many reports demonstrated that single residue exchanges within an antigenic peptide can make it more immunogenic (and therapeutically more efficient), as shown for the HLA-A2-restricted p53264272 epitope of a tumor-associated Ag (35). We published similar findings using a natural variant of a Kb-restricted HBsAg epitope: a variant with a higher affinity for Kb could overcome specific tolerance established by a variant of the peptide with lower affinity for Kb (13, 14). The study described in this article shows that variant-induced T cell populations are restimulated more efficiently by the variant that primed them than by alternative, natural variants. Importantly, the new clonotypes establish cross-reactive CD8 T cell immunity to alternative variants even in a mouse tolerant to these alternative variants. It is the specific but degenerate recognition of T cells primed to variants of the same epitope that makes this approach an interesting candidate for therapeutic vaccination.
Can variation of viral Ags through limited single residue exchanges produce changes in the immunogenicity of the Ag by other means? We reported in the HBsAg system three possible, additional ways by which variation of the Ag can enhance the immunogenicity of the surface Ag and override the tolerance that prevails in chronic infection. The first (described above) is the generation of variants with higher affinity for their restricting element. The second involves attenuation of immunodominant (suppressive) epitopes (22, 23, 24) that may reveal a large panel of subdominant (or cryptic) epitopes. The third involves residue exchanges in epitope-flanking sequences that are permissive or inhibit processing of the antigenic peptide (13, 14). Thus, different options are available to rationally design variant Ag constructs for the specific therapy of chronic virus infection.
Single, conservative residue exchanges presumably within TCR contact regions of the epitope can thus prime distinct but cross-reactive CD8 T cell immunity to HBV in mice, and these cross-reactive T cells can escape tolerance induction in transgenic mice. It will be critical to demonstrate in transgenic mice that cross-reactive, variant-specific CD8 T cells exert liver-specific, antiviral effector functions. If so, the data would support the notion that HBsAg variants are attractive candidates for therapeutic immunization. It was equally important to show in this study that HBV envelope-specific CD8 T cells able to recognize peptides with conservative variants are primed during natural infection. This demonstrates that CTL cross-reactivity between envelope epitopes is not restricted to mice but is naturally present in patients who recovered from HBV infection. Whether cross-reactive, HBV-specific CD8 T cells play a role in the final control of infection is not known, but this can be potentially tested in the spontaneous remission of chronic HBV infection in patients. HBV variants have been shown to be present during acute flare-ups of HBV chronic infection, leading to hepatitis B Ag seroconversion (36). The possibility exists that HBV genetic variability, which potentially increases at the time of hepatitis B e Ag seroconversion, produces new immunogenic epitopes able to break HBV-specific tolerance in chronic hepatitis B patients. Such evidence would support our assumption on the usefulness of variant epitopes in the specific immunotherapy of the chronic infection.
| Acknowledgments |
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| Disclosures |
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| Footnotes |
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1 This work was supported by a grant from the European Commission (CTLALTVAX; QLRT-2001-00700) to A.B., J.R., and R.S. ![]()
2 Address correspondence to Dr. Reinhold Schirmbeck, Department of Internal Medicine I, University of Ulm, Albert Einstein Allee 11, Ulm, Germany. E-mail address: reinhold.schirmbeck{at}uni-ulm.de ![]()
3 Abbreviations used in this paper: HBV, hepatitis B virus; HBsAg, small hepatitis B surface Ag. ![]()
Received for publication October 6, 2005. Accepted for publication January 3, 2006.
| References |
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-2a, lamivudine, and the combination for HBeAg-positive chronic hepatitis B. N. Engl. J. Med. 352: 2682-2695.
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