MULTIPLE VIRAL-INFECTION AS THE MOST COMMON-CAUSE OF FULMINANT AND SUBFULMINANT VIRAL-HEPATITIS IN AN AREA ENDEMIC FOR HEPATITIS-B - APPLICATION AND LIMITATIONS OF THE POLYMERASE CHAIN-REACTION

We tested serum samples from 25 fulminant hepatitis and 7 subfulminant hepatitis patients for hepatitis A, B, C, D and E viral markers and n ucleic acids by means of polymerase chain reaction to determine the ro le of each virus on such catastrophic events in an area endemic for he patitis B. Of these 32 patients, 14 (44%) were hepatitis B virus carri ers with hepatitis D virus superinfection (1 with hepatitis C virus in fection), 3 others had coexisting hepatitis B virus and hepatitis C vi rus infections, 6 had reactivation of underlying chronic hepatitis B, 4 had acute hepatitis B, 2 had acute hepatitis C and 1 had acute hepat itis E. Pathogenesis in the remaining two cases was unclear. Serum hep atitis B virus DNA was detectable in most carriers without superinfect ion and in one third of those with superinfection detected on polymera se chain reaction (6 of 7 vs. 6 of 16, p < 0.05). Of the polymerase ch ain reaction-positive samples, only 17% yielded positive results on sp ot hybridization. Hepatitis B virus DNA was the only marker to indicat e coexisting hepatitis B virus infection in one patient positive for h epatitis C virus antibody. Only three of the six hepatitis C virus-inf ected cases were positive for hepatitis C virus antibody; diagnoses in the remaining three were established by means of detection of hepatit is C virus RNA. Of the hepatitis D virus-infected patients, infection in only half was diagnosed by means of total hepatitis D virus antibod y assay. Twelve (86%) were positive for anti-hepatitis D virus IgM and nine (64%) had detectable hepatitis D virus RNA on reverse transcript ion-polymerase chain reaction. Only one third of reverse transcription -polymerase chain reaction positive cases had positive results on Nort hern-blot hybridization. Hepatitis D virus RNA was the only marker ind icating hepatitis D virus infection in two (14%) of the hepatitis D vi rus-infected patients. In conclusion, most fulminant and subfulminant viral hepatitis in Taiwan is caused by multiple viral infection (hepat itis B virus with hepatitis D virus or hepatitis C virus), which might be underestimated if only one kind of marker were used.