Journal of Hepatology 46 (2007) 160170

www.elsevier.com/locate/jhep

Review

Occult hepatitis B virus infection

Giovanni Raimondo*, Teresa Pollicino, Irene Cacciola, Giovanni Squadrito
Unit of Clinical and Molecular Hepatology, Department of Internal Medicine, University of Messina, 98124 Messina, Italy

The persistence of hepatitis B virus (HBV) genomes in HBV surface antigen (HBsAg) negative individuals is termed
occult HBV infection. Occult HBV status is associated in some cases with mutant viruses undetectable by HBsAg assays,
but more frequently it is due to a strong suppression of viral replication and gene expression. Occult HBV infection is an
entity with world-wide diusion, although the available data of prevalence in various categories of individuals are often
contrasting because of the dierent sensitivity and specicity of the methods used for its detection in many studies. Occult
HBV may impact in several dierent clinical contexts, including the transmission of the infection by blood transfusion or
organ transplantation and its acute reactivation when an immunosuppressive status occurs. Moreover, much evidence sug-
gests that it can favour the progression of liver brosis and above all the development of hepatocellular carcinoma.
2006 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

1. Introduction graphically summarized in Fig. 1. In particular, a funda-

Occult hepatitis B virus infection (HBV) can be
dened as the long-lasting persistence of viral genomes
in the liver tissue (and in some cases also in the serum)
of individuals negative for the HBV surface antigen
(HBsAg). Suspected to exist since the early 80s, this
peculiar form of chronic viral infection has been better
identied during the past ten years, when the availability
of highly sensitive molecular biology techniques made it
possible to disclose several of its virological aspects, to
show its worldwide diusion and to reveal its possible
implication in various clinical contexts.
The aim of this review is to re-examine the available
data about occult HBV infection, pointing out the
aspects that most need to be claried.
2. Virological aspects
The molecular basis of the occult infection is strictly
related to the peculiar life cycle of the HBV, which is
Available online 7 November 2006
*
Corresponding author.
E-mail address: giovanni.raimondo@unime.it (G. Raimondo).
mental step is the conversion of the 3 Kb relaxed circu-
lar genome into a covalently closed-circular DNA
(cccDNA), a long lived HBV replicative intermediate that
persists in the cell nuclei as a stable chromatinized epi-
some and that serves as template for gene transcription
[1,2]. The stability and long-term persistence of viral
cccDNA molecules [3,4] together with the long half-life
of hepatocytes imply that HBV infection, once it has
occurred, may possibly continue for life [5].
Why the occult HBV carriers are HBsAg negative
despite the presence in their liver of episomal, free
HBV genomes remains an unresolved question. Some
of these individuals are infected by viral variants either
producing an antigenically modied HBV S protein
undetectable by the available HBsAg assays [611] (even
when the most sensitive ones are used [1214]), or carry-
ing mutations capable of inhibiting the S gene expres-
sion and/or the viral replication [1517]. However,
much evidence indicates that the genomic heterogeneity
of the virus does not account for the occult status in the
majority of the cases [1820]. This consideration clearly
emerges from the studies that extensively examined
HBV isolates from liver tissue of occult HBV carriers
[21,22]. Thus, the occult infection appears to be mostly
due to a strong suppression of viral replication and gene

0168-8278/$32.00 2006 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.jhep.2006.10.007
 G. Raimondo et al. / Journal of Hepatology 46 (2007) 160170 161

HBV
Entry of HBV
into cell and
Tra nsport to c ell
uncoating
m em b ra n e
Golgi
c o mp l ex

Core particle plus Spheres and Filaments

strand synthesis containing HBsAg

recycling Small HBs

M e d i u m H B s Envelope
Core particle minus Large HBs
strand synthesis ER
r e p ai r

Core a s s e mbly and

R N A p a c k ag ing
cc c D N A P r e- ge no m ic RN A
Core
Pol
mRNA
transport pr eCo re S e c r e t ed H B e A g
Subgenomic and
min Genomic RNA HBX
ichro
mo
som
e translation
Ribosome
mRNA
tra n sc ri p ti o n nucleus cytoplasm

Fig. 1. Schematic representation of HBV life cycle.

expression aecting viruses whose genetic variability is
comparable to that of HBV strains from individuals
with overt chronic HBV infection [23]. Relevant
though indirect conrmation on this assumption is pro-
vided by the observations that occult HBV may be
transmitted (experimentally to chimpanzees and by
blood transfusion or organ transplantation to humans)
inducing classic acute hepatitis B in the recipients [24
29] and that occult HBV carriers may show an acute
reactivation of the infection with the reappearance of
the typical hepatitis B serological prole [3034]. The
mechanisms responsible for the inhibition of HBV activ-
ities remain at present largely obscure, and all the
hypotheses proposed are essentially based on indirect
evidence. Schematically, the available data suggest that
(a) the hosts immune response, (b) co-infection with
other infectious agents, and (c) epigenetic factors may
play important roles in inducing the occult status, as
briey discussed below.
(a) The hosts immune-surveillance probably has a
critical role in the development of the occult HBV
infection, as suggested by at least two main arguments:
rst, there is evidence showing that a vigorous memory
T-cell response against HBV antigens is still present
many years after clinical recovery from acute B hepati-
tis, probably because the long-lasting persistence of the
occult infection produces a minute (and undetectable)
amount of antigens able to maintain an ecient anti-
viral T-cell response [35,36]; second, all the conditions
inducing immunosuppression may provoke the reacti-
vation of the occult HBV infection with the reappear-
ance of the typical serological prole of the
productive infection [3034]. These occurrences strong-
ly support the hypothesis that during occult infection a
kind of balancing between the virus and the hosts
immune system is established, and, besides the cytotox-
ic T lymphocytes, the cytokines synthesized in the liver
might also exert a control on HBV replication. In fact,
there is evidence indicating that cytokines like tumor
necrosis factor a and interferon c may strongly inhibit
the HBV gene expression at post-transcriptional level
[37,38].
(b) The virus interference has been taken into account
as an additional factor that might negatively inuence
HBV replication and gene expression. Co-infection with
other agents may be of relevance in inducing HBV inhibi-
tion. Of note, the highest prevalence of occult HBV has
been found in patients with hepatitis C virus (HCV) infec-
tion, and in vitro studies have clearly demonstrated that
the HCV core protein strongly inhibits HBV replica-
tion [3941]. Moreover, it cannot be excluded that also
non-viral infectious agents might potentially induce a
suppression of HBV activities. In this context, it has
recently been shown that schistosoma mansoni infection
162 G. Raimondo et al. / Journal of Hepatology 46 (2007) 160170
is capable of strongly inhibiting HBV replication in a
transgenic mice model [42].
(c) Recent evidence demonstrates that epigenetic
mechanisms have an important role in the regulation
of HBV replication and transcription. In fact, nuclear
HBV cccDNA molecules organized as viral minichro-
mosomes, as mentioned above seem to be subjected to
the same enzymatic activities involved in chromatin
remodelling [43]. According to this scenario, one might
theoretically suppose that suppression of viral replica-
tion is achieved by active mechanisms of repression of
the viral transcription mediated by deacetylases and
methylases that, cooperating with other enzymatic activ-
ities and signalling pathways, establish posttranslational
modications of cccDNA-bound histones. Since several
liver-enriched and ubiquitous host factors are involved
in the regulation of HBV transcriptional program, we
might hypothesize that HBV suppression is the result
of functional (and potentially reversible) modications
of the intracellular environment that can be due to co-
infection by other pathogens or chemical agents or cyto-
kines. In this context, it has been reported that DNA
damaging agents are able to suppress HBV replication
through transcriptional repression of the virus mediated
by the tumor suppressor protein p53 [44].
The strong suppression of HBV activity is responsible
not only for the HBsAg negativity but also for the very
low or even undetectable levels of serum HBV DNA
characterizing most of the cases with occult infection
[19,4547]. In fact, the studies evaluating the presence
of occult HBV both in liver and in serum samples have
shown that a relevant percentage of subjects who are
negative for HBV DNA in the serum prove to be posi-
tive at liver tissue level [21,4850]. However, the fact
that occult HBV carriers have very low viremia levels
does not necessarily imply that the amount of viral gen-
omes present in the liver is also very low. In fact, the
quantication of intra-hepatic viral DNA in dierent
sets of chronic HBV infected individuals demonstrated
that the amount of HBV DNA in the liver of occult
HBV infected patients is often comparable to that
detected in HBsAg positive individuals [51].
Another relevant aspect to be discussed is that,
although occult HBV infection is signicantly associat-
ed with the presence of anti-HBV antibodies (namely,
anti-HBc and anti-HBs antibodies directed against
the viral core antigen and the HBsAg, respectively), it
must be stressed that more than 20% of the occult car-
riers are negative for all serum markers of HBV infec-
tion, as evaluated by a recent review [46]. At present, it
is unknown whether the complete HBV seronegativity
is dependent on a progressive disappearance of all viral
markers developing in the years after the resolution of
an acute infection, whether it occurs from the begin-
ning of the infection or whether both these two condi-
tions may occur in the various cases. What is clear is
that the comprehension of the biological reasons
underlying the existence of the two categories of sub-
jects with cryptic infection (individuals positive for
anti-HBV antibodies and individuals negative for all
serum HBV markers) as well as the identication of
hypothetical clinical dierences between them consti-
tute, at present, a major challenge in the occult HBV
eld of research.
2.1. Detection of occult HBV infection
Considering what is reported above, there is no doubt
that the analysis of liver DNA extracts is the most cor-
rect methodological approach for occult HBV detection.
However, it must be considered that the availability of
liver tissue specimens depends on the execution of a nee-
dle liver biopsy that, as is obvious, cannot be performed
in the great majority of the subjects. In fact, most of the
available data on occult HBV infection come from stud-
ies performed by analysing blood samples. Moreover,
the technical procedures used so far have diered greatly
from one study to another in terms both of specicity
and sensitivity and, as a consequence, the results
obtained have frequently been contradictory. Commer-
cial, standardized and valid assays for studying the cryp-
tic infection are not yet available. Therefore, at present,
the gold standard to test for occult HBV is still the
home made analysis of DNA extracts from liver as
well as from blood samples performed by a nest-
ed-PCR technique and the use of oligonucletide prim-
ers specic for at least three dierent HBV genomic
regions. With this approach, only the cases in which
HBV DNA is detected using at least two dierent sets
of primers may be considered positive for the cryptic
infection [19,21,22,46,52].
2.2. Animal models
The occurrence of an occult infection has also been
demonstrated both in ground squirrels and in wood-
chucks infected, respectively, by the ground squirrel hep-
atitis virus (GSHV) and the woodchuck hepatitis virus
(WHV), two viruses of the Hepadnaviridae family closely
related to HBV [53,54]. In particular, interesting ndings
have recently been obtained with the woodchuck model.
In fact, it has been shown that the lifelong silent persis-
tence of WHV is an invariable consequence of resolved
acute viral hepatitis [55], and that this virus is transmitta-
ble from mothers to newborns where it induces an asymp-
tomatic long-term infection [56] Moreover, this model
revealed that the virus, when inoculated at doses contain-
ing less than 103 virions, may establish an infection that
initially engages the lymphatic system and only later
on may involve the liver too and persists in the absence
of all the virus serological markers [57]. This primary
occult infection does not protect against re-infection with
 G. Raimondo et al. / Journal of Hepatology 46 (2007) 160170 163

Table 1
Reported prevalence of occult HBV infection in haemodialysis patients
Study Country No. of patients Occult HBV No. (%) Methods
a
Siagris et al. (2006) [67] Greece 49 10 (20.4) Single step PCR
Kanbay et al. (2006) [68] Turkey 138 21 (15.2) Real time PCR
Goral et al. (2006) [69] Turkey 50a 0 Single step PCR
Fabrizi et al. (2005) [70] Italy 213 0 Single step PCR
Minuk et al. (2004) [71] Canada 239 9 (3.8) Real time PCR
Besisik et al. (2003) [72] Turkey 33a 12 (36.4) Double step (nested) PCR
a
All patients were anti-HCV positive.

a large WHV dose in contrast to the secondary (residu-
al) silent WHV persistence, which normally endures after
the resolution of viral hepatitis and is positive for antibod-
ies to the virus antigens [57].
2.3. Prevalence
Occult HBV infection is a world-wide diused entity,
although its distribution may reect the general
prevalence of the HBV in the various geographic areas
and in the various populations.
There is a fairly general agreement in considering
HCV infected patients as the category of individuals
with the highest prevalence of occult HBV [18,19,45
47]. In particular, HBV DNA is detectable in about
one-third of HBsAg negative HCV carriers in the Med-
iterranean basin, and this prevalence is even higher in
Far East Asian countries [21,22,5861]. Patients with
HCV-negative chronic liver disease have been less inves-
tigated than HCV infected ones, and variable prevalence
has been reported in subjects with cryptogenic liver dis-
ease [15,18,21,6264].
Besides the patients with liver disease, the categories
of individuals at high risk of parenteral-transmitted
infections have also been widely investigated for occult
HBV. In general, a high prevalence has been reported,
with 45% in intravenous drug addicts in Baltimore [65]
and 51% in hemophiliacs in Japan [66]. On the contrary,
the studies performed up to now on hemodialysis
patients provide widely divergent results, reporting a
prevalence of occult HBV that ranges from 0% to 36%
in the most recent reports [6772]. As mentioned above,
however, these discrepancies appear to be mainly depen-
dent on the dierent sensitivity and specicity of the
assays utilized in the various studies (Table 1). In this con-
text, it is of note that several authors consider occult HBV
as a possible source of virus spread in hemodialysis units
(thus representing a risk of infection for both patients and
sta), and suggest some precautions including HBV DNA
screening for all hemodialysis patients [71].
A category of patients where the available data of
occult HBV prevalence are wildly divergent is that of
HIV positive individuals. In fact, the published preva-
lence ranges from 0% to 89% [73,74], with a considerable
number of other studies reporting results between those
two extremes [7583] (Table 2). The great dierence in
sensitivity and specicity of the assays used in these var-
ious studies has already been denounced in a previous
review [84]. For this purpose, it is of note that the study
nding the highest prevalence of occult HBV both used
a very sensitive HBV DNA amplication procedure and
examined serial serum samples from each individual
[74]. Indeed, since serum HBV DNA levels seem to uc-
tuate even in cryptic HBV carriers, it is becoming clear

Table 2
Reported prevalence of occult HBV infection in HIV positive patients
Study Country No. of patients Occult HBV No. (%) Methods
Hofer et al. (1998) [74] Switzerland 57 51 (89) Double step (nested) PCRb
Torres-Baranda et al. (2006) [75] Mexico 35 7 (20) Double step (nested) PCR
Filippini et al. (2006) [76] Italy 86 17 (20) Single step PCRb,c
Mphahlele et al. (2006) [77] South Africa 140 31 (22) Double step (nested) PCR
Pogany et al. (2005) [78] Netherlands 93a 4 (4) Single step PCRd
Neau et al. (2005) [79] France 160a 1 (0.6) Single step PCRd,e
Santos et al. (2003) [80] Brazil 101a 16 (16) Single step PCRc
Wagner et al. (2004) [81] France 30a 11 (37) Double step (nested) PCR
Goncales et al. (2003) [82] Brazil 159 8 (5) Double step (nested) PCR
Nunez et al. (2002) [73] Spain 85 0 Single step PCRd
Piroth et al. (2000) [83] France 37 13 (35) Single step PCRb,c
a
All patients were positive for anti-HBV antibodies.
b
Amplication test performed in serially collected serum samples.
c
Amplication test performed with the use of multiple sets of primers.
d
Amplication test performed with the use of single set of primers.
e
Fifty-two patients tested at two dierent time points.
164 G. Raimondo et al. / Journal of Hepatology 46 (2007) 160170
that repeating the HBV test over time is a useful tool in
identifying the occult HBV status [76,85].
Concerning the populations of apparently healthy
individuals, occult HBV has been quite extensively
explored in blood donors and much less in the general
population. Again, the available data provide incom-
plete information. Among the blood donors, this cryptic
infection appears to be a rare occurrence in the western
world, whereas it is frequently detected in the developing
countries [86]. As far as the general population is con-
cerned, in a recent study evaluating the occult HBV
prevalence in HBsAg negative residents of a Canadian
Inuit community, Minuk et al. detected HBV DNA in
18% of anti-HBc positive subjects and in 8% of HBV
seronegative individuals, respectively [87], whereas
Kim et al. found occult HBV in 31 of 195 (16%) Korean
HBV/HCV negative healthy subjects with normal trans-
aminase values [88], and Hui et al. detected occult HBV
genomes in 19 out of 124 (15.3%) healthy hematopoietic
stem cell donors from Hong Kong [89].
3. Clinical relevance
The emerging evidence of the potential, considerable
clinical relevance of the occult HBV infection is the main
reason for the growing interest in this topic. Occult HBV
may impact in several dierent clinical contexts that we
have schematically grouped into four main points which
are briey discussed below.
3.1. Transmission of occult HBV infection
Carriers of occult infection may be a source of HBV
transmission in the case of blood transfusion [27,90,91]
with the consequent development of a typical type B
hepatitis in the recipients. This possible occurrence was
rst reported in the late 1970s [26,92] and experimentally
conrmed in chimpanzees some years later [93]. At pres-
ent, post-transfusional hepatitis B is a rare event in the
western world [94] (although the residual risk of trans-
mission of the HBV by transfusion is surely higher than
HCV or HIV [86]) and occult HBV infection of the
donors appears to be the main factor responsible for
the residual cases [95]. Interestingly, occult HBV is the
major cause of transfusionally transmitted HBV infec-
tion also in countries like Taiwan and India where the
incidence of post-transfusional hepatitis B is still any-
thing but negligible [96,97]. After HIV and HCV, nucleic
acid amplication techniques (NAT) are now commer-
cially available also for HBV testing. Obviously, it is
not the task of this review to enter in the debate about
the appropriateness of introducing this assay in blood
donor screenings. What is clear, however, is that all
the discussion regarding the use of NAT for HBV detec-
tion concerns its ability to identify occult HBV.
Occult HBV infection may also be transmitted in the
event of organ transplantation, and in particular in the
cases of orthotopic liver transplantation (OLT) as obvi-
ous consequence of the fact that the hepatocytes are the
reservoir of the viral strains [25,29,98,99]. Indeed, occult
HBV transmission appears to be a very low risk occur-
rence in cases of kidney or heart [28,100], and it is
uncommon also in bone marrow transplantation [101].
In cases of OLT, from 17% to 94% of HBsAg nega-
tive/anti-HBc positive donors may transmit HBV infec-
tion to the recipients (reviewed in [102]), while the
transmission of the occult infection from HBV seroneg-
ative individuals is uncertain (and also dicult to
recognize).
3.2. Reactivation of occult HBV infection
As mentioned above, the state of suppression of viral
replication and gene expression typical of the occult
HBV status may be discontinued, leading to the develop-
ment of a typical hepatitis B that often has a severe
and sometimes even fulminant clinical course. This
event is usually observed in patients under condition
of immunosuppression induced by therapies and/or
related to diseases that involve the immune system
[24,3034,103108]. In fact, an occult HBV carrier
becoming immunocompromised may show a reactiva-
tion of the viral replication because of the fault of the
immunological control, and, once recovery is achieved
and immune surveillance re-constituted, the CTL-medi-
ated hepatocyte injury may occur leading to the devel-
opment of hepatitis. The virological and clinical
reactivation of the occult HBV infection has been
repeatedly observed in several dierent clinical condi-
tions including hematological malignancies, HIV infec-
tion, hematopoietic stem cell transplantation, and
organ transplantation (Table 3). In this context, it is
of note that occult HBV infected patients undergoing
OLT may present re-infection of the new liver [109],
and occasionally this event may be followed by
virological and clinical re-activation [110]. Moreover,
Table 3
Categories of occult HBV carriers known to be prone to viral
reactivation
Patients with
Haematological malignancies
HIV infection
Patients underwent
Bone marrow transplantation
Liver transplantation
Kidney transplantation
Chemotherapy
Treatment with anti-CD20 (Rituximab)
Treatment with anti-CD52 (Alemtuzumab)
Treatment with anti-TNF (Iniximab)
 G. Raimondo et al. / Journal of Hepatology 46 (2007) 160170 165

the availability of new, potent immunosuppressive Table 4

drugs like the anti-CD20, the anti-CD52 and the anti- Studies describing the association of occult HBV infection with severe
chronic liver disease and/or HCC
TNF monoclonal antibodies, recently introduced in the
therapeutic schedules of various clinical settings seems Study Geographic area Aetiology
to have further increased the risk of HBV reactivation Occult HBV and chronic liver disease
in cryptically infected individuals that may present very Sagnelli et al. (2001) [124] Italy HCV
De Maria et al. (2000) [125] USA HCV
severe clinical sequels [111115]. Cacciola et al. (1999) [21] Italy HCV
Finally, an aspect that is still unclear is the frequency Villa et al. (1995) [61] Italy HCV
of occult HBV reactivation. For this purpose, Onozawa Squadrito et al. (2006) [126] Italy HCV
et al. recently reported an interesting study performed Zhang et al. (1993) [64] China Cryptogenic
on 14 anti-HBs/anti-HBc positive patients who under- Chemin et al. (2001) [62] France Cryptogenic
Berasain et al. (2000) [63] Spain HCV/cryptogenic
went allogenic hematopoietic stem cell transplantation Chen et al. (2002) [123] Taiwan HCV/cryptogenic
[116]. Twelve individuals experienced the progressive Fukuda et al. (1996) [130] Japan Cryptogenic
and persistent disappearance of anti-HBs and 7 HBsAg Jilg et al. (1995) [122] Germany HCV/Cryptogenic
re-seconvertion. Of these last 7 cases, only one devel- Liang et al. (1991) [48] Israel Cryptogenic
oped symptomatic acute hepatitis and needed hospitali- Occult HBV and HCC
sation. This article thus suggests that occult HBV Shafritz et al. (1981) [133] South Africa Unknown
reactivation is quite a frequent event in immunocompro- Brechot et al. (1981) [134] France Unknown
Paterlini et al. (1990) [135] South Africa, Unknown
mised patients, but, since it is usually investigated only
Italy, France,
in the case of development of acute hepatitis, its recog- and Japan
nition might be missed in most of the cases. All these Paterlini et al. (1993) [136] France HCV/cryptogenic
data clearly justify the recommendation to monitor all Sheu et al. (1992) [138] Taiwan HCV/cryptogenic
patients undergoing immunosuppressive therapy very Yu et al. (1997) [139] USA HCV/cryptogenic
Koike et al. (1998) [59] Japan HCV
carefully for HBV serology and/or viremia particularly
Kubo et al. (1998) [140] Japan HCV
if they are antibody to viral antigen(s) positive and to Huo et al. (1998) [141] Taiwan HCV/cryptogenic
continue this monitoring for months (or even years) Pollicino et al. (2004) [22] Italy HCV/cryptogenic
after stopping treatment. In fact, the precocious identi- Donato et al. (2006) [132] Italy HCV/Alcoholic
cation of a virological reactivation makes it possible to Yotsuyanagi et al. (2004) [142] Japan Alcoholic
Squadrito et al. (2006) [126] Italy HCV
begin specic antiviral therapy early, which may prevent
the occurrence of hepatitis B that appears to be very
dangerous in this subset of patients [117].
topic although not all of them suggest [21,61,122
3.3. Occult HBV infection and chronic liver disease 127] (Table 4). The possible negative inuence of cryptic
HBV on the clinical outcome of chronic hepatitis C is,
Individuals who have recovered from self-limited obviously, one of the most important issues of the entire
acute hepatitis may persistently carry HBV genomes chapter of occult HBV infection, and denitive clarica-
for decades without showing any clinical or biochemical tion of this matter should be of fundamental impor-
sign of liver damage [35,36,118,119]. However, when the tance. In this context, considering that only cross-
liver tissue of this kind of subjects has been examined, sectional evaluations have been performed so far, it is
the histological patterns of a mild necroinammation hopeful that a methodologically correct (also from the
have been revealed up to 30 years after the resolution diagnostic point of view) prospective study will be per-
of the acute hepatitis [50,120]. Very similar results were formed in the near future.
observed in woodchucks convalescent from acute WHV As a note, we have to report that several studies per-
hepatitis: these animals show the lifelong persistence of formed in the 1990s suggested that occult HBV may
small amounts of replicating virus associated with a mild exert its negative inuence on chronic hepatitis C also
liver necroinammation continuing for life [55]. in terms of a reduced response to IFN therapy
These data tempted us to speculate that at least in [21,58,125,128,129]. The mechanisms by which the
conditions of immunocompetence the occult infection occult HBV may help HCV to resist IFN are at present
is inoensive in itself, but when other important causes totally unknown. Although this topic is intriguing and
of liver damage co-exist, the minimal lesions produced potentially very relevant, from a practical point of view
by the immune response to the occult virus might con- we must point out that all the cited reports concerned
tribute to making the course of the liver disease worse treatment schedules using the conventional IFN thera-
over time [121]. This hypothesis is consistent with the py, whereas there are no reliable studies evaluating
evidence that occult HBV infection might favour or whether occult HBV infection may interfere with the
accelerate the progression of chronic liver disease in response to PEG-IFN plus Ribavirin (the present
HCV infected individuals, as most of the studies on this gold-standard therapy for the chronic hepatitis C
166 G. Raimondo et al. / Journal of Hepatology 46 (2007) 160170
treatment). This particular aspect of the possible interac-
tion between the two viruses must be completely re-eval-
uated once more valid data are available.
Several reports indicate that occult HBV infection is
associated with the progression of liver brosis and cir-
rhosis development also in patients with cryptogenic liv-
er disease [18,48,6264,122,123,130]. This observation is
not easy to explain, also in consideration of the above-
mentioned hypothesis that occult HBV might be unable
to produce severe hepatic injury by itself. A plausible
explanation is that some of the patients with productive
HBV infection may present a progressive reduction of
viral replication and serum HBsAg amount. The HBsAg
may even disappear over time despite the presence of
severe liver disease that had been provoked by the overt
B hepatitis and then maintained once the occult HBV
status occurs [123].
3.4. Occult HBV infection and HCC
A great deal of solid evidence indicates that occult
HBV infection is a risk factor for HCC development
(reviewed in [19,46,131,132]). The association between
occult HBV and liver cancer was suggested by the rst
epidemiological and molecular studies performed in
the 1980s, and subsequently widely conrmed also when
the most sensitive and specic molecular techniques
became available [22,59,132142] (Table 4). Moreover,
our very recent observational cohort study showed that,
among HBsAg negative patients with chronic hepatitis,
HCC mostly develops in carriers of occult HBV [126].
Finally, experiments in animal models demonstrated
that both woodchucks and ground squirrels, once infect-
ed by WHV and GSHV, respectively, are at high risk of
developing HCC also after the apparent clearance of the
virus [53,54]. The cryptic infection appears to exert its
pro-oncogenic role in HCV infected patients as well as
in alcoholics and in individuals with cryptogenic liver
disease [22,132,142]. Initially, the transforming capacity
of the occult HBV was considered the consequence of
the integration of viral DNA into the hosts genome.
However, the subsequent observations that (a) the
occult strains usually persist as free episomal forms
[143] (that can be detected also in tumor liver tissues
[22]) maintaining the capacities to transcribe and repli-
cate; (b) the lifelong persistence of these replicating
viruses may induce a mild liver necroinammation
continuing for life; (c) cirrhosis is the most important
risk factor for HCC development and, as mentioned
above, occult HBV infection is believed to contribute
to progression toward cirrhosis in HBsAg-negative
chronic liver disease, suggesting that occult HBV might
contribute to hepatocellular transformation through the
same mechanisms traditionally considered the basis of
the tumorigenic properties of the HBV, which it
should not be forgotten has been classied as a Group
1 human carcinogen and is considered the second most
important oncogenic agent after smoking tobacco
[144,145].
In conclusion, occult HBV infection is a phenomenon
mainly related to the intrahepatic persistence of viral
cccDNA and to a strong suppression of viral replication
and gene expression. In consideration of the very low
levels of serum HBV DNA, its detection requires the
use of highly sensitive and specic molecular biology
techniques. The inhibition of HBV replication may be
reversible and the occult infection may reactivate lead-
ing to acute and severe forms of classical hepatitis B,
which may also occur after transmission of occult
HBV by blood transfusion or organ transplantation.
The long-lasting persistence of the virus in the liver
may provoke a very mild but continuing necroinam-
mation that if other causes of liver damage co-exist
may contribute over time to the progression of the
chronic liver damage toward cirrhosis. Moreover, occult
HBV seems to maintain the pro-oncogenic properties
typical of the overt infection, and in fact it is an impor-
tant risk factor for HCC development. Considering
what is summarized above, we believe that the clinicians
should take into account the presence of occult HBV
infection in several categories of patients, such as immu-
nosuppressed subjects and cirrhotic individuals who,
when they carry this peculiar infection, are at the highest
risk of developing viral reactivation and liver cancer,
respectively.
Several additional arguments (i.e. possible extrahepat-
ic sites of the occult HBV reservoir; occult HBV and
HBsAg-negative fulminant hepatitis; inuence of occult
HBV on the liver disease of particular populations such
as HIV infected patients, etc.) have not been discussed
in this review, since we considered the available data still
too incomplete. Occult HBV infection is a complex entity
comprising many conditions and situations that may be
widely dierent from each other both from the biological
point of view and in terms of clinical consequences. These
considerations imply the need for a critical re-evaluation
of the large amount of available information by experts
who should also establish a common denition and the
best ways of increasing our knowledge on this fascinating
eld of bio-medical research.
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