(Acta Paediatr Jpn 1991; 33: 327 - 334)

Combination Theram with Transfer Factor and

High Dose Strongei Neo-Minophagen C in
Chronic Hepatitis B in Children (HBe Ag Positive)
Keiichiro Sumiyama, M.D., Masakazu Kobayashi, M.D.,
Eikichi Miyashiro, M.D., Michio Koike, M.D.

Department of Pediatrics, Wakayama Medical College, Wakayama

This study mainly describes the efficacy of the combination therapy with Transfer Factor
(TF) and high dose Stronger Neo-Minophagen C (SNMC) for HBV carrier children with
HBe Ag positive chronic hepatitis. There were 12 patients, 10 males and 2 females aged from
7 months to 14 years 8 months. Liver biopsy was done in 11 patients, and the
histopathological findings of the liver were chronic active hepatitis (8 cases) and chronic
inactive hepatitis (3 cases). In 6 of 8 patients, HBe-Ag became negative (75%) within 18 weeks
(mean 8 weeks) after the initiation of the combination therapy with T F and SNMC (HBe-
seronegative), and 4 of these 8 patients (50%) became anti-HBe positive within 29 weeks
(mean 15 weeks) (HBe-seroconversion). These results suggest that combination therapy with
TF and high dose SNMC may be beneficial in the treatment of chronic hepatitis B in
children.

Key Words
Transfer factor, Stronger neo-minophagen C, Chronic active hepatitis, Hepatitis B virus

Introduction and asymptomatic, chronic HBV infection can

Disorders associated with hepatitis B virus
(HBV) infection represent a global health
problem. There are 217 million carriers of
HBV in the world and 78% of them are
concentrated in Asia. In Japan, there are
approximately three million HBV carriers,
accounting for 2-3% of the total population.
Although the carrier state is usually benign
Received December 5, 1990
Revised February 12, 1991
Accepted March 8, 1991
Correspondence address: Keiichiro Sumiyama, M.D.,
Department of Pediatrics. Wakayama Medical College,
27-7-bancho, Wakayama-shi. Wakayama 640, Japan
lead to chronic active hepatitis (CAH) and
cirrhosis between the ages of 30 and 50. There
are even a few pediatric cases of CAH. We
have reported the efficacy of steroid with-
drawal therapy, interferon therapy and SNMC
therapy in CAH in children [ I , 21. However, a
strategy is not yet established in the treatment
of this disease. Furthermore, a hypothesis,
regarding the pathogenesis of CAH, has been
developed concerning the complexity of
interaction between HBV and host immune
response. It is reported that persistent hepatic
inflammation occurs as the result of an
inadequate T-cell response to HBV infected
liver cells, which leads to chronic hepatocel-
Mar destruction and at the same time the
perpetuation of HB virus replication. The
following is an open trial study of the
combination therapy with T F and SNMC
conducted on 12 patients with HBs and HBe
antigen positive chronic hepatitis.
Patients and Methods
The subjects enrolled in this study had
persistent liver dysfunction for 6 months or
more, including a transaminase of greater
than 200 IU/ 1. The age of the subjects ranged
from 7 months to 14 years, with a mean of 5
years and 8 months. The sex ratio was 10
males to 2 females. Liver biopsies revealed
chronic active hepatitis in eight cases, and
chronic inactive hepatitis in three cases ( 1 case
was not biopsied). The pretreatment observa-
tion period was from 7 months to 10 years,
with a mean of 2 years and 5 months. The
subjects were followed from 1 year and 7
months to 4 years and 2 months, with a mean
of 2 years and 7 months, after treatment.
We thought it necessary to select a therapy
having as few side effects as possible,
considering that the subjects were children.
Thus we chose the following strategy in the
treatment of chronic hepatitis B in children: I )
40 to 100 ml daily of SNMC (0.2%
glycylrrhizin, 0.1% cysteine and 2% glycine)
was administered for more than 2 weeks by
intravenous drip infusion. Glycylrrhizin is a
licorice extract. 2) If SNMC was ineffective,
then 1 unit of TF was injected subcutaneously
2 to 3 times a week, more than 10 units in all.
Simultaneously SNMC was administered,
(total dose of non-specific T F 10-20 U, mean
12U: total dose of HB specific TF 10-15 U,
mean 11 U). 3) In cases in which the previous
two treatments proved ineffective, steroid
withdrawal therapy was attempted. The inter-
val of each therapy was 3 months or more.
The patients received these treatments after
informed consent was obtained. The T F
preparations were prepared according to the
Lawrence [3] method at the Osaka Red Cross
Blood Center. HB specific TF was prepared
from lymphocytes of patients who had
recovered from hepatitis B. i.e. who have anti-
HBs.
Results
Table 1 shows the efficacy of the SNMC
therapy, TF therapy, and combination therapy
with TF and SNMC and steroid withdrawal
therapy respectively. SNMC therapy was
effective in 2 of 10 cases. Combination

7-able l . The reiult of therapy of children uith HBs Ag and HBK Ag positive chronic hepatitis (SNMC
therapy. T F therapy. combination therapy with T F and SNMC and steroid withdrawal therapy)

Response The efficacy

SNMC TF TF+SNMC Pred.*
of treatments

Type 1: HBs A g ( + ) - ( - ) I 0 0 0 I
anti-HBs ( - )- (+)
Type 11-1: HBe A g ( + ) - ( - ) I 0 4 2 7
anti-HBe ( - )- (+)
normalized liver function
Type 11-2: HBe A g ( + ) - ( - ) 0 0 2 0 2
anti-HBe ( )
~

normalized h e r function
l y e 111-1: HBK A & ( + ) 0 I 0 0 I
normalized liver function
Type 111-2: HBe A & ( + ) 8 2 2 0 I
abnormal liver function
Total 10 3 8 2 12
* I'he types of responses to treatment by Merigan et a1 (modified by Koike)
** Steroid withdrawal therapy

Acta Paediatr Jpn

 Transfer,factor and neo-minophagen C in hepatitis B ( 5 1) 329

therapy with T F and SNMC was effective in 6 py, HBe antigen became negative in six out of
of 8 cases. eight cases, after an average of 8 weeks. In
The changes in HBe antigen and antibody four out of these six cases anti-HBe became
are shown in eight cases of the TF and SNMC positive, and it took 15 weeks on the average,
group (Fig. 1). Case 3 showed a temporary after starting the treatment. In cases 3 and 7,
effect with non-specific TF and SNMC, and who failed to respond to non-specdc TF, HB
HBe antigen became negative 2 weeks after specific TF proved to be effective.
administration of HB specific TF and SNMC. Monthly changes of serum GPT levels are
In cases 4 and 5, HBe antigen became shown before and after treatment in Fig. 2
negative 3 weeks after administration of T F and 3. Fig. 2 shows the results observed with a
and SNMC, and thereafter became anti-HBe single therapy of SNMC. Serum GPT levels
positive. In case 6 HBe antigen became were decreased transiently after treatment, but
negative after 18 weeks, and case 7 showed were increased again after cessation of
HBe seroconversion after 16 weeks. Case 8 treatment. In contrast, serum GPT was
showed HBe seroconversion after 8 weeks. decreased to normal levels in most cases
Cases 9 and 10 were not responsive to either within 2 weeks after treatment with T F and
SNMC therapy or combination therapy. Case SNMC (Fig. 3).
9 responded to steroid withdrawal therapy, Fig. 4 shows the summary of the results
and case 10 had persistent liver dysfunction. obtained with this therapeutic schedule. The
In summary, using the combination thera- oblique lines show the effective cases (the

(Month)
Just before
I 2 3 4 5 6 7 8 9 10 I I 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Case No. TF
eAg 3.1 3.9 1.1 + 3.5 6.4 1.5 0.3 0.1 0.7 0.8
-
anti-e 8
-x-x
23 43
-
26 22 28 53 15
-,x-x-x-x-x
I4 28

tF&
eAg AZ
anti-e 33
5.5
23
- - -
6a 77 68 67
- -
88
-
69
-+
c-)x-+xx-x--
eAg 6.7 1.9 1.6 0.3
anti-e - 39 54 pa 95

eAg 5.5 4.8 5.65.95.3 0.7 0.50.4 0.5 0.3 0.4 0.4 0.3
anti-e 7 6 I2 9 42 54 59 69 63 55 61 57

PX-x-x-x-x-x-x X

2.8 3.3 3.3 5.2 3.96.8 4.2 3.3 0.8 0.4 0.4 0.3 0.4
8a;z-e 26 4A 26 13 0 24 18 22 63 $6 96 99 96

TFA0
eAg 3.1 3.2 2.70.80.50.70.5 0.3 0.3 0.4 0.5 0.4 0.3
anti-e 5 30 44 71 62 52 62 82 85 96 96 98 101

eAg 4.0 5.6 4.85.0 2.1 0.9 1.5 1.3 1.5 0.70.605 0.6 0.7 0.8 0.6 -
anti-e 8 19 0 0 6 1 34 42 53 62 79 81 85 79 71 72 82 +
-x-x-x-x- c s "
c
t
Steroid withdrawal therapy
eAg 43 3.5 6.2 4.3 3.6 3.64.3 4.0 3.9 4.7 2.9 5.1 4.1 +
anti-e 13
0
-
=-
- 3 10 0 0 16 I 7
-- -- --
0 13 0
0
-

Fig.1: The change of HBe antigen and anti-HBe in 8 cases treated with combination therapy with TF and SNMC.
eAg: HBe antigen (cut off index), anti-e: anti-HBe (% inhibition), 0 : HBe antigen positive, 0: anti-HBe positive.
X: HBe antigen negative and anti-HBe negative.

Vol. 33 No. 3 June 1991

330 ( 5 2 ) Sirmij>an)aP I at.

Start (Month)
-10 -9 - 8 -7 -6 -5 -4 -1 -2 -I +.,ti t 2 t3 + 4 t5 t 6 t7 tS t 9 + l o + I I t l 2 + I 3 + I 4 t 1 5 + I 6 +I7 + I 8

GPT
(lull,
600

500

400

300

200

100

Fig. 2: Monthly changes of serum GPT before and after treatment in the cases treated with single
therapy with SNMC.

Start (Month)

Fig. 3: Monthly changes of serum GPT before and after treatment in the cases treated with combination therapy with TF
and SSMC. *The case treated with single therapy with TF.

response of type f, type 11, type 111-1). At the In total, combination therapy with TF and
first treatment, single therapy with SNMC SNMC was effective in six out of eight cases,
was effective in two out of ten cases, and among whom four cases showed HBe serocon-
combination therapy with TF and SNMC was version, and the remaining two cases showed
effective in one out of two cases. In the second an HBe seronegative effect. The serum level of
treatment, cornbination therapy with TF and transaminases had been normalized for a long
SNMC was effective in three out of seven term in one out of three cases treated with
cases, and single therapy with TF was effective single therapy of TF. The final results revealed
in one out of two cases. In the third treatment, that these therapeutic strategies were effective
the combination of HB specific TF and in 11 out of 12 cases. No side effects were
SNMC was effective in two cases, and steroid observed (Table 2).
withdrawal therapy was effective in two cases.

Acta Paediatr Jpn

 Transfer.factor and neo-minophagen C in hepatitis B (53) 33 1

effective 0ineffective Galbraith et al have already reported, on the

aggravation of hepatitis in relation to the
12 - TF -12 withdrawal of steroid [6, 71. In TF and
11 - SNMC Pred. -11 SNMC therapy serious adverse effects were
in - SNMC - 10 not encountered in any case. We also treated 4
9- SNMC -9 patients with chronic hepatitis B with interferon
TF
8- SNMC -8
7-
TF
-7 alpha therapy. One case had HBe seroconver-
6- TF -6 sion, but 3 cases failed to respond. In all cases
5- -+ -5 fever as an adverse effect was observed for 1-3
’ I
SNMC TF
SNMC + - 4
4-
} +Prd. SNMC - days. When considering the efficacy and
3- TFm
2- SNk -2
adverse effect, combination therapy with T F
1- -P TF -1 and SNMC is more beneficial compared with
-
-c Pred.
- these two treatments.
I St II nd P rd Final Efficacy SNMC. is an intravenous solution composed
of glycyrrhizin, cysteine and glycine. Gly-
Fig. 4: The summary of the effect of various therapies in
chronic hepatitis B with positive HBe antigen. The cyrrhizin is a kind of saponin and one of the
oblique lines show the effective cases which responded to main active components of licorice extract.
type I, 11-1, 11-2, 111-1 according to our criteria on the Licorice extract is a herbal drug which has
response to treatment.
long been used as a demulcent and elixir in
Chinese medicine. In the experiments in vitro,
SNMC had the following immuno-modulating
Discussion effects [8- 101: stabilization of cell membrane,
prevention of inflammation and allergies,
Since this study is not a controlled trial, and enhancement of proliferation of the antibody
natural HBe seroconversion is observed in producing lymphocytes, and activation of NK
about 10% of children who are HBV carriers cells and macrophages. It also had steroidlike
per year [4, 51, the possibility of spontaneous effects and induced interferon and interleukin
remission must make us cautious when 1. TF is a soluble lymphocyte component
interpreting our results. However, favorable which has the ability to transfer cell mediated
effects were observed in many cases just after immunity against a specific antigen from a
starting treatment, and combination therapy sensitized donor to a previously non-responsive
with TF and SNMC was more effective than subject. It has been reported that TF may
either treatment alone. Therefore we con- induce production of interferon and interleukin
sidered that the HBe seroconversion rate as I , and activate NK cells [ 1 I]. This agent has
shown in our results was better than that in been used in several studies in an attempt to
the natural course, and also showed the treat patients with chronic hepatitis B [ 12-20].
efficacy of combination therapy with TF and Therefore it seems that SNMC and TF act
SNMC on children with chronic hepatitis B. synergistically in treating chronic hepatitis B.
We have also reported the efficacy of Since our results were obtained in a clinical
steroid withdrawal therapy, interferon thera- study, it is difficult to evaluate the effect of T F
py, and SNMC therapy in CAH in children directly from these results. Reported cases on
[I, 21. We treated 3 patients with HBs and the effect of single therapy with TF for
HBe antigen positive chronic active hepatitis, chronic hepatitis in children are shown in
with steroid withdrawal therapy. HBe antigen Table 3 [21-251. Half of the previous reports
became negative in all these cases and 2 cases appear to indicate that little evidence supports
showed seroconversion, i.e. having HBe the efficacy of TF in the treatment of chronic
antibodies. The result was fairly effective. hepatitis in children, However, in order to
However, this therapy has the possibility of a evaluate the efficacy of TF, assessment of the
severe adverse reaction, as Shimizu et a1 and appropriate dose of T F used and the severity

Vol. 33 No. 3 June 1991

 '4
w
h)
T'ahlr 2. Summ:ir> 0 1 caber. -
wl
P
I
Follow-up period HfleAg HHeAb
Case Age Side ~~f~~~~ TF wII1{ SNMC ?
Scu Treatment *Response After BiOpsY HBsAg &fore After After 3
.-.
KO. (y:m) e ' f ~ t ireiltmeiit treatment +
treatment treritment trcatnicnt (0) (1') (ml X ~ W )
(y:m) (y:ni) 5
-
:
I 2:II M SNMC' 111-2 2:9 <'AH + t + 60 x I 2 2
'IF 111-2 + t - 20
Pred.** 11-1 * 4:2 + - t ?
2 S:3 M SNMC' 111-2 1:s CAH t t t - 60 x 20
1-F 111-1 * 3:2 t + - 10
3 12:2 M ,rF 111-2 CAH t + t - 5
TF+SNMC 111-2 2:7 t + - 15 IOOX 10
TFH 13 t S N M C I1-2 * 1.7 + - - 15 100x49
4 2:3 M SNMC 111-2 0: 10 CAH + + + - 20 X 52
-rF t SNMC 11-1 * 2:6 + - + I0 30 x 20. 40 x 7
5 7:9 M 'JFtSNMC 11-1 * 2:o 3:2 CIH t + - t I0 60 x I2
6 14:X M SNMC 111-2 1O:O CIH t t + - 6 0 X 10
T F t SNMC 11-2* 2: I + - k I0 80 63
x
7 I:X M SNMC 111-2 0 5 CI H + t + - 40 x 32
TF+SNMC 111-2 + +- - 10 o x 34
TFHH+SNMC 11-1 * 2:X + t 10 60x18
X 6:9 M SNMC I 11-2 2: 10 CAH + + + - m x 12
TF+SNMC 11-1 * 218 + - + 10 60 x I 2
9 8:l M SNMC 111-2 I:II CAHcLC + + + - 60x9. 80x30
TFHB+SNMC 111-2 + +- - 10 10 60x120
Pred.** 11-1 * 2:0 + +
10 0:7 M SNMC 111-2 - 0:7 CAH t + + - 40 X 33
TFHBtSNMC 111-2 - I : 10 + + - 10 40x167

II 2:8 F SNMC I * - 2:8 2:l CAH +-- t - k 6 0 X 12

12 0:9 F SNMC 11-1 * - 0: 9 3:3 n.d + + - + 40 X 24

* The types of responses to treatment by Merigan et a1 (modified), ** Steroid withdrawal therapy, +: effective
 Transferfactor and neo-minophagen C in hepatitis B (55) 333

Table 3. Reported cases on the effect of single therapy with T F in chronic hepatitis B in children.

Patients Efficacy
T F (donor) Total dose (Effective/
Age Disease Of TF (") Total cases)
Kohler (1974) 4mo Type B CH HB specific
Grob (1975) 5yr Type B CAH non-specific
Iwatsuki (1981) 5yr Type B CAH ?
Takahashi (1983) 1 yr 1 mo Type B CAH 7 HB specific
- 12yr CH 4
lseki (1985) -
1 I5 yr Type B CH 8 HB specific -
10 20 1/8
Present cases (1985) -
7 mo 14 yr Type B CAH 5 HB specific 10- 15 6/8*
CIH 3 non-specific -
10 20

* Combination therapy with SNMC

CH: chronic hepatitis; CAH: chronic active hepatitis; CIH: chronic inactive hepatitis.

Table 4. Summary of cases by Takahashi (1983)

~~

Case Follow-up Serum GPT Combined Total doses

Age Sex *Response period before just before drugs with
No.
TF TF TF T F (U) TFHB(U)
1 5yr M 11-1* lyr3mo I75 __ 3 20
2 6yr F 111-1 * 5yr 254 - 5 8
3 lyr5mo M 11-1 * llmo 675 -
20
4 IyrImo M undecided 8 mo 82 prednisolone 11 7
5 lyr7mo M undecided 1 yr 5 mo 250 azathioprine 10
6 7yr F undecided 6yr 160 prednisolone 2 2
azathioprine
7 12yr M 11-1 * 6yr 161 - 16
8 lyr8mo M I * lyr4mo 174 - 21
9 2yr2mo F 111-1 * lOmo 423 __ 10
10 3yr7mo F undecided 1yr 4mo 161 - II
II 2yrImo F undecided Ilmo 68 -
9
* The types of responses to treatment by Merigan et a1 (modified), t:effective

of chronic hepatitis prior to treatment are
mandatory.
Takahashi et a1 reported the efficacy of TF
therapy on chronic hepatitis in children [24].
The subjects were children with chronic
hepatitis B. There were 11 cases and 7 of them
had chronic active hepatitis. Four to 23 units
of non-specific and HB specific TF were
administered. HBe-seroconversion occurred in
3 cases, and HBs antigen became negative in
one case. Iseki et a1 reported that 6 of 9
infants with chronic hepatitis B had negative
HBe Ag and normal serum GPT in 22 to 48
months after T F therapy [25]. These results
suggest that T F may be beneficial in the
treatment of chronic hepatitis in children.
Acknowledgements
We wish to thank the late Professor K. Saito of the
Second Department of Pathology at Wakayama Medical
College for his support and the provision of TF.
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