Multiple sclerosis combined with hepatitis B: distinct clinical and neuroimaging characteristics

Multiple sclerosis combined with hepatitis B: distinct clinical and neuroimaging characteristics | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Multiple sclerosis combined with hepatitis B: distinct clinical and neuroimaging characteristics Wu Haotian, Wang Jia, Liu Yixin, Gu Yurong, Guo Zhuoxin, Sun Xiaobo, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6887741/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To explore whether chronic hepatitis B virus (HBV) infection could influent the clinical and neuroimaging characteristics of multiple sclerosis (MS). Methods MS patients consecutively admitted to the Third Affiliated Hospital of Sun Yat-sen University during the period of August 2014 to April 2021 were enrolled. MS were re-diagnosed according to the 2017 revisions of McDonald's criteria. The HBV infection status and clinical features, laboratory data, and MRI findings of all the patients were retrospectively reviewed. Results Ninety-three MS patients, 13 (13.98%) combined with chronic HBV infection, were included. HBV-MS groups more likely to have Optic neuropathy (p = 0.03) in the first attack. Five HBV-MS patients had atypical symptoms, which was more common than non-HBV-MS patients (p = 0.033). Brain atrophy in HBV-MS patients was more frequent than non-HBV-MS patients (p = 0.033). The initial CSF WBC count in HBV-MS patients was higher than non-HBV-MS patients (p = 0.000). Peak EDSS scores during attack before and after disease modifying therapies (DMTs) in HBV-MS patients were both higher than non-HBV-MS patients (p = 0.007 and p = 0.002, respectively). Annal relapse rate (ARR) before DMTs in HBV-MS patients was higher than non-HBV-MS patients (p = 0.00). But ARR after DMTs had no statistical difference. Conclusion Co-infection with chronic HBV aggravates MS. Patients with HBV have more severe clinical manifestations, more atypical symptoms, higher ARR, and more pronounced brain atrophy. However, HBV infection does not affect the response to DMTs. Multiple sclerosis Hepatitis B Atypical symptoms Annal relapse rate Disease modifying therapies Introduction Hepatitis B virus (HBV) infection is commonly spreading worldwide, especially in Asian population. But whether multiple sclerosis (MS) is associated with HBV infection is still an open question 1 . The possibility of either a coincidental or causal association between hepatitis B vaccine and reports of MS was raised in the early 1990s, mainly after massive exposure of the French adult population to the vaccine. In 2002, the US Immunization Safety Review Committee acknowledged there was weak evidence for biological mechanisms by which hepatitis B vaccination could possibly influence an individual's risk of the demyelination of the nervous system. Twelve epidemiological studies have been conducted so far to evaluate the potential risk of central demyelination following immunization against hepatitis B 2 . Most were inconclusive. A few researches indicating a positive association of hepatitis B vaccine with an increased risk of acquired central nervous system demyelinating syndromes, while others concluded as negative results 3 . But Hepatitis B reactivation is a rare event among patients with resolved infection undergoing anti-CD20 antibodies in monotherapy without antiviral prophylaxis: results from the HEBEM study 4 . Unlike vaccination or acute infection, patients with persistent HBV infection have insufficient antiviral immunity. T cell and B cell from patients with chronic HBV infection are functionally altered 5 . Whether chronic hepatitis B virus infection could influent the incidence or phenotype of CNS inflammatory demylimation had not being explored. In this study, we retropectively analyzed the clinical and magnetic resonance manifestations of MS cases with chronic HBV infection in our center, tried to figure out whether there is an innate interaction between these two diseases. Patients and Methods MS patients consecutively admitted to the Third Affiliated Hospital of Sun Yat-sen University during the period of August 2014 to April 2021 were enrolled. The study was approved by the ethics committee of the third affiliated hospital of Sun Yat-sen University. MS were re-diagnosed according to 2017 revisions of the McDonald's criteria retrospectively 6 . All MS patients were tested for AQP-4 antibodies, and all results were negative. MS patients were classified as HBV-MS group and non-HBV-MS group according to HBV infection status. All patients underwent comprehensive HBV serological testing. Chronic HBV infection in MS patients including: 1) HBV carriers: hepatitis B surface antigen (HBsAg) positive for more than 6 months, and no hepatitis-related symptoms and signs. Liver function, ultrasound as well as other physical and chemical tests are normal. 2) Chronic active HBV hepatitis: hepatitis B surface antigen (HBsAg) positive for more than 6 months, had hepatitis-related symptoms and/or abnormal liver function or ultrasound and other physical and chemical tests. We reviewed the clinical features, laboratory data (liver function, Hepatitis B virus antigen and antibody, as well as Hepatitis B virus replication), MRI findings and treatments of all the patients. Medical records were assessed for disease course, number of relapses before the first visit, the annualized relapse rate (ARR) and the peak Expanded Disability Status Scale (pEDSS) 7 during relapse performed before and after the start of the disease modifying therapies (DMTs). Atypical symptoms were defined according to 2017 revisions of the McDonald's criteria 6 . The ARR was calculated for different periods by dividing the total number of relapses by the duration of that period in years. MR assessment, Brain atrophy was evaluated by a neuroradiologist (Guo ZX) based on the expansion of the lateral ventricle and sulci, and cortex thinning. Statistical methods Continuous variables were expressed as mean ± standard deviation or median with range. T tests, Mann-whitney U test, χ2 test or Fisher’s exact test was adopted for comparisons between groups depending on the nature of the variable, respectively. Survival analysis was used to compare the natural history of the disease in both groups and to calculate the time interval from the onset of the disease to EDSS 3. P < 0.05 was considered statistically significant. SPSS version 20.0 software (Chicago, IL, USA) was used to perform the statistical analysis. Results 1. General clinical information, laboratory results and MRI features in HBV-MS patients As shown in Table 1 , ninety-three MS patients were included, among which 13 (13.98%) patients combined with chronic HBV infection. Though without significance, HBV-MS patients tended to have an older onset age and shorter disease duration before the first visit. HBV-MS group also tended to have a higher ratio of progressive course. The HBV-MS groups more likely to have Optic neuropathy (P = 0.03) in the first clinical attack. Atypical symptoms were found in 5 HBV-MS patients, which is more common than in non-HBV-MS patients (P = 0.033). Atypical symptoms included long-segment myelitis in 1, mental symptoms in 2, epilepsy in 1, bilateral optic neuritis in 3 and personality changes and memory loss in 1 patient. Peak EDSS during attack before DMTs in HBV-MS patients was higher than non-HBV-MS patients (P = 0.007). The cerebrospinal fluid (CSF) WBC counts in the initial lumbar puncture in HBV-MS was higher than in non-HBV-MS patients (P = 0.000). ARR before the start of DMTs in HBV-MS patients was higher than non-HBV-MS patients (P = 0.000). Table 1 Clinical and laboratory features for MS patients with and without HBV All (n = 93) HBV-MS (n = 13) Non- HBV MS (n = 80) P Value Female sex, n 7 49 0.76 Age at the onset, year 33.08 ± 7.91 27.73 ± 12.93 0.053 Duration of the disease before the first visit, month 18.77 ± 14.82 38.54 ± 36.81 0.06 MS types, RR/ progresive 10/3 72/8 0.18 Optic neuropathy, n 6 14 0.03 Atypical symptoms, n 5 10 0.033 CSF WBC, ×10 6 /L 10.85 ± 11.83 3.39 ± 4.09 # 0.000 CSF protein, g/L 0.34 ± 0.15 0.26 ± 0.16 # 0.127 Positive CSF OCBs, n 4 ## 46 0.237 Peak EDSS before DMTs (during attack) 5.15 ± 2.29 3.07 ± 1.98 0.007 Peak EDSS after start of DMTs (during attack) 4.31 ± 1.88 2.16 ± 1.99 0.002 ARR before the start of DMTs 4.75 ± 6.52 1.53 ± 1.64 0.000 ARR after DMTs 2.00 ± 1.41(n = 4) 0.5 ± 0.86(n = 18) 0.121 Number of periventricular lesions, n 28.38 ± 23.51 25.47 ± 20.68 0.680 Number of cortical lesions, n 5.08 ± 3.43 5.08 ± 6.96 1.000 Number of subcortical lesions, n 18.23 ± 30.84 13.58 ± 17.88 0.626 Number of infratentorial lesions, n 4.77 ± 4.30 6.03 ± 5.53 0.363 Number of total intracranial lesions, n 56.46 ± 44.43 50.42 ± 38.61 0.651 Confluent paraventricular lesions, n 4 16 0.308 Number of spinal cord lesions, n 2.5 ± 3.18 2.54 ± 3.02 0.969 Spinal cord lesions longer than 3 segments, n 4 ### 13 0.162 # n = 79 ## n = 10 ### n = 12 2. Clinical information, laboratory results and MRI features according to different status of HBV infection. We compared the clinical, laboratory and imaging data according to different HBV infection status. There were 8 HBV-MS patients conducted HBV-DNA examination. 6 patients with HBV-DNA replication > 2000 and 2 patients with HBV-DNA replication < 2000. There was no statistically difference (data not shown) according to HBV-DNA results. There were 3 cases with HBeAg (+) and 10 cases with HBeAg (-). The CSF protein of HBeAg (+) HBV-MS patients was higher than HBeAg (-) HBV-MS (n = 0.035). All 13 HBV-MS patients conducted liver function examination. The results were abnormal in 3 patients, indicating active hepatitis. The results all have no statistically difference except CSF WBC was higher in patients with normal liver function. (7.30 ± 6.83 vs 22.67 ± 18.90, p = 0.042). 3. Clinical information, laboratory features and MRI features for HBV-MS patients and non-HBV-MS patients after DMTs A total of 22 patients (4 HBV-MS, 18 non-HBV-MS) received DMTs. In HBV-MS patients, there were 1 cases using teriflunomide, 2 cases using interferon and 1 cases using rituximab. In non-HBV-MS patients, teriflunomide was used in 4 cases, interferon in 6 cases, fingolimod in 1 case and rituximab in 10 cases. Three HBV-MS patients recieved first-line drugs. In non-HBV-MS patients, there were 7 first-line drugs, 6 second-line drugs, and three cases changed the DMTs sequentially. The peak EDSS during attacks after DMTs in HBV-MS patients was higher than in non-HBV-MS patients (4.31 ± 1.88 and 2.16 ± 1.99 respectively, p = 0.002). ARR of patients after DMTs treatment between HBV-MS patients and non-HBV-MS patients had no statistical difference (p > 0.05). In 4 cases of HBV-MS used DMTs, antiviral therapy was applied in 2 patients. No HBV-DNA replication or hepatitis exacerbation was observed in all 4 cases. Discussion We already know that hepatitis B virus infection is very common in NMOSD patients(7). Despite reports proving that Hepatitis B vaccination (HBV) requires 6 months to complete and is recommended for patients with multiple sclerosis 9 . To the best of our knowledge, this is the first observation on the influence of chronic HBV infection on MS. We found that HBV infection will aggravate the disease severity of MS patients and induce atypical symptoms. HBV-MS patients may also be more susceptible to disease progression (indicating by a higher ratio of brain atrophy). The data for the influence of HBV infection on DMTs efficiency was insufficient. The benefits to the two groups seems equal, though if relapse, HBV-MS patients would have higher peak EDSS scores than patients without HBV. The mechanisms by which an infector can contribute to the pathogenesis of an autoimmune or inflammtory disease including molecular mimicry, epitope spreading, bystander effect, formation of immune complexes (IC) and direct inflammatory damage, et al 10,11 . Chronic hepatitis B activates both cellular immunity and humoral immunity. Autoimmune response has a certain role in the pathogenesis of chronic active hepatitis. HBV is proved to be associated with immune complex diseases, including prodromal serum sickness in acute hepatitis, menbranous glomerulonephritis, cutaneous vasculitis, essential mixed cryoglobulinaemia, and polyarteritis nodosa, et al. HBV infection was also proved to associated with other inflammatory syndromes, including rheumatoid arthritis, polymyalgia rheumatica and polymyositis. The possibility that the immunity to HBV may possess the potential of inducing CNS demyelination raised from the reports that HBV vaccination using plasma-derived HBsAg was followed by optic neuritis, monophasic transverse myelitis, or demyelinating disease of the CNS(11). Injection of HBV-DNA polymerase peptide into rabbits could induce the development of antibodies and T cell reactivity that reacted both with the HBV-DNA polymerase and the native MBP, indicating a molecular mimicry mechanism. CNS specimens obtained from these rabbits had a histological picture reminiscent of the animal model of MS-experimental autoimmune encephalomyelitis (EAE). This study provides the first experimental evidence of between HBV and MS 13,14 . AGA Clinical Practice Guideline on the Prevention and Treatment of Hepatitis B Virus Reactivation in At-Risk Individuals 15 . Clinically, a 46-year-old man with an extremely high titer of HbsAg experienced attacks of transverse myelitis. This report hinted a role of circulating immune complexes 16 . We once also reported atypical lesions involving longer than three cervical spinal cord segments in a demyelinating patient combined with high serum HBV-DNA load 17 . Though the exact mechanisms were not determined, our results indicated a significant influence of chronic HBV infection on the clinical and neuroimagical manifestations of MS. MS patients with HBV infection in the current study are more likely to have optic neuropathy and atypical symptoms, standing in line with our imaging observations. Traditionally, MS is considered to be a central nervous system demyelinating disease mainly affecting the white matter, but we found lesions involving bilateral basal ganglia in 1 case of HBV-MS patient, providing more severe grey matter involvement as a possible explaination for the atypical symptoms such as disturbance of consciousness, mental symptoms, etc. Moreover, this patient cohort present with a higher lesion number and more ratio of brain atrophy on the first visit MR, although their average course of the disease at the first visit is around half below that of the non-HBV MS patients. These results may suggest that HBV-MS patients carry more serious brain tissue damage at the early disease stage, which may contribute to a high score of peak EDSS and ARR before DMTs. We conducted data analysis based on HBeAg, HBV DNA replication and liver function of HBV-MS patients in order to explore the association between HBV infection status and MS manifestation. However, due to the limited number of cases, few specific differences were found. There were few DMTs options in China in the past few years. DMTs were used only in 22 cases. Our limited results indicated that DMTs would be equally effective in HBV-MS patients, though if relapses occured, the peak EDSS would be still higher. Notably, DMTs are able to impair the host immunity to pathogens 18,19 . In 2018 and 2020, there were two reports about the outbreak of hepatitis B after the use of Ocrelizumab and Fingolimod in MS patients 18,20,21 . Therefore, the status of HBV infection in HBV-MS patients should be carefully monitored. Regular and effective anti-virus therapy is suggested combined with DMTs. As a retrospetive study with an insufficient case number, the results should be cautiously interpretated. Population-based prospective study would help to further confirm the impact of chronic HBV infection on the clinical features of MS and the adjustment of treatment options, especially in cases with higher rate of HBV infections among the Asian population. Conclusion In Asian populations, the prevalence of HBV infection is high. HBV infection may not be uncommon in Asian MS patients. Coinfection with chronic HBV aggravates MS. DMTs could be equally effective in MS patients with chronic HBV infection, however the HBV status should be carefully monitored. Declarations -Ethics approval and consent to participate：This study has been reviewed and approved by the Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University. This study complies with the Declaration of Helsinki. This study obtained informed consent from all participants. -Clinical trial number: not applicable -Consent for publication：All authors have agreed to the publication of the article. -Availability of data and material：All data and materials in this article are accurate and reliable. -Competing interest：The authors declare that there are no conflicts of interest regarding the research, authorship, or publication of this paper. -Funding：This work was supported in part by grant from the National Natural Science Foundation of China (81701172). The funding source did not play a role in any aspect of the study or in our decision to submit the paper for publication. -Authors' contributions：Wu Haotian, Wang Jia and Liu Yixin wrote the main manuscript text，Gu Yurong, Guo Zhuoxin and Sun Xiaobo prepared tables，Lu Zhengqi, Qiu Wei and Lu Tingting reviewed the manuscript. # Wu Haotian, Wang Jia, Liu Yixin contributed equally to this work. -Acknowledgements：Not applicable Conflict of interest None References Celik M, Baba C, Irmak C, Ozakbas S, Avkan-Oguz V. Risk of hepatitis b virus reactivation in people with multiple sclerosis treated with ocrelizumab: an observational study from turkey. J Neurol . 2024;271(7):4131-4137. doi:10.1007/s00415-024-12333-0 Mouchet J, Begaud B. Central demyelinating diseases after vaccination against hepatitis b virus: a disproportionality analysis within the VAERS database. Drug Saf . 2018;41(8):767-774. doi:10.1007/s40264-018-0652-4 Kaplanski G, Retornaz F, Durand J, Soubeyrand J. Central nervous system demyelination after vaccination against hepatitis b and HLA haplotype. J Neurol Neurosurg Psychiatry . 1995;58(6):758-759. doi:10.1136/jnnp.58.6.758-a Marzo B, Vidal-Jordana A, Castillo J, et al. Hepatitis b reactivation is a rare event among patients with resolved infection undergoing anti-CD20 antibodies in monotherapy without antiviral prophylaxis: results from the HEBEM study. J Neurol . 2024;271(1):134-140. doi:10.1007/s00415-023-11973-y Poonia B, Ayithan N, Nandi M, Masur H, Kottilil S. HBV induces inhibitory FcRL receptor on b cells and dysregulates b cell-t follicular helper cell axis. Sci Rep . 2018;8(1):15296. doi:10.1038/s41598-018-33719-x Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet Neurology . 2018;17(2):162-173. doi:https://doi.org/10.1016/S1474-4422(17)30470-2 Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology . 1983;33(11):1444-1452. doi:10.1212/wnl.33.11.1444 Ou YW, Tsai YS, Liu YH, et al. Preceding hepatitis b virus infection is highly prevalent in patients with neuromyelitis optica spectrum disorder in taiwan. Mult Scler Relat Disord . 2024;92:105923. doi:10.1016/j.msard.2024.105923 Carvajal R, Guananga-Alvarez D, Tur C, et al. Effect of the number of vaccine doses before starting anti-CD20 therapy on seroprotection rates against hepatitis b virus in people with MS. Neurology . 2025;104(3):e210281. doi:10.1212/WNL.0000000000210281 Maini MK, Burton AR. Restoring, releasing or replacing adaptive immunity in chronic hepatitis b. Nat Rev Gastroenterol Hepatol . 2019;16(11):662-675. doi:10.1038/s41575-019-0196-9 Chang KM, Liu M. Chronic hepatitis b: immune pathogenesis and emerging immunotherapeutics. Curr Opin Pharmacol . 2016;30:93-105. doi:10.1016/j.coph.2016.07.013 Sarkar L, Putchala RK, Safiriyu AA, Das SJ. Azadirachta indica a. Juss ameliorates mouse hepatitis virus-induced neuroinflammatory demyelination by modulating cell-to-cell fusion in an experimental animal model of multiple sclerosis. Front Cell Neurosci . 2020;14:116. doi:10.3389/fncel.2020.00116 Wucherpfennig KW. Mechanisms for the induction of autoimmunity by infectious agents. J Clin Invest . 2001;108(8):1097-1104. doi:10.1172/JCI14235 Maya R, Gershwin ME, Shoenfeld Y. Hepatitis b virus (HBV) and autoimmune disease. Clin Rev Allergy Immunol . 2008;34(1):85-102. doi:10.1007/s12016-007-8013-6 Ali FS, Nguyen MH, Hernaez R, et al. AGA clinical practice guideline on the prevention and treatment of hepatitis b virus reactivation in at-risk individuals. Gastroenterology . 2025;168(2):267-284. doi:10.1053/j.gastro.2024.11.008 Matsui M, Kakigi R, Watanabe S, Kuroda Y. Recurrent demyelinating transverse myelitis in a high titer HBs-antigen carrier. J Neurol Sci . 1996;139(2):235-237. Lu T, Shu Y, Dai Y, et al. B cell depleting therapy for multiple sclerosis overlapping with neuromyelitis optica spectrum disorder. Mult Scler Relat Disord . 2018;22:83-85. doi:10.1016/j.msard.2018.03.017 Lu MC, Shih YL, Hsieh TY, Lin JC. Flare of hepatitis b virus after fingolimod treatment for relapsing and remitting multiple sclerosis. J Formos Med Assoc . 2020;119(4):886-887. doi:10.1016/j.jfma.2019.10.012 Liu J, Yu Y, Zhao H, et al. Latest insights into the epidemiology, characteristics, and therapeutic strategies of chronic hepatitis b patients in indeterminate phase. Eur J Med Res . 2024;29(1):343. doi:10.1186/s40001-024-01942-0 Pourcher V, Todesco E, Dubois C, et al. False hepatitis b and c viral serologies in patients with multiple sclerosis receiving high-dose biotin. Mult Scler . 2018:1626698085. doi:10.1177/1352458518818294 Ciardi MR, Iannetta M, Zingaropoli MA, et al. Reactivation of hepatitis b virus with immune-escape mutations after ocrelizumab treatment for multiple sclerosis. Open Forum Infect Dis . 2019;6(1):ofy356. doi:10.1093/ofid/ofy356 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6887741","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488336311,"identity":"f21ede42-2558-4c6c-bbbe-6d834e38209a","order_by":0,"name":"Wu Haotian","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Wu","middleName":"","lastName":"Haotian","suffix":""},{"id":488336314,"identity":"b61e000b-730e-4da6-a20e-8373869fd49e","order_by":1,"name":"Wang Jia","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Jia","suffix":""},{"id":488336316,"identity":"2f42c2d3-b126-40a4-8e06-68064c9810b5","order_by":2,"name":"Liu Yixin","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Liu","middleName":"","lastName":"Yixin","suffix":""},{"id":488336317,"identity":"c37ea3a4-8f03-4427-bb7b-081869beb559","order_by":3,"name":"Gu Yurong","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Gu","middleName":"","lastName":"Yurong","suffix":""},{"id":488336318,"identity":"f34556be-69ce-4ab2-982d-f108acc44a89","order_by":4,"name":"Guo Zhuoxin","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Guo","middleName":"","lastName":"Zhuoxin","suffix":""},{"id":488336319,"identity":"27666e3f-c057-4780-837f-4f89151a129f","order_by":5,"name":"Sun Xiaobo","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Sun","middleName":"","lastName":"Xiaobo","suffix":""},{"id":488336320,"identity":"a747380a-dc8d-4df5-a559-e7337ec1c2c4","order_by":6,"name":"Lu Zhengqi","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Zhengqi","suffix":""},{"id":488336321,"identity":"dcc3f605-137b-4079-9d54-ce4733f2af72","order_by":7,"name":"Qiu Wei","email":"","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Qiu","middleName":"","lastName":"Wei","suffix":""},{"id":488336322,"identity":"367cca20-b559-4207-9436-bb724fe23c4e","order_by":8,"name":"Lu Tingting","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACPiA+AMQ8MAE5Nvb2A3i1sDEwg7QYwLUY8/GcSSCoBQgM4AKJ8yQcDHAqB2uRyD94uODXHxlz/gXMn3n+HE5vk2BIYPhRsQ2PlmSGwzP7DHgsZzxgk+ZtO5zbJt14gLHnzG38Wnh7DHgMbhxgY+ZtAGqROZDAzNhGnBaIw9gkEgwIa+H5AdRyvoFBmoftcAJhLTyPDQ7zNhgDbWFgk5zblm7YBgzkg/j8ws+e+BjoHjl7g/MHmD+8+WMtL9/efvDBjwrcWsCAsQ1ISOR/YIJF6AH86kHgD8i+AwyMPwgrHQWjYBSMghEIAKVXU4lAzv/DAAAAAElFTkSuQmCC","orcid":"","institution":"the Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Lu","middleName":"","lastName":"Tingting","suffix":""}],"badges":[],"createdAt":"2025-06-13 11:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6887741/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6887741/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96253349,"identity":"95abe489-d269-4b03-adfb-346841faa6b2","added_by":"auto","created_at":"2025-11-19 07:42:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":505179,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6887741/v1/f7a6e451-55d7-4960-a5f4-e7db1b5b114c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multiple sclerosis combined with hepatitis B: distinct clinical and neuroimaging characteristics","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatitis B virus (HBV) infection is commonly spreading worldwide, especially in Asian population. But whether multiple sclerosis (MS) is associated with HBV infection is still an open question\u003csup\u003e1\u003c/sup\u003e. The possibility of either a coincidental or causal association between hepatitis B vaccine and reports of MS was raised in the early 1990s, mainly after massive exposure of the French adult population to the vaccine. In 2002, the US Immunization Safety Review Committee acknowledged there was weak evidence for biological mechanisms by which hepatitis B vaccination could possibly influence an individual's risk of the demyelination of the nervous system. Twelve epidemiological studies have been conducted so far to evaluate the potential risk of central demyelination following immunization against hepatitis B\u003csup\u003e2\u003c/sup\u003e. Most were inconclusive. A few researches indicating a positive association of hepatitis B vaccine with an increased risk of acquired central nervous system demyelinating syndromes, while others concluded as negative results\u003csup\u003e3\u003c/sup\u003e. But Hepatitis B reactivation is a rare event among patients with resolved infection undergoing anti-CD20 antibodies in monotherapy without antiviral prophylaxis: results from the HEBEM study\u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eUnlike vaccination or acute infection, patients with persistent HBV infection have insufficient antiviral immunity. T cell and B cell from patients with chronic HBV infection are functionally altered \u003csup\u003e5\u003c/sup\u003e. Whether chronic hepatitis B virus infection could influent the incidence or phenotype of CNS inflammatory demylimation had not being explored. In this study, we retropectively analyzed the clinical and magnetic resonance manifestations of MS cases with chronic HBV infection in our center, tried to figure out whether there is an innate interaction between these two diseases.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eMS patients consecutively admitted to the Third Affiliated Hospital of Sun Yat-sen University during the period of August 2014 to April 2021 were enrolled. The study was approved by the ethics committee of the third affiliated hospital of Sun Yat-sen University. MS were re-diagnosed according to 2017 revisions of the McDonald's criteria retrospectively\u003csup\u003e6\u003c/sup\u003e. All MS patients were tested for AQP-4 antibodies, and all results were negative. MS patients were classified as HBV-MS group and non-HBV-MS group according to HBV infection status. All patients underwent comprehensive HBV serological testing. Chronic HBV infection in MS patients including: 1) HBV carriers: hepatitis B surface antigen (HBsAg) positive for more than 6 months, and no hepatitis-related symptoms and signs. Liver function, ultrasound as well as other physical and chemical tests are normal. 2) Chronic active HBV hepatitis: hepatitis B surface antigen (HBsAg) positive for more than 6 months, had hepatitis-related symptoms and/or abnormal liver function or ultrasound and other physical and chemical tests.\u003c/p\u003e\u003cp\u003e We reviewed the clinical features, laboratory data (liver function, Hepatitis B virus antigen and antibody, as well as Hepatitis B virus replication), MRI findings and treatments of all the patients. Medical records were assessed for disease course, number of relapses before the first visit, the annualized relapse rate (ARR) and the peak Expanded Disability Status Scale (pEDSS)\u003csup\u003e7\u003c/sup\u003e during relapse performed before and after the start of the disease modifying therapies (DMTs). Atypical symptoms were defined according to 2017 revisions of the McDonald's criteria\u003csup\u003e6\u003c/sup\u003e. The ARR was calculated for different periods by dividing the total number of relapses by the duration of that period in years.\u003c/p\u003e\u003cp\u003eMR assessment, Brain atrophy was evaluated by a neuroradiologist (Guo ZX) based on the expansion of the lateral ventricle and sulci, and cortex thinning.\u003c/p\u003e\u003cp\u003eStatistical methods\u003c/p\u003e\u003cp\u003eContinuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median with range. T tests, Mann-whitney U test, χ2 test or Fisher\u0026rsquo;s exact test was adopted for comparisons between groups depending on the nature of the variable, respectively. Survival analysis was used to compare the natural history of the disease in both groups and to calculate the time interval from the onset of the disease to EDSS 3. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. SPSS version 20.0 software (Chicago, IL, USA) was used to perform the statistical analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1. General clinical information, laboratory results and MRI features in HBV-MS patients\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, ninety-three MS patients were included, among which 13 (13.98%) patients combined with chronic HBV infection. Though without significance, HBV-MS patients tended to have an older onset age and shorter disease duration before the first visit. HBV-MS group also tended to have a higher ratio of progressive course. The HBV-MS groups more likely to have Optic neuropathy (P\u0026thinsp;=\u0026thinsp;0.03) in the first clinical attack. Atypical symptoms were found in 5 HBV-MS patients, which is more common than in non-HBV-MS patients (P\u0026thinsp;=\u0026thinsp;0.033). Atypical symptoms included long-segment myelitis in 1, mental symptoms in 2, epilepsy in 1, bilateral optic neuritis in 3 and personality changes and memory loss in 1 patient. Peak EDSS during attack before DMTs in HBV-MS patients was higher than non-HBV-MS patients (P\u0026thinsp;=\u0026thinsp;0.007). The cerebrospinal fluid (CSF) WBC counts in the initial lumbar puncture in HBV-MS was higher than in non-HBV-MS patients (P\u0026thinsp;=\u0026thinsp;0.000). ARR before the start of DMTs in HBV-MS patients was higher than non-HBV-MS patients (P\u0026thinsp;=\u0026thinsp;0.000).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical and laboratory features for MS patients with and without HBV\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll (n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHBV-MS (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon- HBV MS (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale sex, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at the onset, year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.08\u0026thinsp;\u0026plusmn;\u0026thinsp;7.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.73\u0026thinsp;\u0026plusmn;\u0026thinsp;12.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of the disease before the first visit, month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.77\u0026thinsp;\u0026plusmn;\u0026thinsp;14.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.54\u0026thinsp;\u0026plusmn;\u0026thinsp;36.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMS types, RR/ progresive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10/3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72/8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOptic neuropathy, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtypical symptoms, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCSF WBC, \u0026times;10\u003csup\u003e6\u003c/sup\u003e/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.85\u0026thinsp;\u0026plusmn;\u0026thinsp;11.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.39\u0026thinsp;\u0026plusmn;\u0026thinsp;4.09\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCSF protein, g/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.127\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive CSF OCBs, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.237\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak EDSS before DMTs (during attack)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeak EDSS after start of DMTs (during attack)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eARR before the start of DMTs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;6.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eARR after DMTs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41(n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86(n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of periventricular lesions, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.38\u0026thinsp;\u0026plusmn;\u0026thinsp;23.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.47\u0026thinsp;\u0026plusmn;\u0026thinsp;20.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.680\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of cortical lesions, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of subcortical lesions, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.23\u0026thinsp;\u0026plusmn;\u0026thinsp;30.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.58\u0026thinsp;\u0026plusmn;\u0026thinsp;17.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.626\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of infratentorial lesions, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.77\u0026thinsp;\u0026plusmn;\u0026thinsp;4.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.363\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of total intracranial lesions, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.46\u0026thinsp;\u0026plusmn;\u0026thinsp;44.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.42\u0026thinsp;\u0026plusmn;\u0026thinsp;38.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.651\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConfluent paraventricular lesions, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.308\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of spinal cord lesions, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.54\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.969\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpinal cord lesions longer than 3 segments, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003csup\u003e###\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.162\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e#\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;79\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e##\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;10\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e###\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;12\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e2. Clinical information, laboratory results and MRI features according to different status of HBV infection.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe compared the clinical, laboratory and imaging data according to different HBV infection status. There were 8 HBV-MS patients conducted HBV-DNA examination. 6 patients with HBV-DNA replication\u0026thinsp;\u0026gt;\u0026thinsp;2000 and 2 patients with HBV-DNA replication\u0026thinsp;\u0026lt;\u0026thinsp;2000. There was no statistically difference (data not shown) according to HBV-DNA results. There were 3 cases with HBeAg (+) and 10 cases with HBeAg (-). The CSF protein of HBeAg (+) HBV-MS patients was higher than HBeAg (-) HBV-MS (n\u0026thinsp;=\u0026thinsp;0.035). All 13 HBV-MS patients conducted liver function examination. The results were abnormal in 3 patients, indicating active hepatitis. The results all have no statistically difference except CSF WBC was higher in patients with normal liver function. (7.30\u0026thinsp;\u0026plusmn;\u0026thinsp;6.83 vs 22.67\u0026thinsp;\u0026plusmn;\u0026thinsp;18.90, p\u0026thinsp;=\u0026thinsp;0.042).\u003c/p\u003e\u003cp\u003e\u003cb\u003e3. Clinical information, laboratory features and MRI features for HBV-MS patients and non-HBV-MS patients after DMTs\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 22 patients (4 HBV-MS, 18 non-HBV-MS) received DMTs. In HBV-MS patients, there were 1 cases using teriflunomide, 2 cases using interferon and 1 cases using rituximab. In non-HBV-MS patients, teriflunomide was used in 4 cases, interferon in 6 cases, fingolimod in 1 case and rituximab in 10 cases. Three HBV-MS patients recieved first-line drugs. In non-HBV-MS patients, there were 7 first-line drugs, 6 second-line drugs, and three cases changed the DMTs sequentially. The peak EDSS during attacks after DMTs in HBV-MS patients was higher than in non-HBV-MS patients (4.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88 and 2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99 respectively, p\u0026thinsp;=\u0026thinsp;0.002). ARR of patients after DMTs treatment between HBV-MS patients and non-HBV-MS patients had no statistical difference (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In 4 cases of HBV-MS used DMTs, antiviral therapy was applied in 2 patients. No HBV-DNA replication or hepatitis exacerbation was observed in all 4 cases.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe already know that hepatitis B virus infection is very common in NMOSD patients(7). Despite reports proving that Hepatitis B vaccination (HBV) requires 6 months to complete and is recommended for patients with multiple sclerosis\u003csup\u003e9\u003c/sup\u003e. To the best of our knowledge, this is the first observation on the influence of chronic HBV infection on MS. We found that HBV infection will aggravate the disease severity of MS patients and induce atypical symptoms. HBV-MS patients may also be more susceptible to disease progression (indicating by a higher ratio of brain atrophy). The data for the influence of HBV infection on DMTs efficiency was insufficient. The benefits to the two groups seems equal, though if relapse, HBV-MS patients would have higher peak EDSS scores than patients without HBV.\u003c/p\u003e\u003cp\u003eThe mechanisms by which an infector can contribute to the pathogenesis of an autoimmune or inflammtory disease including molecular mimicry, epitope spreading, bystander effect, formation of immune complexes (IC) and direct inflammatory damage, et al\u003csup\u003e10,11\u003c/sup\u003e. Chronic hepatitis B activates both cellular immunity and humoral immunity. Autoimmune response has a certain role in the pathogenesis of chronic active hepatitis. HBV is proved to be associated with immune complex diseases, including prodromal serum sickness in acute hepatitis, menbranous glomerulonephritis, cutaneous vasculitis, essential mixed cryoglobulinaemia, and polyarteritis nodosa, et al. HBV infection was also proved to associated with other inflammatory syndromes, including rheumatoid arthritis, polymyalgia rheumatica and polymyositis. The possibility that the immunity to HBV may possess the potential of inducing CNS demyelination raised from the reports that HBV vaccination using plasma-derived HBsAg was followed by optic neuritis, monophasic transverse myelitis, or demyelinating disease of the CNS(11). Injection of HBV-DNA polymerase peptide into rabbits could induce the development of antibodies and T cell reactivity that reacted both with the HBV-DNA polymerase and the native MBP, indicating a molecular mimicry mechanism. CNS specimens obtained from these rabbits had a histological picture reminiscent of the animal model of MS-experimental autoimmune encephalomyelitis (EAE). This study provides the first experimental evidence of between HBV and MS\u003csup\u003e13,14\u003c/sup\u003e. AGA Clinical Practice Guideline on the Prevention and Treatment of Hepatitis B Virus Reactivation in At-Risk Individuals\u003csup\u003e15\u003c/sup\u003e. Clinically, a 46-year-old man with an extremely high titer of HbsAg experienced attacks of transverse myelitis. This report hinted a role of circulating immune complexes\u003csup\u003e16\u003c/sup\u003e. We once also reported atypical lesions involving longer than three cervical spinal cord segments in a demyelinating patient combined with high serum HBV-DNA load \u003csup\u003e17\u003c/sup\u003e. Though the exact mechanisms were not determined, our results indicated a significant influence of chronic HBV infection on the clinical and neuroimagical manifestations of MS.\u003c/p\u003e\u003cp\u003eMS patients with HBV infection in the current study are more likely to have optic neuropathy and atypical symptoms, standing in line with our imaging observations. Traditionally, MS is considered to be a central nervous system demyelinating disease mainly affecting the white matter, but we found lesions involving bilateral basal ganglia in 1 case of HBV-MS patient, providing more severe grey matter involvement as a possible explaination for the atypical symptoms such as disturbance of consciousness, mental symptoms, etc. Moreover, this patient cohort present with a higher lesion number and more ratio of brain atrophy on the first visit MR, although their average course of the disease at the first visit is around half below that of the non-HBV MS patients. These results may suggest that HBV-MS patients carry more serious brain tissue damage at the early disease stage, which may contribute to a high score of peak EDSS and ARR before DMTs.\u003c/p\u003e\u003cp\u003eWe conducted data analysis based on HBeAg, HBV DNA replication and liver function of HBV-MS patients in order to explore the association between HBV infection status and MS manifestation. However, due to the limited number of cases, few specific differences were found.\u003c/p\u003e\u003cp\u003eThere were few DMTs options in China in the past few years. DMTs were used only in 22 cases. Our limited results indicated that DMTs would be equally effective in HBV-MS patients, though if relapses occured, the peak EDSS would be still higher. Notably, DMTs are able to impair the host immunity to pathogens\u003csup\u003e18,19\u003c/sup\u003e. In 2018 and 2020, there were two reports about the outbreak of hepatitis B after the use of Ocrelizumab and Fingolimod in MS patients \u003csup\u003e18,20,21\u003c/sup\u003e. Therefore, the status of HBV infection in HBV-MS patients should be carefully monitored. Regular and effective anti-virus therapy is suggested combined with DMTs.\u003c/p\u003e\u003cp\u003eAs a retrospetive study with an insufficient case number, the results should be cautiously interpretated. Population-based prospective study would help to further confirm the impact of chronic HBV infection on the clinical features of MS and the adjustment of treatment options, especially in cases with higher rate of HBV infections among the Asian population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn Asian populations, the prevalence of HBV infection is high. HBV infection may not be uncommon in Asian MS patients. Coinfection with chronic HBV aggravates MS. DMTs could be equally effective in MS patients with chronic HBV infection, however the HBV status should be carefully monitored.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e-Ethics approval and consent to participate：This study has been reviewed and approved by the Ethics Committee of the Third\u003c/p\u003e\n\u003cp\u003eAffiliated Hospital of Sun Yat-sen University. This study complies with the Declaration of Helsinki. This study obtained informed consent from all participants.\u003c/p\u003e\n\u003cp\u003e-Clinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e-Consent for publication：All authors have agreed to the publication of the article.\u003c/p\u003e\n\u003cp\u003e-Availability of data and material：All data and materials in this article are accurate and reliable.\u003c/p\u003e\n\u003cp\u003e-Competing interest：The authors declare that there are no conflicts of interest regarding the research, authorship, or publication of this paper.\u003c/p\u003e\n\u003cp\u003e-Funding：This work was supported in part by grant from the National Natural Science Foundation of China (81701172). The funding source did not play a role in any aspect of the study or in our decision to submit the paper for publication.\u003c/p\u003e\n\u003cp\u003e-Authors\u0026apos; contributions：Wu Haotian, Wang Jia and Liu Yixin wrote the main manuscript text，Gu Yurong, Guo Zhuoxin and Sun Xiaobo prepared tables，Lu Zhengqi, Qiu Wei and Lu Tingting reviewed the manuscript. # Wu Haotian, Wang Jia, Liu Yixin contributed equally to this work.\u003c/p\u003e\n\u003cp\u003e-Acknowledgements：Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCelik M, Baba C, Irmak C, Ozakbas S, Avkan-Oguz V. Risk of hepatitis b virus reactivation in people with multiple sclerosis treated with ocrelizumab: an observational study from turkey. \u003cem\u003eJ Neurol\u003c/em\u003e. 2024;271(7):4131-4137. doi:10.1007/s00415-024-12333-0\u003c/li\u003e\n\u003cli\u003eMouchet J, Begaud B. Central demyelinating diseases after vaccination against hepatitis b virus: a disproportionality analysis within the VAERS database. \u003cem\u003eDrug Saf\u003c/em\u003e. 2018;41(8):767-774. doi:10.1007/s40264-018-0652-4\u003c/li\u003e\n\u003cli\u003eKaplanski G, Retornaz F, Durand J, Soubeyrand J. Central nervous system demyelination after vaccination against hepatitis b and HLA haplotype. \u003cem\u003eJ Neurol Neurosurg Psychiatry\u003c/em\u003e. 1995;58(6):758-759. doi:10.1136/jnnp.58.6.758-a\u003c/li\u003e\n\u003cli\u003eMarzo B, Vidal-Jordana A, Castillo J, et al. Hepatitis b reactivation is a rare event among patients with resolved infection undergoing anti-CD20 antibodies in monotherapy without antiviral prophylaxis: results from the HEBEM study. \u003cem\u003eJ Neurol\u003c/em\u003e. 2024;271(1):134-140. doi:10.1007/s00415-023-11973-y\u003c/li\u003e\n\u003cli\u003ePoonia B, Ayithan N, Nandi M, Masur H, Kottilil S. HBV induces inhibitory FcRL receptor on b cells and dysregulates b cell-t follicular helper cell axis. \u003cem\u003eSci Rep\u003c/em\u003e. 2018;8(1):15296. doi:10.1038/s41598-018-33719-x\u003c/li\u003e\n\u003cli\u003eThompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. \u003cem\u003eThe Lancet Neurology\u003c/em\u003e. 2018;17(2):162-173. doi:https://doi.org/10.1016/S1474-4422(17)30470-2\u003c/li\u003e\n\u003cli\u003eKurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). \u003cem\u003eNeurology\u003c/em\u003e. 1983;33(11):1444-1452. doi:10.1212/wnl.33.11.1444\u003c/li\u003e\n\u003cli\u003eOu YW, Tsai YS, Liu YH, et al. Preceding hepatitis b virus infection is highly prevalent in patients with neuromyelitis optica spectrum disorder in taiwan. \u003cem\u003eMult Scler Relat Disord\u003c/em\u003e. 2024;92:105923. doi:10.1016/j.msard.2024.105923\u003c/li\u003e\n\u003cli\u003eCarvajal R, Guananga-Alvarez D, Tur C, et al. Effect of the number of vaccine doses before starting anti-CD20 therapy on seroprotection rates against hepatitis b virus in people with MS. \u003cem\u003eNeurology\u003c/em\u003e. 2025;104(3):e210281. doi:10.1212/WNL.0000000000210281\u003c/li\u003e\n\u003cli\u003eMaini MK, Burton AR. Restoring, releasing or replacing adaptive immunity in chronic hepatitis b. \u003cem\u003eNat Rev Gastroenterol Hepatol\u003c/em\u003e. 2019;16(11):662-675. doi:10.1038/s41575-019-0196-9\u003c/li\u003e\n\u003cli\u003eChang KM, Liu M. Chronic hepatitis b: immune pathogenesis and emerging immunotherapeutics. \u003cem\u003eCurr Opin Pharmacol\u003c/em\u003e. 2016;30:93-105. doi:10.1016/j.coph.2016.07.013\u003c/li\u003e\n\u003cli\u003eSarkar L, Putchala RK, Safiriyu AA, Das SJ. Azadirachta indica a. Juss ameliorates mouse hepatitis virus-induced neuroinflammatory demyelination by modulating cell-to-cell fusion in an experimental animal model of multiple sclerosis. \u003cem\u003eFront Cell Neurosci\u003c/em\u003e. 2020;14:116. doi:10.3389/fncel.2020.00116\u003c/li\u003e\n\u003cli\u003eWucherpfennig KW. Mechanisms for the induction of autoimmunity by infectious agents. \u003cem\u003eJ Clin Invest\u003c/em\u003e. 2001;108(8):1097-1104. doi:10.1172/JCI14235\u003c/li\u003e\n\u003cli\u003eMaya R, Gershwin ME, Shoenfeld Y. Hepatitis b virus (HBV) and autoimmune disease. \u003cem\u003eClin Rev Allergy Immunol\u003c/em\u003e. 2008;34(1):85-102. doi:10.1007/s12016-007-8013-6\u003c/li\u003e\n\u003cli\u003eAli FS, Nguyen MH, Hernaez R, et al. AGA clinical practice guideline on the prevention and treatment of hepatitis b virus reactivation in at-risk individuals. \u003cem\u003eGastroenterology\u003c/em\u003e. 2025;168(2):267-284. doi:10.1053/j.gastro.2024.11.008\u003c/li\u003e\n\u003cli\u003eMatsui M, Kakigi R, Watanabe S, Kuroda Y. Recurrent demyelinating transverse myelitis in a high titer HBs-antigen carrier. \u003cem\u003eJ Neurol Sci\u003c/em\u003e. 1996;139(2):235-237.\u003c/li\u003e\n\u003cli\u003eLu T, Shu Y, Dai Y, et al. B cell depleting therapy for multiple sclerosis overlapping with neuromyelitis optica spectrum disorder. \u003cem\u003eMult Scler Relat Disord\u003c/em\u003e. 2018;22:83-85. doi:10.1016/j.msard.2018.03.017\u003c/li\u003e\n\u003cli\u003eLu MC, Shih YL, Hsieh TY, Lin JC. Flare of hepatitis b virus after fingolimod treatment for relapsing and remitting multiple sclerosis. \u003cem\u003eJ Formos Med Assoc\u003c/em\u003e. 2020;119(4):886-887. doi:10.1016/j.jfma.2019.10.012\u003c/li\u003e\n\u003cli\u003eLiu J, Yu Y, Zhao H, et al. Latest insights into the epidemiology, characteristics, and therapeutic strategies of chronic hepatitis b patients in indeterminate phase. \u003cem\u003eEur J Med Res\u003c/em\u003e. 2024;29(1):343. doi:10.1186/s40001-024-01942-0\u003c/li\u003e\n\u003cli\u003ePourcher V, Todesco E, Dubois C, et al. False hepatitis b and c viral serologies in patients with multiple sclerosis receiving high-dose biotin. \u003cem\u003eMult Scler\u003c/em\u003e. 2018:1626698085. doi:10.1177/1352458518818294\u003c/li\u003e\n\u003cli\u003eCiardi MR, Iannetta M, Zingaropoli MA, et al. Reactivation of hepatitis b virus with immune-escape mutations after ocrelizumab treatment for multiple sclerosis. \u003cem\u003eOpen Forum Infect Dis\u003c/em\u003e. 2019;6(1):ofy356. doi:10.1093/ofid/ofy356\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multiple sclerosis, Hepatitis B, Atypical symptoms, Annal relapse rate, Disease modifying therapies","lastPublishedDoi":"10.21203/rs.3.rs-6887741/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6887741/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo explore whether chronic hepatitis B virus (HBV) infection could influent the clinical and neuroimaging characteristics of multiple sclerosis (MS).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMS patients consecutively admitted to the Third Affiliated Hospital of Sun Yat-sen University during the period of August 2014 to April 2021 were enrolled. MS were re-diagnosed according to the 2017 revisions of McDonald's criteria. The HBV infection status and clinical features, laboratory data, and MRI findings of all the patients were retrospectively reviewed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNinety-three MS patients, 13 (13.98%) combined with chronic HBV infection, were included. HBV-MS groups more likely to have Optic neuropathy (p\u0026thinsp;=\u0026thinsp;0.03) in the first attack. Five HBV-MS patients had atypical symptoms, which was more common than non-HBV-MS patients (p\u0026thinsp;=\u0026thinsp;0.033). Brain atrophy in HBV-MS patients was more frequent than non-HBV-MS patients (p\u0026thinsp;=\u0026thinsp;0.033). The initial CSF WBC count in HBV-MS patients was higher than non-HBV-MS patients (p\u0026thinsp;=\u0026thinsp;0.000). Peak EDSS scores during attack before and after disease modifying therapies (DMTs) in HBV-MS patients were both higher than non-HBV-MS patients (p\u0026thinsp;=\u0026thinsp;0.007 and p\u0026thinsp;=\u0026thinsp;0.002, respectively). Annal relapse rate (ARR) before DMTs in HBV-MS patients was higher than non-HBV-MS patients (p\u0026thinsp;=\u0026thinsp;0.00). But ARR after DMTs had no statistical difference.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCo-infection with chronic HBV aggravates MS. Patients with HBV have more severe clinical manifestations, more atypical symptoms, higher ARR, and more pronounced brain atrophy. However, HBV infection does not affect the response to DMTs.\u003c/p\u003e","manuscriptTitle":"Multiple sclerosis combined with hepatitis B: distinct clinical and neuroimaging characteristics","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 17:10:04","doi":"10.21203/rs.3.rs-6887741/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1ec964da-2e5e-4b99-acae-d10866662a0b","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-20T08:53:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-22 17:10:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6887741","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6887741","identity":"rs-6887741","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}