PRESENTED BY DR OSAMA MOUSTAFA ELFAYOUMI Consultant Clinical

PRESENTED BY DR. OSAMA MOUSTAFA EL-FAYOUMI Consultant Clinical Pathology Sub-speciality of Haematology Chief Of All Labs SGH Group Madinah Munawarah – KSA

Black seed is a gift to medicine!!

INTRODUCTION While the main principle of success in using the medical description of (Prophetic Medicine) is to believe in it but also we have to go for the scientific explanation for the disease and its pathogenecity as well. The medicine described, its mechanism of action and how it will treat? what is the dose? , what are the drug interactions? and what could cause synergism for its action? In that topic our disease is Hep C virus infection and its complications. Our recommended medicine is Nigella sativa (Black seed).

Nigella sativa (N. sativa) is used as a food condiment in the Middle East, and its seeds/oil have been shown to possess antiinflammatory, antiviral and antineoplastic activity in various in vitro and in vivo studies (Zaher et al. , 2008). So we start the discussion hepatitis C Virus pathogenesis. 6

Pathogenesis A molecular mechanisms that trigger the emergence and development of each of the pathogenic processes have been identified as marked induction of a “Reactive Oxygen Species” (ROS) in infected cells leading to oxidative stress. To date, markers of oxidative stress were observed both in chronic hepatitis C patients and in various in vitro systems, including replicons or stable cell lines expressing viral proteins. 7

Direct measurements in liver tissue from CHC patients revealed An increase of ROS ( Reactive Oxygen Species) concentrations by 2 - 5 orders of magnitude. A significant increase was also described in lymphocytes of patients with chronic and occult HCV infection. These data are backed up by a number of papers reporting : 1 - Elevated level of total pro-oxidant activity. 8

HCV has been shown to activate several different pathways that lead to ROS ( Reactive Oxygen Species) production, both in hepatocytes and blood cells, which reside in liver. Most researchers were focused on revealing ROS sources inside hepatocytes. Induction of oxidative stress in these cells has been assigned to almost all HCV proteins So, ROS ( Reactive Oxygen Species) is the corner stone for pathogenesis. 9

Schematic representation of mechanisms of oxidative stress induction in the HCV-infected cells. Activation of mitochondrial Ca 2+. Enhanced passive leakage of the ions from the Endoplasmic Reticulum(ER) and suppressed SERCA pump, responsible for Ca 2+ import into the ER. Hepatitis C virus (HCV) proteins induces NADPH oxidases (Nox) 1 & 4 which contribute to production of H 2 O 2 & O 2 Finally, the ROS (reactive oxygen species) can be generated through ER (endoplasmic reticulum) cytochrome P 450, 2 E 1 and induced ER (endoplasmic reticulum) stress. 10

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Oxidative Stress and HCV-Associated Diseases HCV infection is associated with various hepatic and extrahepatic disorders, and oxidative stress leads to liver injury. For example, ROS levels, measured in liver using Electron Paramagnetic Resonance Imaging, correlate with histological disease activity although not with levels of serum transaminases. 12

Also Hepatocellular Carcinoma Oxidative stress is considered as one of the mechanisms, by which HCV promotes proliferation of hepatocytes and triggers HCC. in Increased risk on HCC is associated with a polymorphism the gene, which encodes an antioxidant defense enzyme. So, oxidation is increased *oxidative stress* 13

Oxidative stress leads to • DNA damage • Accumulation of mutations. Second, formation of HC Carcinoma was shown to depend on peroxisome proliferator-activated receptor alpha (PPARα) transcription factor, e. g. , Liver Fibrosis They include accumulation of DNA damage in response to ROS ( Reactive Oxygen Species) augmented by suppressed reparation processes. Liver fibrosis is another hepatic dysregulation induced by oxidative stress in the HCV-infected liver. 14

Beneficial Therapeutic Effects of Nigella sativa and/or Zingiber officinale In HCV Patients in Egypt Ethanolic extracts of Nigella sativa and Zingiber officinale were prepared and formulated into gelatinous capsules Each containing 500 mg of Nigella sativa and/or Zingiber officinale Clinical response and incidence of adverse drug reactions were assessed initially, periodically, and at the end of the study. Both extracts as well as their mixture 1 - Significantly ameliorated the altered viral load , alpha fetoproein 2 - Liver function parameters ( with more potent effect for the combined therapy). 15

In that study, 16

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Clinical & Laboratory Assessment: • Full clinical assessment with an emphasis on hepatoand/ or splenomegaly, jaundice, palmar erythema. . • Laboratory investigations of AST, ALT, LDH, ALP, γGT, albumin, total bilirubin, PT, PC, INR • Serum α-fetoprotein (AFP) was assayed • Quantitative real time polymerase chain reaction (q. RTPCR) for HCV 18

Results: Treatment with the mixture of both extracts (N. S + Zing) seemed to be the most effective in reducing viral load and there were five cases who showed a non detectable viremia complete cure. 19

Reference: In that study 20

The used mixture seemed to be more effective in reducing serum AFP levels. 21

The activities of serum liver marker enzymes, AST, ALT, γGT, LDH and ALP were potentially improved following treatment with N. sativa and/or Z. officinale. Serum albumin of the HCV control group exhibited a significant (P<0. 001) decrease in comparison to healthy control group. The efficacy of the mixture might be attributed to the synergistic effect of the included active compounds of Nigella sativa + Zingabele. 22

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N. B: Thymine, the main constituent of N. sativa seeds, protects organs against oxidative damage induced by a variety of free radical generating pathologies So, the administration of both N. sativa and/or Z. officinale ethanolic extracts to HCV patients was safe, tolerable, decreased viral load, and improved clinical condition. In addition, the current study recommends the use of mixtures of herbal therapy to increase their synergetic effects against HCV and decrease their side effects. 25

General Anti-viral effect: In vivo treatment with N. sativa oil induced a striking anti-viral effect against MCMV (Murine CMV) infection, indicating a promising therapeutic potential of N. sativa oil as an anti-viral remedy. Antiviral effect of the N. sativa oil is associated with enhancing response of CD 4 and CD 8 cells, augmenting their ability of IFN-g production that is known to render mice more resistant to MCMV infection. 26

NK cells and specific cells including CD 4 and CD 8 T cells plays a central anti-viral role at a certain time point post infection and this is helped by Nigela sativa Eventually, the anti-oxidant effect of the N. sativa oil may represent another mechanism that contributes to its anti-viral activity. 27

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Effect of Nigella sativa against complications of HCV e. g, Hepatocellular carcinoma 29

HCC as complication of HCV Role of Nigela sativa to supress ROS 30

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Complications of HCV even HC Carcinoma Protective effect of Nigella sativia seeds against dimethyl/aminoazo/benzene (DAB) which can induce HCC The effect of Nigella sativa has been evaluated in animal studies. There are many reports on its biological activities including anti-tumor, Immunopotentiation, antiinflammatory, analgesic, antihypertensive, anti -diabetic, respiratory stimulation, anti-bacterial, antifungal, anticestode and antinematode effects. 32

In that study (HCC), Animals were divided into 4 groups each containing 35 rats. The first is the untreated control group. The second is the carcinogen treated group with 0. 05% DAB mixed with diet. The third group is the N. sativa control group treated only with 5. 0 % grinded seeds of N. sativa mixed with diet. The fourth group is the treated with 5. 0 % N. sativa plus 0. 05% of DAB mixed with diet. 33

Table 1. The levels of the ALT, AST, total protein, albumin, and ALP recorded in the different experimental groups. 34

In histomorphology Analysis, In the control untreated group---- Strictly normal architecture DAB treated group showed---- Dysplasia of liver cells. ----cholangiocarcinoma. 57. 1% Regarding the N. sativa treated group---- Absolutely normal architecture (like control group) DAB plus N. sativa treated group, • 28. 6% of them showed RESISTANT bile duct proliferation • 71. 4% NO cirrhosis, dysplasia or carcinoma NO bile duct proliferation, 35

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DAB is affecting the liver negatively by increasing the level of perioxidation and meanwhile decreasing the level of antioxidant protecting enzymes. And its proved that Nigella sativa prevent its action. 37

N. sativa combined with DAB treatment can effectively maintain the protective enzymatic balance. The prominent antioxidant activity of N. sativa was extensively documented in different experimental situations, including hepatocarcinogenesis In many studies, these results give clear evidence that Nigella sativa lonely induce no harmful effects on the liver. It exerts hepatoprotective carcinogens. effect against hepatobiliary Antioxidant property is mediated its actions. Investigating other underlying mechanisms merits further 38 studies.

Conclusion Nigella sativa has its multifactorial effect on the HCV infection, illness course, outcome and prevention of complications. As it has its antiviral goal effect to prevent viral infection. the anti-oxidant effect of Nigella sativa oil may represent another mechanism that contributes to its anti-viral activity. Anti-inflammatory, antiviral and antineoplastic activities of Nigella sativa have been previously documented in various in vitro and in vivo studies 39

Administration of Nigella sativa and/or Zingiber officinale ethanolic extracts to HCV patients exhibited potential therapeutic benefit Even with HCV Complication (Hepatocellular Carcinoma) it has its general antineoplastic role. It exerts hepatoprotective effect against hepatobiliary carcinogens. Antioxidant property is mediating its actions. Investigating other underlying mechanisms merits further studies until reaching to be FDA approved documented 40

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