[Diagnosis and treatment of chronic hepatitis B. Recommendations of the Czech Hepatology Society of the J. E. Purkinje Medical Society and the Society of Infectious Medicine of the J.E. Purkinje Medical Society]

Chronic hepatitis B is one of the world's most common infectious diseases. In the Czech Republic it has a prevalence of 0.56%. Antiviral therapy for chronic hepatitis B demonstrably increases quality of life and where indication criteria are met and standard therapeutic procedures are followed, it is clearly cheaper than treatment for the complications of advanced cirrhosis of the liver or hepatocellular carcinoma. At the time of issuing of this recommendation, 4 medicines were classified for the treatment of chronic hepatitis B in the Czech Republic--pegylated interferon (IFN) alpha-2a, conventional IFN alpha, lamivudine (LAM) and adefovir dipivoxil (ADV). In a number of other developed states, entecavir (ETV) and telbivudine (LdT) have also been approved for treatment. The most effective treatment available at present is pegylated IFN alpha-2a, which should be the medication of first choice for initial treatment of hepatitis B, HBeAg positive and negative forms, provided that there are no contraindications for IFN alpha treatment. Conventional (standard, classical) IFN alpha can also be used, though clinical studies have shown it to be less effective than pegylated IFN alpha-2a. The main advantage of interferon compared to other commercially available medications is its relatively shorter and more clearly defined treatment period, the high probability of permanent suppression of virus replication and seroconversion of HBeAg/anti-HBe (in HBeAg positive forms of the illness) and the non-creation of mutant strains of HBV resistant to IFN in the course of treatment. If there are contraindications for IFN alpha (pegylated or conventional) or it is ineffective or poorly tolerated, ADV, ETV, LAM or LdT can be used. LAM and LdT treatments are often accompanied by the appearance of mutant strains of HBV, that are resistant to lamivudine or LdT and therefore they are not preferred.

HFE C282Y gene variant is a risk factor for the progression to decompensated liver disease in chronic viral hepatitis C subjects in the Czech population

AIM

To determine the prevalence of selected HFE polymorphisms (C282Y, H63D and S65C) among patients with chronic viral hepatitis B and C and to investigate their role in the progression of liver disease.

METHODS

A total of 207 subjects with chronic B or C viral hepatitis and 243 healthy controls were enrolled in the case-control study. Cases were further classified into three groups according to the clinical stage of liver disease: (A) virus carriers; (B) compensated liver disease; and (C) decompensated liver disease. HFE polymorphisms were detected by polymerase chain reaction-based methodology. Fisher's exact test, chi(2) and Kruskal-Wallis tests were used to test for differences in variables studied between groups. Haplotypes were inferred in silico and their distribution compared by permutation test. Modified survival (time-to-event) analysis was used to test for the differences in the progression to the decompensated liver disease in carriers of C282Y wild-type versus mutated genotypes.

RESULTS

The frequency of HFE genotypes, alleles and haplotypes differed neither between HBV nor HCV patients versus controls. In HCV subjects: (i) the frequency of the 282Y allele was significantly higher in the (C) group compared to (B) group (12.5 vs 2.2%, respectively, P = 0.002, Fisher's exact test); and (ii) carriers of the 282Y mutation exhibited significantly faster progression to decompensated liver disease than wild-type carriers (P = 0.044, log-rank test).

CONCLUSION

Carriage of the minor HFE C282Y polymorphism is associated with decompensated liver disease and its earlier onset in the subjects with chronic viral hepatitis C in the Czech population.

[A sepsis caused by Capnocytophaga canimorsus: diagnostic and therapeutic options]

The authors present a case report of a patient with sepsis caused by Gram negative rod Capnocytophaga canimorsus resulting from a dog bite. The infection had a course of septic shock progressing into multiorgan failure and serious ischemic damage to the extremities. The etiologic agent was identified utilizing molecular genetic methods and its detailed microbiologic characteristics are provided below. The report also outlines diagnostic and therapeutic options of this otherwise most likely under-diagnosed infection.

[Hepatitis C virus infection in sex workers]

OBJECTIVE

The work assessed the prevalence of hepatitis C virus (HCV) infection in a representative sample of both male and female sex workers with the aim of assessing sexual transmission of HCV infection.

MATERIAL AND METHODS

In the first four months of 2006, a total of 209 (195 females, average age 26, average time of providing sexual services 25 months) sex workers from 29 Moravian clubs were tested for the presence of anti-HCV antibodies by the immunochromatographic assay using a drop of capillary blood.

RESULTS

Anti-HCV antibodies were detected in 2 female prostitutes (less than 1 %) of whom one reported intravenous drug use in the past suggestive of blood-borne infection rather than sexual transmission. Nearly half of the subjects (44.5 %) admitted intravenous use of drugs, especially crystal speed ("pervitin"). STDs were reported only by less than 3 % of the subjects.

CONCLUSIONS

In the Czech Republic, sexual transmission of HCV infection is of minor importance. Drug abuse is very common among sex workers.

[Fever of unknown origin--etiology and diagnostic algorithm]

Fever of unknown origin is a frequent and significant diagnostic problem often faced by physicians. The first part of the text is dedicated to its definition and wide-ranging aetiology. On the one hand, fever may be a banal and benign condition, on the other, it can be the symptom of a life threatening disease. The second part presents our suggestions for diagnostic approach to fever of unknown origin. We believe this text may become a useful tool for this extremely complex and interesting differential diagnostic. In view of extension and complexity of the topic, the text of this part is presented in full.

[Metabolic syndrome and HIV/AIDS disorder]

Up-to-date therapy has in recent years substantially modified the clinical course of HIV infections and AIDS. The progress of the disorder has changed-today it is a chronic disease of many years. Already in 1997 and 1998 it transpired that long-term HAART, highly active antiretroviral therapy, produced adverse metabolic changes, which significantly affect the subsequent progress of the disease. The mechanism responsible for these metabolic changes has not, as yet, been fully clarified-in all probability its etiology is multifactorial. Even prior to the introduction of HAART, some metabolic changes were observed in HIV-infected subjects. These changes are, however, not specific for the pathogen concerned, they are generally seen in acute inflammatory reactions. Since the introduction of HAART in 1996 the range of metabolic changes has expanded. Gradually we detect more and more anthropometric, metabolic and coagulation changes, closely resembling changes seen in the metabolic syndrome (SIR, syndrome of insulin resistance), well known from cardiology and internal medicine-dyslipoproteinaemia, insulin resistance, abdominal obesity. A combination of these disorders is clinically significant due to their role in the development of atherosclerosis and their by no means negligible involvement in the onset of ischaemic heart disease. In view of the much lower mean age of HIV-positive subjects the earlier mentioned complications should be expected in much lower age categories than with HIV-negative individuals. The paper discusses the possible pathogenesis and potential mechanisms of metabolic complications related to HAART, its impact on the cardiovascular risk and the possibilities of hypolipidaemic therapy in HIV-positive patients.

[The effect of patient's body weight, gender and baseline viral load on the efficacy of hepatitis C therapy]

Today, the standard therapy of patients with chronic HCV (hepatitis C virus) infection is based on combination of pegylated interferon alpha (PEG-IFN) and ribavirin.

THE STUDY OBJECTIVE

The aim of the study is to find correlations between patient's body weight, gender and baseline viral load and the efficacy of antiviral therapy in terms of achieving end-of-treatment viral response (ETVR) and sustained viral response (SVR). METHODS AND PATIENT SAMPLE: We enrolled 133 patients with chronic HCV infection. All of them were treated by combination of PEG-IFN alpha-2a (180 microg once a week) and ribavirin. Ribavirin doses were the following: For body weight < or = 74 kg - 800 mg daily in patients infected by genotype 2 (G2 - 3 patients) or G3 (18 patients), 1000 mg in patients infected by G1 (106 patients), G4 (1 patient) or G6 (1 patient); for body weight > or = 75 kg - 1200 mg daily in case of infection by G1.

RESULTS

To date, 122 patients completed the therapy; 107 of them completed their therapy at least 24 weeks ago, so they can be assessed for SVR. ETVR was achieved in 76% and SVR in 60% patients. Statistically higher proportion of SVR was observed in women (p = 0.039), patients with relatively lower body weight (p = 0.034), patients in lower baseline viral load (p = 0.010) and patients with genotypes 2 and 3 (p = 0,008). Correlation analysis of individual predictive factors showed the statistically significant correlation between body weight and gender (p < 0.001), gender and baseline viral load (p = 0.027) and body weight and virus genotype (p = 0.003). Therefore, the only independent predictive factor of ETVR (p = 0.020) and SVR (p = 0.010) was the level of baseline viral load.

CONCLUSION

Efficacy of PEG-IFN therapy is significantly influenced by the level of baseline viral load. According to the results of this study, patient's body weight and gender are not independent predictive factors that affect the therapy efficacy.

[The meaning of viral kinetics in the beginning of the pegylated interferon-alpha and ribavirin therapy for chronic hepatitis C]

Pegylated interferon alpha (PEG-IFN) and ribavirin combination therapy is the contemporary standard therapy of the patients chronically infected with hepatitis C virus (HCV).

OBJECTIVE OF THE STUDY

The study is monitoring the changes in viremy through the changes of HCV RNA in serum before and during antiviral therapy and it attempts to find a relationship between the viral kinetics in the beginning of the therapy and the sustained virologic response. SET OF THE PATIENTS AND THE METHODICS: The study involved 133 patients with chronic infection with HCV, of the average age of 38 years (ranged 18-68 years). 86 of them were men. There were 88 patients who had not been treated before (naive patients), 19 of them were relabing and 26 were non-responders to the previous therapy with conventional IFNalpha and ribavirin. 106 patients (80%) were infected with genotype (G) 1, 3 (2%) with G2, 18 (14%) with G3, 1 patient with G4 and 1 with G6 (under 1%), in 4 (3%) the genotype could not be determined. All of them were treated with the combination of PEG-IFNalpha-2a (180 microg once a week) and ribavirin (800 mg per day in the infection with G2 or G3, 1000 mg at the infection with G1 and the weight up to 74 kg, 1200 mg per day at the infection with G1 and the weight 75 kg and higher).

RESULTS

Up to now, 122 patients completed the therapy and 93 of them (76%) had negative HCV RNA in serum at the time of completion of the therapy. Negative HCV RNA after 24 weeks (sustained virologic response SVR) after the completion of the therapy had 64/107 (60%) of the treated patients. In the course of 12 weeks of the therapy the viremy decreased by at least 2 decadic logarithms (early virologic response - EVR) in 87 patients (82%) and in 63 of them (72%) also SVR was noted. Only 19 patients had not EVR and just 1 one of them, nevertheless, achieved SVR (5%).

CONCLUSION

The achievement of EVR is a prerequisite to the successful therapy for chronic infection with HCV with the combination of PEG-IFNalpha and ribavirin. Quantitative determination of HCV RNA in serum before and during antiviral therapy is a prerequisite to the modern antiviral therapy for chronic infection with HCV.

A Double-blind Placebo-Controlled Study of Emtricitabine in Chronic Hepatitis B

BACKGROUND

Emtricitabine is a nucleoside analogue approved for treatment of human immunodeficiency virus 1 with clinical activity against hepatitis B virus (HBV).

METHODS

To compare the safety and efficacy of emtricitabine with placebo in patients with HBV, we conducted a randomized (2:1), double-blind study at 34 sites in North America, Asia, and Europe that enrolled adults between November 2000 and July 2002 who had chronic HBV infection but had never been exposed to nucleoside or nucleotide treatment. Each patient received either 200 mg of emtricitabine (n=167) or placebo (n=81) once daily for 48 weeks and underwent a pretreatment and end-of-treatment liver biopsy. Histologic improvement was defined as a 2-point reduction in Knodell necroinflammatory score with no worsening in fibrosis.

RESULTS

At the end of treatment, 103 (62%) of 167 patients receiving active treatment had improved liver histologic findings vs 20 (25%) of 81 receiving placebo (P<.001), with significance demonstrated in subgroups positive (P<.001) and negative (P=.002) for hepatitis Be (HBe) antigen. Serum HBV DNA readings showed less than 400 copies/mL in 91 (54%) of 167 patients in the emtricitabine group vs 2 (2%) of 81 in the placebo group (P<.001); alanine aminotransferase levels were normal in 65% (109/167) vs 25% (20/81), respectively (P<.001). At week 48, 20 (13%) of 159 patients in the emtricitabine group with HBV DNA measured at the end of treatment had detectable virus with resistance mutations (95% confidence interval, 8%-18%). The rate of seroconversion to anti-HBe (12%) and HBe antigen loss were not different between arms. The safety profile of emtricitabine during treatment was similar to that of placebo. Posttreatment exacerbation of HBV infection developed in 23% of emtricitabine-treated patients.

CONCLUSION

In patients with chronic HBV, both positive and negative for HBe antigen, 48 weeks of emtricitabine treatment resulted in significant histologic, virologic, and biochemical improvement.

[Atypital localisation of pyoderma gangraenosum in patient with ulcerative colitis]

The authors present a case of 61-year-old man with ulcerative colitis and with extraintestinal manifestation of the disease in the form of pyoderma gangraenosum. Multiple skin defects, which developed in atypical localisation (extensive affection of facial and hairy parts of the head) in patient with chronically active form of ulcerative colitis were complicated with bacterial contamination of methicilin-resistant strains of Staphylococcus aureus. After application of the parenteral feeding, corticotherapy and targeted antibiotic therapy the subjective and objective status of the patient markedly improved, stool frequency was reduced, admixture of blood in the stool disappeared, temperatures fell back and there was a decrease in activity of non-specific bowel inflammation in laboratory findings. However endoscopic examination of the intestine confirmed the finding of chronically active ulcerative colitis with ulcerations and bridging polyps. Patient was indicated to total colectomy, but he refused it.

Efficacy and safety of chronic hepatitis C treatment in hemophilic patients

BACKGROUND/AIMS

Chronic hepatitis C infection is very common among hemophiliacs in the developed World.

METHODOLOGY

Retrospective evaluation of the treatment results in hemophiliacs with chronic hepatitis C, all infected with genotype 1b. Twelve patients were treated with interferon-alpha monotherapy, 21 patients with interferon-alpha and ribavirin, and 3 patients with pegylated interferon and ribavirin, all for 48 weeks.

RESULTS

Sustained virologic response (defined as an undetectable serum HCV RNA level 24 weeks after treatment was completed) was not achieved in any of 12 patients treated with interferon-alpha alone. Combination therapy with interferon-alpha and ribavirin was associated with better results: 4/10 (40%) patients still untreated with interferon-alpha, 2/4 (50%) relapsers, and 2/7 (29%) non-responders to previous interferon-alpha monotherapy achieved sustained virologic responses. Combination therapy with pegylated interferon and ribavirin has been used in 3 patients. Sustained response was achieved in one patient who had relapsed after treatment with interferon-alpha and ribavirin and in 1 of 2 non-responders to this combination therapy. There were no serious adverse events and it was not necessary to reduce dosages or even cease therapy prematurely.

CONCLUSIONS

The efficacy and tolerability of antiviral treatment in hemophiliacs did not differ from other patients with chronic hepatitis C.

[Haemopoiesis defects in HIV/AIDS-anaemia.]

Under physiological conditions haemopoiesis is continuous and maintains a stable number of blood elements. A defect at any stage presents as anaemia, neutropenia, thrombocytopenia or their combinations. The cause of haematological abnormalities with an HIV infection is multifactorial. HIV/AIDS patients may present identical haematological disorders as patients free of an HIV infection. Additionally, HIV-positive subjects tend to present disorders specific of an HIV infection. Anaemia may also be the first manifestation of an as yet undetected HIV infection. Moreover, many drugs used in the treatment of HIV/AIDS significantly affect haemopoiesis. Whatever the cause of anaemia, it is essential to initiate simultaneously with its treatment an appropriate highly active antiretroviral therapy. An antiretroviral therapy along the lines of state-of-the-art pharmacotherapy of HIV/AIDS significantly improves the efficacy of the actual haematological treatment. Key words: HIV infection-haemopoiesis-anaemia-antiretroviral therapy.

Bacterial infection and acute bleeding from upper gastrointestinal tract in patients with liver cirrhosis

BACKGROUND/AIMS

Acute bleeding from the upper gastrointestinal tract is a common and serious complication of liver cirrhosis. It is believed that bacterial infection may be the immediate cause of the bleeding and the latest meta-analyses show that bacterial infection is an independent predictive factor of the failure to stop bleeding.

METHODOLOGY

The authors evaluated the presence of bacterial infection (blood, urine, throat and ascitic fluid) in 35 consecutive patients with liver cirrhosis and acute bleeding with portal hypertension and compared these results with a group of 35 patients with liver cirrhosis with portal hypertension without acute bleeding.

RESULTS

According to the results obtained, there is a statistically higher incidence of bacterial infection among patients with acute bleeding with portal hypertension (25 of 35 patients, 71%) than among patients with liver cirrhosis and portal hypertension without acute bleeding (14 of 35 patients, 40%, p < 0.01). The incidence of bacteriological findings in blood and throat samples is statistically higher in patients with acute bleeding as opposed to the control group (p < 0.05).

CONCLUSIONS

These results confirm the necessity of administering antibiotic prophylaxis to all cirrhotic patients with variceal bleeding, not just to those with confirmed infection or symptoms thereof.

[Adefovir dipivoxil-a new effective treatment for chronic infection with hepatitits B virus.]

Adefovir dipivoxil is an up-to-date drug for the treatment of chronic hepatitis B. Adefovir dipivoxil is a lipophilic prodrug of adefovir, an analogue of adenosine monophosphate (AMP). It suppresses efficaciously the replication of the hepatitis B virus and of other viruses. After conversion to its active metabolite, it can inhibit both DNA polymerase and reverse transcriptase. It is well absorbed by the intestinal mucosa, its bio-availability is approx. 59%, it is distributed to most tissues and eliminated by the kidneys. There are no known clinically significant drug interactions. The recommended dose is 10 mg/day; in patients with renal impairment the dose must be adjusted. Treatment has to continue for at least one year. Compared with lamivudine, adefovir resistance develops more slowly. Virus resistant to lamivudine is sensitive to adefovir and vice versa. The efficacy and safety of this treatment have been verified in four published clinical trials with more than one thousand patients, including patients with decompensated cirrhosis prior to and after liver transplantation. In these patients there was an improvement of several virological, biochemical and clinical markers. The drug is well tolerated. Seen adverse side-effects were gastrointestinal disorders, headache and a mild to moderate increase in serum creatinine. There are no specific contraindications to the therapy, with the exception of hypersensitivity. However, there are only insufficient data on the administration of the drug to pregnant women and to children. Adefovir dipivoxil offers a new treatment possibility for patients presenting a chronic infection with the hepatitis B virus, especially those infected with a lamivudine-resistant virus. Key words: adefovir dipivoxil-chronic hepatitis B-hepatitis B virus-lamivudine.

Hepatitis D

Hepatitis D virus (HDV) is a small, RNA-containing virus that requires the concomitant presence of Hepatitis B virus (HBV) in an obligate manner for its survival and pathogenicity. HDV infection is very uncommon in Czech Republic. The results of antiviral therapy of hepatitis D patients are not satisfactory. Alpha-interferon (alpha-IFN) in high doses (9-10 MU three times a week for 12 months) is usually recommended.

[What risk is a health care worker infected with hepatitis B or C virus for his patients?]

Presently, there are no legislative standards in the Czech Republic banning health care workers with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection to do activities with a risk of the transmission of these viral infections to patients (surgeries and other invasive interventions). In a range of developed countries in the world individuals with chronic HBV infection, HBeAg positive individuals, have a restricted access to the risk interventions. A quantitative assessment of viremia is important in the health care workers infected with HBeAg-minus mutant of the virus. There are particular critical viremia values set up (serum HBV DNA levels) which exceeding in the health care workers leads to banning them to do the risk interventions. In cases of proved transmission of hepatitis B infection from a health care worker to a patient, the ban of doing risk interventions is a rule. Transmission of HCV infection from a health care worker to a patient is much less probable so the individuals with chronic hepatitis C are usually not forbidden to make invasive procedures. An exception are cases when there was a patient infected by a particular health care worker in the past. There are various attitudes to the health care workers with chronic HBV or HCV infection in various countries of the world. A necessity to reach a definite consensus is necessary. The first step to it are common recommendations of 12 European countries and the USA which are repeatedly cited in the text. We can expect that these problems will have to be solved very soon in the Czech Republic too.

[Marseille fever imported from Spain]

The authors are presenting a case of young female with Marseille fever contracted in Spain. The clinical manifestation of the illness was characterized by fevers, exanthema, headache and a typical skin rash ("the black spot") and prompted the authors to strongly consider the diagnosis of Marseille fever and to initiate appropriate antibiotic therapy. The diagnosis was confirmed later by serology. The article introduces new taxonomy of Rickettsial species and presents an overview and epidemiological aspects of specific diseases caused by them. The clinical manifestation, diagnosis and treatment of Marseille fever are discussed in greater detail.

[Large-droplet liver steatosis in celiac disease]

Authors monitored a case of a 25 years old woman who was admitted for swelling of lower limbs. Laboratory results showed hypoproteinemia, elevation of liver enzymes, and prolonged prothrombin time. Ultrasound examination proved hepatomegalia with diffusely hyperechogenic liver without central lesion. Computer tomography confirmed hepatomegalia with diffusely hyperechogenic liver and a suspicion of liver steatosis was expressed. Liver biopsy confirmed serious diffuse large droplet steatosis of unclear genesis. Carried out examinations excluded infectious and autoimmune liver diseases, metabolic diseases, and congenital liver diseases (Wilson's disease, porphyria, haemochromatosis etc.). Laboratory results showed gliadin, endomysin, and reticulin antibodies. An enteroscopy picture showed villi decrease. Histology examination of a biopsy specimen confirmed total villi atrophy with non-differentiated enterocytes and round-cell cellulisation of epithelium and proprium. Histology and histochemical findings were distinct proves of coeliac disease. A patient was prescribed a gluten free diet. Her metabolic parameters (normalisation of albumine levels, prothrombine time, and trace elements) and anino transferase levels gradually improved. This case documents development of a serious liver disorder as a result of malnutrition which developed in a young woman as a result of unrecognised coeliac disease.

[Procalcitonin as an indicator of infection in patients with liver cirrhosis]

Incidence of bacterial infections in hospitalised patients with liver disease is high. Due to a liver dysfunction immune reactivity is significantly impaired and bacterial infections are more frequent. Also incidence of nosocomial infections is higher in patients with liver disease compared to patients hospitalised for other conditions. To make a differential diagnosis of infectious and non-infectious aetiology of an inflammation is very difficult. Characteristic laboratory tests for bacterial infection include test of a number of leucocytes in peripheral blood, differential count of leucocytes, erythrocyte sedimentation, procalcitonin, C-reactive protein, tumor necrosis factor alpha, interleukin-1, interleukin-6, interleukin-8, and complement fragment C3a. Clinically the most significant are C-reactive protein test and procalcitonin test. Procalcitonin is a protein, a calcitonin precursor, which is in healthy individuals produced by cells of thyroid gland. A half-life of procalcitonin in serum is 20-24 hours which makes it suitable for daily monitoring and enables to control a course of treatment and to distinguish bacterial infection from other types of inflammations. Procalcitonin levels rise in bacterial, parasite, and yeast infections. Elevated procalcitonin levels appear only in inflammations of an infectious etiology with systemic signs. In patients with liver cirrhosis bacterial infections are more frequent. They usually include spontaneous bacterial peritonitis, infection of the respiratory system, urinary infections, and bacteremia. A timely proof of a bacterial infection and an appropriate and effective antibiotic therapy lead to an improvement of the general state of a patient and to his/her better prognosis. Procalcitonin determination is appropriate for diagnosing infections and control of treatment.

[Successful treatment of chronic hepatitis C in hemophiliacs based on historical development of therapeutic protocols]

Chronic infection with hepatitis C virus is very frequent among hemophilic patients in all developed counties, including the Czech Republic. Because of a possibility of developing serious terminal stages of infection, liver cirrhosis and hepatocellular carcinoma, the tendency in treatment of patients with chronic hepatitis C is to start it as soon as possible and thus reduce the probability of developing these advanced stages of disease which are difficult to treat. Treatment of hemophilic patients with chronic hepatitis C started in the Department of Infectious Diseases, University Hospital Brno Bohunice, in 1996. Used treatment schemes have reflected historical evolution of treatments used to treat chronic hepatitis C. Initially, alpha-interferon (IFN) was administered in monotheraphy (6 patients), later, since 1999, a combination of alpha-IFN and ribavirin was administered (13 patients), and since 2001 a combination of pegylated interferon (PEG-IFN) and ribavirin (3 patients) was administered. In all the patients the individual treatments took 12 month. Sustained negativization of HCV RNA in serum has not been achieved in any patient treated only with alpha-IFN. In patients who were administered the combination of alpha-IFN and ribavirin this effect appeared in 4 from 7 cases without history of treatment with alpha-IFN (57%), one from 2 relapses and one from 3 non-responders. The combination PEG-IFN and ribavirin was effective in the only one patient who relapsed after alpha-IFN and ribavirin and in one from the two non-responders to this combination. The tolerance and safety of treatment was good in haemophilia patients and could be fully compared to those in other patients with chronic hepatitis C.

Treatment of chronic hepatitis C in hemophilic patients

Chronic hepatitis C infection is common among hemophiliacs in all the developed countries. Since 1996, only alpha-interferon (alpha-IFN) in monotherapy has been used for the treatment of chronic hepatitis C in hemophiliacs (6 patients). In Czech Republic a combination therapy with alpha-IFN and ribavirin has been used since 1999 (13 patients). Finally, a combination therapy with pegylated alpha-IFN (PEG-alpha-IFN) and ribavirin is being used since 2001 (still 3 patients). In all cases, the treatment lasted 48 weeks. A sustained virological response (SVR, defined as an undetectable serum HCV RNA level 24 weeks after the treatment was completed) was not achieved in any of 6 patients treated with alpha-IFN alone. A combination therapy with alpha-IFN and ribavirin yielded better results: four of eight patients still untreated with alpha-IFN (naive patients), one of two relapsers, and one of three non-responders to previous alpha-IFN monotherapy achieved SVR. So far the combination therapy with PEG-alpha-IFN and ribavirin has been used only in 3 patients. SVR was achieved in one patient who had relapsed after the combination therapy with IFN-alpha and ribavirin, and in 1 of 2 non-responders to this therapy. We conclude that the efficacy and tolerability of the treatment of chronic hepatitis C in hemophiliacs did not differ from that of chronic hepatitis C in other patients.

[Antibiotic prophylaxis in patients with acute hemorrhage due to portal hypertension--personal experience]

Acute bleeding from upper part of gastrointestinal tract is a frequent and serious complication affecting 20 to 60% of patients with liver cirrhosis and portal hypertension. It is associated with a high death rate of 30 to 50% and a frequent relapse of bleeding occurs in up to 40% of these patients. The most recent meta-analyses have shown that bacterial infection is an independent factor in the failure of blood hemostasis and significantly influenced mortality in these patients. The authors investigated 25 patients with acute bleeding from the upper part of gastrointestinal tract due to portal hypertension in patients with liver cirrhosis. Irrespective of the proved bacterial infection the patients were given antibiotic prophylaxis. In 13 patients the authors administered norfloxacin orally and 12 patients were treated intravenously with ampicilin/sulbactam. The prophylaxis of the bleeding cirrhotic patients by norfloxacin (orally) resulted in a statistically significant prevention of early relapse as compared with the therapy by ampicilin/sulbactam (intravenously). The death rate reached 40% in spite of the antibiotic prophylaxis. There was no significant difference in the death rate between the two groups with different treatments.

Unusual Bochdalek hernia in puerperium

The authors present an unusual case of a true left-sided posterolateral (Bochdalek) hernia containing stomach, transverse colon and spleen within a hernial sac in a 25-year-old female patient. They presume this voluminous herniation took place due to a rupture of congenitally preformed hernial ostium on account of increased intraabdominal pressure during repeated pregnancy. They describe an effective surgical transabdominal laparoscopic treatment.

Treatment of chronic hepatitis B in 2002

Viral hepatitis B is a serious health problem, above all in the world's developing countries. It is estimated that two billion people will be infected with the hepatitis B virus in the course of their lives and between 350 and 400 million people are chronically infected at present. The aims of the treatment of chronic hepatitis B are sustained suppression of viral replication and remission of liver disease. For the treatment of chronic hepatitis B two drugs have been licensed worldwide: alpha-interferon and lamivudine. In chronic hepatitis B therapy there are new developments in antiviral, such as nucleoside analogues--entecavir, emtricitabine, clevudine, beta-L-nucleosides. Studies comparing pegylated interferon with lamivudine and with the combination of lamivudine and pegylated interferon are in progress. Several innovative antiviral approaches have been evaluated in vitro, and in animal models of hepadnavirus infections. These approaches are including antisense oligonucleotides, ribozymes, inhibitors blocking virus entry into hepatocytes, and decoy virus or dominant negative mutants.

[Initial experience with treatment of chronic hepatitis C in HIV-positive patients]

A 30 years old man originating from Ukraine was infected by the human immunodeficiency virus (HIV) and virus of hepatitis C (HCV) due to injection administration of drugs of abuse in his own country before coming to Czech Republic. He was infected by genotype 3 of HCV and the infection became chronic. Under the influence of a three-combination anti-retrovirus therapy his conditions related to HIV infection became stable and it proved to be possible to apply a combined treatment by alpha-interferon and ribavirin at commonly used doses for the period of 12 months. In the course of therapy the HCV nucleic acid (HCV RNA) disappeared from serum and serum activity of alanine aminotransferase (ALT) became normal. However, two months after the therapy ended a relapse of the disease occurred--HCV RNA reappeared in serum and ALT activity increased. The therapy was well tolerated. A rapid decrease of hemoglobin level during the first four weeks of therapy was stopped by reduction of ribavirin dose.

Lamivudine and 24 weeks of lamivudine/interferon combination therapy for hepatitis B e antigen-positive chronic hepatitis B in interferon nonresponders

BACKGROUND/AIMS

Lamivudine is effective in treatment-naive patients with chronic hepatitis B, but its role in interferon nonresponders has not been described. We assessed lamivudine treatment, with or without added interferon, in patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B who had failed interferon therapy previously.

METHODS

Patients were randomized to lamivudine (100 mg) or placebo for 52 weeks or to a 24-week regimen of lamivudine plus interferon. Primary treatment comparisons were at week 52, with a 16-week posttreatment follow-up period. Measurements included histology (primary endpoint), HBeAg response, normalization of alanine aminotransferase, reduction of hepatitis B virus (HBV) DNA, and safety.

RESULTS

Among 238 patients, histologic response was significantly more common in patients treated with lamivudine (52 versus placebo 25%, P=0.002) or the combination regimen (32%, P=0.01). HBeAg loss was also more common with lamivudine (33 versus 13 versus 21%), as were virologic and alanine aminotransferase responses. Among 28 subjects with HBeAg loss/seroconversion, 71% had durable responses 16 weeks posttreatment.

CONCLUSIONS

Lamivudine for 52 weeks is as effective in interferon nonresponders as in previously reported treatment-naive patients; however, a combination of lamivudine for 24 weeks and interferon for 16 weeks was not effective in this population.

[Bacterial infections in patients with acute hemorrhage due to portal hypertension--personal experience]

Acute haemorrhage from the upper gastrointestinal tract is a frequent and serious complication which affects 20-60% patients with cirrhosis of the liver and portal hypertension. It is assumed that bacterial infections can be the direct cause of haemorrhage but accurate data on the influence of infection on the development and course of haemorrhage are lacking. Acute haemorrhage as a result of portal hypertension has a very high mortality, 30-50%, and an early relapse of haemorrhage occurs in as many as 40% of these patients. Most recent meta-analyses indicate that bacterial infection is an independent prognostic factor in failure of haemostasis and has a significant impact on the mortality of these patients. The authors examined for the presence of bacterial infection (blood, urine, throat, ascites) 25 patients with cirrhosis of the liver and acute haemorrhage as a result of portal hypertension and compared the results with a group of 25 patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. According to the results in patients with acute haemorrhage due to portal hypertension there is a significantly higher incidence of bacterial infections than in patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. The results confirm the necessity to administer antibiotic prophylaxis to cirrhotic patients with varicose bleeding, not only to patients with symptoms and evidence of infection but also in their absence. Antibiotic prophylaxis extends the survival period of these patients.

Efficacy of alpha-interferon therapy of chronic hepatitis patients infected with wild type hepatitis B virus and HBEAG-minus mutant

The aim of this study was to evaluate the efficacy of alpha-interferon (alpha-IFN) treatment of 56 chronic hepatitis B (HB) patients positive for HB e antigen (HBeAg), which were previously not treated with alpha-IFN (group A). Seven of them, which did not respond to initial alpha-IFN treatment, were subjected to additional treatment with alpha-IFN (group B). Another 7 patients with chronic HB caused apparently by an HBeAg-minus HB virus (HBV) mutant represented group C. In the alpha-IFN treatment, 5 megaunits (MU) of alpha-IFN were administered subcutaneously three times a week for six months. A trend of improvement of important markers of the disease in the treated patients could be seen with increasing time after completion of the treatment even though it was not statistically significant. In group A, the absence of serum HBV DNA was found in 43% of the patients at the end of the treatment, in 41% 6 months later, and in 46% 12 months later. At the same time intervals group A showed negative HBeAg in 36%, 39% and 46%, positive anti-HBeAg in 36%, 38%, and 46%, negative HBsAg in 9%, 11%, and 14%, and normal level of alanine transaminase (ALT) in 23%, 39%, and 44%, respectively. A trend toward better results of alpha-interferon therapy for the group A patients displaying lower baseline viremia and higher ALT activity could be seen; however, this relationship was not statistically significant. Groups B and C were too small for statistical analysis. Nevertheless, 4 of 7 patients of group B were negative for HBV DNA 12 months after the treatment and HBV DNA was eliminated during the treatment in all patients of group C; however, 3 patients relapsed after the treatment.

[Influence of bacterial infection on the development and course of acute haemorrhage from oesophageal varices]

Acute haemorrhage from the upper portion of the gastrointestinal tract is a frequent complication which develops in ca 35-66 % of patients with cirrhosis of the liver and portal hypertension. It is assumed that one of the trigger mechanisms of varicose haemorrhage can be bacterial infection. However accurate data on the influence of infection on the development and course of haemorrhage are still lacking. The mortality of patients bleeding from oesophageal varices is very high (30-70%). Usually the cause of death is not haemorrhagic shock but haemorrhage-induced changes which lead to hepatic failure. It is assumed that in this very process an important part is played by bacterial infection with subsequent release of endotoxins. Most recent metaanalyses indicate that bacterial infection is an independent prognostic factor as regards failure to arrest haemorrhage and influences in a significant way the mortality of these patients. Antibiotic treatment of patients with varicose haemorrhage increases the survival period of these patients. Therefore to cirrhotic patients with varicose haemorrhage antibiotics should be administered prophylactically, i.e. not only to patients with evidence of infection but also those without these symptoms. The authors consider as the optimal antibiotic treatment administration of quinolones orally or by the i.v. route, possibly cephalosporins which seem to be equally effective as quinolones.

[The SEN virus--will there be another letter in the alphabet of viral hepatitis?] ]

The SEN virus (SENV) is a small nonenveloped single-stranded DNA virus which is probably a circovirus. By phylogenetic analysis it is possible to differentiate genotypes SENV A-H. The pathway of transmission of infection is not known so far but the infection by this virus is frequent in recipients of blood transfusions and liver grafts and in intravenous drug addicts. This suggests possible parenteral transmission of infection. Other routes of transmission of the infection are also possible as the virus can be detected also in a significant proportion of young subjects without the risk of parenteral infection in the case-history. Whether SENV causes hepatitis has not been proved unequivocally so far. The prevalence of this infection does not differ significantly in patients with different liver diseases, acute or chronic viral or non-viral. SENV infection very probably does not influence the course of chronic hepatitis C.

Sarcoidosis associated with interferon-alpha therapy for chronic hepatitis B

Sarcoidosis is one of the possible rare complications of interferon-alpha (IFN-alpha) therapy. Only a few reports have been published on this disease, and these have been associated with the treatment of malignant diseases, essential thrombocytosis, and chronic hepatitis C. We report on a 64-year-old man with chronic hepatitis B (HBsAg, HBeAg, HBV DNA-positive) who was treated with recombinant IFN-alpha-2b (5 MU three times weekly) for 28 weeks. Tolerance to treatment was very good; only a mild flu-like syndrome appeared. Twelve months after completing the therapy, a chest X-ray was performed that revealed bilateral hilar masses, and high-resolution computed tomography (HRCT) of the chest indicated the presence of lymphadenopathy of the anterior and middle mediastinum. Therefore, a right-sided thoracoscopy was performed with excision of a 27-mm lymph node and a histological diagnosis of sarcoidosis was made. No medication for sarcoidosis was indicated. Complete normalization of mediastinal lymphadenopathy (verified on HRCT and chest X-ray) was confirmed 1 year following the thoracoscopy. To our knowledge, this is the first case wherein occurrence of sarcoidosis in a chronic hepatitis B patient treated with IFN-alpha is described. We suppose that IFN-alpha, as a potent stimulator of T-helper 1 (Th1) immune responses, may trigger the compartmentalized Th1 reaction that has been shown to take place in sarcoidosis.

Treatment of chronic hepatitis C patients with combination of alpha-interferon and ribavirin, consensus and pegylated interferons

Hepatitis C is a major health problem. In recent years, the treatment of choice is alpha-interferon in combination with ribavirin. For patients with failure of this treatment the therapy with consensus or pegylated interferons, in monotherapy or in combination with ribavirin, present other possibilities. We can expect the development more potent antiviral drugs or immune modulators for patients, which are primary resistant to alpha-interferon. (Tab. 3, Ref. 31)

[Acute hemorrhage of the upper digestive tract--personal experience]

The authors submit a retrospective investigation of 50 patients hospitalized at the intensive care unit of the Medical gastroenterological department, Faculty Hospital Brno treated in 1999 with the diagnosis of acute haemorrhage into the upper digestive tract. In the investigated group the most frequent cause of haemorrhage was portal hypertension (21 patients, 32.8%) and a peptic gastroduodenal lesion (15 patients, 23.4%). During the investigation period 12 patients died (18.8%), 6 developed haemorrhage as a complication of a serious condition (decompensated cirrhosis of the liver). In haemorrhage from oesophageal and gastric varicosities pharmacotherapy is equally important as endoscopic intervention.

Autoantibodies to asialoglycoprotein receptor in chronic hepatitis C patients

The aim of this study was to determine the incidence of autoantibodies to asialoglycoprotein receptor (ASGPR, anti-ASGPR) in chronic hepatitis C patients and to characterize the anti-ASGPR-positive and anti-ASGPR-negative patients in more detail. A total of 79 chronic hepatitis C patients were screened for the presence anti-ASGPR by ELISA. Anti-ASGPR were detected in 11 (13.9%) patients. No significant differences were found between the anti-ASGPR-positive and anti-ASGPR-negative patients in age, alanine transaminase (ALT) activity, histological findings and response and tolerance to alpha-interferon (alpha-IFN) therapy. The male predominance in the anti-ASGPR positive group was statistically significant. It was surprising that other tested autoantibodies (antinuclear autoantibodies [ANA], smooth muscle autoantibodies [SMA], type 1 liver-kidney microsome autoantibodies [LKM-1], anti-thyroglobulin and thyroid microsome autoantibodies) and increased levels of immunoglobulins A, G and/or M were observed significantly more frequently in the anti-ASGPR-negative group.

[Acute pancreatitis as the road to diagnosis of primary hyperparathyroidism]

The authors present the case of a 78-year-old female patient who was admitted on account of acute pancreatitis complicated by acute myocardial infarction. The authors detected in the patient a serum repeatedly high calcium levels and high levels of intact parathormone. Scintigraphic examination revealed marked foci in the middle of the neck at the level of the inferior pole of the thyroid gland. These examinations confirmed the diagnosis of primary hyperparathyroidism. In view of the patient a serious condition, conservative treatment of hypercalcaemia and acute pancreatitis and myocardial infarction was started. The patient was released into domiciliary care after 40 days in hospital in a state of cardiopulmonary compensation, with cystic transformation of the pancreas and without signs of acute pancreatitis.

[An attack of malignant hyperthermia caused by a combination of the effects of succinylcholine, increased physical exertion and alcohol abuse]

The authors submit the case-history of a 29-year-old man, followed up on account of liver steatosis with a toxic-nutritional etiology who developed, after previous increased physical exertion and alcohol abuse, fever associated with major muscular weakness. Gradually he developed an amental delirious state which was evaluated as suspect delirium tremens. Fever of 40-41 degrees C continued, the patient developed muscular rigidity, tremor and hypotension. After intubation during which succinylcholine was administered, the patient's condition deteriorated further with a rise of temperature and muscular rigidity. The patient developed acute renal failure with anuria and the necessity of repeated haemodialyses and severe acidosis of the mixed type on account of which he was intubated and switched to artificial ventilation. According to the case-history clinical and laboratory picture of the disease (extremely high creatine kinase activity, hyperkalaemia, acidosis, hepatorenal failure) malignant hyperthermia was suspected. After a single intravenous injection of sodium dantrolene, 2.5 mg/kg, the temperature dropped and within 24 hours the patient was afebrile. Gradually the acidosis improved, the blood pressure became stabilized and artificial ventilation was no longer used. The patient was discharged after 34 days in hospital in a state of cardiopulmonary compensation with mild polyuria but without signs of retention of nitrogenous substances with sideropenic anaemia and marginal creatine kinase and lactate dehydrogenase values. Within one month after discharge the laboratory values reached normal levels and only slight muscular weakness and greater fatiguability persisted.

[Indications for immunosuppressive therapy in hepatology]

Immunosuppressive, and in particular corticosteroid therapy, has held its firm place in hepatology for many years. With the development of knowledge on the etiology of liver diseases however the spectrum of diseases where this treatment is administered changes. The authors pay attention in particular to autoimmune hepatitis where the indication for immunosuppressive treatment is beyond doubt. They deal also with viral hepatitis, alcoholic hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis where views on the administration of corticosteroids or immunosuppressive drugs are not uniform. In viral hepatitis administration of corticosteroids is nowadays considered contraindicated as it increases the danger of virus replication and the associated higher risk of a protracted course or development of chronicity. In the contemporary literature the view predominates that corticosteroids reduce the mortality in patients with severe alcoholic hepatitis. In some patients with primary biliary cirrhosis and primary sclerosing cholangitis addition of corticosteroids can improve the inadequate effect of monotherapy with ursodeoxycholic acid. The authors emphasize the necessity of individual evaluation of every single patient before selecting optimal treatment.

[Mutants of the hepatitis virus]

The variability of genomes of the hepatitis viruses leads to the development of viral mutants which are of great importance not only for epidemiology and therapy but also for the prevention of infections they cause. Contemporary knowledge indicates that investigation of mutants of hepatitis viruses is not only necessary for the understanding of the epidemiology, spread, elucidation of the severity of the disease and sequelae after acute infection but also for our therapeutic possibilities in different forms of viral hepatitis (VH). The submitted paper reviews the most important mutants of different types of VH (HA, HB, HC, HD, and HE).