Vacuolating cytotoxin of Helicobacter pylori induces apoptosis in the human gastric epithelial cell line AGS

Helicobacter pylori induces cell death by apoptosis. However, the apoptosis-inducing factor is still unknown. The virulence factor vacuolating cytotoxin A (VacA) is a potential candidate, and thus its role in apoptosis induction was investigated in the human gastric epithelial cell line AGS. The supernatant from the vacA wild-type strain P12 was able to induce apoptotic cell death, whereas the supernatant from its isogenic mutant strain P14 could not. That VacA was indeed the apoptosis-inducing factor was demonstrated further by substantial reduction of apoptosis upon treatment of AGS cells with a supernatant specifically depleted of native VacA. Furthermore, a recombinant VacA produced in Escherichia coli was also able to induce apoptosis in AGS cells but failed to induce cellular vacuolation. These findings demonstrate that the vacuolating cytototoxin of H. pylori is a bacterial factor capable of inducing apoptosis in gastric epithelial cells.

IRP1 activation by extracellular oxidative stress in the perfused rat liver

The expression of several proteins with critical functions in iron metabolism is regulated post-transcriptionally by the binding of iron regulatory proteins, IRP1 and IRP2, to mRNA iron responsive elements (IREs). In iron-deficient tissues and cultured cells, both IRP1 and IRP2 are activated for high affinity IRE binding. Previous work showed that IRP1 is also activated when cultured cells are exposed to H(2)O(2). The well established role of iron and H(2)O(2) in tissue injury (based on Fenton chemistry) suggests that this response may have important pathophysiological implications. This is particularly relevant in inflammation, where cytotoxic immune cells release large amounts of reactive oxygen species. Here, we describe a rat liver perfusion model to study IRP1 activation under H(2)O(2) generation conditions that mimic a physiological inflammatory response, using steady-state concentrations of H(2)O(2) produced by a glucose/ glucose oxidase/catalase system. We show first that stimulated neutrophils are able to increase serum levels of H(2)O(2) by a factor of 10, even in the presence of H(2)O(2)-degrading erythrocytes. We further show that perfusion of rat liver with glucose oxidase leads to a rapid activation of IRE binding activity in the intact organ. Mobility shift assays with liver extracts and IRP1 or IRP2-specific probes indicate that only IRP1 responds to H(2)O(2). Our study demonstrates a principal existence of iron regulation by oxidative stress at the intact organ level. It also provides a link between iron metabolism and the inflammatory response, as H(2)O(2) is a major product of the oxidative burst of neutrophils and macrophages.

[Veno-occlusive liver disease after total infradiaphragmatic lymphoid irradiation. A rare complication]

BACKGROUND

Radiotherapy is potentially curative in early stages of follicle center lymphoma. Frequent side effects are pancytopenia, nausea and abdominal discomfort. A radiation-induced liver injury with serious clinical symptoms and changes in liver function is a rare complication.

CASE REPORT

Whole abdomen was irradiated in a 49-year-old patient with a centrocytic-centroblastic lymphoma, stage IA (localization: left inguinal region). A total dose of 30 Gy was delivered in a weekly fractionation of five times 1.5 Gy. Kidneys were protected by shielding after a dose of 13.5 Gy, liver blocks were positioned after 25 Gy. During the last 2 days of therapy the patient presented with weight gain, ascites, dyspnoea and elevated liver enzymes. Diagnostics revealed hepatosplenomegaly, ascites and an increased portosystemic pressure gradient. Liver biopsy specimen showed a veno-occlusive disease. Complete relief of symptomatology was achieved within 7 days following placement of a transjugular intrahepatic portosystemic stent-shunt (TIPSS), heparinization and diuretics. Liver enzymes are in the normal range.

CONCLUSION

Veno-occlusive disease of the liver (VOD) is a very rare side effect of primary abdominal irradiation of follicle center lymphoma. This complication should be taken into consideration if a patient presents with upper right quadrant pain, ascites and elevation of liver enzymes especially within 4 months following radiotherapy. Genesis of veno-occlusive disease, diagnostics, therapy and a review of the literature are presented.

Interleukin-6 expression and regulation in rat enteric glial cells

As yet, little is known about the function of the glia of the enteric nervous system (ENS), particularly in an immune-stimulated environment. This prompted us to study the potential of cultured enteroglial cells for cytokine synthesis and secretion. Jejunal myenteric plexus preparations from adult rats were enzymatically dissociated, and enteroglial cells were purified by complement-mediated cytolysis and grown in tissue culture. Cultured cells were stimulated with recombinant rat interleukin (IL)-1beta, IL-6, and tumor necrosis factor (TNF)-alpha, and IL-6 mRNA expression and secretion were assessed using RT-PCR and a bioassay, respectively. Stimulation with TNF-alpha did not affect IL-6 mRNA expression, whereas IL-1beta stimulated IL-6 mRNA and protein synthesis in a time- and concentration-dependent fashion. In contrast, IL-6 significantly and dose-dependently suppressed IL-6 mRNA expression. In summary, we have presented evidence that enteric glial cells are a potential source of IL-6 in the myenteric plexus and that cytokine production by enteric glial cells can be regulated by cytokines. These findings strongly support the contention that enteric glial cells act as immunomodulatory cells in the enteric nervous system.

Mouse fatty acid transport protein 4 (FATP4): characterization of the gene and functional assessment as a very long chain acyl-CoA synthetase

FATP4 (SLC27A4) is a member of the fatty acid transport protein (FATP) family, a group of evolutionarily conserved proteins that are involved in cellular uptake and metabolism of long and very long chain fatty acids. We cloned and characterized the murine FATP4 gene and its cDNA. From database analysis we identified the human FATP4 genomic sequence. The FATP4 gene was assigned to mouse chromosome 2 band B, syntenic to the region 9q34 encompassing the human gene. The open reading frame was determined to be 1929 bp in length, encoding a polypeptide of 643 amino acids. Within the coding region, the exon-intron structures of the murine FATP4 gene and its human counterpart are identical, revealing a high similarity to the FATP1 gene. The overall amino acid identity between the deduced murine and human FATP4 polypeptides is 92.2%, and between the murine FATP1 and FATP4 polypeptides is 60.3%. Northern analysis showed that FATP4 mRNA was expressed most abundantly in small intestine, brain, kidney, liver, skin and heart. Transfection of FATP4 cDNA into COS1 cells resulted in a 2-fold increase in palmitoyl-CoA synthetase (C16:0) and a 5-fold increase in lignoceroyl-CoA synthetase (C24:0) activity from membrane extracts, indicating that the FATP4 gene encodes an acyl-CoA synthetase with substrate specificity biased towards very long chain fatty acids.

Copper in disorders with neurological symptoms: Alzheimer's, Menkes, and Wilson diseases

Copper is an essential element for the activity of a number of physiologically important enzymes. Enzyme-related malfunctions may contribute to severe neurological symptoms and neurological diseases: copper is a component of cytochrome c oxidase, which catalyzes the reduction of oxygen to water, the essential step in cellular respiration. Copper is a cofactor of Cu/Zn-superoxide-dismutase which plays a key role in the cellular response to oxidative stress by scavenging reactive oxygen species. Furthermore, copper is a constituent of dopamine-beta-hydroxylase, a critical enzyme in the catecholamine biosynthetic pathway. A detailed exploration of the biological importance and functional properties of proteins associated with neurological symptoms will have an important impact on understanding disease mechanisms and may accelerate development and testing of new therapeutic approaches. Copper binding proteins play important roles in the establishment and maintenance of metal-ion homeostasis, in deficiency disorders with neurological symptoms (Menkes disease, Wilson disease) and in neurodegenerative diseases (Alzheimer's disease). The Menkes and Wilson proteins have been characterized as copper transporters and the amyloid precursor protein (APP) of Alzheimer's disease has been proposed to work as a Cu(II) and/or Zn(II) transporter. Experimental, clinical and epidemiological observations in neurodegenerative disorders like Alzheimer's disease and in the genetically inherited copper-dependent disorders Menkes and Wilson disease are summarized. This could provide a rationale for a link between severely dysregulated metal-ion homeostasis and the selective neuronal pathology.

The hepatic microvascular responses to sepsis

The liver is believed to play a major role in the initiation of multiorgan failure, the most lethal complication in the clinical course of sepsis. Microbes and their virulence factors enter the hepatic circulation where they first activate sinusoidal endothelial cells and Kupffer cells to produce proinflammatory mediators, including TNF-alpha, IL-1, IL-6, reactive oxygen metabolites, and eicosanoids. These mediators cause not only microbial killing, but also structural and functional liver damage concerning mainly the parenchymal cells. Leukocytes are targeted to the liver sinusoids by chemoattractants and, like platelets, tether to the sinusoidal endothelial cells, which are in a procoagulant state of inflammatory activation. Clogging of the sinusoids by these cells leads to a decrease of blood flow through the sinusoids, which is further aggravated by endothelin-1 effectuating the constriction of hepatic stellate cells in the sinusoids. In contrast, both nitric oxide (NO) and carbon monoxide (CO) act as antagonists of endothelin-1 by mediating relaxation of sinusoidal vessels. By maintaining an adequate sinusoidal perfusion, both NO and CO are hepatoprotective during the early, hyperdynamic phase of sepsis characterized by an increased cardiac output and moderate peripheral vasodilation. However, during the late, hypodynamic phase of sepsis, massive overproduction of NO by the inducible NO synthase leads to circulatory collapse, which inevitably includes breakdown of the liver circulation.

Immunogenicity of two accelerated hepatitis B vaccination protocols in liver transplant candidates

OBJECTIVE

It is common practice to immunize patients against hepatitis B virus infection prior to orthotopic liver transplantation (OLT). We compared the seroprotection rates of two accelerated schedules with a recombinant hepatitis B vaccine in patients awaiting OLT.

DESIGN AND METHODS

Patients were prospectively recruited and vaccinated with either 20 micrograms (group 1, n = 14) or 40 micrograms (group 2, n = 20) hepatitis B surface antigen per dosage. Thirty-nine healthy volunteers served as a historical control group. Patients in all groups were vaccinated with an accelerated schedule (0, 7 and 21 days). All patients underwent clinical and laboratory examinations (HBs antibodies, CD4/CD8 ratio, transaminases).

RESULTS

The accelerated hepatitis B vaccination schedules were well tolerated. Eight weeks after the third injection, no significant differences in seroprotection rates were observed between group 1 (31%) and group 2 (26%). There was no correlation with respect to seroconversion rates and gender, smoking habits or CD4/CD8 ratio.

CONCLUSION

These data suggest that accelerated vaccination schedules with a recombinant hepatitis B vaccine are safe and well-tolerated, but only achieve poor seroconversion rates in OLT candidates. Increasing the vaccine dose to 40 micrograms hepatitis B surface antigen per injection did not result in a higher response rate. Because of the low risk of acquiring de novo hepatitis B infection after transplantation, it should be questioned whether routine hepatitis B vaccination with standard recombinant vaccines prior to liver transplantation should be recommended any longer.

Effective infection, apoptotic cell killing and gene transfer of human hepatoma cells but not primary hepatocytes by parvovirus H1 and derived vectors

Autonomous parvoviruses preferentially replicate in and kill in vitro-transformed cells and reduce the incidence of spontaneous and implanted tumors in animals. Because of these natural oncotropic and oncolytic properties, parvoviruses deserve to be considered as potential antitumor vectors. Here, we assessed whether parvovirus H1 is able to kill human hepatoma cells by induction of apoptosis but spares primary human liver cells, and whether the former cells can efficiently be transduced by H1 virus-based vectors. Cell death, infectivity, and transgene transduction were investigated in Hep3B, HepG2, and Huh7 cells and in primary human hepatocytes with natural and recombinant H1 virus. All hepatoma cells were susceptible to H1 virus-induced cytolyis. Cell death correlated with H1 virus DNA replication, nonstructural protein expression, and with morphological features of apoptosis. H1 virus-induced apoptosis was more pronounced in p53-deleted Hep3B and p53-mutated Huh7 cells than in HepG2 cells which express wild-type p53. In Hep3B cells, apoptosis was partially inhibited by DEVD-CHO, a caspase-3 inhibitor. In contrast, H1 virus-infected primary hepatocytes were neither positive for nonstructural protein expression nor susceptible to H1 virus-induced killing. Infection with a recombinant parvovirus vector carrying the luciferase gene under control of parvovirus promoter P38 led to higher transgene activities in hepatoma cells than in the hepatocytes. Taken together, H1 virus kills human hepatoma cells at low virus multiplicity but not primary hepatocytes. Thus, recombinant H1 viruses carrying antitumor transgenes may be considered as potential therapeutic options for the treatment of hepatocellular carcinomas.

Combination therapy with interferon-alpha 2b and ribavirin for the treatment of relapse patients and non-responders with chronic HCV infection

BACKGROUND

Treatment of patients with chronic hepatitis C after failure of an interferon monotherapy remains controversial. While relapse patients have a sustained response after a combination therapy with interferon-alpha 2b 3 x 3 MU/week plus ribavirin 1,000/1,200 mg daily for 24 weeks in up to 49%, the standard therapy for initial non-responders remains to be determined.

METHODS

We therefore conducted a large multicenter trial to compare efficacy and safety of a combined interferon/ribavirin therapy in 327 non-responders and 181 relapse patients with chronic HCV infection outside of highly specialized institutions.

RESULTS

After 6 months therapy with interferon-alpha-2b 3 MU thrice a week plus ribavirin 1,000/1,200 mg daily for 24 weeks 31% of relapse patients and 11% of initial non-responders achieved a sustained response according to an intent to treat analysis.

CONCLUSIONS

These data could not confirm the high rate of sustained responders in relapse patients. In addition we were only able to induce a sustained response in every tenth non-responder. These results might reflect the realistic sustained response rates in a non-biased European population of HCV-infected patients.

Isolation of enteric glia and establishment of transformed enteroglial cell lines from the myenteric plexus of adult rat

Although enteroglial cells (EGCs) may play a key role in the inflammatory response of the enteric nervous system, little is known about their immunophysiological properties. To facilitate further characterization of enteric glia, we have developed a novel method to isolate and purify EGCs from the myenteric plexus. Myenteric plexus preparations were enzymatically dissociated and EGCs purified by complement-mediated cytolysis of contaminating cells and transformed by retroviral gene transfer. Primary and transformed cells were characterized immunohistochemically and by dot-blot analysis. Functionally, c-fos mRNA expression was assessed in primary and transformed enteroglial cells. All cells displayed robust glial fibrillary acidic protein, S-100 and vimentin immunoreactivities, but no Thy-1.1, desmin, smooth muscle alpha-actin or C3 complement receptor immunoreactivity. This confirmed their enteroglial lineage and excluded contamination with other cell types. Both primary and transformed EGCs displayed little constitutive c-fos mRNA expression. This, however, could be upregulated by various stimuli, including proinflammatory cytokines. In summary, we present a novel method to purify EGCs from rat myenteric plexus for tissue culture and to establish transformed EGC lines that retain their glial nature and functional properties. Such cell lines are now available for physiological studies of the functional properties of enteric glia in vitro.

IL-1beta and IL-10 have dual effects on enteric glial cell proliferation

Inflammatory bowel disease is typically accompanied by functional and structural changes of the enteric nervous system. In pathological studies, cellular loss and axonal degeneration have been described in the myenteric plexus. However, more recent studies suggest that the proliferation rate of myenteric glial cells is enhanced in animal models of intestinal inflammation. Therefore, we have investigated the effect of different cytokines on the proliferative response of enteric glial cells (EGCs), comparing transformed enteric glial cell lines, primary astrocyte cultures and transformed oligodendrocytes. Cells were incubated in serum-free chemically defined medium in the presence or absence of either interleukin (IL)-1beta or IL-10 at concentrations ranging between 0.1 and 100 ng mL(-1) for 48 h. Subsequently, [3H]thymidine was added to each culture dish for an additional 6 h, and the amount of incorporated [3H] was assessed. IL-1beta significantly and dose-dependently suppressed [3H]-uptake by EGCs. In contrast, IL-10 induced a biphasic response; IL-10 at low concentrations (0.1 ng mL(-1)) caused a significant suppression of [3H]-uptake, whereas high concentrations (5-100 ng mL(-1)) significantly enhanced [3H] uptake. These results indicate that EGC proliferation can be modulated by cytokines. The differential effects of IL-1beta and IL-10 suggest that during intestinal inflammation there may be a regulatory interplay between different classes of cytokines modulating EGC proliferation.

Functional and histochemical analysis of MDR3 P-glycoprotein in a tetracycline-controlled gene expression system

Aim of the present study was to establish a cell system to study the physiological function of human MDR3 P-glycoprotein in cellular phosphatidylcholine (PC) secretion. MDR3 cDNA was expressed in HeLa cells using the tet-off system together with a luciferase reporter gene. MDR3 Pgp expression was turned on upon removal of doxycycline as shown by Western blot analysis. Immunohistochemistry using a specific anti human MDR3 Pgp antibody revealed a prominent staining of MDR3 Pgp covering the cytoplasm and the area of the plasma membrane. In presence of doxycycline MDR3 Pgp expression was turned off. For analysis of PC secretory activity, MDR3 Pgp expressing and non-expressing cells as well as control HeLa cells with low endogenous MDR3 were preincubated with [(3)H]choline for synthesis of cellular [(3)H]PC. Cells were then incubated for 2 h in media with 0-4 mM taurocholate (TC) and release of cellular [(3)H]PC was recorded. [(3)H]PC secretion was observed in presence of TC without impairing cell viability. There was a significant increase in [(3)H]PC excretion in MDR3 Pgp expressing cells compared to non-expressing controls (e.g. 4.5 fold at 4 mM TC), revealing a high efficiency of transport activity (turnover). From the data it is concluded that the MDR3 Pgp expressing cell system under control of a doxycycline responsive promotor is functionally active and provides a tool to further study MDR3 Pgp mediated transport.

Hepatic iron overload in aceruloplasminaemia

We report the case of a 52 year old male with diabetes mellitus and long standing evidence of hepatic iron excess. Initially considered to have haemochromatosis, this patient was reevaluated when hepatic iron stores were found to be unaffected by a prolonged course of weekly phlebotomy. The development of neurological disease prompted diagnostic consideration of aceruloplasminaemia, which we confirmed by demonstration of a novel frameshift mutation in the ceruloplasmin gene. Our inability to resolve the patient's iron overload by regular phlebotomy is consistent with recent animal studies indicating an essential role for ceruloplasmin in cellular iron efflux. Evaluation of this case underscores the clinical relevance of aceruloplasminaemia in the differential diagnosis of hepatic iron overload and provides insight into the pathogenetic mechanisms of hepatocellular iron storage and efflux.

[Pulmonal sarcoidosis: A rare side effect of interferon-alpha treatment for chronic hepatitis C infection]

This is a case report of a 44-year-old woman who received a 1-year-treatment with interferon-alpha for chronic hepatitis C virus infection. 3 months after cessation of the therapy she relapsed and was successfully retreated 12 months with a combination of interferon-alpha and ribavirin thereafter. During the treatment the patient developed a typical flue-like syndrome, dry cough with exertional dyspnea that was initially interpreted as a typical side effect of interferon-alpha treatment. Due to the persisting cough, further radiologic and histologic work up was done and results were significant for interstitial sarcoidosis. After interferon-treatment was stopped the pulmonary symptoms resolved completely while pathologic changes in radiographic imaging persisted. Interferon-alpha may have contributed to the development and progression of sarcoidosis by activation of cellular immunity. Although there are only few reports about pulmonary sarcoidosis associated with interferon-alpha treatment, this entity should be included in the differential diagnosis of putative side effects of interferon-alpha therapy.

[Ulcers of the colon in association with nonsteroidal anti-inflammatory drugs (NSAID)--a rare cause of gastrointestinal bleeding? Report of 3 cases]

Although adverse side effects of nonsteroidal anti-inflammatory drugs (NSAID) can affect the whole gastrointestinal tract, most reports refer to upper gastrointestinal tract complications. We report on 3 patients with lower gastrointestinal bleeding (patient 1 and 2) respectively detectable fecal blood loss (patient 3) after the use of NSAID. Patient 1 and 3 were taking NSAID over at least 6 months for the treatment of rheumatic diseases while patient 2 reported a single use of 2 g acetylsalicylic acid. Colonoscopy showed a single ulcer of the colon in patients 1 and 2. Due to acute bleeding patient 1 required interventional endoscopic treatment. Colonoscopy of patient 3 revealed multiple colonic ulcerations. Gastroduodenoscopy also detected adverse NSAID-effects on the upper gastrointestinal tract in patient 1 and 3 (ulcers of the stomach, erosive duodenitis). NSAID-medication was discontinued in all patients and, additionally, mesalazine was administered to patient 3. Consecutively, symptoms and lesions disappeared. Our cases stress the clinical importance of NSAID-toxicity distal to the small intestine which may exist concomitantly to lesions of the upper gastrointestinal tract and is not obligatory dose-dependent.

Chemotherapy with gemcitabine in patients with advanced gallbladder carcinoma

BACKGROUND

Advanced or metastatic gallbladder carcinoma is regarded not much sensitive to chemotherapy. Standard chemotherapy regimens have not been established up to now.

PATIENTS

We report on 5 patients with advanced gallbladder carcinoma who received chemotherapy with gemcitabine.

RESULTS

Of these 5 patients, 3 demonstrated a partial remission and stable disease was achieved in another patient. Only one patient had no benefit from treatment with gemcitabine.

CONCLUSION

We conclude that gemcitabine may be an effective drug in the palliative treatment of gallbladder cancer, and thus its efficiency warrants evaluation in further studies.

Fatty acid transporters in plasma membranes of cardiomyocytes in patients with dilated cardiomyopathy

BACKGROUND

Long-chain fatty acids are one of the major cardiac energy substrates. Although the exact mechanism of myocardial fatty acid uptake is not known, several proteins, including the integral membrane proteins FATP1 (fatty acid transport protein 1) and FAT (fatty acid translocase), are being implicated in this process. The aim of this study was to further investigate FATP1 and FAT in the heart and its potential role in myocardial fatty acid utilization. -

METHODS

The expression of FATP1 and FAT in mouse myocardium and in myocardial biopsies of 14 patients with different cardiomyopathies was detected by immunocytochemistry and visualized with a laser scanning microscope. -

RESULTS

FAT and FATP1 are co-expressed on the plasma membrane of cardiac endothelial cells and on the sarcolemma of cardiomyocytes. The staining-pattern and the intensity of signal for both transport proteins was constant in different cardiomyopathies compared with the expression in biopsies of patients with other cardiac diseases and the expression in the myocardium of healthy mice. -

CONCLUSION

Cardiac endothelial cells and cardiomyocytes express FAT and FATP1 in vivo, suggesting an active part of these proteins in the uptake process of long-chain fatty acids. However, we did not find evidence for an altered expression of fatty acid transport proteins in patients with dilated cardiomyopathy, suggesting that these proteins are of minor importance in this kind of heart failure.

[Standardized morphology-adjusted resection in treatment of benign nodular struma]

In 1996 we performed a prospective study with 279 patients suffering from benign nodular goiter. The study investigates the influence of a standardized morphologically adjusted resection technique--SMART--on complication rates in surgery. Apart from the number of transient and permanent recurrent laryngeal nerve lesions and hypocalcemia, we focused in particular on the rate of "false relapses" associated with residual nodular tissue after resection. Bilateral ligation of the inferior thyroid artery in a bilobal approach as well as the entire preparation towards the ligament of Berry permit a reduction in irreversible nerve lesions in all lobal resections to 0.4% and permanent hypocalcemia to 0.3%. Bilateral ligation of the inferior thyroid artery results in a significantly larger number of transient hypocalcemia, without any impact on the long-term course. By applying a standardized surgical technique, a residual nodular goiter rate of 1.4% can be achieved. In spite of thorough intraoperative exploration, false relapses cannot completely be ruled out, however. Nodular tissue might remain undetected by conventional intraoperative exploration even in the presence of sophisticated preoperative ultrasound of the thyroid gland. Also, performing an enucleation can lead to remaining nodules, particularly in the posterior areas. For the future intraoperative ultrasound may be an interesting method in these doubtful cases.

Long-Term Clinical Remission in a Patient with Metastatic Gastric Cancer after Palliative Chemotherapy

BACKGROUND: More than 50% of patients with gastric cancer initially present with locally advanced or metastatic disease. In general, gastric cancer in an advanced or metastatic stage is regarded as incurable. Despite treatment with palliative chemotherapy, the median survival time is still limited and does not exceed 12 months. CASE REPORT: We report on a patient with advanced and metastatic gastric cancer who received palliative surgery and subsequent palliative chemotherapy. RESULTS: Complete remission occurred after R2 resection and palliative chemotherapy. The patient is now disease-free for 10 years after the end of chemotherapy. CONCLUSIONS: Palliative chemotherapy for metastatic gastric cancer may seldom lead to long-term clinical remission. Copyright 2000 S. Karger GmbH, Freiburg

Extrapulmonary sarcoidosis primarily diagnosed in the liver

Sarcoidosis is a relatively common, chronic, multisystem disease of unknown origin characterized by the presence of noncaseating epithelioid granulomas. Although an array of organs may be affected by the disease, the commonest site of affection is the lung. We describe a 73-year-old patient admitted to our hospital because of fatigue, weight loss, and an increased alkaline phosphatase level. In conjunction with clinical presentation, laboratory variables, and imaging analysis, a liver biopsy finally confirmed the diagnosis of a systemic sarcoidosis without affection of the lung or mediastinal lymph nodes. Treatment with ursodeoxycholic acid before diagnosis did not improve clinical symptoms and cholestasis indicators. After prednisone treatment, liver enzyme values normalized and remained normal during follow-up for 2 years after diagnosis. The literature on hepatic manifestation of sarcoidosis, its diagnosis, treatment, and prognosis is reviewed. This single case of sarcoidosis presented to the clinician almost exclusively with liver enzyme abnormalities. The consideration of sarcoidosis in such cases is of utmost importance, since the differential diagnosis of hepatic granulomas includes infectious diseases in which treatment with corticosteroids could be fatal.

Spontaneous regression of intrahepatic lesions mimicking metastatic disease

This is a case report of a 53-year-old male with chronic hepatitic C infection presenting with weight loss and elevated liver function tests. Repeated ultrasonography, computed tomography and magnet resonance imaging showed multiple intrahepatic lesions suggestive of metastatic disease. Repeated ultrasound-guided biopsies from the lesions as well as from the adjacent normal appearing liver tissue revealed no malignancy but showed inflammation and significant fibrotic tissue, consistent with chronic hepatitis C. 2 years after the first admission liver function tests were all within the normal range and remained so until today. Computed tomography at that time showed complete remission of all intrahepatic lesions. The exact diagnosis remained elusive but the rare case of reversible focal fibrosis is the most likely cause of these spontaneously regressive lesions.

Can monovalent hepatitis A and B vaccines be replaced by a combined hepatitis A/B vaccine during the primary immunization course?

A combined hepatitis A/B vaccine (Twinrix Adult) has been licensed in Germany since 1997. We investigated possible differences in immunogenicity and safety when changing over from vaccinations with monovalent vaccines made by different manufacturers to vaccinations with the combined hepatitis A/B vaccine in an open, randomized, multicenter trial. We therefore compared four different schemes changing over from concomitant vaccinations with monovalent vaccines against hepatitis A and B (Havrix 1440+Engerix-B or Vaqta+Gen H-B-Vax) to combined vaccination against hepatitis A+B with three injections of the combined hepatitis A/B vaccine (0, 1, and 6 month schedule). Local and general symptoms were mostly mild in all five groups. With complete three-dose course using the combined vaccine or an early changeover from monovalent vaccines to the combined vaccine, higher overall anti-HBs seroprotection rates and geometric mean concentrations (GMCs) against hepatitis B could be achieved as early as after 2 months as compared to those groups switching later to the combined vaccine. This study demonstrated for the first time that switching from monovalent hepatitis A and B vaccinations to the combined hepatitis A and B vaccination has no negative influence on the tolerability and improves the immunogenicity.