Ethanol inhibits δ-aminolevulinate dehydratase and glutathione peroxidase activities in mice liver: Protective effects of ebselen and N-acetylcysteine

Changes in sulfhydryl status have been shown to be involved with the ethanol-induced hepatotoxicity. In addition, evidence shows the importance of replenishing thiols in patients with alcoholic liver disease. This study was undertaken to examine the possible beneficial effects of the individual and simultaneous treatments with two antioxidant drugs (N-acetylcysteine and ebselen) against ethanol-induced changes in thiol status, as well as on the activities of δ-aminolevulinate dehydratase (δ-ALA-D) and glutathione peroxidase (GPx) in mice liver. Daily ethanol administrations (3g ethanol/kg, by gavage) decreased liver nonprotein thiols (NPSH) concentration after 30 days of treatment and N-acetylcysteine (300mg/kg once a day, i.p.) or ebselen (5mg/kg once a day, subcutaneously) treatment restored this variable to control levels. However, additive beneficial effects concerning NPSH levels were not observed after the simultaneous administration with both drugs. While liver GPx and δ-ALA-D activities were inhibited by ethanol exposure and these inhibitions were significantly blunted by N-acetylcysteine or ebselen treatment, the simultaneous administration with both drugs did not show additive beneficial effects in relation to the enzymes' activities. NPSH levels were positively correlated with GPx and δ-ALA-D activities. The results presented herein show that ebselen and N-acetylcysteine alone are able to restore ethanol-induced thiols as well as the inhibition of hepatic enzymes whose catalytic functions depend on their thiol (δ-ALA-D) and selenol (GPx) groups.

Adrenomedullin improves the blood-brain barrier function through the expression of claudin-5

AIMS

Brain vascular endothelial cells secret Adrenomedullin (AM) has multifunctional biological properties. AM affects cerebral blood flow and blood-brain barrier (BBB) function. We studied the role of AM on the permeability and tight junction proteins of brain microvascular endothelial cells (BMEC).

METHODS

BMEC were isolated from rats and a BBB in vitro model was generated. The barrier functions were studied by measuring the transendothelial electrical resistance (TEER) and the permeability of sodium fluorescein and Evans' blue albumin. The expressions of tight junction proteins were analyzed using immunocytochemistry and immunoblotting.

RESULTS

AM increased TEER of BMEC monolayer dose-dependently. Immunocytochemistry revealed that AM enhanced the claudin-5 expression at a cell-cell contact site in a dose-dependent manner. Immunoblotting also showed an overexpression of claudin-5 in AM exposure.

CONCLUSIONS

AM therefore inhibits the paracellular transport in a BBB in vitro model through claudin-5 overexpression.

Assessing patients' understanding of hepatitis C virus infection and its impact on their lifestyle

AIMS

To assess how much patients with hepatitis C virus infection know about their condition and what impact it has on their lifestyle.

MATERIALS AND METHODS

A multiple-choice questionnaire was administered anonymously to 364 hepatitis C virus-infected subjects just before their first specialist visit.

RESULTS

Even before hepatitis C virus infection was diagnosed, 257 subjects (70.6%) already knew something about this infection. Overall, 36% of patients had changed the way they behaved within the family, 25.5% had changed their sexual habits, 46.9% had changed their diet, and 69% reported having stopped or limited their alcohol intake after being told they were hepatitis C virus positive. Hepatitis C virus infection had a negative impact on the psychological status in 44.2% of patients. This effect was significantly greater among women and was independent of either the duration of their infection or any counselling received from the general practitioner. The need for specific treatment was reported by 59.8%. A demand for more detailed information about hepatitis C virus was expressed by 89.9% of patients.

CONCLUSIONS

Hepatitis C virus changes all aspects of lifestyle and psychological status. The patients' strong demand for more information suggests that counselling and educational programmes must be an integral part of the activities of both the general practitioner and the specialist.

Sarcoïdose chez deux malades traités par interféron pégylé pour une hépatite chronique C

One side effect of the immunomodulatory effect of interferon is the possible triggering or exacerbation of systemic or cutaneous sarcoidosis. We report two new cases and offer an exhaustive review of the literature. A 39-year-old man with type C chronic active hepatitis developed new respiratory symptoms and pulmonary infiltrates with hilar and mediastinal adenopathy after 7 months of treatment with pegylated interferon. The evolution was favourable after stopping treatment. The second patient developed cutaneous lesions after 6 months of treatment. Resolution occurred after the discontinuation of the treatment. In these two cases ribavirin was stopped before the first signs of sarcoidosis.

Destructive granuloma derived from a liver cyst: A case report

We herein report the case of an idiopathic liver cystic mass which aggressively infiltrated the thoraco-abdominal wall. A 74-year-old woman who had a huge cystic lesion in her right hepatic lobe was transferred to our hospital for further examinations. Imaging studies revealed a simple liver cyst, and the cytological findings of intracystic fluid were negative. She was followed up periodically by computed tomography (CT) scans. Seven years later, she complained of a prominence and dull pain in her right thoraco-abdominal region. CT revealed an enlargement of the cystic lesion and infiltration into the intercostal subcutaneous tissue. We suspected the development of a malignancy inside the liver cyst such as cystadenocarcinoma, and she therefore underwent surgery. A tumor extirpation was performed, including the chest wall, from the 7th to the 10th rib, as well as a right hepatic lobectomy. Pathologically, the lesion consisted of severe inflammatory change with epithelioid cell granuloma and bone destruction without any malignant neoplasm. No specific pathogens were evident based on further histological and molecular examinations. Therefore the lesion was diagnosed to be a destructive granuloma associated with a long-standing hepatic cyst. Since undergoing surgery, the patient has been doing well without any signs of recurrence.

Rectus sheath hematoma: review of 126 cases at a single institution

Rectus sheath hematoma (RSH) is an uncommon condition characterized by abdominal pain and an abdominal wall mass. We reviewed the clinical features, treatment, and outcomes of 126 patients treated for RSH at Mayo Clinic from January 1, 1992, to December 31, 2002. Most patients (64%) were women and the mean +/- SD age was 67.9 +/- 16.5 years. Most patients (69%) were on some form of anticoagulation therapy. The mean international normalized ratio was 2.6 +/- 2.4, and mean activated partial thromboplastin time was 64.2 +/- 42.7 seconds. No patients were pregnant or had a peritoneal dialysis catheter at the time of diagnosis. Approximately half of the patients (48%) had nonsurgical abdominal trauma around the time of diagnosis, with 37 patients (29%) having a cough. The most common presenting signs and symptoms were abdominal pain (84%) and an abdominal wall mass (63%). CT of the abdomen and pelvis was the most commonly used method to establish the diagnosis (83%). Most patients (86%) were successfully treated with symptom management and blood transfusion. Ten patients (7.9%) underwent surgery or endovascular embolization of bleeding vessels, and 2 patients (1.6%) died as a result of RSH bleeding. Although RSH is rarely fatal, the clinician should be aware of important risk factors that lead to RSH including female sex, older age, anticoagulation therapy, and cough or other abdominal trauma. Rapid diagnosis with directed history, physical examination, and CT of the abdomen and pelvis may help decrease unnecessary laparotomy and lead to better triage of patients who present with RSH.

N-acetylcysteine ameliorates carbofuran-induced alterations in lipid composition and activity of membrane bound enzymes

The present work investigates the protective effects of N-acetylcysteine (NAC) on carbofuran-induced alterations in lipid composition and activity of membrane bound enzymes (Na+-K+-ATPase and Ca2+-ATPase) in the rat brain. Animals were exposed to carbofuran at a dose of 1 mg/kg body weight, orally, for a period of 28 days. A significant increase in lipid peroxidation in terms of TBARS was observed in brain after carbofuran exposure. NAC administration (200 mg/kg body weight) on the other hand lowered the carbofuran-induced lipid peroxidation to near normal. The increased lipid peroxidation following carbofuran exposure was accompanied by a significant decrease in the levels of total lipids, which is attributed to the reduction in phospholipid levels. Furthermore, NAC administration had a beneficial effect on carbofuran-induced alterations in lipid composition. The ratio of cholesterol to phospholipid, a major determinant of membrane fluidity, was increased in response to carbofuran exposure. This was associated with decreased activity of Na+-K+-ATPase and Ca2+-ATPase. NAC was observed to offer protection by restoring the cholesterol to phospholipid ratio along with the activity of Na+-K+-ATPase and Ca2+-ATPase. The results clearly suggest that carbofuran exerts its neurotoxic effects by increasing lipid peroxidation, altering lipid composition and activity of membrane bound enzymes. NAC administration ameliorated the effects of carbofuran suggesting its potential therapeutic effects in carbofuran neurotoxicity.

Interferon-induced sarcoidosis

Interferons (IFNs) are widely used for the treatment of various medical diseases. They have marked immunomodulatory effects, and many reports have been published associating IFN therapy with the induction of autoimmune phenomena and other disorders of immune regulation such as sarcoidosis. The clinical presentation of IFN-induced sarcoidosis (IIS) is insidious and can be confused with common constitutional side effects of these drugs. The age of onset of IIS is later than that of naturally occurring sarcoidosis. The most common organs involved are the lungs and skin. In the majority of cases, IIS follows a benign course. As we show in an illustrative case report, complete resolution after discontinuation of IFN therapy can be expected. This review summarises 65 cases of IIS reported in the literature and highlights the pathophysiology, clinical features, diagnostic modalities and therapeutic options for this increasingly recognised phenomenon.

Effects and mechanisms of crude astragalosides fraction on liver fibrosis in rats

Astragalosides is the major active constituent of Radix Astragali. The present study was carried out to investigate the effect of crude astragalosides fraction (CAF) on rats liver fibrosis and its possible mechanisms. Hepatic fibrosis was induced by subcutaneous injection with 50% CCl(4) in Sprague-Dawley rats. The amount of CCl(4) administered was 1 mg kg(-1). The alanine aminotransferase (ALT), aspartate aminotransferase (AST) levels in plasma and hydroxyproline (Hyp), malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GSH-px) contents in liver tissue were assayed by spectrophotometry. The hyaluronic acid (HA) and procollagen III (PC III) were assessed by radioimmunoassay. Tumor necrosis factor-alpha (TNF-alpha) and transforming growth factor-beta1 (TGF-beta1) levels in culture supernatants of Kupffer cells (KCs) were determined with ELISA. Liver samples collected after 8 weeks of CCl(4) treatment were stained with hematoxylin-eosin (HE) and massion, and scored. Intragastric administration of CAF (10, 20 and 40 mg kg(-1)) significantly decreased indices of liver and spleen, the serum transaminase activities, HA and PC III levels, and Hyp and MDA contents in liver tissue in rats of hepatic fibrosis. Decreased SOD and GSH-px levels were reversed after administration of CAF. Histopathological scores showed CAF had inhibitory effect on the progression of hepatic fibrosis. In the in vitro experiments, CAF significantly reduced TNF-alpha and TGF-beta1 levels in culture supernatants of KCs. The results showed CAF significantly inhibited the progression of hepatic fibrosis induced by CCl(4), and the inhibitory effect of CAF on hepatic fibrosis might be associated with its ability to scavenge free radical and inhibit the production of TNF-alpha and TGF-beta1 from activated KCs.

Spontaneous resolution of systemic sarcoidosis in a patient with chronic hepatitis C without interferon therapy

A 39-year-old male patient complaining of bilateral hand joint arthralgia was evaluated and found to have chronic hepatitis C and systemic sarcoidosis involving lung, skin, liver, and spleen. Hepatic and cutaneous sarcoidoses were confirmed by the presence of numerous noncaseating granulomas on histological examination. Pulmonary and splenic involvements were diagnosed by imaging studies. Fifteen months later, the sarcoidotic lesions in lung, liver, and spleen were resolved by radiological studies and a liver biopsy showed no granuloma but moderate to severe inflammatory activity. systemic sarcoidosis is a rare comorbidity of chronic hepatitis C which may spontaneously resolve.

Elevated levels of DNA repair enzymes and antioxidative enzymes by (+)-catechin in murine microglia cells after oxidative stress

(+)-Catechin possesses a broad range of pharmacological properties, including antioxidative effect. However, little is reported on the mechanism by which (+)-catechin protects microglia cells from DNA damage by oxidative stress. In this study, TUNEL assay and DNA electrophorysis indicated that (+)-catechin markedly blocked DNA fragmentation and apoptosis of microglia cells by tBHP exposure. A potent antioxidative effect of (+)-catechin was confirmed by comparison with a putative antioxidant agent, N-acetylcysteine at the lower doses. Furthermore, the increased intracellular ROS by tBHP exposure were scavenged by elevated activities of catalase (CAT) and superoxide dismutase (SOD) after (+)-catechin treatment. (+)-Catechin partially inhibited the activation of caspase-3, thereby both cleavage of poly (ADP-ribose) polymerase (PARP) and degradation of inhibitor of caspase-activated DNase (ICAD) were effectively abolished. In addition, the expression of PARP for repair of impaired DNA was significantly increased by (+)-catechin treatment. Taken together, these data suggest that protective effects of (+)-catechin against oxidative DNA damage of microglia cells is exerted by the increased expression of DNA repair enzyme PARP and antioxidant enzyme activities.

Characterization of HCV strains in an oncohematological pediatric department reveals little horizontal transmission but multiple introductions by un-screened blood products in the past

Because several children were found infected with hepatitis C virus (HCV) at a pediatric oncohematological department in Vilnius, 474 children were tested for anti-HCV. Fifty-eight percent of 96 children treated with blood and plasma products manufactured before the introduction of anti-HCV screening of blood in Lithuania in 1994 were positive for anti-HCV versus 3.4% of those treated after 1994. The possible route of transmission for 45 of these was investigated by phylogenetic analyses within the NS5B region. Children treated before 1995 were infected with a multiplicity of strains of different subtypes, predominantly 1b found in 21 cases, 3a in 5 cases, 2 in 3 cases, 1a in 1 case, and not subtypeable genotype 1 strains in 2 cases. Children who had received blood products after 1994 were infected with only two subtypes, 1b in six and 3a in seven. Genetic analysis showed multiple introductions of HCV before 1995 and that horizontal spread between patients had occurred only to a minor extent at the department. However, two transmission chains involved children treated before 1995. Another chain involved five children treated after 1994. Since the most important risk factor for acquiring hepatitis C was blood products manufactured before the introduction of donor screening for anti-HCV, the spread between children would not have been revealed without molecular tools. These and the background strains provide the first reported sequence data on Lithuanian HCV strains. In general, these were shown to form autochthonous clades, except the 3a strains that were related to strains from the former USSR.

Carbofuran-induced neurochemical and neurobehavioral alterations in rats: attenuation by N-acetylcysteine

Carbofuran, a widely used carbamate pesticide, has been reported to cause neurotoxicity. However, the underlying mechanisms involved in carbofuran neurotoxicity are not well understood. The present study was envisaged to investigate the possible role of oxidative stress in carbofuran neurotoxicity and to evaluate the protective effects of N-acetylcysteine (NAC). Acetylcholinesterase activity was significantly inhibited in all the regions of brain after carbofuran exposure (1 mg/kg body weight, orally, for 28 days). NAC, on the other hand, was found to partially restore the activity of acetylcholinesterase in carbofuran treated animals. Carbofuran exposure resulted in increased lipid peroxidation (LPO) in brain regions accompanied by decreased levels of glutathione. NAC administration to the carbofuran exposed animals lowered LPO along with partial repletion in glutathione levels. Concomitantly, the activities of superoxide dismutase, catalase, glutathione peroxidase and glutathione reductase were significantly decreased after carbofuran exposure, while no significant change in the activity of glutathione-S-transferase was observed. NAC treatment to carbofuran treated rats resulted in protective effect on the activities of these enzymes. Marked impairment in the motor function was seen following carbofuran exposure, which is evident by significant decrease in the retention time of the rats on rotating rods. Cognitive deficits were also seen after carbofuran exposure as indicated by the significant decrease in active avoidance response. NAC treatment significantly improved the carbofuran-induced neurobehavioral deficits. The results clearly demonstrate that carbofuran exerts its neurotoxic effects by accentuating oxidative stress and suggest neuroprotective role of NAC in carbofuran neurotoxicity.

New psychiatric and psychological aspects of diagnosis and treatment of hepatitis C and relevance for opiate dependence

PURPOSE OF REVIEW

This review highlights the aspects of the hepatitis C virus that are important to the psychiatrist.

RECENT FINDINGS

Hepatitis C virus infection is frequently associated with mental clouding, depression, neurocognitive impairment, and deterioration in the quality of life. In recent studies psychiatric symptoms have been linked to psychiatric comorbidity rather than to direct hepatitis C virus neurotoxicity. Infection of the central nervous system, however, is thought to play a role at least in hepatitis C virus associated neurocognitive deficits. Application of the anti-hepatitis C virus agent interferon-alpha is regularly accompanied by psychiatric symptoms, most often depression. Antidepressant treatment may support interferon therapy, but its general indication and timing remain debatable. The problem of hepatitis C virus treatment in manic patients is still unsolved. Hepatitis C infection rates in injection drug users are often 90% and higher, while these patients in particular face barriers when trying to access treatment. Recent studies demonstrated feasibility of hepatitis C virus treatment in injection drug users in specialized treatment settings.

SUMMARY

Hepatitis C virus infection is associated with psychiatric comorbidity and injection drug use, while treatment of the virus is frequently accompanied by neuropsychiatric symptoms. Psychiatrists are particularly qualified to support diagnosis of hepatitis C associated comorbidity and to render treatment feasible. Evaluation of treatment options and settings in infected patients with psychiatric comorbidity or injection drug users is required, as well as investigation of association of hepatitis C virus infection, and psychiatric and neurocognitive symptoms in properly defined samples.

Sarcoidosis occurring after interferon-alpha therapy for chronic hepatitis C: Report of two cases

We report two patients who were diagnosed with sarcoidosis after receiving interferon (IFN)-alpha therapy for chronic hepatitis C, and conduct a review the relevant literature. The first patient was a 52-year-old female who developed multiple subcutaneous nodules 2 months after finishing IFN-alpha therapy. A skin biopsy from subcutaneous nodules on the right elbow joint revealed sarcoid granulomata. These lesions resolved spontaneously 4 months later. The second patient, a 57-year-old male, developed bilateral hilar and mediastinal lymph node enlargement 2 years after finishing IFN-alpha 2a therapy. A transbronchial lung biopsy demonstrated sarcoid granulomata. In addition, he had uveitis and left ulnar nerve involvement. His eye and nerve involvement gradually improved over 20 months. It is feasible that IFN therapy has been a trigger for sarcoidosis in these patients.

Production of reactive oxygen species following acute ethanol or acetaldehyde and its reduction by acamprosate in chronically alcoholized rats

The salicylate trap method, combined with microdialysis, has been used to validate whether reactive oxygen species, particularly hydroxyl radicals, ((*)OH), are generated in the hippocampus of male Wistar rats after acute intraperitoneal administration of either ethanol, 2 and 3 g/kg, or acetaldehyde, 200 mg, or during the initial stages of ethanol withdrawal after chronic ethanol intoxication. Salicylate (5 mM) was infused into the hippocampus via the microdialysis probe and the products of its metabolism by hydroxyl radical, particularly 2,3-dihydroxybenzoic acid (2,3-DHBA) as well as 2,5-dihydroxybenzoic acid (2,5-DHBA) assayed by HPLC (High Pressure Liquid Chromatography). Acetaldehyde, 200 mg/kg, and the higher acute dose of ethanol, 3 g/kg, induced transitory increases in 2,3-DHBA and 2,5-DHBA microdialysate content. At the cessation of four weeks of chronic ethanol intoxication, (by the vapour inhalation method), the mean blood alcohol level was 1.90 g/l. Significant increases of microdialysate 2,3-DHBA and 2,5-DHBA levels were assayed 3 h after alcohol withdrawal which were sustained for a further 5 and 1 h 40 min respectively. Oral administration of Acamprosate, 400 mg/kg/day, during the chronic ethanol intoxication procedure prevented the increased formation of 2,3- and 2,5-DHBA by comparison to rats chronically ethanol intoxicated alone.

Resistance of Erythrocytes to Lipid Peroxidation in Cirrhotic Rats

BACKGROUND

The aim of the present study was to investigate erythrocyte prooxidant-antioxidant balance in relation to liver and plasma lipid peroxidation in thioacetamide (TAA)-induced liver cirrhosis in rats.

METHODS

Liver cirrhosis was produced by the administration of TAA (0.3 g/L of tap water) for a period of 3 months in rats. Serum, liver and erythrocyte lipid peroxide levels as well as liver glutathione (GSH) levels and superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities were determined in cirrhotic rats.

RESULTS

Hepatic cirrhosis was assessed by biochemical and histopathological findings. Serum alanine transaminase (ALT) and aspartate transaminase (AST) activities and malondialdehyde (MDA) levels increased in cirrhotic rats. This treatment caused increased MDA and diene conjugate (DC) levels as well as decreased GSH levels and GSH-Px activities in the liver of cirrhotic rats. In these conditions, no significant changes in erythrocyte cholesterol, phospholipid levels as well as endogenous DC, and GSH levels and spontaneous hemolysis values were observed in erythrocytes of rats with TAA-induced liver cirrhosis. However, H(2)O(2)-induced MDA levels were detected to decrease significantly in erythrocytes of cirrhotic rats.

CONCLUSIONS

Our results indicate that erythrocytes of TAA-induced cirrhotic rats have a resistance against peroxidative stress in contrast to the findings in plasma and liver.

Beneficial effects of N-acetylcysteine on acetic acid-induced colitis in rats

Ulcerative colitis is a chronic recurrent inflammatory bowel disease in which oxidative stress has been implicated. The aim of the present study was to evaluate possible protective effects of N-acetylcysteine against acetic acid-induced colitis in a rat model. Rats were administered intrarectal saline (control group) or acetic acid (colitis model group). Rats with acetic acid-induced colitis were treated by intraperitoneal or intrarectal administration of N-acetylcysteine (500 mg/kg) (treated group). Another series of rats were pre-treated by intraperitoneal or intrarectal administration of N-acetylcysteine, then administered intrarectal acetic acid (pre-treated group). The degree of tissue injuries was assessed by macroscopical and histopathological scores of the colonic mucosa. Malondialdehyde, myeloperoxidase, reduced glutathione, superoxide dismutase, and catalase levels were measured in tissue extracts of the dissected colon. Administration of N-acetylcysteine intraperitoneally or intrarectally ameliorated macroscopic score alterations produced by acetic acid in treated groups. In addition, microscopical improvement was observed in all N-acetylcysteine-treated rats compared to untreated animals with colitis. In the colonic tissues of the acetic acid-induced colitis, myeloperoxidase activity and malondialdehyde levels were elevated, while the reduced glutathione levels and superoxide dismutase and catalase activities were decreased. However, intraperitoneal or intrarectal treatment with N-acetylcysteine reversed these parameters, compared to the untreated colitis group. Notably, intrarectal administration of N-acetylcysteine elevated the reduced glutathione levels more markedly compared to the other treatment groups. Superoxide dismutase levels were increased in intraperitoneally or intrarectally N-acetylcysteine-treated groups significantly compared to the control, colitis and pre-treated groups. But there was no significant increase in catalase activity. In conclusion, N-acetylcysteine could be beneficial as a complementary agent in treatment of ulcerative colitis.

Pulmonary Sarcoidosis Induced by Interferon-α Therapy

Recombinant interferon-alpha (IFN-alpha) is being increasingly used in the treatment of chronic hepatitis C. It has been recently recognized that IFN-alpha can induce the development of sarcoidosis, presumably through its ability to stimulate the TH1 immune response. IFN-associated sarcoidosis is histologically similar to de novo sarcoidosis and is characterized by tightly compact epithelioid non-necrotizing granulomas. IFN-induced sarcoidosis may be unsuspected clinically, as the most common side effects of IFN-alpha simulate the symptoms of sarcoidosis. It is therefore important for pathologists to be aware of this association and encourage clinicians to carefully review the medication history in cases of pulmonary non-necrotizing granulomatous inflammation where there is a history of hepatitis C, as discontinuation of IFN-alpha can ameliorate the symptoms of sarcoidosis.

[Update on sarcoidosis]

Since the first description more than a century ago, intensive research continues to focus on sarcoidosis. Based on our current knowledge, sarcoidosis can be considered as an immune syndrome resulting from a variable combination of predisposing genetic, ethnic, and environmental factors. Over the last few years, several teams have proposed a link between certain genetic polymorphisms, particularly of the HLA system, and the risk of development or progression of sarcoidosis. Other pathogenic mechanisms involved in the formation of the sarcoid granuloma are becoming more clear and have led to the development of new therapeutic approaches such as anti-TNF currently being evaluated in multicentric trials.

Uterine Sarcoidosis Potentially Associated With Interferon-α Use for Chronic Hepatitis C Infection

BACKGROUND

A regimen including interferon-alpha has become the standard of care in the treatment of chronic hepatitis C over the last decade. One rare adverse effect associated with the use of interferon-alpha is a granulomatous pulmonary reaction.

CASE

A unique case of uterine sarcoidosis associated with the use of interferon-alpha for chronic hepatitis C infection is presented.

CONCLUSION

Gynecologists should be aware of a potential association between interferon-alpha therapy and granulomatous reactions occurring not only in the lung but also in the female genital tract.

Metastatic tuberculous abscesses in an immunocompetent patient

The decreased incidence of infectious diseases in developed countries may make their diagnosis difficult. Cutaneous tuberculosis is an example of this fact. A 44-year-old man presented with two painful abscesses on his lower extremities, which developed into chronic ulcers. A cutaneous biopsy revealed necrotizing granulomas in the dermis. Ziehl-Neelsen and periodic acid-Schiff stain were negative. Mantoux test was positive. Tc-99m scintigraphy showed increased uptake in the bone tissue of the left ankle and right tibiae, without direct relation to cutaneous lesions. Chest X-ray showed micronodular, apical, bilateral infiltrates, reduced volume of the right lung, and cavitation of the right superior lobe. Mycobacterium tuberculosis was grown from sputum and skin biopsy samples. Isoniazid, rifampin and pyrazinamide treatment for 2 months, followed by isoniazid and rifampin for 12 months, resulted in complete resolution. The clinical features of cutaneous tuberculosis in our patient were characteristic of tuberculous abscesses. Some uncommon findings, such as the low number of lesions, negative acid-fast resistant stains in cutaneous biopsy samples and his preserved general state of health, may be explained by a higher competence of the immune system than is usual in this clinical subset of disseminated tuberculosis. Cutaneous tuberculosis should be included in the differential diagnosis of cutaneous abscesses in immunocompetent patients.

Vascular contractile response and signal transduction in endothelium-denuded aorta from cirrhotic rats

AIM: The mechanism of decreased vascular reactivity to vasoconstrictors in portal hypertension is still unclear. In addition to nitric oxide, defects in post-receptor signal transduction pathway have been suggested to play a role. However, substantial evidences observed equivocal changes of vascular reactivity following different agonists that challenged the hypothesis of the post-receptor defect. The current study was to evaluate the vascular reactivity to different agonists and the inositol trisphosphate (IP₃) changes in signal transduction cascade from cirrhotic rats with portal hypertension.

METHODS: The endothelial denuded aortic rings from cirrhotic and sham-operated rats were obtained for ex vivo tension study and measurement of the corresponding [³H] IP₃ formation following different receptor and nonreceptor-mediated agonists’ stimulation. Additionally, iNOS protein expression was measured in thoracic aorta. The contractile response curves to phenylephrine were performed in endothelial denuded aortic rings with and without preincubation with a specific iNOS inhibitor (L-N(6)-(1-iminoethyl)-lysine, L-NIL).

RESULTS: In endothelial denuded aortic rings of cirrhotic rats, the vascular responses were reduced with phenylephrine and arginine vasopressin (AVP) stimulation but were normal with U-46619, NaF/AlCl₃, and phorbol esterdibutyrate (PdBU) stimulation. Compared to the corresponding control groups, the degree of the increment of [³H] IP₃ formation from basal level was also decreased with phenylephrine and AVP stimulation, but was normal with U-46619 and NaF/AlCl₃ stimulation. The preincubation with L-NIL did not modify the hyporesponsiveness to phenylephrine. Additionally, the iNOS protein expression in thoracic aorta was not different in cirrhotic and sham-operated rats.

CONCLUSION: Without the influence of nitric oxide, vascular hyporeactivity to vasoconstrictors persisted in cirrhotic rats with portal hypertension. However, the decreased vascular reactivity is an agonist-specific phenomenon. In addition, G-protein and phospholipase C pathway associated with the IP₃ productions may be intact in cirrhotic rats with portal hypertension.

Oxidative stress and nitric oxide in rats with alcohol-induced acute pancreatitis

AIM: Oxygen free radical mediated tissue damage is well established in pathogenesis of acute pancreatitis (AP). Whether nitric oxide (NO) plays a deleterious or a protective role is unknown. In alcohol-induced AP, we studied NO, lipooxidative damage and glutathione in pancreas, lung and circulation.

METHODS: AP was induced in rats (n = 25) by injection of ethyl alcohol into the common biliary duct. A sham laparatomy was performed in controls (n = 15). After 24 h the animals were killed, blood and tissue sampling were done.

RESULTS: Histopathologic evidence confirmed the development of AP. Marked changes were observed in the pulmonary tissue. Compared with controls, the AP group displayed higher values for NO metabolites in pancreas and lungs, and thiobarbituric acid reactive substances in circulation. Glutathione was lower in pancreas and in circulation. Glutathione and NO were positively correlated in pancreas and lungs of controls but negatively correlated in circulation of experimental group. In the experimental group, plasma thiobarbituric acid reactive substances were negatively correlated with pancreas thiobarbituric acid reactive substances but positively correlated with pancreas NO.

CONCLUSION: NO increases in both pancreas and lungs in AP and NO contributes to the pathogenesis of AP under oxidative stress.

Sexual transmission of HCV between spouses

BACKGROUND AND AIMS

The sexual transmission of hepatitis C virus (HCV) is debated. By excluding other risk factors, the role of sexual intercourse in the transmission could be detected more accurately. We screened HCV prevalence and risk factors in the spouses of chronic hepatitis C (CHC) patients and followed the seroconversion rate of anti-HCV negative spouses.

PATIENTS AND METHODS

Six hundred spouses of CHC patients were recruited. The spouses' HCV risk factors were questioned and the spouses were tested for anti-HCV. The 216 spouses who were anti-HCV negative were checked annually for anti-HCV.

RESULTS

Anti-HCV was positive in 12 of 600 (2%) of the spouses. Of the 12 anti-HCV positive spouses, 11 were HCV-RNA positive. Of anti-HCV positive and negative spouse groups, mean age was 52.3 +/- 9.8 and 49.8 +/- 12.4 yr; duration of marriage was 1521 +/- 506.7 and 1532.4 +/- 670.2 wk (p > 0.05); and the number of total sexual intercourse was 434 +/- 295 and 307 +/- 333 (p= 0.055), respectively. In our prospective study, none of the spouses developed anti-HCV seroconversion in mean 35.7 +/- 6.3 months and 257.9 +/- 72.2 sexual intercourse.

CONCLUSIONS

Anti-HCV was found positive in 2% of the spouses. None of the seronegative spouses developed seroconversion in the 3-yr follow-up period. This is the first study that stresses the importance of the total number of sexual intercourse in sexual transmission (p= 0.055). Our results of special monogamous group with very limited risk factors support the role of number of total sexual intercourse in HCV transmission. However, the seroprevalence rate of the spouses was still within the upper limit of our country population.

Sarcoidosis in patients with chronic hepatitis C virus infection: analysis of 68 cases

We describe the clinical characteristics, the patterns of association, and the role of antiviral therapies in patients with sarcoidosis associated with chronic hepatitis C virus (HCV) infection. Sixty-eight patients were included in the current study, 56 cases identified in the literature search plus 12 unpublished cases from our department. In 50 HCV patients, sarcoidosis appeared after starting antiviral therapy. Antiviral therapy associated with triggered sarcoidosis consisted of alpha-interferon monotherapy in 20 cases and combined therapy with alpha-interferon and ribavirin in 30. Sarcoidosis appeared during the first 6 months after starting therapy in 66% of patients. The clinical picture of sarcoidosis included predominantly pulmonary disease in 38 (76%) patients and cutaneous sarcoidosis in 30 (60%). Antiviral therapy was discontinued in 60% of patients and continued or adjusted in 14%, while sarcoidosis appeared after completed therapy in the remaining cases. Specific therapy for sarcoidosis was started in only 21 patients, mainly with oral corticosteroids. The outcome of patients was detailed in 46 cases: remission or improvement was observed in 38/46 (83%) patients, stabilization of sarcoidosis in 5/46 (11%), and reactivation of sarcoidosis after an initial improvement in 3/46 (6%). Finally, 18 treatment-naive HCV patients presented sarcoidosis, with 14/18 (87%) patients presenting with pulmonary involvement and 8/18 (44%) with cutaneous involvement. In summary, sarcoidosis may be observed in HCV patients in 2 different situations: triggered by antiviral therapy (in 75% of cases) and unrelated to treatment. Sarcoidosis during antiviral therapy may present mainly as cutaneous or pulmonary disease, with a benign, uncomplicated evolution in more than 85% of cases. However, more complicated cases are observed, especially in HCV patients with preexisting sarcoidosis and/or with previous antiviral treatment. Clinicians should be aware of the possibility that sarcoidosis may initially manifest or be reactivated during or shortly after treatment with antiviral therapy in patients with chronic HCV infection.

Potential effects of L-NAME on alcohol-induced oxidative stress

AIM: Nitric oxide (NO) is a highly reactive oxidant synthesized from L-arginine by nitric oxide synthase (NOS). NO may cause injury through the generation of potent radicals. Nw- nitro-L-arginine methyl ester (L-NAME) is a non-selective inhibitor of NOS. We aimed to evaluate whether L-NAME treatment had protective effects against oxidative stress in rats intragastrically fed with ethanol during a 4 wk-period.

METHODS: Thirty-six male Wistar rats were divided into 3 equal groups: group 1 (control group-isocaloric dextrose was given), group 2 (6 g/kg·d ethanol-induced group) and group 3 (both ethanol 6 g/kg·d and L-NAME 500 mg/L in drinking water-given group). Animals were sacrificed at the end of 4 wk-experimental period, and intracardiac blood and liver tissues were obtained. Biochemical measurements were performed both in plasma and in homogenized liver tissues. Alanine amino transferase (ALT), aspartate amino transferase (AST), malondialdehyde (MDA), NO, superoxide dismutase (SOD), catalase (CAT) and glutathione (GSH) levels were measured by spectrophotometry.

RESULTS: ALT and AST in group 2 (62 U/L and 128 U/L, respectively) were higher than those in group 1 (24 U/L and 38 U/L) and group 3 (37 U/L and 81 U/L) (P<0.001 for both). Plasma and tissue levels of MDA in group 2 (4.66 μmol/L and 0.55 nmol/mg protein) were higher than in group 1 (2.65 μmol/L and 0.34 nmol/mg protein) and group 3 (3.43 μmol/L and 0.36 nmol/mg protein) (P<0.001 for both). Plasma and liver tissue levels of NO in group 2 (54.67 μmol/L and 586.50 nmol/mg protein) were higher than in group 1 (34.67 μmol/L and 435.33 nmol/mg protein) and group 3 (27.50 μmol/L and 412.75 nmol/mg protein ) (P<0.001 for both). Plasma and liver tissue SOD activities in group 2 (15.25 U/mL and 5.38 U/ mg protein, respectively) were lower than in group 1 (20.00 U/mL and 8.13 U/ mg protein) and group 3 (19.00 U/mL and 6.93 U/ mg protein) (P<0.001 for both). Plasma and liver tissue CAT activities in group 2 (145 U/mL and 37 U/ mg protein, respectively) were lower than in group 1 (176 U/mL and 73 U/mg protein) and group 3 (167 U/mL and 61 U/mg protein) (P<0.001 for both). Meanwhile, erythrocytes and liver tissue levels of GSH in group 2 (4.12 mg/g Hb and 5.38 nmol/mg protein, respectively) were lower than in group 1 (5.52 mg/g Hb and 4.49 nmol/mg protein) and group 3 (5.64 mg/g Hb and 4.18 nmol/mg protein) (P<0.001 for both).

CONCLUSION: Our findings show that L-NAME may produce a restorative effect on ethanol-induced liver damage via decreasing oxidative stress and increasing antioxidant status.

Spectrum of pulmonary toxicity associated with the use of interferon therapy for hepatitis C: case report and review of the literature

Hepatitis C is one of the leading causes of liver disease in the United States, and current recommendations for its treatment include the use of interferon (IFN). Pulmonary side effects, although uncommon, have been reported in association with the use of IFN. We report a case of interstitial granulomatous pneumonitis that occurred after therapy with IFN and ribavirin, and we review the literature concerning this entity and other forms of IFN-associated pulmonary toxicity in patients with hepatitis C. The purpose of the present study is to increase awareness of the unusually wide spectrum of pulmonary toxicities associated with the use of IFN and ribavirin, with the anticipation that IFN will be used more frequently in the future for the treatment of hepatitis C.

Drug-induced and iatrogenic infiltrative lung disease

At present more than 350 drugs are known to cause injury of the lung parenchyma,upper and lower airways, pulmonary circulation, pleura, mediastinum, lymph nodes,and neuromuscular system. Infiltrative lung disease (ILD) is the most common pattern of drug-induced injury. This article, which is clinically oriented rather than drug oriented, reviews the patterns of ILD produced by therapeutic drugs and radiation therapy.

Interferon-induced granulomatous lung disease

PURPOSE OF REVIEW

Interferon therapy can induce or exacerbate sarcoidosis. With the increasing use of interferons it is highly likely that more cases of sarcoidosis will be encountered by clinicians. We describe three unusual cases of interferon-induced sarcoidosis and review the most recent relevant literature on this subject.

RECENT FINDINGS

Interferons, on account of their antiviral antigrowth and immunomodulatory effects, are used to treat various internal and dermatological diseases. Exogenously administered interferons stimulate the Th-1 response, which plays a major role in granuloma formation. In most of the patients with interferon-induced sarcoidosis, the disease subsides when interferon is discontinued. Occasionally, treatment with corticosteroids may become necessary.

SUMMARY

Interferon therapy can induce or exacerbate sarcoidosis, the disease disappears when interferon is discontinued, sometimes treatment with corticosteroids is required.

Interstitial Lung Disease Induced by Drugs and Radiation

An ever-increasing number of drugs can reproduce variegated patterns of naturally occurring interstitial lung disease (ILD), including most forms of interstitial pneumonias, alveolar involvement and, rarely, vasculitis. Drugs in one therapeutic class may collectively produce the same pattern of involvement. A few drugs can produce more than one pattern of ILD. The diagnosis of drug-induced ILD (DI-ILD) essentially rests on the temporal association between exposure to the drug and the development of pulmonary infiltrates. The histopathological features of DI-ILD are generally consistent, rather than suggestive or specific to the drug etiology. Thus, the diagnosis of DI-ILD is mainly made by the meticulous exclusion of all other possible causes. Drug dechallenge produces measurable improvement in symptoms and imaging in the majority of patients, whereas corticosteroid therapy is indicated if symptoms are present or drug dechallenge is without an effect. Rechallenge is justified in a minority of patients, and is discouraged for diagnostic purposes only. Pneumotox (www.pneumotox.com) provides updated information on drug-induced respiratory disease.

Duodenal ulcers preceding cervical tuberculous lymphadenitis

Lymphadenitis is the most common presentation of extra pulmonary tuberculosis, whereas gastrointestinal localization, particularly duodenal involvement, is rare. We report a case of extra pulmonary tuberculosis with association between cervical lymphadenitis and duodenitis with multiple ulcers, not responsive to treatment with protonic pump inhibitors, in a human immunodeficiency virus-seronegative adult woman of Eritrean origin. Clinical patterns of duodenal TB, diagnostic difficulties and aetiopathogenesis are discussed according to the literature. In this case report it is suggested that tuberculous infection must be considered when duodenal ulcers fail to respond to proton pump inhibitors, especially when the patient comes from an endemic area.

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Rheumatologic manifestations of sarcoidosis

PURPOSE OF REVIEW

This review emphasizes the importance of the rheumatological signs and symptoms in the presentation of sarcoidosis. Often the presence of musculoskeletal findings may lead to the diagnosis of the disease and the institution of the appropriate treatment.

RECENT FINDINGS

There have been significant advances in the treatment of sarcoidosis with the use of biologic agents for recalcitrant and severe manifestations of the disease as well as some new data regarding pathogenetics and new applications of diagnostic imaging studies such as positron emission tomography scanning.

SUMMARY

Although pulmonary disease is the most frequent manifestation of sarcoidosis, musculoskeletal symptoms are not only common, but may be the initial presentation of this systemic inflammatory process and could mimic other arthritic and autoimmune disorders. This article focuses on the rheumatological aspects of sarcoidosis and includes a review of the most recent literature, which shows new data on the diagnosis, pathogenesis, and treatment of this condition.

The prevalence of hepatic granulomas in chronic hepatitis C

OBJECTIVES

Hepatic granulomas are not usual findings in chronic hepatitis C. A few studies addressing the frequency of hepatic granulomas in chronic hepatitis C reported it as less than 10%. The presence of it has been suggested to predict a favorable response to interferon treatment. Also, case reports described the development of hepatic granulomas after interferon treatment. In this study, we aimed to detect the prevalence of hepatic granulomas in chronic hepatitis C and to identify the causes other than chronic hepatitis C, if present, to search whether there is an association between the presence of granuloma and response to interferon treatment and also to see whether interferon leads to the formation of hepatic granulomas.

METHODS

Patients from 3 university clinics were included. All patients with chronic hepatitis C were determined. All patients with hepatic granulomas were screened for the other causes of hepatic granuloma with tuberculin skin test, chest X-ray and computed tomography, Venereal Disease Research Laboratory, and Brucella agglutination tests. The histologic assessment of liver biopsies was done by the same pathologist in each center.

RESULTS

A total of 725 liver biopsies of 605 patients with chronic hepatitis C were screened. In 8 patients, hepatic granulomas were detected in the initial liver biopsies. Four patients had repeat biopsies, and all had hepatic granulomas again. The prevalence of hepatic granulomas in patients with chronic hepatitis C was calculated as 1.3% (8 of 605) in reference to patient population. Presence or absence of hepatic granulomas was seemingly stable. All patients with hepatic granulomas had negative results of tuberculin skin test, Venereal Disease Research Laboratory, chest X-ray and computed tomography, and Brucella agglutination tests. All repeat biopsies were obtained after interferon (+/- ribavirin) in varying doses and duration. Four of 8 patients with hepatic granulomas were found to respond interferon therapy. No patient was found to develop hepatic granulomas after interferon therapy.

CONCLUSION

Hepatic granulomas are a rare finding in HCV infection. The presence of it does not seem to predict the response to interferon therapy. The development of hepatic granulomas during interferon therapy is not usual.

Typhoid fever as a rare cause of hepatic, splenic, and bone marrow granulomas

During the course of typhoid fever, the usual histologic finding of the liver is "nonspecific reactive hepatitis." Hepatic granuloma (HG) is a rare complication of typhoid fever. We present two cases of typhoid fever with HG and review the relevant literature. Case 1 (a 53-year-old female) was found to have both hepatic and splenic granulomas. This is the first case of typhoid fever with splenic granulomas in the English language literature. Case 2 (a 66-year-old male) developed granulomas in the bone marrow in addition to HG. It should be considered that typhoid fever may lead to granulomas in several organs.

The oxidant-antioxidant balance in mild asthmatic patients

We investigated the oxidant-antioxidant balance and the effect of inhaled corticosteroids on this balance in mild stable asthmatics. Included in the study were 30 mild asthmatic patients (11 male, 19 female, mean age (year) +/- SD: 35.1 +/- 9.7) and 26 healthy adults (7 male, 19 female, mean age (year) +/- SD: 40.8 +/- 13.3). In all study groups, the peripheral venous blood samples were taken for plasma malonyldialdehyde (MDA), a parameter of lipid peroxidation caused by the oxidants, and erythrocyte superoxide dismutase (SOD), an antioxidant enzyme. The mean plasma MDA level was lower in the asthmatic group (5.7 +/- 1.2 nmol/ml) than in the healthy group (6.3 +/- 1.7 nmol/ml); and the mean erythrocyte SOD level was higher in asthmatic group (1086.4 +/- 247.4 U/gHb) than in the healthy group (1028.0 +/- 230.0 U/gHb). However, there were no significant differences in measurements of both plasma MDA levels and erythrocyte SOD enzyme activities between the groups (respectively, p = 0.1 and p = 0.4). When asthmatic patients were divided into subgroups as "inhaled steroid user" and "no inhaled steroid user", no significant differences were observed in the measurements of either plasma MDA level or erythrocyte SOD enzyme activity between the mentioned subgroups. According to the results of our study, we can say that oxidant-antioxidant balance is not significantly affected in mild asthmatics or measurement of plasma level of MDA and erythrocyte SOD enzyme activity is not sensitive to the oxidant-antioxidant balance in mild asthmatics.

Sarcoidosis in untreated chronic hepatitis C virus infection

Chronic hepatitis C has been implicated in the pathogenesis of sarcoidosis in several cases of patients treated with interferon-alpha. On the other hand, only in a few cases previously has a possible link between sarcoidosis and untreated chronic hepatitis C virus infection been demonstrated. We report on a patient with chronic hepatitis C who developed cutaneous sarcoidosis without prior interferon-alpha treatment. We hypothesize that viral persistence seen in chronic hepatitis C virus infection might be one of the potential factors that trigger cellular immune response in granulomatous reactions as seen in sarcoidosis, in genetically predisposed patients.

Granulomatous liver disease and cholestasis

Development of hepatic granulomas, especially those located within portal tracts, is associated with injury to septal and interlobular bile ducts. Dysfunction of the bile ducts in turn leads to cholestasis,and ongoing damage by the granulomatous inflammation eventually results in ductopenia. A multitude of causes of hepatic granulomas have been described over the last few decades. Diligent and prioritized search for cause of hepatic granulomas should proceed within the environmental and epidemiologic context of a given patient. The therapeutic approaches, including amelioration of the cholestatic syndrome, are often determined by successful identification of specific etiologic factors causing the granulomas in the liver.

Cytomegalovirus Enteritis in Common Variable Immunodeficiency

A woman with previously undiagnosed common variable immunodeficiency presented with diarrhea and volume depletion. Biopsies from upper and lower endoscopy revealed atrophic gastritis, villous atrophy, and an inflammatory bowel disease-like chronic colitis, with absence of plasma cells in all sites. Cytomegalovirus inclusions were demonstrated in the colon and small bowel mucosa. Despite therapy with intravenous immunoglobulin and ganciclovir, the patient deteriorated rapidly and subsequently died. This case report highlights the potential for cytomegalovirus to cause extensive disease in patients with common variable immunodeficiency and, thus, the importance of considering it in the initial differential diagnosis so that further morbidity and mortality might be prevented.

Hepatic granulomas: a 10 year single centre experience

BACKGROUND

Epithelioid granulomas have been reported in 2-15% of unselected liver biopsies, with numerous underlying aetiologies described. However, all UK series were reported before identification of hepatitis C virus (HCV).

AIM

To evaluate the current aetiologies of hepatic granulomas and to assess the prognosis for the "idiopathic" group, in which all investigations for a recognised cause were negative or normal.

METHODS

A retrospective review of patient case notes between 1991 and 2001; all patients who had a liver biopsy at Glasgow Royal Infirmary revealing epithelioid granulomas had their case notes and liver biopsies reviewed and a standard proforma completed.

RESULTS

Over the study period, 1662 liver biopsies were performed. Hepatic granulomas were found in 63. Of those identified, 47 were female, with a mean age of 42 years (range, 17-81). Underlying aetiologies were as follows: primary biliary cirrhosis (PBC; 23.8%), sarcoidosis (11.1%), idiopathic (11.1%), drug induced (9.5%), HCV (9.5%), PBC/autoimmune hepatitis (AIH) overlap (6.3%), Hodgkin lymphoma (6.3%), AIH (4.8%), tuberculosis (4.8%), resolving biliary obstruction (3.2%), and other single miscellaneous causes (9.5%). Of the seven patients with idiopathic hepatic granulomas, one was lost to follow up, one died of stroke, and the remaining five were well with no liver related morbidity at a mean follow up of 6.2 years.

CONCLUSIONS

The aetiology of hepatic granulomas is broad ranging, with HCV an important cause in this population. Despite extensive investigations, a 10-15% of patients still had "idiopathic" hepatic granulomas. However, the prognosis for this last group appears to be excellent.