Phenotypic variability in Bartter syndrome type I

Limited phenotypic variability has been reported in patients with Bartter syndrome type I, with mutations in the Na-K-2Cl cotransporter gene (BSC). The diagnosis of this hereditary renal tubular disorder is usually made in the antenatal-neonatal period, due to the presence of polyhydramnios, premature delivery, hypokalemia, metabolic alkalosis, hypercalciuria, and nephrocalcinosis. Among nine children with hypercalciuria and nephrocalcinosis, we identified new mutations consistent with a loss of function of the mutant allele of the BSC gene in five. Three of the five cases with BSC gene mutations were unusual due to the absence of hypokalemia and metabolic alkalosis in the first years of life. The diagnosis of incomplete distal renal tubular acidosis was considered before molecular evaluation. Three additional patients with hypokalemia and hypercalciuria, but without nephrocalcinosis in the first two and with metabolic acidosis instead of alkalosis in the third, were studied. Two demonstrated the same missense mutation A555T in the BSC gene as one patient of the previous group, suggesting a single common ancestor. The third patient presented with severe hypernatremia and hyperchloremia for about 2 months, and a diagnosis of nephrogenic diabetes insipidus was hypothesized until the diagnosis of Bartter syndrome type I was established by molecular evaluation. We conclude that in some patients with Bartter syndrome type I, hypokalemia and/or metabolic alkalosis may be absent in the first years of life and persistent metabolic acidosis or hypernatremia and hyperchloremia may also be present. Molecular evaluation can definitely establish the diagnosis of atypical cases of this complex hereditary tubular disorder, which, in our experience, may exhibit phenotypic variability.

[The role of liver in muscular dystrophy]

Epidemiological or anamnestical data may either help or confuse the differential diagnosis of various diseases mainly characterized by asymptomatic hypertransaminasemia. Occasional finding of transaminase elevation may lead to suppose chronic or persistent hepatopathy, particularly when the patient seems to be asymptomatic and presents anamnestic data suggesting intoxication, acquired infection from blood derivatives, origin from geographic areas with high prevalence of viral hepatitis. However, the true existence of hepatic damage, concurrent to a myopathy, may be also related to the primitive diseases. There is evidence, in fact, that in the presence of muscular dystrophy, a disease caused by structural defects of muscular membranes, also hepatocytes show ultrastructural defects. The present work reports the cases of 5 children, hospitalized at the 1st Clinic of Infectious Diseases of the University of Genoa, affected by persistent hypertransaminasemia and showing anamnestical data suggesting hepatitis; histological findings of hepatitis were effectively shown in 3 patients after needle biopsy. All patients proved to be affected by muscular dystrophy. Hepatic damage results cannot be correlated to known causes of hepatopathy. During disease courses heralded by asthenia and hypertransaminasemia, differential diagnosis must take into account non-hepatic diseases, like muscular dystrophy. Although this disease mainly affects the muscle, also the liver seems to be involved, as suggested by histological changes found in some patients.

HBV-DNA-related hepatocellular carcinoma occurring in childhood. Report of three cases

In a series of 325 HBV chronically infected children observed over an 18-year period, three developed HCC. These three children were born in southern Italy, a region characterized by a high endemic HBV infection rate; each had been infected perinatally, developed an acute hepatitis, and became a chronic carrier. Two of the three with cirrhosis were HBsAg positive at the time their HCC was detected. The remaining case had seroconverted to HBsAb but HBV-DNA integration could be demonstrated in the absence of cirrhosis; moreover HBV antigens were not expressed in the tissue of this case. The interval between HBV infection and HCC appearance in these three cases ranged from six to 11 years. A similarity between these three Italian cases and the majority of HCC arising in chronically infected children in the Far East is noted.

[Liver cirrhosis in childhood. Considerations on 22 cases with different etiology]

Although rather uncommon and multifactorial in etiology, liver cirrhosis is a severe and often rapidly fatal disease in pediatrics. In our institution, during the last 15 years, 22 children with liver cirrhosis have been followed. The underlying predisposing condition was HBV infection (8 cases), CMV perinatal infection (2 cases), Wilson's disease (4 cases), chronic cholestasis (2 cases) and alcohol abuse (2 cases); in 4 cases no predisposing condition was evident. In all cases the histological examination of the liver was the diagnostic cornerstone. The mean age at diagnosis was 6 years and 8 months, with an early onset especially in the posthepatitis cirrhosis. In 10 out of 22 patients, cirrhosis was not preceded by an history of chronic liver disease. Poor subjective symptomatology was present in 13 of the cases, hepatomegaly in all, splenomegaly in 18 cases, signs of hepatic failure in 13 cases. In all patients various impairments of hepatocellular synthesis were detectable, especially during the period preceding the development of hepatic insufficiency. The mean time to cirrhosis was 5 years. The average duration of the follow up was 3 years and 4 months: during the follow up 6 patients improved, 5 patients showed no clinical or functional modifications of their hepatic disease, 3 patients worsened and 8 died. In order to perform suitable treatment of liver cirrhosis the need of early diagnosis and etiological definition should be emphasized.

[Anatomo-histopathological and immunological correlations in chronic hepatitis]

An immunohistological survey was made of cryostat liver sections from 30 patients: 17 adults and 13 children affected by chronic hepatitis were studied. Immunofluorescent techniques were used to determine the following: HBsAg, HBcAg, HDV, IgG, serum antibodies, B lymphocytes and CD4+, CD8+ and activated T lymphocytes. The tissue antibody response and the inflammatory infiltrate was more evident in CAH than in CPH. The prevalent cell subpopulation in HBV hepatitis is represented by CD8+ while in non-A non-B and autoimmune forms by CD4+. Furthermore, in histologically more serious forms 75% of the T cells were activated with respect to 25% in non active forms. The difference was statistically significant.

Treatment of children with chronic hepatitis B with a combination of steroids and human lymphoblastoid interferon

The efficacy of human lymphoblastoid interferon (Wellferon) therapy was measured in 20 children with chronic hepatitis B with or without pretreatment with prednisolone. Patients were randomised to receive 0.6 mg/kg/day prednisolone for 3 weeks, then at 0.3 mg/kg for a fourth week or placebo. All patients then received interferon 5 MU/m2 i.m. for 12 weeks; daily for 5 days then three times a week for the remaining 11 weeks. Preliminary results show that 25% of children had a permanent loss of viral markers of replication. However, response to interferon varied widely between individuals and a prolonged follow-up is required in order to determine the influence of prednisolone pretreatment on the efficacy of interferon therapy.

Hepatitis B virus (HBV)-DNA-positive hepatocellular carcinoma following hepatitis B virus infection in a child

Integrated hepatitis B virus (HBV) DNA sequences were found in neoplastic liver tissue of a hepatitis B surface antigen (HBsAg)-negative child who had previously suffered from HBsAg-positive chronic active hepatitis and was anti-HBs and anti-hepatitis B core (HBc) positive at the time of tumor development. Reintegration pattern was consistent with the presence of a single integration site of the HBV genome into cellular DNA, and clonal proliferation of such infected cells. A normal liver, tested in the same experiment with the same amount of total DNA, was negative for viral DNA sequences. These findings support the possible oncogenic role of HBV in the development of liver cancer, not only in adults, but also in children, even in patients who are negative for HBsAg at the time of tumor diagnosis.

Infection with the delta agent in children

Serological evidence of infection with the hepatitis B virus associated delta agent (delta) was found in 34 of 270 Italian children with HBsAg-positive liver disease. In different histological forms of chronic HBsAg hepatitis the prevalence of delta infection increased in parallel with the activity of the disease and was maximal in children with cirrhosis. During two to seven years of follow up the hepatitis deteriorated in 38% of the 34 patients with delta infection and ameliorated only in 9%. By contrast the disease usually ran a mild course in the 236 delta-negative carriers of HBsAg, with remission in 55% of these children and deterioration in only 7%. The outcome of chronic hepatitis associated with delta infection was not influenced by treatment with steroids and azathioprine. Chronic delta infection in children is usually accompanied by serious liver disease, that has a tendency to progress and is unresponsive to conventional immunosuppressive treatment.

A long-term study of hepatitis B virus-related antigens and immunological parameters in children with chronic hepatitis

Forty-two children with HBsAg positive chronic hepatitis who received immunosuppressive therapy underwent multiple liver biopsies over periods ranging from one to five years. The presence of HBsAg, HBcAg, deltaAg, antinuclear antibodies and immune complexes was studied using immunofluorescent techniques. The data were correlated with the clinical status of the patients. The presence of HBsAg, HBcAg and deltaAg remained unchanged throughout the study in most positive patients. All 30 HBcAg positive cases were still positive at the end of the study. One of the negative cases became positive. Eight of the ten delta antigen positive cases showed no change. Intrahepatic immunoglobulins, immune complexes and antinuclear antibodies showed a decrease in positivity in a significant number of patients. Fifteen of the 36 patients positive for intrahepatic immunoglobulins became negative during the study, as did 12 of the 29 immune complex positive subjects and 22 of the 33 antinuclear antibody-positive cases. The persistence of HBV antigens seems to be independent of the clinical course. On the other hand, the persistence of positive immunological indices corresponds to a less favourable outcome.

[Comparison between immunofluorescent aspects of chronic HBsAG+, HBAG-hepatitis and some cases of chronic toxic-dismetabolic liver diseases]

In the study the aspects noticed on hepatic biopsies by I.F. in HBsAg+ and HBsAg- chronic hepatitis and in some cases of hepatitis on dismetabolic basis in Wilson's disease are compared. Great differences occurred between HBsAg+, HBsAg- and the Hepatitis in Wilson disease. In fact in the first case reactivity is often present due to immunological phenomena (presence of IgG immunocomplexes and autoantibodies) while in Wilson's disease these aspects are not found confirming the hypothesis that in the latter case is a question of an exclusively toxic damage.

[The use of an immunofluorescence technic in the control of chronic HBV hepatitis]

The direct and indirect immunofluorescence technique has been used to study liver biopsies in children affected by different forms of chronic HBsAg positive Hepatitis. The method allows to study the long run changes of the antigens correlated to HBV and of the related immunological phenomena both in serum (autoantibodies) and in the tissue (immunoglobulins and immunocomplexes in the liver). The results obtained are satisfactory.

[Chronic HBsAg negative hepatitis in childhood, Stud using the immunofluorescence method]

13 children with chronic HBsAg negative hepatitis were examined in this work with the I.F. method. Comparison can be made with a previous work on chronic HBsAg positive hepatitis. 8 of these patients were cases of ECP, 1 was a ECA-A and 4 were ECA-B. Research has been done to point out immunoglobulins and immunocomplexes in the liver and serum. On the whole, fluorescence was less both in liver and serum than fluorescence in chronic HBsAg positive hepatitis. Reasons of it can be: the absence of anti-virus B antibodies (HBcAb, delta-Ab, HBsAb), the relative lightness of our cases and, probably, a better answer of HBsAg negative hepatitis than of HBsAg positive one to immunodepressive treatment.

[Immunofluorescence studies on HBsAg positive chronic hepatitis in children. Correlation with the clinical pattern]

The results obtained in a study of liver biopsies from children affected by different forms of chronic hepatitis during an immunodepressive treatment, accomplished by means of immunofluorescence are summarized. The different antigens correlated to B virus, localized in the nuclei (core and delta), the immunological phenomena observed in the tissue (immunoglobulins and immunocomplexes) and in serum (autoantibodies) have been investigated. The presence of HBcAg, looking finely granular, has been found in 77% of cases of CAH, similar to that found in adults. Delta Ag has been found only in 29% of cases, in the nuclei, like core Ag, but nuclei were more large and not homogeneous. The 2 antigens could be found also in the same patient, differently from adults. The absence of the two antigens has a good prognostic significance; the presence of delta antigen has on the contrary a bad prognostic meaning; the persistence of core antigen under immunodepressive treatment may correspond to a tolerance against antigen. Immunoglobulins and/or immunocomplexes, binding complement, were found in 69% of cases. The fluorescence can be found in different patterns: nuclear, due to immunocomplexes of HBV and antibodies penetrated through impaired membranes; of hepatocyte membranes, linear, probably against auto-antigens (lipoproteins liver-specific) or neo-antigens induced by the virus; in inflammatory cells (K-cells or phagocytic monocytes); or scattered granular, may be from non-eliminated immunocomplexes. Autoantibodies in serum, tested on autologous substrates, were present in 97% of cases, in prevalence antinuclear or against hepatocytary membranes, but also against cytoplasmatic components. Important variations exist between the different forms, both as for what concerns the morphological patterns and the intensity of the reactions. A statement about the severity and the evolution of the disease, with prognostic implication could be hypothetically made in the future, after further studies.

[Research on the core and delta antigens of human hepatitis virus B using immunofluorescence, with liver biopsy of pediatric subjects affected by various forms of chronic hepatitis]

On liver biopsies of 20 children with different forms of chronic HBsAg-positive hepatitis, submitted to immunodepressive treatment, the presence and the distribution of core and delta antigens and their correlation with the different clinical forms have been studied with the direct immunofluorescence technique. Core antigen was present in 11 patients, delta antigen in 4 patients: both antigens in 3 cases. The percent rate of positive nuclei varied from 5 to 80%. All subjects negative for both antigens showed a favourable course. Delta antigen seems to be associated to forms with unsatisfactory course notwithstanding therapy, particularly to relapses and recurrences of chronic hepatitis in such a way as to hypothesize the possible responsibility either of another hepatitic virus (non A, non B virus) or of a different virus. Core morphological expression frequent in chronic hepatitis submitted to immunodepressive treatment, corresponded approximately to the finding thus far reported for the adults. The interpretation of these results, though difficult, shows remarkable interest for the pathogenetic and therapeutic considerations which follow.

[Research on surface antigens with immunofluorescence on enterobiopsies of patients with hepatitis B]

ABsAg surface antigen was detected, on enterobiopsies at duodenal level by means of Crosby capsule, in 12 subjects with various types of hepatitis B and in 2 control subjects, by means of immunofluorescence. The antigen was present in the duodenal mucosa of a certain number of subjects with hepatitis: this case-list included subjects with a tendency to relapse or with a poor chronic course notwithstanding the treatment. Some interpretative hypotheses are set forth.

Gentamicin in the treatment of Salmonella infections

Changes in the ecology of Salmonella organisms impose the use of highly specific chemotherapeutic agents both in animals and in attempts ot combat salmonella typhi in man. An examination of inhibition achieved by the use of a number of antibiotics against strains isolated from 52 hospitalized patients in our clinic, over the past three years, has shown the majority of strains to be sensitive to gentamicin (78%), followed by nalidixic acid, nitrofurantoin, chloramphenicol (44%) and other chemotherapeutic agents, including the combination of sulphamethoxazole and trimethoprim (28%) and ampicillin (11%).

[Combination of antifungal chemotherapeutic agents in experimental candidiasis in mice]

For the valuation of therapeutical activity of many new recent antifungal drugs, these were employed in the various possible associations in the experimental candidosis of the mouse. From the results obtained calculated on the survivance percentage, was concluded that the best antifungal is the 5 fluorocytosine + amphotericin B association.