Predicting response to initial therapy with interferon plus ribavirin in chronic hepatitis C using serum HCV RNA results during therapy

In patients with chronic hepatitis C, 48 weeks of therapy with interferon (IFN) plus ribavirin results in a sustained virologic response of 40%. Preliminary analysis suggests that measuring HCV RNA at week 24, rather than week 12, might provide the best prediction of treatment response. To assess the clinical utility of serum HCV RNA determinations at different times during therapy as a predictor of a sustained virologic response we evaluated 912 treatment-naïve patients. Patients were randomized to receive IFN-alpha2b, 3 million units (MU) three times weekly (tiw), for 24 or 48 weeks with either ribavirin or placebo, and then followed for 24 weeks. Serum HCV RNA was measured at weeks 4 and 12 in patients treated for 24 weeks; at 4, 12, and 24 weeks during therapy in those treated for 48 weeks, and week 24 post-therapy in all patients. Sustained response was defined as loss of serum HCV RNA at week 24 follow-up. Other patients were considered virologic nonresponders. For patients receiving 48 weeks of combination therapy, detectable serum HCV RNA at week 24 predicted nonresponse (positive predictive value) in 99% of patients compared to 89% at week 12. In patients treated for 24 weeks, testing at week 12 was more predictive of nonresponse than testing at week 4 in the combination-therapy group but not in the monotherapy group. Hence, for combination therapy, testing for serum HCV RNA as a predictor of nonresponse is most accurate at week 24 of therapy; a positive test correctly identified 99% of nonresponders.

Tracheobronchitis as an initial presentation of ulcerative colitis

We describe a patient with ulcerative colitis (UC) and the rare extraintestinal manifestation of fulminant tracheobronchitis. A 50-year-old man presented with respiratory compromise and bloody diarrhea. His evaluation showed large airway inflammation with fibrinopurulent debris and colonic inflammation and ulcerations consistent with UC. The etiology for the pulmonary pathology was thoroughly investigated and was thought to be an extraintestinal manifestation of the UC.

Current and future therapies of hepatitis C

With recent advances in the treatment of chronic hepatitis C, patients with elevated aminotransferase levels, detectable HCV RNA in the serum, and chronic inflammation are candidates for therapy. The best initial therapy is interferon plus ribavirin, achieving a sustained response rate in 40% of patients. The duration of therapy should be based on HCV genotype (48 weeks for genotype 1; 24 weeks for other genotypes). Serum HCV RNA should be measured at week 24 to assess response and guide further therapy in patients with genotype 1 infection. Patients unsuitable for combination therapy can be treated with interferon monotherapy. Side effects, dose modification and discontinuation are generally more frequent with interferon plus ribavirin, but can be managed with close follow-up and careful monitoring. With rapid developments in treatment, new therapies will require careful prospective evaluation according to HCV genotype and viral-load characteristics. Recommendations for therapy will probably change every few years, and novel approaches may provide effective therapy for most patients with hepatitis C.

Pancreatitis due to Ascaris lumbricoides: second occurrence after 2 years

Pancreatitis is a common disease in the United States, with the most likely etiologies being biliary tract disease and alcohol use. Infections with parasites such as Ascaris lumbricoides comprise a small percentage of pancreatitis cases in the United States, but they are a common etiology in developing countries. In the United States, the incidence of pancreatic and biliary ascariasis has been increasing because of the migration of people from endemic countries, as well as increased travel by Americans to such countries. Patients treated for this roundworm can have reinvasion for the same reasons. We report the case of a patient with two episodes of pancreatitis due to A. lumbricoides 2 years apart.

Acute hepatitis after ingestion of herbs

Herbal preparations are marketed as natural and safe alternatives to conventional medicines for the prevention and treatment of a variety of ailments. However, consumers may not be fully aware of their potential side effects. We report two cases of acute hepatitis after the ingestion of herbal preparations. One of the mixtures included chaparral and bee pollen; the other was pure bee pollen. Chaparral has been reported to have similar effects in other patients, but we found no reports of acute hepatitis from bee pollen. We discuss chaparral and several other hepatotoxic herbs and review the literature. Our case reports remind primary care physicians to ask their patients about herbal use and discuss their potential toxicities.

An unusual case of mesenteric ischemia in a patient with new-onset diabetes mellitus

The early detection of acute mesenteric ischemia is crucial for the preservation of bowel viability. The emergency physician must have a high index of suspicion to identify mesenteric ischemia when there is a paucity of physical examination findings. We discuss the case of a patient who presented to the emergency department with confusion, hyperglycemia, abdominal tenderness, and metabolic acidosis who also developed mesenteric ischemia.