HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

ER stress induces NLRP3 inflammasome activation and hepatocyte death

The incidence of chronic liver disease is constantly increasing, owing to the obesity epidemic. However, the causes and mechanisms of inflammation-mediated liver damage remain poorly understood. Endoplasmic reticulum (ER) stress is an initiator of cell death and inflammatory mechanisms. Although obesity induces ER stress, the interplay between hepatic ER stress, NLRP3 inflammasome activation and hepatocyte death signaling has not yet been explored during the etiology of chronic liver diseases. Steatosis is a common disorder affecting obese patients; moreover, 25% of these patients develop steatohepatitis with an inherent risk for progression to hepatocarcinoma. Increased plasma LPS levels have been detected in the serum of patients with steatohepatitis. We hypothesized that, as a consequence of increased plasma LPS, ER stress could be induced and lead to NLRP3 inflammasome activation and hepatocyte death associated with steatohepatitis progression. In livers from obese mice, administration of LPS or tunicamycin results in IRE1α and PERK activation, leading to the overexpression of CHOP. This, in turn, activates the NLRP3 inflammasome, subsequently initiating hepatocyte pyroptosis (caspase-1, -11, interleukin-1β secretion) and apoptosis (caspase-3, BH3-only proteins). In contrast, the LPS challenge is blocked by the ER stress inhibitor TUDCA, resulting in: CHOP downregulation, reduced caspase-1, caspase-11, caspase-3 activities, lowered interleukin-1β secretion and rescue from cell death. The central role of CHOP in mediating the activation of proinflammatory caspases and cell death was characterized by performing knockdown experiments in primary mouse hepatocytes. Finally, the analysis of human steatohepatitis liver biopsies showed a correlation between the upregulation of inflammasome and ER stress markers, as well as liver injury. We demonstrate here that ER stress leads to hepatic NLRP3 inflammasome pyroptotic death, thus contributing as a novel mechanism of inflammation-mediated liver injury in chronic liver diseases. Inhibition of ER-dependent inflammasome activation and cell death pathways may represent a potential therapeutic approach in chronic liver diseases.

Functional bowel symptoms in quiescent inflammatory bowel diseases: role of epithelial barrier disruption and low-grade inflammation

OBJECTIVE

To determine the role of colonic barrier defects and low-grade inflammation in irritable bowel syndrome (IBS)-like symptoms in quiescent inflammatory bowel disease (IBD).

DESIGN

Caecal biopsies were collected from 51 IBS, 49 quiescent IBD (31 Crohn's disease (CD) and 18 ulcerative colitis (UC)) patients and 27 controls. IBS was assessed using the Rome III criteria and the IBS severity score. Epithelial barrier integrity was evaluated by determining the paracellular permeability of biopsies mounted in Ussing chambers and the mRNA expression of tight junction proteins (ZO-1, α-catenin and occludin). Low-grade inflammation was evaluated by counting cells, including intraepithelial lymphocytes (IELs), eosinophils and mast cells, and by determining the mRNA and protein expression of tumour necrosis factor (TNF)-α in biopsies and culture supernatants.

RESULTS

IBS-like symptoms were present in 35.4 and 38% of CD and UC patients, respectively. Paracellular permeability was significantly increased in both quiescent IBD with IBS-like symptoms and IBS compared with quiescent IBD without IBS-like symptoms (p<0.01, respectively) or controls (p<0.01, respectively). Significantly lower expression of ZO-1 and α-catenin was detected in IBS and quiescent IBD with IBS-like symptoms. IELs and TNF-α were significantly increased in quiescent IBD with IBS-like symptoms, but not in IBS.

CONCLUSIONS

In quiescent IBD, IBS-like symptoms related to persistent subclinical inflammation associated with increased colonic paracellular permeability. A persistent increase in TNF-α in colonic mucosa may contribute to the epithelial barrier defects associated with abdominal pain in quiescent IBD, but not in IBS. Optimisation of anti-inflammatory therapy may be considered in quiescent IBD with IBS-like symptoms.

Esophageal varices in chronic intestinal insufficiency in absence of portal hypertension or liver cirrhosis: case report

We report the case of a 62-year-old man with short-bowel syndrome, referred for intestinal transplantation, who had esophageal varices (EV) due to superior vena cava (SVC) thrombosis. Pretransplantation work-up revealed protein S deficiency. Results of liver function tests were normal. Upper endoscopy showed grade II to III EV in the upper and middle segments of the esophagus. Computed tomography demonstrated thrombosis of the jugular, subclavian, and SVC veins and marked collateral vessels in the chest. Transient elastography yielded normal findings. A liver biopsy specimen showed a normal aspect of the liver, without fibrosis or liver cirrhosis. Presence of EV in a patient with chronic intestinal insufficiency may be related to collateral venous circulation associated with SVC thrombosis in the absence of portal hypertension. In this situation, an isolated intestinal graft is indicated.

Bone metastasis from endometrioid ovarian carcinoma: a case study and literature review

INTRODUCTION

Bone metastases from epithelial ovarian carcinoma are rare, usually discovered postmortem. The survival of these patients is poor. Furthermore, only two cases of endometrioid ovarian carcinoma with metastasis to the skeletal structures have been described in the literature.

CASE REPORT

We present the case of a 58-year-old woman with a lytic metastasis in the left iliac ramus from endometrioid ovarian carcinoma that occurred seven years after the initial diagnosis.

DISCUSSION

A review of the literature since 1966 on bone metastasis of ovarian cancer is also presented. In patients suffering from a neoplasm that rarely metastasises to bone, histological proof should be obtained to diagnose uncommon sites of disease relapse.

Mast cells and cellularity of the colonic mucosa correlated with fatigue and depression in irritable bowel syndrome

BACKGROUND

A subset of patients with irritable bowel syndrome (IBS) have an increased number of mast cells (MCs) in the colonic mucosa. Psychological factors are believed to contribute to the course of IBS.

AIMS

To examine associations between fatigue, depression and MCs of the colonic mucosa in IBS.

METHODS

Colonic biopsies were taken from 50 Rome II IBS patients, 21 healthy controls and 11 depressed/fatigued patients without IBS. The cellularity of the lamina propria was determined as the number of inflammatory cells per high power field (hpf) through a 400x microscope. The Fatigue Impact Scale (FIS) and the short form Beck Depression Inventory (BDI) evaluated the severity of fatigue and depression.

RESULTS

IBS patients had a significant increase in the cellularity of the lamina propria compared with controls or with depressed patients (mean (SD) 94.5 (48-110) vs 68 (58-82) and 78 (87-90) cells per hpf, p = 0.005 and p = 0.05, respectively), in particular of MCs (9.3 (5.6-11.7) vs 4.0 (2.7-6.8) and 4.3 (2.8-7.8) cells per hpf, p = 0.001 and p = 0.005, respectively). Both the FIS and BDI scores were significantly higher in IBS or in depressed patients than in controls (p<0.001). In IBS, the FIS score correlated significantly with the cellularity of the lamina propria (r = 0.51, p<0.0001) and MCs (r = 0.64, p<0.0001). In IBS, the BDI score correlated significantly with MCs (r = 0.29, p = 0.03).

CONCLUSIONS

Elevated MCs counts are a key feature of the low-grade inflammatory infiltrate in the caecal mucosa of IBS. Fatigue and depression are associated with mucosal cell counts, in particular MCs, suggesting that psychological factors are associated with the low-grade inflammatory infiltrate in IBS.

Imagerie des pseudo-tumeurs inflammatoires hépatiques

PURPOSE

To describe the imaging features of inflammatory pseudotumors of the liver.

INTRODUCTION

Inflammatory pseudotumors of the liver are rare benign lesions that may simulate malignancy on imaging studies. Diagnosis is most frequently confirmed after surgical resection of the lesion.

MATERIALS AND METHODS

Retrospective study from 1998 to 2006 of histologically proven cases of inflammatory pseudotumors of the liver. A combination of the following imaging modalities were utilized: US, contrast enhanced US, helical CT and MRI.

RESULTS

A total of seven lesions (mean diameter of 61.4 mm) were detected in 6 patients (mean age of 66 years). Clinical and laboratory results were non-specific. The following imaging studies were available: US in 5 cases, including one with contrast material, CT in 5 cases and MRI in 3 cases. All tumors were hypoechoic on US, with no enhancement after injection of Levovist. The tumors were generally hypodense on noncontrast CT and enhancement, when present, was delayed and moderate. On MRI, the tumors were iso- or slightly hyperintense on T2W images and iso- or slightly hypointense on T1W images with subtle peripheral enhancement on delayed imaging.

CONCLUSION

The differential diagnosis of inflammatory pseudotumor of the liver should be known to radiologists and could be suggested in a clinical context of chronic inflammatory process in patients with non-specific liver mass showing imaging features of partial fibrosis with delayed enhancement.

Transjugular liver biopsy: prospective evaluation of the angle formed between the hepatic veins and the vena cava main axis and modification of a semi-automated biopsy device in cases of an unfavorable angle

In cases of transjugular liver biopsies, the venous angle formed between the chosen hepatic vein and the vena cava main axis in a frontal plane can be large, leading to technical difficulties. In a prospective study including 139 consecutive patients who underwent transjugular liver biopsy using the Quick-Core biopsy set, the mean venous angle was equal to 49.6 degrees. For 21.1% of the patients, two attempts at hepatic venous catheterization failed because the venous angle was too large, with a mean of 69.7 degrees. In all of these patients, manual reshaping of the distal curvature of the stiffening metallic cannula, by forming a new mean angle equal to 48 degrees , allowed successful completion of the procedure in less than 10 min.

Kaposi's sarcoma confined to the colorectum

Reported is a new case of a Kaposi's sarcoma involving only the colorectal area in an HIV-negative patient presenting with hemorrhagic rectocolitis. The colonoscopic examination and the radiological imaging showed the presence of multiple nodular pseudopolypoid formations in the rectum, which suggested, in the differential diagnosis, primarily a malignant non-Hodgkin lymphoma.

Traumatic neuroma of the cystic duct with biliary obstruction. Report of a case

A case of amputation neuroma of the biliary tract occurring 12 years after a cholecystectomy is reported. The patient, a 81 year-old man, presented with obstructive jaundice due to a stricture of the extrahepatic biliary tract. The stricture was resected and biliary reconstruction was achieved with a Roux-en-Y jejunal loop. The diagnosis of neuroma was obtained only at histology that showed hyperplastic nerve bundles, positive for protein S 100. The patient is well one year and six months after surgery without signs of recurrence of the stricture. Although the amputation neuroma of the biliary tract has already been reported, it seems worthwhile to emphasise this further report. This lesion is an unusual cause of benign stricture of the biliary tract that may pose difficult diagnostic problems.

[Delayed diagnosis of neurocysticercosis: two case reports]

INTRODUCTION

Neurocysticercosis is the most frequently encountered cerebral parasitic infection worldwide. It is due to infection of the central nervous system by Taenia solium larval form. According to the location of the cysts, parenchymal and extra-parenchymal forms may be identified, with different clinical expressions.

EXEGESIS

We report two cases of neurocysticercosis, one with typical parenchymal involvement and the second with extra-parenchymal involvement revealed by increased intra-cranial pressure. In both cases, the diagnosis was established over 10 years after the onset of symptoms.

CONCLUSION

Neurocysticercosis is very frequent in non-Islamic developing countries, and its incidence is increasing in industrialized nations in relation to tourism and immigration from highly endemic areas. Symptoms usually appear several years after infection and this accounts for the frequent delays before the diagnosis is established.

Caspase inhibition protects from liver injury following ischemia and reperfusion in rats

Normothermic ischemia and reperfusion of the liver results in microcirculatory failure followed by necrosis and cell death. Recently, another type of cell death, apoptosis or programmed cell death, was found to be activated during the early phase of reperfusion after liver ischemia. Caspases are cysteine proteinases specifically involved in the initiation and execution phases of apoptosis. The aim of this study was to demonstrate that inhibition of apoptosis by a specific inhibitor of caspases might protect the liver against ischemia/reperfusion injury. Rats were divided into three groups: group 1, control, PBS administration; group 2, Z-Asp-cmk (Z-Asp-2,6-dichlorobenzoyl-oxymethylketone) treatment; group 3, sham-operated control animals. Z-Asp-cmk (0.5 mg Z-Asp-cmk dissolved in 300 microl PBS solution containing 1% DMSO) was injected intravenously, 2 min prior to induction of 120 min ischemia. Survival rates were compared and serum activities of aspartate aminotransferases and alanine aminotransferases were assessed in the blood collected from the suprahepatic vena cava. Histology of the liver was assessed 6 h after the end of ischemia. Apoptosis was detected by the terminal deoxynucleotidyl transferase-mediated dUTP-FITC nick end-labeling method (TUNEL method) and by electrophoresis for analysis of DNA fragmentation. Caspase activity was determined by measuring hydrolysis of the CPP32-like substrate Ac-DEVD-pNA and absorption of paranitroaniline. Z-Asp-cmk treatment significantly increased 7-day survival (95%) compared with that in nontreated rats (30%, P < 0.001). Serum activities of aminotransferases and the extent of liver congestion and necrosis were significantly (P < 0.001) decreased after treatment with Z-Asp-cmk. TUNEL-positive cells were detected 3-6 h after reperfusion in the control group. In Z-Asp-cmk pretreated rats, a dramatic decrease in the number of TUNEL-positive cells was observed. Analysis of DNA fragmentation of freshly isolated hepatocytes confirmed these results. Caspase activity was increased 3-6 h after reperfusion in the control group, but significantly (P < 0.001) decreased after treatment with Z-Asp-cmk. These findings demonstrate that liver injury following ischemia and reperfusion can be prevented by inhibition of caspases. Caspase inhibitors may have important implications for therapy in liver disease and after liver transplantation.

Role of non-parenchymal liver cells in ischaemia-reperfusion liver injury: protective effects of muramyl dipeptide

It has been suggested that non-parenchymal liver cells play a central role after ischaemia and reperfusion of the liver. Male Lewis rats were subjected to 90 min of warm liver ischaemia. Four groups were constituted: group 1, no treatment; group 2, muramyl dipeptide treatment, activation of Kupffer cells; group 3, dextran sulphate injection, Kupffer cell blockade; and group 4, gadolinium chloride administration, Kupffer cell blockade. Dextran sulphate (4 mg/100 g) and gadolinium chloride (GdCl2, 0.7 mg/100 g) were given intravenously on day 2. MDP was injected intravenously (500 mg/250 g) 24 h before and 10 min after the intervention. Mortality rates were assessed and serum transaminases, histology of the liver and Kupffer cell phagocytic activity were evaluated 6 h after the end of ischaemia. MDP treatment significantly (P < 0.001) reduced mortality (30%) in comparison with the non-treated group (60%). The mortality rate was significantly higher in the dextran sulphate-treated (80%) and gadolinium chloride-treated (90%) groups in comparison with group 1. A significant reduction in transaminase levels was observed after MDP treatment, while blockade of Kupffer cells resulted in higher serum transaminase levels. The extent of necrosis and congestion was improved by MDP administration, while disruption of the vascular and sinusoidal integrity of the liver and extensive areas of necrosis were observed in dextran sulphate and gadolinium chloride-treated rats. Sheep red blood cell 51Cr liver uptake was deeply depressed 6 h after the end of ischaemia in group 1 (10 +/- 1.2%/g tissue). MDP injection restored the Kupffer cell activity (30.6 +/- 3.22%/g tissue) while dextran sulphate and gadolinium chloride administration markedly decreased SRBC 51Cr liver uptake. Our findings demonstrate that MDP in able to protect the liver from ischaemic insult while blockade of Kupffer cells was deleterious in rats subjected to liver ischaemia.

Chondrex (YKL-40), a potential new serum fibrosis marker in patients with alcoholic liver disease

OBJECTIVES

Chondrex (YKL-40) is a mammalian member of a protein family that includes bacterial chitinases. The pattern of its expression in certain tissues such as human liver or cartilage suggests a function in remodelling or degradation of extracellular matrix. The purpose of this study was to assess whether circulating YKL-40 might be a serum fibrosis marker in alcoholics.

METHODS

Plasma YKL-40 was determined in 146 consecutive heavy drinkers (106 men, 40 women; mean age, 49.2 +/- 9.0 years). Liver biochemical parameters and serum fibrosis markers such as hyaluronate were also measured. Fibrosis and inflammation in liver biopsy were evaluated using a semi-quantitative scoring system.

RESULTS

Plasma YKL-40 increased in parallel with the severity of fibrosis (P<0.00001). YKL-40 also increased in the presence of hepatic inflammation (P<0.01). Receiver operating characteristic curves of Chondrex revealed that a threshold of 330 microg/l gave a specificity of 88.5%; however, the sensitivity was only 50.8%. Only 11.5% of patients without severe fibrosis displayed a Chondrex plasma level above this threshold. A positive correlation was found between Chondrex and hyaluronate (r=0.40, P<0.0001), and a negative correlation was shown between Chondrex and the prothrombin index (r=-0.37, P<0.0001).

CONCLUSIONS

The severity of liver fibrosis is associated with elevated circulating Chondrex levels. The overlap in YKL-40 values prevents use of Chondrex in a screening programme. High levels of Chondrex (above 330 microg/l) are predictive of severe liver fibrosis. Increased plasma YKL-40 may reflect the remodelling of liver fibrosis in alcoholics.

[Vaccination by suicide gene therapy against a model of hepatic metastasis from colon cancer in the rat]

Suicide gene therapy consists of transferring into tumor cells a viral or bacterial gene encoding for an enzyme which converts a non-toxic product into a lethal drug.

STUDY AIM

To analyze the therapeutic potential of vaccination with tumor cells expressing the bacterial cytosine deaminase (CD) gene and 5-fluorocytosine (5-FC) treatment in a rat liver metastasis model.

MATERIAL AND METHOD

We used a rat colon carcinoma cell line which, after subcapsular or intraportal injection in syngenic animals, generates single or multiple experimental liver metastases, respectively. We have shown that introduction of a vector expressing the CD gene in this colon carcinoma cell line results in 5-FC sensitivity (PRObCD).

RESULTS

Intrahepatic subcapsular injection of PRObCD tumor cells, followed by 5-FC treatment, induces total regression of a wild-type tumor pre-established in the contralateral liver lobe in 45% of animals with a 96% decrease in mean volume (p < 0.0001), demonstrating the existence of a distant bystander effect. This vaccination significantly increased the survival of rats with single (log-rank p < 0.0001) or multiple (log-rank p = 0.01) liver metastasis

CONCLUSIONS

These results suggest that suicide gene-modified tumor cells can act as potent therapeutic vaccines against liver metastasis from colon carcinoma.

Non invasive prediction of severe fibrosis in patients with alcoholic liver disease

OBJECTIVES

The aim of this study was to assess the diagnostic accuracy of noninvasive markers of liver fibrosis in alcoholic liver disease.

PATIENTS AND METHODS

Fifty-four clinical and biochemical parameters including serum fibrosis markers (hyaluronate and transforming growth factor beta1) were analyzed in 146 consecutive heavy drinkers (106 men, 40 women; mean age 49.2 years). Following liver biopsy, fibrosis was evaluated using a semi-quantitative scoring system (no fibrosis (0) to severe fibrosis (3 + )). Multivariate analysis was performed to determine the markers that were best correlated with the fibrosis score.

RESULTS

Fifty-nine patients (40.4 %) had severe fibrosis (3 +) while 87 (59.6 %) had no fibrosis or moderate fibrosis (0 to 2 +). In multivariate analysis, serum hyaluronate and the prothrombin index were the best markers for the prediction of severe fibrosis. Hyaluronate and the prothrombin index had a diagnostic accuracy of 91.1 % and 89.7 %, respectively in the whole population. Finally, a significant negative correlation was found between hyaluronate and the prothrombin index (r =- 0.86, P <0.0001).

CONCLUSIONS

Using only hyaluronate and the prothrombin index, 9 out of 10 alcoholic patients can be correctly classified according to the severity of liver fibrosis.

Effects of 1-year interferon-alpha 2a treatment in patients with chronic hepatitis C and persistently normal transaminase activity

BACKGROUND

Certain chronic hepatitis C carriers have persistently normal transaminase activity. The aims of this study were to determine the virologic and histologic effects of 1 year of interferon-alpha treatment in such patients.

METHODS

Thirty-one patients were followed up in our Liver Unit. Eleven accepted interferon-alpha therapy; the 20 others were not treated and served as controls. Interferon-alpha, 3 MU, was given thrice weekly for 1 year. Serum was examined for hepatitis C virus (HCV)-RNA before, at the end of, and 6 months after treatment. Liver biopsy was performed 6 months after the cessation of treatment in 10 of 11 treated patients (one refused biopsy) and after a mean of 30.6+/-22.7 months in the 20 untreated patients.

RESULTS

At the end of follow-up two of the treated patients had undetectable serum HCV-RNA and five had increased alanine aminotransferase (ALAT) values. In contrast, only one of the untreated patients had abnormal ALAT activity. All 20 untreated patients were constantly viremic. No significant histologic improvement was observed in the treated patients evaluated by means of post-treatment liver biopsy. The mean annual progression rate of fibrosis was very slow and similar in the treated and untreated patients (0.09 (range, 0-0.62) versus 0.07 (range, 0-0.60) fibrosis units).

CONCLUSIONS

One year of interferon-alpha treatment can suppress HCV-RNA in patients with chronic hepatitis C and persistently normal ALAT values followed up over long periods. The rate of fibrosis progression in such patients is very slow, and therapeutic strategies should take this fact into account. Antiviral treatment is debated for patients without fibrosis in initial biopsy specimens.

Regression of experimental liver tumor after distant intra-hepatic injection of cytosine deaminase-expressing tumor cells and 5-fluorocytosine treatment

Cytosine deaminase (CD) gene of E. coli converts the non-toxic compound 5-fluorocytosine (5-FC) into 5-fluorouracil. We have introduced a vector expressing the CD gene in a rat colon carcinoma cell line. Expression of the CD gene confers 5-FC sensitivity to these cells in vitro and in vivo. In a bifocal model consisting in a simultaneous engrafment of a CD+ tumor on one lobe of the liver and a wild-type parental tumor on the opposite lobe, treatment with 5-FC results in regression of both type of tumors, indicating the existence of a distant bystander effect.

The histological spectrum of visceral leishmaniasis caused by Leishmania infantum MON-1 in acquired immune deficiency syndrome

Visceral leishmaniasis (VL) due to Leishmania infantum is endemic in Southern France and can be considered as an opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). Co-infection with Leishmania sp. and human immunodeficiency virus (HIV) is emerging, but pathological findings of leishmaniasis in AIDS have been poorly documented, and scattered case reports have include morphological descriptions. The clinicopathologic analysis of 16 patients with HIV and VL were evaluated. The clinical presentation was characteristic of VL, with fever, hepatosplenomegaly, and pancytopenia in 6 patients, and the diagnosis was confirmed by finding amastigotes of Leishmania sp. in bone marrow smears and biopsy specimens. In 4 patients, the initial diagnosis of VL was made fortuitously in gastrointestinal biopsies performed systematically (3 patients) or in case of diarrhea (1 patient). In one duodenal biopsy, Leishmania sp. and Mycobacteria sp. were associated. Liver biopsy allowed the diagnosis of VL in 3 cases. Autopsy was performed in 9 patients, showing a disseminated leishmaniasis with very unusual localizations (adrenal and heart) in 2 cases. Cutaneous leishmaniasis involvement was noted before (4 patients), at the same time (2 patient), or after (1 patient) the diagnosis of VL. Inflammatory infiltrates noted with Leishmania sp. infection were made by CD68 macrophages with (8 patients) or without (8 patients) associated CD8 positive lymphocytes. Immunoperoxidase study using polyclonal anti-Leishmania sp. antibodies contributed to the diagnosis in all cases. Electron microscopy of 2 digestive biopsy specimens showed the ultrastructural characteristics of Leishmania sp. amastigotes. The zymodeme MON-1 of L infantum was identified by isoenzyme electrophoresis in all patients. The mean of CD4 counts was 37/mm3 at the time of diagnosis, and the mean duration before the death was 8 months. As shown in this study, VL in AIDS can be diagnosed in gastrointestinal or liver biopsies. Diagnosis of VL was made when the CD4 count was very low and was correlated with a poor prognosis.

Chronic pancreatitis and inflammatory bowel disease: true or coincidental association?

OBJECTIVE

Several cases of pancreatitis have been described during the course of Crohn's disease (CD) or ulcerative colitis (UC), but many of them were related to either biliary lithiasis or drug intake. We tried to evaluate the clinical and morphological features of so-called idiopathic pancreatitis associated with inflammatory bowel disease and to define their pathological characteristics.

METHODS

Chronic idiopathic pancreatitis was diagnosed on the basis of abnormal pancreatograms suggestive of chronic pancreatitis associated with or without impaired exocrine pancreatic function, or pathological examination in patients undergoing pancreatic resection. We found 6 patients presenting with features of chronic idiopathic pancreatitis and UC and 2 patients with CD seen between 1981 and 1996 in three hospital centers of the south of France. A review of the literature has identified 6 cases of pancreatitis associated with UC and 14 cases of pancreatitis associated with CD based on the above criteria.

RESULTS

Hyperamylasemia was not a sensitive test since it was present in 44% and 64% of patients with UC or CD. In UC, pancreatitis was a prior manifestation in 58% of patients. In contrast, the pancreatitis appeared after the onset of CD in 56% of the cases. In patients with UC, pancreatitis were associated with severe disease revealed by pancolitis (42%) and subsequent surgery. Bile duct involvement was more frequent in patients with UC than with CD (58% vs 12%) mostly in the absence of sclerosing cholangitis (16% vs 6%). Weight loss and pancreatic duct stenosis were also more frequent in UC than in CD (41% vs 12% and 50% vs 23%, respectively). Pathological specimens were analyzed in 5 patients and demonstrated the presence of inter- and intralobular fibrosis with marked acinar regression in 3 and the presence of granulomas in 2 patients, both with CD.

CONCLUSIONS

Pancreatitis is a rare extraintestinal manifestation of inflammatory bowel disease. Chronic pancreatitis associated with UC differs from that observed in CD by the presence of more frequent bile duct involvement, weight loss, and pancreatic duct stenosis, possibly giving a pseudotumor pattern.

Autopsy findings in the acquired immunodeficiency syndrome (AIDS). A report of 395 cases from the south of France

Necropsy findings in 395 adult patients with the acquired immunodeficiency syndrome (AIDS) who died in Nice, France, between March 1983 and May 1996 were compared retrospectively with antemortem diagnoses, risk factors and number of positive T CD4 lymphocytes at the time of death. Special emphasis on bacterial infections was made in this study. Lesions observed from 1983 through 1989 and from 1990 through 1996 were compared. We assessed the role of organ lesions in the immediate cause of death. The organ system distribution of major opportunistic infections and neoplasms was similar throughout the years of the study. The most common diagnostic disease entities in all organ sites were cytomegalovirus infection, toxoplasmosis and candidiasis. Toxoplasmosis was more common in the intravenous drug abuser group. Bacterial infections were frequent and contributed to the mortality and morbidity of all risk factor groups. Kaposi' sarcoma continued to occur more frequently in the homosexual population. Cytomegalovirus infection remained one of the most common causes of death from 1983 to 1996. Mortality from fungal and bacterial infections, and mycobacteriosis increased in frequency during the course of this study whereas deaths from pneumocystosis declined. The death rate from malignant lymphoma and carcinoma increased after 1989. The clinical cause of death concurred with the pathological cause in 55% of the cases. Lung was the most frequent organ involved followed by the central nervous system the gastrointestinal tract and the heart.

[Inflammatory pseudotumor of the intrahepatic biliary tract]

Hepatic inflammatory pseudotumors are rare, presenting with a severe clinical pattern mimicking neoplasm. The diagnosis is almost always based on pathological examination showing inflammatory lesions with a polymorphous infiltrate and variable amounts of fibrous tissue. Development in the biliary tract is rare. We report the case of a 53-year-old patient who was referred for poor general condition and jaundice; the initial diagnosis was cholangiocarcinoma. Pathological examination of the surgical specimen showed a right intrahepatic biliary duct inflammatory pseudotumor. The patient developed recurrent jaundice three months after surgery due to a lesion of the left biliary ducts. Treatment with cortisone resulted in rapid improvement of jaundice.

A caspase inhibitor fully protects rats against lethal normothermic liver ischemia by inhibition of liver apoptosis

Apoptosisis activated during the early phase of reperfusion after liver ischemia and after liver transplantation in animals. However, the molecular basis of ischemia-induced cell death remains poorly understood. In this study we show that hepatocytes from ischemic liver lobes undergo apoptosis after reperfusion. In vivo pretreatment of rats with a specific inhibitor of caspases abrogates the apoptotic response in ischemic liver lobes. Inhibition of apoptosis can be accounted for by total inhibition of caspase activation as assessed in an enzymatic assay and by specific affinity labeling. Treatment with a caspase inhibitor fully protects rats from death induced by ischemia/reperfusion. These findings indicate that liver injury after ischemia/reperfusion can be prevented by inhibition of caspases. Thus, caspase inhibitors may have important therapeutic implications in liver ischemic diseases and after liver transplantation.

[The biocompatibility of suture materials used in colon surgery. An experimental study in the rat]

BACKGROUND

The aim of this experimental study was to compare the tissue behavior of biofragmentable anastomotic ring (BAR) with other synthetic materials used in colonic surgery.

METHODS

Thirty-three rats were divided into four groups: group 1, sham-operated control animals without material implanted; group 2, with fragments of polypropylene monofilament implanted extraperitoneally in abdominal wound, between musculature and peritoneum; group 3, with metal clips implanted extraperitoneally in abdominal wound, between musculature and peritoneum and group 4, with fragments of biofragmentable anastomotic ring implanted extraperitoneally in abdominal wound, between musculature and peritoneum. Animals were sacrificed 30 days after the operation. Macroscopic and histological criteria were used to characterize the resistance of the wound and the tolerance of the host to the foreign material.

RESULTS

The inflammatory cell reaction of host tissue was significantly greater in group 4 compared with other groups (p < 0.05). In three cases, in group 4, we observed the adhesion of implanted fragment to epiploa. The enumeration of giant cells and the degree of fibrotic reaction was similar in all groups with material implanted, but no significant difference between the groups was observed. Our findings showed the greater biocompatibility of polypropylene and metallic clips, compared to the biofragmentable ring anastomosis. The strong inflammatory reaction in the host tissue caused by biofragmentable anastomotic ring may explain partially clinical postoperative complications (anastomotic wound infection and/or dehiscence and/or stricture).

CONCLUSIONS

In conclusion, the choice of suture materials should be based not only on the mechanical properties, but also on their biological interactions between host and suture materials and on the evaluation of their effective cost/benefit.

Improvement of normothermic rat liver ischemia/reperfusion by muramyl dipeptide

Normothermic ischemia and reperfusion (I/R) of the liver remains a major problem after liver surgery and transplantation. Activation of Kupffer cells (KCs) after normothermic I/R is responsible for a massive release of various monokines such as tumor necrosis factor alpha (TNF-alpha) and a decrease in phagocytic activity. Muramyl dipeptide (MDP) is an immunostimulant that increases phagocytic activity of KCs. The aim of this study was to demonstrate that MDP pretreatment might protect the liver against I/R injury by a modification of KC functions. Rats were divided into three groups: group 1, control, Ringer's lactate administration; group 2, MDP (N-acetyl-muramyl-d-alanyl-d-isoglutamine) treatment; group 3, sham-operated control animals. MDP (500 microg/250 g) was injected intravenously 5 min before the induction of 90 min ischemia. Survival rates were compared and serum activities of TNF-alpha, aspartate aminotransferase, and alanine aminotransferase were assessed in the blood collected from the suprahepatic vena cava. Histology of the liver and KC activity were assessed 6 and 9 h after the end of ischemia, respectively. MDP treatment significantly increased 7-day survival (86.6%) compared with nontreated rats (40%, P < 0.001). Serum activities of TNF-alpha and aminotransferases were significantly decreased after MDP treatment, whereas phagocytic capacity of KCs was partially restored. The extent of liver necrosis was decreased after MDP administration. A significant difference was observed for other histological parameters studied, except for steatosis. Our findings have demonstrated that MDP is able to protect the liver from ischemic insult by modulation of KC activity (TNF-alpha release and phagocytic capacity). Control of macrophage activity may offer a new strategy to reduce ischemic injury of the liver.

Lack of influence of hepatitis G virus infection on alcohol-related hepatic lesions

BACKGROUND

The purposes of this study were to analyse the prevalence and histologic impact of hepatitis G virus (HGV), a newly discovered virus, in alcoholic patients, a population known to be at risk for viral hepatitis.

METHODS

One hundred and thirty-nine consecutive alcoholics admitted to our liver unit (106 men and 33 women; mean age, 47.1 +/- 10.9 years) were included in the study. All patients had consumed more than 60 g of ethanol per day for at least 1 year. One hundred healthy blood donors constituted a control group. Antibodies to HGV E2 protein and HGV-RNA testing by reverse transcription-polymerase chain reaction (RT-PCR) with primers derived from the NS5 coding region were performed in all serum samples.

RESULTS

A significantly higher seroprevalence of anti-E2 antibodies was observed in alcoholic patients than in healthy blood donors (41 (29.5%) versus 8 (8%); P < 0.0001). Moreover, the prevalence of HGV-RNA was significantly higher in alcoholic patients (13 (9.3%) versus 1 (1%); P = 0.01). HGV-RNA and anti-HGV antibodies were never detected simultaneously. HGV viraemia was not associated with an increased risk of cirrhosis or hepatocarcinoma in alcoholic subjects.

CONCLUSIONS

Our study reports a high prevalence of HGV in alcoholic patients. HGV infection does not modify or aggravate the course of alcoholic liver disease.

[Primary neuroendocrine tumor in the intrahepatic bile ducts: a rare finding in an asymptomatic patient]

Neuroendocrine tumors of the biliary tree are rare. In all cases except one, diagnosis was made in symptomatic patients. We report a case of an asymptomatic intrahepatic bile duct neuroendocrine tumor in a 74-year old man. To our knowledge, this is the second reported case of an asymptomatic intrahepatic bile duct neuroendocrine tumor. Diagnosis was only made by anatomopathological examination of the tumor after resection. Systemic and immunohistochemical hormonal screening was negative. Twenty months after surgery, the patient was asymptomatic and there was no recurrence.

[A rare case of severe pulmonary artery hypertension. Thrombosing pulmonary microangiopathy due to tumor]

We report a case of acute respiratory insufficiency with acute cor pulmonale and a fatal outcome. Right cardiac catheterisation enabled a diagnosis of precapillary pulmonary arterial hypertension to be made with a mean pulmonary arterial pressure of 61 mmHg and a pulmonary capillary pressure of 12 mHg. An autopsy was carried out and this revealed a microscopic pulmonary tumour emboli with lymphangitis carcinomatosis. In particular, it showed an association of fibrocellular proliferation at the level of the intima in the small calibre pulmonary arteries and arterioles permitting the unusual diagnosis of thrombosing pulmonary microangiomathy due to tumour. The physiopathological mechanism of this particular form of pulmonary tumour emboli is discussed; it would be secondary to an activation of the coagulation systems by the embolic tumour cells. Once activated, it is the lesions in the intima and not the carcinoma cells which generate the pulmonary arterial hypertension by vascular obstruction.

[Hepatic resection and transplantation for hepatocellular carcinoma in patients with cirrhosis]

OBJECTIVES

Liver resection and liver transplantation are the only curative treatments for hepatocellular carcinoma in patients with cirrhosis. The aim of this retrospective study was to compare survival and tumor recurrence in patients with cirrhosis after hepatic resection or liver transplantation for hepatocellular carcinoma in patients with cirrhosis.

METHODS

Between March 1988 and March 1995, 34 patients underwent liver resection and 30 patients with cirrhosis had liver transplantation for hepatocellular carcinoma. The probability of survival and recurrence were studied according to clinical, biological and pathological factors, defined in liver specimens. Comparisons were performed by the actuarial method and log rank test.

RESULTS

Five-year survival after resection and transplantation was 13% and 32.6%, respectively, and 5-year recurrence was 92.6% and 40.9%, respectively (P < 0.01). The diameter of nodules was a significant predictive factor of recurrence in resected patients; the number of nodules was a significant predictive factor in transplanted patients. The combination of these two factors could be used to identify two groups: patients with large carcinoma (diameter > 5 cm and/or number of nodules > 3), and patients with small carcinoma (diameter < or = 5 cm and number of nodules < or = 3). The five-year survival rate of large hepatocellular carcinoma was 17.3% after resection and 0% after transplantation. The five-year survival rate of small hepatocellular carcinoma was 0% after resection and 69.3% after transplantation (P < 0.01). The five-year recurrence of large hepatocellular carcinoma was 72.3% after resection and 100% after transplantation. The five-year recurrence of small hepatocellular carcinoma was 82.6% after resection and 11.1% after transplantation (P < 0.01).

CONCLUSIONS

Liver transplantation seems to be the best treatment for small hepatocellular carcinoma, mainly because of a lower recurrence rate. On the other hand, both treatments had a high recurrence rate in large hepatocellular carcinoma.

Histiocytoid cardiomyopathy: a cause of sudden death in infancy

We report the case of an infant aged of 14 months deceased of sudden death. The diagnosis of histiocytoid cardiomyopathy was made on a necropsic basis. The pathologic examination showed a cardiac hypertrophy characterized by yellowish areas with irregular outlines, disseminated in the myocardium, and made of histiocyte-like cells with foamy or granular cytoplasm. These cells reacted positively with desmin and myoglobin labels, and had rare and disorganised myofibrils in electron microscopy, proving their muscular origin. The illness affects infants and usually causes severe cardiac troubles leading to death without treatment. This case is the fourteenth associated with sudden death.

Phenotyping of intrahepatic and peripheral blood lymphocytes in patients with chronic hepatitis C

The host immune responses have been suggested to play a role in liver injury occurring in patients with chronic hepatitis C. In order to explore the relationship between the relative proportions of intrahepatic and peripheral blood lymphocytes (IHL, PBL), the levels of viremia, and the histological hepatitis activity score, three-color fluorescence-activated cytometric analysis was performed for 36 patients with chronic hepatitis C and six control subjects without chronic hepatitis. The liver biopsy was performed before any antiviral therapy. Each liver specimen was divided into two parts: one for histological examination and one for immunological analysis. Tricolor CD45 was used to improve "lymphogating." Fluorescein isothiocyanate- or phycoerythrin-conjugated monoclonal antibodies with specificity for CD3, CD4, CD8, and CD20 (lymphocyte subpopulations), for CD69 (activated lymphocytes), and for CD16/56 (natural killer cells) were used. The livers of patients with chronic hepatitis C contained a greater proportion of CD4+ lymphocytes that exhibited marked expression of CD69 than in control subjects (20.7 +/- 7.3% vs 10.2 +/- 4.6%, P = 0.027). Moreover, in patients with chronic hepatitis C, the proportion of CD4+ IHL correlated with the histological hepatitis activity evaluated by the Knodell score (r = 0.48, P = 0.004). No correlation was found between the percentage of CD4+ IHL and the level of viremia or transaminase activities. Our findings clearly indicate that a cellular immune response does take place in HCV-infected livers and could thus contribute to the outcome of hepatitis C virus infection.

Prolongation of discordant heart xenograft survival after liver hemoperfusion: role of nonparenchymal liver cells

In the discordant guinea pig (GP)-to-rat combination, heart xenografts are hyperacutely rejected. The aim of the present study was to demonstrate that a donor-species-specific extracorporeal liver hemoperfusion can prolong survival of discordant heart xenografts and to specify the role of non-parenchymal cells. GP hearts were grafted into Brown Norway rats (group 1) In group 2, heart xenografting was carried out immediately after a 15-min GP hemoperfusion. In group 3, Kupffer cells of the GP liver were blockaged by intravenous injection of dextran sulfate (4 mg/100 g) 30 min before hemoperfusion. In group 4, Kupffer cells of the liver were activated by intravenous injection of muramyl dipeptide (MDP; 500 micrograms/250 g) 24 h before hemoperfusion. Lymphocytotoxic antibodies were detected according to a complement-dependent antibody assay. A donor-specific liver hemoperfusion can delay hyperacute rejection of heart xenografts (67.6 +/- 47.1 min in group 2 versus 8.0 +/- 2.4 min in group 1; p < 0.01) and reduce the level of lymphocytotoxic antibodies. Deposits of immunoglobulins and complement were significant on the hemoperfused liver and moderate on the transplanted heart. In group 3, after blockade of Kupffer cells with dextran, heart xenograft survival was less prolonged (31.8 +/- 8.2 min) and the decrease in antibody levels was not significant and associated with moderate deposits of immunoglobulins and complement on the hemoperfused liver and significant deposits on heart xenografts. In group 4, after stimulation of Kupffer cells by MDP, a significant decrease in antibody levels was present, and significant deposits were observed. These results show that donor-specific liver hemoperfusion can prolong the survival of discordant heart xenografts and support the hypothesis that nonparenchymal liver cells play a major role by absorption of preformed antibodies and complement.

Oral inflammatory pseudotumour: immunohistochemical investigation of a case involving the submandibular gland and review of the literature

Inflammatory pseudotumours (IPs) are rare lesions. Most commonly reported in the lung, they are almost ubiquitous, but few oral cases have been described. Their rapid growth, local invasiveness and recurrence, and their ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) aspects are confusing and mimic benign or malignant neoplasms. Their recognition and distinction from malignant tumors is of importance but their histopathological diagnosis may represent a challenge. In the case reported involving the submandibular gland, the spindle cells had the immunohistochemical profile of myofibroblasts, broader cells with a larger nucleus were CD68 and/or Mac387 positive and the dense plasmacytic infiltrate was polyclonal. Histopathology of IPs covers a spectrum of appearances according to the cellularity and the degree of fibrosis. The recognition of a variable mixture of three main cell types: histiocytes or macrophages, myofibroblasts or fibroblasts and abundant plasma cells, with low mitotic activity and absence of cytological abnormalities in an ill circumscribed and rather fibrous lesion is recommended for the diagnosis of oral IP.

[Comparative profitability of hepatic biopsy and microbiological tests in patients with HIV infection]

OBJECTIVES

Diagnostic liver biopsy is proposed in HIV-positive patients who present unexplained fever. This invasive procedure is truly useful if it allows establishing a difficult diagnosis or improves survival rate. We conducted a retrospective study to determine the diagnostic and prognostic power of liver biopsy in HIV-positive patients with fever.

METHODS

One hundred thirty-eight liver biopsies were performed in 129 patients. Utility was defined as demonstration of the pathogen or identification of a tumoral process.

RESULTS

The liver biopsy met the utility criteria in 27 cases showing mycobacterial infections (n = 22) and herpes hepatitis, type 1 herpes simplex virus, cytomegalovirus and cryptococcosis infections (n = 1 each). These last 4 diagnoses were also possible with other tests. Comparing non-contributive liver biopsies (n = 111) with those demonstrating hepatic mycobacterial infection (n = 22) showed that the two groups were not different in terms of demographic data. Splenomegalia was more frequent in the non-contributive group (68% vs 37%, p = 0.007) as was superficial lymph node enlargement (45% vs 12%, p < 10(-3)). Laboratory tests were not discriminating. Mycobacterial infection was diagnosed in 22 patients in the non-contributive group. Bacteriological samples were positive for mycobacterium in 20 of the 22 patients in the contributive group. The mean delay to the first positive test for mycobacterium was 15 +/- 8 days compared with 30 +/- 10 days for liver tissue cultures. Mean survival after liver biopsy was 10 months: patients with a positive Ziehl-Neelson stain on the liver biopsy did not have a longer survival (9.7 +/- 7.6 vs 10.2 +/- 10.4 months).

CONCLUSION

In most cases, liver biopsy in HIV-positive patients with fever provides a diagnosis which can be obtained with non-invasive techniques without improving prognosis.

Normothermic ischemia induces major histocompatibility complex class I expression in hepatocytes

The hepatic expression of major histocompatibility complex (MHC) antigens is normally limited. However aberrant expression may occur in cholestatic diseases or following liver transplantation. The aim of this work was to investigate the effect of normothermic ischemia on hepatocellular MHC expression. Temporary (90-min) normothermic ischemia of the liver was induced in inbred rats. There was a significant elevation of aspartate aminotransferase and alanine aminotransferase levels after ischemia, rising to their maximum by 6 h. Histologic findings showed large, confluent areas of necrosis, and preserved areas were seen with centrolobular congestion and macrovacuolar steatosis. Expression of MHC class I and II antigens was detected using the immunoperoxidase technique, 1 h, 12 h, 3 days, 7 days and 1 month after the end of intervention. A marked induction of the expression of class I, but not of class II, MHC antigens was observed on the hepatocyte membranes after ischemia. We suggest that normothermic ischemia can occur postoperatively in human liver transplantation and may cause increased expression of class I MHC antigens on hepatocytes, leading to increased sensitivity of liver allografts to rejection by cytotoxic T cells.

[Hemorrhagic pancreatic cystadenocarcinoma with colonic fistula. An unusual mode of manifestation]

We report a case of a cystadenocarcinoma of the pancreatic tail, in a 85-year-old man. This tumor was successively revealed by a wirsungorrhagia and a hemorrhagic pancreatico-colic fistula. To our knowledge, it's an exceptional revelation of a pancreatic cystadenocarcinoma and the first case reported in the literature.

[1,5 Tesla MRI in focal nodular hyperplasia. Review of the literature apropos of 7 cases]

Six patients with 7 focal nodular hyperplasia lesions were investigated with 1.5 Tesla magnetic resonance imagery (MRI). Surgical specimens were obtained in all cases and histological examination confirmed the diagnosis of focal nodular hyperplasia. In all cases, the tumour was isointense on the T1 weighted sequences. On the T2 weighted sequences in six cases, the tumour gave a hypersignal compared with the surrounding healthy liver tissue. Central scar tissue was found in all the lesions. On the T2 weighted images, the center gave a hypersignal 4 times and a hyposignal 3 times. Gadolinium injection on the echo gradient sequences (GRASS) showed product uptake suggestive of vessels within the central scar in one case. The report in the literature confirm the variability of focal nodular hyperplasia depending on the magnetic field used. In 1.5 Tesla MRI an isointense signal on at least one sequence would appear to be sufficient for the diagnosis of focal nodular dysplasia if the tumour is homogeneous and if the central scar is hyperintense in T2 sequences.