Selection of different 5' untranslated region hepatitis C virus variants during post-transfusion and post-transplantation infection

BACKGROUND

Hepatitis C virus (HCV) translation is initiated in a cap-independent manner by an internal ribosome entry site (IRES) located within the 5' untranslated region (5'UTR). Sequence changes in this region could affect translation efficiency and presumably viral replication.

AIM

To determine translation efficiency of 5'UTR variants developing during post-transfusion hepatitis C in two immunocompetent subjects and in two immunosuppressed liver recipients with recurrent HCV.

METHODS

Sequential samples were screened for 5'UTR changes by single-strand conformation polymorphism followed by cloning and sequencing whenever band pattern suggested sequence changes. 5'UTR variants were tested for IRES activity using a bicistronic dual luciferase expression plasmid transfected into HepG2 and Huh7 cell-lines.

RESULTS

In the transfused patients, translation efficiency of 5'UTR variants from early post-transfusion samples was 5.1- to 13.7-fold higher than that of predominant variants found in late follow-up samples. Post-transplant variants in the other two patients had 2.6- to 5.9-fold higher translation efficiency than those present only in pretransplant samples.

CONCLUSION

In the immunocompetent host there may be selection of low translation efficiency HCV variants over the course of infection. However, in immunosuppressed subjects the opposite seems to be true as low translation efficiency variants are superseded by high translation efficiency variants.

Impairment of health-related quality of life in patients with inflammatory bowel disease: a Spanish multicenter study

BACKGROUND

Inflammatory bowel disease impairs patients' perception of health and has a negative impact on health-related quality of life (HRQOL). Most studies include patients from a single hospital. This may bias limit results through the use of small patient samples and/or samples within a restricted disease spectrum.

METHODS

HRQOL was measured in patients with ulcerative colitis (UC) and Crohn's disease (CD) from 9 hospitals located in different geographical areas in Spain using 2 questionnaires: the Spanish version of the Inflammatory Bowel Disease Questionnaire (IBDQ) and the EuroQol. Results are expressed as medians.

RESULTS

The study included 1156 patients (528 patients with UC and 628 with CD; median age, 35 yr; slight predominance of women, 617 versus 539). HRQOL worsened in parallel with disease severity to a similar extent in both UC (IBDQ scores of 6.1, 4.7, and 4.0 for the 3 disease severity groups, respectively) and CD (IBDQ scores of 6.1, 5.0, and 4.1, respectively). A similar inverse relation between clinical activity and quality of life was observed when EuroQol preference values were used. All 5 dimensions of the IBDQ showed significantly lower scores in patients with active UC and CD than in patients in remission. The pattern of scores by IBDQ dimensions differed between patients in relapse (who scored worse on the digestive symptoms dimension) and patients in remission. Variables related with disease activity, time of evolution since diagnosis and female sex, were significantly associated with having a worse perception of HRQOL. The type of disease or geographical area of residence did not influence results on the IBDQ.

CONCLUSIONS

UC and CD impair patients' HRQOL, and the degree of impairment depends on disease activity but is independent of the type of disease and place of residence.

[Ehlers-Danlos syndrome associated with acute pancreatitis]

Ehlers-Danlos syndrome is an inherited connective tissue disease characterized by articular laxity, hyperelastic skin and tissue fragility. The syndrome is genetically, biochemically and clinically heterogeneous and several well-defined subtypes have been identified. We describe a patient with the type IV variant of this syndrome who developed acute spontaneous pancreatitis.

Pyogenic liver abscesses of bacterial origin. A study of 45 cases

OBJECTIVE

to determine the clinical, microbiological, diagnostic and therapeutic characteristics of pyogenic liver abscesses of bacterial origin.

METHODS

retrospective analysis of pyogenic liver abscesses diagnosed at the Aránzazu Hospital in San Sebastián (northern Spain) between 1989 and 1998.

RESULTS

we studied 45 patients with pyogenic liver abscesses of bacterial origin (30 men, 15 women, mean age 61 years 11 months). The site of the liver abscess was biliary in 28.9% of the patients, portal in 11.1%, and unknown in 33.3%. Elevated erythrocyte sedimentation rate (95.5%), leukocytosis (86.7%) and fever (82.2%) were the most frequent clinical and laboratory findings. The abscesses were solitary in 55. 5% of the patients. Echography was diagnostic in 68.4% of patients, and computed tomography was diagnostic in 100%. Cultures of pus from the abscess and blood were positive in 77.1% and 50% respectively. Of the abscesses diagnosed as being of bacterial origin, 44.4% involved multiple organisms. Escherichia coli and Streptococcus milleri were the germs isolated most frequently. Percutaneous drainage was done in 22 patients (48.9%), with satisfactory results in 18. Overall mortality related with abscesses was 15.5%.

CONCLUSIONS

the clinical presentation of pyogenic liver abscess did not vary during the study period. Computed tomography is fundamental for diagnosis and treatment. Percutaneous drainage associated with early antibiotic therapy is the treatment of choice.

[Massive hemorrhage due to esophageal varices as a form of presentation of autoimmune hepatitis]

Autoimmune hepatitis is a necro-inflammatory disease of unknown etiology. An acute or fulminant presentation is rare. We report a 18-year-old man presented with acute variceal hemorrhage. The patient was treated with endoscopic sclerotherapy, somatostatin, balloon tamponade and TIPS. The patient died within a week of massive bleeding and hepatic failure. This patient's history strongly suggests that autoimmune hepatitis can be presented as fulminant hemorrhage. The importance of diagnosis and treatment is emphasized to improve prognosis.

[Bleeding of the upper digestive tract due to gastric metastasis of squamous lung carcinoma]

Bronchogenic lung carcinoma, melanoma and breast cancer are the neoplasms which have most frequently been reported to metastasize to the stomach. These lesions are usually located on the fundus and on the upper part of the gastric body. They are usually asymptomatic with the diagnosis being made at necropsy. We present a patient who developed gastrointestinal bleeding as the first symptom of squamous lung cancer secondary to a gastric metastasis.

Mixed cryoglobulinaemia in patients with chronic hepatitis C infection: prevalence, significance and relationship with different viral genotypes

In order to analyse the prevalence and significance of cryoglobulinaemia in patients with chronic hepatitis C virus (HCV) infection and the possible relationship of cryoglobulinaemia with the genotypes of HCV, we studied 89 patients with chronic HCV infection, 42 healthy controls and 22 patients with alcoholic cirrhosis. The patients with HCV were divided into three different groups according to the presence of cirrhosis and alanine aminotransferase levels. Moreover, in 20 patients with HCV and cryoglobulinaemia, HCV RNA sequences were quantified in serum and in cryoprecipitate. Cryoglobulins were detected more frequently in patients with chronic HCV infection than in healthy controls (42.6% vs. 4.7%; P<0.0001). Cryoglobulins were present in 68.4% of patients with HCV-related cirrhosis, which was nearly twice the figure in noncirrhotic HCV-infected patients and alcoholic cirrhotic patients. There were no differences in age, sex, aminotransferase levels or HCV genotype distribution in HCV-infected patients with or without cryoglobulinaemia. Only 13% of patients with chronic HCV infection and cryoglobulins showed symptoms of cryoglobulinaemia. There was a linear association between HCV RNA concentration in sera and in cryoprecipitates (P<0.0005). Patients with chronic HCV infection had a high prevalence of cryoglobulinaemia, especially in advanced forms of the disease, but clinical findings are few. There was no relationship with the genotype of HCV. The presence of HCV RNA in cryoprecipitates supported the hypothesis on the aetiological role of HCV in mixed cryoglobulinaemia.

Late disappearance of hepatitis C virus RNA from peripheral blood mononuclear cells in patients with chronic hepatitis C in sustained response after alpha-interferon therapy

OBJECTIVE

We aimed to investigate the modifications of HCV RNA (genomic and antigenomic strands) in peripheral blood mononuclear cells (PBMCs) of long-term responder patients to alpha-interferon therapy, and their usefulness as criteria of definitive HCV eradication.

METHODS

We studied 10 patients with chronic hepatitis C with > 1 yr of sustained response after alpha-interferon therapy (normal alanine aminotransferase [ALT] and negative serum HCV RNA). Serum HCV RNA and genotyping were determined. Approximately 2 and 4 yr after completion of treatment we investigated the presence of HCV RNA (genomic and antigenomic strands) in PBMCs. Eight of 10 patients were rebiopsed 2 yr after discontinuation of treatment.

RESULTS

The mean follow-up was 46.6 +/- 4.6 months (range, 39-51 months). In this period, all patients remained in sustained response. In the first determination, all patients had HCV RNA genomic strands and two patients had antigenomic strands detectable in PBMCs. Two years later only two patients had genomic and none had antigenomic strands detectable. After 4 yr of sustained response, eight of 10 patients lost HCV RNA from PBMCs.

CONCLUSIONS

In the long-term follow-up, the majority of patients with chronic hepatitis C with sustained response after alpha-interferon therapy progressively lost HCV RNA from PBMCs. This determination in PBMCs is not a predictor of response.

[Spontaneous bacteremia due to Salmonella hadar in liver cirrhosis with transjugular intrahepatic portosystemic shunt]

Bacteriemia is a frequent infection in patients with hepatic cirrhosis, which is associated with a high mortality. Spontaneous bacteriemia is generally caused by gramnegative bacilli. We present an episode of Salmonella hadar's spontaneous bacteriemia in a patient with cirrhosis of the liver and transjugular intrahepatic portosystemic shunt. The role of the prosthesis in the pathogenesis of bacteriemia in hepatic cirrhosis is discussed.

[Cholestatic acute hepatitis induced by amoxycillin-clavulanic acid combination. Role of ursodeoxycholic acid in drug-induced cholestasis]

We report two cases of acute hepatotoxicity after treatment with amoxicillin-clavulanic. Viral hepatitis serology and autoantibodies were negative. Biliary tree obstruction and other etiologies were excluded. After discontinuation of the drug the evolution was favorable with clinical improvement and normalization of liver tests. Liver biopsy made in one patient showed cholestasic hepatitis with hepatocellular necrosis and other patient was treated with ursodeoxycholic. Also, we analyse potential utility of ursodeoxycholic acid administration in toxic cholestasis.

AIDS-associated cholangiopathy in a series of ten patients

OBJECTIVE

To present the clinical, biological, radiologic and cholangiographic findings in patients with clinical suspicion of AIDS associated cholangiopathy in our hospital.

PATIENTS AND METHODS

We have revised the clinical charts of 10 patients admitted in our hospital from 1991 to 1995.

RESULTS

Ultrasonography and/or abdominal CT were carried out on all the patients. Biliary tract dilatation was observed in 11 cases. From the 12 ERCP, biliary tract was fulfilled in 11. In 5 cases papillary stenosis was diagnosed, sclerosing cholangitis in 2, normal biliary tract in 3 and acute cholangitis in one case. Sphincterotomy was done in 5 patients, with clinical improvement. In one case, another sphincterotomy was needed because of reestenosis.

CONCLUSIONS

ERCP is very important in the diagnosis of AIDS associated cholangiopathy. Endoscopic sphincterotomy relieves abdominal pain in these patients. Cholangiopathy occurs in very immunocompromised HIV positive patients. Survival is very short.

Helicobacter pylori infection: a seroepidemiological study in Gipuzkoa, Basque Country, Spain

Helicobacter pylori is one of the most common bacterial infections worldwide. To evaluate the prevalence of this infection in Gipuzkoa (Basque Country, Spain) we studied the presence of antibodies against Helicobacter pylori (HPAb) using a second-generation EIA (Cobas Core). The study was performed on two groups of subjects: a middle-class group, 2-78 years-old (n = 1335) and a group of slum dwellers, 2-15 years-old (n = 89). In the middle-class group the prevalence of HPAb in children under 6 was 3.1% (3/96); the prevalence was significantly greater in older compared to younger age groups, reaching 84.3% (102/121) in adults 50-59 years. The geometric mean of the titer in seropositive subjects was also greater in older age groups. By logistic regression analysis the prevalence of HPAb was associated with age, educational level and geographic origin but not with sex, smoking, alcohol consumption, or use of nonsteroid anti-inflammatory drugs. The prevalence of HPAb was much higher in the slum-dwelling group 2-15 years-old (55.5% of children 2-5 years-old). The results indicate that H. pylori infection was more common in adult people from our geographic region than in those from other developed countries and show that socioeconomically deprived children constitute at present a group at high risk of acquiring infection in our region.

[The gastrointestinal changes in dystrophia myotonica]

Myotonic dystrophy is a multisystemic disorder inherited as an autosomal dominant trait. The secondary gastrointestinal disturbances are not well recognized. Two cases of myotonic dystrophy in a 51-year-old and 39-year-old woman with gastrointestinal symptoms disturbances are reported. One patient presented motor dysfunction in the colon and esophagus, organoaxial gastric volvulus and cholestasis. The second patient developed an acute colonic pseudo-obstruction. The patient improved with cisapride. The digestive manifestations of myotonic dystrophy and the treatment are reviewed.

Spontaneous rupture of the liver in amyloidosis

Hepatic rupture is an unusual complication of hepatic amyloidosis. We report the case of a 59-yr-old man with a subcapsular hematoma of the liver with hepatic rupture secondary to amyloidosis. The patient died during the surgery. The etiology, pathology, diagnosis, and treatment of this complication are discussed. Previously reported cases of subcapsular hematoma of the liver secondary to amyloidosis are reviewed. This knowledge and an awareness of the possible diagnosis will help to decrease the high mortality rate associated with this complication.

[Chronic anemia and intestinal pseudoobstruction as presentation form of hamartomatous polyp of the Vater's ampulla]

We report the case of a 70-year-old female with chronic anemia and intestinal pseudoobstruction from a large hamartomatous polyp of the ampulla of Vater. The patient had been operated by obstructive jaundice of possible biliary etiology and a cholecystojejunostomy was performed. Later, due to cholangytis of unknown etiology cholecystectomy and choledochoduodenostomy were done. The polyp was resected by surgery.

[Hepatotoxicity caused by cloxacillin]

We describe acute mixed hepatitis (cholestatic and hepatocellular) in two women probably induced by cloxacillin. Viral causes, autoimmune hepatitis, biliary tree obstruction and other risk factors were excluded. After discontinuation of the drug evolution was favorable and clinical signs and hepatic laboratory tests became normal in both cases. We also review the literature about hepatotoxicity induced by anti-Staphylococci semisynthetic penicillins.

Treatment of achalasia with botulinum toxin

We studied the efficacy of local injections of botulinum toxin in the treatment of patients with achalasia. Four patients diagnosed of achalasia using manometric, radiologic and endoscopic criteria, were treated with botulinum toxin (80 U) injected directly into lower esophageal sphincter (LES), via a sclerotherapy injector. Response to treatment was assessed by changes in symptom scores and LES pressure. All determinations were repeated after 10, 30, 90, 120 and 180 days of treatment. The patients improved after the initial injection. This improvement was accompanied by improved relaxation of the LES. Two patients relapsed after 30 and 65 days and the other two patients remained symptom-free 5 months after treatment.

CONCLUSION

Botulinum toxin is probably a safe and effective alternative for the treatment of achalasia and should be considered in patients in whom pneumatic dilation has failed or who are poor surgical candidates. Long-term evaluation of the safety and efficacy of botulinum toxin in the treatment of achalasia is required.

Lewis, secretor, and ABO phenotypes, and sulfomucin expression in gastric intestinal metaplasia

The closely interrelated Lewis, secretor, and ABO phenotypes have long been linked to the risk of peptic ulcers and gastric cancer and may modulate the interaction between Helicobacter pylori and the gastric surface epithelium. We explored the association between the expression of sulfomucins in gastric intestinal metaplasia, a known marker of preneoplastic progression, and the expression of Lewis, secretor, and ABO phenotypes, in 523 subjects from Nariño, Colombia, and 856 subjects from northern Spain. In both study populations, Lewis (a+/b-) and nonsecretor phenotypes showed a significant positive association with the expression of sulfomucins (odds ratios, 2.4 and 2.6, respectively).

[Primary herpetic esophageal infection in an immunocompetent patient]

Herpetic esophageal primary infection is not a common event in immunocompetent patients. The case of a 27-year-old immunocompetent woman who developed herpetic esophagitis involving the whole esophagus as a manifestation of primary herpetic infection is presented. The endoscopic appearance initially suggested esophageal candidiasis, which is not an exceptional event.

Genotyping of hepatitis C virus isolates from Basque Country, Spain

The genotype of HCV was determined in 161 chronic HCV-infected patients. The patients were classified into three groups on the basis of the origin of the HCV infection: 50 patients had a history of intravenous drug use (IVDU) but no HIV infection; 41 patients had received blood transfusions, and 70 patients had no known exposure. The distribution of HCV genotypes was associated with the origin of infection and age of patients: genotype 1b was predominant among patients who had received blood transfusions and those without evidence of parenteral exposure (84.6% and 67.7%, respectively), whereas genotype 3a was present in 65.3% of IVDUs. Patients with genotype 1b were older than those with genotypes 1a or 3a: 50.3 +/- 12 vs. 34.1 +/- 9.9 and 31 +/- 5.4 years, respectively. These findings suggest that the pattern of HCV genotypes in our region is changing and that genotype 1b may be substituted by 3a as the dominant genotype in the future.

[Gastric adenocarcinoma in hamartomatous polyp in Peutz-Jeghers syndrome]

The Peutz-Jeghers syndrome is characterized by gastrointestinal polyposis and mucocutaneous melanin pigmentation. Between the complications are the appearance of gastrointestinal neoplasms. There is an increasing evidence suggesting the hamartoma-adenoma-carcinoma sequence in Peutz-Jeghers syndrome. We present a 32-years-old man with Peutz-Jeghers syndrome who developed an adenocarcinoma arising in a gastric hamartomatous polyp. We discuss the risk to develop gastrointestinal neoplasms and the necessity for periodic surveillance.

[A multicenter clinical trial. Zinc acexamate versus famotidine in the treatment of acute duodenal ulcer. Study Group of Zinc acexamate (new UP doses)]

A multicentric double-blind trial comparing 600 mg/d of Zinc Acexamate (ACZ) and 40 mg/d of Famotidine (FMT) in the short term treatment of acute duodenal ulcer included 199 patients, diagnosed by endoscopy. One-hundred and five patients received ACZ and 94 FMT, during four weeks. A clinical control took place at two weeks and a second clinical and endoscopic control at the end of the treatment (4 weeks). Complete cicatrization of the ulcer was observed in 56.5% of patients on ACZ and in 69.5% of patients of FMT (N.S.). A reduction of more than 50% of the ulcer diameter was recorded in 78.8% of the ACZ group and in 79.9% of the FMT group. Alcohol and smoking did not influence the results. Both treatments were equally effective in the disappearance of symptoms. The incidence of adverse reactions was very low in both groups (< 5%) and no patient dropped from the trial for this reason. In conclusion, a dosage of 600 mg/d of ACZ has shown to be as effective as 40 mg/d of FMT in the healing of duodenal ulcer.

Ischemic hepatitis secondary to the spontaneous rupture of a hepatocellular carcinoma in a patient with cirrhosis

A patient with alcoholic cirrhosis who developed fatal ischemic hepatitis induced by hemorrhagic shock, due to the spontaneous rupture of a hepatocellular carcinoma, is reported. This was the first manifestation of the hepatic neoplasm. To our knowledge, this is the first case report of ischemic hepatitis of this origin.

[Ticlopidine-induced cholestatic hepatitis. A case report]

A 74-year-old man with cholestatic hepatitis after 3 months of taking ticlopidine is presented herein. Viral serology and autoantibodies were negative. There was no evidence of biliary tree obstruction. After ticlopidine was discontinued, liver tests were normal in 3 months. We review the other cases published in the literature.