[Acute fatty liver of pregnancy and mitochondrial fatty acid oxidation. Consequences for the offspring]

Acute fatty liver of pregnancy (AFLP) is a rare liver disease unique to pregnancy that can lead to acute liver failure. The prognosis, initially often fatal for both mother and child, has been improved by prompt delivery. The diagnosis should be highly suspected if the mother presents epigastric pain, nausea and/or vomiting, or polyuria-polydipsia in the third trimester of pregnancy. AFLP has been found associated with a genetic deficiency of fatty acid beta-oxidation, which may cause sudden death in infancy. Consequently, the mother and her newborn should undergo screening for this deficiency.

[Prophylaxis of mother-to-infant transmission of hepatitis B virus]

Hepatitis B virus (HBV) infection is a worldwide health problem and mother-to-infant (or vertical) transmission is the main source of chronic infection in Asian countries. Administration of HBV vaccine to the infant at birth, with or without concurrent specific immunoglobulin, efficiently prevents such transmission (efficacy>90%). In France, testing Ag HBs is mandatory during pregnancy in all pregnant women. Infants born to Ag HBs-positive mothers should receive the first injection of vaccine and one injection of specific immunoglobulins at birth. Vaccination should thereafter be completed according to a three-injection protocol (at 1 and 6 months) or a four-injection protocol in case of prematurity. Failure of immunoprophylaxis can be observed when the viral load is very high in the mother during pregnancy (HBV-DNA levels>200,000 IU/mL). In such women, antiviral therapy with analogs (lamivudine, telbivudine, or tenofovir) during the third trimester of pregnancy and 1 month post-partum, in association with accurate immunoprophylaxis, may prevent vertical transmission. The optimal cut-off value of maternal viral load for antiviral therapy in late pregnancy and post-partum to prevent vertical transmission is still under debate.

ABCB4 gene mutations and single-nucleotide polymorphisms in women with intrahepatic cholestasis of pregnancy

AIM

To evaluate the nature and frequency of ATP-binding cassette subfamily B member 4 (ABCB4) gene variants in a series of French patients with intrahepatic cholestasis of pregnancy (ICP).

METHODS

In this prospective study, the entire ABCB4 gene coding sequence was analysed by DNA sequencing in 50 unrelated women with ICP defined by pruritus and raised serum alanine aminotransferase activity or bile acid concentration, with recovery after delivery. Genomic variants detected in patients with ICP were sought in 107 control pregnant women. Patients with ICP and controls were of Caucasian origin.

RESULTS

Eight genomic variants were observed. One nonsense mutation (p.Arg144Stop) and two missense mutations (p.Ser320Phe and p.Thr775Met) were revealed each in one heterozygous patient. A third missense mutation (p.Arg590Gln) was detected in three heterozygous patients and in two homozygous patients also homozygous for a particular haplotype of three single-nucleotide polymorphisms (c.175C>T, c.504T>C, c.711A>T). The chromosomal frequency of the p.Arg590Gln variant was significantly different between the ICP and control group (7.0% vs 0.5%; p = 0.0017; OR 16.03, 95% CI 1.94 to 132.16). An association was also found between allele T of the c.504T>C silent nucleotide polymorphism and ICP (68.0% vs 53.7%; p = 0.017; OR 1.83, 95% CI 1.08 to 3.11). The chromosomal frequency of the p.Arg652Gly variant did not differ between the ICP and control group (p = 0.40).

CONCLUSIONS

This study shows that 16% of Caucasian patients with ICP bear ABCB4 gene mutations, and confirms the significant involvement of this gene in the pathogenesis of this complex disorder.

Hepatitis B virus reactivation after a resolutive acute hepatitis leading to a diagnosis of T cell lymphoma

A case of hepatitis B virus reactivation leading to the diagnosis of a T cell lymphoma is reported. A 66-year-old woman with a past history (10 years before) of spontaneously recovered acute hepatitis B (with disappearance of serum hepatitis B surface antigen and appearance of anti-HBs), has been referred for hepatologic consultation for acute hepatitis. The patient was found positive again for hepatitis B surface antigen as well HBeAg and hepatitis B virus DNA. No other cause of liver disease was identified and a diagnosis of spontaneous hepatitis B virus reactivation was made. Five months later a peripheral T cell lymphoma was diagnosed. This unusual case confirms that natural immunity is not protective against hepatitis B virus reactivation and shows that such hepatitis B virus reactivation may precede the usual clinical manifestations of a peripheral T cell lymphoma.

Liver fibrosis staging with contrast-enhanced ultrasonography: prospective multicenter study compared with METAVIR scoring

We prospectively assessed contrast-enhanced sonography for evaluating the degree of liver fibrosis as diagnosed via biopsy in 99 patients. The transit time of microbubbles between the portal and hepatic veins was calculated from the difference between the arrival time of the microbubbles in each vein. Liver biopsy was obtained for each patient within 6 months of the contrast-enhanced sonography. Histological fibrosis was categorized into two classes: (1) no or moderate fibrosis (F0, F1, and F2 according to the METAVIR staging) or (2) severe fibrosis (F3 and F4). At a cutoff of 13 s for the transit time, the diagnosis of severe fibrosis was made with a specificity of 78.57%, a sensitivity of 78.95%, a positive predictive value of 78.33%, a negative predictive value of 83.33%, and a performance accuracy of 78.79%. Therefore, contrast-enhanced ultrasound can help with differentiation between moderate and severe fibrosis.

[Portal hypertension and pregnancy]

Pregnancy in patients with portal hypertension is rare but worrying for the clinician. Although the effects of portal hypertension during pregnancy have not been fully elucidated, there is an evident increase in morbidity, especially associated with cirrhosis, which justifies the idea of at-risk pregnancy and requires management by a multidisciplinary team. The prevention and treatment of gastrointestinal haemorrhage is quite similar to that in nonpregnant patients. Investigation and management of portal hypertension before and at the beginning of pregnancy can reduce the risks of foetal loss, restricted intra-uterine growth, premature birth and maternal mortality, which are closely related to gastrointestinal haemorrhage. The risks related to the underlying disease, such as liver failure with cirrhosis and thromboembolic risk with vascular diseases associated with thrombophilia must be taken into consideration. Generally, vaginal delivery with early analgesics for the mother assisted by an extraction device should be preferred to caesarean section, which must be reserved for obstetrical indications.

Périartérite noueuse cutanée associée à une infection par le virus de l’hépatite C, régressive après une bithérapie antivirale

BACKGROUND

Hepatitis C virus (HCV) frequently causes leucocytoclastic vasculitis as a result of type II or III cryoglobulinemia. HCV-associated vasculitis without cryoglobulinemia is less common.

PATIENTS AND METHODS

A 33-year-old woman consulted for infiltrative necrotic purpura of the lower limbs, responsible for leg ulcers measuring less than 1 cm. Histopathological examination revealed vasculitis affecting the hypodermic arterioles and caused by periarteritis nodosa. No extracutaneous involvement was observed. The patient had presented asymptomatic untreated HVC infection (genotype 3) for two years. Antiviral treatment resulted in elimination of the patient's viremia and no relapse of skin lesions was observed two years after the end of treatment.

COMMENTS

This patient presented vasculitis due to cutaneous nodular periarteritis associated with HVC without cryoglobulinemia. Hepatic impairment was mild and did not require any antiviral treatment. No further skin involvement was seen after treatment with colchicine and because the patient's viral genotype was favorable, we decided to initiate antiviral therapy. This therapeutic approach should be considered by dermatologists, but it is nevertheless important to assess the risk of interferon-induced aggravation of vasculitis.

[Asymptomatic pneumothorax diagnosis on pre-biopsy sonogram of the liver]

Liver biopsy is an invasive procedure which is widely used for the management of liver diseases. An asymptomatic pneumothorax was detected on sonography prior to biopsy for chronic hepatitis C. The complications from biopsy, potentially severe, are decreased by ultrasound guidance. Currently, ultrasound guidance is recommended at the time of liver biopsy.

[An anicteric cholectasis and nephrotic syndrome: AL amyloïdosis in a 51 years-old man]

Amyloidosis is a multiple-organ disease for which the diagnosis is often confusing and thereby delayed. Here, we present an archetypal case illustrating such difficulties. A 51 years-old man presented a mixed dyslipemia in November 2002, in June 2004 he has finally been diagnosed with a primary AL-amyloidosis. Within these two years, the arising of a non-icteric cholestasis and a nephrotic syndrome have triggered the search for a disease related to a multiple-organ protein deposition. Confirmation of the AL-amyloidosis was obtained through an histological examination, including direct immuno-fluorescence. Amyloidosis is a life threatening disease that need to be diagnosed at an early stage, in order to maximise the therapeutic expectations. The average survival after the diagnosis of AL-amyloidosis is 5% at 10 years. Often, treatments are initiated late in the course of the disease, at a time when organ lesion are constituted, severely affecting the prognosis.

Improvement of a CIDP associated with hepatitis C virus infection using antiviral therapy

A 57-year-old man with chronic inflammatory demyelinating polyneuropathy associated with hepatitis C virus infection was treated successfully with the combination of peginterferon-alpha-2b and ribavirin. Viral eradication was confirmed during the 4th week of treatment and was followed 3 weeks later by neurologic improvement. The patient resumed normal activity 1 year after the therapy was completed.

Carbohydrate-deficient transferrin (CDT) determination by nephelometry using a commercial kit. Analytical and diagnostic aspects

Carbohydrate-deficient transferrin (CDT) has been proposed as the most efficient marker of alcohol abuse. Absolute and relative concentrations of CDT were measured with a commercial assay (%CDTTIA from AXIS-Shield, Oslo, Norway) using rate nephelometry for transferrin determination. One hundred eighty-eight alcoholic patients (154 males, 34 females) and 132 control patients (113 males, 19 females) were included in the study. Within-run and day-to-day imprecision were 3.15% and 9.77%, respectively. The calibration curve was stable for more than 4 months with a shift below 5%. The commercial assay lacked sensitivity (Se = 0.48), but was highly specific (Sp = 0.98). Lowering the cut-off from 6% to 4.6% raised the sensitivity of the %CDTTIA test to 0.76 with a specificity of 0.90. We conclude that this adaptation to the Array Protein System (Beckman-Coulter) is suitable for routine use and offers precise results. It, however, requires an adaptation of the cut-off value for patients and of the target value for kit controls.

Serum amylase and lipase activities in normal pregnancy: a prospective case-control study

OBJECTIVE

The diagnosis of acute pancreatitis during pregnancy is usually based on the association of upper abdominal pain, nausea or vomiting, and elevated serum amylase or lipase activities. The changes in these enzymatic activities have not been clearly established during normal pregnancy. The aim of this study was therefore to evaluate serum amylase and lipase activities in healthy pregnant women.

METHODS

Serum amylase and lipase activities were measured in 103 pregnant women (first trimester, n = 34; second trimester, n = 36; third trimester, n = 33) and in 103 nonpregnant women matched for age and not receiving oral contraception.

RESULTS

Serum amylase activity was similar in pregnant women and nonpregnant women during all trimesters of pregnancy. Serum lipase activity was significantly lower during the first trimester of pregnancy compared to nonpregnant women (48.6+/-27.6 vs 59.2+/-29.3 IU/L, p < 0.05) and compared to the third trimester (48.6+/-27.6 vs 76.3+/-35.8 IU/L, p < 0.001). Serum lipase activity was not statistically different between pregnant and nonpregnant women during the second and third trimesters.

CONCLUSION

An increase in serum amylase and lipase activities during pregnancy should be taken into account, as in nonpregnant women.

Two successive hepatitis C virus infections in an intravenous drug user

We report the case of an occasional intravenous drug user who developed two successive hepatitis C virus (HCV) infections. The first infection led to seroconversion (anti-HCV antibodies detected) and the detection of HCV RNA in serum. After a spontaneous recovery (normalization of alanine aminotransferase levels and HCV RNA clearance), a second HCV infection was observed, with the recurrence of HCV viremia. Antibody directed against HCV serotype 1 was detected throughout the follow-up monitoring, but two different HCV strains were identified during the two infectious episodes: genotype 1a for the first and genotype 3a for the second. This observation shows that primary HCV infection does not confer protective immunity against subsequent infection with viruses of other genotypes. This may hamper the development of a vaccine. Conflicting results were obtained in genotyping and serotyping assays, suggesting that the serotyping method cannot be used to identify the HCV type in patients, such as intravenous drug users, who are exposed to successive HCV infections.

Decrease in serum ALT and increase in serum HCV RNA during pregnancy in women with chronic hepatitis C

BACKGROUND/AIMS

The natural history of chronic hepatitis C infection during pregnancy has not been clearly established, and thus our aim was to assess serum alanine aminotransferase levels and serum HCV RNA levels during pregnancy.

METHODS

Twenty-six pregnant women with chronic hepatitis C were studied. Serum alanine aminotransferase was assessed within the 3 months before, monthly during and within the 3 months after pregnancy. In 12 women, serum HCV RNA levels were quantified by the branched DNA assay. Twenty-six age-matched non-pregnant women with chronic hepatitis C were followed up for 1 year, and used as a comparison group.

RESULTS

During pregnancy, serum alanine aminotransferase levels decreased in the second and third trimesters. The third trimester levels were significantly lower than serum alanine aminotransferase levels before pregnancy (p=0.0001). Seventy-seven percent of the pregnant women with increased pre-pregnancy levels had normalization of serum alanine aminotransferase levels. In the second or third trimesters, serum HCV RNA levels increased. The third trimester serum HCV RNA levels were significantly higher than levels before pregnancy (p=0.01). No significant change in serum alanine aminotransferase or HCV RNA levels was observed in the control group.

CONCLUSION

In pregnant women with chronic hepatitis C, serum alanine aminotransferase levels decrease, and serum HCV RNA levels increase during the second and third trimesters.

[Liver and pregnancy]

Transaminase level elevation during pregnancy should be viewed as abnormal and evaluated. A high index of suspicion for acute fatty liver of pregnancy should be maintained during the third trimester, since early delivery has radically transformed the maternal and fetal prognosis of this condition. Pruritus is the main symptom of intrahepatic cholestasis, which carries a risk for the fetus. Urinary tract infection can cause cholestasis or worsen intrahepatic cholestasis of pregnancy. In patients with preeclampsia, rapid delivery should be considered if there is evidence of HELLP syndrome. Patients with mild chronic viral hepatitis can usually carry a pregnancy to term without undue difficulty. Neonates born to HBsAg-positive mothers should receive HBV-Ig and vaccine at birth to prevent perinatal transmission of the HBV. In patients with chronic hepatitis C, serum transaminase levels often return to normal during pregnancy, although the virus remains detectable in the blood. Mother-to-infant transmission of the HCV is possible but fairly uncommon if the mother is HIV-negative.

Ultrastructural and physicochemical characterization of the hepatitis C virus recovered from the serum of an agammaglobulinemic patient

Hepatitis C virus (HCV) morphology and physicochemical properties remain unclear because HCV usually circulates in a complexed form in association with immunoglobulins. In the present work, we were interested in the characterization of HCV particles derived from the serum of an anti-HCV negative/HCV RNA positive agammaglobulinemic patient suffering from chronic type C hepatitis. Physicochemical properties of the virus particles were determined by serum centrifugation on a 10-60% isopycnic sucrose density gradient. HCV RNA quantified by bDNA was found in a major peak at density 1.13 g/ml and in a minor peak at densities 1.05-1.07 g/ml. By electron microscopy, 45 nm large core-like particles were found at the 1.13 g/ml density while 60 nm large virus-like particles similar to other members of the Flaviviridae family were visualized at the 1.06-1.07 g/ml densities. This confirms some studies reporting the low density of HCV as compared to other members of the Flaviviridae family.

The kinetics of antibodies against hepatitis C virus may predict viral clearance in exposed hemophiliacs

Several studies have reported the spontaneous loss of hepatitis C virus (HCV) antibodies in HCV-exposed persons. However, the relationship between seroreversion and spontaneous virus clearance has yet to be precisely determined in a single homogeneous population of untreated immunocompetent patients. In this study, 32 human immunodeficiency virus-seronegative hemophiliacs who had been exposed to HCV were followed for a mean duration of 141 months; 22 remained chronic carriers (68.8%). All but 1 of the nonviremic patients (90.0%) showed partial (8 cases) or complete (2 cases) seroreversion. In contrast, all but 1 of the viremic patients (95.1%) had a stable serologic profile when analyzed by a recombinant immunoblot assay. The results indicate that any HCV antibody-positive immunocompetent patient with no detectable serum HCV RNA and normal alanine aminotransferase values and whose serial samples show a progressive decrease in the level of HCV antibodies present may be considered as having a resolved infection.

[Thyroid function and autoimmunity in 215 patients seropositive for the hepatitis C virus]

The aim of this study was to estimate thyroid function and the prevalence of thyroid antibodies among HCV seropositive patients. We undertook a screening for thyroid dysfunction, and antithyroperoxidase (ATPO) and antithyroglobulin (ATG) antibodies, in 215 HCV seropositive patients referred for hepatologic consultation, 118 males and 97 females, mean age 44 +/- 14 years, range 16-80 years. No patient was treated with interferon and all were seronegative for HIV. Eighteen patients (8%) had antithyroid antibodies, 12 with ATPO antibodies (5.6%) and 10 with ATG antibodies (4.7%). Four patients had both ATPO and ATG antibodies (1.8%), one case of Graves' disease and 3 cases of autoimmune hypothyroidism found during this study. Five patients (2.3%) had hyperthyroidism, three cases of Graves' disease, one case of iodine load and a case of Grave's disease incidentally diagnosed during medical examination. Eleven patients (5.1%) had hypothyroidism, one case already known and treated without antithyroid antibodies, 4 cases of autoimmune etiology (3 diagnosed in consultation and one already known and compensated hypothyroidism), one case of amiodarone-induced hypothyroidism discovered during this study, 5 cases of hypothyroidism without antibodies (two cases of compensated hypothyroidism with normal TRH stimulating test, two cases with severe liver cirrhosis and one case with chronic hepatitis). Twelve patients had antithyroid antibodies with normal TSH levels. The prevalence of ATPO and ATG antibodies in our study is similar to the prevalence usually observed in general population and does not suggest a pathogenic role of HCV in autoimmune thyroid disorders.

Acute fatty liver of pregnancy

Acute fatty liver of pregnancy is a rare clinical entity unique to pregnancy that occurs during the third trimester. The obstetric team must be familiar with this disease because early diagnosis and prompt delivery have dramatically improved prognosis, which was often fatal for both mother and child. Clinicians must have a high index of suspicion for this condition when a woman has nausea or vomiting, abdominal pain (particularly epigastric), jaundice, polyuria-polydipsia (without diabetes), increased serum transaminase activity or thrombocytopenia in late pregnancy. The disease rarely recurs during a subsequent pregnancy. The cause is unknown, but some cases of acute fatty liver of pregnancy have been associated with a genetic deficiency of fatty acid beta-oxidation. Because of the possibility of this congenital deficiency, infants of affected mothers should undergo close follow-up from birth.

Tenoxicam, a non-steroid anti-inflammatory drug, is unable to increase the response rate in patients with chronic hepatitis C treated by alpha interferon

The purpose of this study is to compare a combination of interferon (IFN)-alpha2a (Roferon) + Tenoxicam with IFN-alpha2a alone in the treatment of chronic hepatitis C. This prospective, randomized double-blind study included 149 patients, all of whom were diagnosed with active chronic hepatitis C but non-cirrhotic (ALT > or = 1.5 upper limit of normal, anti-hepatitis C virus (HCV) positive by enzyme-linked immunosorbant assay2 and RIBA3). The patients were randomized in two groups, as follows: G1 (n = 76): IFNalpha2a 3 million units times per week during 6 months + placebo; and G2 (n = 73): IFNalpha2a 3 million units three times per week + Tenoxicam (20 mg/day) during 6 months. Alanine aminotransferase (ALT) and HCV RNA were determined before and at months 6 and 12 of treatment. 2'5' oligoadenylate synthetase activity (2'5' AS) was dosed in mononuclear cells before and at 3-month treatment intervals in 28 patients. Liver biopsy was performed before and 6 months after the end of therapy. Parameters were similar before therapy for both groups. Biochemical and virological responses were similar for both groups at month 6 (49.3% vs. 42.9% and 43.3% vs. 38.3%, respectively) and month 12 (28.3% vs. 23.8% and 17.2% vs. 17.5%, respectively). HCV RNA level significantly decreased in both groups at month 6, with no difference whatever the therapy; however, the HCV RNA level returned to initial values at month 12 and was the only significant prognostic factor of a sustained response. No peak of 2'5' AS activity was observed during treatment in patients with dual therapy. A histological improvement was also noted in both groups without difference, regardless of therapy. The percentage of adverse events was identical for both groups. Paracetamol intake, assessed in 80 patients, was 49.1 g per 6 months in the G1 group and 22.5 g per 6 months in the G2 group (not significant). In conclusion, the non-steroid anti-inflammatory drug, Tenoxicam, does not increase IFNalpha efficacy in the treatment of chronic hepatitis C. This combination is well tolerated and partially lowers Paracetamol intake, but not preexisting alpha-IFN adverse events.

Intrahepatic cholestasis of pregnancy: a French prospective study

The aim of this prospective study was to analyze the characteristics of intrahepatic cholestasis of pregnancy (ICP) in a French population. From 1989 to 1995 we studied 50 consecutive pregnant women with ICP (41 single, 7 twin, and 2 triplet pregnancies) referred for hepatologic consultation. All patients suffered from pruritus and/or jaundice associated with elevated fasting serum levels of total bile acids (mean 49 micromol/L, range 7-290). No patients had concomitant liver disease and all recovered normal liver function after delivery. Overall prematurity rate was 60%: 100% in multiple pregnancies and 41% in single pregnancies. Three of 61 babies died. Systematic clinical interviews revealed that 34 patients had been treated with oral micronized natural progesterone (200-1,000 mg/d) during the current pregnancy for risk of premature delivery, including at least 32 (64%) before the onset of pruritus. Onset of pruritus was statistically earlier in patients previously receiving progesterone than in patients not receiving progesterone (217 +/- 21 vs. 240 +/- 26 days, P < .01). This was also found in the single pregnancy subgroup of patients (222 +/- 19 vs. 240 +/- 26 days, P < .05). Pruritus disappeared before delivery in 10 of 50 patients, i.e., after withdrawal of progesterone in 7 patients (only one concurrently treated with cholestyramine), after decrease in dose of progesterone in 1 patient, and spontaneously in 2 patients. During the same period, the percentage of pregnant women without ICP who had been treated with progesterone during pregnancy was statistically lower than the percentage of patients treated with progesterone before the onset of pruritus in our group of patients with ICP (36% vs. 64%, P < .01, odds ratio 3.16, 95% CI:1.29-7.80). These results suggest that orally administered progesterone might be an exogenous factor which triggers ICP in predisposed women.

[Spontaneous reactivation of the hepatitis B virus?]

The authors present 4 cases of chronic AgHBs positive hepatitis, with reactivations of hepatitis B virus. The reactivations occurred spontaneously, as mentioned in references. The authors appreciate that the cause of B virus reactivation bases upon factors which modify the immune status of the host. Alcohol is one of these factors, not yet mentioned in references as cause of virus B reactivation. Are also presented data about the existence of virus B mutants, in the studied patients, which could play a role in the reactivation of chronic hepatitis B.

Liver function tests in normal pregnancy: a prospective study of 103 pregnant women and 103 matched controls

Except for increased serum alkaline phosphatase (AP) levels, the changes in liver function test (LFT) values during normal pregnancy have not been clearly established, mainly because most studies do not include matched controls. We therefore measured the serum values of routine liver tests including 5'-nucleotidase and total bile acids in 103 healthy pregnant women (first trimester, n = 34; second trimester, n = 36; third trimester, n = 33) and in 103 age-matched controls not receiving oral contraception. Fasting blood samples were taken. Because of hemodilution, serum albumin levels were significantly lower during all trimesters. As expected, AP activity was significantly higher in the third trimester. Serum aspartate transaminase (AST) activity and total bile acid (TBA) concentrations did not differ between pregnant and nonpregnant women. Serum alanine transaminase (ALT) activity was slightly higher in the second-trimester pregnant women than in controls (6.8 +/- 4.5 vs. 8.2 +/- 5.8, P = .04), although all values remained within normal limits. In pregnant women, total and free bilirubin concentrations were significantly lower during all three trimesters, as was conjugated bilirubin during the second and third trimesters. Serum gamma-glutamyl transpeptidase (GGT) activity was significantly lower in the second and third trimesters. Serum 5'-nucleotidase activity was slightly but significantly higher in the second and third trimesters. The knowledge of these results is useful for the interpretation of LFT values and the management of liver diseases during pregnancy.

[Exacerbation of an autoimmune thrombocytopenic purpura during treatment with interferon alpha in a woman with chronic viral hepatitis C]

We report the case of a 40-year-old woman with chronic viral hepatitis C and latent idiopathic thrombocytopenic purpura who developed severe thrombocytopenia during alpha interferon therapy. Platelet-associated IgG titers were elevated, and platelet antibodies were detected in the serum. Intravenous administration of high-dose polyvalent immunoglobulins was ineffective, but a normal platelet count was obtained after corticosteroid therapy. A history of idiopathic thrombocytopenic purpura could be considered a contraindication for alpha-interferon therapy in patients with chronic viral hepatitis.

Ciprofloxacin and long-term prevention of spontaneous bacterial peritonitis: results of a prospective controlled trial

The aim of this prospective double-blind study was to evaluate the value of long-term antibiotic prophylaxis using ciprofloxacin for the prevention of spontaneous bacterial peritonitis (SBP) in 60 cirrhotic patients with low ascitic fluid protein levels (< 15 g/L). The patients were assigned to two groups: group I (n = 28) ciprofloxacin 750 mg per os once a week for 6 months, group II (n = 32) placebo. The two groups were similar for clinical and laboratory characteristics. Twelve patients developed an intercurrent disorder, and 10 patients died during the trial. There were no adverse effects in the treated group. There was a significant decrease in the incidence of SBP (3.6 vs. 22%) (P < .05) and duration of hospitalization (9.3 +/- 4.5 vs. 17.6 +/- 6.2 days) (P < .05) in the treated group as compared with the placebo group. The bacteriological study showed no acquired resistance to ciprofloxacin after 6 months' treatment. These results suggest that long-term preventive antibiotic prophylaxis based on the weekly administration of 750 mg of ciprofloxacin is effective in the prevention of SBP in cirrhotic patients.

[Carbohydrate-deficient transferrin and liver diseases. Study of 94 patients]

OBJECTIVES AND METHODS

Carbohydrate-deficient transferrin has been proposed as a marker of alcohol consumption. The aim of this study was to evaluate the accuracy of the carbohydrate-deficient transferrin serum level, measured by ion exchange chromatography followed by radioimmunoassay (Kit CDTect), for the diagnosis of excessive alcohol intake in patients with liver diseases. Ninety-four patients (68 men, 26 women, age 21-71 years), 42 with alcoholic liver diseases and 52 with non-alcoholic liver diseases, were studied. Twenty-six patients consumed > or = 40 g alcohol per day (mean alcohol intake: 84 +/- 52 g per day) and were considered to be excessive drinkers.

RESULTS

The sensitivity of carbohydrate-deficient transferrin for the diagnosis of excessive alcohol intake was 35%, and the specificity was 91%. By pairing carbohydrate-deficient transferrin with other markers of alcohol consumption, the sensitivity of the association of carbohydrate-deficient transferrin and gammaglutamyl transpeptidase was 96%, and the specificity was 59%.

CONCLUSION

In patients with liver diseases, carbohydrate-deficient transferrin is a specific marker of excessive alcohol intake but a lack of sensitivity may limit its use.

Adenine arabinoside 5'-monophosphate in patients with chronic hepatitis B: comparison of the efficacy in patients with high and low viral replication

This study compared the response to adenine arabinoside 5'-monophosphate (ARA AMP) in 60 patients with chronic hepatitis B according to the pretreatment serum hepatitis B virus DNA concentration. The level of hepatitis B virus replication was defined as low (30 patients) or high (30 patients) when serum hepatitis B virus DNA concentration was below or above 100 pg/ml, respectively. Patients received a 28 day course of ARA AMP and a second course of ARA AMP was given six months later to patients with persistent hepatitis B virus replication. At the end of the first course of ARA AMP, 11 of the patients (37%) with low replication and one of the patients (3%) with high replication became negative for hepatitis B virus DNA (p = 0.0012); five of the patients (17%) with low replication and none of the patients with high replication had HBe seroconversion (p = 0.06). Two of these five patients lost HBsAg. Kinetics of serum hepatitis B virus DNA during treatment showed a considerable but transient antiviral effect of ARA AMP. Three of 32 retreated patients became negative for hepatitis B virus DNA and one patient had HBe seroconversion. In conclusion, ARA AMP exerts a considerable but transient antiviral effect on hepatitis B virus. Complete and sustained inhibition of hepatitis B virus replication was only obtained in the patients with low hepatitis B virus replication.

Serum conjugated bile acid profile during intrahepatic cholestasis of pregnancy

BACKGROUND/AIMS

Intrahepatic cholestasis of pregnancy is a specific liver disease of pregnancy of unknown cause. The serum bile acid profile has not been clearly described in this disease and the aim of this study was to investigate the serum conjugated bile acid profile.

METHODS

Thirteen patients with intrahepatic cholestasis of pregnancy were studied. Ten patients had been treated with natural progestatin before the onset of pruritus. The glyco- and tauroconjugated bile acids were quantified by high-performance liquid chromatography and direct spectrometric detection at 199 nm.

RESULTS

There was no difference between total bile acid concentrations measured by high-performance liquid chromatography (43.5 +/- 22.6 microM, mean +/- S.D.) or by an enzymatic procedure (43.4 +/- 24.6 microM), indicating a low concentration of free bile acids. Primary bile acids represented 88% of total bile acids, i.e. 72.7% for cholic acid and 15.3% for chenodeoxycholic acid. For both cholic and chenodeoxycholic acids glyco- and tauroconjugates were equivalent. Secondary bile acids represented 11.3% of total bile acids. Ursodeoxycholic acid was identified at very low concentrations in only three samples.

CONCLUSIONS

We conclude that in intrahepatic cholestasis of pregnancy primary bile acids are very predominant.

Specific pruritic diseases of pregnancy. A prospective study of 3192 pregnant women

BACKGROUND AND DESIGN

For a period of 1 year, all pregnant women presenting with itching were investigated by clinical, histologic, immunopathologic, and laboratory studies. Fifty-one of 3192 pregnant women were studied.

RESULTS

We identified (1) two typical cases of herpes gestationis, with an approximate incidence of one in 1700 pregnancies; (2) 22 cases of pruritus gravidarum, including five cases with a polymorphous skin eruption, with an incidence of one in 145 pregnancies; (3) 25 cases of polymorphic eruption of pregnancy, including diseases without maternal or fetal side effects and without criteria defining herpes gestationis or pruritus gravidarum, with an incidence of one in 130 pregnancies; and (4) two cases of intercurrent disease (one scabies and one exfoliative dermatitis).

CONCLUSION

Our study is a prospective homogeneous account of pruritic dermatosis of pregnancy. Our results show that the incidence of herpes gestationis is higher than is usually reported in the literature and that pruritus gravidarum must be considered in the presence of itching occurring during pregnancy, with or without skin eruption.

Hemodynamic effects of acute administration of furosemide in patients with cirrhosis receiving beta-adrenergic antagonists

In patients with cirrhosis, both beta-blockers and diuretics decrease the degree of portal hypertension. Since their mechanisms of action differ, the combination of these two substances should induce a more pronounced effect on portal pressure than one of these substances alone. Thus, the hemodynamic effects of furosemide were evaluated in ten patients with cirrhosis receiving beta-blockers. One hour after furosemide (0.75 mg/kg intravenously) administration, cardiac output decreased significantly from 6.2 +/- 0.6 to 5.2 +/- 0.3 l/min and blood volume from 8.0 +/- 1.6 to 5.3 +/- 0.5 l. Mean arterial pressure was not affected. Wedged and free hepatic venous pressures did not change significantly; nor did the hepatic venous pressure gradient (19.6 +/- 1.7 to 18.6 +/- 1.5 mmHg). Azygos blood flow was not affected (0.46 +/- 0.05 to 0.50 +/- 0.07 l/min). In conclusion, this study did not demonstrate that the addition of furosemide to propranolol further decreased portal pressure in patients with cirrhosis. The long-term effects of this combination are unknown and should be tested.

Acute fatty liver of pregnancy: the hepatologist's view

Acute fatty liver of pregnancy is a rare clinical entity unique to pregnancy that can lead to hepatic failure and encephalopathy and, if the diagnosis is delayed, to death for the baby and the mother. The characteristic histological picture demonstrates microvesicular fatty infiltration of hepatocytes. Acute fatty liver of pregnancy is a disease of the third trimester of pregnancy. The most significant clinical findings are nausea or vomiting, abdominal pain, jaundice, hepatic encephalopathy, increased transaminase levels, decreased platelet count, increased prothrombin time, and renal failure. Hypertension and proteinuria are common. Liver biopsy is not always necessary for diagnosis but may be useful in atypical cases. The primary therapy is early delivery and supportive care. Both the obstetric team and the medical consultants must have a high index of suspicion for this disease because early delivery is lifesaving and has transformed the prognosis for the mother and the baby. Collaboration between obstetricians and gastroenterologists is necessary to make the diagnosis and also to improve our understanding of this disease of unknown etiology.

Prevalence and significance of hepatitis C virus (HCV) viremia in HCV antibody-positive subjects from various populations

Hepatitis C virus (HCV) infection is currently assessed by detection of antibodies to HCV with immunoassays. However, in the absence of an in vitro system to isolate the virus, or an immunoassay to identify HCV antigen in blood, an ongoing acute or chronic HCV infection can be diagnosed only by detection of HCV RNA by polymerase chain reaction. We used a reverse transcription-nested polymerase chain reaction to detect an HCV 5' noncoding viral RNA sequence in serum specimens collected from anti-HCV-positive individuals belonging to different risk groups and compared the results with those obtained with a prototype recombinant immunoblot assay (Chiron HCV SIA prototype recombinant immunoblot assay [RIBA]) containing four different viral peptides (c22, c33c, c100, and NS5). The prevalence of HCV viremia ranged from 25.9% in HCV antibody-positive blood donors to 92% in HCV antibody-positive hemophiliacs. Elevated alanine aminotransferase values in HCV antibody-positive patients were clearly associated with viremia. Ninety-six percent of HCV RNA-positive patients reacted to two viral antigens or more, compared with only 64% of HCV RNA-negative patients. Contrary to previous reports, HCV viremia was not associated with either the presence or the absence of a particular antibody specificity. The newly introduced NS5 peptide did not improve the sensitivity or specificity of the RIBA. Although 20% of the patients in our study whose sera reacted to all of the antigens were HCV RNA negative, the positive predictive value of a RIBA considered positive by the manufacturer (two or more bands), was rather high (78%) and may allow suspicion of viremia in EIA2 enzyme-linked immunosorbent assay-positive patients.

Renal hemodynamics in patients with cirrhosis: relationship with ascites and liver failure

In patients with cirrhosis and ascites decreased renal blood flow might be related to the severity of liver disease but the relationship between the severity of cirrhosis and renal perfusion has not yet been established. Thus we measured renal, systemic and splanchnic hemodynamics in 63 patients with ascites and in 28 without ascites. When compared to patients without ascites, patients with ascites had lower renal blood flow (1,170 +/- 100 vs. 935 +/- 55 ml/min/1.73 m2; mean +/- SEM, p < 0.05) and renal perfusion pressure (78 +/- 2 vs. 72 +/- 1 mm Hg, p < 0.05 and higher inferior vena cava pressure (6.5 +/- 0.7 vs. 10.7 +/- 0.7 mm Hg, p < 0.05). Patients with ascites had significantly higher serum bilirubin concentrations, hepatic venous pressure gradient and lower serum albumin concentrations, indocyanine green (ICG) extraction than patients without ascites. Renal vascular resistance, glomerular filtration rate, mean arterial pressure, cardiac index and systemic vascular resistance were not significantly different between the two groups. By multiple regression analysis no significant correlation was found between liver tests (i.e., prothrombin time, serum bilirubin and albumin concentrations, ICG extraction), hepatic venous pressure gradient, cardiac index and systemic vascular resistance on the one hand and renal blood flow on the other. No significant correlation was found between glomerular filtration rate and liver tests. In conclusion, in patients with cirrhosis and ascites, renal hypoperfusion is not related to the severity of liver disease.