Changing pattern of fascioliasis prevalence early in the 3rd millennium in Dakahlia Governorate, Egypt: an update

Fascioliasis is an important food- and water-borne parasitic zoonosis caused by liver flukes of genus Fasciola (Digenea: Fasciolidae) of worldwide distribution. In Egypt, fascioliasis was encountered in nearly all Egyptian Governorates, particularly in the Nile Delta and specifically in Dakahlia. All enrolled cases were subjected to complete history taking, clinical examination, routine investigations and abdominal ultrasonography. Stool analysis, IHA and ELISA were used for fascioliasis diagnosis. Rural areas showed highest prevalence of fascioliasis than urban areas, however, but.without significance (x2= 0.042 & P= 0.837). Regarding human fascioliasis in examined the centers, no statistically significant difference (x2 =2.824 & P=0.243) was detected. Regarding gender variation, the difference was statistically insignificant (x2= 0.166 & P= 0.683). The difference between the age groups was statistically insignificant (x2= 3.882 & P=0.274). Clinically, 7 cases (35%) were asymptomatic and another 13 cases (65%) had different clinical pictures. Abdominal pain, anemia, eosinophilia, and tender hepatomegaly were seen in 70%, 80%, 70%, and 10%; respectively. Of them, 1 1cases showed positive abdominal ultrasonographic findings suggestive of fascioliasis.

Colorectal schistosomiasis: Is it still endemic in delta Egypt, early in the third millennium?

Background:

Several governmental efforts have been exerted toward controlling schistosomiasis during the last decades in Egypt. This work was designed to study the prevalence of colorectal schistosomiasis in patients with different gastrointestinal symptoms.

Materials and Methods:

Patients presented to the gastroenterology unit with different gastrointestinal symptoms were endoscopically examined, where three to six tiny biopsies were taken from those with visible, suspected schistosomal lesions for histopathological examination and two additional rectal biopsies were taken from the apparently normal colonic mucosa. Form each patient, at least three stool samples were examined by the formal-ether concentration method for schistosoma ova.

Results:

Colonic abnormalities were detected in 510 out of 984 patients presented with different gut symptoms. Schistosoma mansoni was detected in 205 patients (180 males, 25 females) with an age range (18-65years). Six patients only had schistosomal polyps and excised successfully by snare polypectomy. The squash technique established the diagnosis of schistosomiasis in all endoscopically normal 118 (50.75%) cases by demonstrating the schistosomiasis ova and their associated histopathological findings showed no or minimal reaction in 96 (46.82%) cases and variable degrees of submucosal granulomata in the remaining cases. Stool examination detected the schistosomiasis ova in 25 (9.83%) patients only of the biopsy-positive cases.

Conclusions:

Our data revealed that despite governmental efforts, the prevalence of colorectal schistosomiasis (20.83%) is significant among patients with gut symptoms. Gaps in health care services should be detected and filled appropriately.

Distinct immunoregulatory cytokine pattern in Egyptian patients with occult Hepatitis C infection and unexplained persistently elevated liver transaminases

Background/Aim:

The immunopathogenesis of occult Hepatitis C virus (HCV) infection is a matter of great controversy and has been suggested to involve a complex balance between cytokines with pro- and anti-inflammatory activity. This work aimed at studying the serum Th1 and Th2 cytokine production in patients with occult HCV infection.

Materials and Methods:

Serum levels of cytokines of Th1 (interleukin [IL]-2, INF-γ) and Th2 (IL-4) were measured in 27 patients with occult HCV infection and 28 patients with chronic hepatitis C infection.

Results:

The levels of IL-2 and interferon-γ were highly significantly increased in patients with chronic HCV infection (P<0.001). IL-4 was highly significantly increased in occult HCV infection (P<0.001). Significant increases were noted in chronic HCV infection regarding bilirubin (P<0.001), ALT (P = 0.009), AST (P = 0.013), AFP (P<0.001), while serum albumin was significantly higher in occult HCV infection (P<0.001). Necroinflammation (P<0.001), fibrosis (P<0.001), and cirrhosis (P = 0.03) were significantly increased in chronic HCV infection.

Conclusion:

Our data revealed a high prevalence of occult HCV infection (25%) in patients with unexplained persistently abnormal liver function test results. Those patients exhibited a distinct immunoregulatory cytokine pattern, favoring viral persistence and explaining the less aggressive course of this disease entity than chronic HCV infection.

Portal hypertensive colopathy and haematochezia in cirrhotic patients: an endoscopic study

BACKGROUND AND STUDY AIMS

In patients with liver cirrhosis, portal hypertensive colopathy (PHC) and anorectal varices (ARVs) are thought to cause lower gastrointestinal (GI) bleeding. In the present work, we studied the diagnostic yield of colonoscopy in cirrhotic patients and haematochezia.

PATIENTS AND METHODS

The current study was conducted on 77 consecutive cirrhotic patients who underwent colonoscopy at Mansoura Emergency Hospital, Egypt, between May 2007 and May 2011. Following rapid evaluation and adequate resuscitation, a thorough history was obtained with complete physical examination including digital rectal examination and routine laboratory investigations. Colonoscopic evaluation was performed for the included patients by recording endoscopic abnormalities and obtaining biopsies from lesions.

RESULTS

There was no significant difference between the PHC-positive group when compared with the PHC-negative group regarding patients' age, sex, severity of haematochezia, positive family history and the history of intake of non-steroidal anti-inflammatory drugs (NSAIDs). Significant difference was noted regarding the Child-Pugh class (p<0.05), history of splenectomy (p<0.05), prior history of endoscopic sclerotherapy (EST) or endoscopic variceal ligation (EVL) (p<0.05), prior history of upper gut bleeding (p<0.05), the presence of gastric varices (GVs) (p<0.05), presence of portal hypertensive gastropathy (PHG) (p<0.05), presence of haemorrhoids (p<0.05) and rectal varices (<0.05) and therapy with β-blockers (p<0.05). Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation. Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation.

CONCLUSION

Our data revealed that it is not only PHC which is involved in haematochezia in cirrhotic patients despite the significant association. Instead, a high prevalence of inflammatory lesions came on the top of the list. Complete colonoscopy is highly advocated to detect probable proximal neoplastic lesions.

Seroprevalence of subclinical HEV infection in asymptomatic, apparently healthy, pregnant women in Dakahlya Governorate, Egypt

Background and Aim:

Hepatitis E virus (HEV) is a major public health problem in the developing countries. HEV infection in pregnant women is more common and fatal in the third trimester. The present study was designed to determine the seroprevalence of subclinical HEV infection in asymptomatic pregnant women.

Materials and Methods:

A total of 116 asymptomatic pregnant women divided into 2 groups: Group 1 included 56 pregnant women with HCV positive serology and group 2 included 60 pregnant women with negative HCV serology were included in this study. Prevalence of anti-HEV antibodies and anti-HCV were determined by an enzyme linked immunosorbent assay (ELISA) kit.

Results:

The overall prevalence of anti-HEV IgG was highly significant among pregnant women with chronic HCV infection 40/56 (71.42%) than pregnant women free from chronic HCV infection 28/60 (46.7%) (P = 0.006). Chronic HCV infection in pregnant women appeared to be a risk factor associated with HEV IgG seropositivity (OR = 2.86, CI = 1.24-6.6). The seropositivity of anti-HEV IgG was significantly high in rural areas than urban areas (62.5% vs. 37.5%) in group 1 and (78.58% vs. 21.42%) in group 2 (P = 0.15) and OR = 2.2, CI = 0.65-7.7). A decrease in albumin level (P = 0.047) and an increase in bilirubin (P = 0.025), ALT (P = 0.032), and AST (P = 0.044) in pregnant women with positive HCV and IgG anti-HEV than the second group with negative HCV serology.

Conclusions:

The seroprevalence of anti-HEV IgG in pregnant women is high in Egypt especially in rural areas. With chronic HCV coinfection, a marked increase in anti-HEV IgG seropositivity and significant worsening of the biochemical liver indices were noted. Increased public awareness about the sound hygienic measures for a less prevalence of HEV is strongly advised. The need for HEV vaccination for those at risk, especially pregnant ladies, should be considered.

Screening for minimal hepatic encephalopathy in asymptomatic drivers with liver cirrhosis

BACKGROUND AND STUDY AIMS

Minimal hepatic encephalopathy (MHE) represents a part of the spectrum of hepatic encephalopathy (HE). It can have a far-reaching impact on quality and ability to function in daily life and may progress to overt HE. This study was designed to screen for MHE in drivers with liver cirrhosis in Mansoura, a city in the Nile delta in Egypt.

PATIENTS AND METHODS

A total of 174 consecutive drivers with positive serology for viral markers and cirrhosis were screened for MHE. Questionnaires and standard psychometric tests and well-informed consent were performed at the same setting. The diagnosis of MHE was made when one or both symbol digit test (SDT) and number connection test (NCT) appeared abnormal. Beck's inventory and Mini Mental State Examination questionnaires were performed for those diagnosed as MHE. After overnight fasting, venous blood samples were taken for haematologic tests and routine liver function tests by conventional methods. Arterial ammonia was also measured.

RESULTS

A total of 66 patients showed evidence for MHE out of 139 patients who fulfilled the inclusion criteria. No significant differences were present, apart from a significantly elevated arterial ammonia level (p-value <0.001) and a bad self-reported driving history (p<0.05) in the MHE-positive group when compared with the MHE-negative group. Multivariate logistic regression revealed that advanced Child-Pugh grade (p<0.001), hepatitis B virus (HBV)-related aetiology (p<0.001) and smoking are significant risk factors for MHE. MHE is significantly commoner among Child-Pugh C patients (p<0.05) when compared with the other Child-Pugh grades.

CONCLUSION

Our data revealed a high prevalence of MHE (47%) among Egyptian drivers with liver cirrhosis. It is hence recommended to include the driving history as well as regular pencil-paper standard psychometric testing in evaluating those at risk, especially in the outpatient setting, for early detection and proper management.

Detection of the G34R mutation in the 5 alpha reductase 2 gene by allele specific PCR and its linkage to the 89L allele among Egyptian cases

The 5 alpha-reductase type 2 deficiency is an autosomal recessive disorder of sexual development among 46,XY individuals. In Egypt, there is a prevalence of a G34R disease underlying mutation. This study aimed to devise a rapid diagnostic method based on allele specific PCR (AS-PCR) and a linked polymorphism (V89L). The results showed that one set of primers was capable to differentiate between normal, heterozygous, and affected individuals efficiently. All 34R mutation carrying sequences had 100% linkage to the 89L allele, contrasting normal ones with low 89L frequencies. This linkage infers a founder effect among Egyptians having G34R mutation.

Screening for six Mediterranean mutations in 90 Egyptian patients with phenylketonuria

OBJECTIVES

The aim of this study is to assess the prevalence of six common mutations in the Mediterranean basin and Turkey among a large group of Egyptian PKU cases

BACKGROUND

Phenylketonuria (PKU) is one of the most common inborn errors of amino acid metabolism that is caused by deficiency of hepatic phenylalanine hydroxylase (PAH). This deficiency is attributed to more than 528 mutations in the PAH gene.

METHODS

Ninety unrelated patients with PKU (180 alleles) were screened for six mutations (IVS10-11G>A, R261Q, R252W, Y277D, E221G and G272S) using polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

The IVS10-11G>A mutation was found in thirty alleles (17%), the R261Q in twelve (7%) and R252W in three (1.6%), while Y277D, E221G and G272S were not found in this patient group.

CONCLUSION

Screening for six Mediterranean mutations identified a heterogeneous pattern among Egyptian PKU patients with a high frequency of IVS10-11 G>A (17%) (Tab. 2, Ref. 31). Full Text (Free, PDF) www.bmj.sk.

The milder phenotype of the dystrophin gene double deletions

OBJECTIVES

This study aimed to examine the genotypephenotype correlation in Duchenne muscular dystrophy (MD) patients with double deletion (Ddel) mutations in comparison with those having single deletions (Sdel).

MATERIALS AND METHODS

The study included 250 Duchenne/Becker MD male patients from whom the 10 Ddel patients were compared with 20 Sdel subjects of same age and disease durations. The patients were subjected to neurological examination including functional disability grading scale (FDGS), molecular analysis of the dystrophin gene and immunohistochemical studies of some muscle biopsies.

RESULTS

The mean FDGS value in the Ddel group was lower than that in Sdel patients. The Ddel patients had partial expression of dystrophin in their skeletal muscles, while Sdel cases showed complete absence of the protein.

CONCLUSION

Patients with double deletion mutations within the dystrophin gene have a milder phenotype than patients harboring single deletions at either major or minor hot spots of the gene.

A novel point mutation of the androgen receptor (F804L) in an Egyptian newborn with complete androgen insensitivity associated with congenital glaucoma and hypertrophic pyloric stenosis

Androgen-insensitivity syndrome (AIS) is a major cause of male pseudohermaphroditism (MPH). Although AIS is usually reported as a monogenic disease resulting from androgen receptor (AR) mutations, on rare occasions it has been observed as part of a multiple congenital anomaly syndrome. We report here a patient who was the first newborn girl of an unrelated couple. Shortly after birth, the diagnoses of congenital glaucoma and pyloric stenosis were made. A detailed history of the father's family revealed that nine members presented glaucoma before 40 years of age. Clinical and ultrasound evaluation showed two inguinal testes, with female external genitalia and no Mullerian derivatives. The patient had a 46,XY karyotype, good testicular response to gonadotrophin stimulation and a remarkably high T : dihydrotestosterone ratio. Sequencing of the five exons of the 5alpha-reductase type 2 gene (SRD5A2) was normal. Conversely, a de novo point mutation was found in exon 6 of the AR gene, resulting in an F804L substitution, which has never been described previously. To our knowledge, the association of complete AIS, congenital glaucoma and pyloric stenosis has also never been reported previously.

Schistosoma hematobium soluble egg antigens induce proliferation of urothelial and endothelial cells

Bladder carcinoma accounts for 26% of reported human malignancies in Egypt, and has been strongly associated with urinary schistosomiasis. Nevertheless, the immediate role of schistosomal egg proteins in bladder carcinogenesis is unexplored. We investigated the effects of crude soluble egg antigens (SEA) of Schistosoma hematobium on urothelial cell proliferation. The proliferation of bovine endothelial Endo, human urothelial J82 and smooth muscle SMC cell lines was assessed by low-density growth assays. SEA induced proliferation of both J82 and Endo cells in a dose-dependent fashion, but not SMC. Preboiling or proteinase K treatment of SEA abolished its effect. In addition, SEA enhanced urothelial expression of B-cell translocation protein (BTG1) and human proliferating cell nuclear antigen (PCNA) mRNAs. Given the strong correlation between cell proliferation and carcinogenesis, the findings suggest that crude SEA may play some role in schistosomal bladder carcinogenesis.

Molecular analysis of androgen resistance syndromes in Egyptian patients

Androgen resistance syndromes [i.e. 5 alpha-reductase deficiency (5 alpha RD) and androgen receptor (AR) defects] are frequently reported among Egyptian intersex patients. This study examined AR and 5 alpha-reductase 2 (5 alpha R2) gene mutations among a sample of such cases as a first step towards instituting a screening program. Five families with a typical hormonal profile of 5 alpha RD were screened for major deletions of exons 3-5 of the 5 alpha R2 gene, using polymerase chain reaction (PCR) and electrophoresis. Thereafter, screening for point mutations was carried out by single strand conformational polymorphism (SSCP) analysis, followed by nucleotide sequencing. Seven patients with androgen insensitivity syndrome (AIS) were subjected to molecular analysis of AR exons B-H by a similar protocol, except for the use of denaturing gradient gel electrophoresis (DGGE) for screening point mutations. No major deletions were found in either gene. One family had abnormal electrophoretic mobility on SSCP of exon 5 of the 5 alpha R2 gene, resulting from a point mutation (C to T substitution) at codon 246. Another family, showing retarded mobility on DGGE, had a point mutation (G to A substitution) at codon 889 of the AR gene. In conclusion, the study revealed two mutations previously reported in other geographically distinct populations, inferring the possibility of mutational hot spots in the genes.

5 alpha-reductase deficiency in patients with micropenis

The enzyme 5 alpha-reductase (5 alpha R), by virtue of its peripheral 5 alpha-reduction of testosterone (T) to dihydrotestosterone (DHT), is believed to play a major role in the differentiation and the subsequent growth of the penis. However, recent studies have reported 5 alpha R deficiency (5 alpha RD) in patients with isolated micropenis and hypothesized that 5 alpha RD is not invariably associated with genital ambiguity. In Egypt, 5 alpha RD has been reported frequently among intersex patients. The aim of this study was to assess the role of 5 alpha RD in the development of micropenis among Egyptian patients with abnormal sexual development. The study included 29 patients who were categorized into three groups (isolated micropenis, 9 patients; microphallus with genital ambiguity, 11 patients; genital ambiguity with normal-sized phallus, 9 patients). Activity of 5 alpha R was assessed by estimating T/DHT ratios in the basal state in pubertal subjects and following human chorionic gonadotropin (HCG) stimulation test in prepubertals. The results showed that the incidence of 5 alpha RD was much higher in cases of ambiguous genitalia with micropenis (5 families out of 10, 50%) than in those with isolated microphallus (1/9, 11.1%) or those with ambiguous genitalia and normal-sized phallus (1/8, 12.5%). In conclusion, the study showed that isolated micropenis is a heterogeneous disorder and that 5 alpha RD, despite its relative prevalence in Egypt, has a minimal role in the aetiology. On the other hand, 5 alpha RD seems to correlate with penile length in intersex cases.

Dihydrotestosterone regulates plasma sex-hormone-binding globulin in prepubertal males

Plasma levels of sex-hormone-binding globulin (SHBG) in man are known to be regulated up and down by oestradiol and testosterone, respectively. To determine whether testosterone reduces SHBG level directly or via its conversion into dihydrotestosterone before puberty, the changes of plasma SHBG, testosterone, oestradiol and dihydrotestosterone following human chorionic gonadotrophin stimulation are studied in ten 5 alpha-reductase-deficient and in six normal prepubertal boys. Three main observations provide evidence that dihydrotestosterone plays a major role in SHBG regulation. (1) Basal plasma SHBG in 5 alpha-reductase-deficient is higher than in normal boys (P less than 0.1). (2) Circulating SHBG fails to decrease (P greater than 0.1) after human chorionic gonadotrophin stimulation despite striking elevation of plasma testosterone in 5 alpha-reductase deficiency where negligible dihydrotestosterone response occurs. This is in contrast to normal boys where SHBG is significantly reduced (P less than 0.01) after stimulation. (3). In normal boys the magnitude of plasma dihydrotestosterone response to human chorionic gonadotrophin correlates with that of SHBG (r = 0.72) more than testosterone does versus SHBG (r = 0.36). It is concluded that dihydrotestosterone decreases SHBG concentration in plasma of prepubertal boys. At least part of the observed decrease in SHBG following testosterone administration in earlier reports must have occurred after its conversion to dihydrotestosterone.

Studies of up-regulation of androgen receptors in genital skin fibroblasts

Prolonged exposure of genital skin fibroblasts (GSF) to dihydrotestosterone (DHT) increases androgen receptor binding of steroid, a process termed 'up-regulation'. Because the extent of up-regulation appears to be quite variable, we have investigated the optimal conditions and the molecular mechanisms that control this phenomenon in seven strains of normal neonatal GSF. When GSF were incubated for 1-48 h with 3 nM methyltrienolone (R1881), maximal up-regulation was reached by 20 h and remained constant thereafter. With DHT, rapid steroid metabolism required replenishment of DHT for maximum up-regulation. Up-regulation levels following 20 h incubation with DHT (including steroid replenishment) and R1881 were 2.07-fold (range = 1.1-3.3) and 2.35-fold (range = 1.86-3.33), respectively. The greater variability observed with DHT may be related to variable rates of steroid catabolism among cell strains. Half-maximal up-regulation was attained at 0.29 nM R1881, which approximates the Kd. Maximal up-regulation was reached only with continuous exposure to R1881 for 24 h. It was completely inhibited by actinomycin D (0.5 micrograms/ml) or cycloheximide (10 micrograms/ml). Following up-regulation, removal of R1881 for 24 h resulted in a highly variable decline of androgen receptors among cell strains. Maximal up-regulation could be reinduced by exposure to R1881 again for an additional 24 h. During up-regulation, androgen receptor levels in nuclei and nuclear matrix rose with increments comparable to those obtained in whole cells. We conclude that the extent of up-regulation and its rate of decline differ greatly among normal cell strains. Hence, its study in cells of patients with androgen insensitivity may have limited value.(ABSTRACT TRUNCATED AT 250 WORDS)

Familial Leydig cell hypoplasia as a cause of male pseudohermaphroditism

A case of familial Leydig cell hypoplasia as a cause of male pseudohermaphroditism is described in two 46,XY female sibs. Biochemical and histologic evidence for such diagnosis is presented.