Hepatitis C genotype 4: genotypic diversity, epidemiological profile, and clinical relevance of subtypes in Saudi Arabia

Hepatitis C virus genotypes 4 [HCV-4] is the most prevalent genotype in Saudi Arabia, although it's various subtypes, mode and route of transmission remains unknown. The aim of this study was to analyze [i] the variability of the HCV-4 subtypes, the route and source of HCV transmission and [ii] the influence of HCV-4 subtypes on their therapeutic response. Sixty-four HCV-4 patients were analyzed retrospectively for the prevalence of various sub-genotypes and the possible mode of transmission, and it was correlated with their treatment response to pegylated interferon [PEG-IFN] alpha-2a and ribavirin therapy. Positive history of blood or blood products transfusion was noted in 22 patients [34%], hemodialysis in 10 patients [15.6%], surgery in 7 patients [11%], and unknown etiology in 25 patients [39%]. Prevalence of HCV-4 subtypes was 4a = 48.4% [31/64], 4d = 39% [25/64], 4n = 6.25% [4/64], and remaining combined [4m, 4l, 4r, 4o] 6.25% [4/64]. No significant correlation between subtypes and the source of transmission was recognized [P = 0.62]. Sustained virological response in all HCV-4 patients was 64% [41/64], while in each subtypes separately it was 4a 77.4% [24/31], 4d 52% [13/25], and combined [4n, 4m, 4l, 4r, 4o] 62.5% [5/8] [P = 0.046]. No obvious cause for the mode of HCV transmission was noted in majority of the patients. No significant correlation was observed between HCV-4 subtypes and the source of HCV infection. 4a and 4d subtypes were the most common in Saudi Arabia, and patients infected with 4a subtype responded significantly better to combination therapy than to 4d subtype

Lung Transplantation Triggered "Jackhammer Esophagus": A Case Report and Review of Literature

A 19-years-old girl was referred for lung transplant due to end stage lung disease secondary to idiopathic bilateral bronchiectasis. Her routine pre lung transplant evaluation showed normal esophageal high-resolution manometry (HRM) and 24-hours impedance pH monitoring. Four weeks after the bilateral sequential lung transplantation (LTx), she developed dysphagia, chest pain and regurgitation, complicated by aspiration pneumonia. Repeated HRM showed Jackhammer esophagus, delayed gastric emptying and abnormal 24-hour pH impedance monitoring consistent with the diagnosis of gastroesophageal reflux disease. Twelve weeks after LTx, she was symptom free, HRM and 24-hour impedance pH monitoring returned to normal. To the best of our knowledge, this rare transient esophageal hypercontractility episode occurred after LTx and recovered without any specific treatment was never reported in literature. The etiopathogenesis of Jackhammer esophagus in general and LTx induced dysmotility in particular is discussed and reviewed.