Achalasia in a patient with multiple myeloma: a case report

Achalasia is a medical condition presenting with dysphagia to both liquids and solids. Although it is usually a primary disease, there are cases in which achalasia occurs secondary to other conditions. Despite its presentation as a secondary condition in a number of diseases, it is very rare for achalasia to be associated with multiple myeloma especially as the presenting symptom when the patient's disease has not been diagnosed yet. Initial manifestations of multiple myeloma include array of symptoms such as back pain, bone lesions, and anemia, but as mentioned before it is extremely rare for it to initially present with achalasia. Here we describe a man who initially presented with dysphagia and further studies confirmed the diagnosis of achalasia. Later he was diagnosed as having multiple myeloma following other presentations of the disease, thus making the dysphagia caused by achalasia his presenting symptom of multiple myeloma

Ulcerative colitis following orthotopic cardiac transplantation

Inflammatory bowel disease following a solid organ transplantation while the patient is re-ceiving immunosuppressive therapy is a rare phenomenon. Here we present a 48-year-old man who underwent cardiac transplantation 9 years earlier and was receiving cyclosporine as immunosuppressive therapy since then, presenting with complaints of rectorrhagia and diarrhea. In follow-up, he was diagnosed as having ulcerative colitis. We also reviewed the literature for similar cases, which yielded very few similar ones

Clinical and pathological features of non-functional neuroendocrine tumors of pancreas: a report from Iran

Pancreatic neuroendocrine tumors [PNETs] are rare tumors with variable malignant potential, prognosis, and survival. We aimed to assess the characteristics of patients with non- functional PNET in our hospital. From Nov 2010 to Nov 2013, all patients who came to endosonography unit of Shariati hospital, Tehran, Iran, and had pancreatic lesions were assessed. Tumor samples were obtained through fine needle aspiration. Various characteristics of the non- functional PNET were recorded and patients were followed up to three years. Twenty eight non func-PNET cases, aged 37-72 years were identified, 15 [53.6%] of whom were men. Fifteen [53.6%] tumors were located in the head and 5[17.8%] in the body of the pancreas. The mean tumor size was 3.9 Cm and 10.7%, 28.6%, 32.1%, and 28.6% of the patients were at stages I, II, III and IV, respectively. Of the patients, 12 [43%] underwent surgery, 3 [10.7%] received chemotherapy, and 13 [46.4%] received no treatment. During the mean follow-up of 16 months, the disease had progressed in 3 [10.7%] patients and 10 [35.7%] had died. In univariate analysis, tumor size>3Cm and Ki-67>20% were correlated with survival rate but not in multivariate analysis. Iranian patients with non- functional PNET present similar characteristics to world patients. There is a need to establish efficacy of tumor samples which are obtaining through fine needle aspiration for assessing tumor grading

Cohort profile: Golestan hepatitis B cohort study-a prospective long term study in northern Iran

Hepatitis B virus [HBV] infection is the most common cause of end stage liver disease in Iran and in Golestan province. Large-scale population-based prospective cohort studies with long term follow-up are the method of choice to accurately understand the natural course of HBV infection. To date, several studies of HBV epidemiology, natural history, progression to cirrhosis and association with HCC have been reported from other countries. However, few of these are prospective and fewer still are population-based. Moreover, the underlying molecular mechanisms and immunogenetic determinants of the outcome of HBV infection especially in low and middle income countries remains largely unknown. Therefore, the hepatitis B cohort study [HBCS], nested as part of the Golestan Cohort Study [GCS], Golestan, Iran was established in 2008 with the objective to prospectively investigate the natural course of chronic hepatitis B with reference to its epidemiology, viral/host genetic interactions, clinical features and outcome in the Middle East where genotype D HBV accounts for >90% of infections. In 2008, a baseline measurement of HBV surface antigen [HBsAg] was performed on stored serum samples of all GCS participants. A sub-cohort of 3,505 individuals were found to be HBsAg positive and were enrolled in the Golestan HBCS. In 2011, all first degree relatives of HBsAg positive subjects including their children and spouses were invited for HBV serology screening and those who were positive for HBsAg were also included in the Golestan HBCS

Surveillance for hepatocellular carcinoma after autologous stem cell transplantation in Cirrhosis

During the resent years there has been interest in using bone marrow stem cells to treat liver cirrhosis. However, there is a potential concern for malignant transformation after stem cell therapy. The aim of this study was to evaluate the development of hepatocellular carcinoma [HCC] after autologous bone marrow stem cell transplantation for liver cirrhosis. All the patients who underwent autologous stem cell transplantation for liver cirrhosis between 2005 and 2011 at our center were enrolled. Cellular infusion was made through peripheral vein, portal vein, or hepatic artery.The patients were invited to undergo screening for hepatocellular carcinoma. The screening was made with ultrasonography and alpha-feto protein [AFP] measurement. Thirty two patients [18 males] were included in the study. Mean age of patients was 45.7 years. Fifteen patients [47%] received mesenchymal stem cell [MSC], 9 [28%] received bone marrow mononuclear cells, 5 [16%] were given CD 133-positive bone marrow cells, and 3 [9%] patients received CD 34-positive bone marrow cells. Mean duration of follow up was 20.5months. Mean serum level of AFP was 2.8 ng/ml at baseline and 3.4ng/ml at the end of follow up [p= 0.3]. One patient was found to have hepatocellular carcinoma three months after infusion of bone marrow mononuclear cells. The incidence rate for HCC was 1.8 cases per 100 person-years in this study. Autologous bone marrow stem cell infusion does not appear to increase the risk of hepatocellular carcinoma. The incidence rate of HCC in this study is comparable or even less than the reported rates of HCC in cohort studies of cirrhotic patients

In vitro differentiation of human bone marrow mesenchy-mal stem cells into hepatocyte-like cells

Orthotropic liver transplantation [OLT] is the final procedure of both end stage and metabolic liver diseases. Hepatocyte transplantation is an alternative for OLT, but the sources of hepatocytes are limited. Bone marrow mesenchymal stem cells [BM-MSCs] can differentiate into hepatocyte-like cells and are a potential alternative source for hepatocytes. We aimed to investigate the differentiation potential of BM-MSCs into hepatocyte-like cells. Human BM-MSCs from a healthy donor were cultured and differentiated into hepatocyte-like cells. We investigated the expression of hepatocyte-specific markers in MSC-derived hepatocyte-like cells [MSC-HLC[s]] and evaluated their functionality using metabolic assays. MSC-HLCs expressed hepatocyte-specific markers at both mRNAand protein levels. In addition, the cells had the ability to uptake low density lipoprotein [LDL], clear ammonia, secrete albumin, and store glycogen. MSC-HLCs were transplanted into a familial hypercholesteromia patient. Human MSCs can be differentiated into partially functional hepatocyte-like cells. Thus, they could be a potential source for cell therapy in liver disorders

Hepatitis B virus infection during pregnancy: transmission and prevention

Hepatitis B virus [HBV] infection is a global public health problem. In endemic areas, HBV infection occurs mainly during infancy and early childhood, with mother to child transmission [MTCT] accounting for approximately half of the transmission routes of chronic HBV infections. Prevention of MTCT is an essential step in reducing the global burden of chronic HBV. Natal transmission accounts for most of MTCT, and providing immunoprophylaxis to newborns is an excellent way to block natal transmission. Prenatal transmissions is responsible for the minority of MTCT not preventable by immunoprophylaxis. Because of the correlation between prenatal transmission is responsible for the minority viremia, some authors find it sound to offer lamivudine in women who have a high viral load [more than 8 to 9 log 10 copies/ mL]. In addition to considerations regarding the transmission of HBV to the child, the combination of HBV infection and pregnancy raises several unique management issues. Chronic HBV infection during pregnancy is usually mild but may flare after delivery or with discontinuing therapy. Management of chronic HBV infection in pregnancy is mostly supportive with antiviral medications indicated in a small subset of HBV infected women with rapidly progressive chronic liver disease

Eosinophilic gastroenteritis: a case series from Iran

Eosinophilic gastroenteritis [EG] is a rare inflammatory disorder of the gastrointestinal [GI] tract. There have been several case series of patients with EG from the western world and East Asia. However, there has not been a report of patients with EG from the Middle East region. The aim of this study is to describe clinical characteristics and treatment response in a series of EG patients from Iran. We retrospectively reviewed charts with a diagnosis of EG from 1997 to 2010 at Shariati Hospital and the private clinics of the authors. Clinical characteristics of the patients were evaluated, and the treatment response and relapse rate were assessed. Twenty-two patients [9 male] with EG were identified. Mean age of the patients was 45.1 +/- 15.5 [range: 27-75] years. Median duration between symptom onset and diagnosis was 12 [range 1- 48] months. Twenty [90%] patients had mucosal involvement, one [5%] had muscular involvement and one [5%] had subserosal involvement. Patients were followed for a median duration of 36.5 [range 4- 123] months. Two [90%] patients had mucosal involvement, one [5%] had muscular involvement and one [5%] had subserosal involvement. Patients were followed for a median duration of 36.5 [range 4-123] months. Two patients had spontaneous remission with supportive care. The remaining 20 patients responded well to oral corticosteroid treatments. The relapse rate was 33%. Episodes of relapse were successfully controlled with a repeat course of corticosteroids. Two patients with several relapses required maintenance treatment with azathioprine. The clinical characteristics and treatment responses of EG patients from Iran are similar to reports from other parts of the world. Patients need to undergo close follow up after treatment to detect early signs of relapse

Liver histology and HBV DNA levels in chronically HBV infected patients with persistently normal alanine aminotransferase

Data on histological activity and HBV DNA levels in patients with chronic HBV infection and persistently normal alanine aminotransferase levels are sparse. We aimed to investigate the histological activity and HBV DNA levels in these patients. There were 132 patients with HBeAg negative chronic HBV infection and persistently normal alanine aminotransferase levels that were included prospectively. Data were dichotomized according to the median levels. Associations of histology with HBV DNA and other variables were assessed. A total of 80 patients were male. The median age was 36 years. The median baseline HBV DNA was 2.9Log10 IU/mL. There were 50 cases [38%] with a total score >/= 5, 53 cases [40.2%] had grade >/= 4 and 40 cases [30.3%] had stage >/= 2. A baseline HBV DNA <2000 IU/mL was seen in 24 cases [48%] of those with total score >/= 5, 28 cases [53%] of those with grade >/= 4 and 9 cases [22.5%] with stage >/= 2. Multivariate analysis of baseline HBV DNA above the median level significantly predicted the total score, grade and stage with an adjusted odds ratio of 5.43, 3.47, and 4.23, respectively when compared to below median values. A second liver biopsy was performed in 61 patients. The median time interval between the two biopsies was 40 months. Total scores of 23 cases [38%] progressed by >/= 2 scores and the HBV DNA of 18 cases [22.5%] increased by >/= 1 Log[10] IU when compared to baseline values. HBeAg negative chronic HBV infection with persistently normal alanine aminotransferase is not a silent disease. Active liver disease may be seen in such patients with viral loads less than 2000 IU/mL

Long-term therapy with adefovir dipivoxil for HBeAg-negative chronic hepatitis B

Treatment with adefovir dipivoxil for 48 weeks resulted in histologic, virologic, and biochemical improvement in patients with hepatitis B e antigen [HBeAg]-negative chronic hepatitis B. We evaluated the effect of continued therapy as compared with cessation of therapy. One hundred eighty-five HBeAg-negative patients with chronic hepatitis B were assigned to receive 10 mg of adefovir dipivoxil or placebo once daily for 48 weeks [ratio, 2:1]. After week 48, patients receiving adefovir dipivoxil were again randomly assigned either to receive an additional 48 weeks of the drug or to switch to placebo. Patients originally assigned to placebo were switched to adefovir dipivoxil. Patients treated with adefovir dipivoxil during weeks 49 through 96 were subsequently offered continued therapy. The primary end points were changes in hepatitis B virus [HBV] DNA and alanine aminotransferase levels. Treatment with adefovir dipivoxil resulted in a median decrease in serum HBV DNA of 3.47 log copies per milliliter [on a base-10 scale] at 96 weeks and 3.63 log copies per milliliter at 144 weeks. HBV DNA levels were less than 1000 copies per milliliter in 71% of patients at week 96 and 79% at week 144. In the majority of patients who were switched from adefovir dipivoxil to placebo, the benefit of treatment was lost [median change in HBV DNA levels from baseline, -1.09 log copies per milliliter; only 8% of patients had levels below 1000 copies per milliliter at week 96]. Side effects during weeks 49 through 144 were similar to those during the initial 48 weeks. Resistance mutations rtN236T and rtA181V were identified in 5.9% of patients after 144 weeks. In patients with HBeAg-negative chronic hepatitis B, the benefits achieved from 48 weeks of adefovir dipivoxil were lost when treatment was discontinued. In patients treated for 144 weeks, benefits were maintained, with infrequent emergence of viral resistance

Oral omeprazole in patients undergoing combination endoscopic therapy for bleeding peptic ulcers A: prospective double-blind randomized study

Endoscopic therapies can decrease the morbidity of patients with high risk peptic ulcer. The aim of this study was to evaluate the beneficial effects of oral omeprazole therapy in patients with bleeding peptic ulcer who received combined endoscopic treatment [epinephrine injection and Argon Plasma Coagulation]. Eighty six patients with bleeding from gastric, duodenal or stomal ulcers and endoscopic stigmata of recent bleeding were enrolled in our study. All patients received injection of epinephrine [1:10,000] and also their ulcers were treated with Argon Plasma Coagulator. The patients then randomly assigned to receive oral omeprazole [40 mg every 12 hours] or placebo. Five [11.6%] of 43 patients in the placebo group had rebleeding; but no rebleeding was detected among 43 patients in omeprazole group [p= 0.05]. One patient in the Placebo group underwent surgery for control of his rebleeding; but none of the patients in omeprazole group needed surgery. One patient in the placebo group and none of the patients in the omeprazole group died. The average hospital stay was 5 days in the omeprazole group and 5.8 days in the placebo group. Addition of oral omeprazole to combined endoscopic therapy significantly reduces recurrent bleeding rates