An evaluation of saliva as an alternative to plasma for the detection of hepatitis C virus antibodies.

PURPOSE: Seroepidemiological studies on the prevalence of Hepatitis C virus (HCV) in India have been hampered by reluctance of subjects to provide blood samples for testing. We evaluated the use of saliva as an alternate specimen to blood for the detection of antibodies to HCV. METHODS: Chronic liver disease (CLD) patients attending the liver clinic were recruited for this study. A saliva and plasma sample (sample pair) was collected from each patient included in the study. Saliva samples were collected using a commercially available collection device--OmniSal. Sample pairs were tested with an in-use ELISA for the detection of antibodies to HCV (HCV-Ab), with a minor modification in the manufacturer's protocol while testing saliva. The cut-off absorbance value for declaring a sample as positive was determined by receiver operating curve (ROC) analysis. HCV-Ab positivity in saliva was compared with that in plasma as well as with viral load in plasma and infecting genotype of the virus. Sensitivity, specificity, positive and negative predictive values, and correlation coefficients were calculated using Medcalc statistical software. RESULTS: The optimal accuracy indices were: sensitivity-81.6%; specificity-92.5%; PPV-85.1% and NPV-90.5%. No correlation was found between salivary positivity and HCV viral load in plasma or infecting genotype. CONCLUSIONS: The accuracy indices indicate that the assay must be optimized further before it can be recommended for routine use in epidemiological surveys for HCV-Ab.

Isolated liver abscesses in melioidosis.

Melioidosis is a suppurative chronic infection caused by a gramnegative bacterium, Burkholderia pseudomallei. We report two patients who presented with isolated liver abscesses caused by this pathogen. Both patients presented with high-grade fever and abdominal pain. On examination they were toxic and had tender hepatomegaly. Investigations showed leucocytosis and a shift to the left. Early diagnosis of melioidosis was made by culture and growth of Burkholderia pseudomallei from aspirated pus from the abscesses and the patients were treated with ceftazidime and co-trimoxazole. Despite institution of antibiotics both the patients succumbed to their illness. Melioidosis is an emerging infection in the Indian subcontinent and can cause isolated liver abscesses.

ATP7B mutations in families in a predominantly Southern Indian cohort of Wilson's disease patients.

OBJECTIVE: To analyze ATP7B mutations in Wilson's disease (WD) patients from the Indian subcontinent and to correlate these with WD phenotype. METHODS: We studied 27 WD patients from 25 unrelated families. Twenty-two families were from three southern Indian states - Tamil Nadu andhra Pradesh and Kerala. We applied conformation- sensitive gel electrophoresis (CSGE) to screen for the mutations in patients and their families. PCR products exhibiting aberrant patterns in CSGE were subjected to direct DNA sequencing. As siblings affected by WD within a family share identical ATP7B genotype, we compared WD phenotype among affected siblings within families. RESULTS: ATP7B mutations were detected in 22 of the 25 probands -13 were homozygotes and 9 were compound heterozygotes. Eleven novel mutations were detected. Only two common mutations were found: G3182A in 4 (16%) and C813A in 3 (12%) probands. 'Hot spots' for ATP7B mutations were exons 18 and 13. Lack of common dominant mutations prevented correlation of individual ATP7B mutations with WD phenotype. Symptomatic WD in a live sibling was not found in any family. In 8 families, a sibling died of presumed WD - in 6 of these, WD phenotype was identical to that in the proband. CONCLUSIONS: We describe the spectrum of ATP7B mutations including 11 novel mutations in Indian WD patients and document lack of a single dominant mutation. Identical WD phenotype among siblings in only 6 of 8 families with >1 child affected by WD suggests that factors other than ATP7B mutations influence WD phenotype.

Crohn's disease in rheumatology clinic--an Indian experience.

BACKGROUND: Prevalence of Crohn's disease (CD) among patients with rheumatic illnesses in India is grossly under estimated, especially when it has overtaken that of Ulcerative Colitis in the West. AIM: To study the frequency of histologically unequivocal CD amongst clinically suspected patients with enteropathic arthropathy and to ascertain if the arthritics with CD have any independent clinical predictor. Settings and designs: Retrospective datasheet analysis from a Rheumatology clinic of a large tertiary care centre. MATERIALS AND METHODS: Patients of suspected enteropathic arthropathy were studied by ileocolonoscopy and segmental colonic biopsy for histological evidence of Crohn's disease and followed up. STATISTICAL ANALYSIS: Logistic regression analysis was done to find out any clinical predictor of histologically proven CD. RESULTS: Fourteen of the twenty-nine patients studied had histologically confirmed CD. Those with CD were younger than those without (34.7 yr vs 41.6 yrs, p=0.057). The CD group also had significantly higher number of people with loss of weight (12 vs 1), fever (11 vs 0), perianal fistula (4 vs 0), abdominal pain (8 vs 2), history of dysentery (4 vs 0) and uveitis (6 vs 1) (p=0.00002, 0.00001, 0.026, 0.013, 0.026 & 0.01 respectively). However logistic regression analysis of the most relevant ones among these, namely, loss of weight, fever, and perianal fistula showed loss of weight as only independent predictor of CD in this subset of patients (p=0.03 with odds ratio of 28). CONCLUSION: Presence of significant loss of weight in an Indian patient with clinically suspected enteropathic arthropathy is an independent predictor of CD.

Vesical varix in cirrhosis of liver.

Vesical varices in portal hypertension are rare. We report a patient with portal hypertension who developed recurrent painless hematuria. Cystoscopy was normal. Doppler ultrasound and MR angiography showed a dilated paraumbilical vein within the falciform ligament coursing down to the urinary bladder wall and draining into the right internal iliac vein. He underwent liver transplantation for decompensated chronic liver disease. He is in good health and has not had further episodes of hematuria.

VIPoma of pancreas in a child.

An eleven-year-old girl had massive watery diarrhea. She was found to have pancreatic VIPoma. It responded favorably to surgical resection of the tumor. There was no tumor recurrence at 18 months of follow-up.

Prevalence of enterically transmitted hepatitis viruses in patients attending a tertiary--care hospital in south India.

The prevalance of enterically transmitted hepatitis viruses, namely, hepatitis A virus (HAV) and hepatitis E virus (HEV) were studied in 404 patients with acute hepatitis attending a tertiary-care hospital in south India. Presence of current HAV/HEV infection was ascertained by the demonstration of IgM antibodies. In 381 patients tested for both agents, HAV IgM was present in 51(13.3%) and HEV IgM present in 66(17.3%). There was dual infection in 3 males (0.8%). HEV infection was seen mostly in older children and adults with only 5.5% occurring in children < 12 years of age. HAV infection was commonly seen to occur in < 12 years of age group (52.7%). One hundred and twenty-six patients were from the Vellore region, among whom HAV and/or HEV aetiology was observed in 28.5%. In this region there did not appear to be any correlation between occurrence of acute hepatitis due to these viruses and rainfall or environmental temperature. Acute hepatitis due to enteric hepatitis viruses was seen throughout the year.

A modified radiographic method for estimating segmental colonic transit time in subjects with rapid gut transit.

In this study on Indian subjects, the single X-ray method was assessed for its reliability in measuring the transit of particulate matter through the colon, and if inaccurate a suitable and simple alternative was to be devised. Radio-opaque markers were serially followed in 20 normal male volunteers. This was done by three 12 hourly radiographs and by stool collection to determine the transit time through the colon and its segments. It was compared with similar parameters calculated from the same data using one radiograph and three combinations of two radiographs each. The mean +/- SD colonic transit time determined by using three X-rays was 18.0 +/- 6.6 h which agreed well with the mean mouth-to-anus transit time of 24.2 +/- 6.8 h (mean +/- SDdiff = -6.2 +/- 2.9). When two of the three X-rays were used in various combinations, the best results were obtained with the method including radiographs at 12 and 36 h. Parameters calculated from a single radiograph done 36 h after the ingestion of makers showed lesser agreement with the results of the three radiograph method. Therefore in subjects with rapid gut transit, the simplified method for estimating the colonic and segmental transit times using a single X-ray is inaccurate. Using two radiographs enhances the accuracy.

Eosinophilic gastroenteritis--an Indian experience.

Eosinophilic gastroenteritis is an uncommon disorder with varied presentation. Records of 7 patients (6 men) with eosinophilic gastroenteritis, presenting to a large referral hospital over a 10-year period, were analyzed. The patients were young adults (mean age 32 years) with short duration (median 2 months) of illness. Symptoms included abdominal pain and vomiting (100%), weight loss (57%), diarrhea (43%) and abdominal distension (43%). Peripheral eosinophilia was present in all the patients. The diagnosis was made at duodenal (2 patients) or cecal (1) biopsy or surgical full-thickness jejunal biopsy (4). Three patients had predominantly mucosal disease (Klein type I), whereas two patients each had predominantly muscular (type II) and submucosal (type III) disease. Surgical resection was curative in one patient with type II disease. The other six responded to prednisolone, with complete resolution in one patient.

Diagnosis and management of gastrointestinal angiodysplasia.

Eighteen patients with gastrointestinal angiodysplasia were seen in a single surgical unit over a period of 8 years. The mean age at onset of symptoms was 33 years. The average duration of symptoms was 54 months (range 2 days-16 years). Three patients had gastric angiodysplasia, two had colonic angiodysplasia, both diagnosed endoscopically preoperatively. The remaining patients required further investigation, which included small bowel enema (SBE), erythrocyte tagged scan (ETC), selective visceral angiography and intraoperative enteroscopy (IOE). SBE was useful but not diagnostic in 3, ETC in 3 and angiography in 5. Four patients required IOE for a diagnosis. Follow up of 17 months is available on all patients. Four had recurrence of symptoms. One required re-exploration and resection of 3 feet of small bowel and right hemicolectomy, another is on hormonal therapy and maintaining normal haemoglobin. Two others are asymptomatic on oral iron therapy.

Malignant mesothelioma in the young (with prosthetic aortic valve an unusual association).

A case of malignant mesothelioma (MM) in a 15 year old boy is reported. He had a prosthetic aortic valve implanted in 1980 at our centre for rheumatic aortic regurgitation. Fever, weight loss and chest pain as initial symptoms suggested possibility of prosthetic valve endocarditis. Dysphagia as another initial symptom was interesting and caused further diagnostic dilemma. Role of Computerised Tomography (CT) scan in diagnosis of MM is highlighted.