A case report: antiviral triple therapy with telaprevir in a haemodialysed HCV patient in Turkey.

A 49-year-old woman was diagnosed with chronic hepatitis C 7 years ago. She began haemodialysis at the same time. She was on the waiting list for kidney transplantation (KTx). The real-time PCR technique revealed an HCV RNA viral load of 212,000 IU/ml, genotype 1a, IL28B the rs12979860 minor allele heterozygous CT (rs8099917 TT homozygous). She had a history of first antiviral treatment for 48 weeks of PEG-IFN-alpha 2a, 135 µg/week in 2011, but the HCV infection relapsed. Considering her relatively young age, candidacy for renal transplant, and the heterozygous pattern of IL28B, we decided to proceed with a second (and last) antiviral treatment using triple therapy with telaprevir at the regular dose of 750 mg every 8 hours+PEG-IFN-alpha 2a 135 µg/week sc+200 mg RBV three times a week. At the end of 6-month therapy, HCV RNA was found to be negative at months 3, 5, and 6.The patient has reached the sustained virological response (SVR) and is ready for KTx. All renal transplant candidates (dialysis-dependent, or not) with HCV should be assessed for antiviral treatment given the increased risk of progressive liver disease due to immunosuppressive therapy, increased life expectancy compared to other HCV-positive patients on dialysis, and the inability to receive interferon after transplantation.

A deceiving disease in women for clinicians: peritoneal tuberculosis.

INTRODUCTION: Peritoneal tuberculosis (TB) is uncommon in developed countries, although there is an increase in incidence due to the patients with acquired immunodeficiency syndrome and in immigrants from countries with tuberculosis. The aim of the study was to identify characteristic features of peritoneal tuberculosis (TB), which may be useful for the clinical differential diagnosis and management of this deceiving disease. MATERIALS AND METHODS: For this retrospective study, 18 patients, who were diagnosed with peritoneal TB were identified after surgery. RESULTS: Initial presentation consisted of ascites, pelvic masses, and elevated levels of CA-125. All patients were initially misdiagnosed as ovarian carcinoma. Tissue biopsies obtained from laparoscopy or laparotomy revealed accurate diagnosis of peritoneal TB. CONCLUSION: Peritoneal TB should be included in the differential diagnosis ofascites and pelvic masses and can be accurately diagnosed by laparoscopic biopsy.

Implications of premature ovarian failure on bone turnover markers and bone mineral density.

INTRODUCTION: Premature ovarian failure (POF) is the cessation of ovarian function before the age of 40. The loss of ovarian function, whether premature or not, has an overwhelming impact on female skeletal health, leading to an increased risk of developing osteoporosis because of the lengthened time of exposure to reduced estrogen. The objective of this study was to compare the implications of premature ovarian failure on bone turnover markers and bone mineral density in patients under the age of 40. MATERIALS AND METHODS: Sixty-one patients with a diagnosis of POF were selected for this prospective study. Patients were divided into two groups according to age, patients < 30 years old (n = 30), and patients > or = 30 years old (n = 31). RESULTS: Between the two age sub-groups (< 30 and > or = 30 years old), there was a significant difference in menopause rating scale (MRS), lumbar spine t-score, N-telopeptides crosslinks (NTx), and serum bone specific alkaline phosphatase (bALP) between the two age groups (10.93 +/- 7.79 vs 17.38 +/- 8.62; -1.84 +/- 1.47 vs -1.06 +/- 0.93; 58.80 +/- 21.32 vs 41.1 +/- 11.37; 48.99 +/- 42.16 vs 23.76 +/- 10.08, respectively). CONCLUSION: It is apparent that bone mineral density (BMD) is commonly less in women with POF than normal healthy women. Therefore, measurement of BMD is warranted. At this time, it is not clear how often the tests should be carried out to evaluate BMD. Further prospective studies are required to establish guidelines. However, it seems reasonable to monitor women with POF yearly for the presence of any endocrine dysfunction and to assess BMD at periodic intervals.

Hemoperitoneum and acute abdomen caused by the rupture of ovarian granulosa cell tumor: a case report.

Granulosa cell tumors (GCT) constitute 70% of all ovarian sex-cord stromal tumors, which account for less than five percent of all ovarian carcinoma. The authors herein report a rare case of a ruptured GCT of the ovary in a 43-year-old female who was admitted to the emergency department with signs of acute abdomen.

Acute hemorrhage related to spontaneous rupture of an uterine fibroid: a rare case report.

The authors present smooth muscle tumors of uncertain malignant potential (STUMP) diagnosis and surgical management of a spontaneously-ruptured degenerated uterine fibroids. A 48-year-old nulliparous presented with a two-day history of abdominal pain, bloating, constipation, and menorrhagia. Within eight hours, her distress level increased. Computed tomography (CT) scanning of the abdomen showed a large, 31 x 25 cm solid-cystic lesion. An emergency laparotomy was indicated. Surgery revealed approximately 2,000 cc of blood and a 30 cm degenerated uterine fibroid with a fundal rupture, cystic, and solid components extending to the lower pole of the liver. Pathology results noted mild nuclear atypia, six mitoses per ten high-power fields (hpf) and necrosis spread that was not coagulative with a STUMP diagnosis. STUMP presents a problematic group of uterine smooth muscle tumors for any clinician. In addition, STUMP can rarely cause acute complications like a rupture. Therefore, prompt diagnosis and effective management are important.

A rare case of lymphangiomyomatosis treated with leuprolide acetate: five-years follow-up.

Lymphangiomyomatosis (LAM) is a rare and systemic disease that is characterized by the abnormal proliferation of smooth muscle-like cells in the lungs and along the axial lymphatic system. The authors herein present a rare case of LAM that was treated with long-term use of leuprolide acetate, a gonadotropin-releasing hormone analogue (GnRHa).

Antiviral drug-associated potential vaccine-escape hepatitis B virus mutants in Turkish patients with chronic hepatitis B.

BACKGROUND: The hepatitis B virus (HBV) polymerase (pol) gene completely overlaps with the envelope (S) gene. Mutations in the pol gene of HBV, either from selection of primary or secondary resistance mutations, typically result in changes in the overlapping hepatitis B surface antigen (HBsAg). Recent studies have conferred a new acronym to these HBV pol/S gene overlap mutants: ADAPVEMs, for antiviral drug-associated potential vaccine-escape mutants. The present study aimed to assess the prevalence and pattern of ADAPVEMs in Turkish patients with chronic hepatitis B (CHB). METHODS: The investigation was conducted between March 2007 and July 2010 and involved a total of 442 patients. These patients were in the following phases of HBV infection: immune tolerant (n=50), immune reactive (n=37), inactive carrier (n=90), HBeAg-negative CHB (n=217), and HBsAg-negative (n=12), or were hemodialysis patients (n=36). One hundred eighty-six patients were receiving nucleos(t)ide analogue (NUC) therapy and 256 patients had treatment-naïve CHB. RESULTS: Seven types of ADAPVEM were detected in the total CHB patients: rtM204V/sI195M, rtM204I/sW196S, rtM204I/sW196L, rtV173L/sE164D, rtA181T/sW172*, rtA181T/sW172L, and rtA181V/sL173F. The ADAPVEMs were associated with lamivudine, telbivudine, and adefovir. The prevalence of ADAPVEMs in all CHB patients was found to be 10% (46/442). The difference in the prevalence of ADAPVEMs across the different CHB clinical phases was not significant (Pearson Chi-square, p=0.112). The prevalence of ADAPVEMs was 24% (44/186) in those undergoing NUC therapy and 0.7% (2/256) in the treatment-naïve group; this difference was significant (Pearson Chi-square, p=0.00). CONCLUSIONS: We determined the prevalence and pattern of ADAPVEMs in Turkish patients in the different phases of CHB. Preferred drugs in Turkey, such as lamivudine, have the potential to cause the emergence of ADAPVEMs, with the possibility that these will spread to both individuals immunized with the hepatitis B vaccine and nonimmunized individuals. ADAPVEMs should be monitored in infected and treated patients and their public health risks assessed.

Monitoring of hepatitis B virus surface antigen escape mutations and concomitantly nucleos(t)ide analog resistance mutations in Turkish patients with chronic hepatitis B.

BACKGROUND: The hepatitis B virus (HBV) polymerase gene completely overlaps with the envelope gene. In the present study we aimed to monitor the prevalence and pattern of the typical mutations for hepatitis B surface antigen (HBsAg) escape, and concomitantly nucleos(t)ide analog (NUC) resistance mutations, in Turkish patients undergoing different antiviral therapies and in treatment-naïve patients with chronic hepatitis B (CHB). METHODS: The investigation was undertaken between March 2007 and August 2009 and involved a total of 142 patients under NUC therapy (88 males; mean age 42 years (range 13-68); hepatitis B e antigen (HBeAg) negativity in 94 patients; HBV DNA median log 4.3 log(10) IU/ml (range 2.0->6.0); alanine aminotransferase (ALT) median level 76.1 IU/ml (range 12-1082)) and 185 treatment-naïve CHB patients (120 males; mean age 39 years (range 1-76 years); HBeAg negativity in 132 patients; HBV DNA median log 3.5 log(10) IU/ml (range 2.0-6.0); ALT median level 60.7 IU/l (range 8-874)). RESULTS: The overall prevalence of typical HBsAg escape mutations found in the CHB patients was 8.3% (27/327). In the NUC therapy group the prevalence was 8.5% (12/142), with the following patterns: sY100C+sI110V, sL109I, sP120T, sP127T, sG130R+sG145X, sS132A+sY134N, sY134N+sG145R, sC137G, sD144E, sG145R. In the treatment-naïve group the prevalence was 8.1% (15/185), with the following patterns: sL109I, sI110V, sS117INST, sP120T, sP127T, sM133I, sC137L+sG145R, sS143L. However, NUC resistance mutations were found in 7.7% (11/142) of the patients on NUC therapy and 3.8% (7/185) of the treatment-naïve group patients. Interestingly, the treatment-naïve patients had preexisting drug resistance mutations related to lamivudine (rtL180M+rtM204I), adefovir (rtA181V, rtQ215S, rtI233V), entecavir (intermediate susceptibility with rtL180M+rtM204IHBV variant), telbivudine (rtL180M+rtM204I), and tenofovir (rtA194T). CONCLUSIONS: The findings of this study show preexisting typical HBsAg escape and NUC resistance mutations are possible. The genetic arrangement of the HBV genome with polymerase and surface genes overlapping has substantial public health and diagnostic implications and relevance.

Factors affecting recurrence and disease-free survival in granulosa cell tumors of the ovary.

PURPOSE OF INVESTIGATION: To determine risk factors for prognosis and recurrence in ovarian adult-type granulosa cell tumor (GCT). METHODS: A retrospective review of GCT cases treated at our university hospital between 1991-2006. RESULTS: Of 39 patients with GCT, 82% had Stage I disease. The median follow-up period was 71 months. There were 12 cases of recurrence (30.8%) and seven of them had died of disease. The pelvis and liver were the most common sites of recurrence (8 and 3 patients, respectively). Interestingly lymph node recurrence was encountered in two patients. Estimated disease-free survival for five years was 82%. Stage and presence of residual tumor were calculated to be the only associated risk factors for recurrence and prognosis (p < 0.05). CONCLUSION: Recurrences in GCT might be associated with stage and presence of residual tumor during primary surgery. Although rarely present during diagnosis, lymph node metastasis might be more common in recurrent disease.

Naturally occurring amino-acid substitutions to nucleos(t)ide analogues in treatment naive Turkish patients with chronic hepatitis B.

Naturally occurring amino-acid substitutions in the hepatitis B virus (HBV) polymerase gene may be responsible for resistance to nucleoside/nucleotide (NUCs) analogues. To date, only pre-existing lamivudine resistance has been extensively studied. The aim of the present study was to determine the naturally occurring or pre-existing amino-acid substitutions related to NUCs in treatment naive Turkish patients with chronic hepatitis B (CHB). The investigation involved a total of 88 patients (65 males and 23 females; mean age, 34 years; range, 15-61 years) who were diagnosed with CHB between April 2008 and January 2009. According to HBeAg status, 66 patients were HBeAg-negative and 22 patients were HBeAg positive. Naturally occurring substitutions in the HBV polymerase region were detected by DNA sequencing in 17 (19%) and 30 (34%) patients, based on manual and geno2pheno tool database interpretation, respectively. Each amino-acid substitution appeared alone and included rtA194T, rtV214A, rtQ215S, rtI233V and rtN236T. The median values for viral load, ALT and AST were 3.3 log(10) (2.0-6.0) IU/mL, 36 (12-515) U/L and 27 (13-284) U/L, respectively, but these did not correlate with the observed amino-acid substitutions in the polymerase region. By direct sequencing, genotype D of HBV was found to still be dominant among Turkish patients. In conclusion, every patient who is diagnosed with CHB should be monitored before the start of treatment for more effective management of patient treatment options.

Cranial imaging spectrum in hypertensive disease of pregnancy.

OBJECTIVE: To determine cranial imaging findings in patients with severe preeclampsia, eclampsia and HELLP syndrome and the correlation between these findings and neurological symptoms. MATERIALS AND METHODS: CT or MRI findings of 120 patients diagnosed with severe preeclampsia, eclampsia and/or HELLP syndrome between January 1998 and December 2005 are presented. RESULTS: Pathological imaging findings were observed in 28.1% (n = 32) of the severe preeclampsia group, in 43.3% (n = 30) of the HELLP group, in 51.35% (n = 27) of the eclampsia group and in 61.9% (n = 21) of the eclampsia + HELLP group and in 45% of all patients. Thirty-five patients had specific pathology defined as ischemic lesions, edema, and perivascular microhemorrhage. Infarcts were found in seven, intracranial hemorrhage in seven, hydrocephaly in two, dural sinus thrombosis in two and a pineal cyst in one patient. Specific lesions were generally located in the posterior parietal and occipital lobes. Five patients died due to intracranial hemorrhage and one patient due to septic shock. CONCLUSION: A wide imaging spectrum from the ischemic lesion to severe intracranial hemorrhage can be detected in complicated cases of hypertensive diseases of pregnancy. It is essential to perform cranial imaging in patients with symptoms and neurological deficits.

The response to pegylated interferon alpha 2a in haemodialysis patients with hepatitis C virus infection.

The aim of this retrospective study was to focus the efficacy of pegylated interferon (PEG-IFN) alpha 2a in chronic hemodialysis patients with hepatitis C and to compare the therapy responses with other chronic hepatitis C patients. Of the anti-HCV positive patients who were admitted to the Infectious Diseases and Clinical Microbiology policlinic from January 2004 to December 2006, 99 were candidates for interferon therapy. Of those, 12 patients were on HD. We began 47 patients on PEG-IFN alpha 2a (180 lg/week) subcutaneously plus ribavirin (1,000-1,200 mg/day) (Group 1), and 12 patients on HD, PEG-IFN alpha 2a, without ribavirin at a dose of 135 lg weekly for 48 weeks (Group 2). In this study of PEG IFN alpha 2a with or without ribavirin, the predictability of a sustained viral response (SVR) was based on the early virologic response (EVR) defined at week 12 as an at least 2-log decline from baseline of the HCV RNA level. About 77% (39/47) of patients achieved an EVR in Group 1 and 58% (7/12) in Group 2 (p = 0.004). A total of 34 (72.34%) patients in Group 1 and 6 patients (50%) in Group 2 had negative HCV RNA at the end of the treatment (p = 0.213). We evaluated SVR after 6 months finishing the therapy; 29 (61.7%) patients in Group 1 and 6 patients (50%) in Group 2 had negative HCV RNA (p = 0.109). PEG-IFN alpha 2a (135 lg weekly) for 48 weeks is efficacious and well tolerated in HD patients with HCV, as well as other chronic HCV patients. However, due to more side effects of IFN specially on platelet counts as compared non-renal HCV patients a closer follow-up, in HD patients is suggested.

Pelvic actinomycosis mimicking ovarian malignancy: three cases.

OBJECTIVE: Three cases of pelvic actinomycosis initially diagnosed as pelvic malignancy and treated surgically are reported. CASES: The first case was a 38-year-old multiparous woman who was referred to our clinic because of bilateral ovarian solid masses. With the impression of ovarian carcinoma, a laparotomy was performed. During surgery adhesiolysis, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, appendectomy, peritoneal washings, and peritoneal abscess drainage were performed. The second patient was a 37-year-old woman who presented with a left-sided fixed solid mass highly suggestive of pelvic malignancy. Both ureters were found to be dilated with hydronephrosis in the right kidney supporting the diagnosis of retroperitoneal fibrosis. Excision of the mass, colectomy and temporary diverting colostomy and stent insertion to the left ureter were performed. Colostomy repair was performed five months later. On the fifth day postoperatively, fascial necrosis developed so a Bogota-bag was placed on the anterior abdominal wall and left for secondary healing. The third patient was a 51-year-old postmenopausal woman incidentally diagnosed as having a pelvic mass while having been investigated for constipation and nausea. She had had a colostomy one year before and a reanastomosis two months after. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. In all cases, histopathologic staining of the specimens revealed chronic inflammation containing actinomycosis abscesses confirmed with microbiologic identification. CONCLUSION: Pelvic actinomycosis is an uncommon cause of a pelvic mass. However, it should be kept in mind in the differential diagnosis of pelvic masses, especially in the patients with a history of IUD use to avoid an unnecessary extensive surgical procedure.

Conservative treatment of an early ectopic pregnancy in a cesarean scar with systemic methotrexate--case report.

PURPOSE OF INVESTIGATION: Pregnancy implanted in a cesarean scar is rare, and is a life-threatening condition due to high risk of uterine rupture, hemorrhage, hysterectomy, and maternal mortality. CASE REPORT: We describe a 26-year-old woman who presented with five weeks of amenorrhea and a serum hCG level of 10,440 mIU/ml. Transvaginal sonography revealed a gestational sac of 15 x 11 mm containing a yolk sac located in a previous cesarean scar. She was successfully treated conservatively with multi-dose methotrexate. No side-effects were encountered. The serum hCG levels were undetectable in 58 days. The patient had normal menstrual cycles afterwards. CONCLUSIONS: In the view of increasing cesarean rates, healthcare professionals should be aware of the possibility of a scar pregnancy and the potentially life threatening sequelae. Early diagnosis by transvaginal sonography can improve outcome and minimize the need for emergent surgery. Conservative treatment with systemic methotrexate is an effective option in selected patients.

Malignant germ cell tumors of the ovary: a review of 41 cases and risk factors for recurrence.

OBJECTIVE: To review the outcome of treatment in patients with malignant ovarian germ cell tumors and to define the risk factors for recurrence. MATERIAL AND METHODS: Forty-one patients with malignant ovarian germ cell tumors were reviewed retrospectively. Survival time and survival rate were obtained. Risk factors such as stage, histological type, and type of operation were evaluated for reccurrence. RESULTS: Twenty-three (56%) had dysgerminomas, eight (19.5%) had mixed germ cell tumors, three (7.3%) had yolk sac tumors, three (7.3%) had immature teratomas, two (4.8%) had squamous cell carcinoma arising from a mature teratoma, one (2.4%) had embryonal carcinoma and one choriocarcinoma. Most of the cases (73%) were in Stage I. Twenty-nine patients (70.7%) underwent conservative surgery and 12 patients (29.3%) had at least bilateral salpingo-oophorectomy. Thirty patients were operated on optimally with surgical staging and 11 suboptimally. Seven patients (17%) had recurrence after remission. The overall survival time was 187 +/- 8.43 months for all cases, 195 +/- 8.49 for dysgerminoma and 161 +/- 10.96 for non-dysgerminoma cases with a median follow-up time of 98.52 (8-204) months. Non-dysgerminoma histologic type, being operated on suboptimally and radically, and advanced tumor stage have been found to be risk factors for recurrence. CONCLUSION: Regardless of histologic types and stages the prognosis of germ cell tumors are satisfactory with current therapeutic strategies.

Life-saving hysterectomy in choriocarcinoma: presentation of two cases.

BACKGROUND: Choriocarcinoma is a malignant tumor of the placenta. Life-saving hysterectomy was performed in two cases with choriocarcinoma who had profuse vaginal bleeding. CASE 1: A 25-year-old, gravida 3, para 1, woman was referred to our emergency clinic with the diagnosis of choriocarcinoma and massive vaginal bleeding. She had been transfused seven units of blood at the hospital where she was first admitted. Pelvic examination demonstrated heavy vaginal bleeding and a uterus equivalent to the size of 14 weeks of gestation. Her beta-hCG level was 560,000 mIU/ml. Despite four units of blood transfusion, she had a pulse rate of 130/min, arterial pressure of 90/60 mm/Hg and HCT of 19%. An emergency hysterectomy with vertical incision was performed. CASE 2: A 54-year-old, gravida 3, para 3, woman was referred to our clinic with heavy bleeding with the diagnosis of choriocarcinoma. She was scanned to look for possible metastases and pulmonary metastasis was detected. Chemotherapy was planned but as sudden vaginal bleeding began she was referred to the Gynecology Department. At pelvic examination a soft uterus the size of 20 weeks of gestation was palpated. The beta-hCG level was 554,700 mIU/ml. Due to hemodynamic instability and continuous vaginal bleeding an emergency hysterectomy was performed. CONCLUSION: Although chemotherapy is the cornerstone of treatment for choriocarcinoma, optimal treatment results may depend on the addition of surgery in selected circumstances. Hysterectomy is indicated in cases with life-threatening hemorrhage.

Radiation-induced benign glandular cells in posthysterectomy smears: a cytomorphologic and clinical analysis.

In this retrospective study, we aimed to investigate the frequency and cytomorphologic characteristics of benign glandular cells (BGCs) in hysterectomized individuals. We also discussed the possible effect of radiation therapy on these cells. We reviewed our cytopathology archive material through a 5.5-year period and found 1460 posthysterectomy vaginal smears. Of these, 508 smears were from patients who had undergone hysterectomy for a gynecological malignancy. Review of this vaginal cytology material revealed 17 posthysterectomy patients whose smears contained BGCs. We obtained detailed clinical information in 16 of these. In addition to routine Papanicolaou staining, mucicarmine stain was also used to demonstrate cytoplasmic mucin in some cases. All the patients had a history of gynecological malignancy and had radiation therapy. Glandular cells appeared singly or in rows and honeycomb groups and did not show cytologic atypia. We concluded that radiation might give rise to a metaplastic process in which basal cells of squamous epithelium of the vagina transform into glandular cells. Most probably this process is independent of radiation dosage and period and is irreversible. We also propose that the possibility of encountering glandular cells in posthysterectomy smears is higher than expected, if the mucin stains have been used for the microscopic examination.

Differentiation of benign and malignant adnexal masses: value of a morphologic scoring system.

OBJECTIVE: The purpose of this study was to assess the value of conventional gray-scale ultrasonography, based on a morphologic scoring system, in the differential diagnosis of malignant and benign adnexal tumors. MATERIAL AND METHODS: A total of 58 adnexal masses in 51 patients were classified prospectively as suggestive of malignant or benign, on the basis of gray-scale ultrasonographic morphology. The results were correlated with histopathological diagnosis. RESULTS: Histopathology of 42 masses was found to be benign and 16 masses were found to be malignant. On gray-scale analysis 15 of 16 malignant masses were classified as suggestive of malignant and 37 of 42 benign masses were classified as suggestive of benign. The sensitivity, specificity, positive predictive value and negative predictive value are calculated as 93%, 88%, 75%, and 97%, respectively. CONCLUSION: Prediction of malignancy using gray scale ultrasonograhy based on a morphological scoring system was reliable (NPV = 97%, PPV = 93%). However further investigations about the assessment of adnexal masses with ultrasonography are needed

Laparoscopic evaluation of metastatic ovarian cancer: a case report.

UNLABELLED: OBJECTIVE AND CASE: Both noninvasive and invasive methods have limited value in the diagnosis of metastatic ovarian cancer. We present a case with the initial complaint of abdominal distention in whom primary and metastatic tumor sites were safely diagnosed by using laparoscopy: a gastric tumor with ovarian metastasis. DISCUSSION: Diagnostic laparoscopy by the open technique provides a safe and effective diagnostic option in patients with metastatic ovarian cancer.

Brain metastasis of ovarian cancer after negative second-look laparotomy.

We present a case of ovarian carcinoma that had brain metastasis seven months after having a negative second-look laparotomy and 13 months after the onset of diagnosis. Despite intense multidisciplinary treatment with surgery, chemotherapy and radiotherapy, the patient died seven months after second-look laparotomy.