Anaplastic T-cell lymphoma presenting as fatal acute liver failure.

Acute liver failure (ALF) is an uncommon manifestation of liver disease and constitutes a medical emergency for which early identification is necessary. Hepatic involvement by hematologic malignancies although frequent, rarely causes severe hepatic dysfunction. Even more, acute hepatic failure as the first manifestation of a hematologic malignancy is extremely uncommon, although some cases have been reported in the literature. We describe the case of a 61 y/o puertorrican veteran who developed acute hepatic failure secondary to massive infiltration of the liver by a recurrent non-Hodgkin's lymphoma.

Response to combination therapy of interferon alfa-2b plus ribavirin in Hispanics with chronic hepatitis C.

OBJECTIVE: To evaluate the response rate of Hispanics with chronic hepatitis C to combination therapy of interferon alfa-2b plus ribavirin and to assess its adverse events. BACKGROUND: Hepatitis C virus may lead to chronic infection and multiple complications. Response to combination therapy of interferon plus ribavirin has been studied in many populations. African Americans have been found to have a lower response rate than Caucasians. However, little data exist for Hispanics. METHODS: Hispanic patients from Puerto Rico with chronic hepatitis C were eligible for the study between November 1997 and February 2000. The Institutional Review Boards of the participating institutions approved the study. Written informed consents were obtained. Combination therapy was given for 48 weeks and patients were followed for 24 weeks after treatment. Analysis of response to therapy was performed in an intention-to-treat basis. RESULTS: The most frequent adverse event was anemia (89%), associated to ribavirin. Sustained response was 23% for naive patients, 45% for relapsers, and 8% for non-responders to previous interferon monotherapy (p < 0.001). Data to analyze response was not available in 27% of patients. Hispanic patients had a low response rate to combination therapy. CONCLUSIONS: Response rates to combination therapy for Hispanic naive and previously non-responder patients are lower than in other reported populations. This may be due to a high prevalence of genotype 1 in Puerto Rico, which is associated to poor response. The higher response rate of relapsers, similar to those reported previously, was expected since these patients showed a previous response to interferon monotherapy. Ethnic factors may play a role in the response to therapy and should be further studied to determine proper treatment strategies for this population.

Malignant tumors of the small intestine.

SUMMARY: Malignant tumors of the small bowel are unusual and account for only 1% to 5% of all gastrointestinal tract malignancies. Thirteen cases of malignant tumors of the small bowel identified at the VAMC in Puerto Rico from January 1999 to September 2001 and a review of the literature are presented. The mean age of our cases was 67 (range: 45-78). Vague abdominal pain, nausea, vomiting, and melena were the most frequently reported symptoms. The average time from first symptoms to diagnosis was 3.2 months. A positive test for occult blood or hypochromic microcytic anemia was invariably present. Hyperbilirubinemia and increased alkaline phosphatase were warning signs that allowed earlier diagnosis in patients with duodenal tumors. Fifty-four percent of the lesions were detected by endoscopic examination while 46% relied on radiographic studies. Eleven had carcinomas and two malignant gastrointestinal stromal tumors. Neither carcinoids nor lymphomas were identified. Our report of thirteen cases of malignant small bowel tumors is unusual and exhibits differences with the previously reported data. The cases were identified in a limited Hispanic population in a short period of time. Aggressive evaluation and a high suspicion of these malignancies should be entertained whenever subtle symptoms and unexplained gastrointestinal blood loss are assessed.

Osteopenia in Puerto Ricans with Crohn's disease

BACKGROUND: Osteopenia has been reported in association to Inflammatory Bowel Disease, and in particular Crohn's disease. The use of corticosteroids, resection of the ileum, malabsorption, poor calcium intake, and the effect of inflammatory cytokines have all been considered as contributing factors. As Crohn's disease is more prevalent in young people, when peak bone mass is achieved, the presence of osteopenia is especially significant. OBJECTIVES: The aim of this study was to evaluate the bone density of patients with Crohn's disease in the University of Puerto Rico IBD Clinic; to determine the prevalence of osteopenia in these patients and to correlate bone mineral density with risk factors for osteopenia. METHODS: Sixty-six patients, 30 males and 36 females were included. After informed consent, demographic, clinical and metabolic data was obtained. Serum albumin, calcium, inorganic phosphorus and alkaline phosphatase were measured. Body mass index (BMI) was calculated. Bone density was determined by DEXA of the lumbar spine and femur and expressed as the Z score (standard deviations from normal correlated with sex and age). Severe osteopenia was a Z score > or = -2 and osteopenia was Z < or = -1.99 or > or = 1.01. Results were expressed in means. Pearson correlation coefficient was used for quantitative variables and Pearson chi-square for categorical values. RESULTS: Osteopenia was present in the hip in 69 and in the lumbar spine in 68. Most patients had received steroids; the difference between treated and not treated patients was not significant. Osteopenia did not correlate with ileal resection, gender, BMI, disease characteristics or biochemical parameters. CONCLUSIONS: Low bone density was frequent in patients with Crohn's disease, but no specific risk factors could be identified. Bone density should be determined in patients with Crohn's disease in order to institute appropriate therapeutic measures.