Gilbert's syndrome and Ramadan: exacerbation of unconjugated hyperbilirubinemia by religious fasting.

Gilbert's syndrome is a benign, often familial condition characterized by recurrent but asymptomatic jaundice. We report two cases of recurrent jaundice due to unconjugated hyperbilirubinemia in Muslim subjects during the fast of Ramadan. As the diagnosis of Gilbert's syndrome was not suspected, both patients were extensively investigated before the relationship to fasting was recognized and the correct diagnosis made. We conclude that the possible exacerbation of Gilbert's by fasting should be borne in mind in the evaluation of Muslim patients with jaundice.

Systemic paraphenylenediamine (PPD) poisoning: a case report and review.

A case of suicidal poisoning with paraphenylenediamine (PPD) is reported. The patient presented with typical features of severe oropharyngeal oedema and rhabdomyolysis. He suffered sudden cardiac death within 4 hours of admission despite full supportive treatment. The diagnosis was only established after his death. Systemic poisoning with paraphenylenediamine (PPD) is rare in western countries, and therefore a high degree of awareness and circumstantial evidence is required to make an early diagnosis. The classical and other less commonly reported features of this poisoning are discussed. There is no specific antidote available but some guidelines for management of such a case are reviewed.

Severe orthostatic hypotension in carcinoma of the pancreas.

Autonomic dysfunction has been described in patients with advanced forms of cancer. We report a case of severe orthostatic hypotension in a patient with carcinoma of the pancreas in whom there was no clinical evidence of autonomic failure to account for the severity of the hypotension. Despite normal circulating levels of nor-adrenalin and an appropriate rise in the erect position, the vascular system appeared unresponsive. We suggest that in this patient the orthostatic hypotension was due to a paraneoplastic complication of the pancreatic tumour.

Non-A, non-B hepatitis in West London.

Acute and convalescent sera from 368 patients drawn from a 3-year survey of viral hepatitis in West London were tested for radioimmunoassay for evidence of recent infection with hepatitis A or B and, if neither was found, antibody to Epstein-Barr (EB) virus and cytomegalovirus. In 215 patients (58%) there was evidence of hepatitis A, in 98 (27%) hepatitis B, and in 5 both A and B. 2 patients with evidence of recent EB virus infection were excluded, leaving 48 (13%) attributed to non-A, non-B hepatitis. This illness was milder than hepatitis B as judged by duration of jaundice and peak serum bilirubin alanine-aminotransferase levels. The ratio of men to women was 1.4 to 1, but there was an excess of women in their twenties, most of whom were single. Only one had received blood, and none was a drug addict.

A three-year survey of viral hepatitis in West London.

During a total population survey of viral hepatitis in the London Boroughs of Hounslow, Richmond and Ealing, 784 patients were seen in three years from 1 March 1972 to 28 February 1975. A diagnosis of viral hepatitis was accepted in 489. The annual incidence was 24 per 100 000. 455 of the patients were tested for the hepatitis B surface antigen (HBsAg) by a radioimmunoassay technique and 93 (20%) of these were positive. The majority of the patients with type B hepatitis were in their third or fourth decades. None was under the age of 16. The male to female ratio among patients with hepatitis B was 2 to 1 in those under the age of 30 and 5 to 1 in those aged 30 and over. The seasonal distribution of viral hepatitis showed a peak in the spring, solely from an increased incidence of non-B hepatitis, and a second, smaller peak in the autumn. There was no appreciable clustering of patients except for one local outbreak in a housing estate during the first year affecting mainly children going to the same primary school, and their parents. Patients with hepatitis B had a longer pre-icteric illness (p less than 0.05), greater duration of jaundice (p less than 0.001) and higher peak levels of serum bilirubin (p less than 0.0005) and serum alanine amino transferase (A1T) (p less than 0.03) than patients with non-B hepatitis. The finding of the surface antigen was also associated with a higher frequency of skin rash (p less than 0.0005) and a greater duration of arthralgia (p less than 0.03). Among the HBsAg negative patients the incidence of arthralgia increased with age (p less than 0.0005). Abdominal pain (p less than 0.005) and vomiting (p less than 0.005) were more common in the young. The injection experience of patients with hepatitis B showed a high proportion of 'non-therapeutic' exposure such as drug addiction. Significantly more HBsAg positive men were single than in the local community (p less than 0.001) or among the HBsAg negative men (p less than 0.01). There was no significant difference between the proportions of single women among the antigen positive and negative patients. Many of the HBsAg positive single men were either known to be or strongly suspected of being homosexual. The ad subtype of the HBsAg was found more often in males (p less than 0.01), particularly over the age of 30. All eight drug addicts tested for subtype were ay, as were two non-addicted female consorts. The association between addiction and ay subtype was highly significant in the males (p less than 0.001). The ad subtype was found in all 11 of the admitted homosexual HBsAg positive men and in all but one of the 17 strongly suspected of being homosexual.

Hepatitis B antigen in viral hepatitis in West London.

During the first 12 months of a total population survey 249 patients were seen with viral hepatitis. A total of 215 of these were tested for hepatitis B antigen (HB Ag) by radioimmunoassay and 32 (15%) were positive.More than five times as many men (27) as women (5) were HBAg positive and 19 of the men were between the ages of 20 and 39 years. There were only four drug addicts among those tested, two of whom were positive, as were two of the four patients who were tattooed.Sixty out of 86 children (under 15 years) were tested for HBAg and none was positive.

Autoantibodies and the hepatitis-associated antigen in acute infective hepatitis.

In 39 unselected patients with acute infective hepatitis diagnosed on clinical, epidemiological, and pathological findings, smooth muscle (S.M.) antibody was found in 87% and hepatitis-associated antigen in 33%. The incidence of S.M. antibody was highest during the first month after the onset of symptoms, and the antibody was preponderantly IgM at this stage.S.M. antibody and hepatitis-associated antigen occurred independently, and unlike hepatitis-associated antigen, which was strongly associated with possible parenteral exposure to infection, the incidence of S.M. antibody was not related to the presumed mode of exposure. It is concluded that production of S.M. antibody is more directly related to liver cell damage than to the presence of hepatitis-associated antigen in the serum.

Culture of needle biopsies of the liver from patients with suspected hepatitis.

A technique is described for the culture in Leighton tubes of very small fragments of human adult liver obtained by needle biopsy. Most of the cultures were successful, and even after long storage proved to be as useful as those prepared from fresh suspensions. The diagnostic usefulness of the technique is already proved.