Progression of liver fibrosis in monoinfected patients by hepatitis C virus and coinfected by HCV and human immunodeficiency virus.

CONTEXT: The progression of liver fibrosis in patients coinfected by hepatitis C virus and human immunodeficiency virus (HCV/HIV) has been increasingly studied in the past decade. Studies made before the highly active antiretroviral therapy suggest that HIV can change the natural history of the HCV infection, leading to a faster progression of the liver fibrosis. OBJECTIVE: To evaluate and compare the fibrosis progression in two groups of patients (HCV/HIV coinfected and HCV monoinfected) METHODS: Seventy patients HCV monoinfected and 26 patients HCV/HIV coinfected who had not undertaken HCV treatment and were submitted to serial percutaneous liver biopsies were retrospectively evaluated. There was no difference in the fibrosis progression between the two groups. CONCLUSION: The fibrosis grade evolution was not worse in the coinfected patients. The immunosuppression absence and the shortest time period between the biopsies in the coinfected group are possible explanations.

Progression of iiver fibrosis in monoinfected ptients by hepatitis c virus andd coinfected by hcv and human immunodeficiency virus

Context The progression of liver fibrosis in patients coinfected by hepatitis C virus and human immunodeficiency virus (HCV/HIV) has been increasingly studied in the past decade. Studies made before the highly active antiretroviral therapy suggest that HIV can change the natural history of the HCV infection, leading to a faster progression of the liver fibrosis. Objective To evaluate and compare the fibrosis progression in two groups of patients (HCV/HIV coinfected and HCV monoinfected) Methods Seventy patients HCV monoinfected and 26 patients HCV/HIV coinfected who had not undertaken HCV treatment and were submitted to serial percutaneous liver biopsies were retrospectively evaluated. There was no difference in the fibrosis progression between the two groups. Conclusion The fibrosis grade evolution was not worse in the coinfected patients. The immunosuppression absence and the shortest time period between the biopsies in the coinfected group are possible explanations. .

Contexto A progressão da fibrose hepática em pacientes coinfectados pelos vírus da hepatite C (VHC) e da imunodeficiência humana (VHC/HIV) tem sido mais estudada na última década. Estudos realizados antes da terapia antiretroviral de alta potência (HAART) sugerem que o HIV pode mudar a história natural da infecção pelo VHC, levando a uma progressão mais rápida da fibrose hepática. Objetivo Avaliar e comparar a progressão de fibrose em duas populações de pacientes (coinfectados VHC/HIV e monoinfectados VHC). Métodos Foram avaliados retrospectivamente 70 pacientes monoinfectados VHC e 26 coinfectados VHC/HIV nunca tratados para o VHC e que haviam realizado duas biopsias hepáticas seriadas. Não houve diferença na progressão de fibrose entre os dois grupos. Conclusão A evolução do grau de fibrose não foi pior nos pacientes coinfectados. A ausência de imunodepressão e o menor intervalo de tempo entre as biopsias no grupo de coinfectados são possíveis justificativas. .

Whipple's disease: rare disorder and late diagnosis / Doença de Whipple: patologia rara e de diagnóstico tardio

Whipple's disease is a rare systemic infectious disorder caused by the bacterium Tropheryma whipplei. We report the case of a 61-year-old male patient who presented to emergency room complaining of asthenia, arthralgia, anorexia, articular complaints intermittent diarrhea, and a 10-kg weight loss in one year. Laboratory tests showed the following results: Hb = 7.5 g/dL, albumin = 2.5 mg/dL, weight = 50.3 kg (BMI 17.4 kg/m²). Upper gastrointestinal endoscopy revealed areas of focal enanthema in the duodenum. An endoscopic biopsy was suggestive of Whipple's disease. Diagnosis was confirmed based on a positive serum polymerase chain reaction. Treatment was initiated with intravenous ceftriaxone followed by oral trimethoprim-sulfamethoxazole. After one year of treatment, the patient was asymptomatic, with Hb = 13.5 g/dL, serum albumin = 5.3 mg/dL, and weight = 70 kg (BMI 24.2 kg/m²). Whipple's disease should be considered a differential diagnosis in patients with prolonged constitutional and/or gastrointestinal symptoms. Appropriate antibiotic treatment improves the quality of life of patients.

Doença de Whipple é uma rara infecção sistêmica causada pelo Tropheryma whipplei. Caracteriza-se por fase prolongada de sintomas inespecíficos, levando longo período até o seu diagnóstico. Sem tratamento, pode ser grave e fatal, mas com antibioticoterapia tem ótima resposta clínica e laboratorial. Relatamos o caso de paciente masculino, 61 anos, internado por astenia, anorexia, diarréia intermitente e perda de 10 kg em um ano. Apresentava-se com hemoglobina (Hb) 7,5 g/dL, albumina de 2,5 mg/dL, peso 50,3 kg (IMC 17,4). Endoscopia digestiva alta com áreas de enantema focal da mucosa duodenal e biópsia compatível com doença de Whipple. O diagnóstico foi confirmado com PCR sérica positiva, sendo instituído tratamento com ceftriaxone seguido de sulfametoxazol-trimetropim. Após um ano de tratamento, encontrava-se assintomático, com Hb 13,5 g/dL, albumina sérica de 5,3 mg/dL e peso de 70 kg. Doença de Whipple deve fazer parte da lista de diagnósticos diferenciais em pacientes com sintomas constitucionais e/ou com queixas gastrointestinais com evolução prolongada. O tratamento antibiótico pode curar a infecção, recuperando a qualidade de vida do paciente.

Whipple's disease: rare disorder and late diagnosis.

Whipple's disease is a rare systemic infectious disorder caused by the bacterium Tropheryma whipplei. We report the case of a 61-year-old male patient who presented to emergency room complaining of asthenia, arthralgia, anorexia, articular complaints intermittent diarrhea, and a 10-kg weight loss in one year. Laboratory tests showed the following results: Hb = 7.5 g/dL, albumin = 2.5 mg/dL, weight = 50.3 kg (BMI 17.4 kg/m²). Upper gastrointestinal endoscopy revealed areas of focal enanthema in the duodenum. An endoscopic biopsy was suggestive of Whipple's disease. Diagnosis was confirmed based on a positive serum polymerase chain reaction. Treatment was initiated with intravenous ceftriaxone followed by oral trimethoprim-sulfamethoxazole. After one year of treatment, the patient was asymptomatic, with Hb = 13.5 g/dL, serum albumin = 5.3 mg/dL, and weight = 70 kg (BMI 24.2 kg/m²). Whipple's disease should be considered a differential diagnosis in patients with prolonged constitutional and/or gastrointestinal symptoms. Appropriate antibiotic treatment improves the quality of life of patients.

Hepatitis C in hemodialysis: the contribution of injection drug use.

BACKGROUND: Hepatitis C virus (HCV) infection is the most common cause of acute or chronic hepatitis in patients on hemodialysis (HD). The purpose of this study was to describe the prevalence of positive HCV RNA and investigate injection drug use as an emerging risk factor in patients with chronic renal disease on HD. METHODS: This was a multicenter cross-sectional study with 325 patients with chronic renal disease on HD in the period between August 1, 2005 to August 30, 2006, receiving care at four institutions in the city of Porto Alegre, Southern Brazil. Epidemiological data were collected by means of a structured questionnaire. The following laboratory tests were performed: alanine aminotransferase (ALT), anti-hepatitis C virus antibodies (anti-HCV), and qualitative polymerase chain reaction (PCR). RESULTS: Of 325 patients, 68 had positive HCV RNA results. The comparison between patients with positive and negative PCR results revealed significant differences in duration of HD (mean = 71 versus 52.4 months; p = 0.02); previous blood transfusion (92% versus 72%; p < 0.01); injection drug use (13% versus 0.7%; p < 0.01); anti-HCV positivity at start of HD therapy (60% versus 4%; p < 0.01); and mean ALT value (39 versus 26.5; p < 0.01). Logistic regression analysis showed a positive HCV RNA independently associated to being on HD for more than five years [OR: 2.1 (95% CI 1.2 -3.8)]; previous blood transfusion [OR: 3.7 (95% CI 1.4 - 9.5)]; and injection drug use [OR: 22.6 (95% CI 4.2 - 119.6)]. CONCLUSION: Injection drug use was an independent risk factor for HCV infection among chronic renal disease patients on HD.

Hepatitis C in hemodialysis: the contribution of injection drug use

BACKGROUND: Hepatitis C virus (HCV) infection is the most common cause of acute or chronic hepatitis in patients on hemodialysis (HD). The purpose of this study was to describe the prevalence of positive HCV RNA and investigate injection drug use as an emerging risk factor in patients with chronic renal disease on HD. METHODS: This was a multicenter cross-sectional study with 325 patients with chronic renal disease on HD in the period between August 1, 2005 to August 30, 2006, receiving care at four institutions in the city of Porto Alegre, Southern Brazil. Epidemiological data were collected by means of a structured questionnaire. The following laboratory tests were performed: alanine aminotransferase (ALT), anti-hepatitis C virus antibodies (anti-HCV), and qualitative polymerase chain reaction (PCR). RESULTS: Of 325 patients, 68 had positive HCV RNA results. The comparison between patients with positive and negative PCR results revealed significant differences in duration of HD (mean = 71 versus 52.4 months; p = 0.02); previous blood transfusion (92 percent versus 72 percent; p < 0.01); injection drug use (13 percent versus 0.7 percent; p < 0.01); anti-HCV positivity at start of HD therapy (60 percent versus 4 percent; p < 0.01); and mean ALT value (39 versus 26.5; p < 0.01). Logistic regression analysis showed a positive HCV RNA independently associated to being on HD for more than five years [OR: 2.1 (95 percent CI 1.2 -3.8)]; previous blood transfusion [OR: 3.7 (95 percent CI 1.4 - 9.5)]; and injection drug use [OR: 22.6 (95 percent CI 4.2 - 119.6)]. CONCLUSION: Injection drug use was an independent risk factor for HCV infection among chronic renal disease patients on HD.

Análise dos escores de gravidade como preditores na mortalidade em cirróticos hospitalizados / Evaluation of the prognostic scores to predict mortality in hospitalized cirrhotic patient

Introdução: Diversos índices têm sido propostos na avaliação da gravidade da doença hepática. Objetivo: Analisar os escores de Child-Turcote- Pugh (CTP), APACHE II, MELD e SOFA como índices prognósticos de mortalidade hospitalar em pacientes cirróticos. Metodologia: Foram avaliados prospectivamente todos os cirróticos que se internaram em enfermaria provenientes da emergência de um Hosputal Geral de Porto Alegre, em um período de 6 meses. Os escores CTP, MELD, APACHE II e SOFA foram registrados, bem como o desfecho (alta ou óbito). O nível de significância adotado foi de 5%. Resultados: Foram avaliados 61 cirróticos. Quarenta e três eram homens (70%). A média de idade foi de 54,7±11,7 anos. Álcool e/ou o vírus da hepatite C (HCV) foram responsáveis pela etiologia de 50 (82%) casos. Quanto ao CTP, houve 7 (32%) mortes naqueles CTP A ou B, e 11 (38%) naqueles C (p=0,27). A mediana do escore MELD foi de 15, sendo que houve 3 (11%) mortes naqueles com MELD < 15 e 15 (45%) naqueles com MELD ≥15 (p=0,02). A mediana do escore APACHE II foi de 9, sendo que houve 0 morte naqueles com índice < 9 e 18 (41%) naqueles com índice ≥9 (p<00,1). Em relação ao SOFA, a média foi de 3,6±1,8 naqueles vivos versus 5,6±2,6 naqueles que foram a óbito durante a internação (p=0,005). A mortalidade hospitalar foi de 29% (18 casos). Conclusões: Os escores MELD, APACHE II e SOFA se mostraram bons preditores de mortalidade em cirróticos hospitalizados, mas não a classificação de CTP.

Introduction: A number of indexes have historically been proposed to assess the severity of liver disease. Aim: To evaluate the Child-Turcote-Pugh (CTP), APACHE II, MELD and SOFA scores as prognostic indexes of in-hospital mortality among cirrhotic patients. Methods: This is a prospective analysis of all cirrhotic patients who were admitted to a general hospital of Porto Alegre in a period of 6 months. CTP, MELD, APACHE II and SOFA scores were analyzed, as well as the outcome (discharge or death). The level of significance was 5%. Results: A total of 61 cirrhotic patients were evaluated. Forty-three patients were males (70%) and the mean age was 54.7±11.7 years. Alcohol and/or hepatitis C virus (HCV) were the ethiological agents in 50 (82%) cases. Concerning CTP scores, there were 7 (32%) deaths among CTP A or B and 11 (38%) deaths among CTP C (p=0.27). The median for the MELD scores was 15, and there were 3 (11%) deaths among those with MELD < 15 and 15 (45%) deaths among those with MELD ≥15 (p=0.02). The median for the APACHE II scores was 9, and there were no deaths (0) among patients with indexes ≥9 (p<00.1). Concerning the SOFA, the mean was 3.6±1.8 among living patients versus 5.6±2.6 among those who progressed to death during the hospitalization (p=0.005). The overall in-hospital mortality rate was 29% (18 cases). Conclusions: MELD, APACHE II, and SOFA scores proved to be good predictors of mortality of hospitalized cirrhotic patients, but the CTP did not.

Preditores laboratoriais de atividade inflamatória e de fibrose hepática em pacientes com infecção pelo vírus da hepatite C / Laboratorial tests predictive of inflamatory activity and liver fibrosis in patients with hepatitis C virus infection

Objetivos: Avaliar a relação entre parâmetros laboratoriais e o grau de fibrose e atividade inflamatória na biópsia hepática. Metodologia: Estudo transversal de análise de dados laboratoriais e histopatológicos obtidos de forma consecutiva em 210 pacientes com infecção por VHC que foram submetidos à biópsia hepática às cegas. Foram avaliados alanina e aspartato-aminotransferase (ALT e AST), plaquetas, albumina, tempo de protrombina (TP) e o índice APRI (AST/plaquetas). O exame histopatológico foi classificado segundo o escore METAVIR. Para análise estatística, foi adotado um nível de significância de 5%. Resultados: A população foi constituída por 109 (51,9%) homens e 101 mulheres. A média de idade foi de 48,47 ± 1,31 anos. Quanto ao TP, albumina e AST isoladamente, não houve correlação com atividade ou fibrose. Houve correlação negativa entre plaquetas e o grau de fibrose. Utilizando os dados combinados através de índices APRI e ALT/plaquetas, as correlações são mais consistentes e significativas. Ambos os índices apresentaram boa correlação com o grau de fibrose. Conclusões: Dentre os parâmetros bioquímicos avaliados no presente estudo, o índice APRI e a relação ALT/plaquetas apresentaram melhor correlação com o grau de fibrose. Entretanto, não houve marcador que mostrasse uma relação sensibilidade/especificidade adequada para não justificar a realização de biópsia hepática (AU)

Objective: To correlate biochemical parameters with liver biopsy findings regarding fibrosis grade and inflammatory activity. Methods: A cross sectional study was designed to access the association of liver tests and histopathological data of 210 patients with hepatitis C virus. Platelets count, alanine and aspartate-aminotransferases (ALT and AST), albumin, the protrombin time (PT) and the APRI score (AST/platelets) were correlated with histopathological findings classified by METAVIR score. A significance level of 5% was used to test the association between variables. Results: There were 109 (51.9%) men and 101 women. The mean age was 48.47 +/- 1.31 years. PT, albumin and AST showed no correlation with inflammatory activity or fibrosis grade. There was a negative correlation between platelets and the fibrosis grade. This correlation was consistent with APRI score and ALT/platelets index. Both scores presented a good correlation with the fibrosis grade. Conclusions: APRI and ALT/platelets score presented significant correlation with the fibrosis grade. However, none of those tests showed sensitivity and specificity enough to replace liver biopsy (AU)

[Evaluation of the cellular immunity in patients coinfected by the hepatitis C virus and the human immunodeficiency virus]. / Avaliação da imunidade celular nos pacientes Co-Infectados pelo vírus da hepatite C e vírus da imunodeficiência humana.

BACKGROUND: The immune activation provoked by the hepatitis C virus can be deleterious in patients with human immunodeficiency virus, favouring the destruction of CD4 cells. By the other side, the immune restoration observed after the onset of antiretroviral therapy can be partially obscured in patients with the hepatitis C virus. AIM: The objective of the present study was to evaluate the impact of coinfection by hepatitis C virus and the human immunodeficiency virus in the cellular immunity. METHODS: Two groups of patients were considered: coinfected patients were prospectively evaluated in the gastroenterology clinic at "Hospital Nossa Senhora da Conceição", Porto Alegre, RS, Brazil (group 1 - 385 patients), and monoinfected patients by human immunodeficiency virus based on the review of the charts from the infectious diseases clinic (group 2 - 198 patients). Demographic (gender, race, age) CD4 and CD8 cell count, CD4/CD8 index and human immunodeficiency virus viral load were evaluated. A 5% significance level was adopted. RESULTS: There were no difference between the parameters evaluated: mean CD4 count (374,7 +/- 215,7 x 357,5 +/- 266,0), CD8 (1.512,4 +/- 7.274,6 x 986,7 +/- 436,4) and HIV viral load (83.744,2 +/- 190.292,0 x 104.464,0 +/- 486.880,5) respectively in both groups evaluated, as well as the proportion of patients with CD4/CD8 rate below 1. CONCLUSION: Coinfection by both viruses did not have a negative impact in relation to monoinfection by human immunodeficiency virus, and the immune profile was similar in all groups.

Diagnóstico de tumor estromal gastrointestinal – GIST através de enteroscopia com duplo-balão: relato de caso / Diagnosis of gastrointestinal stromal tumor – GIST by double ballon enteroscopy: case report

O diagnóstico de tumores estromais gastrointestinais (GIST) de jejuno é raro, pois eles são, na maioria das vezes, localizados no estômago. Podem cursar de forma assintomática, ser encontrados acidentalmente (massa abdominal durante investigação com tomografia computadorizada) ou como etiologia de sangramento digestivo obscuro. O diagnóstico e tratamento de doenças localizadas no intestino delgado é um desafio à prática médica. Atualmente dispomos de um novo instrumento desenvolvido para este fim, o enteroscópio de duplo-balão (EDB), que está disponível no nosso meio. A indicação mais freqüente deste exame é na investigação de sangramento obscuro, cujos diagnóstico e tratamento podem ser realizados em várias ocasiões. Este artigo relata um caso de sangramento digestivo obscuro cuja etiologia foi GIST de jejuno, diagnosticado por enteroscopia utilizando o EDB

Gastrointestinal stromal tumors (GIST) of small bowel are infrequent and diagnosis could be troublesome. The majority of these uncommon tumors are located in stomach. GIST might be asymptomatic but usually present with non-specific gastrointestinal symptoms such as abdominal mass, pain, bleeding, anorexia and bowel obstruction. Double Balloon Enteroscopy is an endoscopic technique for visualization of the small bowel. It allows for visualization of the entire small bowel, for the application of therapeutics, for the sampling or biopsying of small bowel mucosa and for the resection of polyps of the small bowel. This article relates a GIST case of jejunum in which the Double Balloon Enteroscopy is the technique used to diagnose this disease by investigation of obscure gastrointestinal bleeding

Esophageal ulcers caused by reactivation of ganglionary tuberculosis: a case report.

The involvement of the esophagus in tuberculosis (TB) is extremely rare. This is a case report of an immunocompetent male patient, who presented ganglionary TB reactivation, with the development of extensive esophageal ulcers. The endoscopic approach made the diagnosis possible and there was a total resolution of the symptoms after the treatment.

[Spontaneous bacterial peritonitis: impact of microbiological changes]. / Peritonite bacteriana espontânea: impacto das mudanças da microbiologia.

BACKGROUND: Spontaneous bacterial peritonitis is a serious complication in cirrhotic patients, and the changes in the microbiological characteristics reported in the last years are impacting the choice of antibiotic used in the treatment. AIM: To evaluate the change in the epidemiology and antibiotic resistance of the bacteria causing spontaneous bacterial peritonitis in a 7 years period. METHODS: All the cases of cirrhotic patients with spontaneous bacterial peritonitis with positive cultural examination were retrospectively studied. Two periods were evaluated: 1997-1998 and 2002-2003. The most frequent infecting organisms and the sensitivity in vitro to antibiotics were registered. RESULTS: In the first period (1997-1998) there were 33 cases, 3 (9%) with polymicrobial infection. The most common were: E.coli in 13 (36,11%), Staphylococcus coagulase-negative in 6 (16,66%), K. pneumoniae in 5 (13,88%), S. aureus in 4 (11,11%) and S. faecalis in 3 (8,33%). In 2003-2004, there were 43 cases, 2 (5%) with polymicrobial infection. The most frequent were: Staphylococus coagulase-negative in 16 (35,55%), S. aureus in 8 (17,77%), E. coli in 7 (15,55%) and K. pneumoniae in 3 (6,66%). No one was using antibiotic prophilaxys. The prevalence of S. aureus methicillin-resitant to quinolone and trimethoprim-sulfamethoxazole changed from 25% to 50%, and vancomicin was the only one with absolute activity during all the period. In the same way, the prevalence of E. coli resistant to third generation cephalosporin and to quinolone changed from 0% to 16%. CONCLUSION: There was a modification of the bacterial population causing spontaneous bacterial peritonitis, with high frequency of gram-positive organisms, as well as an increase in the resistance to the traditionally recommended antibiotics. This study suggests a probable imminent inclusion of a drug against gram-positive organisms in the empiric treatment of spontaneous bacterial peritonitis.

Avaliação da imunidade celular nos pacientes Co-Infectados pelo vírus da hepatite C e vírus da imunodeficiência humana / Evaluation of the cellular immunity in patients coinfected by the hepatitis C virus and the human immunodeficiency virus

RACIONAL: O estado de ativação imune provocado pelo vírus da hepatite C pode agir deleteriamente em indivíduos portadores do vírus da imunodeficiência humana, favorecendo a destruição mais rápida dos linfócitos CD4. Por outro lado, a recuperação imune observada após o início da terapia antiretroviral pode ser parcialmente embotada em indivíduos co-infectados pelo vírus da hepatite C. OBJETIVO: Avaliar o impacto da co-infecção pelo vírus da hepatite C na imunidade celular dos pacientes infectados pelo vírus da imunodeficiência humana. MÉTODOS: Foram avaliados pacientes co-infectados por ambos os vírus, atendidos prospectivamente no Ambulatório de Gastroenterologia do Hospital Nossa Senhora da Conceição, Porto Alegre, RS (grupo 1 - 385 pacientes), e monoinfectados pelo vírus da imunodeficiência humana cujos dados foram obtidos através da revisão dos prontuários do Serviço de Infectologia do mesmo Hospital (grupo 2 - 198 pacientes). Foram avaliados dados demográficos (gênero, raça, idade), contagem de células CD4 e CD8, relação CD4/CD8 e carga viral do vírus da imunodeficiência humana. O nível de significância adotado foi de 5 por cento. RESULTADOS: Não houve diferença estatisticamente significativa quando avaliados os valores médios da contagem de células CD4 (374,7 ± 215,7 x 357,5 ± 266,0), CD8 (1.512,4 ± 7.274,6 x 986,7 ± 436,4) e da carga viral do vírus da imunodeficiência humana (83.744,2 ± 190.292,0 x 104.464,0 ± 486.880,5), respectivamente nos grupos 1 e 2, bem como na proporção de pacientes com relação CD4/CD8 menor que 1. CONCLUSÃO: A co-infecção por estes vírus não trouxe impacto negativo relevante em relação aos monoinfectados pelo vírus da imunodeficiência humana e as características de imunidade foram semelhantes.

BACKGROUND: The immune activation provoked by the hepatitis C virus can be deleterious in patients with human immunodeficiency virus, favouring the destruction of CD4 cells. By the other side, the immune restoration observed after the onset of antiretroviral therapy can be partially obscured in patients with the hepatitis C virus. AIM: The objective of the present study was to evaluate the impact of coinfection by hepatitis C virus and the human immunodeficiency virus in the cellular immunity. METHODS: Two groups of patients were considered: coinfected patients were prospectively evaluated in the gastroenterology clinic at "Hospital Nossa Senhora da Conceição", Porto Alegre, RS, Brazil (group 1 - 385 patients), and monoinfected patients by human immunodeficiency virus based on the review of the charts from the infectious diseases clinic (group 2 - 198 patients). Demographic (gender, race, age) CD4 and CD8 cell count, CD4/CD8 index and human immunodeficiency virus viral load were evaluated. A 5 percent significance level was adopted. RESULTS: There were no difference between the parameters evaluated: mean CD4 count (374,7 ± 215,7 x 357,5 ± 266,0), CD8 (1.512,4 ± 7.274,6 x 986,7 ± 436,4) and HIV viral load (83.744,2 ± 190.292,0 x 104.464,0 ± 486.880,5) respectively in both groups evaluated, as well as the proportion of patients with CD4/CD8 rate below 1. CONCLUSION: Coinfection by both viruses did not have a negative impact in relation to monoinfection by human immunodeficiency virus, and the immune profile was similar in all groups.

Esophageal ulcers caused by reactivation of ganglionary tuberculosis: a case report

The involvement of the esophagus in tuberculosis (TB) is extremely rare. This is a case report of an immunocompetent male patient, who presented ganglionary TB reactivation, with the development of extensive esophageal ulcers. The endoscopic approach made the diagnosis possible and there was a total resolution of the symptoms after the treatment.

Peritonite bacteriana espontânea: impacto das mudanças da microbiologia / Spontaneous bacterial peritonitis: impact of microbiological changes

RACIONAL: A peritonite bacteriana espontânea é uma complicação grave nos pacientes cirróticos com ascite, sendo as alterações das características microbiológicas relatadas nos últimos anos de impacto na escolha do tratamento antibiótico. OBJETIVO: Avaliar as mudanças na epidemiologia e na resistência antibiótica de bactérias causadoras de peritonite bacteriana espontânea em um período de 7 anos. MÉTODOS: Foram avaliados retrospectivamente todos os casos de pacientes cirróticos com peritonite bacteriana espontânea cuja cultura do líquido de ascite foi positiva, sendo estudados dois períodos: 1997-1998 e 2002-2003. Foram verificados os microorganismos mais freqüentes e a sensibilidade in vitro aos antibióticos. RESULTADOS: No primeiro período (1997-1998) houve 33 casos, sendo 3 (9 por cento) com infecção polimicrobiana. As bactérias mais freqüentes foram: E. coli em 13 (36,11 por cento), estafilococos coagulase-negativos em 6 (16,66 por cento), K. pneumoniae em 5 (13,88 por cento), S. aureus em 4 (11,11 por cento) e S. faecalis em 3 (8,33 por cento). Em 2002-2003, houve 43 casos, sendo 2 (5 por cento) com infecção polimicrobiana. As bactérias mais freqüentes foram: estafilococos coagulase-negativos em 16 (35,55 por cento) S. aureus em 8 (17,77 por cento), E. coli em 7 (15,55 por cento) e K. pneumoniae em 3 (6,66 por cento). Nenhum paciente realizava profilaxia para peritonite bacteriana espontânea. A prevalência de S. aureus meticilino-resistentes aumentou, no decorrer desse período, de 25 por cento para 75 por cento, tendo a resistência desse patógeno às quinolonas e a sulfametoxazol-trimetoprim evoluído de 25 por cento para 50 por cento; somente a vancomicina demonstrou atividade absoluta no decorrer do referido período. Da mesma forma, a prevalência de E. coli resistente às cefalosporinas de terceira geração e às quinolonas aumentou de 0 por cento para 16 por cento. CONCLUSÃO: Houve modificação da população bacteriana causadora de peritonite...

BACKGROUND: Spontaneous bacterial peritonitis is a serious complication in cirrhotic patients, and the changes in the microbiological characteristics reported in the last years are impacting the choice of antibiotic used in the treatment. AIM: To evaluate the change in the epidemiology and antibiotic resistance of the bacteria causing spontaneous bacterial peritonitis in a 7 years period. METHODS: All the cases of cirrhotic patients with spontaneous bacterial peritonitis with positive cultural examination were retrospectively studied. Two periods were evaluated: 1997-1998 and 2002-2003. The most frequent infecting organisms and the sensitivity in vitro to antibiotics were registered. RESULTS: In the first period (1997-1998) there were 33 cases, 3 (9 percent) with polymicrobial infection. The most common were: E.coli in 13 (36,11 percent), Staphylococcus coagulase-negative in 6 (16,66 percent), K. pneumoniae in 5 (13,88 percent), S. aureus in 4 (11,11 percent) and S. faecalis in 3 (8,33 percent). In 2003-2004, there were 43 cases, 2 (5 percent) with polymicrobial infection. The most frequent were: Staphylococus coagulase-negative in 16 (35,55 percent), S. aureus in 8 (17,77 percent), E. coli in 7 (15,55 percent) and K. pneumoniae in 3 (6,66 percent). No one was using antibiotic prophilaxys. The prevalence of S. aureus methicillin-resitant to quinolone and trimethoprim-sulfamethoxazole changed from 25 percent to 50 percent, and vancomicin was the only one with absolute activity during all the period. In the same way, the prevalence of E. coli resistant to third generation cephalosporin and to quinolone changed from 0 percent to 16 percent. CONCLUSION: There was a modification of the bacterial population causing spontaneous bacterial peritonitis, with high frequency of gram-positive organisms, as well as an increase in the resistance to the traditionally recommended antibiotics. This study suggests a probable imminent inclusion of a drug...

Impact of human immunodeficiency virus infection in patients infected with the hepatitis C virus.

BACKGROUND/AIMS: The objective of the present study is to evaluate the impact of human immunodeficiency virus (HIV) in patients with hepatitis C virus (HCV) infection. METHODS: Three different groups of patients were considered: group 1, 385 HCV/HIV coinfected; group 2, 198 HIV monoinfected; and group 3, 311 HCV monoinfected. Demographic and epidemiological data were collected. Blood tests included anti-HCV, HCV-RNA test, genotyping, CD4 cell count, anti-HIV, and HIV viral load. Treatment with interferon and ribavirin was proposed. The fibrosis progression rate was assessed. RESULTS: The most prevalent risk factor in the group of coinfected was the use of intravenous drugs; in the HIV monoinfection group, heterosexual relations at risk; in the HCV monoinfection group, the transfusion of blood. There was no difference concerning the distribution of genotypes or HCV viral load between groups 1 and 3. Although the mean time of duration of HCV infection was greater in group 3 than in group 1, there was no difference when the fibrosis progression rate was evaluated. The response to treatment was similar. CONCLUSION: In the present series there was no relevant impact of HCV infection in patients with HIV.

Prevalence of hepatitis C virus in alcoholic patients: role of parenteral risk factors.

BACKGROUND: The prevalence of hepatitis C virus (HCV) infection is elevated in alcoholic patients, but the risk factors are unclear. The role of parenteral risk factors are indeterminated in this population. AIMS: To determine the prevalence of hepatitis C virus infection in alcoholic patients admitted to a detoxification unit and to evaluate the presence of underlying parenteral risk factors. METHODS: A total of 114 consecutive unselected alcoholic patients admitted to a single chemical dependency unit during 14 month were included. Epidemiological data and history of parenteral risk factors for hepatitis C virus infection were obtained with a standardized questionnaire. Blood was collected for determination of aminotransferases and anti-hepatitis C virus antibodies (ELISA-3). Positive samples were confirmed by polymerase chain reaction and tested for genotype. RESULTS: Among the 114 alcoholics, 17 (15%) were anti-hepatitis C virus positive. Of these, 12 (71%) had detectable serum HCV-RNA by PCR. Genotype 1 was found in six cases and genotype 3 in five (one patient was undetermined). Forty-nine (43%) patients had elevated serum ALT and/or AST at baseline. The comparison between the 17 positive and the 97 negative patients showed significant differences in mean serum ALT levels (42 +/- 41 IU/L vs. 22 +/- 20 IU/L), rate of elevated ALT (65% vs. 34%), and presence of parenteral risk factors (94% vs. 10%). Comparison between alcoholic patients with and without elevated aminotransferases showed significant difference only in the rate of positive anti-hepatitis C virus antibodies (24% vs. 7%). Furthermore, among the 17 anti-hepatitis C virus positive patients, the rate of detectable HCV-RNA was significantly higher in the 12 with elevated aminotransferases versus the 5 with normal aminotransferases (92% vs. 20%). CONCLUSIONS: There was a high prevalence of anti-hepatitis C virus antibodies in alcoholics and the majority was confirmed by the presence of detectable HCV-RNA. Intravenous drug use was the main risk factor for hepatitis C virus infection in this population.

Prevalence of hepatitis C virus in alcoholic patients: role of parenteral risk factors / Prevalência do vírus da hepatite C em alcoolistas: a atuação dos fatores de risco parenterais

BACKGROUND: The prevalence of hepatitis C virus (HCV) infection is elevated in alcoholic patients, but the risk factors are unclear. The role of parenteral risk factors are indeterminated in this population. AIMS: To determine the prevalence of hepatitis C virus infection in alcoholic patients admitted to a detoxification unit and to evaluate the presence of underlying parenteral risk factors. METHODS: A total of 114 consecutive unselected alcoholic patients admitted to a single chemical dependency unit during 14 month were included. Epidemiological data and history of parenteral risk factors for hepatitis C virus infection were obtained with a standardized questionnaire. Blood was collected for determination of aminotransferases and anti-hepatitis C virus antibodies (ELISA-3). Positive samples were confirmed by polymerase chain reaction and tested for genotype. RESULTS: Among the 114 alcoholics, 17 (15 percent) were anti-hepatitis C virus positive. Of these, 12 (71 percent) had detectable serum HCV-RNA by PCR. Genotype 1 was found in six cases and genotype 3 in five (one patient was undetermined). Forty-nine (43 percent) patients had elevated serum ALT and/or AST at baseline. The comparison between the 17 positive and the 97 negative patients showed significant differences in mean serum ALT levels (42 ± 41 IU/L vs. 22 ± 20 IU/L), rate of elevated ALT (65 percent vs. 34 percent), and presence of parenteral risk factors (94 percent vs. 10 percent). Comparison between alcoholic patients with and without elevated aminotransferases showed significant difference only in the rate of positive anti-hepatitis C virus antibodies (24 percent vs. 7 percent). Furthermore, among the 17 anti-hepatitis C virus positive patients, the rate of detectable HCV-RNA was significantly higher in the 12 with elevated aminotransferases versus the 5 with normal aminotransferases (92 percent vs. 20 percent). CONCLUSIONS: There was a high prevalence of anti-hepatitis C virus antibodies in alcoholics and the majority was confirmed by the presence of detectable HCV-RNA. Intravenous drug use was the main risk factor for hepatitis C virus infection in this population.

RACIONAL: A prevalência da infecção pelo vírus da hepatite C (VHC) é elevada em pacientes alcoolistas, porém os fatores de risco não estão bem estabelecidos. O papel dos fatores de risco parenterais permanece ainda indefinido nessa população. OBJETIVOS: Determinar a prevalência da infecção pelo VHC em alcoolistas internados em uma unidade de desintoxicação, e avaliar a presença de fatores de risco parenteral subjacentes. PACIENTES E MÉTODOS: Foram estudados 114 alcoolistas, não selecionados, consecutivamente admitidos em uma unidade de dependência química durante 14 meses. Através de questionário estruturado, obtiveram-se os dados epidemiológicos e história de fatores de risco parenteral para infecção pelo VHC. Foi coletado sangue para determinação de aminotransferases e anticorpos anti-VHC (ELISA-3). As amostras positivas foram confirmadas pela PCR e determinado o genótipo. RESULTADOS: Entre os 114 alcoolistas, 17 (15 por cento) eram anti-VHC positivos. Doze (71 por cento) tinham RNA do VHC detectável por PCR no soro. O genótipo 1 foi encontrado em seis casos e o genótipo 3 em cinco (em um paciente foi indeterminado). Quarenta e quatro (43 por cento) pacientes tinham ALT e/ou AST elevadas. A comparação entre os 17 pacientes positivos e os 97 negativos mostrou diferenças significativas na média do nível da ALT (42 ± 41 UI/L vs. 22 ± 20 UI/L), na taxa de ALT elevada (65 por cento vs. 34 por cento), e na presença de fatores de risco parenteral (94 por cento vs. 10 por cento). A comparação entre alcoolistas com e sem aminotransferases elevadas mostrou diferença significativa apenas na taxa de anti-VHC positivo (24 por cento vs. 7 por cento). Entretanto, entre os 17 pacientes anti-VHC positivos, a taxa de RNA do VHC detectável no soro foi significativamente maior entre os 12 com aminotransferases elevadas do que entre os 5 com aminotransferases normais (92 por cento vs. 20 por cento). CONCLUSÃO: A prevalência de anti-VHC foi elevada em alcoolistas, sendo a maioria confirmada pela presença do RNA do VHC no soro. O uso de drogas injetáveis foi o principal fator de risco para infecção pelo VHC nesta população.

Sarcoidose induzida por tratamento com interferon peguilado para hepatite C crônica: relato de caso / Sarcoidosis induced by a pegylated interferon treatment for chronic C hepatitis: a case report

O interferon (IFN), utilizado no tratamento da hepatite C crônica, produz vários efeitos adversos, dentre os quais a indução e/ ou agravamento de sarcoidose - doença multissistêmica, de etiologia desconhecida e patogênese supostamente relacionada à liberaçãp de mediadores inflamatórios. Relata-se o caso de paciente feminina, 44 anos, portadora de hepatite C crônica , genótipo 1, que fez uso de interferon peguilado (Peg-IFN) e ribavirina. A partir do quinto mês de tratamento, apresentou dispnéia progressiva, emagrecimento e sudorese noturna. Ao exame físico, observava-se lesão papular eritematosa em joelho direito. Tomografia de tórax evidenciou importante infiltrado intersticial em vidro fosco em metades superiores dos campos pulmonares, com presença de micronódulos pulmonares e pleurais, espessamento pleural, dilatação brônquica difusa e adenomegalias mediastinais. A biópsia pulmonar apresentou granulomas confluentes, sem necrose com fibrose circunjacente em parênquima pulmonar periférico, sugestiva de sarcoidose, à semelhança do encontrado na biópsia de pele. Conclusão: Apesar de ter sido relatado em poucos casos na literatura, a sarcoidose deve ser lembrada em casos de terapia antiviral com IFN ou Peg-INF, quando ocorrerem manifestações pulmonares e adenopatias

Tuberculose peritoneal: análise de 12 casos / Peritoneal tuberculosis: analysis of 12 cases

A tuberculose peritoneal é uma situação rara com alta morbidade e mortalidade, sendo que o prognóstico depende do diagnóstico e tratamento precoces. Nos últimos anos tem havido aumento de incidência nos países desenvolvidos, principalmente em pacientes imunocomprometidos. Foram analisados retrospectivamente 12 pacientes com tuberculose peritoneal (7 homens, média de idade: 51 anos). As manifestações clínicas, comorbidades e métodos diagnósticos foram revisados. Ascite foi a manifestação mais prevalente. Tuberculose pulmonar associada estava presente em apenas 25% dos pacientes. A biópsia de peritônio foi diagnóstica em todos os casos. Deve haver alto grau de suspeita para estabelecer o diagnóstico de TBC peritoneal (AU)

Peritoneal tuberculosis is a rare condition with high morbidity and mortality, and the prognosis depends of the early diagnosis and treatment. The incidence has been growing in the last years in developed countries, mainly in immunocompromised patients. Twelve patients with peritoneal tuberculosis were retrospectively studied (7 men, mean age 51 years). Data concerning to clinical manifestations, comorbidities and diagnostic methods were obtained. Ascites was the great manifestation. Pulmonar tuberculosis was associated in 25% of patients. Peritoneal biopsy was diagnostic in all patients. To make the diagnosis of peritoneal tuberculosis a high grade of suspicion is necessary (AU)