Multi-organ failure with atypical liver granulomas following intravesical Bacillus Calmette-Guerin instillation.

Bacillus Calmette-Guerin (BCG) intravesical instillation has been adopted in the treatment of patients with superficial bladder cancer. BCG-induced disseminated infection, though rare, has been associated with the histological finding of epithelioid granulomas in different organs, including the liver. We report the case of an adult patient with multi-organ failure, who developed sepsis, acute respiratory failure and acute hepatic failure with encephalopathy whose liver biopsy confirmed the presence of atypical, granulomatous-like lesions. Recovery was observed only after empirical therapy for Mycobacterium bovis with isoniazid, rifampicin, ethambutol and steroids was introduced. This case highlights the importance of a thorough patient assessment in order to exclude other more common causes of hepatic granulomas and to confirm diagnosis. Histological findings may be non-specific when the liver is involved in BCG-induced disseminated infection.

Nitric oxide, ammonia, and CRP levels in cirrhotic patients with hepatic encephalopathy: is there a connection?

GOALS: Comparison of nitric oxide (NO) levels in cirrhotic patients with and without hepatic encephalopathy (HE), evaluation of possible correlation between HE and other clinical or laboratory characteristics, and estimation of utilization of NO levels in clinical practice. BACKGROUND: HE is a neuropsychiatric complication of cirrhosis. The exact pathogenetic mechanisms underlying the presence of HE are not known. However, dysfunction of the NO pathway and ammonia detoxification are thought to play a major role. STUDY: Sixty-seven cirrhotic patients, 36 (53.7%) without HE, and 31 (46.3%) with HE were included in the study. Eighteen healthy individuals were used as control group. Clinical and laboratory data, including ammonia and stable end products of NO using Griess reaction, were collected. RESULTS: NOx levels were statistically significantly higher in cirrhotic patients (225.5 µmol/L) than in control group [(67.94 µmol/L) (P=0.000)]. NOx levels were, also, statistically significantly higher in patients with HE compared with patients without HE (324.67 µmol/L vs. 141.96 µmol/L, P=0.000). Significant correlation between the presence of HE and NOx, ammonia, C-reactive protein, albumin, Model for End-Stage Liver Disease score, and Child-Pugh classification revealed. NOx levels also correlated with severity of HE. NOx and ammonia are independent factors predicting HE according to regression analysis. Diagnostic accuracy for the diagnosis of HE using a combination of NOx and ammonia was superior compared with standalone NOx or ammonia utilization. CONCLUSIONS: NOx levels are correlated with the presence and severity of HE. NOx levels determination, in addition to ammonia levels, could contribute in diagnosis of HE.

Hepatic involvement in Wegener's granulomatosis: a case report.

INTRODUCTION: We report the case of a 58-year-old Caucasian Greek man who presented with dry cough, fever, bilateral alveolar infiltrates and acute hepatitis. CASE PRESENTATION: After a lung biopsy, the patient was diagnosed with Wegener's granulomatosis. The diagnosis was supported by the presence of anti-proteinase-3 anti-neutrophil cytoplasmic antibodies. A liver biopsy demonstrated the presence of mild non-specific lobular hepatitis and periodic acid-Schiff positive Lafora-like inclusions in a large number of his liver cells. The patient was treated with prednisone and cyclophosphamide, which was followed by subsequent remissions of chest X-ray findings and liver function studies. CONCLUSION: What makes this case worth reporting is the coexistence of liver inflammation with a biochemical profile of severe anicteric non-viral, non-drug induced hepatitis coinciding with the diagnosis of Wegener's granulomatosis. Our paper may be the first report of hepatic involvement in a patient diagnosed with Wegener's granulomatosis. The aetiological link between the two diseases is supported by the reversion of hepatitis after the immunosuppression of Wegener's granulomatosis. We favor the hypothesis that hepatic vasculitis may be the cause of acute hepatocellular necrosis.

Brain natriuretic peptide plasma levels as a marker of prognosis in patients with community-acquired infection.

The aim of this study was to determine the role of the N-terminal prohormone form of BNP (NT-proBNP) in patients with acute community-acquired infection as a predictive marker and its correlation with the type of infection. We studied 42 patients with acute community-acquired infection. Levels of NT-proBNP were measured in all patients at hospital admission and on the third day, as well as in a control group of 84 healthy blood donors. NT-proBNP levels were markedly elevated in patients, 5897 versus 108 pg/ml in the control group (P=0.01) A positive association between the NT-proBNP levels and the final outcome of infection (P<0.0001) was found. Multivariate regression analysis identified NT-proBNP levels as the most important predictor of unfavorable outcome (P=0.017). Patients with lower respiratory tract infection had the maximum increase in NT-proBNP levels (P<0.048) and the most unfavorable outcome (P<0.03) regarding other sites of infection.

Brain natriuretic peptide increases in septic patients without severe sepsis or shock.

BACKGROUND: B-type natriuretic peptide (BNP) production increases in critically ill septic patients. We assessed the hypothesis that BNP is elevated in patients with community-acquired infections without severe sepsis or septic shock. METHODS: We studied 54 patients [20 males, median age 39 (interquartile range 23, 71)] without heart disease, persistent arrhythmias, or renal failure. BNP was measured in all patients at hospital admission and at pre-discharge and in a control group of 52 individuals. Myoglobin levels were also measured in septic patients. RESULTS: The infection was microbial in 40 patients, viral in 11, and of undefined etiology in 3. A systemic inflammatory response was evident in 38 patients on the initial evaluation. BNP on admission was higher in patients than in controls [25 (10, 82) pg/ml vs. 13 (5, 30) pg/ml, p=0.01] and it decreased to 16 (5, 47) pg/ml pre-discharge (p=0.0002). Multiple logistic regression identified the presence of microbial infection as the only independent predictor of an elevated BNP value on admission [adjusted odds ratio 9.8 (1.02-93.8), p=0.04]. In patients with microbial infection, location of infection in the lower respiratory tract and the presence of diabetes mellitus were independent predictors of the magnitude of BNP increase. Myoglobin was also increased on hospital admission 80 (37, 231) ng/ml and decreased pre-discharge to 59 (38, 94) ng/ml, p=0.004. Myoglobin level changes from admission to discharge were more prominent with increasing age and in females. CONCLUSION: BNP levels are elevated in the acute phase of community-acquired microbial infections without severe sepsis or septic shock.

Prevalence of hepatitis B and C markers among refugees in Athens.

AIM: To assess the prevalence of hepatitis B and C serological markers in a population of refugees living in Athens. METHODS: One hundred and thirty refugees (81 males and 49 females, mean age +/-SD: 31.7+/-8 years) were included in the study. The hepatitis B virus surface antigen (HBsAg), the hepatitis B virus core antibody (anti-HBc) and the hepatitis C virus antibody (anti-HCV) were detected using a third-generation immunoassay. RESULTS: Twenty individuals (15.4 %) were HBsAg positive and 69 (53.1 %) were anti-HBc positive. The prevalence of HBsAg and anti-HBc was higher among refugees from Albania and Asia (statistical significant difference, P<0.008 and P<0.001 respectively). The prevalence of these markers was found irrelevant to age or sex. Anti-HCV was detected in the serum of 3 individuals (2.3 %). No differences among age, sex or ethnicity regarding anti-HCV prevalence were found. CONCLUSION: It can be concluded that refugees living in Athens are an immigrant population characterized by a high incidence of HBV infection. The prevalence of HBV markers is higher among refugees from Albania and Asia. It is therefore believed that the adherence to general precautions and the initiation of HBV vaccination programs will be necessary in the future, especially in these communities. Although the prevalence of HCV infection seems to be relatively low, extended epidemiological surveys are needed to provide valid results.

Helicobacter pylori infection in diabetic patients: prevalence and endoscopic findings.

BACKGROUND: In patients with diabetes mellitus, chronic infections are frequent and severe, due to the impairment of their immune status. However, data on the prevalence of Helicobacter pylori (H. pylori) infection in diabetics are scanty and contradictory. The aim of our study was to assess the prevalence of H. pylori infection in diabetic patients and to evaluate the association between endoscopic features and H. pylori colonization of the gastric mucosa in diabetes mellitus. METHODS: A cross-sectional study of 172 dyspeptic patients (67 diabetics and 105 nondiabetic subjects) was designed. In all cases, an upper gastrointestinal endoscopy was performed, gastroduodenal lesions were noted, and the presence of gastritis and H. pylori was assessed by histopathological examination. Differences between diabetic patients and nondiabetic subjects were evaluated. RESULTS: The difference of H. pylori prevalence between diabetics (37.3%) and nondiabetics (35.2%) was not significant (P=0.78). Nor did the prevalence of gastritis and peptic ulcer differ significantly between the two groups (59.7% vs. 49.5%, P=0.19; and 32.8% vs. 40.9%, P=0.08, respectively). Studying only H. pylori-positive patients, we found no difference between diabetics and nondiabetics with regard to the prevalence of either gastritis (80% vs. 72.9%, P=0.71) or peptic ulcer (91.8% vs. 76%, P=0.09). CONCLUSIONS: Our data do not support an association between H. pylori infection and diabetes mellitus. This is confirmed by the lack of difference between diabetics and nondiabetics with regard to the prevalence of both H. pylori infection and H. pylori-related gastroduodenal disorders.