Gingival lesions and nasal obstruction in an immunosuppressed patient post-liver transplantation.

Although rare, metastatic hepatocellular carcinoma (HCC) presenting only to the mandible, gingiva, and nasal cavity in patients subsequently found to have primary HCC has been reported. In the age of transplantation, certain HCC patients may receive treatment with an orthotopic liver transplant. Due to the proclivity of HCC for early micrometastases, immunosuppressive therapy can induce significant metastatic lesions. Nasal mass obstruction, gingival lesions, or facial growths in this population must be considered metastatic until proven otherwise.

Combination therapy with thymosin alpha1 and interferon for the treatment of chronic hepatitis C infection: a randomized, placebo-controlled double-blind trial.

Hepatitis C is a major cause of liver disease leading to cirrhosis. Although interferon (IFN) is the only approved therapy, treatment is characterized by low response rates and dose-limiting side effects. We evaluated the addition of thymosin alpha1 (TA1), an immunomodulatory peptide, to the standard treatment regimen for hepatitis C to determine if combination therapy shows biological activity using outcome measures including normalization of alanine aminotransferase levels, histological activity, and viral load during treatment. We performed a randomized, double-blind, placebo-controlled trial to compare the biological activity of a combination TA1 and IFN with that seen for IFN alone in patients with chronic hepatitis C infection. One hundred nine patients were randomized for intention to treat and received 1.6 mg of TA1 subcutaneously twice weekly and 3 MU of IFN three times weekly; 3 MU of IFN three times weekly and placebo TA1; or placebo for both agents. All patients had chronic HCV infection with confirmation of chronic hepatitis on liver biopsy. Biochemical responders were followed up until alanine aminotransferase (ALT) levels became abnormal or for 26 weeks, and relapsers were retreated for 26 weeks in the same treatment arm. One hundred three patients completed treatment for 26 weeks, and six patients dropped out. The groups were similar with regard to sex, gender distribution, baseline histological activity index (HAI) score, risk factors, and viral titers. End-of-treatment biochemical response was seen in 37.1% of patients treated with combination therapy, 16.2% of patients treated with IFN alone, and 2.7% of untreated controls by intent-to-treat analysis (IFN/TA1 vs. IFN, chi2 = 4.05, P = .04). HCV RNA clearance was seen in 37.1% of IFN/TA1-treated patients and 18.9% of IFN-treated subjects. Mean HCV RNA titers were significantly lower than baseline at weeks 8, 16, and 24 after drug initiation among patients treated with IFN/TA1 but not in the other treatment arms. Histological improvement, as evidenced by a decrease in HAI of more than two points, occurred in the combination therapy arm more frequently than in comparison groups. Cumulative sustained biochemical responses were 14.2% and 8.1% in the IFN/TA1 and IFN arms, respectively, based on an intention-to-treat model. The combination of TA1 and standard IFN treatment for chronic hepatitis C showed evidence of biological activity at the completion of treatment by biochemical, histological, and virological outcome measures. Further research involving longer duration and varied dosing is needed.

Talc in the liver of patients with chronic hepatitis C infection.

OBJECTIVES: The presence of talc crystals in the liver has been associated with prior history of i.v. drug abuse (IVDA). Patients with hepatitis C virus (HCV) infection often deny IVDA, and many patients have no other identifiable risk factors. To evaluate the role of prior surreptitous IVDA in patients with chronic HCV infection and to assess the role of talc identification in liver tissue, an epidemiological evaluation was performed. METHODS: One hundred and nine patients with chronic HCV (ALT abnormal > 6 months, HCV ELISA and recombinant immunoblot assay positive) underwent careful evaluation for risk factors potentially associated with HCV infection. All patients then had liver biopsy. Liver biopsies were reviewed by two observers to determine histological stage and were then examined by polarized light microscopy to reveal the presence or absence of typical talc crystals. Patients with discordance between history and histological findings were re-interviewed and were confronted with the information. RESULTS: Patient interviews revealed the following risk factors: IVDA, 17.1%; blood transfusion, 24.3%; possible household/occupational exposure, 14.4%; and tattoos, 15.3%. No identifiable risk factors were noted in 28.8% of the cohort. Talc crystals were seen in 9/109 (8.3%) of liver specimens. Of this group, only two patients admitted to prior history of IVDA. Seventeen patients with an IVDA history did not have identifiable talc crystals. Follow-up phone interviews were possible with five out of seven patients with liver talc who had previously denied IVDA history. Of the five patients, three admitted to prior IVDA but only after being confronted with the liver biopsy evidence. CONCLUSIONS: The findings of talc crystals in liver biopsy specimens appears to be a specific, but not a sensitive, marker for prior IVDA. Identification of talc crystals from liver tissue may contribute to categorization of risk factors in patients with community-acquired HCV infection. Tattoos are an important, and frequently unrecognized, risk factor for HCV infection. Despite these findings, a significant proportion of patients still have no identifiable risk factor for HCV acquisition.

Evaluation of the throat culture as a follow-up for an initially negative enzyme immunosorbent assay rapid streptococcal antigen detection test.

In a study of the efficacy of following up an initially negative enzyme immunosorbent assay (EIA) rapid streptococcal antigen detection test with a throat culture, 2 double swabs (4 total) were obtained from 264 pediatric patients with sore throats. Although a throat culture was more specific (97%) than the EIA (89%), the sensitivity (87%) and negative predictive value (97%) of a single EIA was the same as that of a single throat culture. A follow-up throat culture was more accurate than a follow-up EIA. We conclude that the office EIA tested results in more false positives but misses no more true positives than a single throat culture processed by a well-controlled microbiology laboratory. If a follow-up technique is used for an initially negative EIA rapid streptococcal antigen detection test, the throat culture is the superior test and would be equally applicable following an initially negative throat culture or EIA.