[Serum globulin levels and intensity of hepatic fibrosis in patients with mansonic schistosomiasis]. / Níveis séricos de globulinas e a intensidade da fibrose hepática em pacientes com esquistossomose mansônica.

BACKGROUND: A correlation between the levels of serum globulins and the hepatic fibrosis degree in chronic hepatitis was described, but reports in schistosomiasis mansoni have not been found. OBJECTIVE: To evaluate the serum globulins and IgG levels, and periportal fibrosis intensity measured by ultrasound in patients with schistosomiasis mansoni. METHODS: Between November, 2006 and February 2007, 41 patients which were eligible, filled them a questionnaire and had their levels of serum IgG measured by immunoturbidimetry and globulins indirectly measured by the Biuret method. The ultrasound was carried out by a single researcher, according to the Cairo and Niamey protocols. RESULTS: The average age was 41 years old and 25 female patients (61%). Ten patients (24%) from 41 showed serum globulins levels raised and 21 (51%) presented elevated IgG levels. According to the Cairo classification, 21 patients showed grade I of fibrosis, 18 grade II and 2 grade III; and by the Niamey classification 8 showed standard C, 20 D, and 13 E. Those with grade II or III of fibrosis had higher IgG levels than the ones with grade I (P = 0.047), as well as those who showed standards D and E as compared to C (P = 0.011). There was no association between the globulins levels and the intensity of fibrosis. CONCLUSION: In patients with schistosomiasis mansoni, an increase of the IgG serum levels was observed according to the progression from periportal fibrosis intensity, but the same was not founded with globulins levels.

Níveis séricos de globulinas e a intensidade da fibrose hepática em pacientes com esquistossomose mansônica / Serum globulin levels and intensity of hepatic fibrosis in patients with mansonic schistosomiasis

CONTEXTO: Tem sido descrita correlação entre os níveis séricos de globulinas e o grau de fibrose hepática nas hepatites crônicas, mas não se encontram relatos na esquistossomose mansônica. OBJETIVO: Avaliar os níveis séricos de globulinas e de IgG, e a intensidade da fibrose periportal mensurada pela ultrassonografia em pacientes com esquistossomose mansônica. MÉTODOS: Entre novembro de 2006 e fevereiro de 2007, foram estudados 41 pacientes que preencheram ficha clínica e realizaram dosagens de IgG por imunoturbidimetria e de globulinas indiretamente pelo método do biureto. A ultrassonografia foi realizada por um único pesquisador, seguindo os protocolos do Cairo e de Niamey. RESULTADOS: A média de idade foi 41 anos, sendo 25 pacientes (61 por cento) do sexo feminino. Dez dos 41 pacientes (24 por cento) apresentaram elevação dos níveis séricos de globulinas e 21 (51 por cento) dos de IgG. Conforme a classificação do Cairo, 21 pacientes apresentaram grau I de fibrose, 18 grau II e 2 grau III, e pela classificação de Niamey 8 apresentavam padrão C, 20 D e 13 E. Aqueles com graus II ou III de fibrose tiveram maiores níveis de IgG do que os de grau I (P = 0,047), assim como aqueles que apresentaram padrões D e E em relação ao C (P = 0,011). Não houve associação entre os níveis de globulinas e o grau ou padrão de fibrose. CONCLUSÃO: Em pacientes com esquistossomose mansônica, observou-se elevação dos níveis séricos de IgG de acordo com a progressão do grau e do padrão de fibrose periportal, mas o mesmo não se observou com os níveis de globulinas.

BACKGROUND: A correlation between the levels of serum globulins and the hepatic fibrosis degree in chronic hepatitis was described, but reports in schistosomiasis mansoni have not been found. OBJECTIVE: To evaluate the serum globulins and IgG levels, and periportal fibrosis intensity measured by ultrasound in patients with schistosomiasis mansoni. METHODS: Between November, 2006 and February 2007, 41 patients which were eligible, filled them a questionnaire and had their levels of serum IgG measured by immunoturbidimetry and globulins indirectly measured by the Biuret method. The ultrasound was carried out by a single researcher, according to the Cairo and Niamey protocols. RESULTS: The average age was 41 years old and 25 female patients (61 percent). Ten patients (24 percent) from 41 showed serum globulins levels raised and 21 (51 percent) presented elevated IgG levels. According to the Cairo classification, 21 patients showed grade I of fibrosis, 18 grade II and 2 grade III; and by the Niamey classification 8 showed standard C, 20 D, and 13 E. Those with grade II or III of fibrosis had higher IgG levels than the ones with grade I (P = 0,047), as well as those who showed standards D and E as compared to C (P = 0,011). There was no association between the globulins levels and the intensity of fibrosis. CONCLUSION: In patients with schistosomiasis mansoni, an increase of the IgG serum levels was observed according to the progression from periportal fibrosis intensity, but the same was not founded with globulins levels.

Hepatitis G virus infection in patients with hepatocellular carcinoma in Recife, Brazil.

The evidence of a higher incidence of hepatitis G virus (HGV) infection among patients with hepatocellular carcinoma (HCC) and the relatively high prevalence of patients with primary liver carcinoma without apparent risk factors in our country motivated the present study, the objective of which was to determine the frequency of HGV-ribonucleic acid (RNA) in a series of patients with HCC. The diagnosis of HCC was established based on alpha-fetoprotein levels (>400 ng/ml), a compatible image and/or biopsy of the hepatic nodules. Markers of hepatitis B virus (HBV) (HBsAg and anti-HBc), hepatitis C virus (HCV) (anti-HCV) and HGV (HGV-RNA) were investigated using MEIA and RT-PCR (reverse transcriptase polymerase chain reaction). There were 32 patients evaluated, including 20 males (63%), with a mean age of 58 years. Twenty-eight (88%) patients were cirrhotic (Child-Pugh: A = 8 patients, B = 14, and C = 6) and 50% reported alcohol consumption. Serological hepatitis markers were detected in 26 (81%) patients, including HBV in 19 (59%), HCV in 12 (38%) and HGV in 9 (28%). Only one (3%) patient was positive for HGV alone. The prevalence of HGV in blood donors from the same region is 10%. The findings suggest that, despite the frequent detection of HGV markers in patients with HCC, isolated infection with this agent does not seem to be a relevant factor in the etiology of this carcinoma.

Evaluation of splenomegaly in the hepatosplenic form of mansonic schistosomiasis.

This study was aimed to evaluate splenomegaly in patients with the hepatosplenic (HS) form of mansonic schistosomiasis (MS), analyzing the size and weight of the spleen and their relationships with patients' gender and age. Between October, 1993 to July, 1998, 78 patients with the HS form of MS had undergone splenectomy as treatment of choice for bleeding due to portal hypertension, at Hospital das Clínicas, Pernambuco, Brazil. By means of abdominal palpation, the excess spleen felt below the left costal edge was measured, and the weight was obtained after splenectomy along with the histopathological analysis. Liver biopsy was performed intraoperatively in order to confirm MS and to rule out other liver diseases. The mean age of the 78 patients were 45 years and 41 of them (53%) were female. The average spleen weight was 912g and the mean spleen size palpable below the left costal edge was 9.1cm. There was a positive relationship between size and weight (p<0.001). Spleen weight and size were larger in males (p=0.007 and p=0.001, respectively). An inverse correlation between age and spleen weight was observed (p<0.001). A classification based upon spleen weight showed 53% of patients presenting a moderate (501-1000g) and 33% a severe (>1001g) splenomegaly. As for the spleen size, the classification showed 64% of patients presenting moderate (4.1-10cm below the left costal edge) and 21% severe (>10cm) splenomegaly. In conclusion, splenomegaly may be considered a key physical finding in patients with HS form of MS, and we found a good correlation between the spleen sizes clinically evaluated with its weight. The majority of cases presents a moderate to severe splenomegaly and spleen size is larger in men and it seems to decrease with aging.

Preliminar evaluation of cytokines in the hepatitis C-schistosomiasis co-infection

Evaluation of hepatic fibrosis is usually performed by histopathological examination of biopsies. However, this is an invasive and potentially dangerous procedure. Several studies have proposed serum biological markers of hepatic fibrosis. This communication evaluates the use of serum cytokines as markers of hepatic fibrosis in hepatitis C, schistosomiasis, and co-infection.

Preliminar evaluation of cytokines in the hepatitis C-schistosomiasis co-infection.

Evaluation of hepatic fibrosis is usually performed by histopathological examination of biopsies. However, this is an invasive and potentially dangerous procedure. Several studies have proposed serum biological markers of hepatic fibrosis. This communication evaluates the use of serum cytokines as markers of hepatic fibrosis in hepatitis C, schistosomiasis, and co-infection.

Prevalence and risk factors of hepatitis C virus infection in hemodialysis patients from one center in Recife, Brazil

A hemodialysis population from a dialysis unit in the city of Recife, Northeastern Brazil, was screened to assess the prevalence of hepatitis C virus (HCV) infection and to investigate the associated risk factors. Hemodialysis patients (n = 250) were interviewed and serum samples tested for anti-HCV antibodies by enzyme-linked immunosorbent assay (ELISA). All samples were also tested for HCV RNA by reverse transcriptase nested polymerase chain reaction (RT-nested-PCR). Out of 250 patients, 21 (8.4 percent) were found to be seropositive by ELISA, and 19 (7.6 percent) patients were HCV RNA positive. HCV viraemia was present in 90.5 percent of the anti-HCV positive patients. The predominant genotype was HCV 1a (8/19), followed by 3a (7/19), and 1b (4/19). None of the anti-HCV negative patients were shown to be viraemic by the PCR. Univariate analysis of risk factors showed that time spent on hemodialysis, the number of blood transfusions and a blood transfusion before November 1993 were associated with HCV positivity. However, multivariate analysis revealed that blood transfusions before November 1993 were significantly associated with HCV infection in this population. Low prevalence levels were encountered in this center, however prospective studies are necessary to confirm these findings.

Determination of alanine aminotransferase in blood donor screening--evidence of its usefulness in the prevention of post-transfusion hepatitis.

A total of 408 HBsAg and anti-HCV-negative patients with elevated ALT levels referred from blood banks were studied. Of these, 359 were followed up. HBsAg and anti-HCV were repeated in the first visit and ALT was checked at a 3 months interval. A liver biopsy was indicated when ALT levels remained abnormal for more than 6 months. Of the patients included, 316/359 (88%) were men, with a mean age of 34 years. In the first visit, 3 (0.8%) patients were anti-HCV positive upon serological reevaluation, with persistence of elevated ALT in all of them. A biopsy revealed chronic hepatitis in all three cases. Twenty-two patients were positive for anti-HBc, 20 of them were immune (anti-HBs positive), one developed anti-HBs after a vaccine dose, and one was HBsAg positive. The present study suggests that ALT can be a useful marker for the detection of hepatitis C virus infected donors in whom technical problems might have occurred in serological screening.

[Identification of the cutoff value for serum alanine aminotransferase in hepatitis C screening of patients with chronic renal failure on hemodialysis]. / Identificação de ponto de corte no nível sérico da alanina aminotransferase para rastreamento da hepatite C em pacientes com insuficiência renal crônica em hemodiálise.

The patients with chronic renal failure in hemodialysis present low levels of serum alanine aminotransferases. In order to establish a better cutoff value for ALT in hepatitis C screening of hemodialysis patients, the ALT levels were measured monthly in 235 patients, being excluded those that presented average above the upper limit of normality. The cutoff value was identified by construction of a ROC curve (receiver operating characteristic). Among 202 patients, 15 (7.4%) presented antibodies to hepatitis C virus (anti-HCV) and 187 (92.6%) were anti-HCV negative, with an ALT average of 0.7 and of 0.5 from ULN (p <0.0001), respectively. The better cutoff value for ALT was at 0.6 from ULN, with sensitivity of 67% and specificity of 75% in anti-HCV screening. These results suggest that ULN of ALT could be reduced for 60% from conventional limit, when we are evaluating patients with CRF in hemodialysis.

Identificaçäo de ponto de corte no nível sérico da alanina aminotransferase para rastreamento da hepatite C em pacientes com insuficiência renal crônica em hemodiálise / Identification of the cutoff value for serum alanine aminotransferase in hepatitis C screening of patients with chronic renal failure on hemodialysis

Pacientes com insuficiência renal crônica em hemodiálise apresentam níveis séricos mais baixos de alanina aminotransferase. Para estabelecer melhor ponto de corte nos níveis de ALT, no diagnóstico da hepatite C, avaliaram-se mensalmente, durante 6 meses os níveis desta enzima em 235 pacientes em hemodiálise, sendo excluídos aqueles que apresentassem média acima do limite superior da normalidade. O ponto de corte foi identificado através da construçäo de curva ROC. Entre 202 pacientes, 15 (7,4 por cento) apresentavam anti-VHC positivo e 187 (92,6 por cento) negativo, com média de ALT de 0,7 e de 0,5 do limite superior (p < 0,0001), respectivamente. O ponto de corte para ALT situou-se em 0,6 do limite superior, com sensibilidade de 67 por cento e especificidade de 75 por cento na identificaçäo do anti-VHC. Sugere-se que os limites superiores de normalidade da ALT sejam reduzidos para 60 por cento dos limites convencionais, quando se avaliam pacientes com IRC em hemodiálise.

Therapy with interferon-alpha plus ribavirin for membranoproliferative glomerulonephritis induced by hepatitis C virus.

We describe a treatment made with interferon-alpha (IFN-alpha) plus ribavirin of two patients with membranoproliferative glomerulonephritis (MPGN) induced by hepatitis C virus (HCV): case # 1 was a 22-yr-old woman with leg and facial edema, hypertension and proteinuria, whose liver biopsy revealed chronic active hepatitis; and case # 2 was a 42-yr-old man with anasarca, hypertension and proteinuria, whose liver biopsy indicated cirrhosis. Both had anti-HCV, HCV-RNA and cryoglobulins. IFN-alpha (3 million units (MU), 3 times/week) and ribavirin (1 g/day) were administered for 12 months. The drugs were well tolerated by both patients. Serum alanine aminotransferase (ALT) levels normalized and HCV-RNA became negative. Cryoglobulins disappeared and an improvement in renal disease was seen after 6 months of therapy. However, after 9 months, case # 2 presented ALT elevation, and proteinuria was detected. Two years after the end of therapy, both patients were negative in repeated HCV-RNA and cryoglobulin tests. Case # 1 was asymptomatic, with normal liver and renal tests, and case # 2 had normal blood pressure, with mild edema of the ankles. Based on the evolution of these two cases, the association of IFN-alpha and ribavirin may be a therapeutic option for patients with MPGN related to HCV.

Therapy with interferon-alpha plus ribavirin for membranoproliferative glomerulonephritis induced by hepatitis C virus

We describe a treatment made with interferon-alpha (IFN-alpha) plus ribavirin of two patients with membranoproliferative glomerulonephritis (MPGN) induced by hepatitis C virus (HCV): Case 1 was a 22-year-old woman with leg and facial edema, hypertension and proteinuria, whose liver biopsy revealed chronic active hepatitis; and Case 2 was a 42-year-old man with anasarca, hypertension and proteinuria, whose liver biopsy indicated cirrhosis. Both had anti-HCV, HCV-RNA and cryoglobulins. IFN-alpha (3 million units (MU), 3 times/week) and ribavirin (1 g/day) were administered for 12 months. The drugs were well tolerated by both patients. Serum alanine aminotransferase (ALT) levels normalized and HCV-RNA became negative. Cryoglobulins disappeared and an improvement in renal disease was seen after 6 months of therapy. However, after 9 months, Case 2 presented ALT elevation, and proteinuria was detected. Two years after the end of therapy, both patients were negative in repeated HCV-RNA and cryoglobulin tests. Case 1 was asymptomatic, with normal liver and renal tests, and Case 2 had normal blood pressure, with mild edema of the ankles. Based on the evolution of these two cases, the association of IFN-alpha and ribavirin may be a therapeutic option for patients with MPGN related to HCV.

Angioplastia com colocação de prótese no tratamento da estenose da artéria hepática após transplante de fígado - relato de caso / Stent placement in the therapy of hepatic artery stenosis following orthotopic liver transplantation - a case report

Racional- A estenose da artéria hepática é uma das principais causas de trombose arterial no pós-operatório imediato do transplante ortotópico de fígado. Ela representa grave complicação, uma vez que pode desencadear necrose hepática maciça com formação de abscessos ou estenoses biliares. A angioplastia e colocação de prótese é opção relatada como válida para contornar esta complicação. Relato do caso - Paciente de 52 anos do sexo feminino apresentou em 1994 três episódios de hemorragia digestiva devido à ruptura de varizes esofágicas. Ao exame físico apresentava aranhas vasculares, ascite e esplenomegalia. O diagnóstico confirmado por biópsia revelou cirrose hepática. Submetida à transplante hepático em 2001, apresentou como complicação a estenose de artéria hepática, que foi tratada por angioplastia e colocação de prótese balão - expandida. No 8º mês de pós-operatório, através da ultrassonografia com colocação de prótese é um método pouco invasivo, podendo tornar-se conduta de eleição para o tratamento das estenoses de artéria hepática no pós-operatório do transplante hepático

Seroprevalence of Helicobacter pylori antibodies in medical students and residents in Recife, Brazil.

BACKGROUND: The epidemiology of Helicobacter pylori (Hp) still constitutes a relevant subject of investigation. GOAL: The goal of this study was to determine the seroprevalence rate of Hp antibodies in medical students and residents, and its relationship with medical practice, age, gender and parents' formal education level. STUDY: The study was carried out from March 1999 to March 2000, on a population of 1,119 medical students and residents, from which a randomized and stratified sample was drawn. Each stratum comprised students attending the basic training level, students attending the professional training level, and residents. Independent samples were calculated for each group, making a total of 405 subjects. Each participant was interviewed using a questionnaire. After the interview, serum samples were collected and stored at -20 degrees C for detecting IgG antibodies against Hp by an enzyme-linked immunosorbent assay. RESULTS: A 31.4% seroprevalence rate of Hp antibodies was observed, which significantly increased during the graduation course according to the medical practices, ranging from 23.4% in students up to 38.6% in residents. Seroprevalence rate increased according to the age (p = 0.002), where older individuals had spent more time in practical activities. Seroprevalence was higher in males and was smaller among those whose parents had a university degree. CONCLUSION: The seroprevalence rate of Hp antibodies amongst medical students and residents increases from the basic up to residence level, suggesting that contact with patients during clinical practice may constitute a risk factor for acquiring Hp infection.

Manifestaçöes estra-hepáticas do virus da hepatite C - Parte 1 e 2 / Extrahepatic manifestations of hepatitis C vurus

Após a identificação do vírus da hepatite C (HCV), em 1989, diversos estudos vêm demonstrando a "relação" deste agente viral com desordens imunológicas e manifestações, tidas como extra-hepáticas, tornando-se a mais relevante a crioglobulinemia mista. O presente trabalho visa rever estas manifestações do HCV, analisando os dados publicados, citando exemplos pertinentes e resultados de atividades desenvolvidas no ambulatório de Hepatites da Disciplina de Gastroenterologia da Escola Paulista de Medicina (EPM) - UNIFESP. Serão discutidas amplamente as manifestações bem conhecidas e melhor definidas, tais como a indução de auto-anticorpos (antinúcleo e antimúsculo liso), a crioglubulinemia mista (tipos II e III), o linfoma não-Hodgkin (células B), a glomerulonefrite (membranoproliferativa), a porfiria cutânea tarda e o líquen plano. As manifestações menos freqüentes ou mais polêmicas, tidas ainda com supostas, entre as quais se incluem o diabetes mellitus (tipo 2), a tireoidite (Hashimoto), a sialoadenite a fibrose pulmonar, entre outras, também serão abordadas. Em virtude da grande quantidade de artigos levantados, como conseqüência provavelmente da controvérsia de seus resultados, esta revisão, para fins de publicação, será dividida em duas partes.

Glomerulonefrite associada à infecçäo pelo vírus da hepatite C / Glomerulonephritis associated with hepatitis C virus infection

Descrevem-se pacientes com glomerulonefrites (GNs) associadas à infecçäo pelo vírus da hepatite C (HCV). Entre agosto de 93 e julho de 96 foram observados 4 pacientes, com idade mediana de 41 anos, sendo 2 do sexo masculino. Pesquisaram-se o anti-HCV por ensaio imuno-enzimático e o HCV-RNA por PCR. Também foram pesquisadas crioglobulinas séricas, hemácias dismórficas no sedimento urinário e proteinúria de 24h. Viremia, crioglobulinas, hematúria e proteinúria foram observadas nos 4 pacientes. As biópsias hepáticas revelaram atividade inflamatória nos 3 pacientes em que foram realizadas e as do rim revelaram glomerulonefrite membranoproliferativa em 3 e glomerulonefrite proliferativa mesangial em 1 paciente. Dois pacientes vêm recebendo antivirais (IFN associado à ribavirina) e evoluindo com melhora. A presença de viremia e de hepatite concomitante com as alteraçöes urinárias constituem indícios do envolvimento viral na glomerulopatia. Tais achados säo reforçados pela melhora das alteraçöes urinárias durante o tratamento específico. Conclui-se que a pesquisa de marcadores virais em pacientes com GNs assume relevância na medida em que pode modificar a conduta terapêutica

Critérios diagnósticos de hepatite auto-imune aplicados a pacientes do ambulatório de Hepatites da EPM-Unifesp / Diagnostic criteria for autoimmune hepatitis applied to pacients from Escola Paulista de Medicina -UNIFESP

O presente estudo teve como objetivo realizar levantamento dos casos suspeitos de hepatite auto-imune (HAI) atendidos no Ambulatório de Hepatites da UNIFESP-EPM, e submetê-los aos novos critérios diagnósticos propostos pelo International Autoimmune Hepatitis Group (IAHG) em 1993. De outubro de 1985 a junho de 1996 foram atendidos, no Serviço, 2958 pacientes, dos quais 35 (1,2 por ento) receberam diagnóstico de HAI, baseado em critérios clínicos e laboratoriais adotados na época. Novos critérios incluem sexo, doenças imunológicas associadas, uso de drogas, transfusäo sangüínea, uso de álcool, marcadores virais, gamaglobulinas, relaçäo FA/ALT, auto-anticorpos, quadro histológico e resposta ao tratamento com corticosteróide. Pelos novos critérios, apresentam diagnóstico definido (DD) os pacientes com score maior que 15 pontos; diagnóstico provável (DP) os com score entre 10 e 15; e diagnóstico improvável (DI) indivíduos com score abaixo de 10. Dos 35 casos de HAI, 8 (22,9 por cento) tiveram DD e 18 (51,4 por cento) DP, sendo a confirmaçäo para os casos suspeitos de 74,3 por cento. Concluiu-se que a prevalência de HAI foi de 1,2 por cento, caindo para 0,9 por cento após a adoçäo dos critários internacionalmente aceitos, o que demonstra que a doença é pouco comum em nosso meio. E, 25,7 por cento tiveram DI por estes critérios, sugerindo, além da dificuldade em diagnosticar corretamente esta patologia, que eventualmente os mesmos näo possam ser aplicados a todas as populaçöes indiscriminadamente, devendo-se observar limitaçöes de recursos laboratoriais e variaçöes geográficas peculiares.

Autoantibodies before, during after administration of recombinant interferon-alfa for chronic viral hepatitis

Este estudo teve como objetivo avaliar a presenca de auto-anticorpos em pacientes com hepatite cronica pelos virus B e C, antes, durante e apos o tratamento com o interferon-alfa (IFN-alfa), assim como estudar a relacao destes anticorpos com o tipo de IFN, com a dose e com a resposta terapeutica. Cinquenta pacientes com hepatite viral cronica foram divididos em 2 grupos: grupo-controle constituido por 21 pacientes (10 hepatites B e 11 hepatites C), e foram seguidos durante 6 meses sem tratamento e grupo-IFN constituido por 29 pacientes (8 hepatites B e 21 hepatites C), que receberam IFN alfa durante 6 meses. Anticorpos antinucleo, antimusculo liso, antimitocondria, anticelula parietal e antitireoide foram pesquisados em amostras de soro colhidas antes do inicio, durante e ao final do estudo. Quatro dos 50 pacientes (8 por cento) apresentavam auto-anticorpos no inicio do estudo (2 em cada grupo)...