Indian childhood cirrhosis (ICC) & ICC-like diseases: the changing scenario of facts versus notions.

Indian childhood cirrhosis (ICC), a disease considered to have been endemic in and unique to India has now been documented in children of non-Indian origin from other countries. More recently available findings from a large multicentre study sponsored by the Indian Council of Medical Research (ICMR) have dispelled some of the generally accepted notions and have established several new facts on different aspects of the disease. All relevant reports on ICC and ICC-like diseases, till date, were reviewed to obtain a proper perspective on the current state of our understanding on this non-Wilsonian copper overload liver disease. A primary role of exogenous copper in causing the disease was earlier debated on the basis of studies in India but investigators abroad studying some sporadic cases and a series of endemic ICC-like diseases supported a hepatotoxic injury by ingested copper in genetically susceptible infants and children in ICC- like disease and in ICC. Epidemiologic and morphologic findings in the well controlled ICMR study based on 225 cases of ICC and 426 controls, all confirmed on liver biopsy, have however, convincingly refuted this concept. Additionally, this study revealed that unlike what has been believed earlier, older children more than 3 yr age can get the disease and that in its natural course the hepatic histology can transform between the characteristic one considered diagnostic and some other patterns, any one of which can be the morphologic manifestation at first presentation of the patient. Older children and cases with milder morphologic changes at presentation had longer survival. The overall inference from critical analysis of all available data is that ICC and ICC-like diseases clinically manifest in a child of any age though common in younger ones, and a clinical diagnosis must be made in any child with so-called 'cryptogenic cirrhosis'. Exposure to exogenous copper in food, milk and water should not be a prerequisite for this consideration. A liver biopsy whenever feasible should be mandatory for confirmation with the understanding that the morphologic changes in liver can present a few other patterns besides the characteristic one currently taken to be diagnostic. The ascribed current decline in encountering ICC is likely to be due partly to missing a diagnosis and partly to a true reduction in incidence consequent on time related economic and socio-cultural changes.

Cassia occidentalis poisoning as the probable cause of hepatomyoencephalopathy in children in western Uttar Pradesh.

BACKGROUND & OBJECTIVE: Recurrent annual outbreaks of acute encephalopathy illness affecting young children have been reported for several years in many districts of western Uttar Pradesh (UP). Our earlier investigations over three consecutive years (2002-2005) proved that these outbreaks were due to a fatal multi-system disease (hepatomyoencephalopathy syndrome) probably caused by some phytotoxin and not due to viral encephalitis as believed so far. We conducted a case-control study to investigate the risk, if any, from various environmental factors and also to identify the putative toxic plant responsible for development of this syndrome. METHODS: Eighteen cases with acute hepatomyoencephalopathy syndrome admitted in 2005 in a secondary care paediatric hospital of Bijnor district of western UP were included in the study. Three age-matched controls were selected for each case. A semi-structured questionnaire was developed and applied to all 18 cases and 54 controls. All interviews were conducted within one week of discharge or death of each case. Quantitative data were analyzed using the relevant established statistical tests. RESULTS: Parents of 8 (44.4%) cases gave a definite history of their children eating beans of Cassia occidentalis weed before falling ill, compared with 3 (5.6% controls), the odds ratio being 12.9 (95% CI 2.6-88.8, P<0.001). History of pica was the other associated factor with the disease, odds ratio 5.20 (95% CI 1.4-19.5, P<0.01). No other factor was found significantly associated with the disease. INTERPRETATION & CONCLUSION: Consumption of C. occidentalis beans probably caused these outbreaks, described earlier as hepatomyoencephalopathy syndrome. Public education has the potential to prevent future outbreaks.

Cassia occidentalis poisoning causes fatal coma in children in western Uttar Pradesh.

We investigated cases of the annual seasonal outbreaks of acute hepato-myo-encephalopathy in young children in western Uttar Pradesh for causal association with Cassia occidentalis poisoning, by a prospective survey in 2006. During September-October homes of 10 consecutive cases were visited and history of eating Cassia beans was obtained in all. Nine children died within 4-5 days. There appears to be an etiological association between consumption of Cassia occidentalis beans and acute hepato-myo-encephalopathy.

Recurrent annual outbreaks of a hepato-myo-encephalopathy syndrome in children in western Uttar Pradesh, India.

BACKGROUND & OBJECTIVE: Outbreaks of an acute encephalopathy syndrome affecting children, with high case-fatality, have been reported in western Uttar Pradesh, India for the last many years. We investigated these cases in Bijnor district and present our findings. METHODS: Fifty five children aged 2-10 yr hospitalized from 2003 to 2005 in Bijnor, Uttar Pradesh, with features of acute encephalopathy were selected by defined clinical criteria. Various laboratory investigations were performed. RESULTS: The disease had peak incidence in early winter months. Previously healthy, 2-4 yr old rural children (mean age-3.78 yr) of very low socio-economic background were most vulnerable. Almost all had vomiting preceding unconsciousness and a majority had mild fever and abnormal behaviour/agitation. Abnormal posture of trunk and limbs were distinctive features. Fluctuation of blood pressure was seen in three-quarter cases. Serum aminotransferases, creatine phosphokinase and lactic dehydrogenase levels were found markedly raised virtually in all cases in whom the tests were performed. Serum glucose was found low (<50 mg/dl) in 47.3 per cent cases at presentation. Cerebrospinal fluid (CSF) was under normal or low pressure and without pleocytosis in all cases. No microorganism could be isolated from serum, CSF, urine and visceral specimens. Neuroimaging performed in two cases was also normal. Liver biopsy performed in 21 cases showed acute hepatotoxic injury in all with marked hydropic change and perivenular necrosis. Tibial muscle biopsy done in 8 cases showed focal necrosis while brain biopsy taken in 2 cases had mild spongiosis with focal gliosis. Forty two children succumbed to their illness (case fatality 76.4%), most within 72 h of presentation. Survivors did not show any neurological deficit. INTERPRETATION & CONCLUSION: Our findings showed that the outbreaks were due to a multi-system disease with toxic injury to liver, muscles and brain (hepato-myo-encephalopathy) and not due to viral encephalitis as believed so far. The cause remains unknown but several features suggest the possibility of phytotoxin-induced pathology.

Immunohistochemical detection of serum autoantibodies--a new technique using routine formalin fixed paraffin sections.

Detection of autoantibodies in serum is important in the diagnosis of primary immune mediated diseases. Tests of these antibodies are conventionally done by indirect immunoflourescence (IIF) on frozen sections of fresh target tissues from the murine species. More recently enzyme-linked immunoassays and IIF on cultured human epithelial cells or on fresh frozen sections of murine tissues coated onto wells or glass slides are also being used. But these tests are more expensive and generally not easily available to laboratories in developing countries. Obtaining small animals for preparing frozen sections of fresh tissue is also getting to be increasingly difficult. A simple; new and inexpensive technique was developed to perform IIF on routine paraffin sections of human tissues following antigen unmasking. This, technique offers qualitatively good, consistent, species specific and dependable results with several advantages over the conventional IIF on animal tissue frozen sections, particularly in a sausage block made from different types of tissues. Immunoperoxidase stain for autoantibodies can also be easily performed with the advantages of permanent preservation and clearer evaluation in light microscopy. Most importantly the technique is easily affordable and practicable in all histopathology laboratories.

Hepatocellular carcinoma--a model of human cancer: clinico-pathological features, etiology and pathogenesis.

Hepatocellular carcinoma (HCC), a unique human neoplasm, has interested many in several fields of biological and health sciences. This cancer is credited as the first that can be largely eliminated by a safe anti-viral vaccine and other transmission control measures. It is also the first cancer for which a reliable diagnostic tumour marker was identified and studies on this tumor in humans and animals have provided a large body of information on causation and step-wise evolution of cancers. Being a common and rapidly fatal tumour, mainly affecting males in the more populous developing countries, HCC may well be the commonest cancer of the human male. Clinical features are not specific for HCC but manifestations represent varying combinations of those due to cirrhosis which is a very frequently associated and pre-existent disease, those due to tumour and those due to malignancy. This tumour commonly takes a massive form with satellite nodules or a scattered multinodular form. A fibrolamellar variant is biologically and clinically quite different from the usual HCC and the small capsulated variant is seen in some geographic areas. Microscopically the trabecular variety is common and differentiation from metastatic cancers and benign lesions may need use of newly described immunohistochemical markers in addition to clinical evidence of cirrhosis. Hepatitis B and C viruses, dietary aflatoxin B1 and cirrhosis from any cause are common risk factors in that order of importance. Several lines of evidence including molecular biology and animal studies support these etiological linkages. Studies in experimental animals using chemical carcinogens, different hepatotropic viruses and aflatoxin have greatly helped our understanding of carcinogenesis in general and hepatocarcinogenesis in particular. Individual HCC risk factors may contribute to summation of mutations subsequent to repeated and continued liver cell injury act as carcinogen/co-carcinogen or be involved in both capacities.

A multicentric study with arteether in patients of uncomplicated falciparum malaria.

Two hundred and sixty seven patients of uncomplicated P. falciparum malaria completed study in a multicentric phase III clinical trial of Arteether. Arteether was given intramuscularly in a dose of 150 mg daily for three consecutive days. Each patient was followed upto 28 days of alpha, beta arteether therapy. The cure rate was 97% with fever clearance time between 1-7 days (24-168 hours) and parasite clearance time between 1-3 days (24-72 hours). Parasite reappearance rate was found to be 3% and reported at only three of the centres. Following the treatment no adverse effect was observed on haematological, biochemical and vital clinical parameters.

Multicentric clinical trials for safety and efficacy evaluation of alpha;beta arteether in complicated P. falciparum malaria.

OBJECTIVE: To evaluate efficacy of alpha;beta arteether in patients of P. falciparum malaria presenting with complications was undertaken in a multicentric clinical trial. METHOD: Each patient who consented to undergo clinical trial with parenteral Arteether was treated with a fixed dose schedule of Arteether given intramuscularly in a dose of 150 mg once a day on three consecutive days. Every patient was followed upto 28 days with clinical, haematological and parasitological monitoring every day upto one week and thereafter at 14, 21 and 28 days. The response was assessed in terms of fever clearance time, parasite clearance time, cure rate and parasite reappearance rate. RESULTS: A total of 211 patients of P. falciparum malaria were included in the study from four centres (Bhilai, Guwahati, Jamshedpur and Rourkela). Results of this study showed that fever clearance time ranged between 24-168 hours, parasite clearance time ranged between 24-120 hours and overall mortality ranged between 4-8.5%. Out of 211, only 14 patients expired during the study, of these, 10 patients expired within first two days i.e. before completing the three day schedule of arteether therapy. Tolerability to arteether injection was good in all these patients and no untoward effects were experienced or reported during the study. Overall cure rate observed in these studies was 93%. CONCLUSION: This study shows a rapid parasite and fever clearance in patients of complicated P. falciparum malaria.

Immunohistochemical detection of hepatitis C virus antigen in paraffin embedded liver biopsies from patients with chronic liver disease.

A simple and reproducible immunohistochemical (IHC) staining method that adequately identifies and localizes hepatitis C virus (HCV) in human livers is still not available. We performed IHC staining using both a new monoclonal antibody against HCV and a polyclonal human anti-HCV IgG to 94 liver biopsies from HCV seropositive patients with chronic hepatitis and 15 control liver biopsies. Positive nuclear staining was consistently observed predominantly in hepatocytes and much less in lymphocytes with either antibody in 57% of anti-HCV seropositive cases but in none of the controls. However, the monoclonal antibody yielded a stronger positive reaction and in a greater proportion of hepatocytes. In 78% of the positive cases, more than a quarter of the hepatocytes showed nuclear staining. The degree of hepatic HCV load as revealed by intensity and extent of positive staining did not correlate with histological changes in the liver. The new monoclonal antibody against HCV appeared to be suitable for identifying HCV in tissues by a simple IHC stain and can be used to explore the pathogenesis of liver injury induced by this virus.

Immunohistochemical study of proliferating mesenchymal spindle cells in heterogenous soft tissue lesions.

Proliferation of mesenchymal spindle cells is a main event in a variety of lesions with similar morphological features but widely divergent biological behaviour. In order to identify criteria for precise histological diagnosis, 60 human soft tissue lesions, divided into 40 cases of fibroblastic cell proliferation, 10 smooth muscle cell tumours and 10 nerve sheath cell tumours, were examined for the immunohistochemical profile of the main lesional cell in addition to other histological features. The three groups could be differentiated by determining the lineage of the constituent spindle cell on the pattern of expression of vimentin, alpha-smooth muscle actin (ASMA) and macrophage antigen CD68 (MA-CD68). Smooth muscle cells expressed ASMA and vimentin but not MA-CD68, while nerve sheath cells were negative for ASMA but positive for vimentin and MA-CD68. The fibroblastic cell lesions as a group were easily differentiated on the basis of positive reactivity for all three markers but individual lesions could only be distinguished by additional assessment of histological features. Because of consistent co-expression of ASMA, vimentin and MA-CD68 in the spindle mesenchymal cell present in all varieties of lesions in this heterogeneous group, we suggest that this proliferating "fibroblastic" cell is phenotypically a fibromyohistiocyte.

The nature and significance of liver cell vacuolation following hepatocellular injury--an analysis based on observations on rats rendered tolerant to hepatotoxic damage.

Swelling with nonlipid cytoplasmic vacuolation of diffusely distributed hepatocytes is seen consistently after mild acute and subacute liver injury. Several lines of evidence point to the possibility that this change may reflect a cellular adaptation beneficial to the host, rather than a degenerative change. The nature and significance of this morphological manifestation were tested in batches of albino rats given small doses of a variety of hepatotoxins, some of which were subsequently challenged with a large highly necrogenic dose of carbon tetrachloride (CCl4). Morphological and biochemical investigations showed that cytoplasmic vacuolation of liver cells following low doses of toxins was due to excess accumulation of glycogen, predominantly of the monoparticulate form. These cells lacked features of degeneration or regeneration and were much less susceptible to injury by the large dose CCl4, as assessed by structural and serum enzyme analyses. This tolerance to toxic damage seemed to be associated with excess accumulation of intracellular glycogen. We conclude from these and other observations on animal and human livers that many of the vacuolated hepatocytes seen in liver injury are cells adaptively altered to resist further insult rather than cells undergoing hydropic degeneration, as is commonly believed.

Aluminum monitoring for chronic renal failure patients in kuwait.

The importance of monitoring serum aluminum (Al) level in patients undergoing long-term hemodialysis (HD) is well known. This study on 94 HD patients from Mubarak Hospital, Kuwait revealed that serum Al level was significantly higher in HD patients on aluminum hydroxide therapy (n = 57) than those not on this treatment (n = 37) (p = 100 ug/L. Analysis of water and dialysis fluid showed Al levels just above the permissible limit, on certain occasions, suggesting the need for regular monitoring of these substances for Al contamination. Patients on HD for longer than five years and those above the age of 50 years had higher serum Al levels. The most important single factor causing elevated serum Al levels in the study patients was aluminum hydroxide therapy, administered orally as a phosphate binder.

Indian childhood cirrhosis--like liver disease in an Arab child. A brief report.

An Arab female child presented with rapidly progressive liver disease, with apparent onset in late infancy and death at 15 months. Microscopy showed panacinar hepatitis, portal and pericellular fibrosis, and diffuse Mallory bodies in the absence of steatosis or significant cholestasis. Hepatic copper concentration was moderately elevated. Known causes of early childhood cirrhosis were excluded. This case meets most of the established criteria of Indian childhood cirrhosis, yet is unusual in its occurrence in a child of Arab ancestry and in having a moderate degree of hepatocellular copper overload.

Aflatoxin B1 induced hepatocarcinogenesis in neonatal rats.

Role of cell replication on aflatoxin B1 (AFB1) induced hepatocarcinogenesis was investigated in neonatal rats showing persistence of cell replication in the liver for 21 days of post natal life. Adult (8-10 weeks old) rats displaying no hepatocytic proliferation served as controls. Three doses of AFB1 were administered to both the groups at intervals of 48 hr with the doses starting on 10th day of age in the neonatal group. Appearance of phenotypically altered preneoplastic hepatocytes was quantitated in both the groups. A significantly higher incidence of preneoplastic foci was recorded in neonatal rats as compared to adult animals. The results suggest that presence of cell replication in neonatal rats at the time of AFB1 administration enhances the process of hepatocarcinogenesis.