[Late onset Wilson's disease]. / Morbo di Wilson ad esordio tardivo.

BACKGROUND: Wilson's disease (W.D.) is a metabolic disorder that occurs predominantly in children, adolescents, young adults and, rarely, in patients over 35 years. AIMS: In order to verify the prevalence of the clinical presentation of W.D. in adulthood, we analyzed a wide number of clinical presentation of W.D. with particular attention to the age of onset and to the evolutive stage of liver disease at presentation. PATIENTS: Our study is relative to 11 Sardinian adult subjects, aged 36-57 years, 6 males and 5 females, selected from a series of 120 patients affected by W.D. The only criterion utilized to select the patients was their age at presentation, with a cut off of 35 years. METHODS: Liver biopsies were routinely processed and stained with rhodanine, rubeanic acid, orcein and Timm's methods. On the basis of the histological picture, liver biopsies were subdivided into four evolutive stages: stage I = steatosis; stage II = interface hepatitis; stage III = bridging fibrosis; stage IV = cirrhosis. Molecular characterization of W.D. for gene mutations in the Sardinian population was performed in 7 out of 11 cases (-441/-427 del, 5' UTR and 3436 G > A Exon 16). RESULTS: 3 patients showed histological features of the first evolutive stage, 2 of the second, 1 of the third, and 5 of the fourth stage. Histochemistry for copper resulted positive in 9 of 11 cases at least with one of the four employed methods. In the seven patients in whom molecular characterization was perfomed, the gene mutation of W.D. was the same observed more frequently in the Sardinian population (-441/-427 del, 5'UTR). CONCLUSIONS: Our data show that: 1) W.D. with late onset is not rare in Sardinian population; 2) in spite of the late clinical presentation, W.D. may present in the first (3/10) and in the second evolutive stage (2/10) with mild to moderate changes of the liver architecture; 3) patients may show, at presentation, a severe liver disease, characterized by bridging fibrosis or cirrhosis; 4) from a practical point of view, we ask to consider the diagnosis the W.D. in all patients with chronic liver disease of unknown etiology, even if aged over 35 years.

TT virus infection in Italy: prevalence and genotypes in healthy subjects, viral liver diseases and asymptomatic infections by parenterally transmitted viruses.

This study was aimed to evaluate TT virus prevalence in subjects with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections in patients affected by hepatitis of unknown origin (non-A-non-E hepatitis) and in healthy subjects who had not been exposed to HBV, HCV and HIV. A total of 317 subjects were tested; 40 were HBsAg asymptomatic carriers, 57 subjects were anti-HCV positive (45 without chronic hepatitis and 12 with HCV-related chronic hepatitis), and 27 had chronic non-A-non-E hepatitis. Fifty-seven subjects were intravenous drug users (IVDUs) (52 with HCV or/and HIV infections), seven patients underwent a liver transplant for fulminant hepatitis and 137 were healthy subjects from the general population. Overall, TTV-DNA was detected in 62 subjects (19.6%): in 17.9% of the HBsAg carriers, in 14% of the anti-HCV-positive patients (in 8.3% and in 15.5% of patients with and without chronic hepatitis, respectively), in 22.2% of non-A-non-E hepatitis patients, in 22.8% of IVDUs, in 57.1% of fulminant hepatitis patients. TTV-DNA was also found in 20.4% healthy subjects. The prevalence in the different subgroups was not statistically different. The genotypes were identified in 40 of the 62 (64.5%) TTV-DNA positive samples: genotype 1a in 17.5%, 1b in 27.5%, genotype 2 in 27.5%, genotype 3 in 15.0%, genotype 4 in 5.0% and genotype 5 in 7.5%; the genotype distribution in the subsets of patients was not significantly different. In conclusion, this study showed that TTV infection is common in Italy; it is widespread throughout the entire population and five genotypes are present in Sardinia. Our results further dismiss the role of TTV as cofactor in influencing the clinical course of infections with other hepatitis viruses as well as the role of HIV in enhancing TTV transmission and replication.

Gross pathologic types of hepatocellular carcinoma in Italy.

The prevalence and independent predictors of the different macroscopic types of hepatocellular carcinoma (HCC) were assessed in 1,073 unselected patients of 14 hospitals in Italy from May 1996 to May 1997. Solitary HCC was the most common cancer type (44.6%), followed by multinodular (44.2%), diffuse (8.4%) and massive (2.8%) types. After adjustment for the influence of confounders by multiple logistic regression analysis, Child-Pugh grades B and C were found to be independent predictors of multinodular (odds ratio, OR, 2.0; 95% confidence interval (CI) = 1.5-2.6) and diffuse (OR 2.6; 95% CI = 1.6-4.4) HCC types. These findings indicate that the majority of HCC cases are not detected at a potentially treatable stage. Delayed detection of HCC is associated with a higher likelihood of the multinodular or diffuse gross pathologic type.

Value of histochemical stains for copper in the diagnosis of Wilson's disease.

AIMS: The histochemical demonstration of hepatic copper is important in the diagnosis of Wilson's disease (WD). Conflicting results have been published with regard to the ability of different histochemical methods to demonstrate copper storage in the liver. Therefore, we evaluated the diagnostic value of three available histochemical methods in a large series of patients affected by WD. METHODS AND RESULTS: Seventy-nine consecutive liver needle biopsies, from 74 patients, 39 males and 35 females, aged 4-60 years (mean age 28.5 years) were stained with orcein, rhodanine and using Timm's method. On the basis of the histological picture, liver biopsies were subdivided into three groups: group A, steatosis; group B, interface hepatitis; group C, chronic hepatitis with bridging fibrosis and/or cirrhosis. In group A, 30.4% of the cases were positive using Timm's method, vs 13.2% using the rhodanine and 17.5% using the orcein method. In group B, Timm's method was positive in 40.1% while rhodanine and orcein showed positivity in 26.7%. In group C, the Timm's method stained 58.6%, rhodanine 36.6% and orcein 29.3% positively. CONCLUSIONS: Our data show that: (1) Timm's silver stain is the most sensitive method for the demonstration of copper in all cases of WD; (2) rhodanine and orcein have minor value in the diagnosis of WD, especially in the early stages of the disease; (3) to increase the diagnostic value of histochemistry for copper multiple histochemical stains in serial sections are required; and (4) although hepatic copper concentration is highest in the early stages of WD, the histochemical demonstration fails in a large number of cases.

Characteristics of hepatocellular carcinoma in Italy.

BACKGROUND/AIMS: This study aimed to assess the main features of hepatocellular carcinoma at the time of diagnosis in Italy, particularly in relation to the presence or absence of underlying cirrhosis, hepatitis virus marker patterns, age of the subjects and alpha-foetoprotein values. METHODS: A total of 1148 patients with hepatocellular carcinoma seen at 14 Italian hospitals in the 1-year period from May 1996 to May 1997 were the subjects of this prevalence study. Both newly diagnosed cases (incident cases) and cases diagnosed before May 1996 but still attending the hospitals during the study period (prevalent cases) were included. RESULTS: We found that 71.1% of cases were positive for hepatitis C virus antibodies but negative for HBsAg; in contrast, 11.5% were negative for anti-HCV but positive for HBsAg; 5.3% were positive for both markers; and 12.1% were negative for both viruses. The mean age of detection was over 60 years, with a younger mean age in HBsAg-positive compared to anti-HCV-positive patients (59.3 years vs. 65.6 years, p<0.01). The male-to-female ratio among HBsAg-positive patients was 10.4:1, in contrast to 2.8:1 among anti-HCV-positive patients (p<0.01). The majority of cases (93.1%) had underlying cirrhosis. Cirrhotic patients were more likely to be anti-HCV positive than non-cirrhotic cases (73.2% vs 43.9%; p<0.01); conversely, absence of hepatitis virus markers was more frequently observed in the non-cirrhotic than in the cirrhotic population (40.9% vs. 10.0%; p<0.01). Overall, the alpha-foetoprotein level was altered (>20 ng/ml) in 57.9% of patients; only 18% of cases presented diagnostic (>400 ng/ml) values. Anti-HCV positivity (O.R. 2.0; CI 95%=1.3-3.1) but not HBsAg positivity (O.R. 1.0; CI 95%=0.6-1.8) was shown to be an independent predictor of the likelihood of altered alpha-foetoprotein values by multivariate analysis. CONCLUSIONS: These findings point to differences in the characteristics of the populations infected by hepatitis B and hepatitis C. Factors other than the hepatitis viruses are important in non-cirrhotic patients. A change in the relative prevalence of hepatitis virus markers among hepatocellular carcinoma cases was demonstrated, reflecting a significant change in the rate of HBV endemicity in the Italian population. Finally, the increased trend in the mortality rate from liver cancer in Italy from 4.8 per 100,000 in 1969 to 10.9 in 1994 may reflect the large cohort of subjects infected with HCV via the iatrogenic route during 1950s and 1960s when glass syringes were commonly used for medical treatment.

Scanning electron microscopy of chronic hepatitis C. An OsO4 maceration study on human biopsies.

A study at the scanning electron microscope (SEM) on the liver changes in chronic hepatitis C was carried out in human needle biopsies from four patients. Intracellular structures were visualized by a novel modification of the OsO4 maceration method that allows to investigate human pathological specimens. At low magnification we observed both sinusoidal and hepatic cells alterations: sinusoids appeared occluded by lymphocytes, hypertrophic Kupffer cells, activated perisinusoidal cells, necrotic material and apoptotic bodies. Some hepatocytes showed ballooning, arrangement in rosettes, and structural changes related to apoptosis: cell rounding, detachment from neighbouring cells, clustering of cytoplasmic organelles and cell fragmentation. We also found periterminal, sinusoidal, and pericellular severe fibrosis, and bile duct damage of moderate degree. At higher magnification, after removing the intracellular matrix, all the intracellular structures appeared normal, except for focal dilatation of smooth endoplasmic reticulum. Our findings clearly demonstrate the usefulness of the OsO4 maceration method for the study of chronic hepatitis and of liver disease in general. Thank to this technique, in fact, SEM becomes a diagnostic tool complementary to light microscopy and transmission electron microscopy (TEM), for its unique ability to give both low magnification panoramic views and detailed high magnification 3D images of cell organelles.

Mammillo-hypophyseal duplication (diplo-mammillo-hypophysis).

A first-time description is given of a unique combination of congenital deformities encountered in a female infant born in the 35th week of gestation and surviving for minutes only. The principal malformations comprised duplicity of the hypophysis cerebri and mammillary bodies, olfactory aplasia, agenesis of corpus callosum, Dandy-Walker syndrome, thoracolumbo-sacral rachischisis and hydromyelia, associated with palato-gnatho-cheilo-schisis, defects in the pericardium and cardiac interventricular septum and gross maldevelopment of the diaphragm. Of these cerebral anomalies, we have chosen to concentrate on the condition which we denominate "diplo-mammillo-hypophysis" (mammillo-hypophyseal duplication) as the object of this study. On grounds of embryonal development it is considered to have come about during the first half of the 2nd month of gestation. The likely genesis of the pathologic findings is discussed.

Hepatic expression of hepatitis B and delta virus antigens in patients with acute and chronic hepatitis.

Delta antigen (delta-Ag), hepatitis B surface antigen (HBsAg) and hepatitis B core antigen (HBcAg) were examined by immunofluorescence and immunoperoxidase staining in 106 deparaffinized liver biopsy samples from HBsAg-positive patients with acute and chronic hepatitis. The delta-Ag was present in 15 cases (14%), with nuclear positivity varying greatly in intensity and prevalence. Patients with chronic hepatitis associated with delta infection had a histological picture characterized by foci of intralobular inflammation, many apoptotic bodies and shrunken hepatocytes with no satellite signs of inflammation. The histological pattern of delta antigen-positive acute hepatitis was characterized by the presence of a large number of intralobular apoptotic bodies. The inflammatory reaction mainly involved the portal tracts with piecemeal necrosis, but without collagen production. In the same cases the pattern of expression of HBsAg and HBcAg was unusual: in three cases HBcAg and HBsAg were concomitantly present, whereas in one case none of the hepatitis B virus markers was detectable.

Necrotizing emphysematous pyelonephritis: a case report.

Emphysematous pyelonephritis (EP) is comparatively rare in urological practice. From 1898 to the present time only 45 cases have been described. In this report we describe the case of a 43-year old diabetic man, with right EP without obstruction of the urinary tract and with a urinary infection of E. Coli. This appears to be rather rare as it is more frequently associated with obstruction of the urinary tract. Surgical exploration enabled us to discover a fistula between the kidney and the wall of the vena cava which would have caused fatal complications if it had not been discovered. The micro-organisms more frequently involved were E. Coli, Proteus, Aerobacter and various anaerobes. Mortality has been reported as 75% in patients receiving medical therapy only and 23% in those undergoing surgery. The authors therefore believe that surgical exploration even with no urinary tract obstruction makes it possible to detect complicating pathologies which may remain undiscovered by medical examination and the urinary excretory tract and renal sheath drained. This provides a better opportunity of estimating possible reversibility of the renal lesion.

Neuronal loss in the basal nucleus of Meynert in a patient with olivopontocerebellar atrophy.

A morphometric study of the basal nucleus of Meynert has been performed in a case of familial olivopontocerebellar atrophy with mental deterioration. The magnocellular population of the basal nucleus was found to be substantially reduced in number (over 60%) as compared with that of three age-matched controls. This finding has not been reported previously and might represent one of the anatomic substrates of some of the cognitive disturbances exhibited by a considerable number of patients with olivopontocerebellar atrophy (OPCA).

The basal nucleus of Meynert in idiopathic Parkinson's disease.

The basal nucleus of Meynert (bnM) was examined in 6 patients with idiopathic Parkinson's disease and in 5 age-matched controls. The histopathological study was followed by a quantitative analysis of the magnocellular population of the nucleus, with the determination of the number of neurons and their nucleolar volume. In Parkinson's disease, there was a neuronal loss ranging from 29.9% to 68.3% (mean 45.8%) and numerous surviving cells containing Lewy inclusion bodies. The percentage loss of cells did not display a significant correlation with the age of the patients, the duration of the illness, the mental state or the drug regime. On the other hand, no significant differences in nucleolar volume of bnM neurons were detected between patients and controls. The damage of the basal nucleus of Meynert in Parkinson's disease is less severe than that generally observed in Alzheimer's disease, and is slightly more pronounced than that reported for progressive supranuclear palsy.

The basal nucleus of Meynert in patients with progressive supranuclear palsy.

The neuronal number and nucleolar volume of the magnocellular population of the basal nucleus of Meynert in 6 patients with progressive supranuclear palsy (PSP) - one associated with Alzheimer's disease - were compared with those of 5 controls. In the 5 typical PSP cases, an age-dependent neuronal loss was demonstrated ranging from 12.6% to 54.1%. In the PSP-Alzheimer patient, the loss of cells amounted to 73.8% and the surviving neurons exhibited a reduction in the nucleolar volume, suggesting a reduced protein synthetic capability. The involvement of the basal nucleus is therefore a usual anatomical feature of PSP. The damage is less severe than generally observed in Alzheimer's disease and biochemical studies are required to state whether this is accompanied by a substantial cholinergic deficit.

Basal nucleus of Meynert. A neuropathological study in Alzheimer's disease, simple senile dementia, Pick's disease and Huntington's chorea.

The basal nucleus of Meynert (bnM) was examined in 9 patients with Alzheimer's disease--4 presenile and 5 senile cases--in 3 patients with simple senile dementia, 5 with Pick's disease, 5 with Huntington's chorea and 5 non-demented controls. The histopathological study was followed by a quantitative analysis of the magnocellular population of neurons and by the determination of their nucleolar volume. In Alzheimer's disease there was a neuronal loss ranging from 44 to 76%, which was negatively correlated with both the age at onset and age at death of the patients. Numerous surviving cells showed neurofibrillary tangles, and in 3 cases senile plaques were present. The nucleolar volume of the large neurons was significantly reduced and the percentage reduction correlated with the percentage loss of cells. In contrast, the bnM was relatively unaffected in the other disorders considered. The involvement of bnM in Alzheimer's disease confirms the previous neuropathological observations, providing further evidence that it constitutes a constant anatomical feature of this disorder. The extent of the damage is age-dependent. The sparing of the bnM in simple senile dementia suggests that it may be a different nosological entity from late onset Alzheimer's disease and this may constitute a simple criterion for distinguishing between the two forms of dementia on an anatomical basis.

Neuronal loss in the basal nucleus of Meynert in progressive supranuclear palsy.

A morphometric study of the basal nucleus of Meynert (bnM) has been performed in a 70-year-old man with a 4-year history of pathologically confirmed progressive supranuclear palsy (PSP). An important neuronal loss (52%) was demonstrated in the bnM. This finding has not been previously documented with morphometric methods in PSP, but the involvement of the bnM is well known in other related conditions, i.e., Parkinson's disease, Alzheimer's disease, and Parkinson-dementia complex of Guam. Our findings yield support to the view that the involvement of the bnM, a nucleus with complex connections with various subcortical structures and diffuse cholinergic projections on the neocortex, could play an important role in the physiopatholog of subcortical dementia.