Impact of fibrosis on response to interferon therapy in Egyptian HCV patients.

Hepatitis C virus (HCV) infection is a global health problem which can lead to liver cirrhosis or hepatocellular carcinoma in one-fifth of chronically infected patients. HCV-4 infection is common in the Middle East and Africa, with an extraordinary high prevalence in Egypt. Interferon is a cytokine, a specific protein that is no stranger to the human body. In fact, the human body is constantly making interferon, and makes even greater amounts when trying to fight off an intruder, such as a virus. This work studied the impact of liver fibrosis on the efficacy of interferon in treating HCV.

Lupus nephropathy: clinical, immunohistochemistry and quantitative morphometric analysis studies.

Lupus nephritis includes a wide range of parenchymal injuries and severity. Better predictors to outcome are needed for patients newly diagnosed with lupus nephritis, so that an appropriate management strategy may be selected. This study aimed to determine whether the ratio of hepatocyte growth factor (HGF) to transforming growth factor beta 1 (TGF beta1) in lupus nephritis could be a prognostic factor for response to therapy with cyclophosphamide and steroids at six months. Also, to determine whether a simple automated system for objective scoring of biopsies of lupus nephritis could be a prognostic factor for response to therapy with cyclophosphamide and steroids at 6 months. Consequently, renal biopsy findings and clinical parameters of thirty parasites-free patients with new onset lupus nephritis were recorded. Histopathologic, clinical, immune-histochemical and morphometric data at baseline served to define the predictive value for outcome after 6 months of therapy. The results showed a significant positive relationship between response to therapy and HGF IS (P= 0.007), HGF ES (P= 0.026), HGF IS/ TGFbeta1 IS ratio (P= 0.022) and HGF ES/ TGFbeta1 ES ratio (P= 0.001). A significant inverse relationship was proved between response to therapy and TGFbeta1 IS (P= 0.025) as well as TGFbeta1 ES (P= 0.017). Also, a significant inverse relationship was present between response to therapy and nuclear index, tubular index and matrix index (P = 0.03, 0.03 and 0.029 respectively).

New concept of schistosomiasis lesions of urinary bladder versus development of bladder cancer.

Schistosomiasis haematobium precancerous lesions of urinary bladder included group 1: preneo-plastic non papillary (flat) lesions [reactive atypia, flat hyperplasia, keratinizing squamous metaplasia, glandular metaplasia, dysplasia, carcinoma in-situ (CIS)] and group 2 preneoplastic papillary lesions (typical papillary hyperplasia, atypical papillary hyperplasia, papilloma). The present work studied the content of the schistosomiasis precancerous lesions of the urinary bladder using image analyzer, thereby shedding more light on the significance on the early diagnosis of the high risky group. A total of 140 previously diagnosed schistosomiasis urinary bladder lesions (124 precancerous and 16 cancers as controls) were stained by H & E, and Feulgen stain. The mean SPF was high in CIS (22.7), dysplasia (19.6) & low in atypia (7.91). DNA ploidy, non-diploidy DNA was high in CIS (53%), papilloma, dysplasia and atypical papillary hyperplasia than flat hyperplasia, glandular metaplasia, keratinizing squamous metaplasia and typical papillary hyperplasia that were diploid indicating more tendency and aggressiveness of the first group to turn malignant than the second group.

HCV/PCR positivity in bile and doudenal aspiration of fascioliasis and/or HCV patients.

In this study, three bile aspirates taken from 10 fascioliasis patients (30.0%) showed HCV positivity by PCR/RNA. Also, four duodenal aspirates (66.7%) taken from six HCV/PCR-RNA positive patients and three duodenal aspirates (20%) taken from 15 pure fascioliasis patients showed HCV positivity by PCR/ RNA. This is the first time to demonstrate HCV/PCR-RNA in the bile and duodenal aspirates of fascioliasis patients and in the duodenal aspirates of HCV patients. So, PCR can be used for the detection of HCV in the bile and/or duodenal aspirates of HCV suspected patient. On the other hand, this outcome results may incriminate HCV infection as a concomitant with fascioliasis or incriminate fascioliasis as paving the way to HCV.

The liver profile in patients with hepatitis C virus and/or fascioliasis.

In this study, twenty HCV/PCR-RNA positive patients with neither infection nor infestation were 15 males and five females with ages ranging between 17-78 years old. Liver function tests: S. albumin was decreased in 15 patients (75%), total protein decreased in 3 patients (15%), total bilirubin increased in 7 patients (35%), AST/ALT increased in 3 patients (15%). Globulin value increased in 15 patients (75%). A/G ratio decreased in 12 (60%). Ten normal individuals (five males & five females), gave normal findings. However, a 19 years-old female had non significant elevation (0.26 mg/dl) in direct bilirubin. Liver function tests: one patient had increased AST/ALT, Globulin value decreesed (-0.2) in another one (10%) and A/G ratio increased (+0.3 to +0.6) in three (30%) individuals. Twenty randomly selected patients (15 males and five females) HCV/3rd generation ELISA showed ALT elevation in 17 (85%), AST in all (100%), S. albumin decreased in 9 (45%), and increased in 1 (5%). Total protein decreased in 3 (15%), total bilirubin increased in 7 (35%) and direct bilirubin in 4 (20%), AST/ALT value increased in 3 patients (15%), Globulin value increased in 15 patients (75%). A/G ratio decreased in 12 (60%). Three patients had schistosomiasis, one 30 years old male had increased AST/ALT, normal globulin, increased A/G and positive HBs-Ag. The second one was a 33-year-old male had normal AST/ALT, normal globulin, increased A/G and positive HBs-Ag. The third patient was a 19-year-old female with normal AST/ALT and normal globulin, increased A/G and positive HBs-Ag. Two patients had fascioliasis, one was a 20-year-old male with increased AST/ALT, globulin normal, A/G normal and negative HBs-Ag. The second one was a 26-year-old female with normal AST/ALT and normal globulin, increased A/G and positive HBs-Ag. The other four positive HBs-Ag patients were parasite-free. Also, the other HCV/ELISA positive were negative for HBs-Ag. HCV/ELISA may have cross-reacted with HBs-Ag and/or with elevated ALT and gave false positive HCV. The 3rd generation ELISA in detection of HCV was not as sensitive as PCR/RNA. Out of 41 fascioliasis patients (26 males & 15 females), 14 were positive HCV/ELISA (34.1%), but only six were positive HCV/PCR (14.6%). ALT increased in 18 fascioliasis patients (43.9%), AST in 23 patients (56.1%) but, albumin decreased in 7 patients (17.1%), total protein decreased in 5 (12.2%), but total bilirubin increased in 14 (34.1%) and direct bilirubin increased in 2 (4.9%). Liver function tests of 14 fascioliasis and ELISA positive HCV showed AST/ALT increased in 6 (42.9%), globulin increased in 3 (21.4%) and decreased in 6 (42.8%). A/G decreased in 4 (28.6%) and increased in 8 (57.2%). Liver function tests of pure 27 fascioliasis patients showed that AST /ALT increased in 8 (29.6%), globulin increased in one patient (3.7%) but decreased in 10 (37.0%) and A/G ratio increased in 13 (48.1%).

The clinical picture of hepatitis C virus as a concomitant infection with fascioliasis.

Hepatitis C and human fascioliasis are two of the most important public health problems locally and internationally. Each one has its own complications regarding spreading to man, clinical picture, laboratory and serologic diagnosis, treatment and prevention. Concomitant human infection with both magnified the complications. Clinically, both diseases (HCV and fascioliasis) have their own broad signs and symptoms. In concomitant infection, the clinical pictures of both showed some variations. The most common feature in fascioliasis and HCV patients was easy fatigability in 78.6% and the lowest was 7.18% for each of tympanic abdomen, tender colon, tender right upper quadrant, itching, arthritis, epi-gastric pain, and right quadrant pain. The eosinophilia % ranged from 5-24 and the haemoglobin ranged from 7-11.1 gm/dl. In patients with fascioliasis alone, the most come feature was pallor in 96.15% and the lowest was 3.85% for each of splenomegaly, ascites and itching. Eosinophilia % ranged from 1 to 22 and haemoglobin ranged from 6-12 gm/dl. In general, the double infection with both HCV and fascioliasis magnified the laboratory and clinical pictures of such patients.

A preliminary pilot survey (Culex pipiens), Sharkia Governorate, Egypt.

Sixteen different ecological areas in Sharkia Governorate were surveyed for adult Culex pipiens. The prevalence was investigated among 160 houses of 2800 individuals and their surrounding outdoors. The collected adults were 41488 from October 2003 to November 2004. The collection rates were higher in the rural areas than urban ones. Mosquitoes were common all the year round except January, February and March, with peaks in summer and autumn than in spring and winter. Larvae in descending order were Cx. pipiens the predominant larva followed by Ae. caspius, Culiseta sp. and then Cx. pusillus. Cx. pipiens was described as the most common larva.

Proliferative changes of epidermal cells in lesions of cutaneous leishmaniasis.

In 35 parasitologically proven zoonotic cutaneous leishmaniasis patients, the histopathological and immunohistochemical picture were studied. The haematoxylin and eosin stain, the monoclonal antibodies for T & B lymphocytes, peroxidase anti-peroxidase for P53 protein, and Feulgen staining for DNA imaging cytometry to DNA contents and S-phase (DNA synthesis of cycling cells were evaluated. The out-come results revealed that P53 and S-phase fraction and DNA content must be in mind when dealing with a human cutaneous leishmaniasis. Consequently, the early detection of any nuclear mutation and cellular proliferation in the skin leishmaniasis lesion(s) must be taken into consideration to avoid the miserable formation of the skin cancer.

The liver function profile in PCR-RNA Egyptian HCV-patients and normal controls.

No doubt, Hepatitis C virus (HCV) is a real health problem worldwide. The liver function tests (S.ALT, S.AST, Albumin, Total Protein, Total Bilirubin and Direct Bilirubin) were evaluated in 20 PCR-RNA positive HCV-patients and 10 cross matched apparently healthy population. All the HCV-patients and controls were free from liver helminthes. The results showed that in the HCV-patients, there was elevation in the level of S.ALT (17/20 or 85%), S.AST (20/20 or 100%), Total Bilirubin (7/20 or 35%), and (4/20 or 20%). Besides, there was neither a correlation between sexes nor the degrees of viraemia and the elevation of these four parameters. However, serum levels of Albumin, and Total Protein were within the normal range. On the other hand, in the controls the levels of the six tests were within the normal range. Nevertheless, only one control subject who had positive HBs-Ag, showed elevated Total Bilirulin and Direct Bilirubin. Consequently, these tests are indicative as useful and dependable markers in the non-invasive diagnosis of the hepatitis C virus (HCV).

Non-histological assessment of liver fibrosis in HCV infection.

This study found a correlation between some serum markers [AST/ALT ratio, level of matrix metalloproteinase 9 (MMP9), level of viraemia and HCV serotype] and severity of liver fibrosis in HCV-infected patients. The study included 72 human cases referred to the Early Cancer Detection Unit, for liver biopsy assessment. The severity of liver fibrosis was staged using the METAVIR scoring system into 4 stages. The level of viraemia did not differ significantly in the different stages of liver fibrosis. Also, the type of HCV had no effect on the severity of liver fibrosis. However, the transaminases ratio differed significantly in the different fibrosis stages (P < 0.01). This serum test has a relatively high sensitivity and specificity (92.6% and 94.3%, respectively) in diagnosing severe fibrosis and cirrhosis. The level of MMP9 was, however, inversely correlated with the fibrosis stages and was found to have an 88.9% sensitivity and an 88.6% specificity when diagnosing severe fibrosis and cirrhosis. Although, the sensitivity of these serum markers did not reach 100%, yet their use can reduce the number of liver biopsies when diagnosing and treating HCV-infected patients.

DNA ploidy and S-phase fraction in the patients of chronic HCV and hepatocellular carcinomas.

Four hundred blue Fulgen-stained nuclei were measured from each lesion by using DNA image cytometry. The histopathological and cytopathological observations revealed that (52 cases, 69.3%) had a variable degrees of chronic hepatitis, (12cases 16 %) were emerging into cirrhosis, while (11 cases 14.7%) represented different grades of HCC. Most of the cases with minimal or mild chronic hepatitis were female, while most of male had moderate or severe chronic hepatitis, cirrhosis and HCC. DNA image analysis data gave the support of to the histological observations. All of chronic hepatitis C and cirrhotic cases showed normal diploid and/or tetraploid histograms, although increasing S-phase fraction s' values of the highly diseased chronic hepatitis and cirrhotic cases. Hepatocellular carcinomas and one cirrhotic case only revealed aneuploidy (diploid and tetraploid), while one case of poorly differentiated HCC revealed multiploid histogram. So, histopathological severity in cases of progressive chronic hepatitis seems to be associated with the age and sex of Egyptian society. Also, demonstrates the potential usefulness of image cytometry for the evaluation of the different histopathological problems.

Hepatitis C virus infection at Sharkia Governorate, Egypt: seroprevalence and associated risk factors.

Because many persons with chronic hepatitis C virus (HCV) infection are asymptomatic, population based serologic studies are needed to estimate the prevalence of infection and to develop and evaluate prevention efforts. A sample of 1422 individuals was included in the study by using multistage sampling technique. Their age ranged from 4-78 years with a mean age (34.7 +/- 18.5), 782 were males (55%) and 640 were females (45%). Exposures and demographic characteristics were obtained through a predesigned questionnaire. Antibody to HCV was assessed using micro-particle enzyme immunoassay (MEIA) enzyme assay by IMX, and the HCV RNA was tested by Real-time PCR technique using ABI Prism 7700 system. The seroprevalence of antibodies to HCV were 23.4% and 27.4% in urban and rural areas respectively, with an overall prevalence (25.8%). This reflects prior HCV infection but not necessarily a current liver disease. Prevalence was higher among males than females and increased sharply with age, from 4.8% in those < 20 years old to (41.9%) in older ages (> or = 40 years). Those who were not educated and farmers had a significantly high prevalence. The significant predictors of HCV infection were previous parenteral therapy for schistosomiasis (OR = 4.3, 95% CI = 3.6-7.9), among those over 20 years of age (3.5, 2.18-5.8), blood transfusion (4.1, 2.4-6.9), invasive procedures (surgery and endoscopy), and use of contaminated syringes and needles. Also, shaving at community barbers added significance to the model. Exposures not significantly related to HCV seropositivity were gender, active infection with Schistosoma mansoni, sutures or intravenous and urinary catheterization, water pipe "goza" smoking in group.

New concept in histopathological grading and staging of chronic hepatitis C infection at Sharkia Governorate, Egypt.

Hepatitis C virus (HCV) has been estimated by the WHO to infect 170 million patients worldwide, with a high prevalence rate (about 24.5%) among Egyptians. The disease could be presented with variable hepatic lesions ranging from mild inflammation, fibrosis, cirrhosis to even end stage liver disease and hepatocellular carcinoma. The Knodell histology activity index, published in 1981, was the first system of its type and is widely regarded as the benchmark for objective, semi-quantitative reproducible description of the various morphological lesions of chronic hepatitis. Other proposals for semi-quantitative evaluation have followed. In this study, when applying these systems on the present cases (109 liver biopsies taken from Egyptian patients infected with HCV), the authors found that the presented histopathological features may be unusual for any of the known scoring systems. Therefore, they suggested a new system for grading and staging of liver diseases in Egyptian patients infected with HCV. Accordingly, the degrees of necroinflammations are classified into 3 grades (1-3) and the progression of fibrosis is classified into 3 stages (1-3). The reduced numbers of grades and stages proposed in this study may be attributed to the rapid course among Egyptians who differ in environmental circumstances from abroad.

Molecular cytogentic profiles of hepatitis C infection in patients at Sharkia Governorate, Egypt.

It has become apparent that hepatitis C virus (HCV) infection is a major risk factor for the development of hepatocellular carcinoma (HCC) worldwide. The precise mechanism by which HCV causes HCC is not known. Unlike the hepatitis B virus (HBV), HCV is not a DNA virus and does not become integrated within the genome of hepatocytes. It is more likely that HCC occurs against a background of inflammation and regeneration, associated with liver injury due to chronic hepatitis. In this study, 40 of paraffin blocks liver tissues from HCV-PCR positive patients (HBV seronegative) were examined using DNA image cytometry to evaluate its role in diagnosing HCC associated with HCV infection. Fluorescent in situ hybridization (FISH) technique using LSIZNF 217 chromosome 20q 13.2 probe was applied as well. The results showed high percentage of S-phase fraction in cases of G2S2 and G3S3 with DNA diploidy. Only two cases of G3S3 showed DNA aneuploidy with severe amplification of chromosome 20q 13.2. Consequently, DNA imaging cytometry is a good approach in differentiating dysplasia from well-differentiated HCC on top of HCV infection. In conclusion HCV has an acquired role in development of HCC through amplification of the aggressive tumor behavior oncogene LSIZNF 217 at chromosome 20q 13.2.

Autoantibodies in HCV infected patients at Sharkia Governerate, Egypt.

It is not clear whether HCV induces an autoimmune disease in infected patients or not. The aim of this study is to evaluate some immunological manifestations in chronic heapatitis C patients and to find out its relationship to liver pathology. The study included 109 positive HCV-RNA patients. They were classified according to liver histopathology into three groups: Group I included 22 patients (G1S1), Group II included 67 patients (G2S2) & Group III included 20 patients (G3S3), where G=The degree of necro-inflammatory process & S=Stage of liver fibrosis. All patients were investigated for the presence of: cryo-globulin, anti-neutrophil cytoplasmic (ANCA), anti-liver kidney microsomes (LKM), anti-double stranded DNA, (ds-DNA), anti-nuclear (ANA), anti-mitochondrial (AMA) and anti-smooth muscle (ASMA) auto-antibodies. The following results were obtained: ANCA, LKM, ds-DNA, ANA, ASMA, AMA and cryoglobulin were detected in 83/109 (76.1%), 32/109 (29.4%), 23/109 (21.1%), 38/109 (34.9%), 25/109 (22.9%), 5/109 (4.6%) and 60/109 (55%) of chronic HCV respectively. A highly significant positive correlation was found only between ANCA auto-antibodies and cryoglobulin versus grades of liver cirrhosis. Using ANCA, cryoglobulin, age and gender as covariates and by logistic regression analysis, Odds ratio (OR) revealed that these covariates were significant predictors of cirrhosis that add significance to the model according to the sequence: ANCA, cryoglobulin, age and gender suggesting that these covariates associate significantly with development of cirrhosis in HCV patients and that they are significant predictors of liver cirrhosis in HCV patients. The high prevalence of autoantibodies in chronic HCV patients suggests that HCV may trigger an autoimmune reaction, but most probably do not indicate a distinct autoimmune mechanism. Cryoglobulins and ANCA may be a useful prognostic indicator for increased risk of cirrhosis in chronic HCV patients. Follow up studies are recommended.

Haematologial manifestations in HCV infected patients at Sharkia Governerate, Egypt.

Hepatitis C virus (HCV) is a major cause of morbidity worldwide. The aim of this study is to evaluate hematological manifestations occurring in patients suffering from chronic HCV infection. Positive HCV-RNA cases (109) were subjected to the following C.B.C., P.T., P.T.T., B.T., C.T., detection of F.D.Ps., measurement of plasma AAT then B.M. aspiration and examination for 20 cases of them. Patients were classified into 3 groups according to the histopathological staging and grading of liver biopsy. Comparison between groups according to histopathological grading and staging for hematological and chemical parameters revealed significant statistical difference in platelets count, S. Albumin, ALT and AST levels. Comparison between groups according to histopathological grading and staging for coagulation profile, AAT level and FDPs revealed significant statistical difference regarding all parameters. Bone marrow aspiration and examination revealed mild hypocellularity with increased number of lymphocytes and relevance of plasmacytoid-lymphocytes. From this study we can conclude that patients with chronic HCV infection are in need for good observation and follow up before taking therapy because they have some hematological abnormalities which need more concern in order to decrease their progressive effect before starting therapy for HCV per se. They should be always screened and given liver and marrow supportive supplements.

HCV and associated concomitant infections at Sharkia Governorate, Egypt.

The natural history of hepatitis C virus (HCV) infection has a highly variable course. Many patients develop chronic infection, with its consequent risk of cirrhosis, liver failure and hepatocellular carcinoma. A key question is whether patients at high risk of disease progression can be distinguished from those with relatively benign disease course. The disease progression is influenced by other factors such as duration of infection, age at infection, sex, co-infection with hepatitis B virus (HBV), Epstein Bar virus (EBV), cytomegalovirus (CMV), the level of HCV viraemia and its type. Other endemic infections in the community as bilharziasis may have a role in progression of the condition to serious complications. These factors are correlated with newly proposed grades and stages of the disease. The studied (109) cases were divided into 6 groups according to the concomitant infection with HCV. The result proved that groups 1, 3 & 5 had a higher level of viraemia than other groups, and to be the high-risk groups as 56.4% and 34.6% were in G2S2 and G3S3, respectively. All cases of liver cell dysplasia and hepatocellular carcinoma in this study were seen in these groups. The conclusion showed that these factors play an important role in the progression of HCV infection. Death of the patients of this progressive condition occurs in younger age and is more due to liver failure than to HCC.

Non-invasive markers and predictors of severity of hepatic fibrosis in HCV patients at Sharkia Governorate, Egypt.

Liver biopsy is thought mandatory for management in patients with hepatitis C virus infection (HCV) especially for histopathological grading and staging of the disease to assess suitability for treatment and monitoring disease progression. However, tracking of liver disease progression can't rely on repeated biopsies. The study aimed to evaluate two significant items, we try to develop and validate a non-invasive predictive tool to assess hepatic necro-inflammation and fibrosis. Also, to determine factors that associate severity of hepatic pathology in HCV infected Egyptian patients particularly at Sharkia G. The study included 109 patients with detectable HCV by Real Time-PCR. The patients were classified into three different pathological stages and grades according to the new concept of histopathoglical staging and grading. The different clinical, biochemical, virological and ultra-sonographic parameters were assessed and analyzed and the variables that showed significant association with histopathological staging and grading were included in multivariate logistic regression analysis. The regression model revealed that, platelet count, matrix metalloproteinase-9 (MMP-9), portal vein diameter, splenic longitudinal axis, alanine transaminase, aspartate transaminase and viral load were the factors that add significance to the model in decreasing order of significance. From these findings we generate a new score ranged from 0-9. The score model was applied to our patients to assess its validity where it proved to be accurate in discriminating patients with mild inflammation and fibrosis (sensitivity 81.8%, specificity 80.5% and accuracy 80.7%) and more accurate in detecting patients with cirrhosis (specificity 96.6%, sensitivity 80% & accuracy 93.6%) but less accurate in detecting patients with moderate to severe fibrosis (specificity 66.7%, sensitivity 68.7% & accuracy 67.9%). Also the results revealed that, co-infection with schistosomiasis, old age > or = 45 years and positive history of blood transfusion as a source of infection was significantly associated with severe hepatic pathology. It is concluded that, the score model can't completely replace liver biopsy but at least it could be used to substantially reduce the number of liver biopsies done in patients with HCV infection in assessing disease progression during follow up. Also, it can be used to make decisions about treatment in patients who have contraindications to or who refused liver biopsy. Co-infection with schistosomiasis, age > or = 45 and positive history of blood transfusion in patients with HCV warrant special attention with more intensive follow up. These factors may play a major role in forecasting the course of HCV as well as in determining the therapeutic approach in each case.

The role of aflatoxin-contaminated food materials and HCV in developing hepatocellular carcinoma in Al-Sharkia Governorate, Egypt.

Aflatoxins, particularly aflatoxin B1 (AFB1) have been recognized as one of the most potent chemical carcinogen. In Egypt, HCV is prevalent. The progressive nature of HCV-related liver diseases was found to be influenced by other factors. In this paper, the role of aflatoxin contamination in the onset of liver cancer in HCV-infected patients was studied. The quantitative identification of the possible aflatoxins contamination in six urban and eleven rural areas using high performance liquid chromatography technique, revealed that corn, wheat, pea nut, lupine "termis", white rice, cowpea "lobiya", fava bean and brown rice showed the prevalence of AFB1 to be 64.7%, 53%, 53%, 47%, 47%, 41%, 29.4% & 29.4% respectively. A positive correlation was found between aflatoxin and positive HCV-PCR together with liver disease progression to G3S3, the indicative of hepatocellular carcinoma. Such correlation was not fully understood, but the oncogene amplification caused by HCV-infection may be aggravated by the consumption of aflatoxin contaminated raw food materials or their products.