High Risk Of Reinfection Research Articles

Tantalum Acetabular Augments in One-stage Exchange of Infected Total Hip Arthroplasty: A Case–control Study

During the one-stage exchange procedure for periprosthetic joint infection (PJI) after total hip arthroplasty (THA), acetabular defects challenge reconstructive options. Porous tantalum augments are an established tool for addressing acetabular destruction in aseptic cases, but their utility in septic exchange is unknown. This retrospective case–control study presents the initial results of tantalum augmentation during one-stage exchange for PJI. Primary endpoints were rates of re-infection and short-term complications associated with this technique. Study patients had no higher risk of re-infection with equivalent durability at early follow-up with a re-infection rate in both groups of 4%. In conclusion, tantalum augments are a viable option for addressing acetabular defects in one-stage exchange for septic THA. Further study is necessary to assess long-term durability when compared to traditional techniques for acetabular reconstruction.

Rifamycin drugs as alternatives to standard isoniazid treatment to prevent active tuberculosis (TB) in HIV-negative people at risk of developing active TB

In preventing active TB in patients with LTBI with shorter durations of treatment all the regimens included in this review seem to achieve this goal. Most were from the developed countries. In developing countries with high risk of reinfection, the duration of protection offered by a single course of chemoprophylaxis is unknown. In settings where exclusion of active TB can be problematic, TB chemoprophylaxis (especially with rifampicin-containing regimens) needs to be used with great caution.Research is urgently required into understanding the pathogenesis of latent TB disease, biomarkers to predict progression, improved diagnostics for LTBI and effective treatment regimens for latent infection with drug resistant TB. Cost-effectiveness and implementation research will be required to determine the best strategies to scale-up LTBI treatment at a population level.

Hepatitis C virus reinfection incidence and treatment outcome among HIV-positive MSM

Liver disease secondary to hepatitis C virus (HCV) infection in the context of HIV infection is one of the leading non-AIDS causes of death. Sexual transmission of HCV infection among HIV-positive MSM appears to be leading to increased reports of acute HCV infection. Reinfection after successful treatment or spontaneous clearance is reported among HIV-positive MSM but the scale of reinfection is unknown. We calculate and compare HCV reinfection rates among HIV-positive MSM after spontaneous clearance and successful medical treatment of infection. Retrospective analysis of HIV-positive MSM with sexually acquired HCV who subsequently spontaneously cleared or underwent successful HCV treatment between 2004 and 2012. Among 191 individuals infected with HCV, 44 were reinfected over 562 person-years (py) of follow-up with an overall reinfection rate of 7.8/100 py [95% confidence interval (CI) 5.8-10.5]. Eight individuals were subsequently reinfected a second time at a rate of 15.5/100 py (95% CI 7.7-31.0). Combining all reinfections, 20% resulted in spontaneous clearance and treatment sustained viral response rates were 73% (16/22) for genotypes one and four and 100% (2/2) for genotypes two and three. Among 145 individuals with a documented primary infection, the reinfection rate was 8.0 per 100 py (95% CI 5.7-11.3) overall, 9.6/100 py (95% CI 6.6-14.1) among those successfully treated and 4.2/100 py (95% CI 1.7-10.0) among those who spontaneously cleared. The secondary reinfection rate was 23.2/100 py (95% CI 11.6-46.4). Despite efforts at reducing risk behaviour, HIV-positive MSM who clear HCV infection remain at high risk of reinfection. This emphasizes the need for increased sexual education, surveillance and preventive intervention work.

Relapses Contribute Significantly to the Risk of Plasmodium vivax Infection and Disease in Papua New Guinean Children 1–5 Years of Age

Plasmodium vivax forms long-lasting hypnozoites in the liver. How much they contribute to the burden of P. vivax malaria in children living in highly endemic areas is unknown. In this study, 433 Papua New Guinean children aged 1-5 years were Randomized to receive artesunate (7 days) plus primaquine (14 days), artesunate alone or no treatment and followed up actively for recurrent Plasmodium infections and disease for 40 weeks. Treatment with artesunate-primaquine reduced the risk of P. vivax episodes by 28% (P = .042) and 33% (P = .015) compared with the artesunate and control arms, respectively. A significant reduction was observed only in the first 3 months of follow-up (artesunate-primaquine vs control, -58% [P = .004]; artesunate-primaquine vs artesunate, -49% [P = .031]) with little difference thereafter. Primaquine treatment also reduced the risk of quantitative real-time polymerase chain reaction- and light microscopy-positive P. vivax reinfections by 44% (P < .001) and 67% (P < .001), respectively. Whereas primaquine treatment did not change the risk of reinfection with Plasmodium falciparum, fewer P. falciparum clinical episodes were observed in the artesunate-primaquine arm. Hypnozoites are an important source of P. vivax infection and contribute substantially to the high burden of P. vivax disease observed in young Papua New Guinean children. Even in highly endemic areas with a high risk of reinfection, antihypnozoite treatment should be given to all cases with parasitologically confirmed P. vivax infections.

Low incidence of reinfection with the hepatitis C virus following treatment in active drug users in Amsterdam

More than two-thirds of hepatitis C virus (HCV) infections are associated with injecting drug use. Despite the wide availability of standard treatment with pegylated interferon and ribavirin, active drug users (DU) have limited access to HCV treatment. Physicians may be reluctant to prescribe treatment because of the presumed high risk of reinfection. However, data on reinfection in treated DU remain scarce. Active DU with chronic HCV infection were treated in a multidisciplinary setting. After achieving a sustained virologic response, patients were tested at 6-12-monthly intervals for HCV RNA. To distinguish between relapse and reinfection, sequence and phylogenetic analyses were performed on the NS5B region of the HCV genome. The incidence of reinfection was calculated using person-time techniques. From April 2005 to March 2010, 69 active DU treated for HCV had sufficient follow-up, median 2.5 years (interquartile range, 1.6-3.7). Sustained virologic response was achieved in 42 patients (61%). During follow-up, 41 patients remained HCV RNA-negative; of these, two patients died. During treatment, five out of 41 injected drugs, which increased to 11 out of 41 after the end of treatment. One case of reinfection was observed, followed by spontaneous clearance of the virus. The overall incidence was 0.76/100 person-years (95% confidence interval 0.04-3.73). For only those individuals reporting injecting drug use, the incidence was 3.42/100 person-years (95% confidence interval 0.17-16.90). We report a low incidence of HCV reinfection following treatment in DU participating in a multidisciplinary programme. Active drug use, including injecting, should not preclude access to treatment for HCV.

Novel extra-anatomic intra-abdominal reconstruction for treatment of paravisceral aortic infection

Adequate treatment of native or prosthetic aortic infection requires extensive surgical debridement and establishing flow to the extremities using extra-anatomic or in situ reconstruction, each with its inherent limitations. Infection of the paravisceral aortic segment precludes an axillofemoral bypass as the sole treatment because of inability to provide visceral perfusion. In situ autograft or allograft reconstructions could be limited by conduit availability or significantly prolonged operative time, or both. Placement of an antibiotic-soaked prosthetic in a field with gross purulence carries a high risk of reinfection. We describe a technique for extra-anatomic, intra-abdominal reconstruction using an antibiotic-soaked prosthetic graft to avoid the infected paravisceral aortic bed and achieve antegrade lower extremity and visceral vessel perfusion.

Syphilis Testing Behavior Following Diagnosis With Early Syphilis Among Men Who Have Sex With Men—San Francisco, 2005–2008

In San Francisco, men who have sex with men (MSM) with early syphilis are at high risk of reinfection. We described syphilis testing behavior among MSM after diagnosis, identified factors associated with not testing, and developed algorithms to identify nontesters. We used syphilis surveillance data from 2005 through 2008 to describe follow-up testing behavior among MSM with early syphilis and titers of non-treponemal serologic tests ≥1:16. We analyzed data from contact-tracing interviews to identify factors associated with not testing during the 1 to 6 months post-diagnosis. We developed and applied a multivariate model in a derivation set (2005-2006) and a validation set (2007-2008), respectively, calculating correct classification rates (CCR) to assess predictive ability and evaluating patient characteristics for potential interventions. Among 795 MSM, 260 (33%) did not have a follow-up syphilis test. Not testing was associated with being HIV-uninfected (risk ratio [RR]: 1.9, 95% confidence interval [CI]: 1.5-2.6), residing outside of San Francisco's gay-identified neighborhood (RR: 1.7, 95% CI: 1.0-2.9), and being diagnosed at the municipal sexually transmitted disease clinic (RR: 1.5, 95% CI: 1.2-2.0) (CCR derivation set, 71.6%; CCR validation set, 71.3%). An intervention focusing on MSM with those 3 characteristics would include 13% of syphilis cases among MSM and identify 26% of nontesters. Although MSM in San Francisco are at high risk for syphilis reinfection, one-third of MSM diagnosed with syphilis did not test during the 1 to 6 months post-diagnosis. Interventions to encourage follow-up testing among persons with syphilis might contribute to more effective syphilis prevention and control efforts.

Chlamydia trachomatis Infection in Minority Adolescent Women: A Public Health Challenge

Chlamydia trachomatis is the most common bacterial sexually transmitted infection in the United States. This disease disproportionately affects adolescent minority women, and untreated infection can lead to lasting reproductive tract morbidity. Recommendations for primary prevention include patient counseling to decrease risky behavior and increase barrier protection use; secondary prevention recommendations include screening and treatment of affected individuals and their sexual partners, barrier contraception use, as well as counseling to decrease behaviors that lead to reinfection. Despite these strategies, both incidence and prevalence of Chlamydia have continued to escalate in this population. Interventions to decrease chlamydial infection should encompass all facets of primary and secondary prevention as well as address the fundamental barrier to prevention-lack of perception of risk in this young age group. Obstetricians & Gynecologists, Family Physicians. After completion of this educational activity, the obstetrician/gynecologist should be better able to identify current screening guidelines to test for chlamydial infection in sexually active adolescents; obtain more thorough sexual histories, and understand dynamics of disproportionate disease burden in minority teens; recognize and act to decrease the high risk of reinfection in this patient population; and employ novel methods to increase STI screening.

Factors Associated With Sexually Transmitted Infections in Men and Women

Background: Sexually transmitted infections (STIs) remains a serious healthcare problem costing approximately 13 billion dollars annually to treat. Men and women who contract STIs have a higher risk for reinfection and for developing human immunodeficiency virus (HIV). Determining the risk factors associated with STIs in a community would be helpful in designing culturally appropriate tailored interventions to reduce spread of STIs. Purpose: The purpose of this retrospective chart review was to determine the frequency and type of STIs, as well as to determine the predictor variables associated with STIs among those seeking treatment at a local inner city health unit. Method: A total of 237 medical records were reviewed from a STI clinic. The sample comprised 119 men and 118 women, of whom 70.9% were African American. The mean age was 27, and 38% had a prior STI. Men used significantly more condoms (χ2 = 24.28, p = 0.000), had more sexual partners (χ2 = 18.36, p = 0.003), and had more prior infections of gonorrhea (χ2 = 10.04, p =0.002) than women. Women had significantly more prior infections of Chlamydia (χ2 = 11.74, p = 0.001). Using no type of birth control measures (pills, diaphragm, implants) was a significant predictor of number of sexual partners (t = 2.441, p < 0.015), but negatively associated with condom use (t = −12.290, p < 0.000). Conclusions: Over one-third had a prior STI, indicating that individuals do not perceive themselves to be at risk for another STI, and choose not to use condoms. Reasons why individuals continue to put themselves at risk need to be explored in gender specific focus groups so that tailored sexual risk reduction programs can be designed to meet the needs of different communities.

Preferred Strategies of Men and Women for Managing Chlamydial Infection

Early identification and treatment of sexual partners of women with chalmydial infection is critical because of the high risk of reinfection primarily as a result of resumption of sex with an untreated partner. Management strategies used for identifying and testing sexual partners for possible infection include: (1) partner notification (patient referral) of the sexual partner to a clinic for testing and treatment; (2) patient-delivered partner medication (PDPM) which involves the delivery of antibiotics by the patient to sexual partners; and, (3) a postal testing kit which involves asking partners to mail a urine sample to a laboratory. To determine preference of patients and their sexual partners for one of these strategies, the investigators employed interviewer-conducted questionnaires in women and anonymous, self-administered questionnaires in men. The study subjects were women infected with chlamydia already participating in a study randomizing them to receive one of these strategies, and men attending genitourinary clinics, family planning clinics and hospital fracture clinics. The response rates for the women's questionnaire were 97% (174/180) at study entry and 81% (145/180) at 6-month follow up. For the men's questionnaire, the response rate was 81%. Over two-thirds of the women respondents (67%) preferred PDPM for their partner if given the choice; the majority (57%) also chose PDPM for themselves if a partner tested positive for Chlamydia. The most common reasons given by women for preference of PDPM were greater simplicity and convenience, and quicker treatment of partners. Ninety-three of 142 women (65%) reported that their partners were satisfied with whichever intervention they were randomized to receive. Of the 293 men who responded, 70% preferred patient referral for partners and 53% chose this intervention for themselves. PDPM was more likely to be the preference of men previously tested for Chlamydia (n = 22) compared to those never tested (n = 7) (P < 0.001). Less than 5% of women and 10% of men preferred postal testing kits for partners. The investigators conclude from these findings that PDPM appears to be more popular with women, and at least in theory, patient referral is more popular with men.

Discussing Treatment Options

A sixty-year-old man presented to an orthopaedic surgeon with a periprosthetic infection after total knee arthroplasty performed by another surgeon. He underwent removal of the components, placement of an antibiotic spacer, and antibiotic suppression therapy. Eight weeks later, a revision total knee arthroplasty was performed. The patient did well initially but returned four months after the revision with periprosthetic reinfection. The revision components were removed, another antibiotic spacer was placed, and antibiotic suppression therapy was again administered. During the operation, the entire extensor mechanism, including the quadriceps tendon, patella, and patellar tendon, was found to be necrotic and required radical débridement. Five months later, another operation was performed to remove the spacer, and a plastic surgeon was consulted to assist in the wound closure because of the presence of extensive scar tissue. Intraoperative cultures were negative during these two most recent procedures. The orthopaedic surgeon presented the patient with four treatment options: arthrodesis, resection arthroplasty, amputation, or revision total knee arthroplasty with extensor mechanism allograft and a possible flap closure (rotational or free flap). The patient refused a knee arthrodesis and voiced a strong preference for amputation over arthrodesis. The patient's first choice, however, was to save the knee and to have a second radical revision performed. The surgeon then discussed in detail the risks that would be involved with reconstruction, including the high risk of reinfection and other wound complications. An infection, he explained, could lead to amputation, sepsis, and death. The surgeon also informed the patient that the procedure was not commonly performed, had no proven success rate, and could be fraught with complications. The patient remained steadfast in his choice and elected to undergo radical reconstruction of the knee.

Control of bovine virus diarrhoea at the herd level: Reducing the risk of false negatives in the detection of persistently infected cattle

The need to detect and eliminate cattle persistently infected (PI) with bovine viral diarrhoea virus (BVDV) is key to the control of BVD and has been shown to be very effective in eradicating BVDV from infected herds. However, because of pitfalls in the detection procedures, some PI animals can be missed and, as a result, are not identified and removal is delayed. The high prevalence of BVDV in cattle populations in some countries (such as Belgium and neighbouring countries) means there is a high risk of reinfection of a herd from which BVDV has been eradicated. Based on both practical experience and a literature study, this review considers those points that are critical to minimising the number of false negatives in the detection of PI cattle.

Artemether-Lumefantrine versus Dihydroartemisinin-Piperaquine for Treating Uncomplicated Malaria: A Randomized Trial to Guide Policy in Uganda

BackgroundUganda recently adopted artemether-lumefantrine (AL) as the recommended first-line treatment for uncomplicated malaria. However, AL has several limitations, including a twice-daily dosing regimen, recommendation for administration with fatty food, and a high risk of reinfection soon after therapy in high transmission areas. Dihydroartemisinin-piperaquine (DP) is a new alternative artemisinin-based combination therapy that is dosed once daily and has a long post-treatment prophylactic effect. We compared the efficacy and safety of AL with DP in Kanungu, an area of moderate malaria transmission.Methodology/Principal FindingsPatients aged 6 months to 10 years with uncomplicated falciparum malaria were randomized to therapy and followed for 42 days. Genotyping was used to distinguish recrudescence from new infection. Of 414 patients enrolled, 408 completed follow-up. Compared to patients treated with artemether-lumefantrine, patients treated with dihydroartemisinin-piperaquine had a significantly lower risk of recurrent parasitaemia (33.2% vs. 12.2%; risk difference = 20.9%, 95% CI 13.0–28.8%) but no statistically significant difference in the risk of treatment failure due to recrudescence (5.8% vs. 2.0%; risk difference = 3.8%, 95% CI −0.2–7.8%). Patients treated with dihydroartemisinin-piperaquine also had a lower risk of developing gametocytaemia after therapy (4.2% vs. 10.6%, p = 0.01). Both drugs were safe and well tolerated.Conclusions/SignificanceDP is highly efficacious, and operationally preferable to AL because of a less intensive dosing schedule and requirements. Dihydroartemisinin-piperaquine should be considered for a role in the antimalarial treatment policy of Uganda.Trial RegistrationControlled-Trials.com ISRCTN75606663

Environmental and personal risk factors for toxocariasis in children with diagnosed disease in urban and rural areas of central Poland

To investigate the epidemiology of human toxocariasis a field survey was carried out at homes of 194 children (80 of rural and 114 of urban origin) with diagnosed disease from central Poland. A questionnaire referring to the possible risk factors was directed to their parents. Overall contamination rate of soil by Toxocara eggs was 27.5% in rural and 21.1% in urban environment in the households examined, with difference not significant ( χ 2 = 1.08, p = 0.2986). In rural settlements 29.3% of yards surrounding houses were found contaminated, whereas in urban 25.0% of family gardens, 26.4% of private yards and 10.7% of public sandpits were positive. Frequency of positive samples differs only for rural yards and urban sandpits ( χ 2 = 3.85, p = 0.0499). The study showed a high risk of reinfection for the ill children in sites of their residence. Despite diagnosed toxocariasis kids were not adequately supervised by their parents with no measures undertaken to avoid further infection. These data present strong need for educational programs which should be implemented for prevention of Toxocara infections in children.

Comparative recognition by human IgG antibodies of recombinant proteins representing three asexual erythrocytic stage vaccine candidates of Plasmodium vivax

In previous immuno-epidemiological studies of the naturally acquired antibody responses to merozoite surface protein-1 (MSP-1) of Plasmodium vivax, we had evidence that the responses to distinct erythrocytic stage antigens could be differentially regulated. The present study was designed to compare the antibody response to three asexual erythrocytic stage antigens vaccine candidates of P. vivax. Recombinant proteins representing the 19 kDa C-terminal region of MSP-1(PvMSP19), apical membrane antigen n-1 ectodomain (PvAMA-1), and the region II of duffy binding protein (PvDBP-RII) were compared in their ability to bind to IgG antibodies of serum samples collected from 220 individuals from the state of Pará, in the North of Brazil. During patent infection with P. vivax, the frequency of individuals with IgG antibodies to PvMSP1(19), PvAMA-1, and PvDBP-RII were 95, 72.7, and 44.5% respectively. Although the frequency of responders to PvDBP-RII was lower, this frequency increased in individuals following multiple malarial infections. Individually, the specific antibody levels did not decline significantly nine months after treatment, except to PvMSP1(19). Our results further confirm a complex regulation of the immune response to distinct blood stage antigens. The reason for that is presently unknown but it may contribute to the high risk of re-infection in individuals living in the endemic areas.

Longevity of naturally acquired antibody responses to the N- and C-terminal regions of Plasmodium vivax merozoite surface protein 1.

In an earlier study, we found that individuals with patent infection had significantly higher IgG antibody titers to the 19-kD C-terminal region of Plasmodium vivax merozoite surface protein 1 (PvMSP1) than individuals treated for malaria 1-4 months earlier. These results suggested that the antibody levels decreased rapidly following treatment. The present study was designed to determine the persistence of antibody response to the N- and C-terminal regions of PvMSP1 after infection with P. vivax in individuals from the city of Bélem in northern Brazil. Our results demonstrated that the vast majority of individuals had a significant decrease in antibody titers to the C-terminal region of PvMSP1 in a period of two months following treatment. Among responders to the C-terminal region, 44.4% became serologically negative and 44.4% had their antibody titers reduced by an average of 13-fold. Only 11.2% of the individuals had their antibody titers maintained or slightly increased during that period. A decrease in the antibody response to the recombinant protein representing the N-terminal region of PvMSP1 was also noted; however, it was not as dramatic. The rapid decrease in the antibody levels to the C-terminal region of PvMSP1 might contribute to the high risk of reinfection in these individuals.

Antibodies against the GB virus C envelope 2 protein before liver transplantation protect against GB virus C de novo infection.

GB virus C (GBV-C) is a newly discovered RNA virus related to the Flaviviridae family. Although GBV-C is not yet associated with any cause of liver disease, a humoral immune response against the GBV-C envelope 2 (E2) protein has been observed. Therefore, we studied the prevalence and clinical relevance of GBV-C RNA and anti-E2 antibodies in patients undergoing orthotopic liver transplantation (OLT). In addition, we tested whether the prevalence of anti-E2 antibodies may protect against GBV-C infection. Of the 182 liver recipients included in this study, 117 of these were evaluated for GBV-C recurrence or de novo infection. GBV-C RNA was detected in sera or plasma using single-tube, reverse-transcriptase polymerase chain reaction, and anti-E2 antibody was detected by enzyme immunoassay (EIA). Cumulative patient and graft survival was tested by using Kaplan-Meier analysis. The independence of prognostic values was assessed by using Cox regression analysis. Before OLT, GBV-C RNA and anti-E2 were detected in 4.0% to 28.6% and 10.0% to 68.8%, respectively, of patients suffering from different forms of chronic liver diseases. GBV-C reinfection after OLT was determined in 85.7%. Of the patients without evidence of exposure to GBV-C before OLT, 30 of 65 (46.2%) became GBV-C RNA positive after OLT. None of the 38 patients who were anti-E2 antibody positive before OLT became GBV-C RNA positive after OLT. Neither patient nor graft survival was significantly affected by the presence of either GBV-C RNA or anti-E2 antibody before OLT. Our data indicate that 1) GBV-C RNA positive patients have a high risk of reinfection after OLT, and 2) the presence of anti-E2 antibodies before OLT is associated with an absence of GBV-C infection after OLT, which may indicate a protective role of anti-E2 antibodies.

Prevalence and clinical presentation of glucose-6-phosphate dehydrogenase deficiency in Pakistani Pathan and Afghan refugee communities in Pakistan; implications for the use of primaquine in regional malaria control programmes

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency surveys in Afghan refugees and a local community in the North-West Frontier Province, Pakistan, showed that this trait was most common among Pathan and Uzbak refugees (15·8% and 9·1% respectively). The prevalence among Pakistani Pathans was 7·0%, and that in Tajik and Turkoman refugees was 2·9% and 2·1% respectively. Hospital studies showed that the type of G-6-PD deficiency in Pathans could cause severe haemolytic crises. The potentially fatal side effects of primaquine treatment in the Pathan communities, and the high risk of re-infection, render the antirelapse treatment policy for Plasmodium vivax obsolete. However, epidemic conditions of P. falciparum malaria may justify the use of primaquine as a gametocidal drug, administered as a single dose, during the transmission season. These findings necessitate revision of the recommendations for the use of primaquine in the area.

PROSTAGLANDIN E IN THE TREATMENT OF RECURRENT HEPATITIS B INFECTION AFTER ORTHOTOPIC LIVER TRANSPLANTATION

While orthotopic liver transplantation (OLT) has become the treatment of choice for most irreversible end-stage liver diseases, its role in patients with hepatitis B (HBV) infection is controversial. A high risk of reinfection of the transplanted graft, associated with significant morbidity and mortality, has been reported. Although passive and active immunization can delay reappearance of the virus in the allograft, there is not yet an effective therapy for recurrent HBV infection in liver transplant recipients. Between October 1985 and March 25, 1991, 28 OLT in 25 patients with acute and chronic HBV infections were performed. Twelve of the patients were HBV DNA-negative, six were HBV DNA-positive, and seven were not tested prior to transplantation. Only the 19 patients surviving more than 100 days after transplantation were considered to have sufficient duration of follow-up (mean 734 days; range 500-1545) to include in analysis of recurrence. Five (26%) were free of recurrent disease at the time of last follow-up (mean 1031 days, range 526 to 1770 days. Recurrent HBV in the allograft, as defined by positive immunoperoxidase stains of biopsy sections for viral antigens, was detected in 74% (13 male, 1 female; 7 Asian, 7 white) at a mean of 134 days posttransplantation. Histological changes of viral hepatitis, first appearing an average of 157 days (range 95-326) posttransplantation, were evident in 13 of 14 with positive immunostaining. Twelve of the 14 patients were treated, on an open trial basis, with intravenous and oral prostaglandin E (PGE) because of deteriorating clinical condition. Eleven of the twelve responded to PGE with an initial drop in serum transaminases, improvement in coagulopathy and resolution of encephalopathy. One patient failed to respond and died of a myocardial infarction within 9 days of institution of therapy. Three of the eleven patients with an initial response relapsed and died in liver failure as a direct result of recurrent HBV after 13, 16, and 37 days of treatment in association with generalized sepsis. Eight of the 12 patients (67%) had a sustained favorable response to PGE therapy (mean follow-up 737 days, range 403-1545). All patients with a sustained response had accompanying improvement in histology and reduction in viral antigen staining in hepatocytes. Treatment with PGE appeared to be of benefit in recurrent HBV infection of the transplanted liver with an initial response rate of 92% and a sustained response rate of 67%.

Patterns of hepatitis delta virus reinfection and disease in liver transplantation

Twenty-seven carriers of the hepatitis B surface antigen who underwent liver transplantation in Italy and Belgium for terminal Hepatitis delta virus (HDV) cirrhosis were investigated. In 22 of the patients, HDV infection recurred. Two patients died of coexisting HDV and hepatitis B virus (HBV) reactivation. Four patients who died of unrelated causes were found to have HDV without signs of HBV reactivation. Five patients (18%) cleared both HBV and HDV after transplantation with no evidence of hepatitis (mean follow-up, 29 months). In many surviving patients, HDV infection recurred early without signs of HBV reactivation. Disease returned in the 11 HDV-infected patients in whom HBV also recurred. Histological hepatitis did not recur during an interim of 12–33 months in the 5 HDV-infected patients in whom HBV did not return. The overall medium-term survival in patients with HDV who underwent transplantation was 77.7%. Liver transplantation offers patients with HDV a hope of cure from disease despite a high risk of reinfection. In the transplantation setting, HDV can cause subclinical infections without any apparent assistance from HBV; these infections become symptomatic only if and when HBV reactivates. Thus, HDV may not be in itself pathogenic but requires cooperation from HBV to cause the appearance of the disease.