Risk Factors For Viral Hepatitis Research Articles

Evaluation of Risk Factors for Viral Hepatitis C in Chad

Evaluation of Risk Factors for Viral Hepatitis C in Chad

S3253 A Case of Recurrent Ascites Secondary to Ventriculoperitoneal Shunt in a Patient With Idiopathic Intracranial Hypertension

Introduction: Idiopathic Intracranial Hypertension (IIH) is a rare diagnosis affecting approximately 0.9–3/100,000 adults, mostly females of childbearing age with obesity. Surgical intervention is usually indicated in cases that prove refractory to conservative measures (such as weight loss and acetazolamide) or in cases of progressive papilledema and visual deficit. Ventriculoperitoneal shunt (VPS) is the preferred internalized cerebrospinal fluid diversion method. Here, we present a case of VPS causing ascites in a woman with IIH. Case Description/Methods: A 33-year-old female smoker with obesity, hypertension, and IIH with VPS (Medtronic strata valve, set to 1.0., placed six years ago for headache and visual problems) presents to the ED with increased abdominal distention and discomfort along with shortness of breath. She underwent a paracentesis two weeks prior for new ascites. Paracentesis showed no malignant cells. She had no family history of gastrointestinal pathology, no risk factors for viral hepatitis, and negative hepatitis serologies. She started noticing re-accumulation of fluid that did not improve with prescribed furosemide. She had no other symptoms including fevers, chills, or neurological symptoms. Physical exam showed ascites with a normal neurologic exam. Liver function tests were normal. CT abdomen and pelvis showed an unremarkable liver and VPS catheter without kinking. Pelvic ultrasound was unrevealing except for an ovarian cyst. Repeat paracentesis showed SAAG (Serum Ascites Albumin Gradient) 0.8, WBC 650 cells/ul, and only 10% polymorphonuclear cells (PMN). Culture of peritoneal fluid was positive for Cutibacterium acnes. The patient completed an antibiotics course and underwent a removal of the distal (peritoneal) catheter of the VPS that led to resolution of her ascites. Discussion: We present a case of recurrent ascites resolution following VPS removal. Cerebrospinal fluid (CSF) ascites is one of the rarest intra-abdominal complications of VPS. Only 29 cases have been described in the literature and only six of them were in adults. In such cases, VPS are removed and Ventriculo-pleural or Ventriculo-atrial shunts are placed. While pathophysiology behind IIH is hypothesized to be due to inability of CSF to be reabsorbed by arachnoid granulations and extracranial lymphatics, there is no satisfactory explanation in the literature regarding the pathophysiology of CSF ascites due to VPS. It is suspected that our patient’s infected VPS caused device malfunction leading to ascites.

S3259 A Case of Propofol-Induced Acute Liver Failure

Introduction: Propofol is a parenteral anesthetic routinely used for procedures given its beneficial pharmacokinetic profile of rapid onset of action and reversal. Propofol drug toxicity is rare but has been associated with idiosyncratic acute liver injury in a small number of cases. To the best of our knowledge, we present the second case of propofol-induced acute liver failure (ALF) reported in literature. Case Description/Methods: An 88-year-old male with concern for gastrointestinal bleed underwent an upper endoscopy with propofol used as the anesthetic agent. The patient tolerated the endoscopy well with no hemodynamic compromise during or afterwards. No source of bleeding was identified so the plan was to proceed with a colonoscopy the next day. Shortly after the procedure, he was noted to have altered mental status. Evaluation with routine laboratory testing revealed elevated AST of 3248 IU/L and ALT of 2411 IU/L, both increased from 35 IU/L and 24 IU/L, respectively. He was also found to have high anion gap metabolic acidosis and bicarbonate level less than 9 mEq/L. His altered mentation continued to worsen, and he became hemodynamically unstable requiring transfer to the intensive care unit. He had no history of liver disease or excessive alcohol use, no risk factors for viral hepatitis, and took no medications known to cause liver injury. Work-up was unremarkable for acute and chronic liver disease. Propofol was ultimately surmised as the cause of ALF. Unfortunately, the patient’s mental status progressively worsened despite hemodynamic stabilization and normalization of liver enzymes. His family ultimately chose to transition to comfort measures and the patient passed soon after. Discussion: The incidence of drug-induced liver injury is increasing in developed countries and is a major etiology of ALF, accounting for greater than 50% of cases. Drug toxicity secondary to an idiosyncratic reaction is unpredictable and occurs infrequently in certain individuals. While propofol is generally considered a safe agent widely used for sedation, propofol-induced acute liver injury is a rare outcome. To the best of our knowledge, it is reported to have caused five cases of acute hepatitis and one other case of ALF. We report the second case of ALF due to propofol with a lethal outcome. We recommend close monitoring of patients treated with propofol for signs of hepatitis and that ALF due to a drug insult should be considered after common causes have been excluded.

20-Year-Old Man With Elevated Liver Tests

20-Year-Old Man With Elevated Liver Tests

Prevalence of hepatitis B in HIV-positive patients in Zabol

Today, due to the increase in life expectancy in HIV-infected patients, the incidence of related diseases such as hepatitis B and C due to similarity in transmission routes has become a major concern of the health community. Therefore, this study was performed to determine the prevalence of hepatitis B among HIV + patients in Zabol. This descriptive cross-sectional study was performed on 37 HIV-infected patients in Zabol city (2021-2022). In the present study, HIV-infected patients were screened for hepatitis B by measuring serum levels of HBC Ab and HBs Ag. Finally, the data in SPSS V21 software were analyzed. In the present study, a total of 37 HIV-infected patients with a mean age of 40.81- 11.64 years were evaluated. The present study's prevalence of HIV and HCV co-infection was 21.6%. Also, 13.5% of HIV patients had HBV and HCV simultaneously. Examination of risk factors for viral hepatitis in HIV-infected patients showed that unprotected sex (100%), injecting drug use or IDU (87.5%), dental procedures (75%), history of imprisonment (62.5%) and tattooing (50.5%) were the most common factors in HIV patients. Family history of hepatitis B (12.5%), alcohol (12.5%), transfusion (12.5%) and cupping (25%) were among the lowest cases in these patients. the frequency of HBV infection and co-infection with HCV and HBV in HIV-positive patients were relatively high. Except for the history of tattoos, there is no significant relationship between other risk factors and hepatitis B among HIV-positive patients.

S2642 A Case of Syphilis Masked as Seronegative Autoimmune Hepatitis

Introduction: Syphilis is a sexually transmitted infection that infects individuals at increasing rates every year. Syphilitic hepatitis (SH) is known to be a very rare complication of the infection, and can often be missed as a diagnosis.1 Here we present a unique case of SH disguised as what appears to be seronegative autoimmune hepatitis (AIH). Case Description/Methods: A 25 year old African-American female with history of tobacco and cannabis use presented with a 1 month history of fatigue, lymphadenopathy, that went away prior to presentation, and recent onset of pruritus, nausea and vomiting. She denied any risk factors for viral hepatitis or new medications. Physical exam was unremarkable except for sublingual and conjunctival icterus. Labs were significant for AST 1042 [12-39 U/L], ALT 877 [7-52 U/L], and ALP 189 [37-117 U/L]. Total bilirubin was 19.7 (direct 17.3). GGT and IgG were normal. Acute hepatitis panel, ANA, ASMA, AMA, and anti-LKM titers were negative. Wilson’s disease and alpha-1-antitrypsin deficiency were ruled out. Rapid plasma reagin (1:128) and Treponema antibody levels were positive. She had hepatomegaly with no ductal dilatation on ultrasound and MRCP. Liver biopsy was significant for peri-central and patchy sinusoidal congestion, canalicular cholestasis, and inflammatory portal tract infiltrates with bridging inflammation. Iron, PAS, VZV and spirochetes stains were negative. The patient was treated with penicillin for syphilis and started on prednisone for a suspicion of seronegative AIH. Steroid treatment was discontinued after a month due to concern for SH. Repeat liver enzymes were within normal limits 2 weeks after the prednisone was stopped and continued to remain normal. Discussion: SH is known to cause higher elevations in GGT and ALP, unlike our case, along with moderately impressive total bilirubin rise. There has been one report to date that identifies a case of concurrent SH and AIH, with a more impressive rise of AST and ALT.2 Our case is the first to present as SH with a questionable diagnosis of seronegative AIH.

Prevalence of HBsAg and anti-HCV antibodies during a screening campaign in August 2019

Introduction: Hepatitis B (HBV) and C (HCV) virus infections represent a major public health problem, with significant mortality and morbidity worldwide. The aim of this study was to determine the prevalence of HBsAg and anti-HCV antibodies, and to investigate the risk factors associated with these two infections. Patients and methods: An analytical cross-sectional study was carried out during a free screening campaign for viral hepatitis B and C organized by the University Teaching Hospital of Yaounde from 20th to 23rd August 2019. Screening for HBsAg and anti-HCV antibodies was carried out using a rapid diagnostic test (On Site HBsAg/HCV Ab Rapid Test (CTK Inc 10110 Mesa Rim Road San Diego, CA 92121 USA) in accordance with the manufacturer’s Instruction. Positive samples had a confirmatory ELISA test. A structured questionnaire was used to investigate the risk factors for viral hepatitis B and C. Results: A total of 746 participants (412 women, 334 men) were registered. The average age of the participants was 29.6 ± 15.5 years. The prevalence of HBsAg was 10.3% (men: 14.7%; women: 7%; p = 0.002). The prevalence of HCV-Ab was 4.7% (men: 6.3%; women: 3.4%; p = 0.08). Unprotected sexual intercourse (59.4%), dental care (38.7%) and scarification (37.1%) were the main factors of HBV and HCV transmission. Male sex (OR = 2.2; IC = 1.3 – 3.6; p = 0.002), lack of vaccination (OR = 3.4; IC = 1.2 – 9.6; p = 0.01), tattoos (OR = 6.6; IC = 1.4 – 30.2; p = 0.02) and close contact with an HBV-infected person (OR = 1.7; IC = 1.01 – 2.9; p = 0.04) were the factors associated with HBV transmission. Age groups ≥ 55 years (OR = 1.3; IC = 1.1 – 1.5; p < 0.0001) and [45 – 54] (OR = 1.06; IC = 1.0 – 1.1; p = 0.03) unprotected sexual intercourse (OR = 3.5; IC = 1.4 – 8.7; p = 0.003), dental care (OR = 2.3; IC = 1.1 – 4.5; p = 0.02) were associated with HCV infection. Conclusion: The prevalences of HBsAg and HCV-Ab are high in this population. Unprotected sexual intercourse, dental care and scarification were the most common risk factors.

Association between behavioural risk factors for chronic liver disease and transient elastography measurements across the UK: a cross-sectional study

ObjectiveChronic liver disease (CLD) is a largely preventable condition with increasing burden on National Health Service resources. We aimed to determine the prevalence of behavioural risk factors for CLD and...

S3525 Primary Biliary Cholangitis: A Not so Primary Suspect

INTRODUCTION: Primary biliary cholangitis (PBC) is an increasingly prevalent autoimmune (AI) chronic cholestatic disease with specific bile duct pathology. The anti-mitochondrial antibody (AMA) is found in 95% of cases and is highly specific for PBC. It is most commonly seen in females (90–95%), Caucasians, and age of diagnosis usually ranges from 30 to 65 years old. The most common symptoms include fatigue and pruritus. We present a case of an adult African male presenting with jaundice who was AMA negative and found to have PBC. CASE DESCRIPTION/METHODS: A 60-year-old African male with a past medical history of diabetes mellitus, hypertension and sickle cell trait presented with jaundice, fatigue, diffuse itching, and a 14 lb unintentional weight loss over 6 months. He had no risk factors for viral hepatitis, did not consume alcohol, and had no personal or family history of AI disorders. Physical exam was notable for scleral icterus and excoriations on extremities. Labs revealed a total bilirubin of 10.1 mg/dL, alkaline phosphatase 840 IU/L, AST/ALT 78/54 IU/L, INR 1.2 and normal iron studies. Viral hepatitis panel was negative for hepatitis A, B and C with negative AMA, ANA, and anti actin antibody. A MRCP revealed early cirrhosis vs. hepatitis, mild ascites and suboptimal visualization of the pancreatic duct but no evidence of biliary duct dilatation. EGD and colonoscopy findings were normal. EUS was done in which a prominent pancreatic head was seen; biopsies were negative. An ERCP revealing ductopenia and small intrahepatic ducts. A liver biopsy revealed pericholangitis and bridging fibrosis consistent with PBC. He was started on ursodeoxycholic acid. One month later he was seen in clinic with resolution of fatigue and pruritus. Labs revealed a total bilirubin of 5 mg/dL down from 10 mg/dL and an alkaline phosphatase of 470 IU/L down from 840 IU/L with AST/ALT 85/38 IU/L. DISCUSSION: Although PBC is commonly diagnosed in women and AMA is positive 95% of time, this case identifies an African male with negative AMA found to have PBC based on liver histology. It is important to note there have been increased cases of males diagnosed with PBC. It is unclear how many of these males are AMA negative. AMA-negative PBC has been shown to have greater bile duct damage and loss compared with AMA-positive PBC. However whether there are differences in clinical outcomes has not been determined and more studies are needed.

Risk factors for viral hepatitis A infection in Gampaha District, Sri Lanka: an unmatched case control study

BackgroundHepatitis A virus (HAV) is one of the commonest food and water borne infectious diseases. The objective of the study was to determine the risk factors of HAV infection in the Gampha District in Sri Lanka.MethodsThis was an unmatched case control study conducted between January 2015 and November 2016 comprising of 504 participants with a case control ratio of 1:1. The study population included individuals of age 1 year and above who were permanent residents of the district. Cases included participants admitted to four secondary care state hospitals with an acute HAV diagnosed by detecting serum anti-HAV IgM antibodies. Controls were randomly selected individuals from the community with serum negative for Anti-HAV IgM and IgG. An interviewer administered questionnaire was used for the data collection and multiple logistic regression was applied to determine the independent risk factors. The results are expressed as adjusted odds ratios (AOR) and 95% confidence intervals (CI).ResultsRisk factors for HAV infection were poor knowledge regarding hepatitis (AOR;3.98, 95% CI = 1.97–8.05), unhygienic sanitary practices (OR = 2.73; 95% CI = 1.42–5.23), unhygienic practices related to drinking water (OR = 2.67; 95% CI = 1.37–5.21), residing in urban areas (OR = 5.94; 95% CI = 2.98–11.86) and lower family income (OR = 2.83; 95% CI = 1.30–6.13).ConclusionsThe independent modifiable risk factors for HAV infection were poor knowledge regarding hepatitis, unhygienic sanitary practices, and unhygienic practices related to drinking water. Community awareness must be raised on hygienic practices and safe water drinking practices. Inequities of social determinates of health must be addressed.

2306 Hydroxychloroquine-Induced Acute Liver Injury

INTRODUCTION: Hydroxychloroquine is a commonly prescribed medication with antimalarial and anti-inflammatory properties. A very rarely reported side effect of this medication is drug induced acute liver injury. CASE DESCRIPTION/METHODS: A 62-year old female with a history of rheumatoid arthritis, on long term prednisone, presented to the emergency department with two day history of arthralgias, generalized weakness, and fever of 104 F. She had no history of alcohol use or any risk factors for viral hepatitis. Clinical exam was unremarkable. Laboratory data showed Aspartate aminotransferase (AST) or 798 IU/L and Alanine aminotransferase (ALT) of 1254 IU/L, with normal serum bilirubin, alkaline phosphatase and coagulation profile. Serologic tests for viral etiology including Hepatitis A, Hepatitis B, Hepatitis C, Cytomegalovirus, Epstein-Barr virus, and Human immunodeficiency virus were non-reactive. Anti-nuclear antibody, smooth muscle antibody, and anti-double-stranded DNA antibody were unremarkable. Her urine and blood cultures showed no growth. Abdominal ultrasound showed an echogenic liver consistent with hepatic steatosis and no evidence of biliary obstruction. Chest X-ray was normal. Upon review of her medications, patient had started hydroxychloroquine two weeks prior to admission. The medication was discontinued upon admission, after which she continued to improve. At follow up ten days later, she remained asymptomatic and her liver function tests continued to improve with AST of 46 and ALT of 161. DISCUSSION: Acute transaminitis due to hydroxychloroquine is rare. Only four reported cases have been noted per literature review. Mechanism of injury to hepatic cells is unknown however the drug is metabolized in the liver and may alter the metabolism of other drugs. Porphyria cutanea tarda is a disease that may be treated with low doses of hydroxychloroquine. It is known that higher doses of hydroxychloroquine usually greater than 100 mg twice a week can trigger acute liver injury in patients with history of Porphyria cutana tarda. These patients present with sudden onset of fever and marked serum enzyme elevations with increased excretion of porphyrins and photosensitivity. The presented patient in the case report did not have underlying Porphyria cutanea tarda.

Risk factors for viral hepatitis C infection in Rwanda: results from a nationwide screening program

BackgroundThe epidemiology and risk factors for hepatitis C virus (HCV) infection in Rwanda are not well known; however, this information is crucial to shaping the country’s public health approach to hepatitis C control.MethodsA HCV screening campaign was conducted in the general population in 24 districts previously identified to have a high HCV disease burden. At the time of sample collection, sociodemographic information and self-reported risk factors were collected. Bivariate and multivariate logistic regressions were conducted to assess risk factors independently associated with hepatitis C antibodies (HCVAb) seroprevalence.ResultsOut of a total of 326,263 individuals screened for HCVAb, 22,183 (6.8%) were positive. In multivariate analysis, risk factors identified as statistically associated with HCVAb Seroprevalence include history of traditional operation or scarification (OR = 1.09, 95% CI: 1.05–1.14), presence of viral hepatitis in the family (OR = 1.27, 95% CI: 1.15–1.40), widowed or separated/divorced (OR = 1.36, 95% CI: 1.26–1.47), Southern province (OR = 1.98, 95% CI: 1.88–2.08) and aged 65 years and older (OR = 4.86, 95% CI: 4.62–5.11). Ubudehe category 3 (OR = 0.97, 95% CI: 0.93–1.01) and participants using RAMA (Health insurances for employees of public and private sectors) insurance (OR = 0.76, 95% CI: 0.70–0.85) had lower odds of HCV seroprevalence.ConclusionsOur findings provide important information for Rwanda’s strategy on prevention and case-finding. Future prevention interventions should aim to reduce transmission through targeted messaging around traditional healing practices and case-finding targeting individuals with a history of exposure or advanced age.

Hepatitis B virus, hepatitis C virus and human immunodeficiency virus infections among people who inject drugs in Kuwait: A cross-sectional study

Injection drug use (IDU) is one of the most significant risk factors for viral hepatitis (B and C) and human immunodeficiency virus (HIV) infections. This study assessed seroprevalence rates of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in people who inject drugs (PWID) in Kuwait. We conducted a cross-sectional study from April to September 2017. A total of 521 consecutive subjects, admitted at Al-Sabah Hospital. The serological and virological markers of HBV, HCV, and HIV were tested using automated platforms. The mean age of the participants was 32.26 yrs, and the sex ratio (Male/Female) was 15.28. The prevalence rates of HBsAg, anti-HCV, and anti-HIV antibodies were 0.38% (95% CI: 0.07–1.53%), 12.28% (95% CI: 9.65–15.48), and 0.77% (95% CI: 0.25–2.23%), respectively. HCV-RNA was evident in 51.72% (95% CI: 38.34–64.87%) among anti-HCV positive participants. Multivariate analysis showed that the high prevalence of HCV infection amongst PWID is associated with age. Whereas, multivariate analysis revealed no significant associations with age and gender regarding HIV and HBV infections. The results suggest that high rates of HBV, HCV, and HIV infections among injecting drug users than the general population. These findings emphasize the importance of introducing interventions and harm reduction initiatives that have a high impact on reducing needle sharing.

Prevalence of Hepatitis C Virus and Associated Risk Factors among Inmates at New Bell Prison, Douala, Cameroon

Although a high prevalence of HCV infection in correctional facilities has been well reported in several countries around the world, there has been no such data from Cameroon. The aim of this study was to determine the prevalence and factors associated with viral hepatitis C seropositivity among prisoners incarcerated at the New Bell Central Prison in Douala. From the 2nd to the 27th of July 2018, 940 inmates selected using a systematic random sampling method were interviewed to collect data on sociodemographic status, duration of incarceration, number of incarcerations and risk factors for HCV transmission. Blood samples were collected for screening of anti-HCV antibodies via HEPA-SCAN HCV CARD Test. Positive samples had a confirmatory ELISA test. Data were analysed using EPI DATA 4.4.0.0 software. Statistical significance was set at a p < 0.05. Of the 940 prisoners selected, 94.1% (884) were males. The mean age of the study population was 33.81 ± 10.35 years (extremes: 14 and 74 years). HCV prevalence was 4.4% (40). The use of non-injectable illicit drugs (OR 2.87 95% CI 1.44 - 5.73) (p = 0.002) but not injectable illicit drugs (OR 1.91 95% CI 0.43 - 8.41) (p = 0.42), male homosexuality (OR 17.45 95% CI 7.58 - 40.13) (p < 0.001), sharing of needles (OR 3.45 95% CI 1.59 - 7.83) (p = 0.001), past history of tattooing or piercing (OR 5.94 95% CI 2.80 - 12.16) (p < 0.001) and age ≥ 50 (OR 4.069; 95% CI 1.9 - 8.68) (p = 0.003) were significantly associated with HCV antibodies positivity. Inmates in New Bell Central Prison accumulate risk factors for viral hepatitis C, thus contributing to the high prevalence in this setting. Control strategies and programs that reach this particular population should urgently be implemented.

A situation where hepatocellular carcinoma (HCC) may be more common in women than men: Clinical and genetic patterns of non risk-factored HCC.

e15614 Background: Men are classically diagnosed with HCC three times more frequently than women. The gender difference persists after adjusting for confounding risk factors of viral hepatitis and alcoholic cirrhosis, presumably due to protective role of estrogens in women. In rare and unclear circumstances, HCC can arise in patients with no identified risk factor. Methods: Archival FFPE samples from patients with HCC and no underlying liver disease who consented to an IRB-approved protocol from 2014 onward were analyzed using the MSK-IMPACT platform, a hybridization capture based next generation sequencing assay for targeted deep sequencing of all exons and selected introns of &gt; 400 key cancer genes. Tumor and matched normal libraries were sequenced on an Illumina HiSeq 2500. Sequencing output was processed using a custom analysis pipeline. Demographic and treatment data was prospectively collected. Fisher’s exact tests were performed to look for associations between clinical characteristics and genetic alterations. Results: 16 patients were identified with 12 (75%) women affected versus 4 men only. Median age at diagnosis was 64 years. 5 (21%) patients had concomitant other malignancy, being melanoma, lymphoma, mesothelioma, rectal and prostate adenocarcinoma. 75% of patients underwent upfront surgery while only 12% presented with metastatic disease. Median number of genetic mutations was 4. Genetic sequencing did not reveal a specific molecular signature in this subgroup of patients; TERT and CTNNB1 were the most commonly mutated genes, found in 37% of cases. Median follow-up was 20 months and all patients were alive at last follow-up. Conclusions: In contrast to HCC in the general population, we found that HCC in the absence of risk factors is diagnosed more commonly in women than men in this small cohort. Patients in this cohort appear to live longer which can be attributed to normal underlying liver function or different disease biology. The pattern and number of genetic mutations reported herein are not different from those previously reported in risk-factored HCC. The study of a larger cohort of this non-previously defined non-risk factored HCC is warranted.

Multivariate analysis of molecular markers in peripheral blood associated with recurrence and metastasis of hepatocellular carcinoma.

Invasion, metastasis, and recurrence are the most common causes of death in patients with hepatocellular carcinoma (HCC) and are therefore critical factors for both therapy and prognosis. Current methods for diagnosis of HCC rely mainly on serological markers such as alpha-fetoprotein and liver enzymes, together with physical assessment and imaging techniques. The availability of more accurate serum markers may facilitate screening and early diagnosis, which will improve prognosis. This retrospective cohort analysis included 50 consecutive patients with cirrhosis and single or multifocal HCC and 40 control subjects with no liver disease or risk factors for viral hepatitis. Expression of epidermal growth factor-like domain 7 (EGFL7), osteopontin (OPN), and prostaglandin E2 (PGE2) were detected using an enzyme-linked immunosorbent assay. The mean serum levels of EGFL7, OPN, and PGE2 in the HCC group were 132.11 pg/mL, 11.77 ng/mL, and 179.37 pg/mL, respectively, which were all significantly higher than the levels in the control group (23.03 pg/mL, 2.31 ng/mL, and 47.36 pg/mL, respectively; P < 0.001). Serum levels of EGFL7, OPN, and PGE2 levels may thus be useful for screening and surveillance of HCC among high-risk populations, and have the potential to improve prognosis of these patients.

Acute Autoimmune Hepatitis: Disguised by a Normal IgG Gammaglobulin Level and Negative Autoimmune Markers

Purpose: We report a rare case of acute liver injury secondary to seronegative autoimmune hepatitis (AIH) with IgE hypergammaglobulinemia. The purpose of this report is to bring to light the complexity in diagnosing seronegative AIH and the importance of prompt diagnosis to prevent progression to liver failure. A 20-year-old African America female with a history of polycystic ovarian syndrome (PCOS) and new-onset type 2 diabetes mellitus (T2DM) was transferred to our facility after presenting to a local hospital with symptoms of malaise, nausea and vomiting. Laboratory studies revealed INR of 1.1, AST of 1108 U/L and ALT of 1031 U/L and total bilirubin of 8.2 mg/dL. She exhibited no signs of hepatic encephalopathy or ascites. Thorough history revealed no risk factors for viral hepatitis or alcohol/toxic exposures. Her medications - discontinued upon admission - included drospirenone/ethinyl estradiol oral contraceptive pills begun a year ago for the treatment of PCOS and metformin started 1 month prior for T2DM. Serologic studies for acute hepatitis A, B, C, E, CMV, HSV, HIV, and EBV were negative. Iron studies, serum ceruloplasmin and copper were all within normal limits. The anti-mitochondrial, antinuclear, alpha-1 antitrypsin, anti-smooth muscle, and anti liver/kidney microsomal antibodies were negative. The immunoglobulins (Ig) G, IgM, and IgA were normal. The IgE was elevated at 963 IU/mL. Doppler ultrasound of the liver revealed a normal appearing liver with patent hepatic vasculature with flow in the normal direction. A liver biopsy revealed no steatosis, moderate mixed inflammatory infiltrate of the portal tracts with mild interphase activity and moderate ductular reaction, pericholangitis with periportal and focal bridging fibrosis. Given the absence of typical IgG hypergammaglobulinemia and serologic markers for AIH, the presence of T2DM, and normal liver synthetic function, initiation of immunosuppression was deferred and laboratory studies reassessed frequently. Although liver enzymes initially declined after discontinuation of her medications, both AST and ALT stabilized at nearly 400 U/L. However, after 6 weeks, a slight rise in her INR to 1.4 was noted and prednisone therapy was promptly initiated. Within 2 weeks after initiation of prednisone therapy, liver enzymes decreased by >50% confirming a therapeutic response to immunosuppression and reaffirming a diagnosis of seronegative autoimmune hepatitis. In retrospect, based on the Revised Original Scoring System of the International Autoimmune Hepatitis Group, this patient's pretreatment aggregate score was > 15, making AIH a definite diagnosis in spite of the normal IgG and negative autoimmune markers.

Splenic Arteriovenous Fistula: A Rare Cause of Portal Hypertension

Purpose: Portal hypertension is a common condition encountered by gastroenterologists. While this is most commonly encountered in the setting of cirrhosis, other conditions affecting portal venous blood flow dynamics can present with findings consistent with portal hypertension. We present a rare case of portal hypertension caused by a splenic arteriovenous (SAV) fistula. A 69-year-old female presented with hematemesis after a prolonged bout of nausea and vomiting. Endoscopic evaluation showed large esophagogastric varices which were amenable to esophageal banding. There was no evidence for alcohol abuse, hepatotoxin exposure, or risk factors for viral hepatitis. Serologic studies for viral hepatitis, antinuclear antibody, antismooth muscle antibody, antimitochondrial antibodies, and iron studies were normal. Initial radiographic imaging did not suggest cirrhosis and a percutaneous liver biopsy was normal. She was referred to our center for further management. Following initial esophageal banding, she did not rebleed. Our review of the previous CT images suggested a possible splenic arteriovenous (SAV) fistula. CT angiography showed contrast in the splenic and portal veins during the arterial phase and aneurysmal splenic vein enlargement confirming the diagnosis of a SAV fistula. Transcatheter arterial embolization was done with only a small branch of the splenic artery still feeding the dilated splenic vein postembolization. Upon further questioning, she denied any major abdominal trauma and had two normal pregnancies. She did not experience any further bleeding and was discharged. SAV fistula is a rare cause of portal hypertension and should be suspected in female patients who present with variceal bleeding, but have no signs of chronic liver disease. In a SAV fistula, portal hypertension is due to enhanced arteriovenous flow as blood bypasses the capillary bed of the spleen. The hemodynamic changes that ensue lead to dramatic and rapid increases in portal venous pressures and subsequent clinical sequellae. The etiology of an acquired SAV fistula may be spontaneous, iatrogenic, or traumatic. A significant female predominance of spontaneous cases and relatively young presentations that are temporally associated with pregnancy have suggested that hormonal factors (perhaps associated with pregnancy) lead to arterial wall elastin weakening. Gastrointestinal hemorrhage has been the most common presentation in the literature. Our patient demonstrates that an SAV fistula should be considered as a cause of noncirrhotic portal hypertension in females even well beyond the child-bearing years.

Risk factors of viral hepatitis: Yet to explore

Background and aimsThe safety of donated blood is the most vital concern of a blood transfusion organization. Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) screening for blood transfusion products has gained more importance where knowing the prevalence rate will help health policy makers. In this paper, we will evaluate the prevalence of viral infection in donated blood in the province of Qazvin in 2009. Materials and methodsThis study has been conducted using a registration system of computerized records for donors in Qazvin in 2009 using the consensus mode on 20,591 blood donors. The results of their HBV, HCV, and HIV viral markers were evaluated and analyzed using the chi square statistical test. ResultsThe prevalence rate of HBV, HCV, and HIV viral markers using the ELISA primary test in the individuals studied has been 0.28%, 1.59% and 0.1%, respectively, and on the basis of their confirmatory tests, 0.23%, 0.17% and 0%, respectively. There was no significant statistical difference in their infection rate on the basis of sex and marital status. Regular donors (46.85%) had a smaller infection rate compared to others (P<0.005). There was a significant statistical difference in the rate of prevalence of infection for hepatitis B and C in the regular donors compared to first-time donors. ConclusionConsidering the lower prevalence of viral markers in regular donors it is recommended that more use be made of them for blood donation.

A case of hepatitis attributable to repeated exposure to methoxyflurane during its use for procedural analgesia

A 33-year-old woman was admitted to our service for investigation and management of acute hepatitis. She reported symptoms of nausea, fatigue, pruritus and right upper abdominal discomfort. The symptoms had first occurred 3 weeks earlier, resolving over 5 days, then recurred 2-3 days before presentation. The symptoms were temporally related to varicose vein sclerosing procedures, of which she had had three in total. The first procedure occurred 4 weeks before admission, with no subsequent side effects. It was after the second procedure, 1 week later, that symptoms first developed. The final procedure occurred a week before admission. During each procedure, the patient was given methoxyflurane as an inhaled analgesic administered from a 3 mL disposable cartridge. Other medications administered during the procedures were the sclerosing agent sodium tetradecyl sulfate and fexofenadine. There was no history of exposure to alcohol or to other prescription or over-the-counter medications. The patient had no risk factors for viral hepatitis, and there was no history of hepatitis or liver disease in her family. Clinical examination revealed jaundice and mild tender hepatomegaly only. Initial investigations showed hepatic enzymosis, with an elevated alanine transaminase level (2710 U/L [reference range, < 34 U/L]) and hyperbilirubinaemia (bilirubin 921 μmol/L [reference range, < 20 μmol/L]). Markers of liver synthetic function (albumin and prothrombin time) were within normal limits, as were full blood counts, electrolyte levels and renal function. Abdominal ultrasound demonstrated a normal-sized spleen and mild hepatomegaly, with an increased liver echotexture. Doppler sonography of the portal vein was normal. Serological tests for hepatitis A, B and C, Epstein-Barr virus, cytomegalovirus and HIV were negative. Iron and copper studies and levels of α-1-antitrypsin, antinuclear antibodies, antimitochondrial antibodies, anti-liver/kidney microsomal antibodies, anti-smooth-muscle antibodies and antinuclear cytoplasmic antibodies were all normal. Paracetamol was undetectable. Bilirubin levels continued to rise over the following 8 days (peaking at 202 μmol/L), although liver synthetic function remained normal throughout this time. A liver biopsy revealed evidence of resolving acute hepatitis with confluent perivenular hepatocyte dropout and bridging necrosis. There was no evidence of cholestasis or underlying fibrosis. The pathological diagnosis was of an idiosyncratic drug reaction, with the implicated drug being methoxyflurane. The patient's condition continued to improve, with resolution of symptoms over 4 weeks and associated normalisation of liver enzyme and bilirubin levels. She has since remained well, and has been advised to avoid future exposure to methoxyflurane. ♦