[Hyperdynamic circulation in Manson's hepatosplenic schistosomiasis]

Twenty two patients having indication for surgical treatment of portal hypertension due to hepatoesplenic schistosomiasis were prospectively studied. Each patient was submitted to preoperative monitoring with pulmonary artery catheterization. The results showed hemodynamic alterations characterized by an increase of cardiac index (4.50 +/- 0.96 l/min/m2) associated to a decrease of systemic vascular resistance index (1638.60 +/- 441.86 dyn.s/cm5.m2). The stroke index and all right and left cardiac work indeces were increased. The pulmonary artery mean pressure was increased (17.23 +/- 8.63 mmHg) and the pulmonary vascular resistance index was decreased (147.95 +/- 126.21 dinas.seg/cm5.m2). We concluded that hepatoesplenic schistosomiasis determines hyperdynamic systemic circulation, probably correlated with portosystemic shunt, and pulmonary hypertension.

Systemic and hepatic hemodynamics in hepatosplenic Manson's schistosomiasis with and without propranolol

Systemic and hepatic hemodynamics were prospectively studied in 11 patients with Manson's schistosomiasis and portal hypertension, as well as alterations resulting from the use of propranolol. It was decided that patients whose portal pressure was reduced by 30% with the use of the drug would not undergo surgery and that treatment would consist of the chronic use of propranolol, associated with sclerosis of esophageal varices. This objective was not met by any of the patients whose portal pressure was measured and the study was interrupted. Results show that patients with Manson's schistosomiasis and portal hypertension have hyperdynamic circulation, mild pulmonary hypertension, greatly increased splenic blood flow, and preservation of total hepatic blood flow. Administration of propranolol corrects hyperdynamic circulation, aggravates pulmonary hypertension, does not alter portal pressure and reduces the sectorial portal blood flows, especially of the azygos vein, with maintenance of total hepatic blood flow. These data favor the hypothesis of portal overflow in the physiopathology of portal hypertension of schistosomiasis.

Clinicopathological features and histopathology of experimental hepatic capillariasis in muskrats (Ondatra zibethicus)

Ten muskrats (Ondatra zibethicus) each were infected with 17,000 eggs (long-term study) and eight muskrats each were infected with 8,000 eggs (short-term study) of Capillaria hepatica (Nematoda). Food intake, body weight, and selected clinicopathological parameters were measured every 2 days for 28 days in the short-term study and every 14 days for 184 days in the long-term study. Muskrats in the short-term study had moderate to severe necrotizing granulomatous hepatitis associated with mild anorexia and weight loss, varying degrees of leukocytosis with eosinophilia and elevation of serum alanine and aspartate aminotransferases. No significant changes in packed cell volume, hemoglobin, total plasma protein, albumin, blood urea nitrogen, bilirubin, lactate dehydrogenase or alkaline phosphatase were found among animals from the short-term study. Muskrats in the long-term study had severe necrotizing granulomatous hepatitis associated with marked anorexia, weight loss and 60% mortality over 39 days post-inoculation (PI); animals that survived for 184 days did not return to pre-inoculation body weights despite returning to normal food intake. Hepatic lesions at 184 days PI consisted of minimal to severe liver replacement by C. hepatica eggs. No statistically significant differences in values of clinical parameters between inoculated animals and a non-inoculated control group from the long term study were found.

Hyperfibrinolysis in hepatosplenic schistosomiasis

AIM

To evaluate the nature of accelerated fibrinolysis in hepatosplenic schistosomiasis.

METHODS

The biological activity of plasminogen (Plg), plasminogen activators (PA), alpha 2-antiplasmin (alpha 2-AP) and plasminogen activator inhibitor-1 (PAI-1) was determined by photometric analysis in 15 compensated and 35 decompensated patients with endemic Egyptian hepatosplenomegaly. Quantitative measurement of plasma concentrations of tissue t-PA, t-PA-PAI-1 complex, alpha 2-antiplasmin-plasmin complex (alpha 2-APP), fibrinogen degradation products (FbDP), D-dimers (D-D), thrombin-antithrombin complex (TAT) and prothrombin fragment (F 1 + 2) complexes, using double antibody sandwich enzyme linked immunosorbent assays and grading of the degree of hepatic insufficiency according to the Child-Pugh classification, were also carried out.

RESULTS

The progressive deterioration of liver function in schistosomal patients, which matched the severity of the disease, led to simultaneous defects in profibrinolytic (decreased Plg and increased PA and t-PA) and antifibrinolytic (decreased alpha 2-AP and PAI-1) factors-the latter defects being the most prominent-resulting in significant generation of plasmin (increased APP complexes) and therefore enhanced fibrinolysis (increased FbDP and D-dimer). The raised concentrations of FbDP, D-D, TAT and F 1 + 2 established its secondary nature.

CONCLUSION

These findings suggest that the amount of PAI-1 available to bind and neutralise circulating t-PA may be a critical factor in the progress of hyperfibrinolysis observed in hepatosplenic schistosomiasis, and that the pronounced reduction in its plasma concentration may be regarded as a potential warning indicator of haemostatic imbalance in decompensated schistosomal patients at high risk of variceal bleeding.

Systemic and splanchnic hemodynamic changes in patients with hepatic schistosomiasis

Although hepatic schistosomiasis is a common cause of portal hypertension, only a few hemodynamic studies, in humans, have been published on this subject. The aim of this study was to determine the systemic and splanchnic hemodynamic changes in hepatic schistosomiasis and to evaluate the influence of liver fibrosis on these changes. A retrospective analysis of a series of 13 patients with hepatic schistosomiasis who had undergone hemodynamic studies was performed. Portal or perisinusoidal fibrosis was present at liver biopsy in 8 patients. The control group included 22 patients with chronic hepatitis and normal hepatic venous pressure gradients. Patients with schistosomiasis exhibited high cardiac index (4.11 +/- 1.15 l.min-1.m-2 vs 2.99 +/- 0.85 l.min-1.m-2; p < 0.05) and low systemic vascular resistance (1039 +/- 316 dyn.s.cm-5 vs 1334 +/- 336 dyn.s.cm-5; p < 0.05). The hepatic venous pressure gradient and hepatic blood flow were normal. Azygos blood flow was markedly increased (0.90 +/- 0.66 l.min-1 vs 0.13 +/- 0.04 l.min-1; p < 0.05). Hemodynamic values were not significantly different between patients with liver fibrosis and those without fibrosis at liver biopsy. In conclusion, patients with hepatic schistosomiasis had a hyperkinetic systemic and splanchnic circulation. In patients with esophageal varices, a normal hepatic venous pressure gradient confirmed presinusoidal portal hypertension. The presence of portal or perisinuoidal fibrosis did not influence hyperdynamic splanchnic state.

Schistosoma mansoni: influence of infection on mouse behavior

Schistosoma mansoni infection in humans and animals induces abnormal neurobehavioral responses following granuloma formation. In mice, granulomas in the liver are observed 8 weeks after infection, while after 15-20 weeks, the presence of eggs and granulomas in the brain has been reported. In this study, outbred CD-1 female mice were infected with S. mansoni and examined in several behavioral tests (open field, novel object investigation, black/white box, and hot plate) 8 and 15 weeks after infection. The detected effects of schistosome infection were a reduction of body weight in 8-week infected mice, marked changes in exploration/activity, rearing, and wall-rearing in 8- and 15-week infected mice, an enhancement of sniffing and grooming in 8-week infected mice, and finally an increase in the threshold of pain response to the hot plate in 15-week infected mice. The results of the present study indicate that S. mansoni infection markedly alters exploratory behavior of mice, affecting particularly the vertical movements of the animals, and suggests that the differences in behavioral abnormalities between 8- and 15-week infected mice might be associated with modifications in the levels of nerve growth factor and cytokines induced by granulomas.

Evaluation of colchicine with or without praziquantel therapy in the control of hepatic fibrosis in murine schistosomiasis

Colchicine alone or following praziquantel was given to mice infected with Schistosoma mansoni either 6 or 10 weeks post infection. Praziquantel increased body weight gain, histologically reduced number, diameter and cellularity of granuloma and improved liver function parameters. Early praziquantel therapy decreased hepatic collagen content as detected by the colorimetric method and the serum procollagen propeptide (PIIIP), while later treatment at the 10th week of infection increased hepatic collagen content and serum PIIIP. Colchicine therapy significantly decreased body weight gain with significant weight loss after early treatment. Colchicine did not change the histologic picture of schistosomal liver fibrosis; it induced a detectable hepatocytic injury recorded ultrastructurally and histologically with excitation of the inflammatory reaction in the granuloma and in portal tracts after early treatment. Excess pigmentation in macrophages and Kupffer cells, binucleation and large sized hepatocytic nuclei were evident after colchicine therapy. Colchicine increased hepatic collagen content microgram/mg protein, raised globulin and total serum protein and normalized the raised serum PIIIP of infected mice, but had no effect on PIIIP of normal mice. Early cessation of schistosomal infection evidently minimized the adverse effects of colchicine.

Liver function in Clonorchis sinensis-infected rabbits

Nine rabbits were fed with Clonorchis sinensis metacercariae (MC) and the blood samples chronologically obtained were analyzed biochemically. Rabbits infected by less than 100 flukes were grouped into Group I, and by 100-250 flukes into Group II. The serum level of alanine aminotransferase (ALT) was increased from 3 weeks after the infection of the metacercariae (AIM) and showed a peak at 8 weeks, and decreased from 12 weeks AIM. The serum level of aspartate aminotransferase (AST) was raised to 92.3 +/- 65.4 U/L at 3 weeks AIM and stayed high until 8 weeks, then lowered thereafter. The serum level of gamma-glutamyl transpeptidase (gamma-GT) was increased rapidly to the highest value (18.9 +/- 14.6 U/L) at 16 weeks AIM, and decreased to the control level after 20 weeks. The serum level of alkaline phosphatase (ALP) was headed down from the early infection to 52 weeks AIM. The serum cholesterol level was increased from 8 weeks and reached at a peak 16 weeks AIM, and decreased thereafter to the control level. It is suggested that serum ALT, AST, ALP and gamma-GT tests be useful to diagnose the early infection of C. sinensis.

Liver morphology and function in visceral leishmaniasis (Kala-azar)

AIM

To study the morphology and function of the liver in visceral leishmaniasis (Kala-azar).

METHODS

Percutaneous liver biopsy specimens from 18 patients with confirmed visceral leishmaniasis were examined under light and electron microscopy before and after treatment with pentovalent antimony. The tissue was also examined for hepatitis B surface and core antigens using immunoperoxidase staining. Liver function was investigated in nine patients before and after treatment.

RESULTS

Specimens before treatment showed Kupffer cells and macrophages colonised by leishmania parasites in 40% of cases. A chronic mononuclear cell infiltrate had affected the portal tracts and lobules. Ballooning degeneration of the hepatocytes, fibrosis of the terminal hepatic venules, and pericellular fibrosis were common findings. The fibrosis was related to Ito cells transforming to fibroblast-like cells. None of the patients had hepatitis B infection. All patients had biochemical evidence of liver dysfunction before treatment. Liver function improved after treatment.

CONCLUSION

Visceral leishmaniasis causes morphological and functional disturbance in the liver. Focal fibrosis rather than cirrhosis occurs. The exact aetiology of hepatic damage is unclear but may have an immunological basis.

[Hepatosplenic schistosomiasis: case report and clinical review]

Although seen rarely in Switzerland, schistosomiasis is a parasitosis affecting 200 to 250 million people round the world, mainly in tropical and subtropical regions of Africa, Asia, Central and South America. Depending on the parasitic species, the ureters and the bladder (S. haematobium) or the intestine and the liver (S. mansoni, S. japonicum, S. mekongi) are primarily involved. Other organs may be affected (lung, kidneys and central nervous system). Hepatosplenic schistosomiasis represents a special form of chronic infection by S. mansoni, S. japonicum or S. mekongi predominantly occurring in adolescents heavily and repeatedly infected during childhood, together with an additional genetic predisposition for the disease. Hepatosplenic schistosomiasis on a worldwide scale is one of the most prevalent causes of portal hypertension in man. We describe a 33-year-old Portuguese female with mansonian hepatosplenic schistosomiasis 12 years after leaving Africa, who had hepatosplenomegaly, portal hypertension, esophageal varices and hypersplenism. Splenomegaly and slight anemia had been known for years without prompting further work-up. Two months before diagnosis she had been delivered of a normal child after pregnancy without portal-hypertensive complications, namely esophageal hemorrhage. Because of placenta accreta, however, erythrocyte transfusion had been performed after delivery and was possibly responsible for hepatitis C found later on. Pathophysiology, clinical findings and therapy of the disease are discussed.

Theophylline metabolism in patients with hepatosplenic mansoniasis and cirrhosis

The pharmacokinetics of theophylline were studied in 12 patients with hepatosplenic mansoniasis, 14 patients with cirrhosis and 16 normal controls. Following a single intravenous dose of aminophylline volumes of distribution, serum half-lives and body clearances were determined. Volumes of distribution of theophylline in patients with schistosomiasis (mean 0.624 l/kg) did not differ from cirrhotic patients (mean 0.616 l/kg) or normal controls (mean 0.593 l/kg). Cirrhotic patients had a prolonged half-life compared to normal subjects (mean 22.1 vs. 9.9 h), while patients with schistosomiasis did not substantially differ from normal controls (15.8 vs. 9.9 h). Body clearance in patients with schistosomiasis was similar to controls (34.02 vs. 49.20 ml/h per kg) but decreased (29.24 ml/h per kg) in patients with cirrhosis. Individual analysis of the group with schistosomiasis disclosed three patients with reduced theophylline elimination. No relationship was found between laboratory tests of liver function and the pharmacokinetics of theophylline in any group. The administration of theophylline to patients with hepatosplenic schistosomiasis, although less dangerous than in cirrhosis, must be closely followed.

Hepatosplenic schistosomiasis. Pathophysiology and treatment

HSS represents a special model of intrahepatic portal hypertension characterized by a presinusoidal portal block and a well-preserved liver parenchyma. Symmers' fibrosis appears in a small but significant proportion of patients with a high worm load. Its pathogenesis is not well established, although experimental and clinical studies point to egg granulomata as the main pathogenetic factor. The eggs carried continuously through the portal circulation produce inflammation and gross amputation of the intrahepatic veins, portal and periportal granulomas, and, eventually, a coarse perilobular fibrosis ("pipe-stem"). Portal hypertension, esophageal varices, and hepatosplenomegaly are the main consequences of these morphologic changes. Gastrointestinal bleeding is the most frequent cause of death. Unlike in cirrhosis, advanced liver failure is not seen except when HSS is associated with liver lesions from other causes such as virus and alcoholism. Helminthiasis treatment is based on chemotherapy with praziquantel or oxamniquine. Bleeding esophageal varices are managed by sclerotherapy or surgical procedures. Splenectomy with gastroesophageal devascularization seems to be the best choice.

Duplex Hemodinamic evaluation of hepatosplenic mansoni schistosomiasis

Conventional ultrasonography highly contributes to a non invasive diagnosis of HS schistosomiasis (Cerri et al., 1984). The introduction of Doppler allowed new advances in the knowledge of the portal dynamics of this disease (Taylor et al. 1985; Moriyasu et al., 1986). The aim of this paper was to analyze the hemodynamic behavior of the portal vessels, considering caliper, maximum flow speed, direction of flow and preferential disposition of the collateral vessels. Thirty two patients with schistosomiasis mansoni with confirmed hepatosplenic form (HSSM), were analyzed. Fourteen patients with the intestinal form, have been analyzed as a control group. The results demonstrated that the maximum speed of the portal vein in the two groups has not been significantly different. Nevertheless, the diameter of the PV in the hepatosplenic group has been larger. The splenic vein presented speed and caliper larger than the superior mesenteric vein. The hepatic artery has been detected in only 40% of the cases. The hepatic veins presented normal caliper and spectral pattern. The duplex proved to be an useful technic complementary and non-invasive, in the study of HSSM.

Hepatic regeneration after hepatectomy in schistosomatic fibrosis

After partial hepatectomy (approximately 30%), the labelled hepatocyte index (LHI) of the normal mouse is increased and reaches its highest value 48 h after surgery. In mice with schistosomatic fibrosis (SF), the LHI was lower than in the controls at 24, 48 and 72 h after hepatectomy.

[The effect of cholagogic preparations and Essentiale on the natriuretic hormone content of the blood plasma and on kidney function in patients with liver pathology]

The effect of cholagogic drugs on blood plasma content of natriuretic hormone (NH) in 41 patients with chronic opisthorchiasis was studied. The drugs were found to exert no effect on NH content and the kidney function in this pathology. The use of essentiale in patients with persistent hepatitis and cirrhosis of the liver was shown to increase sodium excretion due to an increase of NH content.

Praziquantel in the treatment of hepatosplenic schistosomiasis: biochemical disease markers indicate deceleration of fibrogenesis and diminution of portal flow obstruction

Serological indicators for disease activity and portal vein obstruction and/or deviation were assessed in 23 patients with hepatosplenic schistosomiasis before, and up to 18 months after, praziquantel treatment, as well as in 25 matched local controls. Cessation of egg-induced immunopathology was reflected by the return to normal of serum procollagen-III-propeptide and neopterin concentrations. Reversibility of portal vein pathology was indicated by normal clearance of cholylglycine in cases without signs of decompensating portal hypertension. In most patients with a history of ascites and/or haemorrhage, serum cholylglycine concentration remained pathological. The results provide evidence that the fibrogenic process ceases after specific chemotherapy, and that portal vein pathology regresses in a substantial proportion of hepatosplenic schistosomiasis cases.

Liver function and plasma protein metabolism in rodent model of filariasis

Rodent model of filariasis was developed by infecting Wistar rats with Litomosoides carinii. Liver function tests, plasma protein concentrations, and synthesis rates of liver-formed proteins were estimated in these rats at 63 and 90 days post-infection. At 63 days post-infection, aspartate aminotransferase and alkaline phosphatase were significantly increased. Alanine aminotransferase, plasma total proteins and plasma albumin were in the normal range. However, at 90 days post-infection all these parameters were affected, reflecting progressive liver involvement. Hypoalbuminemia at 90 days post-infection did not appear to be due to decreased synthesis rate, indicating higher catabolism and/or altered distribution in pools.

Effects of induction of anti-embryonation immunity on liver granulomas, spleen weight and portal pressure in mice infected with Schistosoma japonicum

BALB/c mice sensitized with injections of viable immature Schistosoma japonicum eggs had significantly fewer and smaller granulomas in the liver, lower portal pressure and smaller spleens at D + 75 of infection compared to similarly infected unsensitized controls. The portal pressure and spleen weights of the mice sensitized with immature eggs were not different from uninfected unsensitized mice of similar ages at D + 75 of infection. The results strongly support our hypothesis that it should be possible to prevent serious hepatosplenic disease in schistosomiasis japonica by vaccination to induce anti-embryonation immunity.

Lack of correlation between jejunal mucosal morphology and intestinal absorption in the hepatosplenic form of schistosomiasis mansoni

Eleven patients with the hepatosplenic form of schistosomiasis mansoni were studied. Intestinal absorption of fat and xylose was normal in all patients. Despite these normal absorption parameters, the mucosa showed variable degrees of villus atrophy and an increase of the number of inflammatory cells in the lamina propria. Through morphometric analysis it was seen that the villi were shorter and the ratio villus height/crypt depth was increased in schistosomiasis patients as compared to normal control children. Five of the 11 biopsies contained granulomata with ova in the mucosa or submucosa.

Aging of the murine immune system is reflected by declining ability to generate antibodies that promote elimination of Trypanosoma musculi

Trypanosoma musculi established extracellular infections in aged BC3F1 and C57BL/6 mice that were approximately 10 times greater and twice as long in duration as those in young adult mice. Elimination of T. musculi infections was found to be an antibody-dependent, cell-mediated process involving effector (presumably phagocytic) cells in the liver and, to a lesser extent, the spleen. A major difference between young and aged mice of the C57BL/6 strain was the deficiency in the ability of aged animals to generate antibodies of appropriate specificity and/or isotype in sufficient amount to promote trypanosome elimination. Indeed, at the time when infected young-adult mice began to produce antibodies that facilitated rapid trypanosome clearance (in young adult, but not in aged animals), the serum of aged mice was found to contain substances that inhibited parasite clearance. Overall, however, the development of antibodies of different isotypes, capable of reacting with intact trypanosomes, was about the same in young and aged animals. Hepatic and splenic effector cells of old mice were at least as efficient as those of young adults. The immunoblotting procedure was used to try to detect trypanosome Ag against which aged animals failed to generate antibodies of one or more isotypes. The complexity of the reactions of infected mouse serum antibodies with the spectrum of trypanosome Ag precluded a precise analysis. However, it was apparent that a delay in the appearance of antibodies of IgG2a and IgG2b isotypes, against Ag of relatively high m.w., was typical of aged, in comparison to young, mice. More exacting analyses, involving fractionated trypanosome extracts and mAb of varying isotypes, are underway to identify key trypanosome Ag that elicit antibodies of isotypes that can facilitate hepatic and splenic clearance of the parasites. This line of investigation will provide information that, in addition to its intrinsic interest, may be vital in judging the future impact of endemic parasitic infections on the emerging cohort of elderly persons in developing tropical nations.

[Biometric data on adult patients with schistosomiasis, Bahia (Brazil)]

De dezessete indivíduos esquistossomóticos, hepatosplênicos, pareados com outros dezessete controles, hepatointestinais, da mesma região, foram aferidas 17 medidas antropométricas. Todas as pessoas tinham de 21 a 50 anos de idade. Esta e outros critérios foram previamente estabelecidos como fatores de pareamente, de inclusão e exclusão no estudo. Porém, não se observou diferenças estatísticas entre as médias dos dois grupos de pacientes.

Pathophysiology of severe falciparum malaria in man

The term severe falciparum malaria implies an infection with manifestations and complications which are potentially fatal in man, the natural host for this parasite. Much that has been written on the pathophysiology of animal malarias is of doubtful relevance to the understanding of the mechanism ofPlasmodium falciparuminfection in man. The clinical picture of severeP. falciparuminfection differs in several respects from severe animal malarias, even those of non-human primates. Cerebral dysfunction is the most common severe manifestation of falciparum malaria in man. Coma develops suddenly after a generalized convulsion or gradually towards the end of the first week of illness. There are signs of a symmetrical upper motor neurone lesion and brain-stem dysfunction, but only about 5% of survivors show persisting neurological deficit after 2 or 3 days of unconsciousness. The mortality of cerebral malaria depends on how it is defined and on the predominant age group and other factors. In patients with proved acuteP. falciparuminfection with unrousable coma, in whom other causes of encephalopathy have been excluded, the mortality is between 15 and 50% despite treatment with antimalarial drugs (Warrell, Looareesuwan, Warrell, Kasemsarn, Intaraprasert, Bunnag & Harinasuta, 1982).

Effect of oral contraceptive on liver function tests of women with schistosomiasis in the Philippines

A prospective study was undertaken to determine the effect on liver function tests of a combined oral contraceptive containing norethisterone 1 mg and mestranol 0.05 mg, in women with schistosomiasis japonica in Leyte, Philippines. Women who volunteered and met the standard criteria for oral contraception, with and without infection, were followed for six months of pill intake. Concurrently, non-pill users, both infected and uninfected, were similarly followed. Baseline and six-month liver function tests were compared. Of the 466 subjects admitted in the study, 383 completed six months, and 83 discontinued. At the start of the study, there were no significant differences among the four groups in liver function tests except that the infected women had a higher total protein and alkaline phosphatase, and lower alanine aminotransferase levels. After six months, the only statistically significant finding was a lesser decrease in total protein among the infected pill users compared to the uninfected pill users. This finding was not clinically significant since there was no associated clinical complications; there were fewer number of subjects with abnormal values at the sixth month; and the mean values of this variable remained within normal limits. Our findings show that the use of low dose progestin and estrogen oral contraceptive in the presence of mild schistosomiasis japonica infection does not appear to have adverse effect on liver function tests of young women after six months of contraceptive use.