CD138 immunohistochemistry identifies more plasma cells compared with hematoxylin and eosin staining in autoimmune hepatitis. An observational study

INTRODUCTION

Autoimmune hepatitis (AIH) is associated with periportal infiltration by plasma cells. Plasma cell detection is routinely performed through hematoxylin and eosin (H&E) staining. The present study aimed to assess the utility of CD138, an immunohistochemical plasma cell marker, in the evaluation of AIH.

MATERIALS AND METHODS

A retrospective study was conducted, in which cases consistent with AIH, within the time frame of 2001 and 2011, were collected. Routine H&E-stained sections were used for evaluation. CD138 immunohistochemistry (IHC) was performed to detect plasma cells.

RESULTS

Sixty biopsies were included. In the H&E group, the median and interquartile range (IQR) was 6 (4-9) plasma cells/high power field (HPF) and was 10 (IQR 6-20) plasma cells/HPF in the CD138 group (p < 0.001). There was a significant correlation between the number of plasma cells determined by H&E and CD138 (p = 0.31, p = 0.01). No significant correlation was found between the number of plasma cells determined by CD138 and IgG level (p = 0.21, p = 0.09) or stage of fibrosis (p = 0.12, p = 0.35), or between IgG level and stage of fibrosis (p = 0.17, p = 0.17). No significant correlation was found between the treatment response and the number of plasma cells determined by H&E (p = 0.11, p = 0.38), CD138 (p = 0.07, p = 0.55), or stage of fibrosis (p = 0.16, p = 0.20). CD138 expression was different between the treatment response groups (p = 0.04).

CONCLUSION

CD138 increased the detection of plasma cells in liver biopsies of patients with AIH, when compared with routine H&E staining. However, there was no correlation between the number of plasma cells determined by CD138 and serum IgG levels, stage of fibrosis, or response to treatment.

Sofosbuvir-velpatasvir in Mexican patients with hepatitis C: A retrospective review

INTRODUCTION

The sofosbuvir-velpatasvir (SOF/VEL) combination is a direct-acting antiviral therapy that is authorized and available in Mexico, making the performance of a real-world multicenter study that evaluates the sustained virologic response at 12 weeks post-treatment a relevant undertaking.

METHODS

A retrospective review of the case records of 241 patients seen at 20 hospitals in Mexico was conducted to assess hepatitis C treatment with the SOF/VEL combination (n = 231) and the sofosbuvir/velpatasvir/ribavirin (SOF/VEL/RBV) combination (n = 10). The primary efficacy endpoint was the percentage of patients that achieved SVR at 12 weeks after the end of treatment.

RESULTS

Overall SVR was 98.8% (95% CI 97.35-100%). Only three patients did not achieve SVR, two of whom had cirrhosis and a history of previous treatment with peg-IFN. Of the subgroups analyzed, all the patients with HIV coinfection, three patients with genotype 3, and the patients treated with the SOF/VEL/RBV combination achieved SVR. The subgroups with the lower success rates were patients that were treatment-experienced (96.8%) and patients with F1 fibrosis (95.5%). The most frequent adverse events were fatigue, headache, and insomnia. No serious adverse events were reported.

CONCLUSION

Treatments with SOF/VEL and SOF/VEL/RBV were highly safe and effective, results coinciding with those of other international real-world studies.

Asociación Mexicana de Hepatología A.C. Clinical guideline on hepatitis B

Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.

Asociación Mexicana de Hepatología A.C. Clinical guideline on hepatitis B

Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.

Sofosbuvir-velpatasvir in Mexican patients with hepatitis C: A retrospective review

INTRODUCTION

The sofosbuvir-velpatasvir (SOF/VEL) combination is a direct-acting antiviral therapy that is authorized and available in Mexico, making the performance of a real-world multicenter study that evaluates the sustained virologic response at 12 weeks post-treatment a relevant undertaking.

METHODS

A retrospective review of the case records of 241 patients seen at 20 hospitals in Mexico was conducted to assess hepatitis C treatment with the SOF/VEL combination (n = 231) and the sofosbuvir/velpatasvir/ribavirin (SOF/VEL/RBV) combination (n = 10). The primary efficacy endpoint was the percentage of patients that achieved SVR at 12 weeks after the end of treatment.

RESULTS

Overall SVR was 98.8% (95% CI 97.35-100%). Only three patients did not achieve SVR, two of whom had cirrhosis and a history of previous treatment with peg-IFN. Of the subgroups analyzed, all the patients with HIV coinfection, three patients with genotype 3, and the patients treated with the SOF/VEL/RBV combination achieved SVR. The subgroups with the lower success rates were patients that were treatment-experienced (96.8%) and patients with F1 fibrosis (95.5%). The most frequent adverse events were fatigue, headache, and insomnia. No serious adverse events were reported.

CONCLUSION

Treatments with SOF/VEL and SOF/VEL/RBV were highly safe and effective, results coinciding with those of other international real-world studies.

The Mexican consensus on alcoholic hepatitis

Alcoholic hepatitis is a frequent condition in the Mexican population. It is characterized by acute-on-chronic liver failure, important systemic inflammatory response, and multiple organ failure. The severe variant of the disease implies elevated mortality. Therefore, the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología brought together a multidisciplinary team of health professionals to formulate the first Mexican consensus on alcoholic hepatitis, carried out utilizing the Delphi method and resulting in 37 recommendations. Alcohol-related liver disease covers a broad spectrum of pathologies that includes steatosis, steatohepatitis, different grades of fibrosis, and cirrhosis and its complications. Severe alcoholic hepatitis is defined by a modified Maddrey's discriminant function score ≥ 32 or by a Model for End-Stage Liver Disease (MELD) score equal to or above 21. There is currently no specific biomarker for its diagnosis. Leukocytosis with neutrophilia, hyperbilirubinemia (> 3 mg/dL), AST > 50 U/l (< 400 U/l), and an AST/ALT ratio > 1.5-2 can guide the diagnosis. Abstinence from alcohol, together with nutritional support, is the cornerstone of treatment. Steroids are indicated for severe disease and have been effective in reducing the 28-day mortality rate. At present, liver transplantation is the only life-saving option for patients that are nonresponders to steroids. Certain drugs, such as N-acetylcysteine, granulocyte-colony stimulating factor, and metadoxine, can be adjuvant therapies with a positive impact on patient survival.

The Mexican consensus on nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) affects nearly one third of the population worldwide. Mexico is one of the countries whose population has several risk factors for the disease and its prevalence could surpass 50%. If immediate action is not taken to counteract what is now considered a national health problem, the medium-term panorama will be very bleak. This serious situation prompted the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología to produce the Mexican Consensus on Fatty Liver Disease. It is an up-to-date and detailed review of the epidemiology, pathophysiology, clinical forms, diagnosis, and treatment of the disease, whose aim is to provide the Mexican physician with a useful tool for the prevention and management of nonalcoholic fatty liver disease.

[Mexican consensus on portal hypertension]

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

Pulmonary vascular complications in portal hypertension and liver disease: a concise review

Chronic liver disease and/or portal hypertension may be associated with one of the two pulmonary vascular complications: portopulmonary hypertension and hepatopulmonary syndrome. These pulmonary vascular disorders are notoriously underdiagnosed; however, they have a substantial negative impact on survival and require special attention in order to understand their diagnostic approach and to select the best therapeutic options. Portopulmonary hypertension results from excessive vasoconstriction, vascular remodeling, and proliferative and thrombotic events within the pulmonary circulation that lead to progressive right ventricular failure and ultimately to death. On the other hand, abnormal intrapulmonary vascular dilations, profound hypoxemia, and a wide alveolar-arterial gradient are the hallmarks of the hepatopulmonary syndrome, resulting in difficult-to-treat hypoxemia. The aim of this review is to summarize the latest pathophysiologic concepts, diagnostic approach, therapy, and prognosis of portopulmonary hypertension and hepatopulmonary syndrome, as well as to discuss the role of liver transplantation as a definitive therapy in selected patients with these conditions.

[Thickening of the colon and terminal ileum documented with computer tomography and its correlation with colonoscopic findings at a third-level hospital]

BACKGROUND

Tomographic finding of thickening of colon and terminal ileum and its correlation with colonoscopic findings has been poorly studied. Various radiographic patterns of intestinal thickening suggestive of benign disease have been described, but they cannot completely rule out malignancy.

OBJECTIVE

To determine if a relationship exists between colonic wall or terminal ileum thickening documented by computed tomography with abnormal colonoscopic findings and colon cancer.

METHODS

Retrospective study of radiology database of a tertiary hospital identifying patients with report of thickening of terminal ileum or colon and have colonoscopy performed. It was investigated the performance of endoscopic biopsies and histopathological outcome.

RESULTS

We included 24 patients. The main site of colonic thickening on CT was sigmoid in 8 (33.3%) cases. The most common colonoscopic finding was colorectal tumor probably malignant in 7 (29.2%) patients, but adenocarcinoma was reported in 8 (33.3%) patients. There was a statistically significant relationship between colonic thickening and colorectal cancer (p < 0.001) but no statistically significant association was found between thickening and sigmoid colon cancer. There was statistical significant correlation between weight loss, melena, anemia, constipation, diarrhea, and hematochezia with diagnosis of cancer (p < 0.01).

CONCLUSIONS

The finding of thickening of colon documented by computed tomography is significantly associated with the presence of colorectal carcinoma. Additional colonoscopy must always be performed in an attempt to elucidate the origin of this thickening.

Liver transplantation for neurologic Wilson's disease: reflections on two cases within a mexican cohort

BACKGROUND

Liver transplantation (LT) in Wilson s disease (WD) is mostly indicated when progressing liver disease or acute liver failure occurs. In patients with neurological manifestations, this procedure has not gained wide acceptance based on previous reports of dismal prognosis.

OBJECTIVE

To describe a Mexican cohort of pa- tients with WD with special focus on LT in patients with deteriorating neurological manifestations.

MATERIAL AND METHODS

Patients with confirmed WD and their first-degree relatives were evaluated at the hepatology clinic of a tertiary referral hospital. Attention was placed on therapy and outcome.

RESULTS

Eleven patients were followed for a period of up to 80 months (7 probands and 4 affected family members), 10 patients having hepatic manifestations and 4 having neuro psychia- tric phenomena. Pharmacologic treatment was uniform in most patients, and LT was indicated in 2 cases because of deteriorating neurological status. These patients had total remission of their neurological manifestations with marked improvement on imaging studies.

CONCLUSIONS

Follow-up and pharmacologic treatment was flawed by several adverse conditions present in our population. Patients with progressing neurological disease had a favorable outcome after LT, a similar response to the one reported by several authors. In conclusion, LT should be strongly considered for the treatment of these patients.

Cardiac conduction disturbances in mixed connective tissue disease

BACKGROUND

Myocardial involvement occurs in about 20% of patients with mixed connective tissue disease. The purpose of this study was to determine the prevalence of conduction disturbances, their association with other manifestations of the disease.

OBJECTIVE

Determine the prevalence of cardiac conduction disturbances in patients with mixed connective tissue disease attended in an institute in Mexico City and their relation with other manifestations of the disease.

METHODS

One hundred thirteen patients admitted to the Institute with a diagnosis of mixed connective tissue disease were divided into those with conduction disturbances (n = 23) and those without (n = 90). Over a mean follow-up of 10.2 +/- 7.8 years, clinical course, treatment, duration of the disease, types of conduction disturbances and systemic alterations were examined.

RESULTS

There was an overwhelming predominance of women in both groups. Conduction disturbances occurred in about 20% of the patients with mixed connective tissue disease and that was not possible to find significant differences in the outcome of them. As could be expected a significant difference between the two groups was QRS axis, related to anterior hemiblock, the most common conduction alteration observed. During the follow-up one patient death in-group A, but none in group B.

CONCLUSION

Conduction disturbances were present in 20%; in agree with other authors in the literature. However, did not participate in the outcome of the disease.

[Descriptive analysis of 41 patients with a pyogenic hepatic abscess]

OBJECTIVE

To identify the clinical, laboratory and imaging characteristics of 41 patients with a pyogenic hepatic abscess.

RESEARCH DESIGN

Retrospective, descriptive.

SETTING

Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán.

STUDY UNITS

41 patients with a pyogenic hepatic abscess.

MAIN MEASUREMENTS

The measurement of the following variables was carried out: previous background, period of evolution, symptoms, signs, laboratory studies, imaging, treatment, complications and evolution.

RESULTS

41 patients were evaluated. The average age of the group was 52.5 years (SD = 14.3) and 30 (73%) were male. The most frequent associated disease was diabetes mellitus which was found in 15 patients (37%). The most frequent clinic data were: fever in 38 patients (93%), chills in 26 (63%) and pain in the upper right quadrant in 25 (61%). The most common source of the formation of the abscess was of biliary origin in six patients (15%) and the serum amoeba test was positive in 10% of the cases. The localization of the abscess in our series was as follows: 33 cases (81%) were from the right lobe, five (12%) from the left lobe, three (7%) from both lobes and 87% were solitary. The germ found more frequently was E. coli in five patients (15%). As for the treatment, puncture by computed tomography was carried out in 25 patients (61%), four patients had a surgery and the rest were treated only with antibiotics. Regarding mortality, only one patient died (2%) due to a septic shock.

CONCLUSIONS

An association with diabetes mellitus was identified and the most frequent origin was biliary, these data have already been reported in other studies. On the other hand, mortality and morbidity rates in our study were low.