Efficacy of subcutaneous immunoglobulins in primary immunodeficiency with Crohn's-like phenotype: report of a case

Common variable immune deficiency (CVID) is the most frequent primary immunodeficiency in adults. In CVID, the prevalence of gastrointestinal manifestations ranges between 2 and 50% with a complication-related morbidity second only to that of the respiratory tract. In some cases, clinical and endoscopic features are undistinguishable from those of inflammatory bowel disease (IBD). We describe the case of a 28-year-old man in which a diagnosis of Crohn's disease was firstly suspected. Subsequently, a diagnosis of Crohn's-like disease in a patient with CVID was made and a replacement therapy with human normal immunoglobulin intravenously was started. Unfortunately, serum IgG levels remained below 2.0 g/l in pre-infusional controls with persistence of gastrointestinal symptoms and malnutrition despite anti-inflammatory therapy (mesalazine, corticosteroids). Then, the patient began treatment with human normal immunoglobulins administered subcutaneously. The follow-up visits showed a progressive increase in serum IgG. Moreover, the patient reported improvement of gastrointestinal symptoms with reduction of diarrhoea, and laboratory tests showed a progressive and significant improvement. We confirm that therapy with subcutaneously administered immunoglobulins is safe and effective. In addition, our observations indicate that, for patients with CVID and enteropathic complications, replacement therapy with subcutaneous IgG may be the treatment of choice.

Herbal hepatotoxicity: a case of difficult interpretation

Herbal medicines are widely used in the world and are generally considered effective and safe, although many studies have demonstrated their potential toxic effects, particularly for the liver. We present a case of a woman, who developed a mixed cholestatic/hepatocellular liver injury due to herbal products. Firstly, she was admitted to Division of Surgery for right upper abdominal pain and jaundice and, for the suspect of biliary obstruction, she underwent to cholecystectomy. For persistence of liver enzymes elevation, she was admitted to our Gastroenterology Unit. We excluded every etiologies of hepatitis and, after an intensive dialogue with the patient, we obtained a history of herbal medicines use. Then, we performed a liver biopsy which was compatible with hepatotoxic injury. Therapy with ursodeoxycholic acid (UDCA) was started. Liver function tests returned to normal in two months. We describe this clinical case to encourage the communication doctor/patient in phytotherapy area and physician knowledge about efficacy and side effects of herbal medicine to avoid delayed diagnosis.

[Prevalences of HIV, hepatitis B and hepatitis C in blood donors in the Republic of Djibouti]

Screening for hepatitis B (HBV) surface antigen (Ag HBs) and for antibodies to hepatitis C (HCV) and human: immunodeficiency virus (HIV) was carried out in 9006 volunteer blood donors at the National Blood Bank in the Republic of Djibouti from 1998 to 2000. Results demonstrated the presence of Ag HBs in 934 patients (10.4%), antibodies to HCV in 21 patients (0.3%), and antibodies to HIV in 175 patients (1.9%). In comparison with neighboring countries the prevalence of HBV, HCV, and HIV infection in Djibouti was low. These findings should be used to guide preventive action against these viral infections in the Republic of Djibouti. Estimations of HIV infection (11.7%) based on modeling by the World Health Organization should be reviewed.

[A cholera epidemic in Dijibouti (May 2000-January 2001)]

The purpose of this report is to describe a cholera outbreak that occurred in the Republic of Djibouti from May 2000 to January 2001. Because the Somalian index cases involved were identified, this outbreak can be used as a model for imported epidemics. Development of the disease in the Djibouti City is promoted by a combination of poor living conditions and inadequate water supply. Unlike in previous epidemics in Djibouti, bacteriological study demonstrated the emergence of Vibrio cholerae strains presenting antibiotic resistance similar to that observed in Somalia. At the only facility available for cholera treatment in the country, 1920 patients were admitted and 36(1.9%) died. An epidemiological study of these patients demonstrated that females accounted for most cases in the 15-to-44-year age group (p < 0.0001) whereas males accounted for most cases in the age groups ranging from 0 to 1 year (p = 0.003) and 5 to 14 years (p = 0.002). These findings suggest that the mode of contamination and access to care vary according to sex and age.

Tamoxifen in the treatment of hepatocellular carcinoma: 5-year results of the CLIP-1 multicentre randomised controlled trial

BACKGROUND

In 1998, when data of a meta-analysis on tamoxifen in the treatment of hepatocellular carcinoma (HCC) had suggested a little advantage for this treatment, we published the results of a multicenter randomised controlled trial, that showed no survival benefit for tamoxifen vs. control. Here we report an updated analysis of the study results 4.5 years after the closure of enrollment.

METHODS

The study had a planned sample size of 480 patients. Patients with any stage HCC were eligible, irrespective of locoregional treatment. Tamoxifen was given orally, 40 mg/die, from randomisation until death.

RESULTS

496 patients were randomised by 30 Institutions from January 1995 to January 1997. Information was available for 477 patients. As of July 2001, 374 deaths (78%) were recorded, and median survival times were 16 and 15 months (p=0.54), in the control and tamoxifen arm. Data were further analysed separately for advanced patients and for those eligible to potentially curative locoregional treatments: relative hazard of death for patients receiving tamoxifen was equal to 0.98 (95% CI 0.76-1.25) for the former group and 1.38 (95% CI 0.95-2.01) for the latter. The prognostic score recently devised by our group (CLIP score) was, as expected, strictly correlated (p<0.0001) to the locoregional treatment received and strongly correlated with prognosis.

CONCLUSIONS

the update of the present study confirms that tamoxifen is not effective in prolonging survivals, both in advanced patients and in those potentially curable and that the CLIP score is able to predict prognosis.

Long-term follow-up evaluation in HCV chronic hepatitis treated with alpha-2b interferon. A comparison of two protocols

In a long-term study (27 months) of patients affected by C-virus active hepatitis we have evaluated the effect of decreasing the dose of interferon by 50% and by 75% with respect to the initial efficacious dose (6 MU tiw). Sixty patients received recombinant interferon alpha-2b(r-IFN- alpha-2b) 6 MU tiw for two months followed by 3 MU for seven months (Group A), and 60 patients received r-IFN alpha-2b 6 MU tiw for two months followed by 1.5 MU for seven months (Group B). Three patients in group B failed to return to follow-up and were not considered in subsequent evaluations. Side effects such as to cause suspension of treatment occurred only during the first two months of the study at 6 MU of interferon (3 patients in group A and 6 in group B). During the two months at 6 MU, transaminase values returned to normal in 94 patients (80%). At the end of follow-up, 49 of these patients (42% of the 117 patients examined; or 48.3% in group A and 35.1% in group B) had normal transaminase levels. In no case did the anti-HCV test become negative. On a reduced dose of interferon, relapses occurred more frequently in group B (21.4%) than in group A (9.6%), but the difference was not significant. No difference between responders and non-responders, including relapsing patients, was observed in relation to gender, age, presence of cirrhosis, presence of B-virus antibodies and initial levels of serum transaminase.

Transglutaminase changes in intestinal mucosa after experimental small bowel resection in the rat

The low serum transglutaminase found in various intestinal disorders (celiac disease and IBD) suggested to us to study the serum and mucosal transglutaminase behaviour in an experimental model of small intestine resection in rats to reduce cellular mass and induce enterocyte hyperproliferation in the proximal part left in continuity. Transglutaminase activity in the intestinal mucosa was significantly higher in resected rats than in control and sham operated animals from days 4 (121 +/- 10 v basal 94 +/- 3 mU/g protein, p < 0.01) to 10 (165 +/- 37 mU/g protein, p < 0.05) after surgery; no significant difference was observed at days 12 and 15 (110 +/- 15 and 105 +/- 23 respectively). Both serum alkaline phosphatase activity (partly produced in enterocytes) and serum transglutaminase were significantly lower in resected rats at each time-point beginning at day 6 (208 +/- 34 v 557 +/- 125 UI and 1.55 +/- 0.11 v 3.78 +/- 0.70 mU/ml, p < 0.001 respectively). These data suggest an involvement of transglutaminase in enterocyte proliferation and confirm the association between reduced intestinal mass and low levels of the enzyme in serum.

Behaviour of transglutaminase activity in intestine of starved and refed rats

Starvation causes an intestinal mucosa atrophy which is greater in jejunum than in ileum. Hypoplasia is promptly reversed by refeeding. Transglutaminase (TG) has been controversially implicated in cell proliferation and its role in intestine is not defined. We investigate, by the above described model, the behaviour of TG in proximal and distal small bowel as well as in colon of rats after 4 days of starvation and at day 1, 2, 3, 4, 5, 7 and 10 of refeeding. Our results emphasize a significative reduction of TG in small bowel induced by starvation (day 0) and a prompt recovery of the enzyme activity after refeeding; furthermore, in the first intestinal tract TG activity reaches from day 2 to day 5 values which are significantly higher than basal. Four days of starvation do not affect TG in colon. In conclusion, our study demonstrates that in rats high values of TG activity are coincident with the intense proliferative phase in small intestine subsequent to starvation atrophy.

Prophylactic sclerotherapy of high-risk esophageal varices: results of a multicentric prospective controlled trial

In this prospective, multicenter trial, 140 cirrhotic patients with no previous upper gastrointestinal bleeding and with esophageal varices endoscopically judged to be at high risk of hemorrhage were randomized to receive either sclerotherapy or conservative treatment for the prevention of first variceal bleeding. The end-points of the study were bleeding and death. Life table curves showed that prophylactic sclerotherapy significantly diminished the incidence of variceal hemorrhage (p less than 0.001) and overall mortality (p less than 0.01). Two-year cumulative bleeding rate was 18% in the sclerosis group (95% confidence interval = 10 and 31) and 57% (95% confidence interval = 40 and 72) in the control group. Two-year cumulative mortality rate was 30% (95% confidence interval = 19 and 45) in the sclerotherapy group and 56% (95% confidence interval = 39 and 72) in the controls. One patient died after hemorrhage from an ulcer secondary to sclerotherapy. Analysis by the Cox model of the factors potentially confounding or interacting with the effect of sclerotherapy suggested that sclerotherapy was more efficient in preventing first bleeding in patients with decompensated disease (Child B and C) than in those in good condition (Child A). However, the 2-year cumulative bleeding rate of untreated Child A patients was only 19%, showing how in this group the endoscopic findings were unreliable in selecting high-risk varices and explaining why after a 2-year follow-up prophylactic sclerosis did not show any benefit in such patients. We conclude that sclerotherapy can decrease the incidence of first variceal bleeding and death for a period of 2 years in cirrhotic patients with high-risk varices.