Landscape and climatic characteristics associated with human alveolar echinococcosis in France, 1982 to 2007

Binary file ES_Abstracts_Final_ECDC.txt matches

Personalized management of patients with inoperable alveolar echinococcosis undergoing treatment with albendazole: usefulness of positron-emission-tomography combined with serological and computed tomography follow-up

The present study aimed to identify a sub-group of inoperable alveolar echinococcosis (AE) patients undergoing long-term treatment with benzimidazole (BZM) who presented with an evolution suggestive of a parasitocidal effect. An evolution compatible with parasite death was observed in five patients.

Coeliac disease in chronic hepatitis C: a French multicentre prospective study

BACKGROUND

A prevalence of 1.2% of coeliac disease (CD) in patients with chronic hepatitis C was recently reported, suggesting a possible epidemiological link between these two diseases. However, other studies have not found this relationship.

AIM

To conduct a French multicentre prospective study to assess the prevalence of CD in hepatitis C virus (HCV)-infected patients.

METHODS

Between June 2003 and November 2005, 624 consecutive HCV-positive out-patients were tested for antiendomysial IgA antibodies (AEA), antigliadin IgA and IgG antibodies (AGA). Patients with positive AEA or IgA AGA and positive IgG AGA in a context of a high suspicion of CD were asked to undergo gastroscopy with duodenal biopsies.

RESULTS

Isolated IgA AEA, IgA AGA and IgG AGA were 0.16%, 5.7% and 4.4%, respectively. Gastroscopy was required for 39 patients, 31 were performed (eight refusals), but only 25 duodenal biopsies were performed as six patients had cirrhosis. CD was never detected.

CONCLUSIONS

The prevalence of CD in HCV-positive patients was 0% (95% confidence interval: 0-0.59%), but there is a low prevalence of CD in the whole French population.

Is the management of hepatitis C patients appropriate? A population-based study

BACKGROUND

In order for hepatitis C patients to receive antiviral treatment, they must reach medical care.

AIM

To assess the proportion of patients reaching medical care after hepatitis C diagnosis in a general population (1 006 171 inhabitants) in France.

METHODS

Between 1994 and 1999, 1508 cases were diagnosed, of which 1251 were eligible for the study.

RESULTS

Two-hundred and two patients did not have any medical care; among them, 55.4% had normal alanine transferase, 58.4% had risk factors related to lifestyle and 22.8% were alcoholics. Amongst the 1049 other patients, 41.6% had a liver biopsy, 25.0% were treated. Treatment was more often carried out in males than in females (OR: 1.59; P = 0.001), and in patients under 65 than in older patients (OR: 2.22; P < 0.008). Among non-treatment reasons, alcoholism (P = 0.001), drug-addiction (P = 0.04) and escaping monitoring (P = 0.04) were more frequent in males than in females, whereas normal alanine transferase was more frequent in females than in males (P = 0.004). Amongst 278 patients with a Metavir score >A1F1, 71 (25.5%) did not undergo treatment.

CONCLUSION

In a general population, one patient in six did not receive on-going health care; a quarter of patients with a Metavir score >A1F1 did not receive any treatment. These results showed insufficient clinical management, which could compromise the effectiveness of treatment in general population.

Acute vanishing bile duct syndrome after ibuprofen therapy in a child

We report the case of a 10 year-old girl who had Stevens-Johnson syndrome and cholestasis after ibuprofen therapy. Liver histology was compatible with vanishing bile duct syndrome. She received ursodeoxycholic acid, and liver tests normalized within 7 months. This report confirms that ibuprofen may induce acute vanishing bile duct syndrome.

Polymorphisms of the TAP1 and TAP2 genes in human alveolar echinococcosis

We postulated that TAP genes may influence the susceptibility of some individuals to Echinococcus multilocularis infection. Six coding region variants (codons 333 and 637 in TAP1, and 379, 565, 651 and 665 in TAP2) were typed in 94 patients and 100 controls. Thr/Thr homozygosity at TAP2/665 was more prevalent in patients than in controls [64% vs. 45%, respectively; odds ratio (OR) = 2.1 (95% confidence interval (CI) 1.1; 2.7)] and Thr/Ala heterozygozity was less prevalent (32% vs. 50%, respectively) (P = 0.014). Of the 38 patients with progressive lesions, 76% were Thr/Thr, as compared with 55% of patients without progressive lesions and 45% of controls (P = 0.058 and 0.02, respectively), independent of HLA status. To determine whether this association is functionally relevant, functional analyses and/or confirmation in distinct populations of patients with alveolar echinococcosis would be required.

Intracerebral alveolar echinococcosis

There are two species of the genus Echinococcus, Echinococcus multilocularis (also called alveolar hydatid) and Echinococcus granulosus, characterized by distinct growth features in humans. The main endemic regions for human alveolar echinococcosis (AE) caused by E. multilocularis are Central Europe, Russia, Turkey, Japan, China, eastern France and North America. Human echinococcosis is usually caused by an intrahepatic growth of parasitic larvae. Cerebral occurrence of E. multilocularis disease is rare, accounting for only 1% of cases, and is generally considered to be fatal. This report presents two cases of intracerebral E. multilocularis disease which occurred in two infected patients with AE pulmonary metastases. The anatomical and clinical features are discussed. Our retrospective survey would indicate that surgical treatment should be envisaged whenever possible.

Epidemiology of alveolar echinococcosis with particular reference to China and Europe

Human alveolar echinococcosis (AE), caused by the metacestode of the fox tapeworm Echinococcus multilocularis, is the most pathogenic zoonosis in temperate and arctic regions of the northern hemisphere. Prospective collection of human cases in some areas and mass screenings using ultrasound imaging and confirmation with serological techniques have markedly improved our knowledge of the epidemiology of the disease in humans during the past two decades. Transmission occurs when eggs of the tapeworm, excreted by the final hosts (usually foxes but also dogs, wolves and cats), are ingested accidentally by humans or during normal feeding by a variety of rodents and small lagomorphs. However, the species of host animals differ according to regional changes in mammalian fauna. This review mostly focuses on epidemiology of alveolar echinococcosis in those parts of the world where new and more accurate epidemiological data are now available, i.e. China and Europe, as well as on new epidemiological trends that can be suspected from recent case reports and/or from recent changes in animal epidemiology of E. multilocularis infection. The People's Republic of China (PRC) is a newly recognized focus on AE in Asia. Human AE cases were firstly recognized in Xinjiang Uygur Autonomous Region and Qinghai Provinces at the end of 1950s and infected animals were first reported from Ningxia in central China and northeast of Inner Mongolia in the 1980s. E. multilocularis (and human cases of AE) appears to occur in three areas: (1) Northeastern China (northeast focus): including Inner Mongolia Autonomous region and Heliongjiang Province (2) Central China (central focus): including Gansu Province, Ningxia Hui Autonomous Region, Sichuan Province, Qinghai Province and Tibet Autonomous Region and (3) Northwestern China: including Xinjiang Uygur Autonomous Region, bordered with Mongolia, Russia, Kazakhstan and Kyrgyzstan. The highest prevalence of the disease, up to 15 per cent of the population in some villages, is reached in China. In Europe, data from the European Echinococcosis Registry (EurEchinoReg: 1982-2000) show 53 autochthonous cases of AE in Austria, 3 in Belgium, 235 in France, 126 in Germany, 1 in Greece, and 112 in Switzerland, and 15 'imported' cases, especially from central Asia; 14 cases were collected in Poland, a country not previously considered endemic for AE. Improved diagnostic technology, as well as a real increase in the infection rate and an extension to new areas, can explain that more than 500 cases have been reported for these 2 decades while less than 900 cases were published for the previous 7 decades. New epidemiological trends are related to an unprecedented increase in the fox population in Europe, to the unexpected development of urban foxes in Japan and in Europe, and to changes in the environmental situation in many countries worldwide due to climatic or anthropic factors which might influence the host-predator relationship in the animal reservoir and/or the behavioural characteristics of the populations in the endemic areas.

[Cutaneous complications following liver transplantation: epidemiologic and clinical study in 86 patients]

INTRODUCTION

Organ transplanted patients exhibit cutaneous lesions caused by immunosuppressive treatment and/or immunosuppression itself. Several selected studies concerning kidney transplants have been reported, but few concerning liver transplants. We report a retrospective study of skin diseases after liver transplantation.

PATIENTS AND METHOD

This study was carried out on liver transplanted patients at the University hospital in Besançon since 1986. Eighty six patients were examined between January 1997 and May 1998. Standardized data obtained at the clinical examination and from past history were compiled concerning cutaneous side effects of immunosuppressive treatments as well as infectious and tumoral skin lesions.

RESULTS

Cutaneous side effects related to immunosuppressive treatments: 46.5p. 100 of patients exhibited hypertrichosis, 18.5p. 100 gingival hyperplasia, 8.2p. 100 acne, 23.2p. 100 skin atrophy, 13.9p. 100 senile purpura and 17.4p. 100 sebaceous hyperplasia. Infectious diseases were 2 erysipelas, 2 folliculitis, 29 p. 100 of common fungal infections, 13.9p. 100 of mucocutaneous herpes simplex infections, 3p. 100 of zoster, 38.3p. 100 of cutaneous warts (24.4p. 100 of common warts and 7p. 100 of condylomata). Tumoral skin lesions were 17.4p. 100 of actinic keratoses, 13.9p. 100 of skin cancer (7 squamous and 11 basal cell carcinoma). A correlation was shown between time past graft and the occurrence of skin cancer, between actinic keratoses and skin cancer and between common warts and squamous cell carcinoma.

DISCUSSION

We have demonstrated that drug induced skin disorders, infections and tumoral skin diseases were similar and as frequent in liver as in kidney transplanted patients. However, a lower frequency of warts was observed in liver transplanted patients as well as a higher frequency of basal cell carcinoma, compared with squamous cell carcinoma. This ratio is reversed in kidney grafted patients. These results suggest that immunosuppression is lower in liver transplanted patients with possible age involvement.

[The hepatopulmonary syndrome]

DEFINITION

The hepatopulmonary syndrome (HPS) associates a chronic hepatic affection, hypoxemia < 70 mm Hg and pulmonary vasodilatation.

PHYSIOPATHOLOGY

The mechanisms leading to pulmonary vasodilatation are complex and unclear. There appears to be an imbalance between the vasodilatating and vasoconstricting mediators. Nitrogen monoxide and endotheline-1 are well known. Hypoxia can be explained by the association of heterogenic ventilation-perfusion, shunts (rare), and a default in "diffusion-perfusion".

CLINICAL ASPECTS

In a hypoxic patient, platypnoea and orthodeoxia are characteristic of HPS. Stellar angioma associated with digital hippocratism and signs of portal hypertension are usually present.

TO PERMIT DIAGNOSIS

The air of blood gases, followed by 100% O2, standing and reclining, must be measured in all cirrhotic patients to detect hypoxemia. Contract sonography is the key diagnostic examination. Pulmonary perfusion scintigraphy establishes prognosis. Pulmonary angiography differentiates two groups of patients and, for type II patients, embolization therapy can be proposed. Preliminary data indicate that densitometry, conducted in rigorous conditions, can show pulmonary vasodilatation. Its interest must be confirmed by further studies on larger cohorts of patients.

THERAPEUTIC POSSIBILITIES

The only efficient treatment of HPS is hepatic transplant (HT). The placing of an intra-hepatic portal systemic shunt can be proposed while waiting for HT, or in certain patients not requiring HT. No medical treatment has demonstrated its efficacy, but better knowledge of the physio-pathologic mechanisms should improve this situation in the future.

[Echinococcoses]

Human echinococcoses, cystic echinococcosis and alveolar echinococcosis are due to infections with the cestodes Echinococcus granulosus and E. multilocularis, respectively. Both zoonoses share a prolonged latency period before clinical presentation. However their evolution is fairly different: that of a begin tumor of the liver or lung for cystic echinoccocosis, and that of a slowly developing malignant tumor of the liver for alveolar echinoccocosis, with subsequent invasion of liver vessels and bile ducts and metastatic dissemination. Ultrasonography, CT-scan and specific serology are the key-exams for diagnosis. In both forms, surgery is the treatment of choice when a complete resection is possible. Liver transplantation may be an ultimate treatment option in very advanced cases of alveolar echinoccocosis. However, alternative treatment procedures have been proposed in the past 15 years and, combined with an earlier diagnosis, they have markedly improved patients survival and quality of life. Interventional radiology (puncture, aspiration, injection, reaspiration) has become a fully validated treatment of cystic echinoccocosis, and may be used in alveolar echinoccocosis for alleviating some of the complications of the disease such as biliary obstruction or bacterial superinfection. Albendazole, at high dosage, is a necessary complementary treatment after any intervention procedure, and for life when radical resection is not possible. Prevention relies on personal measures of hygiene and heating of contaminated food, and on collective measures aimed at reducing cestode egg shedding by the feces of infected canivores.

Transglutaminase-mediated cross-linking is involved in the stabilization of extracellular matrix in human liver fibrosis

BACKGROUND/AIMS

Lysyl oxidase-mediated cross-linking contributes to the stabilization of collagen in liver fibrosis. We have investigated transglutaminase-mediated cross-linking, to determine if it participates in the stabilization of extracellular matrix in human liver fibrosis.

METHODS

Transglutaminase activity was assessed in vitro by incorporation of biotinylated amine into liver proteins. The product of the transglutaminase-catalyzed cross-linking reaction, Nepsilon(gamma-glutamyl)lysine, and the extracellular proteins cross-linked by it, were localized by immunohistochemistry in fibrotic livers. The cross-linked complexes were extracted from liver tissue, immunopurified and characterized by Western blot.

RESULTS

Transglutaminase, detected by immunohistochemistry, Western blot and by enzymatic activity, was found in higher amounts in fibrotic than in normal liver. The Nepsilon(gamma-glutamyl)lysine cross-link, undetectable in normal liver, was present extracellularly in fibrotic liver, where it was co-distributed with osteonectin, mostly in inflammatory areas submitted to an intense remodeling. Cross-linking of osteonectin by transglutaminase was confirmed by Western blot. In parasitic fibrosis transglutaminase also originates from the parasite.

CONCLUSIONS

Transglutaminase-mediated cross-linking occurs in liver extracellular matrix during the early, inflammatory, stage of liver fibrosis, whereas cross-linking by pyridinoline occurs mostly later in the fibrotic process. This could lead to the development of new anti-fibrotic treatments targeted to a specific stage of fibrosis.

Interferon alpha therapy in haemophilic patients with chronic hepatitis C: a French multicentre pilot study of 58 patients

BACKGROUND AND OBJECTIVES

Information about the long-term efficacy of interferon alpha (interferon-alpha) in haemophilic patients with chronic hepatitis not co-infected with the human immunodeficiency virus (HIV-1) is still limited. Previous studies seemed to indicate a low rate of response. The aim of this study was to evaluate the safety and long-term efficacy of interferon treatment in multi-transfused haemophiliacs.

METHODS

Fifty-eight haemophiliacs were scheduled to receive 3 MU of interferon-alpha 2b three times a week for 12 months. The patients were followed up for at least 24 months post-treatment. Response was assessed by measurements of serum hepatitis C virus (HCV) RNA.

RESULTS

Twenty-four patients (41.4%) dropped out. Except for seven patients, the symptoms that led to interrupting interferon treatment would probably not have resulted in the same decision in non-haemophilic patients. One patient developed an inhibitor to the deficient clotting factor without haemorrhagic consequences. In an intent to treat, the sustained virological response rate was 14%. However, when considering only the 34 patients who received the full treatment, HCV-RNA was cleared in eight patients (23%).

CONCLUSIONS

This study suggests that multi-transfused haemophiliacs with chronic hepatitis not co-infected with HIV-1 respond to prolonged treatment with interferon-alpha in a similar proportion to that observed in non-haemophiliacs. There was a high rate of patients who did not complete the interferon-alpha treatment, and this seems to be characteristic of this patient population.

Pattern of chromosomal imbalances in non-B virus related hepatocellular carcinoma detected by comparative genomic hybridization

Only limited data are available on comparative genomic hybridization (CGH) in hepatocellular carcinoma (HCC). They concern mainly B virus related HCC. Therefore, we used CGH to detect chromosomal imbalances in 16 non-B virus related HCC in alcoholic cirrhosis in 7 cases (HA1 to HA7), in C virus cirrhosis in 7 cases (HC1 to HC7), in non-cirrhotic liver in 2 cases (NC1, NC2), and in 9 non-malignant cirrhotic tissues. The most frequent imbalances in HCC were gains of whole chromosomes or chromosomal regions 7 or 7q (10/16, 62%), 1q (9/16, 56%), 5 or 5q (9/16, 56%), 8q (8/16, 50%), 6p (6/16, 37%), 15q (5/16, 31%), 20 or 20q (5/16, 31%), and losses of 17p (6/16, 37%), and 8p (5/16, 31%). High-level gains were identified in HCC on 1q (2/16), 3q (1/16), 7q (1/16), and 8q (3/16). No chromosomal imbalances were detected in any of the cirrhotic tissues. Most of the gains, losses, and amplifications detected in this CGH study corresponded well to those identified in previous studies, except for gains of whole chromosome 5 or 7 and/or of chromosome arms 5q or 7q and losses on 4q. Our results suggest that other chromosomal regions are involved in hepatocarcinogenesis.

Treatment of mild chronic hepatitis C with interferon alpha-2b: results of a multi-centre randomized study in 80 patients

OBJECTIVE

The natural history of mild chronic hepatitis C is not well-known and the benefit of treating this form of the disease is not well-defined. We conducted a pilot study to answer this question.

DESIGN

Mild chronic hepatitis C was defined by positivity for anti-HCV antibodies, detectable serum HCV RNA by PCR, and a Knodell score < or = 5 on a liver biopsy performed within the previous 6 months. Eighty patients from six centres were randomized into two groups receiving interferon alpha-2b, 3 MU three times a week for 6 months (group 1, n = 39) or no treatment (group 2, n = 41). Sustained response was defined by the loss of detectable serum HCV RNA at 6 months after therapy.

RESULTS

The two groups were not different at entry with respect to age, sex ratio, source of infection, disease duration, genotype, viral load and Knodell score. One patient (group 1) was excluded from the study, while two patients in group 1 (5%) and seven in group 2 (17.1 %) did not complete the trial. A sustained response was observed in seven patients (18%) in group 1 versus none in group 2 (P < 0.01). The difference in mean Knodell score remained non-statistically significant between the two groups at the end of the study. Reduction or interruption of interferon was necessary in eight patients (24.2%).

CONCLUSIONS

This first randomized controlled study in mild chronic hepatitis C shows a proportion of sustained responders to interferon alpha-2b similar to that observed in active chronic hepatitis C.

Immunodiagnosis of Echinococcus infections: confirmatory testing and species differentiation by a new commercial Western Blot

The Echinococcus Western Blot IgG (LDBIO Diagnostics, Lyon, France), using a whole larval antigen from Echinococcus multilocularis, was evaluated for serodiagnosis and differentiation between two human parasitic infections of worldwide importance: cystic echinococcosis, due to Echinococcus granulosus, and alveolar echinococcosis, due to E. multilocularis. Fifty and 61 serum samples from patients with cystic and alveolar echinococcosis, respectively, were used for assessing diagnostic sensitivity. The sensitivity of the assay was compared with those of screening tests used for these applications. Sera used for assessing cross-reactivities were from 154 patients with other diseases, either parasitic or not. The assay allowed the detection of serum immunoglobulin G antibodies in 97% of Echinococcus-infected patients. It had a higher sensitivity than screening assays for the detection for each echinococcosis. The assay allowed us to correctly distinguish between E. granulosus- and E. multilocularis-infected patients in 76% of cases. It did not allow us to distinguish active from inactive forms of both echinococcoses. The occurrence of cross-reactivities with neurocysticercosis indicates the necessity for retesting sera with species-specific antigens, for rare patients with neurologic disorders. This study shows the usefulness of the commercially available Echinococcus Western Blot IgG for the serological confirmation of human echinococcosis.

[Organized hepatitis C screening. Results and cost of a one-year campaign in a pilot area]

OBJECTIVES

The management and monitoring process and the efficiency of targeted hepatitis C screening in the French health care system are not known. We assessed the main results and the cost of the program established in the Doubs area, where organized screening was integrated into the activities of voluntary physicians.

METHODS

All biological laboratories in the area, 23% of the private general practitioners, 42% of occupational physicians, one prison health service and one health centre agreed to participate. Screening was targeted to the following risk factors: transfusion before 1991, intravenous drug use, tattooing and household contact. The prescription form specified the indication and allowed free testing.

RESULTS

Among the volunteers, 58% of the general practitioners, 63% of the occupational physicians and 50% of the laboratories prescribed at least one screening test. In one year, 948 serologies were prescribed, mainly for tattooing (45%) or transfusion (28%). Only 83% of the tests were performed, with patient observance depending on age, indication and the place of prescription. Thirty-one patients were positive (4%). The cost of the campaign was 10 994 F per screened case.

CONCLUSION

Mobilizing health professionals for organized screening is difficult which affects the efficiency of strategies.

A twenty-year history of alveolar echinococcosis: analysis of a series of 117 patients from eastern France

OBJECTIVES

Alveolar echinococcosis of the liver is a very rare and severe parasitic disease due to the growth of the larva of Echinococcus multilocularis. The aim of this paper was to describe a 20-year study of the epidemiological, clinical and therapeutic aspects of alveolar echinococcosis in eastern France.

DESIGN

One hundred and seventeen consecutive cases, diagnosed and followed in our liver unit, were studied from 1972 to 1993.

METHODS

Data from 85 patients followed since 1983 (period B) were compared to data from a first series of 32 patients (period A) collected from 1972 to 1982; 1983 was chosen as the cut-off year because of the numerous changes that occurred in the diagnosis, follow-up and treatment of the disease at this time, in particular the introduction of parasitostatic benzimidazoles.

RESULTS

The results of patient follow-up were evaluated in December 1997. The cumulative prevalence was 2.5 per 100,000 persons in period A whereas it reached 6.6 per 100,000 in period B. The annual incidence in period B was 7.3 on average, compared with 2.7 in period A. Twenty-nine per cent of patients from period B were asymptomatic at the time of diagnosis compared with 10% in period A. This change was correlated with less advanced liver lesions, and was related to the extensive use of abdominal ultrasound, and from 1987, serological screening. Curative resections were performed in 24% of the cases in period B versus only 3% in period A. From 1986, liver transplantations were performed in eight patients from period A and 13 patients from period B. In period B, palliative surgery was frequently replaced by radiological non-operative procedures to treat abscesses and jaundice. From 1982, 73 patients received benzimidazoles for a period of time ranging from 4 to 138 months. Stabilization of the lesions was observed in two-thirds of the patients. Episodes of jaundice or digestive haemorrhage due to portal hypertension were 31.5 and 11 times less frequent respectively in patients from period B compared with period A. Actuarial survival at 5 years improved from 67% in period A to 88% in period B in patients of similar age.

CONCLUSIONS

Radical changes in the diagnosis and the management of alveolar echinococcosis have occurred during the last decade. Together they have contributed to an improvement in the status of the patients affected by this very severe parasitic disease.

Water vole (Arvicola terrestris scherman) density as risk factor for human alveolar echinococcosis

Concern is growing in Europe about alveolar echinococcosis (AE) with the increase in grassland rodent and red fox populations, intermediate and definitive hosts for Echinococcus multilocularis, respectively. The objective of this study was to assess the influence of rodent densities on human AE distribution. Spatial Poisson regression analyses were performed with geomorphologic features, landscape composition, climatic characteristics, and water vole density as independent variables. The outcome consisted of AE cases diagnosed over the period 1980-1992. High vole density yielded a 10-fold risk (relative risk [RR] = 10.34, 95% confidence interval [CI] = 2.78-38.39), and the first plateau (400-700 m altitude) compared with the plain (200-400 m) was associated with a large increase in risk (RR = 7.10, 95% CI = 1.30-38.63). These results confirm that human AE is strongly influenced by the densities of arvicolid species. Foxes feeding almost exclusively on grassland rodents when the latter expand could mediate this relation.

Primary disease recurrence after liver transplantation for alveolar echinococcosis: long-term evaluation in 15 patients

Between 1986 and 1991, 21 patients received liver grafts in our center for incurable alveolar echinococcosis (AE). The aim of this study was to analyze the long-term results in 15 of these 21 patients who survived more than 1 year after undergoing a liver transplantation (LT). The follow-up, mainly aimed at the diagnosis of recurrence, consisted of repeated radiological and specific immunological investigations. The role of pre- and post-LT benzimidazole (BZM) therapy was also evaluated. Among the 15 patients, 8 patients had a palliative LT related to previously known pulmonary AE metastases and/or inextirpable abdominal parasitic foci. In the 7 remaining patients, LT was considered curative. In June 1998, the mean follow-up duration was 96 months (range: 28-138 months). Five late deaths occurred, 2 of them were directly related to residual AE. A reinfection of the graft was observed in 4 patients. Preoperative BZM therapy seemed useful in preventing or delaying the parasitic recurrence. Post-LT BZM was able to stabilize and even to reduce residual AE. The anti-Em2 enzyme-linked immunosorbent assay (ELISA), which is the standard test used in patient follow-up after partial liver resection for AE, did not appear useful in detecting recurrence here; however, an ELISA, using a crude heterologous antigen (Echinococcus granulosus) allowed early diagnosis of residual AE. In conclusion, primary disease recurrence is not rare after LT for AE. Immunosuppressive therapy may favor larval growth in extrahepatic sites; therefore, an extensive extrahepatic radiological check-up has to be performed before LT. BZM therapy seems to stabilize residual foci. Anti-Eg immunoglobulin G (IgG) follow-up is the most useful test for early diagnosis of parasite recurrence.

The level of the collagen cross-link pyridinoline reflects the improvement of cutaneous lesions in one case of skin alveolar echinococcosis

Cutaneous parasitic lesions, associated with a dense fibrous reaction, markedly improved under albendazole treatment in one case of supraumbilical skin localization of alveolar echinococcosis. Since collagen cross-linking increases during fibrogenesis and contributes to the stability of fibrotic lesions, we monitored the level of the cross-links pyridinoline and pentosidine in skin lesions from this patient to determine if they would reflect the changes occurring during treatment. We looked at the deposition of cross-linked type I collagen by immunohistochemistry and also measured the serum concentrations of pentosidine and of a fragment of type I collagen (ICTP), which contains a site of pyridinoline formation. Albendazole treatment did not affect either the collagen content of skin lesions or the serum concentrations of ICTP and pentosidine, but it led to a pronounced decrease in pyridinoline level concomitant with the disappearance, observed by immunohistochemistry, of extensively cross-linked fibrotic type I collagen. The follow-up of collagen cross-linking by pyridinoline in skin tissue thus appears to be useful in reflecting the improvement of fibrotic skin diseases during therapy.

HLA and alveolar echinococcosis

Evidence in animal intermediate hosts that susceptibility to larval infection with Echinococcus multilocularis is restricted to individual host factors prompted us to investigate the susceptibility markers in humans. Because antigens of the extracellular parasite E. multilocularis are possibly presented by MHC molecules in a restricted way, we speculated that MHC polymorphism may influence resistance of the host towards infection and course of disease. We studied HLA-A, -B, -DRB1, -DQB1 and -DPB1 polymorphism in 151 patients with alveolar echinococcosis. Patients with an observation period of more than 2 years were grouped according to the clinical follow-up into cured (no recurrence following surgery) patients and patients with regressive or progressive forms of disease during benzimidazole chemotherapy. By comparing phenotypic frequency between patients with alveolar echinococcosis and healthy controls, HLA-DRB1*11 was associated with a reduced risk for disease development (odds ratio=0.55, 95% confidence interval=0.34-0.88; P=0.01). HLA-DQB1*02 was more frequent in patients with progressive disease when compared with patients with regressive disease (54.3% vs 28.3%, P=0.02). The result suggests that HLA-DRB1*11 might confer protection against alveolar echinococcosis and that HLA-DQB1*02 may indicate a risk for progressive disease development. The findings may facilitate the search for immunodominant T-cell epitopes of E. multilocularis.

Tenoxicam, a non-steroid anti-inflammatory drug, is unable to increase the response rate in patients with chronic hepatitis C treated by alpha interferon

The purpose of this study is to compare a combination of interferon (IFN)-alpha2a (Roferon) + Tenoxicam with IFN-alpha2a alone in the treatment of chronic hepatitis C. This prospective, randomized double-blind study included 149 patients, all of whom were diagnosed with active chronic hepatitis C but non-cirrhotic (ALT > or = 1.5 upper limit of normal, anti-hepatitis C virus (HCV) positive by enzyme-linked immunosorbant assay2 and RIBA3). The patients were randomized in two groups, as follows: G1 (n = 76): IFNalpha2a 3 million units times per week during 6 months + placebo; and G2 (n = 73): IFNalpha2a 3 million units three times per week + Tenoxicam (20 mg/day) during 6 months. Alanine aminotransferase (ALT) and HCV RNA were determined before and at months 6 and 12 of treatment. 2'5' oligoadenylate synthetase activity (2'5' AS) was dosed in mononuclear cells before and at 3-month treatment intervals in 28 patients. Liver biopsy was performed before and 6 months after the end of therapy. Parameters were similar before therapy for both groups. Biochemical and virological responses were similar for both groups at month 6 (49.3% vs. 42.9% and 43.3% vs. 38.3%, respectively) and month 12 (28.3% vs. 23.8% and 17.2% vs. 17.5%, respectively). HCV RNA level significantly decreased in both groups at month 6, with no difference whatever the therapy; however, the HCV RNA level returned to initial values at month 12 and was the only significant prognostic factor of a sustained response. No peak of 2'5' AS activity was observed during treatment in patients with dual therapy. A histological improvement was also noted in both groups without difference, regardless of therapy. The percentage of adverse events was identical for both groups. Paracetamol intake, assessed in 80 patients, was 49.1 g per 6 months in the G1 group and 22.5 g per 6 months in the G2 group (not significant). In conclusion, the non-steroid anti-inflammatory drug, Tenoxicam, does not increase IFNalpha efficacy in the treatment of chronic hepatitis C. This combination is well tolerated and partially lowers Paracetamol intake, but not preexisting alpha-IFN adverse events.

Increased basal production of interleukin-10 by peripheral blood mononuclear cells in human alveolar echinococcosis

The secretion of IL-10 by peripheral blood mononuclear cells (PBMC) and the expression of IL-10 mRNA in fractionated CD4+ and CD8+ lymphocyte subsets and non-B-non-T cells, with and without stimulation by the mitogen phytohemagglutinin-C (PHA-C) and specific Echinococcus multilocularis (E. multilocularis) antigens, were assessed in 7 patients with alveolar echinococcosis (AE) and 6 healthy subjects. Results of studies on IL-10 were compared to those on IFN-gamma, IL-4 and IL-5 in the same patients and control subjects. IL-10 production was significantly higher in patient PBMC-culture supernatants than in the control group supernatants, both at the basal level and after mitogen or specific E. multilocularis antigen stimulation. Both CD4+ and CD8+ lymphocyte populations and non-B-non-T cells of AE patients and controls expressed IL-10 mRNA. Semi-quantification of IL-10 mRNA revealed a significantly higher transcript level in unstimulated-CD8+ T cells from AE patients in comparison with CD8+ T cells of healthy donors. PBMC from patients produced very low levels of IL-4 but the production of IFN-gamma was not significantly depressed compared to the controls. PBMC, isolated from 4 AE patients and 4 control subjects stimulated with specific E. multilocularis antigens, secreted IL-5; IL-5 mRNA was only detected in the CD4+ lymphocyte subset. The secretion of IL-5 and the expression of IL-5 mRNA in healthy subjects could be due to the presence of non-specific mitogenic parasitic factors. This non-specific mitogenic activity of the parasite, besides inducing a high secretion of IL-10 in patients with evolutive AE, may contribute to the lack of host control of parasite growth and to the persistence of granulomatous lesions, due to the inhibition of an efficient Th1 immune response.

[Pseudotumor form of hepatic distomatosis: successful treatment with praziquantel]

Human Fasciola hepatica infection is usually discovered either early, during the acute (invasive) phase, or in the advanced phase, which is characterized by biliary complications. We report a case of liver distomatosis with nodular intra-hepatic lesions in a 58-year-old woman. Radiological investigations showed 3 nodular lesions in the VII segment, which were difficult to distinguish from liver metastases or liver abscesses. Distomatosis serology was positive with passive hemagglutination. After a 5-day treatment with praziquantel, clinical symptoms resolved quickly while serological tests became negative. Radiological images slowly decreased to a calcified scar at 13 months. No side-effects were noted. Praziquantel, whose efficacy in the common presentations of liver distomatosis has recently been demonstrated, also seems effective and well tolerated in case of nodular intra-hepatic lesions.

Antibodies against Echinococcus multilocularis alkaline phosphatase as markers for the specific diagnosis and the serological monitoring of alveolar echinococcosis

The immunological properties of the purified alkaline phosphatase (pAP) of Echinococcus multilocularis metacestodes have been investigated using alveolar echinococcosis (AE) patient sera in ELISA tests. A comparative study was done with EmC-Ag (crude antigen) and pAP-Ag (purified antigen). When the parasite purified enzyme pAP was used as antigen, the specificity of the ELISA was markedly increased since it reached 100% without any decrease of its sensitivity (100%). The serologic follow-up of AE patients was conducted during several months with these two antigens in three categories of patients: cured, stabilized and aggravated. There was a good correlation between clinical and serologic data when the pAP was used as antigen in ELISA tests. The anti-pAP antibodies titres did change more rapidly than anti-EmC antibodies titres when a recurrence occurred. Modifications of the anti-pAP antibodies levels were also observed during the patient's therapy: mebendazole, albendazole and Isoprinosine. These results suggest that pAP-Ag should be used for the diagnosis and the follow-up of AE patients.

[Obliterative arteriopathy in chronic rejection after hepatic transplantation. Search of cytomegalovirus genome by in situ hybridization and viral antigens by immunohistochemistry]

OBJECTIVES

This study was performed to assess the role of cytomegalovirus in the parietal infection of intrahepatic arteries in the pathogenesis of obliterative arteriopathy from chronic rejection after orthotopic liver transplantation.

METHODS

We studied two groups of liver transplants by in situ hybridization and immunohistochemistry: group 1, including 10 liver grafts with obliterating arteriopathy, and group 2 including 7 liver grafts without any arterial disorders. The results were correlated with clinical data (cytomegalovirus infection and acute rejection).

RESULTS

By in situ hybridization, cytomegalovirus DNA was identified in the media in 70% of transplants in group 1 and 42% in group 2. Detection of immediate early and late antigens by immunohistochemistry was negative. Cytomegalovirus infections were often associated with acute rejection.

CONCLUSION

These results suggest that cytomegalovirus detected in arteries is latent, and that cytomegalovirus probably does not play a role in the pathogenesis of chronic rejection obliterative arteriopathy.

[Acute cytolytic hepatitis caused by coumarin. 2 cases]

Coumarin is a drug which is extensively used to treat lymphedema. We report two cases of acute hepatitis probably due to coumarin. Two women, 40 year and 45 year-old, were treated with 90 mg/d of coumarin for 5 months. Clinical features included jaundice, pruritus, and diarrhea. A marked increase in serum aminotransferases was observed (ALT: 30 and 100 times the upper limit of normal, respectively). Coumarin withdrawal was rapidly followed by a favorable outcome in both cases. Rechallenge in one case induced a relapse of symptoms and liver test abnormalities. Coumarin can induce acute cytolytic hepatitis.

[Liver transplantation in adults. Indications and results]

Liver transplantation is currently the standard treatment for terminal stage liver disease. Overall actuarial survival rate at 5 years is 65 to 70%. However, because of the increasing number of transplantations being performed throughout the world, the number of potential recipients exceeds the number of donor organs available. The long waiting lists thus imply rigorous candidate selection. At the same time, the indications for transplantation have evolved. In light of survival rates, certain indications, such as hepatitis B with viral replication before transplantation or hepatocellular carcinoma less than 3 cm in diameter, may be debatable. There are also new indications with excellent short-term results, such as alcoholic cirrhosis or hepatitis C cirrhosis. The long waiting lists have led to the development of intermediary management schemes: intrahepatic porto-systemic shunts to decrease portal pressure and facilitate subsequent dissection; neoadjuvant chemotherapy for hepatocellular carcinoma; or lamivudin to inhibit B virus replication. The limiting factor remains the lack of sufficient donor organs. It will not be possible to pursue wider indications unless the number of donors can be increased. This objective raises a vital challenge to the medical community.

Mechanism of collagen network stabilization in human irreversible granulomatous liver fibrosis

BACKGROUND & AIMS

Cross-linking participates in the increased stability of collagen towards proteolytic degradation. Liver collagen cross-linking by pyridinoline, from the lysyl oxidase pathway, and by pentosidine, issued from glycation, was investigated to determine their respective contribution to collagen stabilization in patients with an irreversible liver fibrosis caused by the parasitic granulomatous disease alveolar echinococcosis.

METHODS

Liver pyridinoline and pentosidine were analyzed by high-performance liquid chromatography, and urinary pyridinoline was analyzed by immunoassay. Cross-linked type I collagen was localized by immunohistochemistry with an antibody against the C-terminal part of the molecule, involved in pyridinoline formation, that was measured in serum by radioimmunoassay.

RESULTS

In contrast to pyridinoline, pentosidine decreased in fibrotic lesions. Cross-linked I collagen was located predominantly in collagen bundles in the periparasitic granuloma. Serum pentosidine and urinary pyridinoline levels did not differ significantly from controls, but the serum concentration of the C-terminal telopeptide of type I collagen increased significantly.

CONCLUSIONS

Lysyl oxidase-mediated cross-linking is the major process contributing to the stabilization of collagen in granulomatous fibrosis, and glycation is not significantly involved in it. The changes induced by alveolar echinococcosis in liver collagen metabolism are associated with an increase in serum C-telopeptide of type I collagen.

A single dose of ursodiol does not affect cyclosporine absorption in liver transplant patients

OBJECTIVE

To study the possible influence of ursodiol (ursodeoxycholic acid), a hydrophilic bile acid, on cyclosporine (CsA) bioavailability.

METHODS

Seven adult liver transplant recipients participated in a randomised cross-over pharmacokinetic study comparing ursodiol (600 mg) with placebo in single doses. Blood concentrations of CsA were measured by HPLC.

RESULTS

There was no significant effect of ursodiol on CsA absorption: AUC was 5011 vs 5486 ng.h.ml-1, Cmax was 832 vs 871 ng.ml-1 and tmax was 2 vs 2 h, after ursodiol and placebo, respectively.

CONCLUSION

Although a significant period effect was observed, we conclude that a single dose of ursodiol has little effect on CsA absorption in liver transplant patients and that an interaction in the intestinal lumen between these two drugs is unlikely.

Effect of the transition from intravenous to oral dosing on cyclosporin-A trough concentrations in liver transplant patients

Cyclosporin A (CsA) absorption is low and variable after liver transplantation, and during the intravenous-oral transition period CsA concentrations may not be maintained within the therapeutic range. Trough whole blood CsA concentrations were measured by high-performance liquid chromatography before and after the transition period in 27 liver transplant patients. Mean (SD) CsA concentrations decreased from 291 (92) to 198 (96) ng/ml (p < 0.001). When analyzed on individual charts, a decrease was observed in 15 of 27 patients and it was associated with a duration of 2 days or less (p < 0.01) and a total bilirubin value below 3.5 mg/dl (p < 0.05). Our results show that, despite therapeutic drug monitoring, CsA blood concentrations may decrease during the intravenous-oral transition period.

Skin localization of alveolar echinococcosis of the liver

Alveolar echinococcosis is a rare parasitic disease caused by the intrahepatic growth of Echinococcus multilocularis larvae. Secondary localizations can be observed; pulmonary metastases are the most frequent and are observed in 22% of patients. Other extrahepatic localizations are less frequent. We describe two patients with abdominal skin involvement. To our knowledge, this has never before been reported. In both patients, the liver lesion was located in the left lobe, and larvae probably spread to the skin via the falciform ligament. In one patient albendazole therapy was effective.