Unsuspected infective cholestatic jaundice after bilateral tubal ligation

Severe bacterial infection from a primary septic focus remote from the liver is accepted to be a cause of hepatic dysfunction. This may range from minor biochemical abnormality of standard liver function tests to fulminant hepatic failure. This report highlights a presentation with deep obstructive-type jaundice associated with profound bio-chemical changes suggestive of cholestatic hepatitis. There was no clinical indication of infection during the first 4 weeks and at admission. As a result, the absence of fever and leucocytosis was misleading. Halothane hepatitis was the working diagnosis until the sixth week when pelvic sepsis emerged as the possible cause. However, drainage of the abscess led to prompt clinical and biochemical resolution of jaundice so that it is unlikely that halothane exposure was a primary contributing cause. In addition, other common causes of jaundice were excluded by serological and sonographic screening. This case was an unusual case in which the cause of cholestatic jaundice occurred after a minor gynaecological operation commonly performed in developing countries (AU)

Epidemiology of acute hepatitis in the Stann Creek District of Belize, Central America

Hepaptits is common in the Stann Creek District of Southern Belize to determine the etiologies, incidence and potential risk factors for acute jaundice, we conducted active surveillance for cases. Cases of jaundice diagnosed by a physician within the previous 6 weeks were enrolled. Evaluation included a questionnaire and laboratory tests for Hepatitis A, B. C, D, and E, a blood film for malaria, and a serologic test for syphilis. Etiologies of jaundice among 62 evaluable patients included acute hepatitis A, 6 (9.7 percent), acute hepatitis B, 49 (79.0 percent) hepatitis non-A-E, 2 (3.2 percent), and malaria, 5 (8.1 percent). There were no cases of acute hepatitis E. One patient each with antibody to hepatitis C and D were detected. The annualized incidence of hepatitis A was 0.26 per 1000. All cases of hepatitis A were in children 4-16 years of age. The annualized incidence of hepatitis B, 2.17 per 1000, was highest in adults aged 15-44 years (4.4 per 1000) and was higher in men (36 cases; 3.09 per 1000) than women (13 cases; 1.19 per 1000). Four (31 percent) of the women with hepatitis B were pregnant. The annualized incidence was significantly higher in Mestizo (6.18 per 10000 and Maya (6.79 per 1000) than Garifuna (0.38 per 1000) or Creole (0.36 per 1000). Persons with Hepatitis B were significantly more likely to be born outside of Belize (82 percent), had been in Belize < 5 years (73 percent), and lived and worked in rural areas (96 percent) than was the general population. Of those o 14 years of age with Hepatitis B, only 36 percent were married. Few persons admitted to transfusions, tattoos, IV drug use, multiple sexual partners, visiting prostitutes, or sexually transmitted diseases. Only 1 of 49 had a reactive test for syphilis. Six patients were hospitalized (including 3 with acute hepatitis B and one with Hepatitis A), and none to our knowledge died. Acute hepatitis B is the most common cause of viral hepatitis in the Stann Creek District, but the modes of transmission remain obscure. Infants, women attending prenatal clinics, and new workers are potential targets for immunization with Hepatitis B vaccine. (AU)

Perinephric abscess mimicking fulminant hepatic failure

We describe a female diabetic patient who presented with features suggestive of hepatobiliary disease and who exhibited clinical signs of fulminant hepatic failure. Identification and drainage of a right perinephric abscess resulted in prompt resolution of both the physical signs and biochemical indices of liver disease. Infection remote from the hepatobiliary tree can mimic fulminant hepatic failure, and recognition of this unusual presentation of infection is important if dangerous delay in diagnosis and treatment is to avioded. (AU)

A survey of hepatitis B among health workers in Jamaica - abstract

A convenience sample of 1537 health staff in Jamaica were surveyed in 1990/91 for hepatitis B markers and/or exposure to blood or hepatitis. Antibodies to either hepatitis B surface antigen (HBsAg) or hepatitis B core (HBc) were found in 19.8 per cent of 817 persons tested. HBsAg was found in 5.3 per cent persons tested. One or more needlestick accidents were reported by 60 per cent of the sample and blood or liquor splashing on the face was reported by 48 per cent. Jaundice and hepatitis was reported by 1.2 per cent and 3.5 per cent respectively. Prevalence of antibodies to hepatitis B virus (HBV) increased with age (p = 0.004) and years of service (p = 0.28) while HBsAg carrier status was associated with years of service (p = 0.039). Males were more likely to have antibodies to HBV than females (Odds Ratio 1.63, 95 per cent, CI 0.98 - 2.71). This survey reaffirms the importance of health workers being immunized with hepatitis B vaccine and adhering rigorously to universal precautions in patient care and laboratory practice (AU)

Hyperamylasemia and pancreatitis in leptospirosis

Hyperamylasemia has been documented in up to 65 percent of our patients with leptospirosis and jaundice. However, pancreatitis is an uncommon complication of leptospirosis. Three patients with leptospirosis and pancreatitis are described and compared with two leptospirosis patients who had hyperamylasemia but in whom the diagnosis of pancreatitis could not be substantiated. The cause of the hyperamylasemia in the latter patients was nonpancreatic. The elevation of the amylase in these latter two patients could not be explained by renal insufficiency, because the level of the amylase was greater than three to fourtimes the normal value, the upper limit to which amylase rises in renal failure.Thus, hyperamylasemia in patients with leptospirosis can be from pancreatic and nonpancreatic sources. Leptospirosis should be considered in the differential diagnosis of hyperamylasemia and pancreatitis (AU)

Leptospirosis in Barbados: a clinical study

A 39-month clinical study of leptospirosis was undertaken at the Queen Elizabeth Hospital, Barbados. Eighty-eight patients had a confirmed diagnosis of the disease during the period. The major serogroups identified were autumnalis (including a new serovar bim), icterohaemorrhagiae, ballum and canicola. The majority of patients presented with jaundice (95 percent), anorexia and headaches (85 percent), fever (76 percent) and conjunctival suffusion (54 percent). While abnormal creatinine levels were seen in 49 percent of patients on admission, only 16 percent were judged to have renal failure. The urine to plasma urea ratio showed high sensitivity and specificity in the diagnosis of pre-renal azotemia. Cardiac arrthymias and myocarditis occurred in 18 percent of patients and pericarditis in 6 percent. An elevated serum amylase was found in 65 percent of cases. The bilirubin level took 5.5 weeks to return to normal. Thrombocytopenia was shown not to be due to a disseminated intravascular coagulation, and a randomised trial dose penicillin did not reveal any benefit to jaundiced patients. The overall mortality during the study was 5.7 percent (AU)

A serological survey for leptospiral agglutinins among patients in a Barbadian general practice - abstract

Sera from 1,419 patients who attended a Barbadian general practice for a variety of complaints between 1st April and 30th April 1988 were examined for leptospiral agglutinins by the microscopic agglutination test. Sera from patients presenting with pyrexia of unknown origin, jaundice or kidney complaints, and from those whose titre was > 1:400, were also examined by the ELISA for IgM and IgG antibodies. Only one patient was diagnosed clinically as possibly having mild leptospirosis, but three others had been recently infected and some mild cases may have been missed. Altogether, 177 of the patients (12.5 percent) were positive at titres> 1:50. These were 104 of the 739 males (14 percent) and 73 of the 680 females (11 percent) (no statistically significant difference). Seropositivity tended to increase with age (p<0.01), and the highest rates were in agricultural workers (35 percent), labourers (24 percent) and non-manual outdoor workers (19 percent). The difference in seropositivity between the various indoor and outdoor occupational groups was highly significant (p<0.005). Autumnalis (31 percent of the sero postives), Panama (15 percent), Australia (14 percent) and Pyrogenes (11 percent) were the serogroups most commonly recorded among the seropositive patients. Autumnalis predominated in each of the main occupational groups except indoor non-manual workers where Panama, Pyrogenes and Australis occurred more frequently. Ninety-five per cent of the positive titres ranged between 1:50 and 1:400. Titres tended to increase with age, but there was no obvious association between higher titres and particular occupations (AU)

Leptospirosis in Barbados - abstract

Leptospirosis was first documented in Barbados by Bayley in 1939. Since that time it has continued to be a major cause of jaundice on the island, accounting for approximately fifty percent of the cases admitted to the medical wards. In 1979, the Government of Barbados in collaboration with the Medical Research Council (MRC) of the UK set up a laboratory for the diagnosis and study of the disease. In serological surveys carried out on the Island, Everald showed that 18.5 percent of 529 individuals tested from urban and rural areas had significant titres indicating previous exposure. Likewise, in a survey of school childern, he showed that 7.6 percent of 538 samples tested had significant titres. The majority of cases were exposed to the serovar Autumnalis. Autumnalis bim was first isolated by Jones from a stray dog in Bridgetown. It has subsequently been shown that bim is the most frequent cause of severe disease in man in Barbados. Two hundred and seventy-six hospital cases of leptospirosis have been confirmed since the inception of the laboratory in late 1979 to the end of December 1987. The cases seen in hospital have varied from 25 to 57 in any one year. On average, 15 cases per 100,000 population are admitted each year. The overall mortality rate has been 14.1 percent; however, since the inception of clinical research studies and aggressive supportive care in 1983 the mortality rate has been reduced to 9.4 percent. In 1981, a retrospective study of the incidence of thrombocytopenia in leptospirosis confirmed our published retrospective study showing that 30 of 49 (61.2 percent) patients had a platelet count of 100,000 or less. The association of thrombocytopenia and renal failure was also confirmed. In a study of twenty-four patients at the end of the first year of our MRC/UK-sponsored research programme, thrombocytopenia was demonstrated in 14 of these pateints. The only additional laboratory evidence suggestive of a disseminated intravascular coagulation lay in a mild elevation of the fibrinogen degradaton products, but this occurred with equal frequency in the non-thrombocytopenic patients. There was thus no casual relationship between the DIC and thrombocytopenia of leptospirosis. A randomized control study of high dose intravenous pencillin in icteric leptospirosis was conducted over a three-year period ending in December 1986. Thirty-eight patients were randomised to antibiotic therapy and forty-one to recieve intravenous fluids only. The two groups showed no significant difference in the time to defervence, return of biochemical parameters to normal, incidence of iritis or mortality in the two groups. Three patients (7.3 percent) died in the control group and one (2.6 percent) in the treatment group. The overall mortality for the study was 5.9 percent. Leptospires were recovered from urine cultures in six patients from the control gorup and none in the antibiotic group. It was concluded that while intravenous penicillin may sterilise the urine, it had little effect on the overall clinical outcome of jaundiced patients with leptospirosis. Twenty-four percent of patients had a cardiac arrhythmia, pericarditis or mycarditis when monitored by electrocardiagrams, halter monitor and echocardiagrams. Studies on the high incidence of hyperamylasemia (65 percent) in our leptospirosis patients are now in progress. The laboratory is continuing studies on the early diagnosis of the disease, looking at the application of common and specific DNA sequences from serovars of Leptospira interrogans for the diagnosis and distribution of leptospirosis, with the help of a new grant from the EEC (AU)

Central rupture of the liver with massive liver-cell necrosis: A case report and review of the literature

A case of massive central rupture of the liver in which the patient became jaundiced is described. Autopsy revealed, in addition to the intrahepatic haematoma, large areas of infarction in the liver, some of which had become infected and had given rise to septic embolization to various organs. There was deranged liver function which is ascribed to the structural changes found in the liver. The occurrence of hepatocellular jaundice with this type of liver injury has not, to our knowledge, been previously recorded. It is suggested that immediate investigation and treatment are essential if the patient is to survive.(AU)

Relatively benign sickle-cell anaemia in 60 patients aged over 30 in the West Indies

A study in Jamaica of 60 patients with sickle-cell anaemia over the age of 30 years showed that most of them were in full-time employment. Pains in the bones or joints, leg ulceration, and jaundice were the most frequent types of presentation, but only two patients had a haemoglobin level consistently below 6 g./100 ml. Most of the patients were well developed and of average height, and, though the development of secondary sexual characteristics was delayed, there was an average of 2.6 pregnancies per patient. These findings suggest that the course is more benign than has been realized. (AU)

Sickle-cell disease in pregnancy

17 patients with sickle-cell disease were followed through pregnancy. 9 of them had sickle-cell anaemia, 7 had sickle-cell/haemoglobin-C disease, and one had an unusual form of sickle-cell thalassaemia. The maternal and foetal hazards are discussed, and seem to be considerably less serious than in most other reports. Complications were more frequent in the puerperium. 5 out of 7 cases of sickle-cell/haemoglobin-C disease had no complications at any time. The birth-weight of the infants in this series was very much below average. The incidence of sickle-cell disease amongst pregnant women in Jamaica seems to be very similar to the incidence in the general population (Summary)

Some clinical aspects of abnormal haemoglobins

A short survey will be given of the different possible clinical consequences of the possession of abnormal haemoglobins both in the heterozygous and in the homozygous states. Haematuria, the crisis in sickle cell anaemia and related conditions and jaundice will be discussed in somewhat greater detail (AU)

Needle biopsy of the liver: an aid in the differential diagnosis of prolonged jaundice in infancy

Needle biopsy of the liver has been carried out in 25 infants aged 3 weeks to 18 months in whom normal bleeding, coagulation and prothrombin times had been determined. In 14 subjects the jaundice was secondary to biliary atresia and in 11 to hepatitis. The technique of biopsy is described. The histologic criteria for the differentiation of hepatitis and biliary atresia have been outlined. According to the criteria described above, 12 of 14 biopsies in cases of biliary atresia and 6 of 11 biopsies in patients with hepatitis have been adequate for diagnosis. In five patients, the correct diagnosis of biliary atresia was made on the basis of the biopsy specimen when certain findings were more suggestive of hepatitis. The actual or potential value of needle biopsy in avoiding unnecessary laparotomy is described in four subjects with hepatitis. Needle biopsy, by permitting early definitive diagnosis, may be an aid in avoiding the development of biliary cirrhosis in patients with types of biliary atresia amenable to surgical correction (SUMMARY)

Veno-occlusive disease of the liver

The clinical picture and autopsy findings of a fatal case of veno-occlusive disease of the liver (V.O.D.) occurring in a 10 month old Jamaican infant is reported. Points of similarity between V.O.D. and Budd-Chiari's syndrome, senecio poisioning and Indian infantile cirrhosis are noted . The possible eiology of V.O.D. is considered. It is postulated that V.O.D. is an important cause of cirrhosis of the liver in Jamaican children (Summary)