Comparison of liver biopsy and noninvasive techniques for liver fibrosis assessment in patients infected with HCV-genotype 4 in Egypt.

In Egypt, as elsewhere, liver biopsy (LB) remains the gold standard to assess liver fibrosis in chronic hepatitis C (CHC) and is required to decide whether a treatment should be proposed. Many of its disadvantages have led to develop noninvasive methods to replace LB. These new methods should be evaluated in Egypt, where circulating virus genotype 4 (G4), increased body mass index and co-infection with schistosomiasis may interfere with liver fibrosis assessment. Egyptian CHC-infected patients with G4 underwent a LB, an elastometry measurement (Fibroscan(©)), and serum markers (APRI, Fib4 and Fibrotest(©)). Patients had to have a LB ≥15 mm length or ≥10 portal tracts with two pathologists blinded readings to be included in the analysis. Patients with hepatitis B virus co-infection were excluded. Three hundred and twelve patients are reported. The performance of each technique for distinguishing F0F1 vs F2F3F4 was compared. The area under receiver operating characteristic curves was 0.70, 0.76, 0.71 and 0.75 for APRI, Fib-4, Fibrotest© and Fibroscan©, respectively (no influence of schistosomiasis was noticed). An algorithm using the Fib4 for identifying patients with F2 stage or more reduced by nearly 90% the number of liver biopsies. Our results demonstrated that noninvasive techniques were feasible in Egypt, for CHC G4-infected patients. Because of its validity and its easiness to perform, we believe that Fib4 may be used to assess the F2 threshold, which decides whether treatment should be proposed or delayed.

Role of Helicobacter pylori in patients with HCV-related chronic hepatitis and cirrhosis with or without hepatocellular carcinoma: possible association with disease progression.

The discovery of Helicobacter hepaticus as a causal agent of hepatitis and hepatocellular carcinoma (HCC) in mice has stimulated interest in looking for Helicobacter species in human liver samples. In this study, we searched for association between H. pylori and HCV-related liver disease. Liver specimens were collected from eighty-five patients; they were divided into five different groups according to liver pathology (METAVIR system). Group I (the 1st control group) consisted of 16 patients with chronic hepatitis C without histological activity. Group II consisted of 25 patients with chronic active hepatitis C, Group III, 17 patients with HCV-related cirrhosis and Group IV, 16 patients with HCV-related cirrhosis and HCC. Group V (2nd control group) consisted of 11 patients suffering from gastro duodenal and gall bladder diseases but negative for HCV. All cases were tested by polymerase chain reaction on liver samples for the presence of H. pylori DNA Cag A gene. Routine biochemical, radiological and RT-PCR for HCV RNA were also performed for all cases. The positivity of H. pylori PCR CagA gene in liver tissue was directly proportional to the severity of liver pathology, this being 75%, 52.9% and 32% in groups IV, III and II, respectively, which was more significant than the 1st and 2nd control groups (P < 0.001). There was a significant difference between H. pylori PCR values when compared to METAVIR staging (F) in different groups (P = 0.001). Helicobacter pylori PCR (Cag A gene) was positive in about 28.2% cases of late fibrosis (F3 + F4) while positivity was (5.9%) in early fibrosis (F1 + F2) (P = 0.0001). There was significant difference between H. pylori PCR (Cag A gene) in liver tissue and METAVIR activity in different groups (P = 0.002) as most of H. pylori PCR-positive cases were METAVIR activity A1 and A2 (15.3% and 12.9%, respectively). There was no association between H. pylori PCR and quantitative HCV RNA (P = 0.531). Also there was no significant difference of Child-Pugh staging in the H. pylori PCR-positive group when compared to the negative group (P = 0.996). There may be an association between the presence of H. pylori (Cag A gene) in the liver and disease progression in HCV-related chronic hepatitis and cirrhosis with and without HCC.

Progressive stridor: could it be a congenital cystic lung disease?

UNLABELLED: Bronchogenic cyst of the mediastinum, a cause of stridor early in life, is the result of abnormal budding of the ventral segment of the primitive foregut. Bronchogenic cysts are often asymptomatic in older children and adults. However, symptomatic cases usually manifest early in life with cough, stridor or wheezing due to airway compression. We report a female infant aged 4.5 months with a normal full-term pregnancy, who developed respiratory distress with stridor. This stridor was preceded by a history of slowly progressive noisy breathing. Physical examination revealed evidence of bilateral obstructive emphysema. Chest radiograph revealed bilateral overinflation. Fibro-optic bronchoscopy revealed posterior mediastinal compression. Possibility of congenital cystic lung disease (CCLD) was considered, emphasizing the value of computed tomography (CT) chest, which revealed a cyst probably bronchogenic. Surgical excision was performed with evident histological confirmation of bronchogenic cyst. CONCLUSION: we highlight that in any infant, presented with slowly progressive noisy breathing in the first year of life, CCLD should be considered in the differential diagnosis even with normal X-ray chest. CT chest should be performed for exclusion or diagnosis of the case.

Bilateral testicular tuberculomas: a case detection.

Genitourinary tuberculosis (TB) is the most frequent manifestation of extrapulmonary TB, where the epididymides, seminal vesicles and prostate are the commonly infected sites, followed by the testes. We report a 29-year-old man who presented with primary infertility since 2 years. He had a history of bilateral painful scrotal swelling with fever since 4 years, diagnosed as pyogenic scrotal abscess, which was managed by incision and drainage. At presentation, fever, weight loss and night sweats were absent. On examination, he had ovoid slightly tender, firm to hard irregular masses in the lower poles of both testes with no line of separation encroaching on both epididymes. Both testes were not felt distinctly and the overlying scrotal skin showed no signs of inflammation. Semen analysis revealed azoospermia. Scrotal colour coded duplex ultrasonography demonstrated moderately enlarged testes having well defined hypoechoic masses with foci of calcifications. Magnetic resonance imaging confirmed these findings. Biopsy and histopathology detected the presence of caseating granuloma and Ziehl-Neelsen staining of paraffin sections demonstrated acid-fast bacilli. The patient was treated with combination therapy. Tracing of the condition is discussed.

Living-Donor Liver Transplantation in Hepatitis C Virus Era: A Report of 500 Consecutive Cases in a Single Center.

BACKGROUND: Living donor liver transplantation (LDLT) is considered a safe alternative to deceased donor liver transplantation (DDLT). In Egypt, DDLT program is still awaited, making LDLT the only hope for patients with end-stage liver disease, mainly due to chronic hepatitis C virus (HCV) infection. The current study is conducted to evaluate our experience of LDLT and discuss the lessons learned from 500 consecutive cases in HCV area. METHODS: We reviewed the data of patients who underwent LDLT at Gastrointestinal Surgery Center, Mansoura University during the period between May 2004 and March 2017. RESULTS: During the study period, 500 cases underwent LDLT at our unit. The median age was 51 years, and most of our cases were males (446, 89.2%) and had HCV infection (453, 90.6%). The median MELD score was 15. Median ICU stay was 5 days, and hospital stay was 22 days. Postoperative morbidities occurred in 220 cases (44%). Early mortality occurred in 69 patients (13.8%), and late mortality occurred in 45 patients (9%). The 1-, 3-, 5-, and 7-year overall survival rates of all cases were 80.9%, 78.2%, 75.7%, and 75%, respectively. Preoperative creatinine, worm ischemia, blood transfusion, ICU stay, postoperative morbidities, and small for size syndrome were independent predictors for overall survival. CONCLUSIONS: In countries lacking DDLT, LDLT is the only effective alternative. LDLT requires a teamwork to achieve successful outcomes. LDLT should only be performed in centers with the adequate experience to avoid and decrease the hazards related to this procedure.

A simple bedside blood test (Fibrofast; FIB-5) is superior to FIB-4 index for the differentiation between non-significant and significant fibrosis in patients with chronic hepatitis C.

INTRODUCTION: A simple non-invasive score (Fibrofast, FIB-5) was developed using five routine laboratory tests (ALT, AST, alkaline phosphatase, albumin and platelets count) for the detection of significant hepatic fibrosis in patients with chronic hepatitis C. The FIB-4 index is a non-invasive test for the assessment of liver fibrosis, and a score of ≤1.45 enables the correct identification of patients who have non-significant (F0-1) from significant fibrosis (F2-4), and could avoid liver biopsy. The aim of this study was to compare the performance characteristics of FIB-5 and FIB-4 to differentiate between non-significant and significant fibrosis. METHOD: A cross-sectional study included 604 chronic HCV patients. All liver biopsies were scored using the METAVIR system. Both FIB-5 and FIB-4 scores were measured and the performance characteristics were calculated using the ROC curve. RESULTS: The performance characteristics of FIB-5 at ≥7.5 and FIB-4 at ≤1.45 for the differentiation between non-significant fibrosis and significant fibrosis were: specificity 94.4%, PPV 85.7%, and specificity 54.9%, PPV 55.7% respectively. CONCLUSION: FIB-5 score at the new cutoff is superior to FIB-4 index for the differentiation between non-significant and significant fibrosis.

The interplay between c-Myc oncogene expression and circulating vascular endothelial growth factor (sVEGF), its antagonist receptor, soluble Flt-1 in diffuse large B cell lymphoma (DLBCL): relationship to patient outcome.

UNLABELLED: The c-Myc is a ubiquitous and multifunctional oncogene. Recently, data obtained from experimental study suggests the involvement of c-Myc oncogene in angiogenesis. In the present study the interrelation of sVEGF, sFlt-1 concentrations and c-Myc oncoprotein expression at diagnosis were assessed in DLBCL and their impact on the patient outcome. Forty-five DLBCL patients beside 10 normal controls were included. C-Myc oncoprotein was assessed by immunohistochemistry. SVEGF and sFlt-1 were determined by enzyme linked immunosorbent assay. C-Myc over-expression was detected in 66.6% of DLBCL. The DLBCL patient group with positive c-Myc over-expression showed significantly higher sVEGF and significantly decreased sFlt-1 as compared to group with negative c-Myc over-expression (P = 0.000 and P = 0.009 respectively). SVEGF was positively correlated to sLDH and s.beta2 microglobulin (r = 0.6, P = 0.000, r = 0.69, P = 0.000) respectively. On the other hand sFlt-1 was negatively correlated to sLDH and s.beta2 microglobulin (r - 0.25, P > 0.05, r - 0.49, P = 0.001) respectively. The non-living DLBCL group showed significantly higher expression of c-Myc, higher concentration of sVEGF and lower concentration in sFlt-1 level as compared to the living group (P = 0.000 for all). Multivariate analysis revealed that c-Myc over-expression; high sVEGF and normal sFlt-1 levels at diagnosis had independent adverse influence on survival (relative risk: 17.9, 35.7, 29.3, 2.63; P < 0.0001, P < 0.0001, and P = 0.03 respectively) IN CONCLUSION: C-Myc over-expression significantly associated with high sVEGF and normal sFlt-1 level in DLBCL patients, suggesting a complex interrelationship between c-Myc oncogene expression and angiogenic regulators. C-Myc over-expression, high sVEGF and normal sFLt-1 levels at diagnosis had an independent adverse influence on survival in DLBCL patients and considered bad prognostic markers.

Cellular proliferation and ploidy of the gastric mucosa: the role of Helicobacter pylori.

BACKGROUND/AIMS: Recently, H. pylori has been recognized as a risk factor for gastric adenocarcinoma. As such, we have analyzed the DNA content of gastric epithelial cells in an attempt to reveal the role of H. pylori in gastric carcinogenesis. METHODOLOGY: Fifty-three subjects presented with gastric dyspepsia, 39 males and 14 females, with a mean age of 42.15 (+/- 13.16) years. They were referred to the out-patient clinic to undergo endoscopic examination for the first time. Biopsy specimens from the antrum of each subject were subjected to culture for the presence of H. pylori histologic diagnosis, and DNA flow cytometry for the analysis of cellular proliferation and DNA policy. RESULTS: The endoscopic diagnoses were normal appearance (12), Gastric ulcer (12), duodenal ulcer (29). Thirty-eight (72%) subjects were positive, and 15 (28%) subjects were negative for H. pylori. Abnormal DNA-content (aneuploidy) was found in specimens from the antrums of 3 patients, 2 patients with duodenal ulcers (DU, and one with a gastric ulcer (GU). The cellular proliferation detected by flow cytometry in the form of proliferative index (PI; percentage of cells in the DNA S and G2M phases) was 27.88 (+/- 12.48) and 14.17 (+/-2.94) in the antrums of those positive and negative for H. pylori, respectively. A very significant increase in the PI (p < 0.005) was found between subjects positive and negative for H. pylori. Patients with DU and H pylori infection had the highest PI, and the PI was significantly higher than in patients with DU, but without infection. Regarding histology, there was a significant increase in the PI in the presence of H. pylori infection in either CAG or dysplasia groups as compared to cases without infection in the same groups. CONCLUSION: These results show that H. pylori infection is associated with changes in the DNA-content and cellular proliferative activity, suggesting that H. pylori may be implicated in gastric carcinogenesis. Also, the significant increase in the PI along the progression of severity of the disease suggests that measuring this parameter might allow more accurate monitoring of patients, so that a targeted therapeutic protocol may be defined.

Apoptosis in chronic gastritis: evaluation of the gastric mucosa by DNA flow cytometry and the expression of the high molecular weight cytokeratin.

BACKGROUND/AIMS: A series of premalignant lesions, including chronic gastritis (CG), intestinal metaplasia (IM) and dysplasia are associated with gastric carcinogenesis. The present study aimed to define these precancerous gastric lesions further by the study of the cellular DNA using flow cytometry, and the expression of the high molecular weight (68 KDa) Cytokeratin "CK1" proposed as a marker for epithelial cells dying by apoptosis. MATERIAL AND METHODS: Multiple antral biopsies from each of 92 cases with gastric dyspepsia were subjected for DNA content analysis using flow cytometry, and immunostaining using anti-CK1 monoclonal antibody. RESULTS: Chronic gastritis (CG) was present in 85 (92.4%) of cases, 14/85 (16.5%) cases showed chronic superficial gastritis (CSG), and 71/85 (83.5%) cases were chronic atrophic gastritis (CAG). Sixty two of the 85 (74.7%) cases with CG revealed variable degrees of activities. A hypodiploid "Sub-G1" peak was detected in 35 of 85 cases with CG. This peak was significantly higher in active chronic gastritis (ACG) than in the inactive (ICG) cases (p < 0.005). Proliferative activity of cases with CG was higher than in normal cases (p < 0.05) and in cases with ACG than in ICG (p < 0.05). Abnormal DNA-content (aneuploidy) was present in 16 (18.8%) of the 85 cases with CG. The presence of gastric epithelial cells with morphological changes typical of apoptosis in cases showing hypodiploid "Sub-G1" peak, high proliferation, and DNA-aneuploidy, suggests that these cells may be apoptotic bodies. Mild degree of apoptosis was present in some cases (57%) with histologically normal mucosa, while dense apoptotic bodies occurred in 87% of cases with chronic gastritis. These apoptotic bodies were constantly expressing CK1, except those in normal mucosa, suggesting that CK1 can be used as a marker for dying epithelial cells by apoptosis. CK1 was detected in 16 (100%) aneuploid cases which also showed apoptosis. CONCLUSION: The presence of apoptotic bodies in cases with chronic gastritis especially in those showing DNA-aneuploidy, may accounts for the deletion of cells with altered DNA.

Correlation between endoscopy, histopathology, and DNA flow cytometry in patients with gastric dyspepsia.

BACKGROUND/AIMS: Gastric cancer has a poor prognosis, this is partly due to the advanced stage in which the tumor is diagnosed. The objective of this study is to elucidate the clinical significance of DNA flow cytometry and study its impact on monitoring the progression of gastric precancerous lesions in patients with gastric dyspepsia, and to correlate between endoscopic and histopathological findings with results of DNA flow cytometry. MATERIAL AND METHODS: A total of 92 cases underwent upper gastrointestinal endoscopy, 69 males with mean age 44.0 years and 23 females with mean age 38.7 years. Based on the endoscopic appearance, patients under study were classified into: 15 cases with endoscopic normal mucosa (EN), 26 cases with endoscopic gastritis (EG), 43 cases with duodenal ulcer (DU), and 8 cases with gastric ulcer (GU). Two antral biopsies were taken for histopathology and DNA flow cytometry. RESULTS: Chronic gastritis (CG) was present in 12 (80%) of EN cases. In DU patients, CG was present in 42 (97.7%) of cases, and it was associated with intestinal metaplasia (IM) in 11 (25.6%), and with dysplasia in 9 (20.9%) of these cases. While in GU patients, CG was present in all cases. Two (13.3%) of endoscopic normal cases revealed DNA aneuploidy in specimens with CG. The incidence of aneuploidy increases as the endoscopic findings changes from EG (15.4%), DU (16.3%) to GU (37.5%), and as the histopathological changes progresses from chronic atrophic gastritis (CAG) (18.2%), IM (21.7%) to dysplasia (33.3%). CONCLUSION: DNA aneuploidy is a useful marker for recognizing the presence of abnormal cells in epithelial lesions of the stomach, and for monitoring the progression of gastric lesions. Patients with gastric dyspepsia should not only be subjected to endoscopy but also to biopsy and DNA flow cytometry to allow the early detection of malignant transformations in gastric precancerous lesions.

Improvement of steatosis after interferon therapy in HCV genotype 4 is related to weight loss.

INTRODUCTION: Hepatic steatosis is common in patients with chronic hepatitis C virus (HCV) infection, and its occurrence may be related to both host and viral factors. Relationship between improvement in steatosis and response to anti-viral treatment remains unclear. This study assessed the factors associated with steatosis in patients infected with genotype 4 HCV, and to correlate degree of changes in steatosis with host factors and response to treatment. METHODS: Records of 175 patients with chronic genotype 4 HCV infection, who had received interferon and ribavirin combination therapy, were reviewed retrospectively to extract data on body mass index (BMI), presence of diabetes mellitus, and liver histology findings. Paired BMI data and liver biopsies (pre- and 24-weeks post-treatment) were available in 86 patients. Baseline steatosis and its changes (before and after treatment) were the dependent variables in a univariate and multivariate analyses. RESULTS: Steatosis was found in 88/175 (50.3%) of baseline biopsies. Its presence was related to baseline BMI (r=0.33, P<0.01), but not with viral load, or grade of liver inflammation or fibrosis. On follow up, improvement in steatosis was significantly associated with degree of weight loss but not with response to anti-viral treatment. CONCLUSION: Steatosis is common in genotype 4 HCV infection, and its presence appears to be related to high BMI, but not to viral load or degree of liver injury.

Does schistosomiasis interfere with application of Knodell score for assessment of chronic hepatitis C?

BACKGROUND: Schistosoma Mansoni (SM) is a significant etiology of liver disease in Egypt. Chronic hepatitis, predominantly HCV, is a major health problem worldwide. Whether, schistosomal affection could interfere with assessment of necroinflammatory injury and degree of fibrosis in liver biopsy of chronic hepatitis, is not a settled issue. The present study is an attempt to highlight this problem. MATERIAL AND METHODS: 185 individuals--pure schistosomal affection (25 pts), pure HCV (100 pts), and mixed schistosomal and HCV (HCV + SC) (60 pts)--were included. They were selected from among 222 biopsied patients with chronic liver disease attending the liver unit of Internal Medicine Department, Mansoura University July 1999-May 2000. They were subjected to rectal snip and serological test for schistosomiasis, liver functions, HBV, HCV serological markers, serum qualitative and quantitative PCR and liver biopsy. Masson trichrom stain was performed to assess fibrosis. Immunohistochemical staining for HBsAg & HBcAg were performed. Modified Knodell score was applied to assess the biopsy. RESULTS: Five out of the 25 pure schistosomal and only 2 of the mixed group revealed schistosomal granuloma. 30% and 33% of pure HCV and mixed patients, respectively, were found to be cirrhotic. No significant statistical difference was identified between the two groups with respect to necroinflammatory injury and Knodell score (p = 0.81). Additionally, no significant difference was identified related to the stage of fibrosis (p = 0.77). CONCLUSION: Schistosomal hepatic affection does not alter or interfere with assessment of necroinflammatory injury or fibrosis in mixed HCV-schistosomal liver affection.

c-Myc oncogene and Cdc25A cell activating phosphatase expression in non-Hodgkin's lymphoma.

UNLABELLED: The product of proto-oncogene c-Myc is a potent activator of cell proliferation. The prognostic importance of the over expression of c-Myc and its transcriptional target Cdc25A in non-Hodgkin lymphoma (NHL) patients remains to be elucidated. To determine the role and the prognostic relevance of c-Myc and Cdc25A over expression in this group, we analyzed the expression of c-Myc oncoprotein by immunohistochemistry and Cdc25A mRNA by reverse-transcription polymerase chain reaction (RT-PCR) in the biopsied lymph nodes of 59 NHL patients. Over expression of c-Myc oncoprotein (P62) was observed in 32 out of 59 samples (54.2%) and Cdc25A in 36 out of 59 (60.1%). The percentage of c-Myc oncoprotein and Cdc25A mRNA over expression was significantly increased from low grade (4/12=25%, 4/16=25%) through intermediate grade (9/20=45%, 10/20=50%) to high grade lymphoma (19/23=82.6%, 22/23=95.6%) respectively (P=0.001 for both). The proportion of patients with positive c-Myc and Cdc25A over expression was significantly higher among patients with elevated serum lactic dehydrogenase (sLDH), and serum beta 2 microglobulin compared to those with normal levels (P<0.05, <0.01, respectively). Moreover, 80 and 90% of NHL patients with bone marrow infiltration at diagnosis had c-Myc and Cdc25A over expression, respectively. On the other hand, positive c-Myc, and Cdc25A over expression were not significantly related to the grade of international prognostic index, or the presence of B symptoms or to histopathological type. The expression of c-Myc and Cdc25A was significantly elevated in those who died when compared to survivors (P<0.001 for both). Moreover, positive c-Myc and Cdc25A over expression was associated with shortened overall survival. IN CONCLUSION: over expression of c-Myc and Cdc25A may be poor prognostic factor in NHL and associated with poor outcome. Assessments of c-Myc and Cdc25A expression in NHL at diagnosis are likely to be helpful in predicting patient outcome and selecting optimal therapeutic regimen.