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Acute hepatitis E is becoming increasingly recognised in Europe with up to 40% of the population in Southern France being exposed to the virus, which is harboured in pigs. Patients with known liver disease may present with acute hepatitis E and present a diagnostic challenge. For example patients with autoimmune hepatitis (AIH) who are immunosuppressed and contract hepatitis E may be at increased risk of developing chronicity due to concurrent immunosuppression. Importantly, the diagnosis may be missed with the infection misdiagnosed as an autoimmune flare, and immunosuppression increased by the attending physician, thus enhancing the risk of chronicity of infection leading to progressive liver injury in immunocompromised patients. We report a case of acute hepatitis E in a patient with AIH and discuss the features that helped us differentiating it from an autoimmune flare.
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Hepatite E/diagnóstico , Hepatite Autoimune/diagnóstico , Doença Aguda , Adulto , Doença Crônica , Diagnóstico Diferencial , Progressão da Doença , Quimioterapia Combinada , Feminino , Hepatite E/imunologia , Hepatite E/virologia , Hepatite Autoimune/tratamento farmacológico , Hepatite Autoimune/imunologia , Humanos , Imunossupressores/uso terapêutico , Valor Preditivo dos TestesRESUMO
Medical tourism is becoming increasingly popular. The most popularly sought operations are cosmetic procedures. With the increase in cosmetic tourism, it is unsurprising that there has also been a rise in skin and soft tissue infections caused by nontuberculous mycobacteria (NTM); in particular by the rapidly growing mycobacteria species. Here we provide a case of a 35 year-old woman who presented after autologous fat grafting with multiple painful, violaceous, and purulent nodules on her arms, legs, and breasts. Infection was found to be due to Mycobacterium abscessus. She was successfully treated with azithromycin, clofazimine, rifabutin, amikacin, imipenem-cilastatin-relebactam (Recarbrio™) and imipenem-cilastatin. This is the first described case of a M. abscessus infection successfully treated using this combination.
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BACKGROUND: Penicillin allergy overdiagnosis has been associated with inappropriate antibiotic prescribing, increased antimicrobial resistance, worse clinical outcomes, and increased health care costs. OBJECTIVE: To develop and validate a questionnaire-based algorithm built in a mobile application to support clinicians in collecting accurate history of previous reactions and diagnosing drug allergy appropriately. METHODS: A survey was completed by 164 medical and nonmedical prescribers to understand barriers to best practice. Based on the survey recommendations, we created a 10-item questionnaire-based algorithm to allow classification of drug allergy history in line with the National Institute for Health and Care Excellence guidelines on drug allergy. The algorithm was incorporated into a mobile application and retrospectively validated using anonymized clinical databases at regional immunology and dermatology centers in Manchester, United Kingdom. RESULTS: A total of 55.2% of prescribers (95% confidence interval, 47% to 63.4%) thought it impossible to draw a firm conclusion based on history alone and 59.4% (95% CI, 51.4% to 67.5%) believed that regardless of the details of the penicillin allergy history, they would avoid all ß-lactams. A drug allergy mobile application was developed and retrospectively validated, which revealed a low risk for misclassification of outcomes compared with reference standard drug allergy investigations in the allergy and dermatology clinics. CONCLUSIONS: Perceived lack of time and preparedness to collect an accurate drug allergy history appear to be important barriers to appropriate antimicrobial prescribing. The Drug Allergy App may represent a useful clinical decision support tool to diagnose drug allergy correctly and support appropriate antibiotic prescribing.
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Sistemas de Apoio a Decisões Clínicas , Hipersensibilidade a Drogas , Aplicativos Móveis , Adulto , Antibacterianos/uso terapêutico , Hipersensibilidade a Drogas/diagnóstico , Hipersensibilidade a Drogas/tratamento farmacológico , Hipersensibilidade a Drogas/epidemiologia , Humanos , Sobrediagnóstico , Penicilinas , Estudos RetrospectivosRESUMO
Trichosporon species are emerging opportunistic yeasts that cause life-threatening disseminated disease in severely immunocompromised patients. Trichosporon japonicum is a very rare cause of invasive trichosporonosis. We describe a case of Trichosporon japonicum fungemia in an immunocompetent patient with a transcutaneous biventricular assist device.
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OBJECTIVE: To report on our 20 years' experience on complications after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) in patients with cirrhosis. METHODS: From 1994 to 2014, 1787 RFA procedures were performed percutaneously in 1162 patients with cirrhosis (852 Child A and 310 Child B) with HCC nodules (1.2-7 cm), prothrombin time >50%, platelet count of 50.000 mm3 and total bilirubin ranging from 0.80 to 4.5 mg dl-1. In 67 patients, RFA was performed on both intraparenchymal HCC nodule and tumour thrombus extended in the main portal vein and/or its branches. RESULTS: Four patients (0.3%) died after RFA. 39 patients (3.2%) changed in Child's class: 26 out of 28 Child A patients with cirrhosis changed to Child B and 2 changed to Child C class; 11 Child B patients changed to Child C class. On multivariate analysis, the total bilirubin pre-RFA was the only independent risk factor for impairment of liver function and death. Complications were hemoperitoneum, abscess and intrahepatic haematoma. CONCLUSION: RFA of HCC in patients with cirrhosis is safe, even in case of invasion of the portal venous system. Functional liver reserve should be strictly monitored, mainly when pre-RFA total bilirubin value is >2.5 mg dl-1. The study was approved by our institutional review board. Advances in knowledge: The total bilirubin value >2.5 mg dl-1 represents the main marker of functional liver reserve that predicts decompensation of liver cirrhosis in patients undergoing RFA for HCC.
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Carcinoma Hepatocelular/cirurgia , Ablação por Cateter/métodos , Cirrose Hepática/cirurgia , Neoplasias Hepáticas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Carcinoma Hepatocelular/complicações , Feminino , Humanos , Cirrose Hepática/complicações , Testes de Função Hepática , Neoplasias Hepáticas/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
Single nucleotide polymorphisms (SNPs) in the IL28B gene were shown to have limited utility in predicting response to telaprevir and boceprevir in treatment of chronic HCV infection in clinical trials. Data outside of the clinical trial setting are lacking. We assessed the value of single and combined IL28B SNPs rs12979860 and rs8099917 genotypes in predicting sustained virological response 12 weeks after cessation of triple therapy (SVR12) with telaprevir or boceprevir in a single-centre cohort of treatment-naïve and treatment-experienced patients with genotype 1 HCV mono-infection (n = 105). The overall SVR12 rate was 65.7%. By unadjusted bivariate logistic regression analysis, rs12979860-CC and rs8099917-TT were significantly associated with SVR12 in the subgroup of patients including all naïve patients and all treatment-experienced patients with the exception of partial- and null-responders to previous HCV therapy. The predictive value of rs12979860-CC was stronger than rs8099917-TT and only rs12979860-CC remained significantly predictive of treatment success when the two variants were assessed by adjusted logistic regression analysis in the whole study cohort. In patients presenting the rs12979860-CC variant, the additional determination of rs8099917 genotype had no value. IL28B rs12979860-CC remained significantly associated with SVR12 also in the multivariate analysis including the other baseline characteristics associated to SVR12 in the bivariate analysis (i.e., female gender, HCV genotype 1b, baseline viral load <800,000 IU/mL, advanced liver fibrosis and prior partial- or null-response to HCV therapy). Our study suggests that testing for the IL28B rs12979860 genotype may still be useful in predicting response to triple therapy with boceprevir and telaprevir in naïve patients and treatment-experienced patients other than partial and null-responders.
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BACKGROUND: Many HIV-infected patients in sub-Saharan Africa are not routinely screened for hepatitis B virus (HBV) infection and are on antiretroviral therapy (ART) regimens containing only lamivudine as anti-HBV active drug. METHODS: In 2009-2011, we screened for hepatitis B surface antigen (HBsAg) in 2820 HIV-infected adults patients at the Mbarara Hospital Uganda and investigated risk factors for HBV infection. Using samples of dried plasma or blood spots, we tested for HBV viral load and HBV drug resistance mutations in all HBsAg-positive patients on ART for ≥ 12 months. RESULTS: In this study, 109 patients tested HBsAg positive (3.9%; 109/2820). HBsAg-positive patients were more likely to have had >4 lifetime sexual partners (p<0.01). Of the 55 HBsAg-positive patients on ART for ≥ 12 months, 53 were only on lamivudine as anti-HBV active drug and two were on tenofovir and lamivudine. HBV-DNA was detected in 30 patients (54.5%; 30/55), all on lamivudine-monotherapy. Of the 23 patients in whom HBV-DNA sequencing was successful, 17 had lamivudine-resistant HBV strains harbouring rtM204V/I mutations accompanied by secondary/compensatory mutations. CONCLUSIONS: Our study suggests that sexual transmission may represent a major mode of spread of HBV in southwest Uganda and confirms the importance of screening for HBV and of using ART regimens containing tenofovir in HIV/HBV co-infected patients.
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Fármacos Anti-HIV/administração & dosagem , Antivirais/administração & dosagem , Farmacorresistência Viral/efeitos dos fármacos , Infecções por HIV/epidemiologia , Antígenos de Superfície da Hepatite B/sangue , Hepatite B Crônica/transmissão , Lamivudina/administração & dosagem , Adulto , Terapia Antirretroviral de Alta Atividade , Coinfecção , Estudos Transversais , DNA Viral/sangue , Feminino , Infecções por HIV/sangue , Infecções por HIV/tratamento farmacológico , Vírus da Hepatite B/imunologia , Hepatite B Crônica/sangue , Hepatite B Crônica/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Dados de Sequência Molecular , Mutação , Uganda/epidemiologiaRESUMO
Patients receiving haemodialysis are at an increased risk of hepatitis B infection; regular screening for incident infection and vaccination of susceptible individuals is recommended. Haemodialysis patients often require repeated high-dose hepatitis B vaccination boosters because of impaired response. Since the hepatitis B surface antigen is used as an immunogenic agent for vaccination and as a marker of hepatitis B infection, it has occasionally been detected in the blood shortly after vaccine administration and can be mistaken for a new infection. These transient results, however, are unlikely to persist for longer than 14â days after vaccination. We report the case of a haemodialysis patient who tested weakly positive for hepatitis B surface antigen 52â days after a vaccine booster. This is the longest vaccine-induced antigenaemia described in the literature and indicates that vaccination can cause weakly positive hepatitis B surface antigen results for longer than previously reported.
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Antígenos de Superfície da Hepatite B/imunologia , Vacinas contra Hepatite B/imunologia , Imunização Secundária , Diálise Renal , Hepatite B/prevenção & controle , Vacinas contra Hepatite B/uso terapêutico , HumanosRESUMO
UNLABELLED: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death. Portal vein tumor thrombus (PVTT) is one of the most dreadful complications of HCC and is associated with a median survival time of 2.7-4.0 months. The optimal treatment for HCC with PVTT has not yet been established. The aim of the present study was to report long-term results of percutaneous radiofrequency (RF) ablation of both HCC single nodule (up to 5 cm in diameter) and neoplastic main portal vein thrombus, compared to no-treatment. PATIENTS AND METHODS: From January 2005 to January 2010, out of 2,847 consecutive cirrhosis patients, 672 had HCC and main portal vein tumor thrombus (MPVTT); among these, 57 had a single HCC with MPVTT. Thirty-five patients with 35 single HCC nodules (ranging from 3.7 to 5 cm in diameter) underwent percutaneous RF ablation of both the nodule and the thrombus (cases); 22 patients refused RF ablation or any other treatment (controls). RESULTS: A complete necrosis of HCC nodules associated with re-canalization of main portal trunk (MPT) and its branches were observed in 26 patients (success rate=74%). The 1-, 3- and 5-year cumulative survival rates of patients were 63%, 30% and 20%, respectively. The 12-month cumulative survival rate of controls was 0% (p<0.0001). The difference was statistically significant (p<0.001; harzard ratio (HR)=2.88; 95% confidence interval (CI)=1.57-5.39). The 3- and 5-year cumulative disease-free survival rates of the patients were 35% and 22%, respectively. No deaths occurred. CONCLUSION: RF ablation of HCC and the accompanying MPVTT significantly prolongs long-term survival compared to no-treatment. The procedure is safe and should be considered as a new and effective tool in the treatment of advanced HCC.
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Carcinoma Hepatocelular/cirurgia , Ablação por Cateter , Cirrose Hepática/complicações , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia/cirurgia , Veia Porta/cirurgia , Trombose Venosa/cirurgia , Idoso , Carcinoma Hepatocelular/etiologia , Carcinoma Hepatocelular/mortalidade , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Cirrose Hepática/mortalidade , Neoplasias Hepáticas/etiologia , Neoplasias Hepáticas/mortalidade , Masculino , Recidiva Local de Neoplasia/etiologia , Recidiva Local de Neoplasia/mortalidade , Estadiamento de Neoplasias , Veia Porta/patologia , Prognóstico , Taxa de Sobrevida , Trombose Venosa/etiologia , Trombose Venosa/mortalidadeRESUMO
OBJECTIVES: To evaluate the role of 18-fluoro-2-deoxyglucose positron emission tomography-computed tomography ((18)F-FDG-PET-CT) in the diagnosis of infectious endocarditis (IE). METHODS: We retrospectively examined 27 consecutive patients who were admitted to the Infectious Diseases Department of Tor Vergata University Hospital between 2009 and 2013 with a suspicion of IE. The final IE diagnosis was defined according to the modified Duke criteria, and the microbiological and diagnostic results were collected for each patient. RESULTS: Twenty out of 27 patients had a suspected prosthetic valve endocarditis (PVE) and seven had a suspected native valve endocarditis (NVE). Twenty-five out of 27 patients (92%) had a confirmed diagnosis of IE (18/25 PVE and 7/25 NVE); 16 had a positive echocardiography evaluation and 16 had positive (18)F-FDG-PET-CT findings. Echocardiography showed a higher sensitivity as a diagnostic tool for the detection of IE compared to (18)F-FDG-PET-CT (80% vs. 55%). However, a greater number of PVE had positive (18)F-FDG-PET-CT results compared to those with positive echocardiography findings (11/13 vs. 9/13), and overall 89% (16/18) of confirmed PVE resulted (18)F-FDG-PET-CT positive. Analyzing only the cases who underwent transoesophageal echocardiography, (18)F-FDG-PET-CT showed a sensitivity of 85% in PVE (vs. 69% for echocardiography and 77% for the Duke criteria). All seven patients with NVE had a positive echocardiography and negative (18)F-FDG-PET-CT findings (p<0.001). CONCLUSIONS: The results of this study further highlight the limitations of echocardiography in the diagnosis of PVE and the potential advantages of (18)F-FDG-PET-CT in these cases.
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Endocardite/diagnóstico , Endocardite/microbiologia , Próteses Valvulares Cardíacas , Imagem Multimodal , Tomografia por Emissão de Pósitrons , Tomografia Computadorizada por Raios X , Adulto , Idoso , Endocardite/diagnóstico por imagem , Endocardite Bacteriana/diagnóstico por imagem , Feminino , Fluordesoxiglucose F18 , Humanos , Masculino , Pessoa de Meia-Idade , Compostos Radiofarmacêuticos , Estudos RetrospectivosRESUMO
Liver hydatidosis is the most common clinical presentation of cystic echinococcosis. Although liver cystic hydatidosis is considered a benign disease and many patients do not develop symptoms for years, its complications can be severe and life threatening (usually as a consequence of rupture in the biliary tree, in the peritoneum, in the bronchi, and of anaphylactic shock), thus, treatment is recommended for all viable and active hydatid liver cysts. Among the therapeutical options available for this disease, such as open and laparoscopic surgery and chemotherapy, percutaneous treatments have gained considerable interest over the last two decades, due to their efficacy, safety and high patient acceptability. Percutaneous treatments for liver cystic hydatidosis were once discouraged due to the risk of anaphylaxis following cyst puncture. Following the first uneventful attempts in the mid '80's, these treatments were increasingly used and techniques such as PAIR (Puncture, Aspiration, Injection, Re-aspiration) and its variants were developed and implemented in clinical practice. Although the evidence currently available is not sufficient to support or refuse the superiority of PAIR in terms of efficacy, numerous studies have demonstrated that it carries lower rates of morbidity, mortality, and disease recurrence and is associated with shorter hospital stays compared with surgery. The present review provides a brief history of percutaneous treatments for liver cystic hydatidosis, summarizes the currently available evidence on the subject, gives a brief overview of potential future developments in this field focusing on radiofrequency ablation techniques and presents some new patents on the issue.
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Ablação por Cateter/métodos , Equinococose Hepática/diagnóstico , Equinococose Hepática/terapia , Punções/métodos , Animais , Ablação por Cateter/tendências , Humanos , Punções/tendências , Resultado do TratamentoRESUMO
Abstract: Acute hepatitis E is becoming increasingly recognised in Europe with up to 40% of the population in Southern France being exposed to the virus, which is harboured in pigs. Patients with known liver disease may present with acute hepatitis E and present a diagnostic challenge. For example patients with autoimmune hepatitis (AIH) who are immunosuppressed and contract hepatitis E may be at increased risk of developing chronicity due to concurrent immunosuppression. Importantly, the diagnosis may be missed with the infection misdiagnosed as an autoimmune flare, and immunosuppression increased by the attending physician, thus enhancing the risk of chronicity of infection leading to progressive liver injury in immunocompromised patients. We report a case of acute hepatitis E in a patient with AIH and discuss the features that helped us differentiating it from an autoimmune flare.
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Humanos , Feminino , Adulto , Doença Aguda , Hepatite E/diagnóstico , Hepatite Autoimune/diagnóstico , Doença Crônica , Valor Preditivo dos Testes , Hepatite E/imunologia , Hepatite E/virologia , Progressão da Doença , Hepatite Autoimune/imunologia , Hepatite Autoimune/tratamento farmacológico , Diagnóstico Diferencial , Quimioterapia Combinada , Imunossupressores/uso terapêuticoRESUMO
PURPOSE: To evaluate the usefulness and safety of radiofrequency ablation for primary and recurrent intrahepatic cholangiocarcinoma (ICC) in our single centre experience. MATERIALS AND METHODS: Ten patients with ICC refusing or not eligible for surgery underwent radiofrequency ablation for their tumor. The ICC was primary in 9 cases and recurrent, after 2 previous resections, in 1 patient. Radiofrequency ablation was performed percutaneously under ultrasound guidance using a 15G perfused electrode. Technical success of the procedure was assessed by contrast-enhanced ultrasound (CEUS). Technical effectiveness was evaluated by CEUS and contrast enhanced CT 1 month after the last course of a defined ablation protocol. Follow-up contrast enhanced CT or MRI were performed every 3-6 months. RESULTS: RFA was always technically successful and effective for ICC lesions ≤3.4 cm and ineffective for lesion ≥4 cm. After a median follow-up of 19.5 months (range 9-64 months), 8 patients were still alive while 2 had died due to tumor progression. The 1-, 3- and 5-year overall survival rate of all patients with ICC of our series were 100%, 83.3% and 83.3%. No major complication was observed. CONCLUSION: Radiofrequency ablation seems to be a safe and effective option for small (≤3.4 cm) ICC nodules. In addition it may be considered as a palliative treatment for larger tumors.
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Ablação por Cateter/métodos , Colangiocarcinoma/radioterapia , Neoplasias Hepáticas/radioterapia , Idoso , Neoplasias dos Ductos Biliares , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma/imunologia , Meios de Contraste/farmacologia , Progressão da Doença , Feminino , Fibrose , Humanos , Neoplasias Hepáticas/imunologia , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodosRESUMO
BACKGROUND: During the progression from low-grade dysplastic nodule (DN) to progressed hepatocellular carcinoma (HCC), intranodular portal tracts gradually disappear, while unpaired arteries develop increasingly. Contrast-enhanced ultrasound (CEUS) is highly accurate in depicting intranodular vascularity. This study evaluates the usefulness of CEUS in the characterization of DN, early HCC and progressed HCC in cirrhotic livers. MATERIALS AND METHODS: Forty consecutive patients with cirrhosis and a single hepatic nodule ≤2 cm underwent CEUS and subsequent ultrasound-guided biopsy of the nodule. Imaging and pathological findings of DN and HCC were compared. RESULTS: The homogeneous pattern of hypervascularization during the arterial phase identified progressed HCC with a sensitivity of 90.9% and a specificity of 100%, whereas the inhomogeneous and reticular pattern identified early HCC with a sensitivity of 85.7% and a specificity of 96.1%. CONCLUSION: DN, early HCC and progressed HCC can be accurately differentiated with CEUS on the basis of the vascularization pattern during the arterial phase.