Evaluation of anti-HBV drug resistant mutations among patients with acute symptomatic hepatitis B in the United States.

BACKGROUND & AIMS: Reported HBV drug resistance mutations among previously untreated patients with chronic hepatitis B are variable. Whether resistant HBV strains are transmitted in the acute setting is uncertain. We sought to document the presence of antiviral resistance (AVR) mutations in patients with acute HBV (AHB) infection. METHODS: AHB infection was defined by HBsAg/IgM anti-HBc positivity, ALT>10X ULN and compatible clinical history. The TRUGENE HBV kit was used to perform genotyping and direct sequencing of the viral polymerase. INNO-LiPA HBV DRv2 and DRv3 were used to detect AVR mutations. Clonal sequencing was conducted on selected specimens. RESULTS: Twenty-three patients were evaluated (mean age, 43 years; 54% male; 39% African American, 39% Caucasian, 13% Hispanic and 4% Asian). The mean peak ALT was 1554.2IU/L and mean peak total serum bilirubin was 12 mg/dl. The HBV DNA median viral load (N = 15) was 5.14 log(10)IU/ml. Nineteen patients were genotype A, and 1 each were genotype C, D, E and G. HBV drug resistance mutations were not detected by direct sequencing or INNO-LiPA. Clonal sequencing was conducted on 192 clones isolated from three patients and showed rtA181T, rtM250V and rtS202G mutations at an overall frequency of 1.54%, 1.39%, and 1.67% respectively. CONCLUSIONS: We detected adefovir/lamivudine and entecavir relevant mutations in a minor population (<2%) of viral clones by clonal sequencing only. The clinical significance of these mutations is uncertain and may represent small populations of quasi-species vs. transmission of drug resistant strains.

Acute hepatitis B in an urban tertiary care hospital in the United States: a cohort evaluation.

BACKGROUND: The incidence of acute hepatitis B virus (HBV) infection in the United States is declining, and precise epidemiology for newly acquired infection remains obscure. GOALS: We sought to clarify the clinical presentation and management of acute symptomatic HBV infection at a hepatology referral center. STUDY: We prospectively evaluated the demographic, epidemiological, clinical, and treatment data of 32 patients with acute symptomatic HBV who were referred to a single urban tertiary care hospital in the United States. RESULTS: Slightly more than half of the patients were male (53%) or belonged to the black race (53%) and slightly fewer than half of the patients (47%) were unemployed. The median patient age was 41.9 years, and 20 (63%) patients were unmarried. The most common HBV risk factor was a new sexual partner over the previous months (34%). Fifteen percent of the patients reported no known risk factors. Four (13%) patients were diabetic. Presenting symptoms included jaundice (75%), abdominal pain (63%), and marked fatigue (59%). The mean peak for aspartate aminotransferase/alanine aminotransferase was 1822/2109 IU/L, for total bilirubin was 12.6 mg/dL, and for International Normalized Ratio was 1.53. Eight patients (25%) were started on oral nucleot(s)ide therapy. One diabetic patient underwent liver transplantation. CONCLUSIONS: In a sample of patients from a US urban tertiary hepatology center, common epidemiological features of acute symptomatic hepatitis B were being middle aged and unmarried and having acquired the infection through a new sexual contact. Antiviral therapy was sometimes but not commonly started. These data reinforce the need for HBV vaccination of individuals at risk, including those not traditionally targeted.

EUS-FNA for the Diagnosis of Retroperitoneal Primitive Neuroectodermal Tumor.

Primitive neuroectodermal tumor (PNET) is a rare "small round blue cell tumor" that is diagnosed by open biopsy or percutaneous biopsy of the lesion under radiologic guidance. In this case report, we present a novel approach to the diagnosis of a retroperitoneal PNET by endoscopic ultrasound- (EUS-) guided fine needle aspiration (FNA). A 35-year-old man presented with the history of left-sided flank pain and swelling of 3-weeks duration. Computerized tomography (CT) scan of his abdomen revealed a 12.8 × 13 × 12.5 cm cystic and solid mass arising from the retroperitoneum and displacing the third and fourth portions of the duodenum. He underwent EUS which revealed a well-circumscribed heterogeneous mass abutting the inferior portion of the stomach. EUS-FNA of the mass revealed malignant cells consistent with primitive neuroectodermal tumor (PNET)/Ewing's sarcoma. EUS-guided FNA is an appropriate technique for diagnosing retroperitoneal PNET/Ewing's sarcoma.