Portal hypertension as a result of the incomplete surgically treated advanced alveolar echinococcosis: a case description.

BACKGROUND: Infection of Echinococcus multilocularis causes in humans the alveolar echinococcosis. Although the infection has world-wide distribution it is rarely detected. Diagnosis of alveococcosis is difficult because of not typical clinical picture and irregular results of radiological examinations suggesting neoplasmatic process which begins in the liver tissue or in the biliary tracts. The parasitic growth is slow, so the illness is quite often established in late invasion period. Treatment of long-lasting and late diagnosed infection is difficult and requires cooperation of parasitologists together with surgeons to avoid life-threatening organ dysfunction. CASE PRESENTATION: We describe a young male patient, diagnosed, according to the radiological, immunological and histological examination results, infection of Echinococcus multilocularis, who was treated with not radical resection of pathologic mass together with persistent albendazole intake. The right hepatectomy was performed. In addition, visible cysts were removed from the left lobe of the liver in nonanatomical resection and suspicious calcified lesions in hepatoduodenal ligament were also removed. After the operation portal hypertension, with splenomegaly and symptoms of the liver cirrhosis occurred (thrombocytopenia, collateral venous circulation, first degree varices oesophagii). The portal hypertension probably could be a result of incomplete surgery due to extended parasitic infection and liver anathomical changes due to performed procedures, because the portal hypertension and it's further complications had not been observed before the operation. CONCLUSIONS: Echinococcus multilocularis should be taken under consideration in differential diagnosis of irregular lesions within the liver. Lon-lasting invasion could be responsible for the irreversible secondary liver changes such as cirrhosis and portal hypertension. The surgery treatment (treatment of choice) is difficult and it's results depends on the invasion period the patient is operated on. After the surgery the patient requires careful follow - up, to detect early complications.

The association of pre-operative anaemia with survival after orthotopic liver transplantation.

Anaemia is common in patients with end-stage liver disease. Pre-operative anaemia is associated with greater mortality after major surgery. We analysed the association of pre-operative anaemia (World Health Organization classification) with survival and complications after orthotopic liver transplantation using Cox and logistic regression models. We included patients undergoing their first orthotopic liver transplantation between 2004 and 2016. Out of 599 included patients, 455 (76%) were anaemic before transplantation. Pre-operative anaemia was not associated with the survival of 485/599 (81%) patients to 1 year after liver transplantation, OR (95%CI) 1.04 (0.64-1.68), p = 0.88. Pre-operative anaemia was associated with higher rates of intra-operative blood transfusions and acute postoperative kidney injury on multivariable analysis, OR (95%CI) 1.70 (0.82-2.59) and 1.72 (1.11-2.67), respectively, p < 0.001 for both. Postoperative renal replacement therapy was associated with pre-operative anaemia on univariate analysis, OR (95%CI) 1.87 (1.11-3.15), p = 0.018.

Effect of intravenous S-ketamine on the MAC of sevoflurane: a randomised, placebo-controlled, double-blinded clinical trial.

BACKGROUND: Ketamine is routinely used in operating theatres, emergency departments, ICUs, and even outpatient units. Despite the widespread use of ketamine, only basic aspects of its interactions with inhalation anaesthetic agents are known, and formal testing of interactions in humans is lacking. The minimum alveolar concentration (MAC) of inhalation anaesthetics is used to guide the depth of anaesthesia, and several drugs are known to influence the MAC. The aim of this study was to investigate whether intravenous application of ketamine influences the MAC of sevoflurane in humans. METHODS: Adult patients undergoing elective surgery were included in this randomised, double-blinded, placebo-controlled study. Patients were assigned to one of three groups, each of which received a bolus of placebo, 0.5 mg kg-1S-ketamine, or 1 mg kg-1S-ketamine followed by an infusion of the same amount per hour after inhalation induction with sevoflurane was performed. The response to skin incision (movement vs non-movement) was recorded. The MAC of sevoflurane was assessed using an up-and-down titration method. RESULTS: Sixty patients aged 30-65 yr were included. Each group consisted of 20 patients. The MAC of sevoflurane was higher in the placebo group (2.1 (sd 0.1) %) than in the low-dose ketamine group (0.9 (0.1)%, P<0.01) and the high-dose ketamine group (0.5 (0.1)%, P<0.01). In addition, the MAC of sevoflurane was higher in the low-dose ketamine group compared with the high-dose ketamine group (P<0.01). CONCLUSIONS: The administration of S-ketamine significantly and dose-dependently reduced the MAC of sevoflurane in humans. CLINICAL TRIAL NUMBER: EudraCT ref. no. 2012-001908-38.

In vitro sensitivity of leukemic cells to nucleoside derivatives in childhood acute leukemias: good activity in leukemic relapses.

Nucleoside analogues such as fludarabine and cladribine are used in therapy of indolent lymphomas and leukemias in adults, while cytarabine is used mainly in protocols for acute leukemias. Mechanisms of their activity is based on inhibition of enzymes involved in DNA, RNA and protein synthesis. The objective of the study was the analysis of in vitro cellular drug sensitivity in childhood acute lymphoblastic (ALL) and myeloid (AML) leukemia. Isolated leukemic cells obtained from 264 patients, including 152 initial ALL, 45 relapsed ALL, 54 initial AML and 13 relapsed AML were tested for cytotoxicity for fludarabine, cladribine, and cytarabine by the MTT assay. Drug concentration lethal to 50% of tested cells was regarded as a value of drug resistance. Three tested nucleoside analogues showed highest cytotoxicity against initial ALL samples. Samples of relapsed ALL and initial AML were more resistant than ALL de novo ones. Unexpectedly, no differences were observed between initial and relapsed AML samples for all tested drugs, what suggests that nucleoside analogues are active drugs in relapsed AML, which is commonly regarded as a resistant disease. All tested drugs presented significant cross-resistance in each of analyzed subgroups. In summary, tested nucleoside analogues presented relatively good activity against childhood leukemias at relapse stage.

Human cystic and alveolar echinococcoses as indication to liver transplantation.

The human cystic and alveolar echinococcoses are zoonotic diseases caused by larval stages of the tapeworms Echinococcus granulosus and E multilocularis. In man the liver form of the diseases develops most frequently. Recent epidemiological data indicate that the distribution of E multilocularis in the central Europe is wider than was previously anticipated; more cases of human alveococcosis during the last years have also been noted in Poland. In the present paper we analyzed several cases of human echinococcoses from Poland with respect to diagnosis and treatment as well as the indications for liver transplantation.

Comparison of the dot immunobinding assay and two enzyme-linked immunosorbent assay kits for the diagnosis of liver cystic echinococcosis.

The dot immunobinding assay for the detection of hydatid antigen-specific antibodies (HA-DIA) was evaluated in patients with liver cystic and alveolar echinococcosis in comparison to two commercial ELISA kits. In 30 patients, E. granulosus infection (CE) was confirmed by histopathology or by the presence of parasite protoscoleces and/or hooks or specific antigen 5 (Ag5) in cyst fluid samples obtained by the fine needle aspiration biopsy (FNAB). Infection of E. multilocularis (AE) was diagnosed in two patients by the detection of specific anti-Em2(plus) ELISA and -Em18 Western blot antibodies and finally confirmed by histopathology. The HA-DIA using bovine hydatid antigens showed a high sensitivity in serum samples from CE patients; specific antibodies were found in 29 of 30 CE patients (96.7%). One negative result has been observed in a patient 2.6 years after radical surgery with a subsequent albendazole chemotherapy. The Echinococcosis ELISA(R) (Dialab Diagnostic) was positive in 23 CE cases (76.7%). The correlation between the HA-DIA and the Echinococcosis ELISA(R) was statistically significant. By contrast, Echinococcus granulosus IgG ELISA(R) (Bordier Affinity Products) gave positive results in only 12 of 30 CE patients (40.0%). Sera from two AE patients were high positive in all three methods analysed in our study. In non-endemic areas, due to the between-strains variations and differences in cyst immunogenic activity, related to the natural history of the parasite, a choice of an optimal method for a diagnosis of liver cystic echinococcosis has been discussed.The high diagnostic sensitivity and a faster one-step procedure, in comparison to traditional enzyme immunoassays, make the HA-DIA a very useful method for the diagnosis of CE in non-endemic areas, especially in a case of small or degenerating lesions and sterile echinococcal cysts with a low immunogenicity. The positive serology for CE frequently requires additional differentiation with E. multilocularis-specific antibodies.

[Clinical value of Echinococcus granulosus--specific immunoglobulin G antibody avidity in liver cystic echinococcosis]. / Znaczenie kliniczne oznaczania awidnosci swoistych przeciwcial IgG w bablowicy watroby wywolanej przez Echinococcus granulosus.

Role of E. granulosus-specific IgG antibody avidity in evaluation of a natural history of the parasite cysts in the liver, duration of infection and immunogenic cysts activity was studied. Thirty-one patients with liver cysts suspected of echinococcosis were examined; E. granulosus infection was finally confirmed by a fine needle aspiration biopsy or surgery in 29 cases (93.5%) and two non-parasitic simple cysts in the liver were diagnosed. E. granulosus-specific IgG antibody was found in 21 patients (67.7%). High IgG avidity values were observed in 14 patients with liver cysts in a degeneration stage confirmed by imaging techniques. Low IgG avidity values were mostly detected in children with hypoechogenic echinococcal cysts being in a recent stage of infection. Determination of anti-E. granulosus immunoglobulin G antibody avidity is a very usefull diagnostic tool for a determination of parasitic cysts activity and their developmental age.

Fine needle aspiration biopsy in the differential diagnosis of the liver cystic echinococcosis.

Liver cystic echinococcosis (CE) in non-endemic areas poses several problems in the differential diagnosis of various space occupying lesions detected by US examination. Fine needle aspiration biopsy (FNAB) using teflon covered needles with a US visible marker may be very useful for the definitive diagnosis. In the Clinic of Parasitic and Tropical Diseases in Poznan, FNAB were performed in 121 patients with liver space occupying lesions, with an addition of an anthelmintic cover of albendazole. The biopsy material was examined parasitologically, cytologically, bacteriologically and immunologically. E. granulosus infection has been confirmed in 25 patients (20.6%), in 16 cases by finding parasite protoscoleces or hooks and in nine cases by detection of an antigen specific for E. granulosus, antigen 5 (Ag5). Additionally nine cases of malignancy (7.4%), four of angioma (3.3%) and three bacterial abscesses (2.5%) were diagnosed. There were no complications related to FNAB puncture. The algorithm of the clinical management of space occupying lesions suspected for CE was proposed. FNAB is a very important technique in the differential diagnosis of cystic echinococcosis.

Detection of specific Echinococcus granulosus antigen 5 in liver cyst bioptate from human patients.

Eighty one liver cyst fluid samples obtained by fine needle aspiration biopsy (FNAB) in human patients were examined for specific E. granulosus antigen 5 (Ag5). The patients were suspected cases of hepatic cystic echinococcosis (CE) but protoscolices and hooks had not been found in the cyst bioptates. Presence of Ag5 was tested for using enzyme linked immuno-sorbent assay (ELISA) technique with monoclonal antibody against Ag5. Sensitivity of the test was approximately 1 ng of antigen/1 ml of examined fluid. Positive results were obtained in the control group of six patients having protoscolices and/or hooks in biopsy samples from liver cysts. Positive Ag5 results were also obtained in the samples from 89 fertile cysts and 28 sterile cysts originated from 15 naturally infected pigs as an experimental control group. Ag5 was present in nine cases (11.1%) out of 81 liver cyst fluid samples from suspected CE patients. In 25 human patients the sensitivity of the microscopic examination for protoscolices and/or hooks in FNAB material was 64% (16/25). In pig hydatid cysts the sensitivity of the microscopic examination for protoscolices and/or hooks in FNAB material was 86.5% and of the detection of Ag5-100%. In conclusion, examination of hepatic cyst biopsy samples for specific Ag5 resulted in increased detection of liver echinococcosis in human patients.

Molecular genetic analysis of human cystic hydatid cases from Poland: identification of a new genotypic group (G9) of Echinococcus granulosus.

We have used nuclear (ribosomal ITS1) and mitochondrial (ND1) sequences to characterize human and pig isolates of Echinococcus granulosus collected by fine needle aspiration biopsy (FNAB) in Poland. The data indicate clearly that the Polish patients were not infected with the common sheep strain (G1 genotype) of E. granulosus, normally associated with human cystic hydatid infection. Instead, the hydatid parasite infecting the Polish patients shares very similar ND1 sequence with the previously characterized pig (G7) genotype but it also exhibits some clear differences. In particular, E. granulosus DNA from the Polish patients amplified a single ITS1 fragment in PCR and distinct ITS1-RFLP patterns were obtained after restriction digestion. The form of hydatid isolated from the Polish patients appears, therefore, to represent a distinct, previously undescribed genotype (designated G9) of E. granulosus.

Evaluating the activity of liver cystic echinococcosis using the delayed-hypersensitivity skin reaction to common antigens.

When 11 patients with active liver cystic echinococcosis were tested with a commercial, delayed-hypersensitivity, skin test (DHST) to seven common antigens (Multitest; Merieux Institute, Lyon) they all reacted less than 30 patients with non-parasitic liver cysts, who had normal reactions. This immunosuppression in cystic echinococcosis was transient, as DHST performed within a few months of treatment were normal. DHST may help in evaluating the activity of Echinococcus granulosus cysts.

Pancreatic structure and function in the immature reserpinized rat.

Immature rats were reserpinized to determine whether the model used for adults may be suitable for the study of pancreatic exocrine insufficiency seen in infants with cystic fibrosis. Rats were reserpinized by injections either into pregnant dams or into newborn rats. The dose of reserpine used by others was lethal to immature rats, so lower doses were used. Pancreas from 1-day-old fetal-treated pups was hypoplastic, but concentration of chymotrypsinogen was elevated. At age 7 days hyperplasia was seen. When rats were reserpinized as neonates, hypoplasia and decrease in all parameters measured was observed at age 7 days. Progressive recovery occurred during the following 2 weeks in both groups. Electron microscopic study of the fetal-treated 24-hr-old pancreas revealed evidence of acinar cell degeneration with the presence of abnormal zymogen granules. At age 7 days the pancreas from neonatal-treated rat pups appeared to have a reduced number of granules. At ages 14 and 21 days the pancreas was similar to that seen at age 7 days except that the granules were larger and some acinar lumina were filled with a finely granular, homogeneously dense material. It is concluded that prenatal and neonatal reserpinization of rats induces changes in pancreas similar to those found in cystic fibrosis.