Molecular characterization and genotyping of hepatitis C virus from Sudanese end-stage renal disease patients on haemodialysis.

BACKGROUND: Hepatitis C virus (HCV) is a global public health problem, with ~ 11 million people in Africa infected. There is incomplete information on HCV in Sudan, particularly in haemodialysis patients, who have a higher prevalence compared to the general population. Thus, our objectives were to genotype and molecularly characterize HCV isolated from end-stage renal disease haemodialysis patients. METHODS: A total of 541 patients were recruited from eight haemodialysis centres in Khartoum and screened for anti-HCV. Viral loads were determined using in-house real-time PCR in seropositive patients. HCV was genotyped and subtyped using sequencing of amplicons of 5' untranslated (UTR) and non-structural protein 5B (NS5B) regions, followed by phylogenetic analysis of corresponding sequences. RESULTS: The HCV seroprevalence in the study was 17% (93/541), with HCV RNA-positive viremic rate of 7% (40/541). A low HCV load, with a mean of 2.85 × 104 IU/ml and a range of 2.95 × 103 to 4.78 × 106 IU/ml, was detected. Phylogenetic analyses showed the presence of genotypes 1, 3, 4, and 5 with subtypes 1a, 1b, 1 g, 3a, 4a, 4 l, 4 m, 4 s, and 4t. Sequences of HCV from the same haemodialysis units, clustered in similar genotypes and subtypes intimating nosocomial infection. CONCLUSION: HCV infection is highly prevalent in haemodialysis patients from Sudan, with phylogenetic analysis intimating nosocomial infection. HCV genotyping is useful to locate potential transmission chains and to enable individualized treatment using highly effective direct-acting antivirals (DAAs).

High malignancy rate in the absence of viral prophylaxis after kidney transplantation in Sudan.

BACKGROUND: Kidney transplantation in Sudan is funded by the government. Cytomegalovirus prophylaxis is provided for patients who receive biological induction or have recipient-negative donor-positive cytomegalovirus serology. Doctor Selma Center for Kidney Diseases joined the national kidney transplant program in May 2019. Since then, we observed the frequent occurrence of cancer in patients who received modest immunosuppression without viral prophylaxis. METHODS: We retrospectively divided kidney transplant recipients between 2019 and 2021 into two groups according to cytomegalovirus prophylaxis and compared tumor occurrence rates. RESULTS: The first group included 77 patients who did not receive biological induction or cytomegalovirus prophylaxis. The second group included 92 patients who received valganciclovir for 3-6 months. There was no other antiviral treatment except entecavir for chronic hepatitis B virus infection in eight patients. Five patients in the first group developed malignancy. The first patient presented eight months post-transplant with Kaposi sarcoma of the stomach and responded to treatment with sirolimus. The second patient presented nine months post-transplant with cutaneous Kaposi sarcoma and also responded to sirolimus. Two patients presented two and four months post-transplant with aggressive non-cutaneous Kaposi sarcoma that involved the gastrointestinal tract and lymphatic system and died soon afterwards. The fifth patient presented three years post-transplant with non-Hodgkin lymphoma of the duodenum and is currently receiving chemotherapy. Malignancy rate (6.5% vs 0.0%, P = 0.02) and Kaposi sarcoma rate (5.2% vs 0.0%, P = 0.04) were significantly higher in the first group. CONCLUSION: In Sudan, omitting valganciclovir prophylaxis after kidney transplantation was associated with a high rate of virus-induced malignancy.

Molecular characterization of hepatitis B virus in liver disease patients and asymptomatic carriers of the virus in Sudan.

BACKGROUND: Hepatitis B virus is hyperendemic in Sudan. Our aim was to molecularly characterize hepatitis B virus from Sudanese individuals, with and without liver disease, because genotypes play an important role in clinical manifestation and treatment management. METHODS: Ninety-nine patients - 30 asymptomatic, 42 cirrhotic, 15 with hepatocellular carcinoma, 7 with acute hepatitis and 5 with chronic hepatitis- were enrolled. Sequencing of surface and basic core promoter/precore regions and complete genome were performed. RESULTS: The mean ± standard deviation, age was 45.7±14.8 years and the male to female ratio 77:22. The median (interquartile range) of hepatitis B virus DNA and alanine aminotransferase levels were 2.8 (2.2-4.2) log IU/ml and 30 (19-49) IU/L, respectively. Using three genotyping methods, 81/99 (82%) could be genotyped. Forty eight percent of the 99 patients were infected with genotype D and 24% with genotype E, 2% with putative D/E recombinants and 7% with genotype A. Patients infected with genotype E had higher frequency of hepatitis B e antigen-positivity and higher viral loads compared to patients infected with genotype D. Basic core promoter/precore region mutations, including the G1896A in 37% of HBeAg-negative individuals, could account for hepatitis B e antigen-negativity. Pre-S deletion mutants were found in genotypes D and E. Three isolates had the vaccine escape mutant sM133T. CONCLUSION: Sudanese hepatitis B virus carriers were mainly infected with genotypes D or E, with patients infected with genotype E having higher HBeAg-positivity and higher viral loads. This is the first study to molecularly characterize hepatitis B virus from liver disease patients in Sudan.

Chemotherapy induced small bowel obstruction in small cell lung cancer.

Lung cancer is the leading cause of cancer related death in men and the second cause in women worldwide. We describe a case of a 51- year old lady with small cell lung cancer who developed small bowel obstruction following chemotherapy with cisplatin and etoposide. Abdominal CT scan showed changes confined to the jejunum and proximal ileum with diffuse mural thickening and hyper-attenuation of the mucosa with sparing of the terminal ileum, caecum and colon. Her condition improved with conservative management and intravenous antibiotics.

Recurrence of hepatitis C virus genotype-4 infection following orthotopic liver transplantation: natural history and predictors of outcome.

BACKGROUND AND OBJECTIVES: There are few reports on hepatitis C virus genotype 4 (HCV-4) recurrences after orthotopic liver transplantation (OLT). Therefore, we undertook a study to determine the epidemiological, clinical and virological characteristics of patients with biopsy-proven recurrent HCV infection and analyzed the factors that influence recurrent disease severity. We also compared disease recurrence and outcomes between HCV-4 and other genotypes. PATIENTS AND METHODS: All patients who underwent OLT (locally or abroad) for HCV related hepatic cirrrhosis from 1991 to 2006 and had recurrent HCV infection were identified. Clinical, laboratory and pathological data before and after OLT were collected and analyzed. RESULTS: Of 116 patients who underwent OLT for hepatitis C, 46 (39.7%) patients satisfied the criteria of recurrrent hepatitis C. Twenty-nine (63%) patients were infected with HCV genotype 4. Mean (SD) for age was 54.9 (10.9) years. Nineteen of the HCV genotype 4 patients (65.5%) were males, 21 (72.4%) received deceased donor grafts, and 7 (24.1%) developed > or =1 acute rejection episodes. Pathologically, 7 (24.1%) and 4 (13.8%) patients had inflammation grade 3-4 and fibrosis stage 3-4, respectively. Follow-up biopsy in 9 (31%) HCV genotype 4 patients showed stable, worse and improved fibrosis stage in 5, 2 and 2 patients, respectively. Of the 7 patients in the recurrent HCV group who died, 6 were infected with genotype 4 and 4 of them died of HCV-related disease. CONCLUSION: This analysis suggests that HCV recurrence following OLT in HCV-4 patients is not significantly different from its recurrence for other genotypes.

Addison's disease due to Histoplasma duboisii infection of the adrenal glands.

Histoplasmosis is a fungal infection caused by Histoplasma capsulatum. In the normal individual, both disseminated histoplasmosis and symptomatic adrenal histoplasmosis are rare. Herein, we describe the case of a 50-year-old gentleman residing in western Sudan who presented with a 7-month history of generalized body weakness, easy fatigue, and frequent attacks of vomiting and diarrhea. Physical examination and laboratory investigations confirmed the diagnosis of Addison's disease due to Histoplasma capsulatum var duboisii infection of the adrenal glands. He was treated with intravenous hydrocortisone, followed by oral prednisolone and itraconazole.

Prevalence of gastric varices and portal hypertensive gastropathy in patients with Symmers periportal fibrosis.

BACKGROUND AND OBJECTIVE: Symmers periportal fibrosis secondary to schistosomiasis is a common cause of portal hypertension worldwide. Data on the prevalence of gastric varices and portal hypertensive gastropathy in this group of patients with portal hypertension is relatively scarce. The aim of this study was to determine the prevalence of gastric varices and portal hypertensive gastropathy in patients presenting with portal hypertension secondary to Symmers periportal fibrosis. PATIENTS AND METHODS: In a prospective study, upper gastrointestinal endoscopy was carried out to determine the prevalence of gastric varices and portal hypertensive gastropathy in patients with portal hypertension secondary to Symmers periportal fibrosis. RESULTS: Of 143 patients studied, 24 patients (16.8%) had gastric varices (grade I in 10.5%, grade II in 6.3%) and 31 patients (21.7%) had portal hypertensive gastropathy (mild in 11.2%, severe in 10.5%). Gastric varices were more prevalent in patients with grade I and II esophageal varices and portal hypertensive gastropathy was more prevalent in those with grade III and IV esophageal varices, but the differences were not statistically significant. CONCLUSION: We concluded that both gastric varices and portal hypertensive gastropathy seem to have a lower prevalence in patients with portal hypertension secondary to Symmers periportal fibrosis when compared to reported data in patients with portal hypertension secondary to liver cirrhosis and non-cirrhotic portal fibrosis.

Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium.

BACKGROUND: Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa. METHODS: We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death). FINDINGS: We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001). INTERPRETATION: Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa. FUNDING: None.

Mortality and rebleeding following variceal haemorrhage in liver cirrhosis and periportal fibrosis.

AIM: To investigate mortality and rebleeding rate and identify associated risk factors at 6 wk and 5 d following acute variceal haemorrhage in patients with liver cirrhosis and schistosomal periportal fibrosis. METHODS: This is a prospective study conducted during the period from March to December 2014. Patients with portal hypertension presenting with acute variceal haemorrhage secondary to either liver cirrhosis (group A) or schistosomal periportal fibroses (group B) presenting within 24 h of the onset of the bleeding were enrolled in the study and followed for a period of 6 wk. Analysis of data was done by Microsoft Excel and comparison between groups was done by Statistical Package of Social Sciences version 20 to calculate means and find the levels of statistical differences and define the mortality rates, the P value of < 0.05 was considered to be significant. RESULTS: A total of 94 patients were enrolled in the study. Thirty-two patients (34%) had liver cirrhosis (group A) and 62 (66%) patients had periportal fibrosis (group B). Mortality: The 6-wk and 5-d mortality were 53% and 16% respectively in group A compared to 10% and 0% in group B (P value < 0.000 and < 0.004). In group A; a Child-Turcotte-Pugh class C and rebleeding within 5 d were significantly associated with 5-d mortality (P value < 0.029 and < 0.049 respectively) and Child- Turcotte-Pugh class C was also a significant risk factor for 6-wk mortality (P value < 0.018). In group B; mortality was significantly associated with rebleeding within the 6-wk follow-up period and requirement for blood transfusion on admission (P value < 0.005 and < 0.049). Rebleeding: The 6-wk and 5-d rebleeding rate in group A were 56% and 25% respectively compared to 32% and 3% in group B (P value < 0.015 and < 0.002). Clinical presentation with encephalopathy was a significant risk factor for 5 d rebleeding in group A (P value < 0.005) while grade III periportal fibrosis and requirement for blood transfusion on admission were significant risk factors for 6-wk rebleeding in group B (P value < 0.004 and < 0.02). CONCLUSION: The 6-wk and 5-d mortality and rebleeding rate were significantly higher in patients with liver cirrhosis compared to patients with schistosomal periportal fibrosis.

Analysis of ultra-deep pyrosequencing and cloning based sequencing of the basic core promoter/precore/core region of hepatitis B virus using newly developed bioinformatics tools.

AIMS: The aims of this study were to develop bioinformatics tools to explore ultra-deep pyrosequencing (UDPS) data, to test these tools, and to use them to determine the optimum error threshold, and to compare results from UDPS and cloning based sequencing (CBS). METHODS: Four serum samples, infected with either genotype D or E, from HBeAg-positive and HBeAg-negative patients were randomly selected. UDPS and CBS were used to sequence the basic core promoter/precore region of HBV. Two online bioinformatics tools, the "Deep Threshold Tool" and the "Rosetta Tool" (http://hvdr.bioinf.wits.ac.za/tools/), were built to test and analyze the generated data. RESULTS: A total of 10952 reads were generated by UDPS on the 454 GS Junior platform. In the four samples, substitutions, detected at 0.5% threshold or above, were identified at 39 unique positions, 25 of which were non-synonymous mutations. Sample #2 (HBeAg-negative, genotype D) had substitutions in 26 positions, followed by sample #1 (HBeAg-negative, genotype E) in 12 positions, sample #3 (HBeAg-positive, genotype D) in 7 positions and sample #4 (HBeAg-positive, genotype E) in only four positions. The ratio of nucleotide substitutions between isolates from HBeAg-negative and HBeAg-positive patients was 3.5 ∶ 1. Compared to genotype E isolates, genotype D isolates showed greater variation in the X, basic core promoter/precore and core regions. Only 18 of the 39 positions identified by UDPS were detected by CBS, which detected 14 of the 25 non-synonymous mutations detected by UDPS. CONCLUSION: UDPS data should be approached with caution. Appropriate curation of read data is required prior to analysis, in order to clean the data and eliminate artefacts. CBS detected fewer than 50% of the substitutions detected by UDPS. Furthermore it is important that the appropriate consensus (reference) sequence is used in order to identify variants correctly.

Overt and occult hepatitis B virus infection in adult Sudanese HIV patients.

OBJECTIVES: Human immunodeficiency virus (HIV) infection in Sub-Saharan Africa is complicated by co-infection with hepatitis B and C viruses (HBV and HCV), which share similar transmission routes. The aims of this study were to determine the prevalence of hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative HBV infection and of HCV infection among HIV-infected patients. METHODS: A cross-sectional study was conducted among treatment-naïve HIV-positive adults in Khartoum State. HBV, HCV, and HIV infections were detected using immunoassays for HBsAg, hepatitis B core antibodies (anti-HBc), hepatitis C antibodies (anti-HCV), and HIV antibodies (anti-HIV), while real-time PCR was used to measure HBV DNA. RESULTS: The mean age of the 358 patients was 35.2±9.3 years and the male to female ratio was 1.3:1.0. The mean alanine aminotransferase (ALT) level was 10.9±18.0 U/l. Evidence of 23, current or past HBV infection was detected in 62.8% of the patients. HBV DNA was detected in 96 patients (26.8%), 42 HBsAg-positive (11.7%) and 54 (15.1%) HBsAg-negative, indicating occult hepatitis B infection. Anti-HCV was detected in 1.7%. CONCLUSIONS: Evidence of HBV infection was detected in 26.8% of HIV patients with HBsAg-negative infection, with viraemia detected in 15.1% of the patients. All HIV-infected patients should be screened carefully for HBV infection with HBsAg and anti-HBc IgG antibodies prior to starting antiretroviral therapy.

Genotyping and virological characteristics of hepatitis B virus in HIV-infected individuals in Sudan.

OBJECTIVES: Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) share common routes of blood-borne transmission. In HBV mono-infected Sudanese individuals, genotypes D, E, and A circulate. The objective of this study was to molecularly characterize HBV from HBV/HIV co-infected individuals. METHODS: The polymerase overlapping the S region and the basic core promoter (BCP/PC) of HBV from 32 hepatitis B surface antigen (HBsAg)-positive and 18 HBsAg-negative serum samples were amplified and sequenced. RESULTS: HBV from 37 samples was successfully genotyped and the genotype distribution was 46.0% D, 21.6% E, 18.9% A, and 13.5% D/E recombinant. Compared to mono-infected individuals, the frequencies of the D/E recombinant and genotype A were higher in HBV/HIV co-infected patients, as was the intra-group divergence of genotype E. BCP/PC mutations affecting hepatitis B e antigen (HBeAg) expression at the transcriptional and translational levels were detected. Two HBsAg-positive individuals had pre-S deletion mutants. The following mutations in the S region could account for the HBsAg negativity: sM133T, sE164G, sV168G, and sS174N. No primary drug resistance mutations were found. CONCLUSIONS: In HBV/HIV co-infected Sudanese patients, the ratio of genotype A to non-A was higher than that in mono-infected patients. The genotype E intra-group divergence in HBV/HIV co-infected individuals was significantly higher than that in HBV mono-infected patients.

Appropriate use and diagnostic yield of upper gastrointestinal endoscopy in a tertiary referral hospital.

BACKGROUND AND STUDY AIMS: This is a prospective, descriptive, hospital-based study to evaluate the appropriateness and diagnostic yield of upper gastrointestinal (GI) tract endoscopy referrals to Soba University Hospital endoscopy unit using the American Society for Gastrointestinal Endoscopy guidelines for appropriate use of endoscopy. PATIENTS AND METHODS: All patients referred to Soba University Hospital for upper GI endoscopy during the study period were enrolled in the study after giving an informed consent. Statistical analysis was done using the Statistical Package for Social Sciences (SPSS) program to calculate frequencies and the X(2) test; P value was taken as significant at a level of less than 0.05. RESULTS: Overall, 220 patients were prospectively enrolled in the study, of which 126 (57%) were males, with a mean age of 46.5 ± 17.9 years. A total of 190 patients (86%) were appropriately referred and the overall diagnostic yield was 46.8%. Those with appropriate referral had a higher diagnostic yield (50%) when compared to those with inappropriate referral (23%). CONCLUSION: The diagnostic yield of upper GI endoscopy was higher when patients were referred appropriately indicating that detection of relevant finding is greatly enhanced by the utilisation of standard guidelines.

Epidemiology of viral hepatitis in Sudan.

Hepatitis virus infections are the most common cause of liver disease worldwide. Sudan is classified among the countries with high hepatitis B virus seroprevalence. Exposure to the virus varied from 47%-78%, with a hepatitis B surface antigen prevalence ranging from 6.8% in central Sudan to 26% in southern Sudan. Studies pointed to infection in early childhood in southern Sudan while there was a trend of increasing infection rate with increasing age in northern Sudan. Hepatitis B virus was the commonest cause of chronic liver disease and hepatocellular carcinoma and was the second commonest cause of acute liver failure in the Sudan. Studies of hepatitis C virus showed a low seroprevalence of 2.2%-4.8% and there was no association with schistosomiasis or with parenteral antischistosomal therapy. Hepatitis E virus was the commonest cause of acute hepatitis among pediatric, adult, and displaced populations. Recent introduction of screening of blood and blood products for hepatitis B virus and hepatitis C virus infections and the introduction of hepatitis B virus vaccine as part of the extended program of immunization is expected to reduce the infection rate of these viruses in the Sudan.

Epidemiology of HCV infection in Gezira state of central Sudan.

This is a cross sectional study carried out in Gezira state of central Sudan, an area with a high prevalence of Schistosoma mansoni infection, to determine the prevalence of hepatitis C virus (HCV) antibodies and risks factors for HCV infection. A total of 410 subjects in Um Zukra village were tested for HCV antibodies, 2.2% were reactive. The prevalence was highest in those between 11 and 20 years old with equal prevalence among males and females. No correlation was found between HCV infection and S. mansoni infection or parenteral antischistosomal therapy. It was concluded that HCV infection is of low seroprevalence and that schistosomiasis and parenteral antischistosomal therapy are not major risk factors for infection in the population studied.

Schistosomal colitis without granuloma formation in a kidney transplant recipient.

BACKGROUND: A 40-year-old male from the White Nile region in Sudan, who had received a kidney transplant 6 years previously, presented with fever, lower abdominal pain and diarrhea stained with blood of 5 months duration. He was on immunosuppressive maintenance therapy, consisting of ciclosporin 75 mg twice daily, prednisolone 10 mg once daily, and azathioprine 75 mg once daily. INVESTIGATIONS: Laboratory investigations, liver function tests, renal function tests, stool microscopy, stool culture, abdominal ultrasound, and colonoscopy. DIAGNOSIS: Severe, left-sided colitis due to Schistosoma mansoni infection, without granuloma formation. MANAGEMENT: Oral antischistosomal therapy with praziquantel at a dose of 40 mg/kg body weight.