Interferon alpha 2B and ribavirin in severe recurrent cholestatic hepatitis C.

Severe recurrent cholestatic hepatitis C after liver transplantation has a poor prognosis and no standard therapy is currently available. Four cases of severe recurrent cholestatic hepatitis C treated with a combination of interferon alpha 2b and ribavirin are described. All four patients were transplanted for hepatitis C-related cirrhosis. The mean age at transplantation was 45 years (range 41-51 years). Three of the patients were male and one was female. All four patients had hepatitis C virus viremia before and after liver transplantation. At 2 to 23 months after liver transplantation, all four patients developed jaundice, cholestatic elevation of liver enzymes, and histopathology consistent with severe recurrent cholestatic hepatitis C. Combination of interferon and ribavirin was given with prompt virological suppression. Despite this rapid viral suppression, all four patients developed progressive graft failure with three deaths.

Hepatitis C: an update on the silent epidemic.

Hepatitis C virus (HCV) currently infects an estimated 2-3 million people in the United States and 175 million people globally. Over 80% of infected patients go on to develop chronic disease. Most patients remain asymptomatic despite silent, insidious progression of the disease. The sequelae of HCV-induced chronic liver disease accounts for 8,000-10,000 deaths annually in the United States and is currently the leading indication for liver transplantation. The cost of this epidemic to the United States was estimated in 1991 at $600 million in terms of medical expenses (excluding costs related to liver transplantation) and work lost. Over the last decade, since the viral genome of HCV was first sequenced in 1989, there has been a great increase in understanding of this infection. This review summarizes current knowledge about the hepatitis C epidemic with particular reference to epidemiology of infection, viral characteristics, risk factors for disease, diagnostic testing, clinical manifestations, and current, as well as potential, therapeutic options.

Enterocytozoon bieneusi infection in patients without evidence of immunosuppression: two cases from Zimbabwe found to have positive stools by PCR.

Patients infected with human immunodeficiency virus (HIV) often also have intestinal infections with Enterocytozoon bieneusi. Recently, infection with this microsporidian has been described in immunocompetent subjects, mainly from Europe. When the stools of six HIV-negative patients who presented with diarrhoea in Zimbabwe were investigated, using a recently described protocol based on PCR, two patients were found to have E. bieneusi infections. These two individuals presented with a self limited diarrhoea, abdominal cramping and nausea. These data indicate that E. bieneusi may be a more common cause of diarrhoea in Zimbabwe than previously thought. Larger, prospective studies are needed.

Intestinal parasites in patients with diarrhea and human immunodeficiency virus infection in Zimbabwe.

OBJECTIVES: To determine the prevalence of intestinal parasites and risk factors for infection associated with diarrhea in HIV-infected patients in Harare, Zimbabwe. DESIGN: Prospective observational study. METHODS: Single stool samples were collected from 88 HIV-infected individuals presenting with diarrhea of greater than 1 week duration. Stools were examined for intestinal parasites using modified acid fast stain, fluorescence- labeled monoclonal antibody for Cryptosporidium parvum, as well as a modified trichrome stain and a PCR-based protocol for Enterocytozoon bieneusi. RESULTS: C. parvum was detected in 9% (seven out of 82) of samples evaluated, but no Cyclospora was detected. E. bieneusi was detected in 18% (10 out of 55) of stool by trichrome staining and in 51% (28 out of 55) of stool examined by PCR. Risk factors for E. bieneusi infection were: living in rural areas, consumption of nonpiped water, contact with cow dung and household contact with an individual with diarrhea. CONCLUSION: E. bieneusi infection was common in HIV-infected patients with diarrhea in Zimbabwe and may be acquired through person-to-person and fecal-oral transmission.

Development and application of genetic probes for detection of Enterocytozoon bieneusi in formalin-fixed stools and in intestinal biopsy specimens from infected patients.

The microsporidium Enterocytozoon bieneusi is closely linked to wasting and diarrhea in a high proportion of individuals with AIDS. However, its relative contribution to disease is uncertain because diagnosis until recently depended on procedures involving endoscopy. A sensitive PCR technique which amplifies a fragment of the small-subunit rRNA gene of E. bieneusi from formalin-fixed stool samples was developed. Of 80 formalin-fixed stool samples collected from 74 Zimbabweans and 6 U.S. patients who were human immunodeficiency virus positive, 50% tested positive for E. bieneusi by PCR, whereas 24% tested positive for E. bieneusi by light microscopy of trichrome-stained fecal smears. In addition, we describe an in situ hybridization technique which detected and identified E. bieneusi as the causative agent in all six intestinal biopsy specimens tested. Both the PCR and in situ hybridization procedures are sensitive diagnostic tools which will complement currently available techniques and enable the differentiation of E. bieneusi from other microsporidia to be made.

Epitrochlear lymph nodes as marker of HIV disease in sub-Saharan Africa.

PIP: Because serological testing for HIV infection is expensive and hard to obtain in Africa, diagnosis often depends upon clinical evaluation. A study was undertaken, therefore, to determine whether the rate of occurrence of enlarged lymph nodes and variations in their size and distribution could provide useful diagnostic markers. Of 260 eligible adult patients admitted to a hospital in Zimbabwe, 259 agreed to take part in the study. 146 (56%) were diagnosed with HIV using serological tests. A doctor who was blinded to these results scored lymph node size in the epitrochlear, submandibular, and axillary regions. Enlargement of axillary and submandibular lymph nodes by or= 1 cm gave positive predictive values of 91 and 89%, respectively, and specificities of 95 and 96%, respectively, but the negative predictive values and sensitivities were all 60%. Thus, the presence of enlarged lymph nodes was a strong marker of HIV disease, but their absence was unhelpful, and they were only occasionally present (in 24 and 12% of patients, respectively). When the criterion for enlargement was or= 0.5 cm, the number of patients with palpable nodes increased, but positive prediction and specificity were poor. Enlargement of the epitrochlear nodes by or= 0.5 cm resulted in a positive predictive value of 85%, a specificity of 81%, and a sensitivity of 84%. Also, these nodes were palpable in 47% of patients. Larger epitrochlear nodes (or= 1 cm) improved specificity to 90% but reduced positive prediction and sensitivity dramatically. A combination of the 2 regions improved positive predictive value to 90% but caused a noticeable fall in sensitivity. These predictive values must not be extrapolated beyond the setting in which they were derived (one of high prevalence). The predictive value of epitrochlear nodes in other clinical settings remains to be determined, but the clinical importance of these nodes deserves attention.^ieng