[Surgical treatment of giant congenital melanocytic nevi: a change of aim]. / Tratamiento quirúrgico del nevus melanocítico gigante: un cambio de objetivo.

OBJECTIVE: To review the surgical experience in Giant Congenital Melanocytic Nevi (GCMN). MATERIAL AND METHODS: Review of GCMN cases consulting at the Department of Pediatric Surgery since 1994. Data registered were: year and age at 1st consultation, type of treatment, number of surgical procedures and complications, histology, central nervous system MRI and follow-up. RESULTS: Eleven patients with GCMN > 10% of body surface consulted at ages ranging from newborn to 8 years. All of them had multiple surgical procedures (2-19), from nevus removal to only biopsies. Eight patients had tissue expansion, completed in 3 of them with skin grafts on dermal substitute. Six patients had complications: 4 expander extrusions, 5 infections, 3 flap necrosis and 1 dehiscence. In 6 children a total or subtotal resection of the nevus was achieved; in 2 the treatment was interrupted, remaining 20% and 50% of the initial nevus; three patients had not had nevus treatment. None of the patients presented cutaneous melanoma; one died from intracranial melanoma; another one has leptomeningeal melanosis. The first 4 patients underwent an average of 16 surgical procedures each, the last 7 patients only 5. CONCLUSIONS: The aim of GCNM management has changed: GCNM treatment is now surgically conservative. Complete excision is now not the aim when technically unfeasible in few procedures; multiple surgical procedures with poor cosmetical results are not acceptable. The gravity is determined by CNS involvement.

Higher proliferative capacity of T lymphocytes from patients with Crohn disease than from ulcerative colitis is disclosed by use of Herpesvirus saimiri-transformed T-cell lines.

BACKGROUND: T lymphocytes play a crucial role in the pathogenesis of inflammatory bowel disease. Achieving stable T-cell lines, rather than continuous bleeding of patients, is desirable in order to dissect their implication in the disease. METHODS: Long-lasting T-cell lines from patients with Crohn disease and ulcerative colitis and from healthy volunteers have been obtained by transformation of T lymphocytes using the lymphotropic Herpesvirus saimiri. Lines were subjected to phenotypic and functional analyses, and the results compared with freshly isolated peripheral blood mononuclear cells. RESULTS: Fresh cells revealed only minor differences between patients and controls, with regard to phenotype and proliferative capacity. In contrast, the use of T-cell lines showed that cells from Crohn disease patients, but not ulcerative colitis patients, over-responded to several membrane or cytoplasmic stimuli when compared to control T-cell lines. Thus, higher responses were found when stimulated with alphaCD3 and IL2, alphaCD3 and alphaCD28, IL2 alone, phorbol esters (PMA) and alphaCD3 and, finally, PMA and alphaCD2 (P < 0.05 in all instances). Further, lines from patients with Crohn disease responded more vigorously to alphaCD3 and alphaCD28 or alphaCD3 and PMA when compared to ulcerative colitis (P < 0.05 in both instances). CONCLUSIONS: The data obtained with these lines suggest that T cells from patients with Crohn disease differ in vivo in their proliferative capacity, as compared with those from ulcerative colitis patients, a finding that may reflect the clear Th-1 phenotype found in the former and absent in the latter.

[Celiac disease and Bud-Chiari syndrome: an uncommon association]. / Enfermedad celíaca y síndrome de Budd-Chiari: una asociación infrecuente.

Celiac disease can present great clinical heterogeneity. Its association with a series of intestinal and non-intestinal diseases, whether immunologically mediated or otherwise, presents a higher than normal frequency. We present a patient with celiac disease and Budd-Chiari syndrome of unknown cause. This association has previously been described only in isolated cases in northern Africa. The appearance of this case in Spain reveals that the coexistence of both processes in a single patient is unlikely to be due to environmental or geographical factors.

Expression of factor VII in the liver of patients with liver disease: correlations with the disease severity and impairment in the hemostasis.

Factor VII (FVII) plasma levels in patients with liver disease may be below the normal range. However, no data are available on FVII expression in liver biopsies from patients with liver diseases other than cirrhosis. We have analyzed the expression of FVII by in situ hybridization in liver biopsies from 50 patients in comparison with the procoagulant activity of FVII, and with the plasma levels as activated FVII (FVIIa) and FVII antigen. The level of FVIIa was significantly lower in stage 4 liver fibrosis patients than in the remaining ones (P < 0.05). The percentage of hepatocytes expressing FVII was significantly lower in stage 4 liver fibrosis patients (4.1+/-1.3%) than in stage 3 (22.7+/-6.1%), stage 2 (31.5+/-6.1%), stage 1 (43.7+/-8.2%) and stage 0 patients (63.8+/-4.4%) (P < 0.001). These percentages correlated inversely in a statistically significant way with the histological activity index and the liver function tests. We have demonstrated that the FVIIa plasma levels in patients with chronic liver disease other than cirrhosis may be below the normal range in the absence of blood coagulation impairment. The percentage of hepatocytes expressing FVII decreases as the severity of liver damage increases.

Twelve-month interferon-alpha therapy induces a similar sustained response in anti-HBe-positive and HBeAg-positive chronic hepatitis B patients.

BACKGROUND/AIMS: We compared the response to interferon-alpha 2a in 35 patients with antibody to HBeAg (anti-HBe) and 20 patients with HBeAg in serum, and histological features of chronic hepatitis B. METHODOLOGY: Patients were treated with 4.5-6 MU of interferon-alpha 2a, three times a week for 12 months, and followed for 30.8 +/- 13.5 additional months. RESULTS: All of them had elevated serum levels of aminotransferases and positive test for hepatitis B virus-DNA in serum. Patients with anti-HBe-positive chronic hepatitis were older and had higher serum aminotransferase levels than HBeAg-positive patients, but no differences were seen between both groups with respect to sex, history of acute hepatitis, mode of transmission of the infection or histological appearance before interferon therapy. Serum levels of alanine transaminase became normal and hepatitis B virus-DNA undetectable by PCR at the end of therapy in 25 (71%) of anti-HBe-positive patients and in 10 (50%) of HBeAg-positive patients (P > 0.05). Although 10 (29%) of the anti-HBe-positive and none of the HBeAg-positive patients relapsed, no significant difference was seen in the rate of sustained response (43% vs. 50%, respectively). The histological improvement was similar in both groups. CONCLUSIONS: The results of this study indicated that biochemical, virological and histological response to 12-month interferon-alpha 2a therapy was similar in patients with anti-HBe antibody than in patients with the classical HBeAg-positive of chronic hepatitis B.

Presence of TTV DNA in serum, liver and peripheral blood mononuclear cells from patients with chronic hepatitis.

The main site of TT virus (TTV) replication remains unknown. Therefore, we have studied the presence and titres of TTV DNA in paired serum, liver and PBMC samples from 50 patients with liver disease (32 with chronic hepatitis B or C, seven with cryptogenic hepatitis and 11 with nonviral liver disease) were included. TTV DNA was analysed by polymerase chain reaction (PCR) using primers from the open reading frame 1 (ORF 1) and from the untranslated region (UTR) and titres were semiquantified by PCR using an external standard. TTV DNA was detected in 26% of serum, 24% of liver and 14% of PBMC samples with ORF 1 primers. When UTR primers were used, 70% of serum and liver samples and 64% of PBMC were TTV DNA positive. No differences between TTV positive and negative patients were found regarding epidemiological or biochemical parameters. Trypsin treatment and fluorescent in situ hybridization confirm the intracellular location of TTV in PBMC. The mean of TTV DNA titres was statistically higher in liver than in serum or PBMC. TTV titres in serum correlated with those in PBMC but not with those in liver. In conclusion, although the liver seems to be the main site for TTV replication, this virus is also able to infect PBMC.

Effects of delayed freezing of liver biopsies on the detection of hepatitis C virus RNA strands.

BACKGROUND/AIMS: There are no data about the influence of handling conditions of liver biopsies on the integrity of viral RNAs. We studied the influence of the time delay between obtaining and freezing the liver biopsy on the stability of intrahepatic positive and negative hepatitis C virus RNA (HCV-RNA) strands. METHODS: Liver samples from 30 anti-HCV patients were included. For each case, one portion of the liver biopsy (first sample) was immediately frozen (20-28 s), while the other section (second sample) was kept at room temperature (1-30 min) before freezing. Each experimental time point was performed in triplicate using liver samples from three different patients. Semi-quantitative analysis of the positive and negative HCV-RNA strands and of the al-antitrypsin mRNA was performed by a Tth-based reverse-transcription polymerase chain reaction. RESULTS: A significant time-related decrease in both positive (r=-0.8412, p=0.001) and negative (r=-0.8539, p=0.001) HCV-RNA strand titres was found in the second liver fractions. There were no appreciable changes in RNA titres in those samples frozen after less than 3 min. The RNA titres decreased in all but two samples incubated for 4-30 min. Thus, 3/15 (20%) and 7/11 (64%) of these samples lost positive and negative HCV-RNA strands, respectively. Alpha-1-antitrypsin mRNA titres decreased significantly (r=-0.8935, p=0.01) in those samples kept at room temperature for more than 4 min. CONCLUSION: Freezing of liver samples immediately after extraction is crucial to avoid false negative HCV-RNA detection results, especially for the antigenomic RNA strand.

Measurement of the procoagulant activity of factor VII in patients with liver cirrhosis and normal prothrombin activity: evaluation of the bleeding risk.

Patients with liver cirrhosis and diminished prothrombin activity (PA) have decreased levels of factor (F)VII coagulation activity (FVII:C) and an increased bleeding tendency. Whether this is also true of cirrhotic patients with normal PA is unknown. This study measured FVII:C levels in such patients and investigated the correlation between altered FVII:C levels and bleeding tendency. Fifteen of 41 patients (37%) had decreased FVII:C levels. Of these, the Child-Pugh score of liver function was A (n = 9), B (n = 5) and C (n = 1), compared to A (n = 25) and B (n = 1) in patients with normal FVII:C values (chi2 = 8.88, P = 0.012). Bleeding time was significantly prolonged in 9/15 patients (60%) with impaired FVII:C activity, compared to 3/26 (12%) patients with normal FVII:C values (relative risk: 5.2, 95% CI: 1.7-16.6; P = 0.003). In conclusion, liver cirrhosis patients may show impaired FVII:C levels despite normal PA. In those with decreased FVII:C activity, prolonged bleeding time is hypothesized to arise from an alteration in platelet activation due to FVII deficiency and diminished platelet count. Bleeding risk should be evaluated, regardless of platelet count, before these patients are subjected to invasive diagnostic or surgical procedures.

Hepatitis C virus RNA in kidney biopsies from infected patients with renal diseases.

Hepatitis C virus (HCV) infection has been associated with several renal pathologies, including membranoproliferative and membranous glomerulonephritis. Although the presence of HCV proteins has been reported, there are no data concerning detection of the viral RNA in renal cells from HCV-infected patients with kidney disease. In this report we analysed, by in situ hybridization, the presence of HCV RNA in renal biopsies from 10 patients who were positive for antibodies to HCV (anti-HCV) and serum HCV RNA positive, and from four patients without HCV infection, with different renal disease. HCV RNA was detected in the renal biopsies from all of the 10 HCV-infected patients. Hybridization signals were detected in the tubular and capillary endothelial cells. No hybridization signals were found in the renal biopsies of the four anti-HCV-negative patients. In conclusion, our results demonstrate that HCV RNA is common in kidney cells of patients with renal diseases who are infected with HCV. The presence of HCV RNA is not necessarily associated with a pathogenetic consequence.

GBV-C/HGV-RNA in serum and peripheral blood mononuclear cells in hemodialysis patients.

BACKGROUND: Hemodialysis patients are at high risk of hepatitis B, C, and G virus infection. The prevalence of GBV-C/HGV-RNA was analyzed in serum and peripheral blood mononuclear cells (PBMCs) from 52 hemodialysis patients. METHODS: GBV-C/HGV-RNA detection was performed by reverse transcription-polymerase chain reaction (RT-PCR) with primers of 5'-noncoding (5'-NC) and NS3 regions of the GBV-C/HGV genome. To increase sensitivity, serum samples were ultracentrifuged prior to the RT-PCR to concentrate the viral particles. The amplified products from 20 serum and 5 peripheral blood mononuclear cells (PBMC) samples were sequenced. RESULTS: GBV-C/HGV-RNA was detected in sera of 9 (17%) and in PBMCs of 30 (58%) patients. After serum ultracentrifugation, GBV-C/HGV-RNA was positive in 20 (95%) of the patients, with GBV-C/HGV-RNA only in PBMCs. Thus, GBV-C/HGV-RNA was detected in serum and PBMCs from 29 (56%) patients, four of whom had antibodies against GBV-C/HGV E2 protein (anti-HGE2); one patient (2%) had GBV-C/HGV-RNA only in PBMCs, but was anti-HGE2 positive. Seven (32%) patients who did not have GBV-C/HGV-RNA were anti-HGE2 positive. The nucleotide sequence homology between serum samples from the patients who were GBV-C/HGV-RNA positive after ultracentrifugation, and paired serum and PBMCs from five of them, ranged from 90 to 96% and from 92 to 98%, respectively. CONCLUSIONS: We found a high prevalence of GBV-C/HGV-RNA in serum and PBMC samples from hemodialysis patients. Whether or not this finding can be extended to other populations requires further study.

[Gaucher's disease suspected by abdominal echography findings]. / Enfermedad de Gaucher sospechada por los hallazgos de la ecografía abdominal.

Abdominal ultrasonographic findings of Gaucher's disease had been reported, but a specific pattern has not been described. We report here a patient with an abdominal sonographic pattern which was concluded to be strongly suggestive of Gaucher's disease: solid focal splenic lesions with different patterns (hypoechoic, hiperechoic and mixed nodules associated with hypoechoic irregular areas) and bright liver and spleen echo pattern with posterior beam attenuation. Gaucher's disease was subsequently confirmed by determination of leukocyte beta-glucosidase activity and mutations of glucocerebrosidase gene.

Assessment of the usefulness of endoscopic signs in Helicobacter pylori associated gastritis.

OBJECTIVE: To determine whether endoscopic signs exist to establish the presence of Helicobacter pylori, which may be used markers of infection in the absence of gastroduodenal peptic lesions. METHODS: A prospective study was carried out in 150 consecutive patients, all symptomatic, who presented endoscopic evidence of gastritis and in whom the absence or presence of H. pylori was undetermined at the time of the study. A quantitative assessment was made of the three types of lesions previously associated with the presence of H. pylori on endoscopy: nodules, erosions, and red patches in the antrum. Biopsy samples were taken for the microbiological and histological studies; a positive result in either study was considered to indicate infection by H. pylori. RESULTS: Of the 150 patients studied, 115 (76%) presented H. pylori infection. No significant differences existed with respect to the clinical findings or the distribution according to sex. The mean age of infected patients was 49 years, being lower in the nodular group (p = 0.008) and higher in the group presenting erosions (p < 0.05); this fact suggests that the endoscopic findings may differ depending on the moment of infection. Evidence of antral nodules was observed in 15 patients, 11 of whom (73%) showed positively for H. pylori; the sensitivity was 9.5% and the positive predictive value was 0.73. Of the 17 patients presenting erosions, 16 were positive for H. pylori (93.8%); the sensitivity was 13% and the positive predictive value was 0.94. Red patches were detected in 63 patients, 48 of whom (76%) were positive for H. pylori; the sensitivity was 48% and the positive predictive value was 0.76. These three patterns did not coincide in any of the patients, for an overall sensitivity and specificity of 70.5% and 80.6%, respectively (p < 0.05). CONCLUSION: The sensitivity and specificity of the set of lesions assessed were high as no two overlapped; when the lesions were dealt with individually, however, the sensitivity was low, showing a low negative predictive value, making it necessary the use of standard detection measures, although in the presence of nodules and/ or erosions the existence of H. pylori infection is practically the norm.