Retrospective analysis of hepatitis B virus chronic infection in 247 patients: clinical stages, response to treatment and poor prognostic factors

Abstract Background: Chronic hepatitis B is a major cause of cirrhosis, and the natural history of the disease has several clinical stages that should be thoroughly understood for the implementation of proper treatment. Nonetheless, curing the disease with antiviral treatment remains a challenge. Aims: To describe the clinical course, response to treatment, and poor prognostic factors in 247 hepatitis B virus chronic infection patients treated in a tertiary hospital in Brazil. Methods: This was a retrospective and observational study, by analyzing the medical records of HBV infected patients between January 2000 and January 2015. Results: Most patients were male (67.2%) and 74.1% were HBeAg negative. Approximately 41% had cirrhosis and 8.5% were hepatitis C virus coinfected. The viral load was negative after two years on lamivudine, entecavir and tenofovir in 86%, 90.6%, and 92.9% of the patients, respectively. The five-year resistance rates for lamivudine, adefovir, entecavir, and tenofovir were 57.5%, 51.8%, 1.9%, and 0%, respectively. The overall seroconversion rates were 31.2% for HBeAg and 9.4% for HBsAg. Hepatocellular carcinoma was diagnosed in 9.7% of patients, liver transplantation was performed in 9.7%, and overall mortality was 10.5%. Elevations of serum alanine aminotransferase (p = 0.0059) and viral load (p < 0.0001) were associated with progression to liver cirrhosis. High viral load was associated with progression to hepatocellular carcinoma (p < 0.0001). Significant risk factors associated with death were elevated alanine aminotransferase (p = 0.0039), liver cirrhosis (p < 0.0001), high viral load (p = 0.007), and hepatocellular carcinoma (p = 0.0008). HBeAg positive status was not associated with worse outcomes, and treatment may have been largely responsible. Conclusions: Elevations of viral load and serum alanine aminotransferase may select patients with worse prognosis, especially progression to cirrhosis and hepatocellular carcinoma, which were strongly association with death.

Metastatic Lymphoepithelioma-like Hepatocellular Carcinoma: a Potential Diagnostic Pitfall and Demonstration of Pd-l1 Expression

Abstract: Lymphoepithelioma-like hepatocellular carcinoma (LEL-HCC) is a rare primary hepatic neoplasm with female predominance and relatively good prognosis. We report a 73-year-old female with chronic hepatitis B who developed metastatic lesions 5 years after underwent resection for LEL-HCC. The metastatic lesions showed a spectrum of morphologic findings, which could be mistaken for other entities such as lymphoma, particularly in lesions with single-cell infiltrative pattern and abundant tumor-infiltrating lymphocytes. Immunohistochemical study to confirm the origin of the neoplastic cells is important to make the diagnosis. We also highlighted the clinicopathologic correlation and potential therapeutic implication of programmed death ligand-1 expression in LEL-HCC.

Prevalence of malnutrition in children with chronic hepatitis b infection

ABSTRACT Background - There have been limited studies investigating the impact of chronic hepatitis B virus infection on the growth of children. Objective - Our objective was to investigate the prevalence of malnutrition in children with chronic hepatitis B infection. Methods - The nutritional status of patients was retrospectively evaluated in the outpatient Clinic of Pediatric Gastroenterology between February and November 2014. During the study, biochemical laboratory parameters, duration of disease, liver biopsy scores, and medication were evaluated. Additionally body mass index and body mass index centiles were calculated. Results - Of the 96 patients in this study, 68 were male and 28 were female, and the mean age was 144.7±43.9 months and 146.1±47.3 months, respectively. According to body mass index centiles five (5.2%) patients were underweight, seven (7.3%) patients were overweight, and seven (7.3%) patients were obese. Conclusions - Moderate rates of malnutrition (including obesity) were found in chronic hepatitis B infection. Additional nutritional status information of healthy and sick children should be assessed in the infection's early period, and timely interventions should be initiated.

RESUMO Contexto - Há limitados estudos investigando o impacto da infecção crônica pelo vírus da hepatite B no crescimento das crianças. Objetivo - O objetivo deste estudo foi investigar a prevalência de desnutrição em crianças com infecção crônica da hepatite B. Métodos - O estado nutricional dos pacientes foi avaliado retrospectivamente em ambulatório de gastroenterologia clínica pediátrica, entre fevereiro e novembro de 2014. Durante o estudo, parâmetros bioquímicos do laboratório, duração da doença, classificação de biópsias hepáticas e medicação foram avaliadas. Além disso, o índice de massa corporal e suas porcentagens foram calculados. Resultados - Dos 96 pacientes, 68 eram do sexo masculino e 28 eram do sexo feminino e idade média era 144.7±43.9 e de 146.1±47.3 meses, respectivamente. De acordo com as porcentagens de índice de massa corporal, cinco (5,2%) pacientes estavam abaixo do peso, sete (7,3%) pacientes estavam com sobrepeso, e sete (7.3%) estavam obesos. Conclusão - Taxas moderadas de desnutrição (incluindo obesidade) foram encontradas em infecção crônica da hepatite B. Informação sobre o estado nutricional das crianças infectadas deve ser colhida inicialmente para que intervenções oportunas sejam tomadas.

Observational descriptive study of cutaneous manifestations in patients from Mato Grosso with viral chronic hepatitis

Abstract: BACKGROUND: Extrahepatic manifestations are seen in association with chronic infection by hepatitis B or C virus including cutaneous disorders. The frequency of these findings seems to vary among different places and reports. There is a lack of information about this issue in Brazil. OBJECTIVES: To estimate the prevalence of cutaneous findings affecting HBV or HCV carriers from a reference outpatient unit in Mato Grosso. METHODS: A cross-sectional observational study. RESULTS: 108 patients were studied. 88.9% presented some cutaneous findings but must of them were nonrelated to chronic viral infection. Four patients had cutaneous or autoimmune syndromes that may be HBV or HCV related. CONCLUSION: In our study we found no statistical association between viral hepatitis and skin diseases.

The prevalence of hepatitis B virus infection markers and socio-demographic risk factors in HIV-infected patients in Southern Brazil

Introduction Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections are two of the world's most important infectious diseases. Our objective was to determine the hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) prevalences among adult HIV-infected patients and identify the associations between socio-demographic variables and these HBV infection markers. Methods This study was performed from October 2012 to March 2013. Three hundred HIV-seropositive patients were monitored by the Clinical Analysis Laboratory of Professor Polydoro Ernani de São Thiago University Hospital, Santa Catarina, Brazil. The blood tests included HBsAg, anti-HBc immunoglobulin M (IgM) and total anti-HBc. Patients reported their HIV viral loads and CD4+ T-cell counts using a questionnaire designed to collect sociodemographic data. Results The mean patient age was 44.6 years, the mean CD4 T-cell count was 525/mm3, the mean time since beginning antiretroviral therapy was 7.6 years, and the mean time since HIV diagnosis was 9.6 years. The overall prevalences of HBsAg and total anti-HBc were 2.3% and 29.3%, respectively. Among the individuals analyzed, 0.3% were positive for HBsAg, 27.3% were positive for total anti-HBc, and 2.0% were positive either for HBsAg or total anti-HBc and were classified as chronically HBV-infected. Furthermore, 70.3% of the patients were classified as never having been infected. Male gender, age >40 years and Caucasian ethnicity were associated with an anti-HBc positive test. Conclusions The results showed an intermediate prevalence of HBsAg among the studied patients. Moreover, the associations between the anti-HBc marker and socio-demographic factors suggest a need for HBV immunization among these HIV-positive individuals, who are likely to have HIV/HBV coinfection. .

Vivências e necessidades de saúde de homens no período pós-nascimento de um filho / Experiences and health needs of men in the period post-birth of a child / Experiencias y necesidades de salud de los hombres en el período post-nacimiento de un hijo

Esta pesquisa aborda percepções de homens sobre suas experiências e necessidades de saúde no pós-nascimento. Objetiva-se distinguir analiticamente, a partir de uma perspectiva de gênero, necessidades de saúde relativas ao evento, experimentadas, expressas e/ou negadas pelos homens. Trata-se de um estudo exploratório-descritivo, qualitativo, realizado em dois territórios de saúde de Cuiabá, Mato Grosso, mediante entrevista semiestruturada e análise temática dos dados. Participaram oito homens que vivenciavam o pós-nascimento de um filho. Estes manifestaram, sobretudo, a necessidade de provimento de segurança financeira à família, destacando também a necessidade de bem estar do filho, acessando o retorno afetivo que a experiência traz. Não se reconheciam com necessidades de saúde no pós-nascimento. O apoio dos serviços locais de saúde é importante para que os homens se percebam na vivência da paternidade e a sua relação com aspectos socioculturais, para que distingam necessidades próprias, valorizem o cuidado de si e adotem uma perspectiva equânime de gênero.

This research addresses men’s perceptions about their experiences and health needs in the post-birth period. The goal is to distinguish analytically and from a gender perspective the health needs related to the event, experienced, expressed and/or denied by men. This is an exploratory, descriptive and qualitative study carried out in two municipal health areas of Cuiabá, state of Mato Grosso, using a semi structured interview and thematic analysis of the data. The participants were eight men who were experiencing the post-birth period of a child. Above all, they expressed the need to provide financial security to the family, emphasizing also the need of their children’s well-being, with the affective return that this experience brings. They did not perceive themselves with health needs during the post-birth period. The support provided by local health services is important so that men can understand the experience of parenthood and its relationship with social and cultural aspects in order to distinguish their own needs, appreciate self-care, and adopt a gender equity perspective.

Esta investigación aborda las percepciones de hombres acerca de sus experiencias y necesidades de salud en el período postparto. El objetivo es distinguir analíticamente, desde una perspectiva de género, las necesidades de salud relacionadas al evento, experimentadas, expresadas y/o negadas por los hombres. Se trata de un estudio exploratorio, descriptivo y cualitativo llevado a cabo en dos áreas municipales de salud de Cuiabá, Estado de Mato Grosso, mediante entrevista semiestructurada y análisis temático de los datos. Participaron ocho hombres que experimentaban el período postparto de un hijo. Ellos expresaron, sobre todo, la necesidad de proveer seguridad económica a la familia, destacando también la necesidad del bienestar de los hijos, con el retorno afectivo que esa experiencia proporciona. No se reconocían con necesidades de salud en el período postparto. El apoyo de los servicios locales de salud es importante para que los hombres entiendan la experiencia de la paternidad y su relación con aspectos socioculturales, para que distingan las necesidades, valoren el cuidado de sí mismos y adopten una perspectiva de equidad de género.

Cirroses hepáticas metabólicas / Hepatic cirrhosis metabolic

A cirrose hepática é importante causa de morbidade e mortalidade em todo o mundo. Entre as principais etiologias destacam-se as hepatites crônicas pelos vírus da hepatite C (HCV) e B (HBV) e o consumo e abuso do álcool. Destacamos, também, as hepatites crônicas e cirroses de natureza autoimune, medicamentosas, dentre outras.

Liver cirrhosis is the most important cause of mortality and morbidity all over the world. Among the mainly etiologies, chronic hepatites highlight due hepatite C (HCV) and B (HBV) and alcohol abuse. We also emphasize chronic hepatitis and cirrhosis from autoimmune and medical origins, among others.

Prevalence and clinical features of celiac disease in patients with hepatitis B virus infection in Southern Brazil

Introduction Celiac disease is an autoimmune disorder that involves gluten intolerance and can be triggered by environmental factors including hepatitis B virus (HBV) infection. This study aimed to describe the prevalence of celiac disease in individuals with HBV infection and to describe the clinical and laboratory characteristics of celiac disease associated with HBV. Methods This cross-sectional study included 50 hepatitis B patients tested for IgA anti-endomysial antibodies (EMAs) and tissue anti-transglutaminase (TTG) between August 2011 and September 2012. Results Fifty patients were included with a mean age of 46.0 ± 12.6 (46.0) years; 46% were female and 13% were HBeAg+. Six patients had positive serology for celiac disease, four were EMA+, and five were TTG+. When individuals with positive serology for celiac disease were compared to those with negative serology, they demonstrated a higher prevalence of abdominal pain (100% vs. 33.3%, p = 0.008), lower median creatinine (0.7mg/dL vs. 0.9mg/dL, p = 0.007) and lower mean albumin (3.6 ± 0.4g/L vs. 3.9 ± 0.3g/L, p = 0.022). All individuals with positive serology for celiac disease underwent upper digestive endoscopy, and three of the patients exhibited a macroscopic pattern suggestive of celiac disease. Histologically, five patients demonstrated an intra-epithelial lymphocytic infiltrate level > 30%, and four patients showed villous atrophy associated with crypt hyperplasia on duodenal biopsy. Conclusions An increased prevalence of celiac disease was observed among hepatitis B patients. These patients were symptomatic and had significant laboratory abnormalities. These results indicate that active screening for celiac disease among HBV-infected adults is warranted. .

Uso de infliximabe em paciente com artrite reumatoide e hepatite B crônica / Use of infliximab in a patient with rheumatoid arthritis and chronic hepatitis B

Os agentes anti-TNF-α emergiram como potente tratamento para os pacientes com artrite reumatoide que não respondem às drogas modificadoras de doença convencionais. Por induzir à imunossupressão, essas drogas têm como principal complicação o aumento da suscetibilidade a várias infecções. A reativação do vírus da hepatite B (HBV) é um dos efeitos colaterais mais preocupantes em pacientes recebendo agentes anti-TNF-α com infecção pelo HBV. Descrevemos o caso de um paciente de 56 anos com quadro de hepatite B estável, com boa resposta à associação dos antivirais lamivudina e tenofovir quando iniciou infliximabe. O paciente obteve boa resposta ao anti-TNF-α , atingindo remissão da doença. Durante os 30 meses de tratamento com o biológico, manteve função hepática estável, sem reativação do HBV.

Anti-TNF-α agents have emerged as a potent treatment for patients with rheumatoid arthritis unresponsive to conventional disease-modifying antirheumatic drugs. Increased susceptibility to infections induced by these drugs is the main complication of their use. Reactivation of hepatitis B virus (HBV) is one of the most worrisome side effects in patients with HBV infection receiving anti-TNF-α. We report the case of a 56-year-old male patient with stable hepatitis B and good response to the antiviral combination of lamivudine and tenofovir when infliximab was started. The patient went into remission. During the 30-month treatment with the biologic, his liver function remained stable, with no HBV reactivation.

Chronic hepatitis virus infection in patients with multiple myeloma: clinical characteristics and outcomes

OBJECTIVES: Cytotoxic agents and steroids are used to treat lymphoid malignancies, but these compounds may exacerbate chronic viral hepatitis. For patients with multiple myeloma, the impact of preexisting hepatitis virus infection is unclear. The aim of this study is to explore the characteristics and outcomes of myeloma patients with chronic hepatitis virus infection. METHODS: From 2003 to 2008, 155 myeloma patients were examined to determine their chronic hepatitis virus infection statuses using serologic tests for the hepatitis B (HBV) and C viruses (HCV). Clinical parameters and outcome variables were retrieved via a medical chart review. RESULTS: The estimated prevalences of chronic HBV and HCV infections were 11.0 percent (n = 17) and 9.0 percent (n = 14), respectively. The characteristics of patients who were hepatitis virus carriers and those who were not were similar. However, carrier patients had a higher prevalence of conventional cytogenetic abnormalities (64.3 percent vs. 25.0 percent). The cumulative incidences of grade 3-4 elevation of the level of alanine transaminase, 30.0 percent vs. 12.0 percent, and hyperbilirubinemia, 20.0 percent vs. 1.6 percent, were higher in carriers as well. In a Kaplan-Meier analysis, carrier patients had worse overall survival (median: 16.0 vs. 42.4 months). The prognostic value of carrier status was not statistically significant in the multivariate analysis, but an age of more than 65 years old, the presence of cytogenetic abnormalities, a beta-2-microglobulin level of more than 3.5 mg/L, and a serum creatinine level of more than 2 mg/ dL were independent factors associated with poor prognosis. CONCLUSION: Myeloma patients with chronic hepatitis virus infections might be a distinct subgroup, and close monitoring of hepatic adverse events should be mandatory.

Associação de ictiose adquirida, linfoma de Hodgkin e Hepatite B / Combination of acquired ichthyosis, Hodgkin's lymphoma and Hepatitis B

Ictiose adquirida é um distúrbio raro da queratinização, associado a diversas doenças, como neoplasias. Aqui relatamos o caso de uma paciente que se apresentou com ictiose de início recente e no decorrer da investigação foi descoberta hepatite B crônica e linfoma de Hodgkin. Não encontramos relatos da associação destas três entidades na literatura.

Acquired Ichthyosis is a rare disorder of keratinization associated with several diseases such as neoplasias. Here we report the case a patient presenting with ichthyosis of recent onset, and along the investigation chronic hepatitis B and Hodgkin lymphoma were diagnosed. No previous report of the combination of these three entities was found in the literature.

História natural da hepatite B crônica / Natural history of chronic hepatitis B

JUSTIFICATIVA E OBJETIVOS: Estima-se que 400 milhões de individuos estão cronicamente infectados pelo vírus da hepatite B (VHB); destes, 15% a 40% podem evoluir para cirrose e carcinoma hepatocelular (CHC), resultando a em 200 a 300 mil mortes/ano; o que justifica rever a história natural da hepatite crônica B (HCB) fundamentando-a em revisão de literatura através de consulta nas bases de dados MedLine e LILACS, com ênfase na progressão da doença e os fatores que influenciam seu curso natural. CONTEÚDO: A história natural da HCB é complexa e altamente variável, sendo influenciada por fatores relacionados ao hospedeiro, ao vírus e a fatores ambientais. O curso natural da HCB pode ser dividido em quatro fases: imunotolerância, clareamento imune, portador inativo e de reativação. A sua progressão para cirrose e CHC está intrinse­camente ligada a fatores do hospedeiro, tais como: idade superior a 40 anos, ao sexo masculino, preferencialmente asiáticos ou africanos, que apresentam "flares" recorrentes e fibrose avançada. Do ponto de vista viral, são considerados fatores de risco carga viral elevada, variantes pré-core/core promoter e pré-S, além da predominância dos genótipos C e D. Devem ser enfatizadas ainda como fatores rela­cionados com a progressão da doença as coinfecções com VHC, VHD e vírus da imunodeficiência humana (HIV). A ingestão crônica de álcool é considerada como importante fator de progressão para cirrose e CHC. CONCLUSÃO: Finalmente, a interação desses vários fa­tores é essencial para a evolução da doença, entretanto um substrato imunogenético parece ser a base para o entendi­mento da história natural da hepatite crônica B.

Chronic liver disease prevention strategies and liver transplantation / Estratégias de prevenção da doença hepática crônica e transplante de fígado

Chronic liver disease is a considerable burden on society, being one of the three main causes of death in certain regions of Africa and Asia. Liver transplant is the only treatment option for cirrhosis, which is the end stage of many chronic liver diseases. This article reviews the preventable causes of cirrhosis and the preventive strategies which could be implemented in order to avoid the catastrophic consequences of cirrhosis. With small variations around the world, 70 to 80 percent of the end stage liver diseases are caused by excessive alcohol consumption and by viral hepatitis, both of which are potentially preventable. Excessive alcohol consumption has important public health consequences because of its involvement not only with cirrhosis, but also with motor vehicle accidents, unemployment, domestic violence etc. Among the viral causes, Hepatitis Virus B and C have the greatest impact on public health. Effective vaccine is available for Hepatitis Virus B and must be put in use. While a vaccine for Hepatitis Virus C is awaited, effective preventive strategies should be undertaken to avoid the preventable cases of end stage liver disease.

As doenças hepáticas crônicas estão entre as três principais causas de morte na Africa e Asia.O transplante de fígado é o único tratamento curativo para esta doença hepática de caráter terminal.O presente artigo tem como objetivo apresentar as causas passíveis de prevenção de cirrose e as estratégias que podem ser utilizadas no sentido de preveni-las. Com pequenas variações ao redor do mundo, 70 a 80 por cento das doenças hepáticas terminais são causadas por consumo excessivo de álcool e por hepatites virais que são doenças passíveis de prevenção.O consumo excessivo de álcool é importante problema de saúde pública, pois envolve violência doméstica, acidentes de trânsito, além da possível evolução para cirrose e suas conseqüências. Entre as causas virais as hepatites pelo vírus B e C têm o maior impacto na saúde pública. Para a hepatite B já há vacinas disponíveis. Enquanto a vacina para a hepatite C é ainda aguardada, estratégias efetivas de prevenção devem ser efetuadas com o objetivo precípuo de se evitar, por conseqüência, casos de hepatopatias crônicas desta natureza.

Curso terapêutica em gastroenterologia, aula 10: hepatite crônica por vírus B / Couse gastroenterology therapeutic: lesson 10th: chronic hepatitis by virus B

A infecção pelo vírus B da hepatite (VHB) é um problema de saúde mundial. De acordo com a Organização Mundial de Saúde, estima-se que até o ano 2000 cerca de 400 milhões de indivíduos tenham sido infectados, o que corresponde a aproximadamente 5 por cento da população mundial. Tem sido observado que, apesar de permanecer elevada, a incidência da infecção pelo VHB vem diminuindo progressivamente, seja pela utilização das vacinas seja principalmente pela introdução de programas de orientação populacional estimulando modificações comportamentais. No presente artigo discute-se as opções disponíveis para tratamento da hepatite B, em especial o interferon-alfa e a lamivudina. Veremos que os achados sorológicos, o quadro clínico e a evolução da infecção são variáveis, dependendo de fatores como tempo de doença (se aguda ou crônica), presença ou ausência de co-morbidades, como a co-infecção pelo vírus C da hepatite (VHC) e(ou) delta (VHD), e também existência de comprometimento do sistema imunológico, como indivíduos pós-transplante, em tratamento quimioterápico ou na existência do vírus HIV associado

Porfiria cutánea tarda: análisis de datos y criterios prospectivos para su manejo clínico / Porphyria cutanea tarda: data analysis and prospective criteria for the clinical manegement

Objetivo: realizar un análisis retrospectivo de los datos obtenidos en pacientes con porfiria cutánea tarda (PCT); establecer pautas de manejo diagnóstico y de seguimiento; evaluar enfermedades asociadas y/o vinculadas a PCT. Material y métodos: pacientes provenientes de la Sección Dermatología del Hospital J. B. Iturraspe de la ciudad de Santa Fe (1985-1997) y del Servicio de Gastroenterología del Sanatorio Allende de la ciudad de Córdoba (1997). Resultados: del total de 14 pacientes, 11 se diagnosticaron en Santa Fe y 3 en Córdoba; rango etario: 36-63; edad promedio 53,2; 11 hombres y 3 mujeres. Signos dermatológicos más frecuentes: lesiones ampollares, hiperpigmentación y fotosensibilidad. Signos oculares encontrados: fotofobias e inyección conjuntival. Factores precipitantes: tóxicos: etilismo (10), alcohol metílico (1), agroquímicos (1). Farmacológicos: estrógenos (1); psicofármacos (1). Enfermedades asociadas: lepra (2), carcinoma testicular y enfermedad de von Recklinghausen, psoriasis, diabetes, anemia hemolítica autoinmune. Determinación de marcadores virales: total de pacientes: 5; resultados: VIH (-) 3/3; VHB (-) 5/5; VHC (+) 4/5. Conclusión: se enfatiza la importancia de la asociación de PCT y hepatopatía crónica, en especial por virus C