Tuberculous peritonitis in Egypt: the value of laparoscopy in diagnosis.

Abdominal laparoscopy was performed on 200 patients with undiagnosed ascites. It was unsuccessful in one patient with tuberculous peritonitis because of extensive adhesions. A presumptive diagnosis of tuberculous peritonitis based on clinical findings and peritoneal tubercles or adhesions visualized during laparoscopy was made in 90 of these patients. The diagnosis was confirmed in 88 by histopathology, bacteriology, or therapeutic response. Two of the 109 remaining patients who had other presumptive diagnoses made during laparoscopy were eventually confirmed to be cases of tuberculous peritonitis. Of 91 patients with tuberculous peritonitis included in this series, 79% were females, with the majority (79%) of them being of child-bearing age. Half had been ill for longer than one month. The most frequent complaints were abdominal pain, fever, anorexia, night sweats, abdominal swelling, and weight loss. Ascites, fever, wasting, pallor, and abdominal tenderness were common findings. Ultrasonography demonstrated ascites in all patients who underwent this procedure; 21% also had adhesions. Pleural effusion was present in 15% and pulmonary tuberculosis was detected in only two patients. Biopsy samples taken during laparoscopy showed that 60% had noncaseous granulomas and 33% had caseous granulomas. Mycobacterium tuberculosis was detected in 77%, with guinea pig inoculation having the highest sensitivity, followed by culture, and lastly by acid-fast smear. Mycobacterium tuberculosis was isolated more easily from biopsy samples than from ascitic fluid. Nine of 20 M. tuberculosis isolates that were identified as to species were M. bovis. Tuberculous peritonitis, a frequent cause of febrile ascites in Egyptian women, was easily diagnosed by histopathologic and bacteriologic studies of biopsy samples taken at laparoscopy. All patients responded rapidly to antituberculosis therapy.

Ultrasonographic changes of the liver in Schistosoma haematobium infection.

Abdominal ultrasonographic examination was performed in 61 hospitalized patients with chronic liver diseases and 253 school children from a village endemic for Schistosoma haematobium and were compared with 142 urban children without exposure to Schistosoma. The prevalence of ultrasound-detectable hepatomegaly and splenomegaly and the degree of periportal fibrosis was compared between those with and without S. haematobium infection. Among 13 patients with biopsy-proven schistosomal hepatic fibrosis, three with coarse changes secondary to S. mansoni infection showed grade III periportal fibrosis, while 10 patients with fine schistosomal hepatic fibrosis due to S. haematobium had borderline (two) or grade I (eight) changes. Ultrasound evidence of periportal fibrosis was not detected in patients with hepatic cirrhosis, chronic active hepatitis, or fatty infiltration. However, three of 14 patients with chronic persistent hepatitis had grade I periportal fibrosis and two had borderline changes. The frequency of ultrasound-detected hepatomegaly and splenomegaly was greater among rural S. haematobium-infected children (35.2% and 22.4%, respectively) than among noninfected rural (21.1% and 13.3%) and urban (16.9% and 4.9%) children. Also, the frequency of grade I periportal fibrosis was significantly greater (P less than 0.01) in S. haematobium-infected children (22.4%) than in noninfected rural (11.7%) and urban (0.7%) children. No patients with S. haematobium infections, either in the hospital or the village, had grade II or III periportal fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasound-detected hepatic periportal thickening in patients with prolonged pyrexia.

Hepatic periportal thickening (HPT) detected by ultrasonography has been established as a reliable tool for measuring hepatic morbidity due to schistosomiasis. During ultrasonographic examination of patients with prolonged pyrexia, we frequently noticed minimal grades of HPT in patients without a history of schistosomiasis. This led to ultrasonographic studies of conditions other than schistosomiasis in which HPT may occur. Subjects included 460 patients with Schistosoma haematobium infection, 107 urban patients with prolonged pyrexia without previous exposure to schistosomiasis, and 288 healthy controls unexposed to schistosomiasis. Grade I HPT was more prevalent (P < 0.001) in patients with pyrexia (56.1%) than in those with S. haematobium (32.2%) and was more frequent (P < 0.001) in patients with S. haematobium than in controls (11.1%). Typhoid fever was the most common febrile illness causing HPT. Grade II lesions were rare in patients with pyrexia (2.8%) or schistosomiasis (0.9%). Grade III lesions were present in only one patient with S. haematobium. Mild grades of HPT can occur in infectious diseases other than schistosomiasis. Cellular infiltration in the portal tract from chronic infectious diseases can frequently give the ultrasonographic appearance of grade I HPT.

Detection of circulating antigens in patients with active Schistosoma haematobium infection.

An antigen-capture ELISA using monoclonal antibody (MAb) 128C3/3/21 was used to detect circulating parasite-derived antigens in the sera of patients actively infected with Schistosoma haematobium (31 males and four females, 5-25 years of age). The assay had a sensitivity of 100% (35 of 35 patients with antigen levels > 80 ng/ml) and a specificity > 99%. We used this ELISA to monitor antigenemia before treatment and one, three, and six months after treatment with a single oral dose of praziquantel (PZQ) (60 mg/kg in 20 patients or 40 mg/kg in 15 patients) and compared our findings with those indicated by other measures of disease progression. Circulating antigen levels decreased drastically after PZQ treatment (P < 0.001), with a significantly higher decrease occurring after treatment with 60 mg/kg than with 40 mg/kg. Although the mean antigen level was still significantly reduced (P < 0.001) at six months after treatment, 16 patients remained antigen-positive after six months, and nine had increased levels of antigenemia, reflecting reinfection in six patients and persistence of infection in another. We observed a correlation (r = 0.6, P < 0.01) between the level of circulating antigen and the intensity of infection as measured by egg count. We also found a direct relationship (P < 0.001) between antigen level and the severity of the disease as monitored by ultrasonography. We conclude that our ELISA may be a useful adjunct to other methods, such as ultrasonography, for monitoring the course of S. haematobium infection and treatment.

Hepatitis C in a community in Upper Egypt: I. Cross-sectional survey.

The prevalence of antibody to hepatitis C virus (anti-HCV) was determined in a cross-sectional survey in a village in Upper Egypt. Exposure and demographic characteristics were obtained through a questionnaire. Antibody to hepatitis C virus was assessed using a second generation enzyme immunoassay, and the presence of HCV RNA was tested using a reverse transcriptase-polymerase chain reaction. Collection of blood samples was targeted at those > or = 5 years old, and obtained from 62.8%. This report describes the community, the HCV infection characteristics of the subjects, and evaluates some factors associated with presence of anti-HCV. Of the 6,031 participants, 522 (8.7%) were anti-HCV positive. Prevalence was higher among males than females (11.3% versus 6.5%; P < 0.001). It was greater among those > 30 years of age than among those < or = 30 years of age (20.0% versus 3.6%; P < 0.001). Those who were less educated, farmed, provided health care, and were currently married had a significantly higher anti-HCV prevalence than those who were not; however, these associations were not significant after adjusting for age. Although active infections with Schistosoma haematobium were not associated with anti-HCV, a history of past infection was (age-adjusted risk ratio [RR] = 2.1, 95% confidence interval [CI] = 1.8, 2.4); 134 persons who had a history of receiving parenteral anti-schistosomal therapy had a higher age-adjusted RR (3.0; 95% CI = 2.5, 3.7) for anti-HCV than those who did not. Hepatitis C virus RNA was detected in 62.8% of the anti-HCV positive subjects, without significant variation by age, gender, education, or marital status. The prevalence of anti-HCV in Upper Egypt is high, albeit lower than in Lower Egypt, with continuing but limited transmission indicated by the lower prevalence in residents < or = 30 years old.

Prevalence of antibodies to hepatitis E in two rural Egyptian communities.

A population-based serosurvey in two rural Egyptian communities was used to assess age-specific prevalence of antibody to hepatitis E virus (anti-HEV). One community is in the Nile Delta (11,182 inhabitants; 3,997 participants) and the other in Upper Egypt (10,970 inhabitants; 6,029 participants). Samples were tested for anti-HEV with a commercial enzyme-linked immunoassay (ELISA) based on antigens derived from open reading frame (ORF)2 and ORF3. Although there was a clear difference in sensitivity among the lots of the commercial test used, it was still possible to determine the seroprevalence. The seroprevalence of anti-HEV exceeded 60% in the first decade of life, peaked at 76% in the second decade and remained above 60% until the eighth decade. Prevalence of this magnitude is among the highest reported in the world, with an age-specific pattern more similar to hyperendemic hepatitis A virus transmission than generally described. Lot-to-lot variation in the sensitivity of the commercial ELISA kit highlights a problem when comparing seroepidemiologic studies of different populations.

Evaluation of an ultrasonographic score for urinary bladder morbidity in Schistosoma haematobium infection.

An ultrasonographic urinary bladder morbidity score was developed and tested in 510 patients with schistosomiasis haematobia, and then evaluated for screening 1,134 randomly selected children from villages endemic for Schistosoma haematobium. The ultrasonographic urinary bladder morbidity score had four grades ranging from normal to marked thickening of the urinary bladder wall or any polyps or masses. Among both patients and randomly screened subjects, the ultrasonographic score was greater (P = 0.01 and P < 0.01) in males than in females. Children examined in the clinic had higher (P = 0.03) ultrasonographic scores than adults. Infected subjects in communities were more likely (P < 0.001) to have urinary bladder morbidity than uninfected subjects, and clinic patients with egg counts > or = 20 eggs/10 ml of urine had higher (P = 0.03) ultrasonographic urinary bladder morbidity scores than those with lighter infections. The geometric mean egg count was higher (P = 0.04) in clinic patients with grade II and III lesions than in those with grade 0 and I lesions. There was progressive improvement of the grade of urinary bladder morbidity scores in patients treated with praziquantel at each follow-up examination (P < 0.001) and there was a positive relationship (P < 0.01) between urinary bladder morbidity scores and ultrasonographic-detected renal back pressure changes. The ultrasonographic urinary bladder morbidity score objectively measured the severity of urinary bladder morbidity and correlated with intensity of S. haematobium infection in our subjects. It can be used in evaluating both morbidity in patients and in community surveys and in following the outcome of chemotherapy.

The epidemiology of schistosomiasis in Egypt: Assiut governorate.

In the Assiut, Egypt Epidemiology 1, 2, 3 investigation, a sample of 14,204 persons in 10 villages, 31 ezbas (satellite communities), and 2,286 households was drawn from a rural population of 1,598,607. Parasitologic examination of urine and stool were made for Schistosoma haematobium and S. mansoni, and physical and ultrasound examinations were made on a 20% subsample. The overall estimated prevalence of S. haematobium was 5.2 +/- 0.5 (+/- SE). This varied considerably by village and ezba, ranging from 1.5% to 20.9%, with ezbas having a slightly higher overall prevalence than villages. The overall estimated geometric mean egg count was 6.6 +/- 0.5 eggs per 10 ml of urine and was consistently low throughout the communities. Infection with S. haematobium was associated with age (peak prevalence of 10.6 +/- 1.5% in 15-19-year-old age group) males, children playing in the canals, a history of blood in the urine, and reagent strip positivity for hematuria and proteinuria. The prevalence of either hepatomegaly or splenomegaly detected by physical examination was low (4.0% and 1.5%, respectively). The prevalence of hepatomegaly determined by ultrasonography was substantially higher, 24.1%. The prevalence of periportal fibrosis (PPF) was 12.0%, but grade II or III PPF was present in less than 1%. Ultrasonography-determined hepatomegaly, in both the midclavicular line and the midsternal line, increased by age to more than 30%. Periportal fibrosis was more common in the age groups in which infection rates were the highest. At the village and ezba level of analysis, the prevalence of hepatomegaly, splenomegaly, and PPF tended to be higher in communities having the highest prevalence of infection with S. haematobium.

Assessment of liver function by the MEGX test in patients with schistosomiasis and cirrhosis.

OBJECTIVES: The aim of this study was to determine the effect of schistosomiasis infection on hepatic function in Egyptian patients with posthepatitic cirrhosis. DESIGN AND METHODS: Hepatic function, was assessed in 66 Egyptian patients, with (n = 30) and without (n = 36) schistosomal liver fibrosis due to Schistosoma mansoni and in 20 healthy controls, using the monoethylglycinexylidide (MEGX) test. Serum MEGX concentrations were measured before and 5, 15, 30, 60, 120, and 180 min after a lidocaine bolus. The sero-prevalence of antibodies to hepatitis C was also determined in the patients. RESULTS: MEGX test results were significantly lower in patients than in controls at all time points. MEGX test results declined with advancing Child Class. Receiver operating characteristic (ROC) curve analysis revealed the following areas under the ROC curves for discrimination of Child Class C from Child Classes A/B: 30 min, 0.762; 60 min, 0.743; 120 min, 0.731; 15 min, 0.728; 180 min, 0.728; 5 min, 0.602. Schistosomiasis infection had no influence on MEGX test results when cirrhotic patients with (Schisto+) and without (Schisto-) schistosomiasis were compared. While the prevalence of the hepatitis B surface antigen was only 16.7% (Schisto-) and 26.7% (Schisto+), there was an extremely high sero-prevalence of antibodies to hepatitis C (HCV) in both groups: 88.9% (Schisto-) and 73.3% (Schisto+). CONCLUSIONS: The association of schistosomal liver fibrosis with cirrhosis does not additionally influence MEGX formation. In addition, HCV rather than schistosomiasis infection must be considered as a major cause for the progressive liver disease in these patients.

Foci of Schistosoma mansoni in Assiut province in middle Egypt.

Following detection of Schistosoma mansoni in a 12 years old boy who had both schistosomal polyposis and periportal fibrosis with hepatosplenomegaly, epidemiological studies to confirm local transmission were performed in his and 30 other villages in Assiut Governorate, Egypt. The index case's brother and 6 of 380 inhabitants of his village who provided stool specimens were infected with S. mansoni and a farmer with dysentery and hepatosplenomegaly had a positive rectal snip biopsy. All had hepatic abnormalities on ultrasound examination. Two of 221 schoolchildren in another village had mixed infections with S. mansoni and S. haematobium; 17 others had only S. haematobium. None of 419 inhabitants living near the infected boys had S. mansoni infection. Snails from canals and drains near both villages were netted, identified, counted and checked for infection: in the second village one of 1039 Bulinus truncatus was infected with Schistosoma sp. but none of 859 Biomphalaria alexandrina was infected. Schistosomiasis mansoni is being focally transmitted in 2 villages in Assiut Governorate and appears to be spreading from Lower to Middle and Upper Egypt. We believe B. alexandrina, which has been present in some of the waterways for at least 15 years, were infected recently by local inhabitants returning from Iraq or by cattle traders or military recruits from the Delta.

Intrasplenic venous flow patterns demonstrated by Doppler ultrasound in patients with portal hypertension.

The flow pattern in the splenic vein has been previously reported in patients with portal hypertension, but with no reference to the flow within the intrasplenic venous radicles. Using Doppler ultrasound, this study describes the intrasplenic venous flow direction in 176 adult patients with intrahepatic portal hypertension. In our series, a normal flow pattern was maintained in all except four patients (2.3%) who had either reversed or dual venous drainage patterns resulting in trans-splenic portosystemic shunts. These abnormal patterns are Doppler signs of portal hypertension which might be associated with a higher risk of oesophageal variceal bleeding. It is recommended that the intrasplenic venous flow pattern should be assessed before surgical intervention involving the spleen in patients with portal hypertension.

Cardiac metastasis of rectal adenocarcinoma. Surgical treatment.

The authors report a case of cardiac metastasis of a rectal adenocarcinoma that infiltrated the right ventricle and partially obstructed its outflow tract. Surgical treatment was performed because of syncopal attacks. The differential diagnosis between organized thrombi and intracardiac tumor is considered.

Risk factors and immune response to hepatitis E viral infection among acute hepatitis patients in Assiut, Egypt.

Hepatitis E virus (HEV) infection is a common cause of acute viral hepatitis (AVH) in Egypt. We aimed to identify risk factors of HEV among acute hepatitis cases, measure HEV specific immune response to differentiate between symptomatic and asymptomatic infections. The study included symptomatic acute hepatitis (AH) patients (n = 235) and asymptomatic contacts (n = 200) to HEV cases. They completed a lifestyle questionnaire, screened for common hepatotropic viruses. Blood and serum samples were collected from patients and contacts after onset of disease and follow-up samples collected until convalescence. PBMC were separated and tested for specific HEV T-cell response by INF-gamma ELISPOT assay. Serum samples were tested for IgM and IgG anti-hepatitis E virus by ELISA. IgM antibodies to HAV were detected in 19 patients (8.1%), 37 (15.7%) with HBV, 10 (4.3%) with HCV. HEV infection was identified in 42 (16%) patients with AVH. Of the 200 contacts, 14 (7%) had serological evidence of recent HEV asymptomatic infection, showed stronger CMI responses than HEV infected subjects (2540 +/- 28 and 182 +/- 389 ISCs/106 cells, respectively; P < 0.05). In conclusion, HEV is a major cause of AVH in Egypt. Asymptomatic HEV patients are likely to have stronger immune responses including CMI responses, than symptomatic cases.

Endoscopic diagnosis of ascites in Assiut province, upper Egypt.

Fifty-nine case of ascites not due to cardiac or renal disease were subjected to clinical, endoscopic and laboratory investigations, including bacteriology and histopathology. Provisional diagnosis divided the cases into 38 patients with ascites as the main finding, and 21 patients with liver cirrhosis and ascites. After investigation, the final diagnosis was totally different from the provisional in 15 cases. Predominance of tuberculosis of the peritoneum per se or in addition to liver cirrhosis was striking, and its documentation was possible only through laparoscopy and biopsy. Oesophagoscopy, a simple procedure, revealing varices in undiagnosed ascites, points to liver cirrhosis. Laparoscopy confirms the diagnosis and reveals other additional factors for ascites as malignancy or tuberculosis.

The pharmacokinetics of antipyrine in patients with graded severity of schistosomiasis.

The pharmacokinetics of antipyrine have been studied in patients with schistosomiasis. In comparison to a control group of subjects (n = 6), patients with early (active) schistosomiasis (passing live ova in urine or stools without clinical and laboratory evidence of liver involvement; n = 6) exhibited similar pharmacokinetic parameters. Of seven patients with hepatosplenic schistosomiasis (exhibiting hepatic fibrosis, splenomegaly, at least one episode of haematemesis, ascites), five showed markedly enhanced antipyrine half-life and reduced clearance. Compared to controls, the mean half-life of this group was increased from 10.9 +/- 2.4 to 19.9 +/- 9.5 h (mean +/- s.d.; P less than or equal to 0.05) and clearance reduced from 3.81 +/- 0.74 to 2.18 +/- 0.80 l h-1 (P less than or equal to 0.01). There was no change in the apparent volume of distribution. Liver biopsy was performed on all patients diagnosed as having hepatosplenic schistosomiasis in the 2 weeks prior to the antipyrine study. The results of this study indicate that hepatic microsomal metabolism is impaired in patients with advanced hepatosplenic schistosomiasis.

Behaviour of hepatitis B antigen in bilharzial patients infected with HBs positive viral hepatitis.

A TOTAL of 204 cases with acute viral hepatitis were studied: 93 bilharzial and 111 non-bilharzial. This study is concerned with the 106 cases showing positive HBS Ag test. Follow up of the cases after discharge from the Fever Hospital was carried out by repeated clinical and laboratory examinations 3 montly in the first year and 6 monthly subsequently. The bilharzial and non-bilharzial patients were found to be equally susceptible to HBS Ag positive hepatitis (p=0.25). However, antigenaemia tended to last longer as a whole in the bilharzial patients (p=0. 005) and was not affected by successful specific antibilharzial treatment. It seems that bilharzial infection predisposes to "retention" of HBs antigen, after subsidance of the acute attack, thus increasing the volume of reservoir for HB virus in our rural community.

Increased interleukin-4 and interleukin-5 production in response to Schistosoma haematobium adult worm antigens correlates with lack of reinfection after treatment.

Acquired immunity to human schistosomiasis correlates with increased serum levels of schistosome antigen-specific IgE. Since interleukin (IL)-4 stimulates IgE production, the hypothesis that Th2-associated cell-mediated immunity participates in protection to reinfection was studied in a cohort of adolescent boys 12-18 months after chemotherapeutic cure in Upper Egypt. Initial Schistosoma haematobium prevalence was 51% and posttreatment incidence was 44%. Water contact was similar between putatively resistant and susceptible patients. Resistant persons had a 3.5- to 14-fold greater frequency of schistosome adult worm antigen (SWAP)-specific lymphocytes secreting IL-5 or IL-4 (by ELISPOT) and IL-5 or IL-4 production in peripheral blood lymphocyte culture supernatants (P < .05 to < .001, n = 48) versus susceptible subjects (n = 38). In contrast, SWAP-induced interferon-gamma and IL-10 production and lymphocyte proliferation were similar between the 2 groups. Schistosome egg antigen and streptolysin O each stimulated similar cytokine production in susceptible and resistant persons. Thus, enhanced SWAP-driven IL-4 and IL-5 production correlates with immunity to reinfection in adolescents exposed to urinary schistosomiasis.