Recurrent bacteremia after injection of N-butyl-2-cyanoacrylate for treatment of bleeding gastric varices: a case report and review of the literature.

BACKGROUND: Bleeding from gastric varices has high mortality rate, and obliteration using N-butyl-2-cyanoacrylate is the treatment of choice. Recurrent bacteremia is rarely reported following the procedure. We aimed to report a case of recurrent bacteremia after N-butyl-2-cyanoacrylate treatment and to review published cases. CASE PRESENTATION AND REVIEW: In May 2014, a 43-year-old Brazilian male presented with lower gastrointestinal bleeding. Endoscopy showed active bleeding from gastric varix. Injection of N-butyl-2-cyanoacrylate was performed and the patient was discharged. Over the next 4 months he presented with three episodes of bacteremia with severe sepsis and no identifiable focus of infection. Oral prophylaxis was initiated in September 2014 and he has remained free of bacteremia. Six other cases of recurrent bacteremia following sclerosis with N-butyl-2-cyanoacrylate were reported in the literature. All patients had portal hypertension and bleeding from gastric varices. Average age of patients was 55.7 years and the median time from endoscopic procedure to the first episode of bacteremia was 105 days (range 14-365). The mean number of episodes of bacteremia per patient was 2.5. CONCLUSION: Recurrent bacteremia associated with endoscopic treatment with N-2-butyl-cyanoacrylate is rare, but should be suspected in patients in which investigation shows no other focus of infection. Secondary prophylaxis should be considered after the first episode.

Successful treatment of de novo autoimmune hepatitis and cirrhosis after pediatric liver transplantation.

Over a 15-yr period of observation, among the 205 children who underwent liver transplantations, one of them developed a particular type of late graft dysfunction with clinical and histological similarity to autoimmune hepatitis. The patient had alpha1-antitrypsin deficiency and did not previously have autoimmune hepatitis or any other autoimmune disease before transplantation. Infectious and surgical complications were excluded. After repeated episodes of unexplained fluctuations of liver function tests and liver biopsies demonstrating reactive or a biliary pattern, without any corresponding alteration of percutaneous cholangiography, a liver-biopsy sample taken 4 yr after the transplant showed active chronic hepatitis progressing to cirrhosis, portal lymphocyte aggregates, and a large number of plasma cells. At that time, autoantibodies (gastric parietal cell antibody, liver-kidney microsomal antibody, and anti-hepatic cytosol) were positive and serum IgG levels were high. Based on these findings of autoimmune disease, a diagnosis of 'de novo autoimmune hepatitis' was made. The treatment consisted of reducing the dose of cyclosporine, reintroduction of corticosteroids, and addition of mycophenolate mofetil. After 19 months of treatment, a new liver-biopsy sample showed marked reduction of portal and lobular inflammatory infiltrate, with regression of fibrosis and of the architectural disruption. At that time, serum autoantibodies became negative. The last liver-biopsy sample showed inactive cirrhosis and disappearance of interface hepatitis and of plasma cell infiltrate. Presently, 9 yr after the transplantation, the patient is doing well, with normal liver function tests and no evidence of cirrhosis. Her immunosuppressive therapy consists of tacrolimus, mycophenolate mofetil, and prednisolone. In conclusion, the present case demonstrates that de novo autoimmune hepatitis can appear in liver-transplant patients despite appropriate anti-rejection immunosuppression, and triple therapy with tacrolimus, mycophenolate mofetil, and prednisolone could sustain the graft and prevent retransplantation.

Associaçäo de doença de Wilson e síndrome extrapiramidal näo wilsoniana na mesma família / Association of Wilson's disease and with non Wilsonian extrapyramidal syndrome in the same family

Distúrbios do movimento, geralmente de tipo distônico, têm sido relatados em heterozigotos para doença de Wilson (DW). O presente relato assinala a presença em uma mesma família de heterozigoto para DW com quadro distônico e sua sobrinha com quadro clássico de DW. Discutem-se as peculiaridades dessa família, comparando-se aos dados da literatura, bem como os possíveis mecanismos etiopatrogênicos envolvidos

O zinco no tratamento de degeneraçäo hepatolenticular: a propósito de 3 casos / The zinc in the treatment of hepatolenticular degeneration: apropos of 3 cases

Säo descritos três casos de degeneraçäo hepatolenticular (DHL) em que o efeito nefrotóxico da D-penicilina (DO) levou à substituiçäo dessa droga por zinco, com resultados satisfatórios. O tempo médio de tratamento com zinco nos casos descritos foi de 2 anos e 7 meses. Com base nos dados de literatura e na experiência com esses pacientes, os autores consideram que os sais de zinco podem ser uma alternativa para o tratamento da DHL quando a DP determina o aprecimento de efeitos colaterais graves que levam à sua retirada definitiva