Autoimmune hepatitis in India: single tertiary referral centre experience.

BACKGROUND AND AIMS: Autoimmune hepatitis is considered to be rare in Asia-Pacific region. There a few long term studies available. This study was planned to estimate the burden, natural history of AIH and challenges associated with management in a single non-transplant tertiary referral center. METHODS: Prospectively maintained data of patients treated as AIH was screened and patients who qualified AIH by retrospective application of simplified criteria's were enrolled. 181 patients qualified. 125 patients with substantial follow up (65 Definite AIH; 81 females; median age 46, range 8 - 79) were included in study. RESULTS: Prevalence of AIH was 1.3% and 8.74% amongst all liver disease patients and chronic liver disease respectively. 89 patients qualified as Type I AIH, 14 as type II AIH and 22 were autoimmune markers negative. Modes of presentation was acute liver failure (n = 8), chronic hepatitis (n = 17), cirrhosis (n = 89), 50 patients were decompensated), ACLF (n = 7), while 2 were clinically asymptomatic. 19 patients had preceding history of drug intake. 33 patients didn't undergo pretreatment liver biopsy. Prednisolone alone was the predominant immunosuppressive agent used, especially in decompensated cirrhotics and those with acute liver failure. First remission rates after first immunosuppression course were 60%, 85% and 63% in type I, type II and autoantibody negative groups. After a median follow up of 7 years (range 1 - 17 years), 15 patients died (12 of liver related complications) and 2 underwent liver transplantation. Failure to normalize ALT had a high hazard ratio predicting liver related death or transplantation. 11 patients had improvement on repeat liver biopsy, with 5 showing complete cirrhosis reversal. 40 patients are on long term maintenance immunosuppression. CONCLUSION: AIH, though uncommon, needs to be kept in mind as early treatment is associated with significantly good long-term prognosis.

Risk of development of hepatocellular carcinoma in patients with NASH-related cirrhosis.

BACKGROUND AND AIMS: The risk of development of hepatocellular carcinoma (HCC) in hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is well established and is being recognized increasingly in non-alcoholic steatohepatitis (NASH)-related cirrhosis. This study aimed to assess the risk of development of HCC in patients with NASH-related cirrhosis. METHODS: From January 2010 to October 2011, we prospectively enrolled 585 patients with liver cirrhosis (men:women ratio 4.4:1, mean age 50.1 +/- 6.1 years, aetiology HBV 19%, HCV 14.2%, NASH-related 7%, cryptogenic cirrhosis 17.8%, already diagnosed cirrhosis 48.2%, and the remaining were newly diagnosed cases). The cumulative follow-up was for 5.9 +/- 0.5, 6.1 + 0.8 and 6.8 + 1.2 years for HBV, HCV and NASH-related cirrhosis, respectively. Patients with advanced cirrhosis, Child class C and associated comorbid conditions where survival was < 1 year were excluded from the study. The remaining patients were followed up 6-monthly with ultrasound examination and alpha-fetoprotein (AFP) test. Patients suspected of HCC underwent triple-phase computed tomography (CT) scan and liver biopsy was done to confirm the diagnosis. RESULTS: A total of 54 patients developed HCC, of which 26 had HBV, 14 had HCV, 9 had- cryptogenic and 6 had- NASH-related cirrhosis. The annual rate of development of HCC was 1.5%, 3.6%, 0.6% and 0.46 in HBV, HCV, cryptogenic and NASH-related cirrhosis, respectively. CONCLUSIONS: The incidence of HCC was highest in HCV and lowest in NASH-related cirrhosis. These figures suggest an intermediate risk of development of HCC when compared to western countries and Japan.

Intrinsic factor antibody negative atrophic gastritis; is it different from pernicious anaemia?

INTRODUCTION: H. pylori gastritis and autoimmune gastritis are the two main types of chronic atrophic gastritis. Parietal cell antibody (PCA) and intrinsic factor antibody (IFA) are characteristic of autoimmune gastritis, of which IFA is more specific. Patients who are IFA negative are considered under the category of chronic atrophic gastritis. AIM: To differentiate IFA positive from IFA negative chronic atrophic gastritis. METHODS: Fifty consecutive patients of biopsy proven chronic atrophic gastritis were included in this study. All patients underwent haematological and biochemical tests including serum LDH, vitamin B12 and fasting serum gastrin levels. PCA and IFA antibodies were tested in all patients. Multiple gastric biopsies from body and antrum of the stomach were taken and evaluated for presence of intestinal metaplasia, endocrine cell hyperplasia, carcinoid and H. pylori infection. Patients were grouped as group A (IFA positive) and group B (IFA negative). The mean laboratory values and histological parameters were compared between the two groups using appropriate statistical methods. RESULTS: Eighteen patients were in group A (mean age 55.5 +/- 13 years, male: female = 16:2) and thirty-two in group B (mean age 49.7 +/- 13 years, male: female = 25:7). There was no statistically significant difference between median values of haemoglobin, MCV, LDH, Vitamin B12 and serum gastrin in both the groups. None of the histological parameters showed any significant difference. CONCLUSION: There was no statistically significant difference in haematological, biochemical and histological parameters in IFA positive and negative gastritis. These may be the spectrum of the same disease, where H. pylori may be responsible for initiating the process.

A retrospective clinico-pathological analysis of neuroendocrine tumors of the gastrointestinal tract.

AIM: Gastrointestinal tract is the commonest site for neuroendocrine tumors. Appendix, ileum and rectum were considered to be common sites for these tumors. However, there has been change in pattern of gastrointestinal neuroendocrine tumors over last few years. There is limited data available on epidemiology and patterns of these tumors in India. METHODS: Analysis of 74 patients with gastrointestinal and pancreatic neuroendocrine tumors over a period of 7 years at a single center in Mumbai, India was done. Clinical details, surgical outcome with follow up and treatment were reviewed. All these patients were analyzed with special emphasis on the site of the tumor. RESULTS: The results showed a male preponderance (ratio of 2.5:1) with a mean age of 53.01 +/- 15.13 years. Of the 74 tumors, the commonest site was found to be stomach 22 (30.2%), followed by pancreas 17 (23.3%) and duodenum 14 (18.9%). Only 3 (4.1%) patients presented with carcinoid syndrome. The disease was localized in 46 (62.2%), regional spread was seen in 14 (18.9%) and distant spread in 14 (18.9%). Majority of gastric and duodenal tumors had localized disease while pancreatic NETs led to most of the cases with distant disease. CONCLUSION: This analysis showed that gastrointestinal and pancreatic neuroendocrine tumors are not rare. Pattern of these tumors has definitely changed over last few years. Stomach was found to be commonest site for gastrointestinal neuroendocrine tumors followed by pancreas and duodenum.

Portopulmonary hypertension in a case of non-cirrhotic portal fibrosis.

Portopulmonary hypertension (PPHT) is the unusual association of portal hypertension (HT) with pulmonary HT. We report a case of noncirrhotic portal fibrosis (NCPF) leading to PPHT which is exceedingly rare with only very few cases reported in the literature. This is an autopsy report of a 30 years old man, a known case of portal HT who died suddenly due to a syncopal attack. Autopsy revealed massive pulmonary thromobembolism with pulmonary HT. Liver showed changes of NCPF. The rarity of NCPF causing PPHT prompted this case report.

Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models.

BACKGROUND AND AIMS: Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical worsening and high mortality. Early prediction of mortality and intervention can improve patient outcomes. We aimed to develop a dynamic prognostic model and compare it with the existing models. METHODS: A total of 1402 ACLF patients, enrolled in the APASL-ACLF Research Consortium (AARC) with 90-day follow-up, were analyzed. An ACLF score was developed in a derivation cohort (n = 480) and was validated (n = 922). RESULTS: The overall survival of ACLF patients at 28 days was 51.7%, with a median of 26.3 days. Five baseline variables, total bilirubin, creatinine, serum lactate, INR and hepatic encephalopathy, were found to be independent predictors of mortality, with AUROC in derivation and validation cohorts being 0.80 and 0.78, respectively. AARC-ACLF score (range 5-15) was found to be superior to MELD and CLIF SOFA scores in predicting mortality with an AUROC of 0.80. The point scores were categorized into grades of liver failure (Gr I: 5-7; II: 8-10; and III: 11-15 points) with 28-day cumulative mortalities of 12.7, 44.5 and 85.9%, respectively. The mortality risk could be dynamically calculated as, with each unit increase in AARC-ACLF score above 10, the risk increased by 20%. A score of ≥11 at baseline or persisting in the first week was often seen among nonsurvivors (p = 0.001). CONCLUSIONS: The AARC-ACLF score is easy to use, dynamic and reliable, and superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week.

Utilization of antihepatocyte clone OCH1E5 (Hep Par 1) in histological evaluation of liver tumors.

Diagnosis of hepatocellular carcinoma (HCC) is not always easy on simple hematoxylin and eosin (H&E) stain. The diagnostic problems arise when tumor shows pseudoglandular, pleomorphic or clear cell differentiation. Various tumors markers have been described with varying sensitivity and specificity. Monoclonal antibody Hep Par 1 (OCH1E5) which is specific for hepatocytes offers great help in separation of these tumors. The aim of the present study was to determine utility of Hep Par 1 (OCH1E5) in differentiating HCC from metastatic tumors and cholangiocarcinoma. Total of 62 cases of liver tumors obtained from biopsies, resected or autopsy specimens were included in the study. Slides having representative sections were subjected to immunohistochemistry with monoclonal antibody Hep Par 1 (Dako Corp) using avidin biotin technique with primary antibody dilution of 1:40. Adjacent nontumorous hepatocytes were taken as positive control. Slides were examined by experienced pathologist without any information of clinical or H&E diagnosis. Cases were considered positive for Hep Par 1 if tumor cells showed cytoplasmic brown colored granules. The intensity and distribution (diffuse/ focal) of immunoreactivity was noted. Subsequently immunohistochemistry results were correlated with histology and clinical diagnosis. Hep Par 1 antibody was positive in 26 (42 %) and negative in 36 (58 %) liver tumors. On correlating with H&E sections, out of 26 positive cases, 25 (89.2%) were HCC and one was the case of metastasis of mucin secreting adenocarcinoma. From 36 tumors with negative staining 3 were cases of HCC, 27 metastatic adenocarcinomas and 6 cholangiocarcinomas. Only one case of liver metastasis of mucin secreting adenocarcinoma showed positivity. None of the cases of cholangiocarcinoma showed positivity for Hep Par 1. The three HCCs which did not take up staining for Hep Par 1 were 2 cases of moderately differentiated HCC having pseudoglandular pattern and a case of well differentiated HCC with trabecular arrangement. In 11(44%) cases staining was diffuse while in 14 (56%) it was focal but intense. Hep Par 1 is a useful marker in differentiating HCC from metastaic tumors and cholangiocarcinoma with sensitivity and specificity of 89 % and 97 % respectively and positive predictive value of 96 %. However one should be aware of limitations of immunohistochemistry.

Frequency analysis of proliferating and cytotoxic T cells in livers and peripheral blood of patients with chronic hepatitis B.

Frequencies of proliferating and cytotoxic lymphocytes from liver biopsy samples and peripheral blood of chronic hepatitis B (CHB) patients and control subjects were monitored by limiting dilution analysis. Precursor frequencies of proliferating T lymphocytes were not significantly different in the liver and peripheral blood compartments of patients and controls. Moreover, similar frequencies of natural killer cells and cytotoxic T lymphocytes were observed in the peripheral blood of patients and controls. A higher frequency of cytotoxic T cells (1 of 22) compared to NK cells (1 of 306) was observed in liver tissues of CHB patients. Dual colour flow cytometric analysis revealed the presence of both CD4+ HLA-DR+ and CD8+ HLA-DR+ T cells in the liver tissues. These results suggest that in livers of CHB patients not only activated CD8+ T cells but also activated CD4+ T cells may play a significant role in the pathogenesis of chronic hepatitis B.

HIV infection in patients of liver cirrhosis.

A total of 130 patients of liver cirrhosis (97 males, 33 females; aged 9-70 yr) of various etiologies were subjected to anti HIV antibodies testing by ELISA and supplementary Western Blot (WB) tests. Eleven patients were positive by ELISA. Of these 11 patients, 5 were WB positive, 4 were WB negative and 2 were indeterminate. Of the 5 WB positive patients none had received blood transfusions and one was a homosexual. These results indicate that HIV infection was present in 3.8 per cent patients of liver cirrhosis. Further studies are required on a large number of patients to recommend HIV testing routinely in cirrhotic patients.

PIP: Health workers took blood examples from 130 9-70 year old patients with liver cirrhosis admitted to the Department of Gastroenterology at BYL Nair Hospital in Bombay, India, between January 1990 and February 1992. Since patients with liver cirrhosis tend to undergo many blood transfusions in emergency situations, because of vomiting blood, researchers wanted to determine whether an association exists between HIV infection and liver cirrhosis. Laboratory personnel tested the samples for anti-HIV antibodies using first the ELISA and then confirming positive samples with the Western Blot (WB) test. The ELISA revealed 11 positive samples (5 were WB positive; 4 were WB negative, and 2 had indeterminate results) and the WB confirmed 5 HIV positive cases (all being 20 to 50 year old males). Thus, the HIV seroprevalence was 3.8% among the liver cirrhosis cases. 1 HIV-positive patient had earlier engaged in homosexual intercourse, 2 others had had multiple sexual partners. 4 HIV=positive patients had chronic alcoholism. 1 HIV-positive patient suffered from extensive intra abdominal tuberculosis and died during his hospital stay. None of the HIV-positive patients had earlier undergone a blood transfusion. The researchers called for more studies to confirm a relationship between HIV infection and liver cirrhosis with or without alcoholism.

Role of routine estimation of creatinine clearance in patients with liver cirrhosis.

BACKGROUND: Frequent occurrence of renal dysfunction without azotemia in patients with decompensated cirrhosis, and its prognostic and therapeutic importance, are not well appreciated. METHODS: Creatinine clearance (CrCl), 24-hour urinary sodium excretion, fractional excretion of sodium, and urine flow were estimated in 68 non-azotemic uncomplicated cirrhosis patients; all these patients were followed up for a period of 6 months. Eighteen patients with ascites and edema were treated with large volume paracentesis without colloid replacement and renal function was evaluated before, and 48 hours and 7 days later. Eight patients with abnormal CrCl were treated with 10 mg of enalapril daily and CrCl estimated at the end of 7 days. RESULTS: Of 68 patients, 22 had CrCl > 80 mL/min (Group I), 21 had CrCl of 50-80 mL/min (Group II) and 25 had CrCl < 50 mL/min (Group III). Renal dysfunction correlated with Child's class. During a mean follow up period of 180 days, patients in Groups II and III had higher mortality rates than those in Group I (23.8% and 36.0% vs 9.1%; p < 0.001). Following large volume paracentesis, CrCl decreased at 48 h and continued to be low at the end of 7 days even though blood urea nitrogen and serum creatinine remained normal. CrCl improved with 10 mg enalapril at 7 days (46.5 +/- 15.4 to 73.2 +/- 19.7 mL/min; p < 0.05). CONCLUSION: More than two-thirds of patients with advanced cirrhosis have abnormal CrCl despite normal blood urea nitrogen and serum creatinine; they also have a higher mortality as compared with patients with normal CrCl. CrCl decreases after large volume paracentesis even though blood urea nitrogen and serum creatinine remain unchanged. Enalapril improves CrCl in patients with liver cirrhosis but its exact clinical utility needs further evaluation.

Alternate-day therapy with omeprazole for duodenal ulcer.

BACKGROUND: Maximal acid suppression produced by a single dose of 20 mg omeprazole has been reported to persist for over 24 hours, with acid secretion returning to normal after 2 days. OBJECTIVES: (i) To study the effect of single oral dose of 20 mg omeprazole on maximal acid output (MAO) and peak acid output (PAO) in duodenal ulcer patients and healthy volunteers. (ii) To compare the efficacy of omeprazole 20 mg daily versus 20 mg on alternate days in the treatment of duodenal ulcer. STUDY DESIGN: Open randomized comparative trial. METHODS: MAO and PAO were estimated in five duodenal ulcer patients and five healthy volunteers before, and 24 hours and 48 hours after, a single 20 mg oral dose of omeprazole. Fifty eight consecutive uncomplicated duodenal ulcer patients were randomized to receive omeprazole 20 mg either daily (n = 30) or on alternate days (n = 28) for four weeks. The two groups were matched for age, sex, duration of ulcer symptoms, smoking, NSAID use, and ulcer size at entry. Symptom scores using a pre-defined scoring system and endoscopic ulcer healing rates were evaluated at 2 and 4 weeks. RESULTS: MAO and PAO showed significant reduction in both duodenal ulcer patients and healthy controls 24 hours after 20 mg omeprazole. Reduction at 48 hours was significant in duodenal ulcer patients but not in controls. Endoscopic healing rates of duodenal ulcer at 2 and 4 weeks were 80% and 93.3% respectively in the daily treatment group and 71.4% and 85.7% respectively in the alternate-day treatment group. These differences were not statistically significant. CONCLUSION: 20 mg omeprazole on alternate days is as effective as 20 mg daily (i) in suppressing MAO and PAO and (ii) in the treatment of duodenal ulcer.

Mucin histochemistry of esophagus in health and malignancy.

AIMS: To study mucin histochemistry of the normal esophagus, esophageal adenocarcinoma, and carcinoma exhibiting glandular and squamous elements, to ascertain the origin of these tumors. METHODS: Mucin histochemistry was studied in sections of the normal cardioesophageal junction obtained from 25 post-mortem specimens and in 12 mucin-secreting esophageal carcinomas. RESULTS: The normal submucosal esophageal glands and three adenocarcinomas secreted predominantly sulfomucins; a mixture of neutral and sialomucins was seen in the nine carcinomas with squamous and glandular traits. Barrett's metaplasia was not encountered. CONCLUSIONS: In the absence of Barrett's metaplasia, esophageal adenocarcinoma probably arises from the submucosal glands, whereas squamous carcinomas with mucin-secreting component could arise from metaplastic change in squamous epithelium, cardiac glands, or multipotent stem cells in the epithelium.

Hepatocellular carcinoma in association with membranous obstruction of inferior vena cava.

We report a patient with hepatocellular carcinoma (HCC) with membranous obstruction of the inferior vena cava (IVC). He underwent balloon dilatation of the IVC with good results. The HCC was managed by chemoembolization followed by resection. At follow up of eleven months the patient is asymptomatic.

Hepatic sarcoidosis.

We describe six cases of hepatic sarcoidosis. Clinical presentation was with weight loss, hepatomegaly and abnormal liver function tests. In addition there was fever, itching, splenomegaly and abdominal lymphadenopathy in some. CT scan revealed mediastinal lymphadenopathy in all. Liver biopsy showed noncaseating epithelioid granulomas. Serum angiotensin converting enzyme was elevated in four cases. All patients had received anti-tuberculosis treatment with clinical diagnosis of hepatic tuberculosis. None of them improved, while some showed clinical deterioration. All patients responded to corticosteroids with disappearance of symptoms and normalization of liver function tests.

Spectrum of liver diseases in HIV infection.

BACKGROUND: Most earlier reports on the spectrum of liver diseases in HIV-infected individuals originated from the West. OBJECTIVE: To study the spectrum of liver diseases in HIV-infected individuals. METHODS: Seventy four consecutive HIV-positive patients (57 men; age range 23-75 years, mean 34) were studied prospectively with clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, markers of hepatitis B (HBV) and C (HCV) viruses, and liver histology whenever necessary. RESULTS: Thirty four patients (45%) were chronic alcoholics. Mean (SD) absolute lymphocyte count was 2521 (1271)/mm3; count < 2000/ mm3 was present in 20 patients. Serum bilirubin, transaminases and alkaline phosphatase levels were elevated in 13%, 13% and 24% of patients, respectively. Ultrasonography detected an abscess in two patients (tuberculous-1, amebic-1). Evidence of exposure to HBV was present in 81% (HBsAg-12, hepatitis B core and/or surface antibody-48); anti-HCV antibody was positive in 29.7%. Five patients with liver tuberculosis (granuloma-4, abscess-1) had AFB either in liver tissue or lymph nodes. CONCLUSION: Chronic alcoholism, HBV and HCV infection, hepatic tuberculosis, and evidence of other liver disease were common in patients with HIV infection.

PIP: A prospective study of 74 consecutive HIV patients (mean age, 34 years) at a public hospital in Mumbai, India, found evidence of hepatitis B and C virus, hepatic tuberculosis, and other liver disease. Clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, hepatitis B and C virus markers, and liver histology were performed. 34 patients (45%) were classified as chronic alcoholics on the basis of a history of consumption of at least 80 g of alcohol daily for at least 5 years and test findings. 59 (80%) had a history of multiple sex partners or encounters with commercial sex workers. 12 patients (16%) were hepatitis B surface antigen-positive and 22 (30%) were positive for hepatitis C virus antibody. Bilirubin, transaminases, and alkaline phosphatase were elevated in 13%, 13%, and 24%, respectively. Liver cirrhosis was present in 5 patients. Hepatitis B virus was detected in 4 patients and dual hepatitis B and C infection was found in another patient. Finally, 5 patients had liver tuberculosis. The mean absolute lymphocyte count was 2521/cu. mm; only 20 had a count indicative of immunosuppression (2000/cu. mm). These findings confirm that hepatic effects are a major feature of HIV infection in India.

Thrombotic obstruction of inferior vena cava treated with streptokinase infusion and balloon dilatation.

A 35 year old male with thrombotic obstruction of the inferior vena cava superimposed on a membrane was treated by prolonged (48 hours) infusion of streptokinase followed by balloon membranotomy. The procedure produced excellent clinical, hemodynamic and angiographic results which are sustained at the end of six months.

Profile of hepatitis B e antigen-negative chronic hepatitis B.

BACKGROUND: Although chronic hepatitis B occurs in hepatitis B e antigen (HBeAg)-negative patients, its prevalence and clinical significance are not known. AIM: To determine the prevalence and profile of HBeAg-negative chronic hepatitis B virus (HBV) infection. METHODS: A retrospective analysis of 363 consecutive patients (mean age 36 y; 288 men) with chronic HBV infection was performed. All patients were HBsAg-positive. Tests for liver profile, HBeAg and anti-HBe antibody were performed in all patients. Serum HBV DNA was tested using branched DNA assay in 245 patients. The patients were classified into three groups: no cirrhosis with normal ALT levels, no cirrhosis with elevated ALT levels, and clinical or histological evidence of cirrhosis. RESULTS: Of 363 patients, 141 (39%) were HBeAg-positive and 222 (61%) HBeAg-negative. Of HBeAg-negative patients, 120 (54%) had normal ALT, 45 (20%) had elevated ALT and 57 (26%) had evidence of cirrhosis; corresponding figures in the HBeAg-positive patients were 40 (28%), 66 (47%) and 35 (25%). HBV DNA was positive in 53 of 131 (40%) HBeAg-negative patients tested; of these 53 patients, 9 (17%) had normal ALT, 20 (38%) had elevated ALT and 24 (45%) had cirrhosis. Thus, 72% of HBeAg-positive and 46% of HBeAg-negative patients had elevated ALT and/or cirrhosis. Among the latter group, 83% of HBV DNA-positive patients had elevated ALT and/or cirrhosis. Overall, 18% of HBsAg-positive patients had HBeAg-negative, HBV DNA-positive liver disease. CONCLUSION: HBeAg-negative chronic hepatitis B is not an uncommon and benign entity and chronic liver disease develops in a significant proportion of such patients.

Tuberculous abscess of the liver associated with HIV infection.

Tuberculosis is an AIDS-defining illness in HIV-seropositive patients. Though disseminated tuberculosis is common in HIV-seropositive patients, hepatic involvement in the form of abscess formation is rare. We report such a patient.

Prevalence of delta virus infection in high risk population and hepatitis B virus related liver diseases.

Two hundred and fifty four high risk persons or patients with hepatitis B virus related liver disease (209 men, 45 women; age range 1-78 years) were tested for anti-delta antibody and IgM anti-HBc to determine the prevalence of delta agent coinfection and superinfection. The prevalence of delta infection was as follows: acute viral hepatitis 23/148 (16%) and chronic liver disease 17/92 (19%), and asymptomatic HBsAg carriers 1/6 (17%). In the high risk population, the delta antibody prevalence was as follows: multiple transfusion recipients 3/8 (38%), patients with chronic renal failure 1/5 (20%) and medical professionals 2/7 (29%). Of 44 patients (34 men, 10 women; age 3-63 years) with delta infection, 26 (59%) had coinfection and 18 (41%) had superinfection. Six patients with anti-delta antibody had received blood transfusion(s) and six others gave history of parenteral exposure.

Frequency of hepatitis B, C and D and human immunodeficiency virus infections in multi-transfused thalassemics.

Of forty multi-transfused thalassemia patients (26 males, 14 females; mean age 8.1 +/- 5.3 years, range 1-35) with no clinical or biochemical evidence of liver disease, HBsAg, anti-hepatitis C virus and anti-human immunodeficiency virus antibodies were present in 18 (45%), 7 (17.5%) and 1 (2.5%) cases respectively. Three of the 18 (16.7%) HBsAg positive patients were anti-delta antibody positive. Our results indicate that more than 50% of multi-transfused thalassemia patients show serological evidence of one or more of hepatitis B, C and D and human immunodeficiency virus infection.

PIP: Transfusion of whole blood or blood components is the mainstay of treatment in patients with beta-thalassemia and hemophilia. Owing to the scarcity of reports regarding the frequency of transfusion-transmitted hepatitis virus infections in thalassemia patients, the frequency of such infections was studied in India in 40 multi-transfused thalassemia patients (26 males, 14 females; mean age 8.1 +or- 5.3 years, range 1-35) with no clinical or biochemical evidence of liver disease. The enzyme-linked immunosorbent assay (ELISA) technique (Abbott) was used for all tests. The patients had received an average of 80 units (range 10-250) of blood. A majority of these units had been screened for hepatitis B surface antigen (HBsAg) using RPHA. HBsAg antibodies were present in 18 (45%), antihepatitis C virus (HCV) in 7 (17.5%), and antihuman immunodeficiency virus in 1 (2.5%) case, respectively. Of 18 HBsAg positive patients, antidelta and anti-HCV antibodies were present in 3 and 4 patients, respectively; 1 patient had both the antibodies. 4 of 40 (10%) patients had evidence of both hepatitis B virus (HBV) and HCV infection. In a US study, the frequencies of HBsAg and anti-HBs positively among thalassemics were 4.5% and 43.5%, respectively. In contrast, 90% of hemophiliacs show serological evidence of HBV infection. Routine screening of blood donors by CEP or RPHA technique was started in the hospital blood bank 7 years ago. The sensitivity of these techniques is much lower than that of RIA and ELISA and a majority of the patients has received initial blood transfusions before HBsAg screening was started. The study indicated that more than 50% of multi-transfused thalassemia patients showed serological evidence of one or more HBV, HCV, HDV, and HIV infection. Thus, screening of blood units for HBV, HCV, and HIV infections to be used for thalassemic patients and vaccination of thalassemic patients against hepatitis B is imperative.