- Email: [email protected]
Spontaneous clearance of chronic hepatitis C during pregnancy
AJG – September, 2000
Two weeks later the patient presented again with the same symptoms, but now with new onset of back pain. Spinal X-ray showed mild thoracic lordosis. Blood work at this time was notable for an ESR of 103. A repeat CT scan now revealed two large hepatic abscess cavities and absence of blood flow to the right portal vein. The patient was started on IV antibiotics and underwent successful percutaneous drainage of the abscess cavities. He ultimately completed five months of home antibiotic therapy with periodic CT scans illustrating a resolution of the hepatic abscesses. Hepatic abscess and protal pylephlebitis are rare complications of inflammatory bowel disease. It is thought to occur through bacterial seeding of the bloodstreams possibly via the mechanism of translocation. A hypercoaguable state which is often found in IBD patients may predispose them to these complications. In patients with IBD and unexplained fevers, hepatic abscess and portal pylephlebitis must be given serious consideration when formulating a differential diagnosis.
708 Severe protein-losing enteropathy secondary to chronic NSAID use Zein Claudia O. MD, Nehra Vandana MD. Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Introduction: Approximately 60% of patients on chronic NSAID therapy develop intestinal inflammation which is frequently associated with lowgrade bleeding and protein loss. The protein loss is typically mild. We present a case of a patient with severe protein-losing enteropathy secondary to NSAID use. Case Report: A 40 year-old male was referred for evaluation of mild anemia. For two years prior to presentation the patient was taking Diclofenac at a dose of 100mg bid for progressive low-back discomfort. The patient was otherwise asymptomatic. Physical examination was unremarkable. Laboratory studies showed a hemoglobin of 10.7 g/dL. A serum protein electrophoresis showed total protein of 4.0 (6.3–7.9), albumin 2.0 (3.4 – 4.8), gamma-globulin 0.3 (0.7–1.7). Other laboratory tests were normal. Urinary protein elimination over 24h was normal. After a 24h stool collection, Alpha-1 Antitrypsin clearance was found to be 607 mL/24h (NR d 27). The fat content was 1.9g/24h (2–7 g/24h). an EGD showed reactive gastropathy (confirmed on biopsy). The small bowel appeared normal (normal biopsy). A colonoscopy showed a shallow ulceration at the ileocecal valve consistent with NSAID-associated injury. The terminal ileum appeared normal. CT scan of the abdomen and pelvis, Upper GI and small bowel XR were unremarkable. Lymphoscintigraphy was normal. A HMPAO white blood cell scan showed diffuse increased activity in the small bowel and colon consistent with an inflammatory process. The NSAID was stopped and the patient was started on Tramadol for his back pain. An albumin level checked 7 weeks after stopping NSAID showed marked improvement (from 2.0 to 3.2 g/dL). Ten weeks after stopping NSAID a repeat stool collection for Alpha-1 Antitrypsin clearance showed dramatic improvement (from 607 to 176 mL/24h). Conclusion: This case illustrates the occurrence of severe protein losing enteropathy secondary to chronic NSAID use. Although most cases of intestinal protein loss secondary to NSAID are mild, in rare cases markedly severe loss can occur.
709 Spontaneous clearance of chronic hepatitis C during pregnancy Zein Claudia O., Abu-Lebdeh Haitham S., Zein Nizar N.* Mayo Clinic and Mayo Foundation, Rochester, MN, United States. Purpose: Introduction: Spontaneous clearance of the hepatitis C virus (HCV) once chronic hepatitis is established is extremely rare. We present a case of spontaneous clearance of HCV during pregnancy. Pregnancy is characterized by significant changes in the maternal immune system. Among these uterine decidual and placental cells produce a large array of cytokines which contribute to deviation of the immune response from Th1 to Th2. Changes in circulating and local T-cell subsets is also described.
Abstracts
2617
Methods: Case Report: A 27-year old woman with an established diagnosis of HCV infection and persistently elevated transaminases for at least three years was seen at Mayo Clinic in August of 1998. A blood transfusion in 1995 was presumed to be the source of HCV acquisition. At the time of initial evaluation at Mayo, transaminases were 4⫻ upper limit of normal, HCV antibodies were detected by EIA ??, and HCV RNA was detected by PCR. RNA quantitation by PCR was 2.64 mEq/mL and HCV genotype was 1a. A liver biopsy showed portal hepatitis consistent with active chronic hepatitis C without fibrosis. The patient received no therapy for HCV infection or any other antiviral agent. Fourteen months after the initial visit the patient became pregnant. Her transaminases, still elevated at the beginning of pregnancy (AST 69, ALT 117), gradually reached normal values after the 5th month of pregnancy. Four months after delivery transaminases continued to be normal. HCV RNA by PCR was persistently negative on two separate occasions 2 weeks apart, confirming spontaneous clearance of HCV RNA. Discussion: Spontaneous clearance of chronic HCV infection is extremely rare. This case illustrates spontaneous HCV RNA clearance and normalization of transaminases during pregnancy in a patient with previously documented chronic hepatitis C. We postulate that changes in the maternal immune system, maybe related to pregnancy, influenced the outcome of this case. In most cases of HCV infection the host’s immune system fails to mediate resolution of the infection, leading to chronic and persistent infection. Further investigation of the changes in immunity elicited by pregnancy and the outcome of chronic and acute HCV infection in pregnant women may improve our understanding of immune mechanisms for HCV clearance.
710 Hepatitis A presenting with meningoencephalitis Zeng N. M.D., Zuckerman M.J. M.D., FACG. Texas Tech University Health Sciences Center, El Paso. Background: Meningoencephalitis may rarely herald the onset of infectious hepatitis. Case report: A 20 year old Hispanic male without previous medical problems presented to the ER after having a seizure followed by decreased mental acuity for 2 days. The seizure was initially tonic clonic and became partial jerking in nature, focused only on the face and left arm. Associated symptoms included fever, nausea, vomiting, drowsiness, and generalized muscle weakness. There was no rash, jaundice or history of head trauma, drug abuse, alcoholism, animal or insect bites, or blood transfusion. He had recently traveled to Juarez, Mexico and eaten seafood. On examination, he was afebrile, anicteric, slightly obtunded and disoriented. Initial laboratory investigations showed normal CBC, electrolytes, liver function tests and chest x-ray. Blood and urine cultures were negative. Serology was negative for EBV, HIV and VDRL. Head CT scan, MRI and EEG were normal. Cerebrospinal fluid was normal. While in the hospital, his neurological condition improved. However, his SGOT and SGPT became elevated at day five (364 and 412) peaking at day six (1768 and 888), with bilirubin elevated at day six (1.8), and peaking at day ten (3.7). The serum hepatitis A IgM antibody was positive and HBsAg and anti-HCV were negative. The patient was discharged in stable condition and had no recurrent seizure. Hepatic enzymes gradually returned to normal. Review of literature: A total of 31 cases of meningoencephalitis preceding, coincident with or after the onset of the icteric phase of infectious hepatitis have been documented in the literature (17 cases were reported before current viral hepatitis serologies were available, 12 cases were hepatitis A and 1 hepatitis B, one both A and C). Neurological manifestations in the 12 hepatitis A patients included mental status changes (7) or generalized tonic-clonic seizures (5). All patients recovered without neurological sequelae. Conclusion: Meningoencephalitis is a rare extrahepatic manifestation of HAV infection. The identification of HAV as a cause of acute viral encephalitis by readily available serologic methods reduces the need for extensive costly diagnostic evaluations and for potentially toxic empiric treatment.
Two weeks later the patient presented again with the same symptoms, but now with new onset of back pain. Spinal X-ray showed mild thoracic lordosis. Blood work at this time was notable for an ESR of 103. A repeat CT scan now revealed two large hepatic abscess cavities and absence of blood flow to the right portal vein. The patient was started on IV antibiotics and underwent successful percutaneous drainage of the abscess cavities. He ultimately completed five months of home antibiotic therapy with periodic CT scans illustrating a resolution of the hepatic abscesses. Hepatic abscess and protal pylephlebitis are rare complications of inflammatory bowel disease. It is thought to occur through bacterial seeding of the bloodstreams possibly via the mechanism of translocation. A hypercoaguable state which is often found in IBD patients may predispose them to these complications. In patients with IBD and unexplained fevers, hepatic abscess and portal pylephlebitis must be given serious consideration when formulating a differential diagnosis.
708 Severe protein-losing enteropathy secondary to chronic NSAID use Zein Claudia O. MD, Nehra Vandana MD. Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Introduction: Approximately 60% of patients on chronic NSAID therapy develop intestinal inflammation which is frequently associated with lowgrade bleeding and protein loss. The protein loss is typically mild. We present a case of a patient with severe protein-losing enteropathy secondary to NSAID use. Case Report: A 40 year-old male was referred for evaluation of mild anemia. For two years prior to presentation the patient was taking Diclofenac at a dose of 100mg bid for progressive low-back discomfort. The patient was otherwise asymptomatic. Physical examination was unremarkable. Laboratory studies showed a hemoglobin of 10.7 g/dL. A serum protein electrophoresis showed total protein of 4.0 (6.3–7.9), albumin 2.0 (3.4 – 4.8), gamma-globulin 0.3 (0.7–1.7). Other laboratory tests were normal. Urinary protein elimination over 24h was normal. After a 24h stool collection, Alpha-1 Antitrypsin clearance was found to be 607 mL/24h (NR d 27). The fat content was 1.9g/24h (2–7 g/24h). an EGD showed reactive gastropathy (confirmed on biopsy). The small bowel appeared normal (normal biopsy). A colonoscopy showed a shallow ulceration at the ileocecal valve consistent with NSAID-associated injury. The terminal ileum appeared normal. CT scan of the abdomen and pelvis, Upper GI and small bowel XR were unremarkable. Lymphoscintigraphy was normal. A HMPAO white blood cell scan showed diffuse increased activity in the small bowel and colon consistent with an inflammatory process. The NSAID was stopped and the patient was started on Tramadol for his back pain. An albumin level checked 7 weeks after stopping NSAID showed marked improvement (from 2.0 to 3.2 g/dL). Ten weeks after stopping NSAID a repeat stool collection for Alpha-1 Antitrypsin clearance showed dramatic improvement (from 607 to 176 mL/24h). Conclusion: This case illustrates the occurrence of severe protein losing enteropathy secondary to chronic NSAID use. Although most cases of intestinal protein loss secondary to NSAID are mild, in rare cases markedly severe loss can occur.
709 Spontaneous clearance of chronic hepatitis C during pregnancy Zein Claudia O., Abu-Lebdeh Haitham S., Zein Nizar N.* Mayo Clinic and Mayo Foundation, Rochester, MN, United States. Purpose: Introduction: Spontaneous clearance of the hepatitis C virus (HCV) once chronic hepatitis is established is extremely rare. We present a case of spontaneous clearance of HCV during pregnancy. Pregnancy is characterized by significant changes in the maternal immune system. Among these uterine decidual and placental cells produce a large array of cytokines which contribute to deviation of the immune response from Th1 to Th2. Changes in circulating and local T-cell subsets is also described.
Abstracts
2617
Methods: Case Report: A 27-year old woman with an established diagnosis of HCV infection and persistently elevated transaminases for at least three years was seen at Mayo Clinic in August of 1998. A blood transfusion in 1995 was presumed to be the source of HCV acquisition. At the time of initial evaluation at Mayo, transaminases were 4⫻ upper limit of normal, HCV antibodies were detected by EIA ??, and HCV RNA was detected by PCR. RNA quantitation by PCR was 2.64 mEq/mL and HCV genotype was 1a. A liver biopsy showed portal hepatitis consistent with active chronic hepatitis C without fibrosis. The patient received no therapy for HCV infection or any other antiviral agent. Fourteen months after the initial visit the patient became pregnant. Her transaminases, still elevated at the beginning of pregnancy (AST 69, ALT 117), gradually reached normal values after the 5th month of pregnancy. Four months after delivery transaminases continued to be normal. HCV RNA by PCR was persistently negative on two separate occasions 2 weeks apart, confirming spontaneous clearance of HCV RNA. Discussion: Spontaneous clearance of chronic HCV infection is extremely rare. This case illustrates spontaneous HCV RNA clearance and normalization of transaminases during pregnancy in a patient with previously documented chronic hepatitis C. We postulate that changes in the maternal immune system, maybe related to pregnancy, influenced the outcome of this case. In most cases of HCV infection the host’s immune system fails to mediate resolution of the infection, leading to chronic and persistent infection. Further investigation of the changes in immunity elicited by pregnancy and the outcome of chronic and acute HCV infection in pregnant women may improve our understanding of immune mechanisms for HCV clearance.
710 Hepatitis A presenting with meningoencephalitis Zeng N. M.D., Zuckerman M.J. M.D., FACG. Texas Tech University Health Sciences Center, El Paso. Background: Meningoencephalitis may rarely herald the onset of infectious hepatitis. Case report: A 20 year old Hispanic male without previous medical problems presented to the ER after having a seizure followed by decreased mental acuity for 2 days. The seizure was initially tonic clonic and became partial jerking in nature, focused only on the face and left arm. Associated symptoms included fever, nausea, vomiting, drowsiness, and generalized muscle weakness. There was no rash, jaundice or history of head trauma, drug abuse, alcoholism, animal or insect bites, or blood transfusion. He had recently traveled to Juarez, Mexico and eaten seafood. On examination, he was afebrile, anicteric, slightly obtunded and disoriented. Initial laboratory investigations showed normal CBC, electrolytes, liver function tests and chest x-ray. Blood and urine cultures were negative. Serology was negative for EBV, HIV and VDRL. Head CT scan, MRI and EEG were normal. Cerebrospinal fluid was normal. While in the hospital, his neurological condition improved. However, his SGOT and SGPT became elevated at day five (364 and 412) peaking at day six (1768 and 888), with bilirubin elevated at day six (1.8), and peaking at day ten (3.7). The serum hepatitis A IgM antibody was positive and HBsAg and anti-HCV were negative. The patient was discharged in stable condition and had no recurrent seizure. Hepatic enzymes gradually returned to normal. Review of literature: A total of 31 cases of meningoencephalitis preceding, coincident with or after the onset of the icteric phase of infectious hepatitis have been documented in the literature (17 cases were reported before current viral hepatitis serologies were available, 12 cases were hepatitis A and 1 hepatitis B, one both A and C). Neurological manifestations in the 12 hepatitis A patients included mental status changes (7) or generalized tonic-clonic seizures (5). All patients recovered without neurological sequelae. Conclusion: Meningoencephalitis is a rare extrahepatic manifestation of HAV infection. The identification of HAV as a cause of acute viral encephalitis by readily available serologic methods reduces the need for extensive costly diagnostic evaluations and for potentially toxic empiric treatment.