Adélia Simão

Chronic hepatitis C treated with peginterferon alfa plus ribavirin in clinical practice

BACKGROUND/AIMS The role of genotype and viremia were retrospectively evaluated on sustained virological response (SVR) rates in routine clinical practice. METHODOLOGY From 1907 patients with chronic hepatitis C proposed for treatment, we analysed 1380 (1124 naive and 256 treatment-experienced) with complete follow-up. Genotype and HCV RNA quantification were assayed by commercial tests. Viremia was considered high if >800,000IU/mL, and low if <400,000IU/mL. Liver fibrosis was staged in 614 patients. RESULTS Genotype 1 was the most frequent (60%), followed by 3 (25%), 4 (9%) and 2 (2%); 3.2% had other or unclassified genotype. Genotype 1 was more prevalent in central Portugal and genotype 4 in the south. Viremia was =800,000IU/mL in 54.6% and <400,000IU/mL in 34.6% of the patients, particularly in genotype 2 (p<0.03) and 4 (p<0.001). Genotype non-1 had a significantly lower viral load (p=0.004). Mild or moderate fibrosis was present in 71.7% and bridging fibrosis or cirrhosis in 28.3%, with no differences among genotypes. Treatment was discontinued in 19.8%. SVR was achieved in 55.3% of naive and 36.3% of re-treated patients. CONCLUSIONS Standard treatment of chronic hepatitis C in real-life achieves similar results obtained in clinical trials, despite differences of demographic and viral parameters.

Severe hyponatremia in older patients at admission in an internal medicine department

Hyponatremia is common in older people, most often of multifactorial origin, and can be associated with poor clinical outcomes. The aim was to analyze the frequency of severe hyponatremia (sodium concentration below 125 mmol/L), risk factors and mortality association in hospitalized older patients. A retrospective study was performed in older patients (over 65 years) with hyponatremia, diagnosed at admission in an Internal Medicine Department during one year. A control group of 127 older patients without hyponatremia was considered. Statistical analysis of the data gathered was made with SPSS Statistics 20. The main results were: a group of 1060 patients with age superior to 65 years was identified (representing 72.26% of total admissions); incidence of hyponatremia in those patients was 27.55% and severe hyponatremia was 5.94%; diagnosis of hyponatremia was mentioned in the discharge note in 66.67% of cases; mortality was 27.0%, against 16.0% in the control group (p=0.057, Odds Ratio (OR)=1.940); drugs were a significant risk factor (p<0.001), specially thiazide diuretics (p=0.029, OR=2.774), angiotensin receptor blockers (ARB) (p=0.001, OR=4.097), proton-pump inhibitors (PPI) (p=0.007, OR=2.561) and spironolactone (p=0.011, OR=4.473); other relevant risk factors were: increased water intake (p=0.004), tube feeding (p<0.001), vomiting (p=0.032, OR=2.492), cirrhosis (p=0.008, OR=10.862) and hyperhidrosis (p=0.017, OR=2.542). We conclude that, although this group of patients had a high mortality, hyponatremia is often not investigated and not always mentioned as a diagnosis. Clinicians should have a clear appreciation of the roles that iatrogenic interventions and lapses in nutrition frequently play in upsetting the homeostatic balance in older patients.

Síndrome de Churg-Strauss: casuística

Churg-Strauss syndrome (CSS) is a systemic necrotizing vasculitis of the small and medium vessels, associated with extravascular eosinophilic granulomas, peripheral eosinophilia and asthma. This is a rare syndrome of unknown etiology, affecting both genders and all age groups. CSS patients usually respond well to steroid treatment, although relapses are common after it ends. Timely diagnosis and treatment generally lead to a good prognosis with a 90% survival rate at one year. A brief review of CSS is presented, with particular attention to diagnosis, therapy and recent developments in this area. The authors then report and discuss the clinical, laboratory and imaging characteristics of four patients admitted to an Internal Medicine Department with this diagnosis. The treatment, response and follow-up of the cases are also described.

Epidemiology of Clostridium difficile infection in Portugal: Experience at a tertiary care hospital

BACKGROUND Clostridium difficile is the main cause of healthcare-associated diarrhoea. Its incidence, severity and relapse rates increased over the past two decades. AIM To study epidemiologic characteristics and treatment of Clostridium difficile infection (CDI) and compare with a previous cohort from the same hospital. METHOD Retrospective analysis of clinical records of CDI diagnosed from 2010 to 2015 and comparison with data from 2004 to 2009. RESULTS 259 cases were diagnosed, compared to 83 in 2004-2009. There was no difference in mean annual incidence (8.66 versus 7.11 per 1000 patients; p = .116), but a dramatic increase was observed in 2009/2010 (peak incidence: 21.63 cases per 1000 admissions). Females were more affected (61.4% versus 69.9%; p = .177). Median age was 80 and 83 (p = .097). We observed an increase in median number of antibiotics previously used (2 versus 3; p = .147) and in community-associated CDI (6% versus 19.7%; p = .003). There was a continued increase in the use of carbapenems and quinolones until 2010 and a high percentage of refractory cases in 2010. Female gender (p = .043), long-term care facility (LTCF) residency (p = .022) and a higher number of previous antibiotics (median of 3; p = .025) were independent predictors for refractory and recurrent CDI. CONCLUSIONS CDI incidence achieved a peak in 2009/2010 coinciding with the introduction of alcohol-based hand products, increase in quinolone and carbapenem prescription and a possible outbreak of an epidemic strain. Female gender, LTCF residency and exposure to three or more antibiotics are risk factors for refractory and recurrent CDI. We emphasize the need to restrict use of large spectrum antibiotics.

Intrahepatic sarcomatoid cholangiocarcinoma

Sarcomatoid carcinoma is a rare tumour composed of intermingled malignant epithelial and mesenchymal cells, and it has been reported in various organs including the liver. Sarcomatoid cholangiocarcinoma (CCC) is an extremely rare liver primary tumour. Here, we report a case of an elderly man who was admitted to our hospital after head trauma. He performed a head CT that diagnosed cerebral metastasis. On abdominal CT, he presented a 10×8×9 cm-sized hypodense liver mass in the VII and VIII segments, with peripheral enhancement. Histological and immunohistochemical examination of the tumour showed a malignant neoplasm with both carcinomatous and sarcomatous components and positive expression of cytokeratin and vimentin antibodies. The patient was diagnosed with intrahepatic sarcomatoid CCC at an advanced stage and died 45 days after the diagnosis. We emphasise the importance of immunohistochemistry which may provide a clue to proper diagnosis.

Prognostic value of plasma D-dimer level in adults with community-acquired pneumonia: A prospective study

Community-acquired pneumonia (CAP) is associated with considerably high morbidity and mortality rates particularly in older patients. Despite advances in antibiotic treatment, prompt diagnosis and treatment are crucial for better outcomes. The accuracy of pneumonia severity scores, namely CURB-65 and pneumonia severity index (PSI) is debateable, and can lead to underestimates of the severity of the disease, leading to inadequate stratification. This explains the increased interest in new biomarkers with better prognostic value and accuracy. One of these new, potentially helpful biomarkers, which has not yet been fully validated, is plasma level of D-dimer (DD). The relationship between DD and CAP is still unclear and has only been evaluated by a limited number of studies, the majority of which have displayed it as a marker of prognosis and treatment response. In order to enhance our knowledge about this matter, we conducted a prospective analysis in adult patients with CAP, admitted to our Internal Medicine ward between December 2013 and April 2014. CAP was defined as a recent chest radiography opacity consistent with acute lung infection associated with typical respiratory symptoms, such as fever and pleuritic pain, and a lack of an alternative diagnosis. The diagnosis was confirmed by the authors in every single case through clinical reports and chest radiography reviews. Our study aimed to investigate the correlation between DD levels and the severity of CAP, assessed by CURB-65 and PSI scores, radiological extent of the disease and in-hospital mortality. In addition to these variables, we performed a standard evaluation that included past medical history, severity risk factors and laboratory findings, specifically DD, at hospital admission. Data analysis was executed by SPSS. A total of 102 patients (65 men and 37 women) were involved. There were no significant age differences between the two groups (mean age 81.57 ± 10.57 years versus 78.59 ± 12.65 years, respectively). DD showed an asymmetric distribution with a median (range) of 1.55 g/ml, (0.17 g/ml -14.69 g/ml). DD was negative (< 0.60 g/ml) in 20% of the patients. Differences of DD levels, PSI and CURB-65 score concerning age ranges were also taken into consideration. All the patients were divided into 4 age ranges (>30-64; 65-74; 75-84; > 85 years) and there were no meaningful differences between these groups. There was also no meaningful statistical difference in DD levels related to gender. Patients were assigned into two different radiographic pattern groups: unilobar and multilobar pneumonia. Although the median DD in the multilobar group was higher (2.06 g/ml versus 1.23 g/ml), as reported by others studies, such as Levi et al. 4 and Ribelles et al., no correlation between DD and the extent of the disease was found. DD increases had some degree of correlation with the CURB-65 score increases (p < 0.008) which is consistent with previous findings, as published by Snijders et al. In fact, the addition of D-dimer has slightly increased the performance of CURB-65, concerning the severity of CAP. On the other hand, no correlation was found with PSI score, which contradicts results from other studies, such as Ribelles et al. The relationship between DD and mortality was also assessed. The area under the curve (AUC) of the receiver operating characteristic (ROC) was used to calculate the mortality predictive value. DD and PSI score showed a low mortality predictive value but, on the other hand, CURB 65 and addition of DD levels to CURB 65 had a substantial positive predictive value (Fig. 1). Several authors have addressed the relationship between DD and clinical outcomes. Ribelles et al. 5 found a strong correlation between mortality rates and DD in CAP, while Kollef et al. 7 demonstrated that increased DD were associated with worse clinical outcomes. This was not confirmed by our study, since we did not find a significant correlation between DD levels of patients who died and those who showed overall improvement. In conclusion, in our study, DD did not exhibit prognostic value in adult patients with CAP, despite multiple comorbidities, and also did not correlate with the severity of the disease, radiological extent and in-hospital mortality rates.

Polymyositis and the Spectrum of Scleroderma Disorders

Polymyositis (PM) is usually associated to other autoimmune or connective tissue diseases. The authors report the case of a 59-year-old man with pulmonary fibrosis, who presented with constitutional symptoms and gradually developed proximal muscle weakness, Raynaud phenomenon, and dysphagia. Besides creatine kinase (CK) elevation, he had positive anti-Polymyositis-Scleromyositis (PM-Scl) and anti-Sjögren’s-syndrome A (SSA) antibodies. Nailfold capillaroscopy showed a scleroderma pattern and muscle biopsy revealed necrosis, regeneration of muscle fibers, and inflammatory infiltrate. Prednisolone was started, with great improvement. Taking into account the overlap features between PM and systemic sclerosis sine scleroderma, it is important to closely monitor the patient for signs of pulmonary and cardiac decompensation. LEARNING POINTS Polymyositis (PM) may be associated with connective tissue diseases such as systemic sclerosis, including its variant without skin involvement. Necrotizing muscle fibers are typically found in patients with overlap syndrome, in opposition to patients only with polymyositis. PM-Scl antibodies are associated to a good response to corticoids.

A 22-year-old male patient with ascites.

A 22-year-old male patient presented with a 3-day history of abdominal pain, diarrhoea, nausea and vomiting. He reported abdominal distention of a couple of weeks’ duration. He had been hospitalised 7 months earlier, owing to the same symptoms, however, the cause was never clarified. Initial examination showed abdominal distention and blood tests indicated eosinophilia. An abdominal CT scan showed mild ascites and a diffuse thickening of the small intestinal loops, and a cystic formation 3 cm in diameter on the liver. The differential diagnosis included parasite infection and eosinophilic gastroenteritis. Liver MRI revealed a simple biliary cyst. Microbiological tests, stool and blood cultures as well as stool examination for parasites were negative. The diagnostic paracentesis revealed eosinophilic ascites. An endoscopy was performed and histopathology revealed presence of moderate to marked lymphoplasmacytic infiltrate containing eosinophils, compatible with eosinophilic gastroenteritis. The patient responded well to the initiation of corticosteroids.