George Bird

The Diversity and Management of Chronic Hepatitis B Virus Infections in the United Kingdom: A Wake-up Call

BACKGROUND Through migration, diversity of chronic hepatitis B virus (HBV) infection has changed, affecting disease burden and control. We describe clinical and viral characteristics of chronic HBV in the United Kingdom. METHODS A total of 698 individuals with chronic HBV infection were recruited from referral liver centers. Demographic, clinical, and laboratory data were collected. RESULTS Sixty-one percent of patients were male, 80% were not born in the United Kingdom, and the largest ethnicity was East/Southeast Asian (36%). Twenty-two percent were hepatitis B e antigen (HBeAg) seropositive; 20.4% (59/289) had cirrhosis and 10 (1.7%) had hepatocellular carcinoma. Genotype D was most common (31%) followed by A, C, B, and E (20%, 20%, 19%, and 9%, respectively). Genotype was significantly associated with country of birth, length of time in the United Kingdom, HBeAg status, and precore and basal core promoter mutations. One-third were on treatment, with men independently more likely to be treated. Only 18% of those on treatment were on recommended first-line therapies, and 30% were on lamivudine monotherapy. Among treated individuals, 27% had antiviral drug resistance. Testing rates for human immunodeficiency virus, hepatitis C virus, and delta coinfections were low. CONCLUSIONS We demonstrated diversity of chronic HBV infections in UK patients, suggesting that optimal management requires awareness of the variable patterns of chronic HBV in countries of origin. We also found less-than-optimal clinical management practices, possible gender-based treatment bias, and the need to improve testing for coinfections.

The Diversity and Management of Chronic Hepatitis B Virus Infections in the UK – A Wake up Call

BACKGROUND Through migration, diversity of chronic hepatitis B virus (HBV) infection has changed, affecting disease burden and control. We describe clinical and viral characteristics of chronic HBV in the United Kingdom. METHODS A total of 698 individuals with chronic HBV infection were recruited from referral liver centers. Demographic, clinical, and laboratory data were collected. RESULTS Sixty-one percent of patients were male, 80% were not born in the United Kingdom, and the largest ethnicity was East/Southeast Asian (36%). Twenty-two percent were hepatitis B e antigen (HBeAg) seropositive; 20.4% (59/289) had cirrhosis and 10 (1.7%) had hepatocellular carcinoma. Genotype D was most common (31%) followed by A, C, B, and E (20%, 20%, 19%, and 9%, respectively). Genotype was significantly associated with country of birth, length of time in the United Kingdom, HBeAg status, and precore and basal core promoter mutations. One-third were on treatment, with men independently more likely to be treated. Only 18% of those on treatment were on recommended first-line therapies, and 30% were on lamivudine monotherapy. Among treated individuals, 27% had antiviral drug resistance. Testing rates for human immunodeficiency virus, hepatitis C virus, and delta coinfections were low. CONCLUSIONS We demonstrated diversity of chronic HBV infections in UK patients, suggesting that optimal management requires awareness of the variable patterns of chronic HBV in countries of origin. We also found less-than-optimal clinical management practices, possible gender-based treatment bias, and the need to improve testing for coinfections.

Primary peritoneal mesothelioma: case series and literature review.

Primary peritoneal mesothelioma is a rare and aggressive tumour. We present six consecutive cases treated by our institution in the last three years. All were between 56-65 years old and only one gave a history of direct contact with asbestos. Four of the patients showed a thrombocytosis on presentation but other blood tests and evaluation of ascitic fluid were normal. In all cases, the diagnosis was made through investigation of mixed abdominal symptoms with CT scanning and laparoscopic biopsy. Despite the use of modern chemotherapy, response to treatment was unpredictable, with survival from ten weeks to three years.

Epstein-Barr virus induced virus-associated hemophagocytic syndrome and monoclonal TCR-beta rearrangement: a case report

Virus‐associated hemophagocytic syndrome (VAHS) is a rare histiocytic proliferative disorder secondary to viral infection affecting children and young adults and in which there is both a poor prognosis and no specific treatment. We report a case of VAHS in a 22‐year‐old woman secondary to infection with Epstein Barr virus in which multiorgan failure developed with a fatal outcome 3 weeks after presentation. Clonal analysis showed EBV incorporation into the T cell genome accompanied by monoclonal rearrangement of the TCR beta gene. Treatment with cyclosporin A resulted in hematological improvement but the patient died of disseminated fungal infection. We propose that bone marrow ablation and allografting should be available for these rare cases and suggest that a protocol should be developed with designated transplant centres to aid early referral.

Late onset of autoimmune hepatitis in myasthenia gravis

Abstract A 35-year-old caucasian female presented with acute onset bilateral ptosis while driving, followed by weakness of the facial and upper limb muscles. A diagnosis of myasthenia gravis (MG) was made on the basis of clinical examination, and confirmed by electromyography, high titres of anti-acetylcholine receptor antibodies and a positive response to pyridostigmine. She underwent thymectomy and her symptoms resolved. She presented again 16 years later (age 51) with tiredness, jaundice and a biochemical hepatitis. Serological and histopathological investigations were in keeping with autoimmune chronic hepatitis and there was a satisfactory response to oral prednisolone. She was unable to tolerate the conventional high dose steroid induction due to a relapse of her MG but subsequently entered remission with intermediate dose regime of prednisolone. Despite a recognised association between both autoimmune hepatitis (AIH) and MG with other autoimmune diseases, a literature search showed the combination of these two conditions to be extremely rare with only one adequately documented previous report.

Endoscopic management of postcholecystectomy biliary leaks

Objective To evaluate the nature of bile duct injuries following cholecystectomy and the success of endoscopic retrograde cholangiopancreatography (ERCP) in their identification and management. Design All patients referred for ERCP with a diagnosis of a postcholecystectomy bile leak were identified prospectively from October 1994 to August 2008. Setting The study was carried out in a district general hospital with the endoscopies performed by a single operator. Patients All patients had undergone imaging with at least two of abdominal ultrasound scanning, CT scanning or MR cholangiopancreatography. Interventions ERCP with treatment of a biliary leak by sphincterotomy and insertion of a temporary 7 Fr plastic biliary stent. Main outcome measurements Clinical healing of the injury was assessed as resolution of symptoms with normalisation of liver function tests, cessation of external drain output and a repeat ERCP with removal of the indwelling stent within 2–8 weeks and no further complications. Results 46 patients were identified, of whom 42 responded well to endoscopic treatment. Four patients ultimately needed surgery, of whom three had recurrent strictures. One patient had complete transection of the biliary duct and endoscopic treatment was not attempted. Conclusion ERCP, with sphincterotomy and temporary plastic stent placement, is successful in the early management of patients with postcholecystectomy biliary leaks, which most commonly involve the cystic duct stump. ERCP carried out in a district general hospital identifies those patients requiring further specialised hepatobiliary care in a tertiary centre.