Kazuhiko Morii

Twenty four-week peginterferon plus ribavirin after interferon-β induction for genotype 1b chronic hepatitis C

AIM To investigate the possibility of shortening the duration of peginterferon (Peg-IFN) plus ribavirin (RBV) combination therapy by incorporating interferon-β (IFN-β) induction therapy. METHODS A one treatment arm, cohort prospective study was conducted on seventy one patients. The patients were Japanese adults with genotype 1b chronic hepatitis C, HCV-RNA levels of ≥ 5.0 Log IU/mL or 100 KIU/mL, and platelet counts of ≥ 90 000/μL. The treatment regimen consisted of a 2 wk course of twice-daily administration of IFN-β followed by 24 wk Peg-IFN plus RBV combination therapy. We prolonged the duration of the Peg-IFN plus RBV therapy to 48 wk if the patient requested it. RESULTS The patients, including 44% males, were characterized by an median age of 63 years (range: 32-78 years), an median platelet count of 13.9 (range: 9.1-30.6) × 10(4)/μL, 62% IFN-naïve, and median HCV-RNA of 6.1 (range: 5.1-7.2) Log IU/mL. The sustained virologic response (SVR) rates were 34% (Peg-IFN: 1-24 wk, n = 61, 95% confidence interval (CI): 24%-47%) and 55% (Peg-IFN: 20-24 wk, n = 31, 95% CI: 38%-71%, P < 0.001; vs Peg-IFN: 1-19 wk). The SVR rate when the administration was discontinued early was 13% (Peg-IFN: 1-19 wk, n = 30, 95% CI: 5%-30%), and that when the administration was prolonged was 50% (Peg-IFN: 25-48 wk, n = 10, 95% CI: 24%-76%, P < 0.05; vs Peg-IFN: 1-19 wk). In the patients who received 20-24 wk of Peg-IFN plus RBV, only the higher platelet count (≥ 130 000/μL) was significantly correlated with the SVR (odds ratio: 11.680, 95% CI: 2.3064-79.474, P = 0.0024). In 45% (14/31) of the patients with a higher platelet count (≥ 130 000/μL) before therapy, the HCV-RNA level decreased to below 3.3 Log IU/mL at the completion of IFN-β, and their SVR rate was 93% (13/14) after 20-24 wk administration of Peg-IFN plus RBV. CONCLUSION These results suggest the possibilities of shortening the duration of Peg-IFN plus RBV combination therapy by actively reducing HCV-RNA levels using the IFN-β induction regimen.

Steatotic regenerative nodules mimicking hepatocellular carcinoma.

A 62-year-old woman had an acute exacerbation of hepatitis B virus (HBV)-related cirrhosis. The serum alanine aminotransferase (ALT) was 238 IU/L; alpha-foetoprotein (AFP), 2126 ng/ml; AFP-L3, 3.4%; HBsAg, positive; HBeAg, negative; anti-HBe, positive; and HBV-DNA, 6.5 log copies/ml. Serum ALT and AFP levels had remained within normal limits until 3 months earlier. She did not have dismetabolic disorders or take any drugs. Enhanced computed tomography (CT) showed numerous uniformly small non-enhancing nodules throughout the liver (Fig. 1a). CT obtained at 6 months earlier pointed out no hepatic nodules (Fig. 1b). An ultrasound-guided biopsy of the nodules demonstrated steatosis of the hepatocytes without cytological or structural atypia (Fig. 1d). Diagnosis of steatotic regenerative nodules was made (1). Steatotic regenerative nodules tend to occur in multiples, as compared with a dysplastic nodule which has a predisposition to a single fatty nodule (2). HBV X protein induces activation of liver X receptor, which leads to the lipid accumulation in hepatic cells (3, 4). Subsequent administration of entecavir had normalized serum ALT and AFP levels. CT obtained at 6 months later showed complete resolution of the hepatic nodules (Fig. 1c).

Increasing incidence of elderly-onset autoimmune hepatitis.

Autoimmune hepatitis (AIH) commonly shows bimodal distribution of onset age: at young adulthood and at 50–60 years‐of‐age. However, in recent times, the incidence of elderly‐onset AIH seems to be increasing. This study aimed to investigate whether the incidence of elderly‐onset AIH is increasing, and whether these patients show any clinical features different from those observed in younger patients.

Toxocara canis-associated visceral larva migrans of the liver

Figure 2. At the initial evaluation, there were multiple ovalor irregular-shaped low-attenuating nodules scattered along the portal veins. They were dominantly located in the subcapsular area. Hepatobiliary phase sequence of the enhanced MRI using hepatocyte-specific agent of Gd-EOB-DTPA. Figure 1. Hepatic ultrasonography showed ill-defined hypoechoic nodules of approximately 10 mm in diameter (arrows).

Mesenteric panniculitis presenting as liver dysfunction

Mesenteric panniculitis is a non-specific inflammatory disorder affecting adipose tissues of the mesentery. Mesenteric adipose tissues contain macrophages and other inflammatory cells, which may secrete tumor necrosis factor α, interleukin (IL)-1, and IL-6. These cytokines collect into the portal vein and thereby flow into the liver, possibly influencing hepatic function. Mesenteric panniculitis often occurs with inflammatory reactions such as fever and elevated erythrocyte sedimentation rates. Systemic inflammatory disorders can evoke acute cholestatic liver involvement, which is mediated by proinflammatory cytokines. However, no reports have focused on the association between mesenteric panniculitis and liver involvement. We report a rare case of mesenteric panniculitis presenting as liver dysfunction. Immunohistochemical staining of the liver demonstrated a marked decrease in expression of canalicular transport systems. These findings indicated cholestatic liver dysfunction associated with mesenteric panniculitis.

Streptococcus Anginosus Group-associated Pyogenic Liver Abscess

A 49-year-old woman with diabetes mellitus was referred to our hospital because of general malaise. Imaging studies and percutaneous drainage resulted in a diagnosis of pyogenic liver abscess (PLA) (Picture 1). Bacterial cultures of blood, aspirates from the abscess, and the dental plaque all grew Streptococcus anginosus. She had untreated periodontitis and resultant tooth losses in the natural course (Picture 2). She also had concomitant septic pulmonary embolisms with cavitations and feeding vessel sign (arrow in Picture 3). Despite a huge PLA, the serum levels of bilirubin, alanine aminotransferase, alkaline phosphatase, and procalcitonin were normal. The Streptococcus anginosus group (SAG), which consists of Streptococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus, is normal flora of the human oral cavity and gastrointestinal tract. It can cause contiguous or distant infections, and notably, abscesses (1). SAG-associated PLAs often show less pronounced serum liver enzymes and biomarkers, and longer incubation periods than other PLAs (2). Furthermore, patients with SAG-associated PLAs frequently have diabetes mellitus, poor oral hygiene, ulcerated gastrointestinal diseases, and thoracic spread of infections. SAG should therefore be recognized as an emerging pathogen that can cause PLAs.

Dubin–Johnson Syndrome

A 48-year-old woman scheduled to receive a laparoscopic cholecystectomy underwent a preoperative evaluation. A laparoscopic exploration, shown in a video, revealed a smooth liver with normal consistency and morphology but with a grossly black appearance.

Successful hepatectomy for intraperitoneal rupture of pyogenic liver abscess caused by Klebsiella pneumoniae

Klebsiella pneumoniae (KP) is the most common cause of pyogenic liver abscess in eastern Asia. KP liver abscess commonly presents as a single large abscess with a predominantly solid consistency. It is sometimes unsuitable for percutaneous catheter drainage because of the poorly liquefied contents. Antibiotic therapy alone may raise a probability of treatment failure and occurrence of complications such as abscess rupture. Hepatic or portal venous thrombosis, hematogenous spread, and spontaneous rupture also occur frequently. We report a case of KP liver abscess with a typical solid appearance, complicated by disseminated intravascular coagulation, spontaneous rupture, and pyogenic spondylitis.

Hepatocellular Carcinoma in a Patient with Hereditary Hemorrhagic Telangiectasia

A 76-year-old woman with hereditary hemorrhagic telangiectasia (HHT) showed elevated serum hepatobiliary enzyme levels, and abdominal imaging studies revealed a hepatic tumor. Her serum alpha-fetoprotein level was 759.5 ng/mL. A pathological examination after hepatectomy confirmed a diagnosis of hepatocellular carcinoma (HCC). An examination of the surrounding liver revealed dilated vessels and thickened endothelial cells without inflammations. HHT patients without other risk factors (like this patient) reportedly have a lower incidence of common cancers, including HCC, in comparison to the unaffected population. One intriguing hypothesis that might explain the hepatocarcinogenesis in this situation is the ischemic liver cirrhosis theory, which suggests that chronic ischemia may cause parenchymal strain and promote inappropriate hepatocyte proliferation.

Infectious Hepatic Cyst: An Underestimated Complication

Objective An infectious hepatic cyst (IHC) is a hepatic cyst complicated with secondary infection and is generally assumed to be rare. However, we have experienced no small number of patients with IHC in recent clinical practice. We therefore examined the incidence and clinical characteristics of IHC. Methods The medical records of patients with IHC who were hospitalized at our institution between January 2012 and December 2016 were retrospectively reviewed. Their demographic factors, biochemical, bacteriological, imaging, and treatment results were explored and compared with those of patients with pyogenic liver abscess (PLA). Patients Twelve patients with IHC and 39 with PLA were identified. Results The IHCs were significantly larger in diameters than the PLAs, and patients with IHCs tended to be older and more often women than those with PLAs. IHCs showed characteristic imaging features, including heterogeneous contents with occasional fluid-debris levels, a thickened cystic wall with rim enhancement, perilesional edema and hyperaemia. Patients with IHCs had a significantly shorter hospital stay than those with PLAs. Conclusion Physicians should note that IHCs are not rare. A careful imaging evaluation can suggest an IHC, and the timely aspiration of the content can lead to an accurate diagnosis. The cystic wall may keep the infectious material confined within the IHC, resulting in the observed good treatment outcome with catheter drainage.