Kozo Nagai

Accurate prediction of fulminant hepatic failure in severe acute viral hepatitis: multicenter study.

Background: We have attempted to predict the development of fulminant hepatic failure at the stage of severe acute hepatitis before the onset of coma. This prediction is valuable because it may be used to block the development of fulminant hepatic failure with appropriate medical treatment. Methods: To establish a discrimination formula, we retrospectively compared 13 clinical and laboratory variables in 36 patients with acute viral hepatitis and prothrombin levels of 40% or less of the control value who later developed fulminant hepatic failure with these variables in 12 patients who recovered spontaneously. A prospective study of 58 patients who developed fulminant hepatic failure and 18 who spontaneously recovered confirmed the validity of this formula. Results: In the retrospective study, we established the following discrimination equation: Z = −0.89 + 1.74 × (causal viruses, 1 point for type A or type B in acute hepatitis B virus [HBV] infection, 2 points for others) + 0.056 × (total bilirubin, mg/dl) −0.014 × (cholinesterase, U/ml). A positive Z value indicates that fulminant hepatic failure will develop. In the prospective study, the specificity, sensitivity, predictive accuracy, and positive and negative predictive values were 0.833, 0.983, 0.947, 0.950, and 0.938, respectively. Conclusions: The present study indicated that fulminant hepatic failure can be predicted, by a simple discrimination equation, at the stage of severe acute hepatitis.

CASE REPORT: Vanishing Bile Duct Syndrome Associated with Chronic EBV Infection

We reported here an adult patient with vanishing bile duct syndrome due to chronic EBV infection. A 22-year-old male was admitted to a nearby hospital complaining of a sore throat and jaundice. He received a high dose of prednisolone for bile stasis of acute viral hepatitis. However, the hepatitis did not improve, and he was transferred to our hospital. He had exhibited jaundice for one year as well as hemophagocytic syndrome and intestinal perforation. Subtotal intestinal resection was successfully performed. Three follow-up biopsied liver specimens indicated vanishing bile duct syndrome. Positive results of EBV-DNA in his serum and mRNA of EBV by in situ hybridization of his liver indicated that massive doses of prednisolone caused chronic EBV infection and vanishing bile duct syndrome.

Intestinal cryptosporidiosis as an initial manifestation in a previously healthy Japanese patient with AIDS

Background:Cryptosporidium parvum infection has been recognized as one of the pathogens causing severe and persistent diarrhea in immunodeficient patients, such as those with AIDS, worldwide. However, in Japan, the frequency of this infection has been rare, except for environmental contamination through the water supply. In this communication, we describe a Japanese patient with AIDS presenting with intestinal Cryptosporidiosis as an initial manifestation. Methods: The oocysts of Cryptosporidium parvum in his stool were detected by the Ziehl-Neelsen method and electron microscopy. The antigen-specificity was proved by immunostaining, using a fluorescein isothiocyanate (FITC)-labeled monoclonal antibody and enzyme-linked immunosorbent assay (ELISA), using Cryptosporidium-specific antibody. Results: A 28-year-old Japanese homosexual man was admitted to our hospital because of severe watery diarrhea of 1-week duration. Numerous oocysts of Cryptosporidium parvum were observed in his stool. Cryptosporidium parvum antigen was detected in stool samples. Serological examinations revealed that anti-HIV-1 antibody was positive, and HIV RNA was positive at a high level. He was diagnosed as having AIDS associated with intestinal Cryptosporidiosis. The circulating CD4+ T-cell count was 152/μl. His diarrhea was not alleviated by administration of loperamide and an ordinary antibiotic agent, but ultimately resolved by the administration of the macrolide antibiotic agent, clarithromycin. Conclusions: We emphasize that the presence of Cryptosporidium parvum infection should be kept in mind in searching for pathogens causative of severe diarrhea in AIDS patients.