Renata Eliane de Ávila

Health related quality of life among patients with chronic hepatitis C: a cross-sectional study of sociodemographic, psychopathological and psychiatric determinants

INTRODUCTION Chronic hepatitis C virus infection patients have higher rates of psychiatric disorders than the general population. Chronic hepatitis C virus infection is known to be associated with impaired health related quality of life. To our knowledge, there is no previous research of health related quality of life in chronic hepatitis C patients that combined structured psychiatric interview and careful psychopathological evaluation, including depression, anxiety and fatigue instruments. The aim of this study was to evaluate health related quality of life of chronic hepatitis C patients and to investigate the association with sociodemographic, psychopathological and psychiatric factors. MATERIALS AND METHODS Eighty-one individuals with chronic hepatitis C virus infection receiving care at a Brazilian public university-based outpatient service for infectious diseases were enrolled in the study. The World Health Organization Quality of Life Scale Brief Version was used to assess health related quality of life. Standard psychiatric interview (Mini International Neuropsychiatric Interview-Plus) was conducted to establish Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I psychiatric diagnosis. Further instruments completed psychopathological investigation: Beck Depression Inventory, Hospital Anxiety and Depression Scale, Brief Fatigue Inventory, Hamilton Depression Scale and Hamilton Anxiety Scale. Pearson Chi-Square and Kruskal-Wallis were performed for categorical and continuous univariate analysis, respectively. Correlation between psychopathological and health related quality of life scores was performed according to Spearmans correlation. Multivariate analysis was performed according to stepwise forward ordinal logistic regression. The significance threshold was fixed at α=0.05. RESULTS Depressive disorders were associated with worse scores in overall health related quality of life and in all domains. Fatigue was associated with lower scores in physical and psychological domains, and married status with higher scores in psychological health related quality of life. We found strong correlation among scores of depression, fatigue and health related quality of life. CONCLUSION Depression and fatigue must be properly investigated and managed in HCV patients in order to improve HRQL. WHOQOL-BREF proved to be a useful instrument to assess HRQL in HCV patients.

Sexual dysfunction and dissatisfaction in chronic hepatitis C patients

INTRODUCTION The prevalence of sexual dysfunction (SD) and dissatisfaction with sexual life (DSL) in patients with chronic hepatitis C virus infection (CHC) was jointly investigated via a thorough psychopathological analysis, which included dimensions such as fatigue, impulsiveness, psychiatric comorbidity, health-related quality of life (HRQL) and sociodemographic and clinical characteristics. METHODS Male and female CHC patients from an outpatient referral center were assessed using the Brief Fatigue Inventory, the Barrat Impulsiveness Scale, the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale, the Hamilton Anxiety Scale (HAM-A), and the World Health Organization Quality of Life Scale-Brief Version (WHOQOL-BREF). Structured psychiatric interviews were performed according to the Mini-International Neuropsychiatric Interview. SD was assessed based on specific items in the BDI (item 21) and the HAM-A (item 12). DSL was assessed based on a specific question in the WHOQOL-BREF (item 21). Multivariate analysis was performed according to an ordinal linear regression model in which SD and DSL were considered as outcome variables. RESULTS SD was reported by 60 (57.1%) of the patients according to the results of the BDI and by 54 (51.4%) of the patients according to the results of the HAM-A. SD was associated with older age, female gender, viral genotype 2 or 3, interferon-α use, impulsiveness, depressive symptoms, antidepressant and benzodiazepine use, and lower HRQL. DSL was reported by 34 (32.4%) of the patients and was associated with depressive symptoms, anxiety symptoms, antidepressant use, and lower HRQL. CONCLUSIONS The prevalence of SD and DSL in CHC patients was high and was associated with factors, such as depressive symptoms and antidepressant use. Screening and managing these conditions represent significant steps toward improving medical assistance and the HRQL of CHC patients.

Febre de origem indeterminada em adultos

A febre de origem indeterminada classica e definida pela presenca de temperatura axilar maior do que 37,8oC, em varias ocasioes, pelo tempo minimo de tres semanas e que se mantem sem causa aparente apos uma semana de investigacao hospitalar. Tal conceito vem sofrendo alteracoes com o tempo e em decorrencia das inovacoes medicas. Em resposta a evolucao do conhecimento e as pressoes ambientais, os casos de febre de origem indeterminada sao atualmente classificados em quatro sindromes: classica, nosocomial, no neutropenico, e no paciente infectado pelo virus da imunodeficiencia humana. No presente artigo procuramos definir e atualizar as informacoes sobre o assunto.

A Follow-Up Study of 50 Chronic Hepatitis C Patients: Adiponectin as a Resilience Biomarker for Major Depression

Objective: Major depression (MD) is a condition associated with both hepatitis C virus (HCV) infection and pegylated interferon (IFN)-α treatment. IFN induces a depressive syndrome that is associated with an inflammatory profile. We aimed to investigate whether there is any specific alteration in plasma biomarkers associated with MD. Methods: HCV-monoinfected patients, with and without IFN treatment, were followed up for 18 months and went through structured psychiatric evaluation. We assessed plasma levels of brain-derived neurotrophic factor, tumor necrosis factor (TNF) and its soluble type 1 and type 2 receptors (sTNFR1 and sTNFR2, respectively), and adipokines (adiponectin, leptin and resistin) using ELISA. Results: Among the 50 patients included in the study, 14 were treated with IFN during the follow-up. Being older, not married, presenting higher body mass index, higher liver inflammatory activity, lower baseline adiponectin levels and use of IFN were associated with MD development. Higher levels of sTNFR1 during IFN treatment were associated with sustained virological response. The lack of a control group without HCV infection did not allow any assumption of a biomarker change exclusively due to the infection itself. Conclusion: Adiponectin may be a resilience biomarker for MD in HCV-infected patients.

Schistosomiasis mansoni and severe gastrointestinal cytomegalovirus disease in a patient with acquired immunodeficiency syndrome

The behavior of the Schistosoma mansoni infection in patients with AIDS has not been explored. The case of a young woman with schistosomiasis mansoni, AIDS, and cytomegalovirus disease is reported. The authors suggest that the helminth was not a bystander in this case, or rather, by interfering with the hosts immune response, it set the stage for the development and/or aggravation of the viral infection.

Serotonin-norepinephrine reuptake inhibitor desvenlafaxine for the treatment of interferon alfa-associated depression in patients with hepatitis C

Chronic infection with the hepatitis C virus (HCV) is a worldwide health problem. The mainstay of treatment includes the use of pegylated interferon-a (peginterferon alfa). Interferon (IFN) therapy is frequently associated with psychiatric adverse events, such as depressive disorders, which occur in approximately 30% of patients. Selective serotonin reuptake inhibitors (SSRI) are the first-line treatment of choice for IFN-associated depression. However, nonresponse or poor response is common. Antidepressants with broader mechanisms of action, such as the serotonin and norepinephrine reuptake inhibitors (SNRI), could theoretically increase remission rates. One such agent, desvenlafaxine, presents a favorable pharmacokinetic profile and its hepatic metabolism consists essentially of glucuronidation. Herein, we report two patients with hepatitis C who developed depression while receiving standard doses of IFN and were treated with desvenlafaxine. There is no previous report of desvenlafaxine use for this specific indication. A 45-year-old man with genotype 1 HCV infection, elevated alanine aminotransferase (337 IU/L), and a METAVIR score of A2F3 (denoting moderate inflammatory activity and advanced fibrosis without cirrhosis) developed depressive symptoms, with Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HAM-D) scores of 15 and 10 respectively. He was prescribed citalopram at a dosage scaled up to 40 mg/ day. Four weeks later, IFN was initiated. After 8 weeks of IFN treatment (week 12 of citalopram), depression worsened, as demonstrated by a severely depressed mood, apathy, hopelessness, suicidal ideation, fatigue, and muscle pain. His BDI and HAM-D scores were 45 and 21 respectively. Citalopram was switched to desvenlafaxine and the dose was titrated up to 100 mg/day. A clinically significant reduction of depressive symptoms was achieved after 8 weeks (week 16 of IFN treatment), with a BDI score of 10 and HAM-D of eight. A 49-year-old man with genotype 1 HCV infection, elevated alanine aminotransferase (123 IU/L), and METAVIR score of A2F2 (denoting moderate inflammatory activity and moderate fibrosis) presented with a complaint of emotional instability, insomnia, loss of appetite, fatigue, sexual dysfunction, muscle and joint pain, and irritability after 16 weeks of IFN treatment. By the 25th week of antiviral treatment, he had developed full-blown major depression. The BDI score increased from four at baseline to 26 at this time point, and the HAM-D score increased from three to 23. Desvenlafaxine was started, with the dose titrated up to 100 mg/day. The patient reported partial improvement of insomnia and irritability, but did not achieve remission of symptoms even after 8 weeks of desvenlafaxine (week 33 of IFN treatment). His BDI and HAM-D scores decreased during this period, from 26 to 19 points and 23 to 14 points respectively. Full remission of depressive symptoms occurred only after the end of IFN treatment. Both patients tolerated desvenlafaxine well, with no increase in liver enzymes. The first patient experienced a clinically significant reduction of depressive symptoms with desvenlafaxine after failing to respond to citalopram. The second patient had only minor improvement of symptoms with desvenlafaxine. Full remission of IFN-associated depression in HCV patients is a clinical challenge. Antidepressants such as the SNRI desvenlafaxine can be regarded as an option to improve its management. Controlled clinical trials are warranted.

Hepatic siderosis in a patient with hepatitis C on hemodialysis

A 49-year-old man with chronic renal failure (CRF) who was on hemodialysis was admitted to hospital for treatment of hepatitis C. Clinical examination revealed hepatomegaly. The Elisa test was positive for anti-HCV antibodies and HCV-PCR gave a positive result on serum. Genotype 1a was identified and the serum alanine aminotransferase level was normal. The patient had received parenteral iron to treat anemia. His iron and ferritin levels in serum were high (255mmol/l and 3840mg/l, respectively). Prussian blue staining showed siderosis in Kupfer cells and hepatocytes (Figure A). Iron granules were visible with the naked eye (siderosis level IV). Liver biopsy revealed severe inflammatory activity and fibrosis (Figures B and C – arrows). Treatment of anemia in CRF patients on hemodialysis includes the use of erythropoietin and high doses of iron, and this may aggravate the fibrosis of hepatitis C.O paciente, de 49 anos, com insuficiencia renal cronica (IRC) em hemodialise, apresentava hepatite C, a admissao hospitalar. O exame clinico revelou hepatomegalia. O anti-HCV (Elisa) e o PCR-HCV eram positivos no soro. Identificou-se o genotipo 1a e os niveis de alanina-aminotransferase eram normais. O paciente havia recebido ferro parenteral para o tratamento de anemia e apresentava elevados niveis de ferro e ferritina no soro (255mmol/L e 3840mg/L, respectivamente). A coloracao azul da Prussia revelou siderose em celulas de Kupfer e em hepatocitos (Figura A). Grânulos de ferro foram vistos sem aumento (siderose grau IV). A biopsia revelou atividade inflamatoria e fibrose hepatica graves (Figuras B e C – setas) . O tratamento da anemia em pacientes com IRC em hemodialise inclui o uso de eritropoietina e altas doses de ferro que pode agravar a fibrose da hepatite C.