Yahia Z. Gad

Seroprevalence of subclinical HEV infection in asymptomatic, apparently healthy, pregnant women in Dakahlya Governorate, Egypt

Background and Aim: Hepatitis E virus (HEV) is a major public health problem in the developing countries. HEV infection in pregnant women is more common and fatal in the third trimester. The present study was designed to determine the seroprevalence of subclinical HEV infection in asymptomatic pregnant women. Materials and Methods: A total of 116 asymptomatic pregnant women divided into 2 groups: Group 1 included 56 pregnant women with HCV positive serology and group 2 included 60 pregnant women with negative HCV serology were included in this study. Prevalence of anti-HEV antibodies and anti-HCV were determined by an enzyme linked immunosorbent assay (ELISA) kit. Results: The overall prevalence of anti-HEV IgG was highly significant among pregnant women with chronic HCV infection 40/56 (71.42%) than pregnant women free from chronic HCV infection 28/60 (46.7%) (P = 0.006). Chronic HCV infection in pregnant women appeared to be a risk factor associated with HEV IgG seropositivity (OR = 2.86, CI = 1.24-6.6). The seropositivity of anti-HEV IgG was significantly high in rural areas than urban areas (62.5% vs. 37.5%) in group 1 and (78.58% vs. 21.42%) in group 2 (P = 0.15) and OR = 2.2, CI = 0.65-7.7). A decrease in albumin level (P = 0.047) and an increase in bilirubin (P = 0.025), ALT (P = 0.032), and AST (P = 0.044) in pregnant women with positive HCV and IgG anti-HEV than the second group with negative HCV serology. Conclusions: The seroprevalence of anti-HEV IgG in pregnant women is high in Egypt especially in rural areas. With chronic HCV coinfection, a marked increase in anti-HEV IgG seropositivity and significant worsening of the biochemical liver indices were noted. Increased public awareness about the sound hygienic measures for a less prevalence of HEV is strongly advised. The need for HEV vaccination for those at risk, especially pregnant ladies, should be considered.

Distinct immunoregulatory cytokine pattern in Egyptian patients with occult Hepatitis C infection and unexplained persistently elevated liver transaminases.

Background/Aim: The immunopathogenesis of occult Hepatitis C virus (HCV) infection is a matter of great controversy and has been suggested to involve a complex balance between cytokines with pro- and anti-inflammatory activity. This work aimed at studying the serum Th1 and Th2 cytokine production in patients with occult HCV infection. Materials and Methods: Serum levels of cytokines of Th1 (interleukin [IL]-2, INF-γ) and Th2 (IL-4) were measured in 27 patients with occult HCV infection and 28 patients with chronic hepatitis C infection. Results: The levels of IL-2 and interferon-γ were highly significantly increased in patients with chronic HCV infection (P<0.001). IL-4 was highly significantly increased in occult HCV infection (P<0.001). Significant increases were noted in chronic HCV infection regarding bilirubin (P<0.001), ALT (P = 0.009), AST (P = 0.013), AFP (P<0.001), while serum albumin was significantly higher in occult HCV infection (P<0.001). Necroinflammation (P<0.001), fibrosis (P<0.001), and cirrhosis (P = 0.03) were significantly increased in chronic HCV infection. Conclusion: Our data revealed a high prevalence of occult HCV infection (25%) in patients with unexplained persistently abnormal liver function test results. Those patients exhibited a distinct immunoregulatory cytokine pattern, favoring viral persistence and explaining the less aggressive course of this disease entity than chronic HCV infection.

Screening for minimal hepatic encephalopathy in asymptomatic drivers with liver cirrhosis.

BACKGROUND AND STUDY AIMS Minimal hepatic encephalopathy (MHE) represents a part of the spectrum of hepatic encephalopathy (HE). It can have a far-reaching impact on quality and ability to function in daily life and may progress to overt HE. This study was designed to screen for MHE in drivers with liver cirrhosis in Mansoura, a city in the Nile delta in Egypt. PATIENTS AND METHODS A total of 174 consecutive drivers with positive serology for viral markers and cirrhosis were screened for MHE. Questionnaires and standard psychometric tests and well-informed consent were performed at the same setting. The diagnosis of MHE was made when one or both symbol digit test (SDT) and number connection test (NCT) appeared abnormal. Becks inventory and Mini Mental State Examination questionnaires were performed for those diagnosed as MHE. After overnight fasting, venous blood samples were taken for haematologic tests and routine liver function tests by conventional methods. Arterial ammonia was also measured. RESULTS A total of 66 patients showed evidence for MHE out of 139 patients who fulfilled the inclusion criteria. No significant differences were present, apart from a significantly elevated arterial ammonia level (p-value <0.001) and a bad self-reported driving history (p<0.05) in the MHE-positive group when compared with the MHE-negative group. Multivariate logistic regression revealed that advanced Child-Pugh grade (p<0.001), hepatitis B virus (HBV)-related aetiology (p<0.001) and smoking are significant risk factors for MHE. MHE is significantly commoner among Child-Pugh C patients (p<0.05) when compared with the other Child-Pugh grades. CONCLUSION Our data revealed a high prevalence of MHE (47%) among Egyptian drivers with liver cirrhosis. It is hence recommended to include the driving history as well as regular pencil-paper standard psychometric testing in evaluating those at risk, especially in the outpatient setting, for early detection and proper management.

Increased α-Fetoprotein Predicts Steatosis among Patients with Chronic Hepatitis C Genotype 4.

Background. The prognostic importance of α-fetoprotein (AFP) level elevation in patients with chronic hepatitis C and its clinical significance in steatosis associated with HCV infection remain to be determined. The present paper assessed clinical significance of elevated AFP in patients with CHC with and without steatosis. Methods. One hundred patients with CHC were divided into 50 patients with CHC and steatosis and 50 patients with CHC and no steatosis based on liver biopsy. Results. AFP was significantly increased in CHC with steatosis than patients without steatosis (P < 0.001). Highly significant positive correlation was found between serum AFP and necroinflammation as well as the severity of fibrosis/cirrhosis and negative significant correlation with albumin level in chronic HCV with steatosis (P < 0.001) but negative nonsignificant correlation with ALT and AST level (P ≤ 0.778 and 0.398), respectively. Highly significant increase was found in chronic hepatitis patients with steatosis than CHC without steatosis regarding necroinflammation as well as the severity of fibrosis/cirrhosis and AFP (P < 0.001). Conclusion. Patients with chronic HCV and steatosis have a higher AFP levels than those without steatosis. In chronic HCV with steatosis, elevated AFP levels correlated positively with HAI and negative significant correlation with albumin level.

Is Combination Therapy Interferon and Ribavirin in Patients with Chronic Hepatitis C Infection Toxic for Eyes

BACKGROUND Many side effects of combination therapy using pegylated interferon (IFN) and ribavirin for treatment of chronic hepatitis C virus (HCV) infection have been well described. Ocular complications are fairly common. Diabetes mellitus (DM) and systemic hypertension are possible suggested risk factors for development of these complications. PURPOSE To determine the frequency of retinopathy and its risk factors in patients treated with combined pegylated IFN and ribavirin for chronic hepatitis C infection. METHODS Eligible 98 patients for HCV treatment with pegylated IFN a-2a, a-2b, and ribavirin between October 2011 and March 2012 were included. All patients underwent a baseline full ophthalmological examination, and any visual complaints during treatment prompted a repeat eye examination. RESULTS Out of the eligible 98 patients, 48 (48.78%) patients received pegylated IFN alpha-2a, and the other 50 (51.21%) patients were treated with pegylated IFN alpha-2b. Out of 98 patients, 21 (21.42%) had diabetes; 19 (19.38%) patients had hypertension and 16 (16.32%) patients had both diabetes; and hypertension. Only 8 patients (8.16%) had documented retinopathy [2 had DM; one had hypertension; 4 had both hypertension and diabetes; and one patient without DM or hypertension]. Univariate logistic regression analysis revealed that diabetic, hypertensive patients are at increased risk for development of IFN-associated retinopathy (IAR) (P=0.007, Odds ratio=6.5, 95% confidence interval=1.56-27. CONCLUSION Retinopathy in chronic HCV-infected patients undergoing treatment with combination of pegylated IFN-alpha and ribavirin therapy appears to be relatively low, and treatment cessation is rarely needed. Diabetic, hypertensive patients are at increased risk for IAR and are recommended to be ophthalmologically followed-up.

Colorectal schistosomiasis: Is it still endemic in delta Egypt, early in the third millennium?

Background: Several governmental efforts have been exerted toward controlling schistosomiasis during the last decades in Egypt. This work was designed to study the prevalence of colorectal schistosomiasis in patients with different gastrointestinal symptoms. Materials and Methods: Patients presented to the gastroenterology unit with different gastrointestinal symptoms were endoscopically examined, where three to six tiny biopsies were taken from those with visible, suspected schistosomal lesions for histopathological examination and two additional rectal biopsies were taken from the apparently normal colonic mucosa. Form each patient, at least three stool samples were examined by the formal-ether concentration method for schistosoma ova. Results: Colonic abnormalities were detected in 510 out of 984 patients presented with different gut symptoms. Schistosoma mansoni was detected in 205 patients (180 males, 25 females) with an age range (18-65years). Six patients only had schistosomal polyps and excised successfully by snare polypectomy. The squash technique established the diagnosis of schistosomiasis in all endoscopically normal 118 (50.75%) cases by demonstrating the schistosomiasis ova and their associated histopathological findings showed no or minimal reaction in 96 (46.82%) cases and variable degrees of submucosal granulomata in the remaining cases. Stool examination detected the schistosomiasis ova in 25 (9.83%) patients only of the biopsy-positive cases. Conclusions: Our data revealed that despite governmental efforts, the prevalence of colorectal schistosomiasis (20.83%) is significant among patients with gut symptoms. Gaps in health care services should be detected and filled appropriately.

Occult hepatitis C infection: the prevalence and profile of its immunoregulatory cytokines

Background/aim The immunopathogenesis of occult hepatitis C virus (HCV) infection is a matter of great controversy and has been suggested to involve a complex balance between cytokines with proinflammatory and anti-inflammatory activity. This work aimed at studying the production of serum Th1 and Th2 cytokines in patients with occult HCV infection. Methods Serum levels of cytokines Th1 [interleukin-2 (IL-2) and interferon-&ggr; (IFN-&ggr;)] and Th2 (IL-4) were measured in 27 patients with occult HCV infection and in 28 patients with chronic hepatitis C infection. Results The levels of IL-2 and IFN-&ggr; were highly significantly increased in patients with chronic HCV infection (P<0.001). In contrast, IL-4 showed a highly significant increase in occult HCV infection (P<0.001). Significant increases were noted in chronic HCV infection with respect to bilirubin (P<0.001), alanine transaminase (P=0.009), aspartate transaminase (P=0.013) and alfa-fetoprotein (P<0.001) levels, whereas the level of serum albumin was significantly higher in occult HCV infection (P<0.001). The degree of necroinflammation (P<0.001), fibrosis (P<0.001) and cirrhosis (P=0.03) was significantly increased during chronic HCV infection. Conclusion Our data revealed a high prevalence of occult HCV infection (25%) in patients with unexplained persistently abnormal liver function test results. These patients exhibited a distinct immunoregulatory cytokine pattern, favouring viral persistence and explaining the less-aggressive course of this disease entity compared with chronic HCV infection.

The role of argon plasma coagulation in the management of Barrett's esophagus: a single-center experience

Background/aim: Patients with Barrett’s esophagus (BE) are 30 times more likely to develop esophageal adenocarcinoma (EAC) than the general population. Data regarding the use of argon plasma coagulation (APC) for treatment of patients with BE in Egypt are still limited. This article discusses the efficacy and safety of APC as a thermoablative modality in Egyptian patients with BE. Materials and methods: A total of 73 referred eligible patients with a confirmed endoscopic and histopathologic diagnosis of BE were enrolled in this study and subjected to thermoablation by high-power (hp)-APC equipment at a 60 W setting until complete ablation or a maximum of five sessions and were followed up clinically and endoscopically at 3-month intervals. Computergenerated randomization allocated patients into APC-treated and control groups (n = 75), all of whom were treated with a proton pump inhibitor. Results: Minor and major complications occurred in 8 of 73 (10.95%) and 1 of 73 (1.36%) patients, respectively. Macroscopic ablation was achieved after one session in 37 of 73 (50.63%) patients, and complete histologic ablation was confirmed after 167 sessions in 69 of 73 (94.52%) patients. At 1-year follow-up, no relapses of BE or progression to EAC were observed. Conclusion: hp-APC at a medium-energy setting of 60 W in an acid-reduced environment can ablate BE effectively and safely with promising initial results.

Candidemia Among Chronic HCV Patients in Intensive Care Unit : Risk Factors and Antifungal Susceptibility Testing

Candida is one of the common causes of blood stream infection (BSI) especially in intensive care unit (ICU) and associated with high mortality rates. Due to low immunity, the patients with chronic hepatitis C virus (HCV) are prone to Candida infection. This study presents data on species distribution, clinical risk factors and antifungal susceptibility profiles of candidemia obtained from chronic HCV patients in hepatic ICU in specialized medical hospital of Mansoura University. All the bloodstream isolates were isolated by manual lysis centrifugation method and identified to species level by CHROMagar Candida and API 20C AUX. Also, multiplex PCR was done to detect candida spp. in blood samples. Antifungal susceptibility was done by M 27A2 (broth microdilution) and M 44 (disk diffusion) methods of the Clinical and Laboratory Standards Institute (CLSI) to fluconazole, voriconazole and amphotricin B. From 342 patients, 33 candida isolates were recovered by manual lysis centrifugation method, and 26 were detected by PCR. Candida albicans (C. albicans) was the predominant species (13/33), followed by Candida parapsilosis (C. parapsilosis) (6/33). Resistance to fluconazole was observed in 15.38% (2/13) of C. albicans isolates, 50% (2/4) Candida glabrata (C. glabrata) isolates, and 100% (4/4) C. krusei isolates. Resistance to voriconazole and AMB were observed in 5 isolates (15.2%) and in 4 (12.1%) isolates, respectively. Neutropenia carries the highest risk factor with candidemia (Odds ratio 14.08 with confidence intervals 95% 6.05-32.8). So, C. albicans is the most common cause of Candidemia among chronic HCV patients in ICU, followed by C. parapsilosis, and the rates of resistance to azoles antifungal and AMB are still low.

Nonalcoholic fatty liver disease in young adult Egyptian women with polycystic ovary syndrome

Background/aims Nonalcoholic fatty liver disease (NAFLD) is currently recognized as the most common form of chronic liver disease in many parts of the world. NAFLD and polycystic ovary syndrome (PCOS) have insulin resistance (IR) in common. Thus, women with PCOS would be at an increased risk of development of NAFLD. In this work, we aimed to study the prevalence and characteristics of NAFLD in young adult Egyptian women with PCOS. Patients and methods Sixty-four eligible women with PCOS were enrolled and divided according to their BMI into two groups: 46 women in the obese group and 17 women in the lean group, during the period from 2009 to 2011. Patients were subjected to thorough assessment of history, the designed anthropometric measurements, abdominal ultrasound scanning, and laboratory tests. Results Twenty-eight out of 46 (60.8%) of overweight-obese patients with PCOS had IR and 24/46 (52.17%) had NAFLD. Four out of 17 lean patients with PCOS (18.2%) had IR and 3/17 had NAFLD. Stepwise multivariate logistic regression analysis showed that homeostasis model assessment of insulin resistance (P<0.001), fasting glucose (P=0.001), and total cholesterol (P=0.002) were the most predictive for development of NAFLD in the women with PCOS studied. Conclusion Our data showed a significant prevalence of NAFLD in patients with PCOS where IR is strongly blamed. Increased clinicians’ awareness, anticipation, and early recognition of liver disease in such women are of paramount prognostic and therapeutic importance.