Orbital apex syndrome from gnathostomiasis.

A 16-year-old Thai girl presented with acute unilateral visual loss, proptosis, and ophthalmoparesis. CT demonstrated thickening and enhancement of orbital tissues including the orbital apex. A history of consumption of raw fish, together with the findings of cutaneous migratory swelling and eosinophilia, made the diagnosis of gnathostomiasis likely. Her serum was positive for Gnathostoma spinigerum using an immunoblotting technique. Parasites removed from the skin lesions revealed the typical head bulbs with 4 circumferential rows of hooklets and fine cuticular spines on their surface. Treatment with an antihelminthic and systemic corticosteroids led to resolution of orbital inflammation but left a persistent optic neuropathy marked by nerve fiber bundle visual field loss with normal visual acuity. Gnathostomiasis should be suspected in patients with an orbital apex syndrome who live or travel in an endemic area, have eaten raw fish, and develop a migratory skin rash.     

Hepatitis C virus genotype 6:Virology,epidemiology,genetic variation and clinical implication

Hepatitis C virus(HCV)is a serious public health problem affecting 170 million carriers worldwide.It is a leading cause of chronic hepatitis,cirrhosis,and liver cancer and is the primary cause for liver transplantation worldwide.HCV genotype 6(HCV-6)is restricted to South China,South-East Asia,and it is also occasionally found in migrant patients from endemic countries.HCV-6 has considerable genetic diversity with23 subtypes(a to w).Although direct sequencing followed by phylogenetic analysis is the gold standard for HCV-6 genotyping and subtyping,there are also now rapid genotyping tests available such as the reverse hybridization line probe assay(INNO-LiPAⅡ;Innogenetics,Zwijnaarde,Belgium).HCV-6 patients present with similar clinical manifestations as patients infected with other genotypes.Based on current evidence,the optimal treatment duration of HCV-6 with pegylated interferon/ribavirin should be 48 wk,although a shortened treatment duration of 24 wk could be sufficient in patients with low pretreatment viral load who achieve rapid virological response.In addition,the development of direct-acting antiviral agents is ongoing,and they give high response rate when combined with standard therapy.Herein,we review the epidemiology,classification,diagnosis and treatment as it pertain to HCV-6.     

Short-term effects of an intensive lifestyle modification program on lipid peroxidation and antioxidant systems in patients with coronary artery disease

The purpose of this study was to compare the short-term effects of an intensive lifestyle modification (ILM) program on lipid peroxidation and antioxidant systems in patients with coronary artery disease (CAD). Twenty-two patients in the control group continued to receive their conventional treatment with lipid-lowering drugs, whereas 22 patients in the experimental group were assigned to intensive lifestyle modification (ILM) without taking any lipid-lowering agent. The ILM program comprised dietary advice on low-fat diets, high antioxidants and high fiber intakes, yoga exercise, stress management and smoking cessation. After 4 months of intervention, patients in the experimental group revealed a statistically significant increase in plasma total antioxidants, plasma vitamin E and erythrocyte glutathione (GSH) compared to patients in the control group. There was no significant change in plasma malondialdehyde (MDA), a circulating product of lipid peroxidation, in either group. We concluded that the ILM program increased circulating antioxidants and reduced oxidative stress in patients with CAD.     

Defining Biomarkers to Predict Natural Resolution in Shrimp Allergy

PurposeTolerance to shrimp has been reported in some patients with a history of shrimp allergy. The predictors of the natural resolution of shrimp allergy have not been widely explored. This study aimed to investigate the role of specific IgE (sIgE) and specific IgG4 (sIgG4) to shrimp extracts and the cross-reactive shrimp allergens tropomyosin (TM), arginine kinase (AK) and myosin light-chain (MLC), as markers of persistent or resolved shrimp allergy (PSA or RSA).MethodsSeventeen patients with a 10-year history of allergy to Penaeus monodon (Pm) and/or Macrobachium rosenbergii (Mr) were recruited. Oral shrimp challenges identified 10 patients with PSA and 7 patients with RSA. Sera from these patients were evaluated for sIgE and sIgG4 to Mr and Pm extracts as well as to TM, AK and MLC.ResultsThe levels of sIgE to Mr and Pm extracts were lower in the RSA than in the PSA groups (P = 0.05 and P = 0.008, respectively), but sIgG4 or sIgG4:sIgE ratio did not show statistical significance. The sIgE to AK and MLC, but not TM, were lower in the RSA group than in the PSA group (P = 0.009 and P = 0.0008, respectively). There was no difference in sIgG4 to TM, AK and MLC between both groups. The ratio of sIgG4:sIgE to MLC, but not TM or AK, was higher in the RSA than in the PSA group (P = 0.02). A higher diversity of sIgE to shrimp components was found in the PSA group than in the RSA group (P = 0.006).ConclusionsSpecific bioassays can be used to identify patients with RSA. Oral shrimp challenges in these patients may provide a higher rate of passing the challenges and finally reintroducing shrimp in their diet.     

Sero-epidemiological study of hepatitis A virus infection among hill-tribe youth and household environmental sanitation, a hill-tribe community in northern Thailand

A cross-sectional analytic study of 190 hill-tribe youth in a community in the north of Thailand was conducted to investigate the sero-prevalence of HAV and factors related to positive anti-HAV antibody. The studied youth, whose ages ranged from 15 to 24 years, were interviewed about socio-economic status and personal hygiene. Blood specimens were collected to detect anti-HAV by ELISA commercial kit. Household environmental sanitation conditions were observed and drinking water samples were screened for bacterial contamination using SI2 medium. Following the anti-HAV assay, the studied youth were divided into two groups: anti-HAV positive, and anti-HAV negative. The studied variables of the two groups were analyzed by chi2 test to find factors related to anti-HAV positivity. The results revealed that 87% of the studied youth were positive for anti-HAV. There was no statistically significant difference between age group/gender and anti-HAV positivity, p = 0.46 and 0.16, respectively. Approximately 35.79 to 45.79% washed their hands with soap before preparing food, before eating and after using the latrine. About 88% did not improve the potability of their drinking water. The results of screening for bacterial contamination in drinking water samples found that 73.53% were contaminated with coliform bacteria. Factors related to positive anti-HAV antibody included monthly income, number of household members, use of latrine, hand-washing with soap after using latrine, household refuse management and control of insects and rodents; p = 0.04, 0.007, 0.013, 0.008, <0.001 and <0.001, respectively. The findings suggested that appropriate household environmental management should be improved in this community to reduce HAV transmission.     

Diagnostic role of serum interleukin 6 and CA 19-9 in patients with cholangiocarcinoma

BACKGROUND/AIMS: Cholangiocarcinoma is particularly common in Northeastern Thailand where the liver fluke, O. viverrini, is endemic. Currently there is no sensitive and specific tumor marker for the diagnosis of this cancer. The aim of this study was to investigate the accuracy of carbohydrate antigen 19-9 and interleukin-6 in the diagnosis of cholangiocarcinoma. The first marker represents the commonly used serum marker in cholangiocarcinoma and the second marker is a multi-functional cytokine associated with cancer development. METHODOLOGY: The serum concentrations of carbohydrate antigen 19-9 and interleukin-6 were simultaneously determined in 45 patients with cholangiocarcinoma, 15 with hepatocellular carcinoma, 15 with metastatic liver cancers, 10 with benign biliary disease and 10 healthy controls. RESULTS: The sensitivity of carbohydrate antigen 19-9 value (> or = 37 U/mL) in diagnosing cholangiocarcinoma was 64.4%, while its specificity was 100% and 56.7% when compared with benign biliary disease and other liver cancers, respectively. The sensitivity and specificity of detectable interleukin-6 (> or = 0.18 ng/mL) for differentiating between cholangiocarcinoma and benign biliary disease was 71.1% and 90%, respectively, whereas the specificity for differentiating cholangiocarcinoma from other liver cancers was 26.7%. When higher concentrations of either carbohydrate antigen 19-9 (> or = 100 U/mL) or interleukin-6 (> or = 50 pg/mL) were used as the cut-off points, they provided additional diagnostic sensitivity and accuracy in differentiating between cholangiocarcinoma and other liver cancers to 80% and 76%, respectively. CONCLUSIONS: The combined assays of both serum carbohydrate antigen 19-9 and interleukin-6 could be useful in diagnosing cholangiocarcinoma, particularly in populations where this cancer is prevalent.     

Resumption of growth after methionyl-free human growth hormone therapy in a patient with neutralizing antibodies to methionyl human growth hormone

A 16-5/12 year-old male was diagnosed with classical growth hormone (GH) deficiency at the age of 8-6/12 years and was treated with recombinant methionyl human growth hormone (m-hGH). Height increased from 104.0 cm to 107.4 cm over the first 6 months. After that, for 1 year, he demonstrated poor growth velocity which was found to be secondary to a high titer of GH antibodies with GH binding capacity >2 mg/l. After a 7-month washout period during which no GH was given, at age 11 years he was placed on recombinant methionyl-free human growth hormone (met-free hGH). His height increased 14.9 cm in 11 months (annualized growth rate of 16.2 cm/year). This report illustrates that evaluation of growth failure during GH therapy should include measurement of anti-GH antibodies so that an appropriate alteration of GH therapy can be made if indicated.     

Baseline and kinetics of serum hepatitis B virus RNA predict response to pegylated interferon‐based therapy in patients with hepatitis B e antigen‐negative chronic hepatitis B

Serum hepatitis B virus (HBV) RNA has emerged as a novel biomarker of treatment response. This study aimed to investigate the role of this marker in predicting long‐term outcome of patients with hepatitis B e antigen (HBeAg)‐negative chronic hepatitis B (CHB) receiving pegylated interferon (PEG‐IFN)‐based therapy. Serial serum samples from 91 patients with HBeAg‐negative CHB previously treated with PEG‐IFN alone or combined with entecavir in a randomized trial were retrospectively analysed. HBV RNA quantification was examined by droplet digital PCR. At the end of 3 years post‐treatment follow‐up, maintained virological response (MVR, HBV DNA < 2000 IU/mL), and hepatitis B surface antigen (HBsAg) clearance were achieved in 37.4% (34/91) and 7.7% (7/91), respectively. Baseline serum HBV RNA concentrations correlated with HBV DNA and covalently closed circular DNA but did not correlate with HBsAg levels. Multiple regression analysis showed that pre‐treatment HBV RNA and HBsAg were independently associated with MVR and HBsAg clearance. Baseline HBV RNA (cut‐off 2.0 log₁₀ copies/mL) had a positive predictive value (PPV) and a negative predictive value in predicting MVR of 80.8% and 80.0%, respectively. At the same cut‐off value, PPV and NPV for predicting HBsAg clearance were 30.8% and 95.4%, respectively. At week 12 during therapy, HBV RNA level ≥ 2 log₁₀ copies/mL displayed high NPVs of achieving MVR and HBsAg clearance (95% and 100%, respectively). In conclusion, the measurement of HBV RNA prior to PEG‐IFN‐based therapy could identify patients with high probability of MVR. In addition, HBV RNA kinetics may serve as a promising “stopping rule” in patients infected with HBV genotypes B or C.