The use of intravenous immunoglobulin in Miller Fisher syndrome

We report a patient with Miller Fisher syndrome who was treated with an intravenous high-dose of immunoglobulin. This syndrome is considered to be a benign variety of acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome). However, there have been several reports of the need for ventilatory support and a few cases have had a fatal outcome. We observed a case of progressive Miller Fisher syndrome in a 3-year-old boy. Following 2 episodes of apnea lasting about 50 s each, he was treated with intravenous immunoglobulin (400 mg/kg/day) for 5 consecutive days. His respiratory state, general muscle strength, truncal ataxia and emotional state improved remarkably after this therapy.     

Interferon therapy for acute hepatitis C viral infection--a review by meta-analysis

BACKGROUND: Hepatitis C viral (HCV) infection poses a major health problem for Australia. Currently interferon therapy is approved only for people with chronic infection, yet the literature contains a number of studies that show that there is a better response to interferon in symptomatic acute HCV. AIM: To review the response to interferon therapy in acute HCV by way of meta-analysis. METHODS: This study was a retrospective review of the data on the use of interferon therapy in acute HCV. The meta-analysis was performed using the methods of DerSimonian and Laird. Data were presented by calculating the risk difference which estimated efficacy by calculating the proportion of patients in treatment groups who responded better (0 to +1.0) or worse (0 to -1.0) than untreated control groups. RESULTS: A meta-analysis of six studies on the use of 3MU of interferon alpha 2b (IFN-alpha 2b) three times a week for six to 24 weeks showed a significant response as measured by long term (> 12 months) normalisation of alanine aminotransferase (ALT) and clearance of HCV RNA (as measured by polymerase chain reaction). The risk of difference was +0.31 (95% CI of +0.19 to +0.43, p < 0.01) and +0.33 (95% CI of +0.08 to +0.58, p < 0.001) respectively. Slightly better results were seen with daily doses of 3MU of interferon beta (IFN-beta) given intravenously over four to seven weeks. This produced a risk difference of +0.57 (95% CI of +0.26 to +0.88, p < 0.02) for normalisation of ALT and +0.83 (95% CI of +0.61 to 1.00, p < 0.001) for clearance of HCV. Results for higher daily doses of both IFN alpha and beta were limited to a few studies and most were uncontrolled. 6MU of IFN-alpha 2b three times a week for 16 to 24 weeks produced a risk difference of +0.53 (95% CI +0.17 to +0.89, p < 0.05) for normalisation of ALT and +0.44 (95% CI +0.06 to +0.82) for clearance of HCV RNA. Results with 6MU daily for eight weeks of IFN-beta in an uncontrolled study, showed up to 90% patients cleared HCV long term. Preliminary results with 10MU of IFN-alpha 2b daily for four to six weeks also showed long term clearance of HCV RNA and normalisation of ALT in 90% of treated patients. CONCLUSION: Short term (six weeks to six months) treatment of symptomatic acute HCV with interferon (both alpha and beta) produced a better long term response rate than prolonged therapy (> 12 months) in chronic HCV. Daily doses of 6MU and 10MU produced better responses than 3MU but more studies are needed to determine the optimum regime.     

Human immunodeficiency virus infection as risk factor for mother-to-child hepatitis C virus transmission; persistence of anti-hepatitis C virus in children is associated with the mother''s anti-hepatitis C virus immunoblotting pattern

Furosine, formed by hydrolysis of 1-deoxy-fructosyl-lysine (fructose-lysine), is a product of the Amadori rearrangement of glucose and epsilon-NH2-lysine. Fructose-lysine can react further with tissue and circulating proteins to produce advanced glycation end-products (AGEs). Peritoneal dialysate used in the treatment of patients with end-stage renal failure contains high concentrations of glucose which may lead to intraperitoneal formation of AGEs. To quantitate the kinetics of formation and peritoneal clearance of glycated peritoneal dialysate proteins, we developed an effective approach to the measurement of furosine in clinical samples of serum and peritoneal dialysate.     

Early therapy with interferon for acute hepatitis C acquired through a needlestick

Chinese hamster lung fibroblast V79 cells have been widely used in studies of DNA damage and DNA repair. Since the p53 gene is involved in normal responses to DNA damage, we have analyzed the molecular genetics and functional status of p53 in V79 cells and primary Chinese hamster embryonic fibroblast (CHEF) cells. The coding product of the p53 gene in CHEF cells was 76 and 75% homologous to human and mouse p53 respectively, and was 95% homologous to the Syrian hamster cells. The V79 p53 sequence contained two point mutations located within a presumed DNA binding domain, as compared with the CHEF cells. Additional immunocytochemical and molecular studies confirmed that the p53 protein in V79 cells was mutated and nonfunctional. Our results indicate that caution should be used in interpreting studies of DNA damage, DNA repair and apoptosis in V79 cells.     

Perinatal transmitted acute icteric hepatitis B in infants born to hepatitis B surface antigen-positive and anti-hepatitis Be-positive carrier mothers

Three infants born to mothers who were hepatitis B surface antigen (HBsAg) positive and had antibody to hepatitis Be antigen (anti-HBe), developed acute icteric hepatitis B within three months of birth. All three infants clinically recovered and developed circulating anti-HBs. Contrary to previous studies, these three cases indicate that mother-infant transmission of the hepatitis B virus (HBV) does occur in infants born to HBsAg-positive, HBe-Ag-negative carrier mothers, and these infants may develop severe acute icteric hepatitis. Therefore, immunoprophylaxis in such newborns may be indicated.     

The development of hepatic granulomas following interferon-alpha2b therapy for chronic hepatitis C infection

A patient with ectodermal dysplasia, Joubert's syndrome, and cerebral cysts is reported. The combination of these findings suggested a disorder of the embryonic ectoderm, manifesting as a neurocutaneous syndrome.     

T- and B-cell responses to different hepatitis C virus antigens in patients with chronic hepatitis C infection and in healthy anti-hepatitis C virus--positive blood donors without viremia

As the host's immune response may determine the course of hepatitis C virus (HCV) infection, we studied the humoral and cellular immune responses to HCV-related antigens in subjects with different outcomes of HCV infection. Lymphoproliferative responses and circulating antibodies to a panel of HCV core- and E1-related 25-mer peptides were examined in 10 healthy anti-HCV-seropositive blood donors (group A) and in 29 patients with chronic hepatitis C (group B). In addition, cellular recognition of recombinant HCV proteins (core, NS3, NS4A, NS5A, NS5B) were investigated. In group A, stronger T-cell responses were detected against both HCV proteins (core, P = .03; NS4, P = .005; NS5B, P = .03) and peptides. Proliferation was induced by the same peptides in each group, defining at least five distinctive epitopes within core (amino acids [aa] of 20-44, aa 39-63, aa 79-103, aa 118-152 and aa 148-172) and three regions within E1(aa 198-252, aa 308-372, and aa 368-392). Subjects with strong T-cell responses had low or no detectable levels of peptide-specific antibodies, and vice versa. In particular, T-cell responses were more common in group A; B-cell responses were more common in group B. From our data, we conclude that a benign course of HCV infection may be the consequence of the effective activation of T-helper lymphocytes.     

Dynamics of hepatitis C viremia following interferon-alpha administration

Knowledge of the dynamics of hepatitis C virus (HCV) in vivo is important for elucidation of its pathogenesis and the establishment of therapeutic guidelines. The aim of this study was to obtain kinetic information about virus load following interferon-alpha (IFN-alpha) administration. Serial serum HCV core protein and HCV RNA levels were measured. IFN-alpha exponentially reduced serum HCV levels. The mean (+/-SD) viral half-life was 7.0 +/- 2.6 h in HCV core protein assay and 7.2 +/- 3.1 h in HCV RNA assay on the first day of therapy. This initial rapid decrease was followed by a slower decrease in serum HCV levels thereafter. Thus, the biphasic reduction in virus load during IFN-alpha therapy was demonstrated.     

Clinical application of hepatitis C virus core protein in early diagnosis of acute hepatitis C

OBJECTIVE: To investigate the prevalence of currently recognised inherited prothrombotic states in a population of children with arterial stroke. METHODS: Children with arterial stroke presenting to a tertiary level paediatric neurology centre between 1990 and 1996 were investigated for inherited prothrombotic states. RESULTS: Sixty seven children with arterial stroke were investigated. Abnormalities were initially identified in 16 patients; however, only eight children (12%) had an inherited prothrombotic state. This was type 1 protein S deficiency in one patient, the factor V Leiden mutation in six, and activated protein C resistance (without the factor V Leiden mutation) in one. The prevalence of the factor V Leiden mutation was not significantly higher in children with arterial stroke (12%) than in a control population of children without thrombosis attending the same institution (5.2%; Fisher's exact test, p=0.19; difference in prevalence between patients and controls (95% confidence interval)=6.8% (-2.78% to 16.8%)). CONCLUSIONS: Currently recognised inherited prothrombotic tendencies were rarely associated with stroke in this group of children, although larger numbers of patients would be needed to confirm this. Age appropriate normal values should be used when interpreting the results of a prothrombotic screen. Prothrombotic abnormalities seen acutely are as often transient as inherited. Longitudinal assessment and family studies are required before low concentrations of an anticoagulant protein found acutely can be attributed to an inherited abnormality.     

Prolonged therapy of chronic hepatitis C with ribavirin

Therapy with ribavirin for 6-12 months is associated with decreases in serum aminotransferases in some patients with chronic hepatitis C. We have assessed the practicality and safety of prolonged therapy with ribavirin. Six patients with chronic hepatitis C were given 1000-1200 mg of ribavirin daily for 24 months. Serum aminotransferases and hepatitis C virus (HCV) RNA levels were monitored during and after therapy. Liver biopsies were carried out before and at the end of treatment. With therapy, mean serum alanine aminotransferase (ALT) levels fell from 161 U/L to 45 U/L at 12 months and to 39 U/L at 24 months. HCV RNA levels did not change. Liver histology improved in five and was unchanged in one patient. When therapy was stopped, aminotransferases rose to pretreatment levels. Side effects included mild fatigue and headaches. Two patients developed gallstones during therapy, perhaps caused by the chronic haemolysis that occurred in all patients. In conclusion, prolonged therapy with ribavirin can result in sustained improvements in serum aminotransferases and hepatic histology in a proportion of patients with chronic hepatitis C. Ribavirin therapy does not cause decreases in viraemia and, therefore, probably must be continued indefinitely to provide lasting benefit. The advantages of such therapy must be weighed against possible long-term side-effects.     

Outbreak of enterically-transmitted hepatitis due to hepatitis A and hepatitis E viruses

PURPOSE: To evaluate the uptake and transport of solid lipid nanoparticles (SLN), which have been proposed as alternative drug carriers, into the lymph and blood after duodenal administration in rats. METHODS: Single doses of two different concentrations of aqueous dispersions of unlabelled and labelled SLN (average diameter 80 nm) were administered intraduodenally to rats. At different times, samples of lymph were withdrawn by cannulating the thoracic duct and blood was sampled from the jugular vein. Monitoring continued for 45 and 180 minutes, for unlabelled and labelled SLN respectively. The biological samples were analysed by photon correlation spectroscopy (PCS), transmission electron microscopy (TEM) and gamma-counting. RESULTS: TEM analysis evidenced SLN in lymph and blood after duodenal administration to rats: the size of SLN in lymph did not change markedly compared to that before administration. The labelled SLN confirmed the presence of SLN in lymph and blood. CONCLUSIONS: The uptake and transport of SLN in the lymph, and to a lesser extent in the blood, were evidenced. The in vivo physical stability of SLN may have important implications in designing drug-carrying SLN.     

Outbreak of fatal salmonellosis in cats following use of a high-titer modified-live panleukopenia virus vaccine

A 14-week-old kitten from a private cattery was examined because of an acute onset of recumbency and epistaxis 10 days after receiving a high-titer modified-live virus vaccine containing panleukopenia virus, calicivirus, and herpesvirus components. The kitten died the following day, and intestinal crypt necrosis; hepatic, splenic, and lymph node inflammation and necrosis; and pneumonia were seen at necropsy. Salmonella typhimurium was isolated from mesenteric lymph nodes and the spleen. The breeder reported that 4 other kittens had died in the previous month, each within 1 to 2 weeks after being vaccinated with the same modified-live virus vaccine. Carcasses of 3 kittens were available for examination, and Salmonella sp was isolated from mesenteric lymph nodes of all 3. Villus crypt necrosis and secondary fibrosis were also found. Three of the remaining 12 kittens in the cattery were also found to be shedding Salmonella sp in their feces. Clinical and pathologic findings in these kittens were likely attributable to salmonellosis and panleukopenia, and suggest that mild immunosuppression induced by vaccination could have facilitated development of fatal salmonellosis in subclinical carrier kittens. However, we cannot prove that vaccination actually played any role.     

Fatal multiple drug intoxication following acute sertraline use

A 53-year-old Caucasian male victim of suicide was suspected of overdose with sertraline and alprazolam after death-scene investigation. The concentration of sertraline, a selective serotonin reuptake inhibitor, was determined by a gas chromatograph with mass selective detection. The concentration of alprazolam, a triazolobenzodiazepine, was determined by high-performance liquid chromatography. The sertraline concentration was reported at 1.0 mg/L in peripheral blood, which is greater than previously reported in other postmortem cases in which death was attributed to a multiple drug overdose. The N-desmethylsertraline concentration was reported at 0.2 mg/L in peripheral blood, which is far less than in other postmortem cases and suggests acute intoxication in this case. The alprazolam concentration was reported at 33 microg/L in heart blood, which is within the therapeutic range. The cause of death was multiple drug intoxication following acute use of sertraline, the manner of death was suicide, and the mechanism of death is an unexplained drug interaction and/or toxicity.