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ABSTRACTS OF PAPERS AT THE 74TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY, 14TH FEBRUARY 2000, 2.30 PM SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. LAMIVUDINE IN DECOMPENSATED LIVER DISEASE DUE TO CHRONIC HBV INFECTION
D N Amarapurkar, A Rao
Though interferon alpha 2B is only established treatment of chronic Hepatitis B (HBV) infection, it is contraindicated in patients with decompensated liver disease. Lamivudine has been shown to be equally effective in compensated chronic HBV infection as interferons. Lamivudine is considered to be safe in patient of decompensated liver disease. Hence to study the utility of lamivudine in decompensated chronic liver disease due to HBV infection. We treated 15 consecutive patients with 150 mg lamivudine PO daily for one year and followed them up 6 months after stopping treatment. Of the 15 patients 13 were male and 2 females with age ranging from 4 to 62 years, 10 patients were infected with wild type virus (HBeAg +ve, HBVDNA +ve) while 5 had pre core mutant infection (Anti HBe +ve HBVDNA -ve). All patients had elevated transaminases with at least 2 times elevation than upper limit of normal. Out of 15 patients 7 had jaundice, 7 had tense ascites and one patient was in encephalopathy. 8/15 (53%) patients recovered (5/10 HBeAg -ve Anti HBe +ve 3/5 HBVDNA -ve), jaundice disappeared, transaminases, normalized encephalopathy and ascites came under control. 2/15 patients died during therapy, one due to massive upper GI bleed and one due to hepatocellular carcinoma. Three patients who were clinically improving showed deterioration and were fulfilled clinical criterias for YMDD mutations and 3 (20%) were non responders (i.e. clinical, biochemical, virological improvement). In conclusions 50% of patients with decompensated liver disease due to HBV infection can show improvement with the lamivudine treatment for one year.
2. EXTRAHEPATIC MANIFESTATIONS OF VIRAL HEPATITIS-HOSPITAL BASED STUDY
D N Amarapurkar*, A D Amarapurkar**, A L Kirpalani***
Viral hepatitis has been shown to be associated with various extrahepatic manifestations. Extrahepatic manifestations can be seen in both acute and chronic liver disease, may precede or follow over liver disease and some times liver disease may not be manifest. To assess the prevalence of extrahepatic manifestation we prospectively evaluated patients with viral hepatitis for extrahepatic manifestations and patients with glomerulonephritis, polyarteritis nodosa etc for evidence of Hepatitis virus infection. A total of 448 patients were evaluated of which 181 had Hepatitis B infection, 142 had Hepatitic C infection, 86 had Hepatitis E infection and 39 had hepatitis A infection. Table shows extrahepatic manifestations in various viral hepatitis.
n Hep. A Hep. B Acute Chronic Hep. C Chronic Hep. E Haematological Thrombocytopenia 4 2 2 Agranulocytosis 2 2 Aplastic anaemia 1 1 Glomerulonephritis 13 10 3 Polyarteritis nodosa 6 6 Cryoglobulinaemia 2 2 Pancreatitis 1 1
Patients with Hep. A and extrahepatic manifestations showed complete recovery in both hepatitis and extrahepatic manifestations. Six patients with PAN were treated with interferon of which four showed excellent response. Three patients of Hep. B and Hep. C related GN were treated with interferon. 4/6 responded well to treatment. In conclusion 6 to 10% patients with viral hepatitis have extrahepatic manifestations. These manifestations recover completely with recovery from viral hepatitis.
3. IS DIABETES MELLITUS AN EXTRAHEPATIC MANIFESTATION OF HEPATITIS C INFECTION?
Deepak N Amarapurkar
Background : Association of chronic liver disease with diabetes is well known. Chronic hepatitis B and C infections are known to occur more frequently in diabetics than in general population because of the frequent parenteral exposure in them. Hepatitis C infection (HCV) does not affect only liver but is also found in various organs outside the liver and is held responsible for various extrahepatic manifestation. Diabetes mellitus has been shown to be associated HCV infection. This study was planned to find the relation of HCV infection with diabetes mellitus.Method : To study correlation of diabetes mellitus with HCV infection 200 consecutive patients of chronic hepatitis C infection and chronic hepatitis B infection each and 200 consecutive patients attending gastroenterology, out patients were evaluated for history of diabetes mellitus and tested with blood sugar assay in fasting and post prandial and glycosylated haemoglobin. Patients were assigned a diagnosis of diabetes mellitus if there was documented use of oral hypoglycaemic agents or insulin and blood glucose level more than 200 mg/dl on two occasions. Diagnosis of chronic viral hepatitis was made on the basis of antiHCV +ve for more than 6 months, evidence of cirrhosis and demonstration of HCV RNA in the serum, and liver biopsy whenever feasible. For diagnosis of chronic HBV infection demonstration of HBsAg positive more than 6 month with or without HBeAg positivity was used. 200 patients without evidence of chronic liver disease and negative for HBsAg and antiHCV served as controls.
Results : Fourteen per cent (28/200) chronic HCV infected patients, 8.5% (17/200) chronic HBV infected patients while 5% (10/200) control patients had diabetes mellitus. Incidence of diabetes mellitus was significantly higher in chronic HCV infection as compared to other groups. For patients with cirrhosis prevalence of diabetes was similar in HCV and in HBV infection. Incidence of diabetes mellitus was significantly higher in HCV infection when entire cohort was considered.
Conclusion : This data suggest significantly strong association between chronic HCV infection and diabetes mellitus.
4. IMMUNOCHEMICAL CHARACTERISATION AND CLINICAL EVALUATION OF PELTOPHORUM FERRUNGINEUM POLLEN GRAIN FROM BOMBAY CITY
U D Mahadik, P V Niphadkar, A B Singh, H L Dhar
The pollen grains are one of the chief environmental cause of seasonal pollinosis. The aerobiological survey of Mumbai city carried out at the Department of life sciences, Mumbai has shown that Peltophorum ferrugineum (P.F) pollen has a highest atmospheric prevalence and commonest aeroallergen in Mumbai citys atmosphere. In electron microscopy investigation under high resolution pollen of Peltophorum ferrugineum exhibit perfect tricolporate pattern and shows highly dense glycoprotein in intine region.559 patients were investigated for total IgE, skin prick test and nasal provocation test. Specific IgE were investigated on 26 severe P.F. allergic patients by ELISA, SDS-PAGE, DOT Blotting and Western blotting. Of the total 559 patients, 39 (6.9%) patients were severely positive of P.F. pollen allergen extract in skin sensitivity test. Six of the total nine patients have shown 90% decrease in nasal resistance and nasal air flow in nasal provocation test.
Of the 26 patients screened for specific IgE by ELISA with PF allergen extract, 19 were highly positive. Dot blot with pooled sera from 26 patients were positive. Allergen extract of Peltophorum ferrugineum resolved into 24-26 CBB stained bands in the molecular weight (Mol. wt) range of 10-116 KDa on 12% SDS - PAGE gel and in a parallel experiment with western blot analysis only 12 protein bands were found to be allergenic and could bind with specific IgE in the patients sera. Amongst the high Mol. Wt, protein bands at 76, 62, 45 and 38 KDa were recognised by Sp. IgE antibodies from 96% of 26 individual sera samples and they are major allergen protein from PF binds with IgE from patients sera.
In conclusion, Peltophorum ferrugineum is an important pollen aeroallergen causing allergic disorders from Bombay city.
5. THYROID DISORDERS AND HYPERTENSION
DM Sharma, DR Jangid, SV Joshi, HL Dhar
This study was conducted in the department of Nuclear Medicine and department of Medical Research. Systemic nonthyroidal illness has effect on the thyroid hormone secretion, transport and metabolism. This study was performed to find the association and correlation of hypertension in thyroid disorders.Detailed clinical history was taken in 650 patients. Their T3, T4, TSH were estimated by RIA. Urea, creatinine, cholesterol, and catecholamines were measured in 52 hypertensive subjects.
It was found that hyperthyroidism and hypothyroidism were prevalent in age group of 36-45 years. Out of 52 hypertensive patients 42.3% had hyperthyroidism 19.1% had hypothyroidism, 23.0% had normal thyroid function while 15.4% had thyroiditis. Increased level of catecholamines were seen in both hyperthyroid and hypothyroid subjects.
In conclusion, hypertension was more associated with hyperthyroidism. This could be due to reduction in peripheral vascular resistance and lightened receptor sensitivity to catecholamines and higher renin - angiotensin activity.
6. DEGREE OF SENSITIZATION TO INHALANT ALLERGENS - THEIR SIGNIFICANCE IN PEAK EXPIRATORY FLOW VARIABILITY IN ASTHMA
S V Joshi, D M Tripathi, H L Dhar
Asthma occurs in association with exposure to different allergen which are the components of our natural environment. They induce and elicit IgE mediated symptoms and diseases. Peak expiratory flow rate is used as a diagnostic tool in establishing airway hyper-responsiveness.Main goal of this study was to correlate the degree of sensitization to inhalant allergens (viz. house dust mite and pollens) and PEFR variability in asthma.
Out of 500 cases referred to allergy department, two hundred (cases of prediagnosed) asthmatic were selected for this study. 63% of subjects were sensitive to house dust mite. Those with elevated total IgE, 83% showed positive reaction for in vivo allergen specific IgE for house dust mite viz. D. farinae and D. pteronyssinus) and 40% for different pollens. Those with normal IgE levels, strong sensitivity for food allergens was predominant 67%, HDM 16% and pollen 17%. Peak expiratory flow rate which is used as a diagnostic tool is significantly lowered in the subjects having hypersensitivity to HDM compared to pollen. Degree of sensitivity in terms of mean wheal diameter (MWD) showed proportional decrease in PEFR compared to pollen sensitive subjects. Allergic Index (AI) had inverse relationship with PEFR values. Mite sensitive asthmatics reacted to exercise test showing lower values of PEFR at different time intervals compared to pollen sensitivity. Lability index was significantly higher in subjects with strong sensitivity for mites.
Our results indicate strong allergic manifestation of house dust mite in terms of PEFR variability compared to pollen and food allergens.
7. TUBERCULOSIS (TB) OF BONES AND JOINTS - ONE YEAR STUDY : 1995
AH Shah, SV Joshi, HL Dhar
Tubercular bacilli reaches the bone either through blood stream or by direct extension from an adjacent focus in joints or soft tissue.
This study aimed at the tropical perspective of extrapulmonary TB particularly of bones and joints. Out of 120 patients, 30 patients (25%) were upto 20 years of age. 75 (62.5%) were upto 21-60 and 15 (12.5%) were elderly 60+.
Radiological finding confirming tuberculosis infection in vertebral bodies was found in 94 patients (78.33%) compared with 20 (16.68%) of bones of hand and foot. 23 patients (19.17%) were suffering from TB of joints mainly knee joints (47.83%) followed by hip (30.43%), sacroiliac (17.39%) and occipital (4.35%).
Pain is the initial symptom (75%) followed by weakness (29.17%) fever (28.33%), loss of appetite (15.83%), weight loss (11.67%) swelling (10%).
Major complications were psoas abscess 13, mainly lumbar spine 8, Potts spine 2, foot, ankle and scapula 1 each. Pyogenic infection was observed in 6, synovitis in 4.
Radiologically pulm. TB was associated with TB of bones and joints in 8 (6.67%) and pleural effusion in 2 (1.67%).
Mycobacteria was isolated from sputum in 3 (2.5%) cases and acid fast bacilli in 1 (0.83%) case. Pus culture was showing pus cells in 9 (64.28%), AFB 4 (28.57), MTB 3 (21.42%), gm +ve cocci in 3 (21.42$), and strepto cocci in 1 (7.14%). Different modalities included MRI 8 (6.67%), CT Scan 14 (11.67%), Bone scan 3 (2.5%).
61 patients (50.83%) showed increased ESR value and 54 patients (45%) were anaemic. SGPT increased in 17 (14.16%), SGOT 13 (10.83%), Alkaline phosphatase in 22 (18.33%) and LDH in 19 (15.83%).
Majority of patients were prescribed INH followed by Ethambutol, Rifampicin, Pyrizinamide and Streptomycin and nearly half received four antitubercular drugs at a time and similar number received 3 drugs and a few 2 drugs. Surgical intervention were mostly for complications and did not alter the drug therapy.
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