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Current Issue

September - October, 2013

Vol. 12 Issue 5

On the cover: Abdominal CT scan showed an homogeneous and complete uptake of lipiodol within the hepatocellular carcinoma, simulating intrahepatic calcification.

HEPATOLOGY HIGHLIGHTS

CONCISE REVIEW

  • Coagulation abnormalities in the cirrhotic patient Jimena Muciño-Bermejo, Raúl Carrillo-Esper, Misael Uribe, Nahum Méndez-Sánchez Page 713-724

    The clotting process is a dynamic array of multiple processes which can be described in four phases: platelet plug initiation and formation, clotting process propagation by the coagulation cascade, clotting termination by antithrombotic mechanisms and clot removal by fibrinolysis. The liver plays a central role in each of these phases of clotting process, as it synthesizes the majority of coagulation factors and proteins involved in fibrinolysis as well as thrombopoeitin, which is responsible for platelet production from megakaryocytes. Many pathological processes associated with cirrhosis, such as portal hypertension and endothelial dysfunction, as well as co-morbid conditions, may also alter the coagulation process. Consequently, patients with liver disease have a disturbed balance of procoagulant and anti-coagulant factors which deviates from the normal coagulation cascade. This situation poses an additional problem in the diagnostic and therapeutic approach to this group of patients, since traditional coagulation test may not be reliable for assessing bleeding or thrombotic risk and traditional transfusional strategies may not be applicable in cirrhotic patients. In this article, we review the pathophysiological bases of coagulation abnormalities, in cirrhotic patients, the diagnostic therapeutic strategies to be followed and its impact on the clinical outcome in the cirrhotic patient.

ORIGINAL ARTICLES

Clinical Studies

Viral Hepatitis
  • Use of proteomic analysis tools to identify HCV-proteins down-regulated by acetylsalicylic acid Adriana Sánchez-García, Clara Patricia Ríos-Ibarra, Ana Rosa Rincón-Sánchez, Rocío Ortiz-López, Aurora Garza-Juárez, Jesús Morlett-Chávez, Herminia Martínez-Rodríguez, Ana María Rivas-Estilla Page 725-732

    Background and aim. Acetylsalicylic acid (ASA) has been shown to downregulate HCV expression; however, the involved mechanisms are unknown. We used proteomic analysis to compare protein expression profiles between human hepatocarcinoma cells (Huh7) and Huh7-HCV cells harboring expression of non-structural HCV proteins, to elucidate the mechanism(s) involved in ASA-mediated downregulation of HCV replication. Material and methods. Both cell lines were treated or untreated with 4 mM ASA and harvested at 0, 24, 48 and 72 h to isolate total proteins, which were resolved by two-dimensional gel electrophoresis (2DE) to separate them by isoelectric point (pI), followed by fractionation by molecular weight (MW). Gels were scanned and analyzed with PD-Quest software V8.0.1, and proteins were elucidated by the specific pI and MW using TAGIDENT software. Statistics analysis included the t-test. Results and Discussion. Different protein patterns among hepatocytes expressing HCV-proteins in ASA treated and untreated cells were found. Among proteins differentially expressed in Huh7-HCV cells, we found proteins related to cell proliferation (MTMR6, FAM22, HDGF and HCF-1) after 24 h of ASA treatment; and upregulation of angiostatin, PI4KA and STAT-1 after 48 h of treatment. Finally, at 72 h of ASA exposure, we identified overexpression of adenylsuccinate synthase, 2'-3'-di-deoxyadenosine, ubiquitin-protein-ligase E6A, adenylosuccinate-lyase and nibrin (NBN). Conclusion. We found that ASA induces different protein patterns in Huh7-HCV cells promoting activation of proteins involved in cell progression, repair of double strand breaks, proliferation, inhibition of apoptosis and growth stimulation at the same time that it decreased HCV expression.

  • The X-ray repair cross complementing protein 1 (XRCC1) rs25487 polymorphism and susceptibility to cirrhosis in Brazilian patients with chronic viral hepatitis Samantha Therezinha Almeida Pereira Leite, Nathália Marques-Guimarães, Júlio César Silva-Oliveira, Francisco José Dutra-Souto, Raquel Alves-dos-Santos, Carmen Lucia Bassi-Branco Page 733-739

    Introduction. The progression of hepatic disease in chronic viral hepatitis is accompanied by an increased production of reactive oxygen species (ROS), as well as an accumulation of oxidative DNA damage, which is primarily repaired through base excision repair. XRCC1 (X-ray repair cross complementing protein 1) is one of the most important proteins involved in this repair pathway. The present study was carried out to verify the possible association of the XRCC1 rs25487 polymorphism with cirrhosis in patients from Central-West Brazil. Material and methods. A total of 227 individuals with viral hepatitis, 53 cirrhotic and 174 non-cirrhotic, were genotyped for the XRCC1 rs25487 polymorphism using PCR-RFLP. Results: There were significantly higher frequencies of both the Arg/Gln genotype and of individuals with at least one Gln allele (Arg/ Gln+Gln/Gln) among cirrhotic patients (56.6% and 69.8%) compared with non-cirrhotic patients (25.8% and 37.9%). Both conditions were significantly associated with cirrhosis, independent of age, sex, alcohol intake or tobacco use (adjusted OR = 3.5, CI = 1.7-7.4, p = 0.001 and adjusted OR = 3.1, CI = 1.5-6.3, p = 0.002, respectively). Similar results were obtained for a group of HCV-infected patients but not for HBV-infected patients. Conclusions. The XRCC1 rs25487 polymorphism may influence the development of cirrhosis in viral hepatitis patients, and additional investigation will be necessary.

  • Non-invasive assessment of liver steatosis and fibrosis in HIV/HCV- and HCV- infected patients Valentina Li Vecchi, Lydia Giannitrapani, Paola Di Carlo, Giovanni Mazzola, Pietro Colletti, Emanuele La Spada, Giovanni Vizzini, Giuseppe Montalto, Maurizio Soresi Page 740-748

    Background. Conflicting data have been reported on the prevalence of liver steatosis, its risk factors and its relationship with fibrosis in patients with human immunodeficiency virus (HIV)/hepatitis C virus (HCV) co-infection or with HCV mono-infection. Aim. The study aims were to assess steatosis prevalence and its risk factors in both HCV groups. We also evaluated whether steatosis was linked with advanced fibrosis. Sixty-eight HIV/HCV co-infected and 69 HCV mono-infected patients were consecutively enrolled. They underwent liver ultrasonography and transient elastography. Bright liver echo-pattern was used to diagnose steatosis; advanced fibrosis was defined as liver stiffness ≥ 9.5 kPa and FIB-4 values ≥ 3.25. The optimal stiffness cut-off according to FIB-4 ≥ 3.25 was evaluated by ROC analysis. Results. No significant difference was found in steatosis-prevalence between mono- and co-infected patients (46.3 vs. 51.4%). Steatosis was associated with triglycerides and impaired fasting glucose/diabetes in HCV mono-infected, with lipodystrophy, metabolic syndrome, total-cholesterol and triglycerides in co-infected patients. Stiffness ≥ 9.5 was significantly more frequent in co-infection (P < 0.003). Advanced fibrosis wasn't significantly associated with steatosis. The area under the ROC curve was 0.85 (95% CI 0.79-0.9). On multivariate analysis steatosis was associated with triglycerides in both HCV mono- and co-infected groups (P < 0.02; P < 0.03). Conclusion. Although steatosis was common in both HCV mono- and co-infected patients, it was not linked with advanced fibrosis. Triglycerides were independent predictors of steatosis in either of the HCV-groups. Dietary interventions and lifestyle changes should be proposed to prevent metabolic risk factors.

Non alcoholic fatty liver disease (NAFLD)
  • Adipocytokines and cytokeratin-18 in patients with nonalcoholic fatty liver disease: Introduction of CHA index Stergios A. Polyzos, Jannis Kountouras, Athanasios Papatheodorou, Evangelia Katsiki, Kalliopi Patsiaoura, Efthimia Zafeiriadou, Christos Zavos, Evridiki Papadopoulou, Evangelos Terpos Page 749-757

    Background and rationale. Insulin resistance (IR), adipocytokines, oxidative stress and hepatic apoptosis play a pathogenetic role in nonalcoholic fatty liver disease (NAFLD). Aims. The evaluation of specific adipocytokines and markers of IR, oxidative stress and apoptosis in NAFLD patients; the introduction of a combined non-invasive index for nonalcoholic steatohepatitis (NASH). Material and methods. Thirty patients with biopsy-proven NAFLD (15 with simple nonalcoholic fatty liver [NAFL], 15 with NASH) and 24 controls were recruited. Blood samples for total and high molecular weight (HMW) adiponectin, visfatin and tumor necrosis factor (TNF)-α, the apoptotic by-product cytokeratin (CK)-18, the reactive oxygen metabolites (ROMs) and standard biochemical tests were measured. Homeostatic model of assessment - insulin resistance (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI) were calculated. Main results: Total and HMW adiponectin were significantly lower and TNF-α higher in either NAFL or NASH group compared to control group; CK-18 was significantly higher in NASH compared to either NAFL or control group. CHAI (an acronym of CK-18, HOMA-IR, AST Index) was calculated as the product of parameters being significantly different between NAFL and NASH groups. CHAI was significantly higher in NASH (24.2 [15.1-214.0]) compared to either NAFL (15.7 [6.8-22.7]) or control (5.1 [2.4-7.6]) group (p < 0.001) and significantly higher as the severity of steatosis, fibrosis, ballooning, lobular and portal inflammation advanced. Conclusion. CHAI was escalating from controls to NAFL and NASH and was higher by increasing the severity of all the main histological lesions. However, a validation study is needed before introducing CHAI in clinical practice.

  • Primary care practitioners survey of non-alcoholic fatty liver disease Adnan Said, Veronika Gagovic, Kristen Malecki, Marjory L. Givens, F. Javier Nieto Page 758-765

    Background. The rising incidence of non alcoholic fatty liver disease (NAFLD) mirrors the epidemics of obesity and metabolic syndrome. Primary care practitioners (PCPs) are central to management of patients with NAFLD, but data on knowledge and attitudes of PCPs towards NAFLD are lacking. Material and methods. We conducted a statewide, stratified survey of 250 PCPs to examine knowledge, practices and attitudes regarding NAFLD and the barriers to providing care for this condition. Results. NAFLD was perceived as an important health problem by 83% of PCPs. Eighty five percent of PCPs underestimated the population prevalence of NAFLD. Although the association of NAFLD with metabolic syndrome was identified by 91% of PCPs, only 46% screened diabetic obese patients for NAFLD. Only 27% of PCPs referred NAFLD patients to a hepatologist for evaluation. PCPs who reported seeing more than 5 NAFLD patients annually, referred to hepatology less frequently (P = 0.01). The majority of PCPs (58%) recommended weight loss and a calorie restriction. Only 8% of PCPs would recommend Vitamin E. The major perceived barrier in managing NAFLD was lack of confidence in understanding of the disease (58% of PCPs). Discussion. An overwhelming majority of PCPs perceived NAFLD as an important health issue in their practice. However, screening rates for NAFLD among obese diabetics were low. A major barrier to managing these patients was self-reported lack of knowledge about NAFLD. Development of guidelines should emphasize strategies for screening vulnerable populations (obese, diabetics), evidence based management and barriers to providing care.

Hepatocellular Carcinoma (HCC)
  • Imaging surveillance and multidisciplinary review improves curative therapy access and survival in HCC patients Ron C. Gaba, Eric R. Kallwitz, Ahmad Parvinian, James T. Bui, Natasha M. Von Roenn, Jamie L. Berkes, Scott J. Cotler Page 766-773

    Introduction. Imaging surveillance and multidisciplinary conference (MDC) review can potentially improve survival in patients with hepatocellular carcinoma (HCC) by increasing access to liver transplantation. Geographic disparities in donor organ availability may reduce this benefit. This study evaluated the impact of HCC surveillance on use of curative therapies and survival in a region with long transplant waiting times. Material and methods. 167 HCC patients were retrospectively studied. Subjects had an established HCC diagnosis or were diagnosed during hepatology follow-up. Collected data included patient demographics, HCC surveillance and MDC review status, portal hypertension complications, laboratory and radiologic parameters, tumor size, therapeutic interventions, tumor progression, and mortality. The primary outcome measures were use of curative treatments and survival. A Cox-regression model was constructed utilizing factors associated with survival in univariate analysis. Results. 58% of subjects underwent surveillance and MDC review of HCC. These patients were more likely to have received treatment with ablation or resection (16 vs. 3%, P = 0.006) and transplantation (23 vs. 4%, P = 0.001), and were less likely to develop tumor progression (45 vs. 68%, P = 0.005) or metastases (0 vs. 19%, P < 0.001). In multivariate analysis, surveillance and MDC review (P = 0.034, HR 0.520, 95% CI 0.284-0.952), tumor meeting Milan criteria (P < 0.001, HR 0.329, 95% CI 0.178-0.607), curative therapy application (P = 0.048, HR 0.130, 95% CI 0.017-0.979), and transplantation (P = 0.004, HR 0.236, 95% CI 0.088-0.632) were associated with survival. Conclusion. In conclusion, imaging surveillance and MDC review is associated with detection of early stage HCC, increased access to curative therapies and transplantation, and prolonged survival.

  • Caspase recruitment domains. New potential markers for diagnosis of hepatocellular carcinoma associated with HCV in Egyptian patients Abdel-Rahman Zekri, Mohamed El-Kassas, Yasmin Saad, Abeer Bahnassy, Hany Khatab Sameh Seif El-Din, Samar K. Darweesh, Hanan Abdel Hafez, Gamal Esmat Page 774-781

    Background and rational for the study. Chronic HCV is a major cause of HCC development. Caspase Recruitment Domains (CARD) is protein modules that regulate apoptosis and play an important role in various carcinogenesis processes, our aim is to assess the possible role of CARD9, CARD10 and Caspase only protein (COP) in progression of liver fibrosis and pathogenesis of HCC in Egyptian chronic HCV patients. Material and methods. 130 patients were recruited and classified into 4 groups; I: chronic HCV, II: chronic active hepatitis, III: liver cirrhosis, IV: HCV related HCC. Biochemical, virological studies, abdominal ultrasonography and liver biopsy were performed. Quantitative estimation of mRNA of CARD9, CARD10 and COP gene expression was performed by RT- PCR in liver biopsy from all patients. Results. In HCC patients; age, AFP and liver profile were significantly higher, HB and platelets were significantly lower (p value <0.01). The expression levels of mRNA of CARD9, CARD10 and COP in liver biopsies of HCC were significantly higher than other groups with direct correlation with age and no correlation with AFP, viral load, liver fibrosis or necroinflammatory activity. On differentiation between HCC and non HCC patients each CARD was assessed separately and combined, on combing the 3 CARDs, the sensitivity was 100%, specificity was 48%, positive predictive value 47% and negative predictive value 100%. Conclusions. CARD9, CARD10 and COP had no role in liver fibrosis but may be involved in hepatic carcinogenesis and they could be used as markers for HCC diagnosis and candid genes for molecular target therapy.

Miscellaneous
  • Treatment of polycystic liver disease: a hypothesis, patient characteristics, short and long-term results Zheng Long-Xian, Liu Ai-Wu, Qin Hua-Dong, Cui Jun, Jiang Hui-Jie, Jia Hong-Bo Page 782-790

    Background. Non-total liver resecting invasive treatment of polycystic liver disease has different recurrence rates. The aim of this study is to illustrate why the recurrence rates are different. We established a hypothesis that the cyst number is a constant in polycystic liver disease in a patient's lifetime. Material and methods. We selected 287 patients with polycystic liver, in which 35 patients had the record of liver volume, while other 252 patients had the record of length of right liver. Data were divided into 5 groups in terms of age. The intergroup comparison with different ages and clinical files of patients were analyzed. Results. The mean difference was statistically insignificant when compared amongst groups in the lengths of right liver respectively. Symptom recurrence rates (q) were 19.05 and 17.65% respectively after cyst aspiration-sclerotherapy and non-cyst aspiration-sclerotherapy. Conclusion. The cyst number is a constant in patients with non-massive or massive polycystic liver disease in their lifetime.

  • Acute liver failure in under two year-olds - are there markers of metabolic disease on admission? Ana Brett, Carla Pinto, Leonor Carvalho, Paula Garcia, Luísa Diogo, Isabel Gonçalves Page 791-796

    Introduction. The early establishment of an etiology for acute liver failure (ALF) in infants is essential for the start of adequate treatment in the shortest timeframe possible. Aim. To identify markers of inherited metabolic disease on admission in children under two years of age with ALF. Material and methods. A retrospective review of the medical records of all children (< 2 years old) with ALF admitted to the pediatric hepatology or intensive care units of a tertiary center over a twenty-three year period (January 1989 to December 2011) was done. Patients were divided into two groups: with (group A) or without (group B) a metabolic etiology. Clinical and laboratory parameters on admission were compared. Results. Twenty-three children met inclusion criteria. Twelve had ALF of metabolic origin (group A). The median age in this group was 2.25 (Q1-Q3: 0.63-4.65) months and in group B 8.0 (Q1-Q3: 1.5-15) months. History of failure to thrive and/or vomiting was more frequent in group A (p = 0.022). Age, gender, encephalopathy and left ventricular hypertrophy were similar in both groups (p = 0.147, p = 1.000, p = 0.637, p = 1.000, respectively). Laboratory tests on admission (plasma lactate, ammonia, cholesterol, phosphate, INR, glucose, bilirubin, ALT, base excess and the presence of reducing substances in urine) showed no statistically significant differences between groups. Conclusion. This study showed that although infants with inborn errors of metabolism showed a trend towards lower age at presentation, the only marker.

  • Within-patient temporal variance in MELD score and impact on survival prediction after TIPS creation Ron C. Gaba, Kruti D. Shah, Patrick M. Couture, Ahmad Parvinian, Jeet Minocha, M. Grace Knuttinen, James T. Bui Page 797-802

    Background. To assess within-patient temporal variability in Model for End Stage Liver Disease (MELD) scores and impact on outcome prognostication after transjugular intrahepatic portosystemic shunt (TIPS) creation. Material and methods. In this single institution retrospective study, MELD score was calculated in 68 patients (M:F = 42:26, mean age 55 years) at 4 pre-procedure time points (1, 2-6, 7-14, and 15-35 days) before TIPS creation. Medical record review was used to identify 30- and 90-day clinical outcomes. Within-patient variability in pre-procedure MELD scores was assessed using repeated measures analysis of variance, and the ability of MELD scores at different time points to predict post-TIPS mortality was evaluated by comparing area under receiver operating characteristic (AUROC) curves. Results. TIPS were successfully created for ascites (n = 30), variceal hemorrhage (n = 29), hepatic hydrothorax (n = 8), and portal vein thrombosis (n = 1). Pre-TIPS MELD scores showed significant (P = 0.032) within-subject variance that approached ± 18.5%. Higher MELD scores demonstrated greater variability in sequential scores as compared to lower MELD scores. Overall 30- and 90-day patient mortality was 22% (15/67) and 38% (24/64). AUROC curves showed that most recent MELD scores performed on the day of TIPS had superior predictive capacity for 30- (0.876, P = 0.037) and 90-day (0.805 P = 0.020) mortality compared to MELD scores performed 2-6 or 7-14 days prior. Conclusions. In conclusion, MELD scores show within-patient variability over time, and scores calculated on the day of TIPS most accurately predict risk and should be used for patient selection and counseling.

  • Oral Acetyl-L-Carnitine treatment in hepatic encephalopathy: view of evidence-based medicine Qian Jiang, Gang Jiang, Ke-Qing Shi, Hong Cai, Yi-xin Wang, Ming-hua Zheng Page 803-809

    Objective. To systematically review the effect of Acetyl-L-Carnitine in patients with hepatic encephalopathy. Material and methods. Design: systematic review and meta-analysis. Data sources: The Cochrane Library, MEDLINE, EMBASE.com, Science Citation Index, Google search and the China Biological Medicine Database to June 2012. Review methods: randomized placebo controlled trials of Acetyl-L-Carnitine in patients with hepatic encephalopathy assessing whether Acetyl-L-Carnitine an effective therapy or not. No language restrictions were applied. Two reviewers independently extracted data and assessed quality. Results. 7 methodologically sound randomized controlled trials were identified involving 660 participants with hepatic encephalopathy, totaling 249 with subclinical hepatic encephalopathy, 189 with West Haven grade 1, 162 with West Haven grade 2 and 60 with West Haven grade 3. Acetyl-L-Carnitine was effective to improve serum ammonia level (weighted mean difference 25.90, 95% confidence intervals 20.89 to 30.91, P < 0.05) and the number connection test completion time (weighted mean difference 16.62, 95% confidence intervals 9.88 to 23.36, P < 0.05). The outcome was consistent in subgroup analyses. No publication bias was detected. Adverse events were reported infrequently and were minor. Conclusions. Acetyl-L-Carnitine is promising as an effective and tolerable treatment for hepatic encephalopathy that associated with improved serum ammonia levels and the number connection test.

  • Aspartate aminotransferase-to-platelet ratio index (APRI) for the non-invasive prediction of esophageal varices Ângelo Zambam De Mattos, Angelo Alves de Mattos, Larissa Faraco Daros, Maiara Isabel Musskopf Page 810-814

    Background & Aims. Variceal bleeding is a dramatic and common complication of cirrhosis, and, therefore, endoscopy is recommended for the screening of EV (esophageal varices) in every cirrhotic. This study evaluates the capacity of APRI (aspartate aminotransferase-to-platelet ratio index) in non-invasively predicting EV. Material and methods. This cross-sectional study evaluated cirrhotics for their APRI value and the presence of EV, with a cutoff point of 1, 3; platelet count, spleen diameter, PC/SD (platelet count/ spleen diameter ratio), aspartate aminotransferase/alanine aminotransferase ratio, Child-Pugh score and MELD (model for end-stage liver disease) score were also studied. Results. The study included 164 cirrhotics, 59.7% male, with a mean age of 56.7 years. APRI demonstrated a sensitivity of 64.7% (95% confidence interval-95%CI = 0.56-0.73), specificity of 72.7% (95%CI = 0.59-0.86), positive predictive value of 86.5% (95%CI = 0.79-0.94), negative predictive value of 43.2% (95%CI = 0.32-0.55). In the univariate analysis, platelet count, spleen diameter, Child and MELD scores, PC/SD and APRI were related to EV (p < 0.05). In the logistic regression, only platelet count and Child score were associated to EV (p < 0.05). Conclusion. APRI is not an independent factor for the prediction of EV. Its sensitivity, specificity and predictive values are insufficient for the index to be used for the screening of EV in cirrhotics.

Basic studies

  • Notch signal protects non-parenchymal cells from ischemia/reperfusion injury in vitro by repressing ROS Heng-Chao Yu, Shu-Qiang Yue, De-Sheng Wang, Lin Wang, Hua Han, Ke-Feng Dou Page 815-821

    Background. We have previously reported that Notch signaling pathway protects hepatocytes from ischemia/ reperfusion (I/R) injury by repressing reactive oxygen species (ROS) production. However, apart from hepatocytes, non-parenchymal cells including vascular endothelia cells, Kupffer cells and hepatic stellate cells are also reported to be involved in hepatic I/R injury. Aim. To clarify the role of Notch signaling in non-parenchymal cells subjected to I/R injury. Materials and methods. Human Umbilical Vein Endothelial Cells (HUVECs), mouse macrophage line RAW264.7 and rat hepatic stellate cell line HSC-T6 were cultured and subjected to I/R injury, respectively. Activation of Notch signaling was assessed by NICD western blot. Then, pharmacological inhibitor (γ-secretase inhibitor GSI) was used to block Notch signaling of related cell lines in vitro. Intracellular ROS was detected and analyzed by FACS and apoptosis was examined by TUNEL staining and Annexin V staining. Results. Notch signaling responded to I/R injury and I/R injury induced activation of Notch signaling in nonparenchymal cells. Notch signal deficiency led to overproduction of ROS and aggravated cell death of non-parenchymal cells subjected to I/R injury. Conclusion. Notch signal protectes non-parenchymal cells from I/R injury by repressing ROS.

IMAGES IN HEPATOLOGY

CASE REPORTS

  • Hepatocellular carcinoma that arose from primary Sjögren’s syndrome Ming-Xian Yan, Jing Yang, Qing Sun, Chang-Hong Liu, Yi-Guo Wang, Wen-Qi Wang Page 824-829

    Hepatocellular carcinoma (HCC) typically originates from HBV or HCV associated liver cirrhosis. Primary Sjögren's syndrome (pSS) is a kind of autoimmune disease. A sixty-two year old female patient with mild liver damage was diagnosed with pSS after excluding viral, alcoholic and drug-induced hepatitis according to serum immunological detection and liver biopsy. But when she was hospitalized for a second time two years later, a CT scan revealed liver neoplasm. Surgery confirmed HCC and liver cirrhosis by pathology. The elevated level of AFP recovered to normal after tumorectomy. In conclusion, HCC might be a candidate outcome in patients with pSS; it is the doctors' responsibility to keep this kind of patient under surveillance.

  • Rhombencephalitis by Listeria monocytogenes in a cirrhotic patient: a case report and literature review Raúl Carrillo-Esper, Luis Daniel Carrillo-Cordova, Isis Espinoza de los Monteros-Estrada, Agustín Omar Rosales-Gutiérrez, Misael Uribe, Nahum Méndez-Sánchez Page 830-833

    We report a case of rhombencephalitis infection by Listeria monocytogenes in a 66-year-old man with cirrhosis. The CSF analysis indicated L. monocytogenes as the most likely pathogen. Blood and CSF culture were positive to L. monocytogenes and MRI findings were suggestive of rhomboencephalitis. The treatment was started empirically and then modified when the culture results were available. The patient had a full clinical recovery without neurologic sequelae. Clinicians should remember that L. monocytogenes most often presents as acute bacterial meningitis, particularly in the elderly, the immunosuppressed, and those with malignancies. L. monocytogenes CNS the infections may present as acute bacterial meningitis, meningoencephalitis, or acute encephalitis.

  • Subacute liver failure by pseudocirrhotic metastatic breast cancer infiltration Christoph Jüngst, Jens Krämer, Günther Schneider, Frank Lammert, Vincent Zimmer Page 834-836

    Hepatic metastases are common in the clinical course of breast cancer and typically appear as mass lesions. This report describes the case of a 70-year-old woman with a history of breast cancer and no previously known liver disease presenting with the first episode of variceal bleeding and subacute hepatic failure. Imaging studies indicated liver cirrhosis without signs of malignant focal lesions. Comprehensive diagnostic work-up was negative for specific causes of liver disease and provided no evidence for tumor recurrence. Finally transjugular liver biopsy revealed a marked diffuse desmoplastic infiltration by breast cancer cells. Malignant pseudocirrhosis is an unusual pattern of metastatic tumor, spread representing a rare but important differential diagnosis of progressive liver failure. Liver biopsy is the key procedure to establish the diagnosis as imaging studies may mimic cirrhosis.

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