Malignant melanoma with liver and spleen metastases: case report

CONTEXT: The diagnosis of primary melanoma is easily confirmed after histological analysis of the lesion, whereas it is rarely diagnosed when the patient even has distant metastases. DESIGN: Case report CASE REPORT: Malignant melanoma is responsible for about 1% of all deaths caused by cancer in the USA and only 3% of all malig-nant skin diseases. Malignant melanoma is a rare disease, although it corresponds to 65% of all deaths caused by skin cancer. The liver and spleen are rarely the first sites of melanoma metastases. This paper reports on the clinical picture of a patient with fatal malignant melanoma and hepatic and spleen metastases. As this was an un-usual presentation, the melanoma diagnosis could only be made after pathological analysis of the skin and hepatic lesions.CONTEXTO: O melanoma maligno é responsável por aproximadamente 1% de todas as mortes causadas por câncer nos EUA e apenas 3% de todas as doenças malignas cutâneas. Embora considerada uma patologia rara, representa 65% de todos os óbitos por câncer de pele. O fígado e o baço raramente são os primeiros sítios de metástases de melanoma. TIPO DE ESTUDO: Relato de caso. RELATO DE CASO: Este artigo relata o quadro de um paciente portador de melanoma maligno evoluindo para óbito com metástases hepática e esplênica. Por ser uma apresentação atípica da doença, o diagnóstico definitivo ocorreu somente após a análise histopatológica das lesões de pele e do fígado.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Department of PathologyUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Gastroenterology DivisionUNIFESP, EPM, Department of PathologyUNIFESP, EPM, Gastroenterology DivisionSciEL

A randomized double-blind study of the short-time treatment of obese patients with nonalcoholic fatty liver disease with ursodeoxycholic acid

In order to determine the effect of ursodeoxycholic acid on nonalcoholic fatty liver disease, 30 patients with body mass indices higher than 25, serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) or gamma-glutamyltransferase (gamma-GT) at least more than 1.5 times the upper limit of normality, and hepatic steatosis demonstrated by ultrasonography were randomized into two groups of 15 patients to receive placebo or 10 mg kg-1 day-1 ursodeoxycholic acid for three months. Abdominal computed tomography was performed to quantify hepatic fat content, which was significantly correlated with histological grading of steatosis (r s = -0.83, P < 0.01). Patient body mass index remained stable for both groups throughout the study, but a significant reduction in mean (± SEM) serum levels of ALT, AST and gamma-GT was observed only in the treated group (ALT = 81.2 ± 9.7, 44.8 ± 7.7, 48.1 ± 7.7 and 52.2 ± 6.3 IU/l at the beginning and after the first, second and third months, respectively, N = 14, P < 0.05). For the placebo group ALT values were 66.4 ± 9.8, 54.5 ± 7, 60 ± 7.6 and 43.7 ± 5 IU/l, respectively. No alterations in hepatic lipid content were observed in these patients by computed tomography examination (50.2 ± 4.2 Hounsfield units (HU) at the beginning versus 51.1 ± 4.1 HU at the third month). These results show that ursodeoxycholic acid is able to reduce serum levels of hepatic enzymes in patients with nonalcoholic fatty liver disease, but this effect is not related to modifications in liver fat content.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de MedicinaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnóstico por ImagemUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de PatologiaUNIFESP, EPM, Depto. de MedicinaUNIFESP, EPM, Depto. de Diagnóstico por ImagemUNIFESP, EPM, Depto. de PatologiaSciEL

Evaluation of an enzyme immunoassay for hepatitis C virus antibody detection using a recombinant protein derived from the core region of hepatitis C virus genome

This study was undertaken to evaluate an enzyme immunoassay (EIA) for hepatitis C virus antibody detection (anti-HCV), using just one antigen. Anti-HCV EIA was designed to detect anti-HCV IgG using on the solid-phase a recombinant C22 antigen localized at the N-terminal end of the core region of HCV genome, produced by BioMérieux. The serum samples diluted in phosphate buffer saline were added to wells coated with the C22, and incubated. After washings, the wells were loaded with conjugated anti-IgG, and read in a microtiter plate reader (492 nm). Serum samples of 145 patients were divided in two groups: a control group of 39 patients with non-C hepatitis (10 acute hepatitis A, 10 acute hepatitis B, 9 chronic hepatitis B, and 10 autoimmune hepatitis) and a study group consisting of 106 patients with chronic HCV hepatitis. In the study group all patients had anti-HCV detected by a commercially available EIA (Abbott®), specific for HCV structural and nonstructural polypeptides, alanine aminotransferase elevation or positive serum HCV-RNA detected by nested-PCR. They also had a liver biopsy compatible with chronic hepatitis. The test was positive in 101 of the 106 (95%) sera from patients in the study group and negative in 38 of the 39 (97%) sera from those in the control group, showing an accuracy of 96%. According to these results, our EIA could be used to detect anti-HCV in the serum of patients infected with hepatitis C virus.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaInstituto BioMérieuxUNIFESP, EPMSciEL

Liver ischemic necrosis and diabetes mellitus: case report

BACKGROUND AND OBJECTIVES: Hepatic infarction is characterized by parenchyma ischemic necrosis involving at least two acinis. It is extremely uncommon due to the arterial and portal venous blood supply. We report a case of a patient not know to have diabetes who developed massive areas of ischemic infarcts of the liver after episode of acutely diabetes decompensated. CASE REPORT: A 67 year-old hypertensive female who has been presenting, for the last 10 days, polydipsia, high urinary volume, visual and gait impairment, nausea and vomiting was admitted to the emergency room (ER). During the physical examination it was observed dehydration, skin discoloration, peripheral cyanosis, hypothermia, tachycardia, hypotension and mild diffuse abdominal pain. Admissional laboratory exams demonstrated total leukocytes: 16.800, Cr: 3.7, Ur: 167, Na: 133, K: 6.9, glucose: 561; arterial gasometry (O2 catheter: 2 L/min): pH: 6.93, pCO2: 12.1, pO2: 107, B.E.: -28.8, HCO3: 2.4, Sat 91.3%, lactato: 79; urinalysis: pH: 6; leukocytes: 13; density: 1015; erythrocytes: 19; protein: ++; glucose: +++; bilirubin: negative; ketonic bodies: + denote ketonemia. EKG: sharp T wave, right branch block. Patient was treated with intravenous insulin, hydration, sodium bicarbonate and ceftriaxone. After initial treatment, the laboratory exams showed Cr: 2.2, Ur: 122, Na: 162, K: 4.3, Ca: 6.4, glucose: 504, pH: 7.01, HCO3: 7.1, B.E.: -22. One day after admission the patient presented with important abdominal pain and peritoneal irritation, followed by difficulty for talking and somnolence; routine laboratory exams showed arterial gasometry: pH: 7.4, pCO2: 31, pO2: 68, BE: -4.4, HCO3: 19, SatO2: 93.5%; Ur: 95,Cr: 1.4, albumin: 2.4, Ca: 0.95, Na: 166, K:4, bilirubin: 0.5, bilirubin D/I: 0.2/0.3, Amylase: 1157, Gamma-GT: 56, AST 7.210, ALT: 2.470, SR (sedimentation rate): 15, Lipase: 84. Abdominal ultrasound was unremarkable. Patient respiratory function and conscience level worsened, requiring intubation. Despite all resuscitation efforts, she died. Necropsy showed multiple ischemic infarcts of the liver with vascular thrombosis, splenic infarcts, generalized visceral congestion and atherosclerosis of aorta and its branches. Pancreas was normal. CONCLUSIONS: The mechanisms of hepatic and splenic infarctions in this case were unclear. The following factors may have contributed to necrosis: vomiting and fever should be considered to induce dehydration and hypotension, which further decreased portal and hepatic arterial inflows; elevated level of catecholamine in hyperglycemic states might induce vasoconstriction effects; widespread atherosclerosis is commonly seen in diabetic and hypertensive patients. This case underlies the importance of searching for hepatic necrosis or infarction in any diabetic patient with elevated liver enzymes. Anticoagulation therapy should be instituted promptly upon recognition of vascular thromboses.JUSTIFICATIVA E OBJETIVOS: O infarto hepático é definido como necrose isquêmica do parênquima hepático envolvendo pelo menos dois ácinos. Trata-se de evento considerado raro devido ao duplo suprimento sangüíneo, arterial e venoso. O objetivo deste estudo foi relatar um caso de paciente não sabidamente diabética que desenvolveu extensas áreas isquêmicas de infarto hepático, após quadro de descompensação aguda da diabete. RELATO DO CASO: Paciente do sexo feminino, 67 anos, hipertensa, procurou o Pronto Socorro com queixas de polidipsia, poliúria, turvação visual, náuseas e vômitos, dificuldade para deambular, havia aproximadamente 10 dias. Ao exame físico foi observado desidratação, palidez cutânea, cianose periférica, hipotermia, taquicardia, hipotensão, dor abdominal leve e difusa. Exames laboratoriais mostraram: leucócitos: 16800, creatinina (Cr): 3,7, uréia (Ur): 167, Na: 133, K: 6.9, glicose: 561; gasometria arterial (cateter de oxigênio: 2 L/min): pH: 6.93, pCO2: 12.1, pO2: 107, BE: -28,8, HCO3: 2,4, Sat 91,3%, lact: 79; urina I: pH: 6,0; leucócitos: 13; densidade: 1015; eritrócitos: 19; proteína: ++; glicose: +++; bilirrubina: negativa; corpos cetônicos: + denotando cetonemia. Eletrocardiograma com onda T apiculada, bloqueio de ramo direito. A paciente foi tratada com insulina, hidratação, bicarbonato de sódio e introduzido antibioticoterapia. Após o tratamento inicial, os exames laboratoriais mostraram: Cr: 2,2, Ur: 122, Na: 162, K: 4,3, Ca: 6,4, glicose: 504, pH: 7,01, HCO3: 7.1, BE: - 22. Um dia após, a paciente apresentou importante dor abdominal acompanhada de irritação peritoneal, além de sonolência e dificuldade para falar; exames laboratoriais mostraram: pH: 7,4, pCO2 : 31, pO2: 68, BE: -4,4, HCO3: 19, Sat.O2: 93,5%; Ur: 95; Cr: 1,4, albumina: 2,4, Ca: 0,95, Na: 166, K:4, bilirrubina: 0,5, bilirrubina D/I: 0,2/0,3, amilase: 1157, Gama-GT: 56, AST 7.210, ALT: 2.470, VHS: 15, lipase: 84. Ultrasonografia abdominal não apresentou alterações significativas. Evoluiu com importante piora clínica, parada cardiorrespiratória e óbito. A necrópsia evidenciou múltiplas áreas de infarto hepático, trombose vascular, infarto esplênico, congestão visceral e aterosclerose de aorta e seus ramos e pâncreas normal. CONCLUSÕES: Os mecanismos de infarto hepático e esplênico neste caso não foram bem elucidados. Alguns fatores devem ter contribuído, tais como: desidratação e hipotensão devido a episódios de vômitos e febre que contribuem para diminuição do fluxo sanguíneo da veia porta e artéria hepática; o nível elevado de catecolaminas que ocorre em estado de hiperglicemia e cetoacidose metabólica pode induzir à vasoconstrição; aterosclerose difusa que é comumente vista em pacientes diabéticos e hipertensos. Este caso enfatiza a necessidade de investigar infarto hepático em pacientes diabéticos com cetonemia e com aumento de enzimas hepáticas. Anticoagulantes devem ser prontamente instituídos se houver trombose vascular.UNIFESP-EPMInstituto Dante Pazzanese de Cardiologia Divisão de PesquisaAMIB AMBUNIFESP, EPMSciEL

Acompanhamento de longo prazo após a ressecção de metástases na tiroide de carcinoma hepatocelular em fígado cirrótico

Thyroid metastasis from hepatocellular carcinoma (HCC) is rare, and has poor prognosis. We report the case of a 62-year-old woman seen at our clinic because of the occurrence of a slightly painful abdominal mass. At that time, alpha-fetoprotein concentration was very high, reaching 49,831.7 ng/mL. Abdominal ultrasound showed a heterogeneous mass in segment IV of the liver, which was diagnosed as HCC upon MRI. The patient underwent surgical resection and histological analysis of the specimen confirmed HCC. Metastases to the thyroid were detected 17 months after liver resection. Although the presence of metastases indicates advanced disease, thyroidectomy was performed, since no other distant metastases were detected. In fact, the patient is doing well 3 years after thyroidectomy and regular imaging exams showed no tumor recurrence. Current alpha-fetoprotein concentration is 8 ng/mL. In conclusion, thyroid metastasis from HCC is uncommon and short-term survival is expected. However, surgical resection should be encouraged, especially in the case of solitary metastases.As metástases de carcinoma hepatocelular (CHC) em tiroide são raras e o prognóstico é ruim. Relatamos o caso de uma paciente de 62 anos de idade atendida em nossa clínica devido a uma massa abdominal levemente dolorida. Naquele momento, a concentração de alta-fetoproteína era muito alta, chegando a 49.831,7 ng/mL. O ultrassom de abdômen mostrou uma massa heterogênea no segmento IV do fígado, que foi diagnosticada como CHC por meio de ressonância magnética. A paciente foi submetida a uma ressecção cirúrgica, e a análise histológica do espécime confirmou o CHC. As metástases na tiroide foram detectadas 17 meses após a ressecção do fígado. Embora a presença de metástases indique doença avançada, a tiroidectomia foi feita porque não foram detectadas outras metástases distantes. De fato, três anos após a tiroidectomia, a paciente está bem e os exames de rotina mostraram não haver recorrência do tumor. A concentração atual de alfa-fetoproteína é de 8 ng/mL. Concluiu-se que as metástases de CHC em tiroide não são comuns e espera-se uma sobrevida curta. Entretanto, deve-se encorajar a ressecção cirúrgica, especialmente no caso de metástases solitárias.Universidade Federal de São Paulo (UNIFESP) Hepatology Unit Department of GastroenterologyUNIFESP Liver Transplant Unit Department of SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Pediatric SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Diagnostic RadiologyUniversidade Federal de São Paulo (UNIFESP) Department of PathologyUNIFESP, Hepatology Unit Department of GastroenterologyUNIFESP, Liver Transplant Unit Department of SurgeryUNIFESP, Department of Pediatric SurgeryUNIFESP, Department of Diagnostic RadiologyUNIFESP, Department of PathologySciEL

An evaluation of the protective effect of an infusion of chilled glucosesolution on thermal injury of the bile ducts caused by radiofrequency ablation of the liver

PURPOSE: To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration. METHODS: Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects. RESULTS: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p<0.006); elongation/palisade arrangement of nuclei (65.1% vs. 87.5%; p<0.001); pseudo-goblet cells (32.9% vs. 56.8%; p<0.001). CONCLUSION: Infusion of 5% glucose solution (5°C) has a protective effect on bile duct subjected to heat (95-110°C, 12 min) from radiofrequency thermal ablation device.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Federal University of São PauloUniversidade Federal de São Paulo (UNIFESP) Department of PathologyUniversidade Federal de São Paulo (UNIFESP) Department of SurgeryAlbert Einstein Israelite Hospital Department of Image DiagnosticUNIFESP School of MedicineUNIFESP, Department of PathologyUNIFESP, Department of SurgeryUNIFESP, School of MedicineSciEL

State Britain and the art of (Im)proper democratic protest

The installation of Mark Wallinger’s State Britain in the Duveen Galleries of Tate Britain recreated Brian Haw’s protest opposite the Houses of Parliament, which had largely been dismantled by the police under the Serious Organised Crime and Police Act 2005. Wallinger’s work bisected a boundary created by the Act inside which the police could be given greater than usual powers to control demonstrations. The intersection exemplified how, when understood in terms of the performative after Jacques Derrida, art may unsettle the ways in which both the law and aesthetics work to protect the political establishment. aesthetics work to protect the political establishment

Hypoinsulinemia in alcoholics with minimal hepatopaty

The chronic pancreatitis (CP) may evolve with low insulin levels and develop clinical picture of diabetes mellitus. Low seric levels of insulin and C peptide after stimulus has also been described in asymptomatic alcoholics even with normal glicemic curves. It is known that the chronic alcoholism is the main etiological factor of CP and hepatic diseases, and that the insulin produced by the pancreas is metabolized mainly by the liver. High levels of periferic insulin are described in hepatic cirrhosis due to decrease of hepatic metabolization alone or associated to increase of periferic resistence. AIM: In alcoholics with minimal hepatic lesions to evaluate the seric insulin and glucose levels after stimulus with intravenous glucose. METHODS: In 8 alcoholic patients with minimal hepatic lesions characterized by hepatic biopsy, and 26 non-alcoholics, healthy controls, it was studied the serum glucose and insulin levels in basal time, 1, 3, 5, and 10 minutes after stimulus with intravenous glucose (0.5 g/kg). RESULTS: The insulin means in time 1, 3 minutes and total integrated response after stimulus were lower (p < 0.05) in alcoholic group than in control, even with normal glucose curves. CONCLUSION: Alcoholics with minimal hepatic lesions showed low seric insulin levels after glucose stimulus, similar to former observations in asymptomatic alcoholics, indicating hypofunction of pancreatic B cells.OBJETIVO: Em alcoolistas portadores de lesões hepáticas mínimas avaliar os níveis de glicose e insulina séricas após estímulo com glicose intravenosa. MÉTODOS: Em oito etilistas, portadores de alterações hepáticas mínimas, caracteriza por biópsia hepática, e em 26 controles sadios não-alcoólicos, foram estudados os níveis glicêmicos e insulinêmicos (RIE) nos tempos 1, 3, 5, e 10 minutos após estímulo com glicose intravenosa (0.5g/Kg de peso). RESULTADOS: As médias da insulina sérica dos tempos 1, 3 minutos e resposta integrada total (RIT-10min) após estímulo foram menores no grupo alcoolista em relação ao controle (p < 0,05) apesar de curvas glicêmicas normais. CONCLUSÃO: Etilistas crônicos com lesões hepáticas mínimas, à semelhança do observado anteriormente em etilistas assintomáticos, apresentam níveis diminuídos de insulina sérica, mas com curvas glicêmicas normais, após estímulo com glicose intravenosa, indicando hipofunção de células beta do pâncreas.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de PatologiaUNIFESP, EPM, Depto. de PatologiaSciEL

Significance of the presence of antibodies against hepatitis C virus in asymptomatic blood donors

In order to determine the significance of anti-hepatitis C virus (anti-HCV) antibodies in blood donors, 46 consecutive asymptomatic individuals were recruited at the blood bank of Hospital Sao Paulo, Sao Paulo, Brazil. They were submitted to an interview to collect epidemiological data and to clinical examination and blood samples were obtained for biochemical, serological and virological analysis. All patients were followed for a minimum period of six months and those with abnormal mean alanine aminotransferase (ALT) levels were submitted to a liver biopsy after giving informed consent. Hepatitis C virus RNA (HCVRNA) was detected by the polymerase chain reaction (PCR) in 22/46 (47.8%) patients and this finding was associated with parenteral risk factors (P = 0.03) and ethanol abuse (P = 0.03). HCVRNA positivity was also associated with abnormal levels of ALT (P<0.001) and gamma-glutamyl transpeptidase (gamma-GT) (P = 0.01). Abnormal ALT levels were a good marker of viremia, with 86.4% sensitivity and 79.2% specificity. Twenty-three patients with elevated mean ALT levels were submitted to a liver biopsy and histopathological changes were observed in 17 of them (73.9%). HCVRNA positivity was associated with severe forms of hepatic disease (chronic hepatitis and cirrhosis). These results indicate the need for a judicious evaluation of all anti-HCV-positive blood donors, including clinical examination, biochemical tests and liver histology when ALT is persistently elevated.UNIV FED SAO PAULO,ESCOLA PAULISTA MED,DEPT GASTROENTEROL,BR-04024002 SAO PAULO,BRAZILUNIV FED SAO PAULO,ESCOLA PAULISTA MED,DEPT PATOL,BR-04024002 SAO PAULO,BRAZILUNIV FED SAO PAULO,ESCOLA PAULISTA MED,DEPT GASTROENTEROL,BR-04024002 SAO PAULO,BRAZILUNIV FED SAO PAULO,ESCOLA PAULISTA MED,DEPT PATOL,BR-04024002 SAO PAULO,BRAZILWeb of Scienc