Faculty Bibliography

We report gastric or duodenal fistulas in 6 patients with Crohn's colitis or ileocolitis. Two patients had duodenocolic fistulas, 1 had a duodenoileal fistula, 2 had gastrocolic fistulas, and 1 had gastric and duodenal fistulas from an ileocolic anastomosis. In each case the fistula originated from the lower bowel segment, and no patient in this series had primary gastroduodenal Crohn's disease. These cases illustrate the range of manifestations of fistulas to the stomach and duodenum in Crohn's disease, and emphasize that the predominant symptoms determining surgical intervention usually arise from the diseased ileum and colon, rather than from the fistula. Our experience demonstrates the simplicity and safety of excision of the fistula with primary closure of the stomach or duodenum when the stomach and duodenum are otherwise normal by endoscopic examination.

Three patients with a relapsing course of serologically confirmed viral hepatitis type A are presented. In addition, one patient had aminotransferase elevations for over 6 mo. In all three, hepatitis ultimately resolved. A relapsing or protracted course does not appear to alter the benign prognosis of hepatitis A.

To evaluate the immunogenicity of hepatitis B vaccine in renal transplant recipients, we administered three 40-microgram doses of vaccine to 17 patients who had previously undergone transplantation and were on immunosuppressive therapy. Life-table analysis revealed a cumulative antibody response rate of only 17.6% at 12 months, and the three responders had low titers of antibody to hepatitis B surface antigen. There were no serious adverse effects and no episodes of graft rejection in responders or nonresponders. In addition, the ratio of helper/inducer (T4) to suppressor/cytotoxic (T8) T cells in vaccinees bore no relationship to the immunogenicity of the vaccine. These data indicate that hepatitis B vaccine is weakly immunogenic in renal transplant recipients and illustrate the need for vaccination prior to transplantation for maximal protection against hepatitis B virus infection.

We report a patient with Wilson's disease whose case is unusual in two respects. First, the patient was 58 years of age when the diagnosis was made based on urinary, serum, and hepatic copper studies, as well as liver histological investigation. Second, despite the patient's neurological impairment, Kayser-Fleischer rings had not developed. We conclude that in patients with chronic, degenerative neurological disease, particularly when associated with hepatic dysfunction, the diagnosis of Wilson's disease should be considered regardless of age at onset or the absence of Kayser-Fleischer rings on slit lamp examination.

We tested sera collected between 1976 and 1984 from 362 persons in a variety of epidemiologic categories with acute and chronic hepatitis B and from 76 hemophiliacs and drug addicts with hepatitis B antibodies for hepatitis D markers. Hepatitis D markers were common in hemophiliacs, drug addicts, Afghanistanis, prisoners and hemodialysis patients; rare in persons from other hepatitis-B endemic areas, persons with sporadic hepatitis B and homosexual men; and absent in health-care workers and institutionalized mentally retarded persons. No change was observed in the frequency of this infection during the 9 years of this study. We found hepatitis D markers in 5% of patients with acute hepatitis B, 1 of 3 with fulminant hepatitis and in 4 (1 in a homosexual male) of 12 episodes of acute hepatitis in hepatitis B carriers. Hepatitis D markers were more frequent in chronic liver disease (18%) than in asymptomatic hepatitis B carriage (2%), but there was no association between severity of chronic hepatitis and hepatitis D. These findings indicate that, to date, health-care workers and institutionalized mentally retarded persons have been spared from infection with this agent but suggest that homosexual males may not continue to be spared. Even in an area nonendemic for hepatitis D, this agent contributed to 20 to 30% of chronic hepatitis B and acute hepatitis superimposed on chronic hepatitis B infection.

We report a patient with ulcerative colitis in whom agranulocytosis was diagnosed 5 wk after the initiation of sulfasalazine therapy. Concomitant features included fever and skin rash, and bone marrow examination revealed severe myeloid hypoplasia. Antineutrophil antibodies were absent from the serum. Recovery began during the 2nd wk and was characterized by a leukemoid reaction with thrombocytosis. Subsequently, the patient received 5-aminosalicylate enemas without adverse effects. Agranulocytosis, a rare effect of sulfasalazine, appears to occur almost invariably during the first 2 months of therapy, and prompt evaluation is therefore required in patients with unexplained fever or other nonspecific illness during this period.

Purified from the plasma of hepatitis B carriers, hepatitis B surface antigen particles have been used in a vaccine to prevent hepatitis B. This plasma-derived vaccine is immunogenic, protective, and has an excellent safety record. Indications and strategies for preexposure and postexposure prophylaxis are reviewed. In addition, novel approaches to hepatitis B vaccine development are being pursued and will provide the basis for the next generation of vaccines. Early progress has also been made toward a hepatitis A vaccine, but clinical availability is not imminent.

We report a patient with icteric hepatitis and abdominal pain caused by Epstein-Barr virus in the absence of other common features of infectious mononucleosis. The peak alanine aminotransferase was 289 IU/I. Hemolytic anemia and urinary retention complicated the patient's course. Patients with infectious mononucleosis commonly have hepatic involvement but isolated symptomatic hepatitis is unusual. Although rare cases of liver failure have been reported, there is no evidence that Epstein Barr virus causes chronic liver disease. The clinical and histological features of Epstein Barr virus-induced hepatitis are reviewed.