Introduction

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Although curative options can afford long-term survival in patients with early-stage tumours, the actual strategy for HCC surveillance misses over one-third of HCC at an early stage. Chronic inflammation and neoangiogenesis play a central role in the promotion of carcinogenesis. SerpinB3 (SB3) is a serine proteinase inhibitor involved in tumorigenesis and promoting a pro-inflammatory milieu. The polymorphic variant SerpinB3-PD (SB3-PD) presents a substitution in the reactive centre loop of the protein (Gly351Ala), determining an improved anti-protease activity.

Aims & Methods

This study aims to investigate the role of SB3-PD as a predictor of mortality in patients with liver cirrhosis and HCC and to assess the effect of SB3-PD in the pro-inflammatory response in vitro. SB3-PD polymorphism was assessed in 107 cirrhotic patients with HCC, followed up from HCC diagnosis to death or transplant for a median period of 21 months. The results were analyzed in relation to clinical, radiological, laboratory data, BCLC stage at baseline, and treatments of HCC during follow-up. In vitro study was conducted on human monocytic leukaemia cell line (THP-1) treated with recombinant protein SB3-wild type (WT) or the polymorphic variant SB3-PD. mRNA quantification of pro-inflammatory cytokines was performed by quantitative real-time PCR, whereas protein quantification was carried out by ELISA.

Results

Patients carrying SB3-PD polymorphism (n=38; 35.5%) at diagnosis showed larger tumours, higher alpha-fetoprotein levels and more frequent vascular invasion and metastasis, associated with significantly lower survival compared with patients carrying SB3-WT (34.3 vs 53.8 months, p=0.009). SB3-PD was an independent predictor of mortality in patients with HCC, along with BCLC stage, ALBI grade, alpha-fetoprotein values, N/L rate and ALP values. "In vitro" results showed that THP-1 cells treated with SB3-PD had more abundant and prolonged cytokine production than controls.

Conclusion

Patients with liver cirrhosis and HCC carrying SB3-PD polymorphism have a poorer prognosis and the SB3-PD variant determines a stronger pro-inflammatory response, supporting its greater carcinogenetic effect. The assessment of SB3-PD polymorphism could help to personalize screening strategies for HCC.

References

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Clinical Case Summary

A 64-year-old male patient presented with acute epigastric pain over 7 days, worsening after meals, nausea, vomiting 2 times without signs of bleeding, diarrhea 5-6 times/day, high blood pressure 180/100 mmHg. He had a 6-year history of recurrent epigastric pain, after multiple EGDSs was diagnosed as gastric ulcer and atrophic gastritis. The patient had undergone HP eradication and received standard anti-ulcer therapy several times, with no clinical improvement. On physical examination, the patient appeared pale. The abdomen was soft, without pain, guarding or rebound tenderness. The patient's medical history was significant for arterial hypertension. Lab abnormalities included WBC 16.32-10x10⁹/L, ESR 94mm/sec, CRP at 184.3 mg/L, FBG 767 mg, Total protein 50.9 g/L, CREA 147 mmol/L, Urea 13.42 mmol/L, Na 129 mmol/L. Intestinal infections were negative. New EGDS revealed an ulcerative lesion with 0.8cm diameter, in the region from antrum to greater curvature, covered with fibrin. Colonoscopy was normal. Duplex ultrasound revealed a 70% stenosis of the celiac trunk and superior mesenteric artery, with atherosclerotic wall deformation and intima-media thickening. A thrombosis was detected in the region of the aortic bifurcation. CT angiography revealed up to 70% stenosis of the suprarenal abdominal aorta, no contrast enhancement was observed in the origins of the celiac trunk, superior mesenteric artery, left renal artery (left kidney appeared atrophic), total occlusion of bilateral common, external, and internal iliac arteries.
Conclusion: Gastric ulcers are mostly associated with HP. However, in rare cases, underlying vascular pathology may be critical in their pathogenesis. This case highlights an overlooked cause of gastric ulcers, particularly in patients with atherosclerotic risk factors. In patients with persistent symptoms despite medical therapy ischemic ulceration should be included in the differential diagnosis.

Clinical Case Summary

Background: Syphilis is a chronic systemic infection caused by the spirochete Treponema pallidum, often referred to as "the great imitator" due to its ability to affect nearly any organ. Syphilitic hepatitis, or "luetic jaundice," is a rare manifestation, indicating spirochete dissemination to the liver.
Case Report: A 26-year-old female was admitted to the hospital with fever (39.5 °C), fatigue, sweating, tremor, dark urine, pale stools, and significant weight loss (15 kg over two months). She also reported lower extremity muscle and joint pain, cough and slowing of speech. On examination, she had icteric skin, a generalized maculopapular rash, and enlarged cervical lymph nodes. No history of alcohol or drug use was noted.
Laboratory tests revealed elevated levels of both cytolytic and cholestatic liver enzymes, along with increased bilirubin an elevated C-reactive protein.
Abdominal ultrasound and contrast CT showed hepatomegaly, hilar and retroperitoneal lymphadenopathy and splenomegaly.
Viral hepatitis markers (HBsAg, HBV PCR, HCVAb, HCV PCR, anti-HAV IgM, anti-HEV IgM) and antibodies for CMV, EBV, HIV, HSV-1,2 were negative. Wright-Hedelson test for brucellosis and serological markers for autoimmune hepatitis were negative while IgG and cerulopasmin levels were within normal range. Given systemic findings and history, syphilis was considered. Serologic tests were positive for Treponema pallidum (ELISA, TPHA, MRP). Liver biopsy revealed mild active hepatitis. The diagnosis of ^secondary syphilitic hepatitis was made. The patient was started on antimicrobial therapy. During follow-up, liver function tests normalized, and systemic symptoms resolved.
Conclusion: This case underscores the importance of considering syphilis in the differential diagnosis of unexplained hepatitis. Although rare, syphilitic hepatitis should be considered in patients with liver enzyme elevations and nonspecific symptoms, particularly when no clear alternative diagnosis is found.

References

1) Malvar G, Cardona D, Pezhouh MK, Adeyi OA, Chatterjee D, Deisch JK, Lamps LW, Misdraji J, Stueck AE, Voltaggio L, Gonzalez RS. Hepatic Secondary Syphilis Can Cause a Variety of Histologic Patterns and May Be Negative for Treponeme Immunohistochemistry. Am J Surg Pathol. 2022 Apr 1;46(4):567-575. doi: 10.1097/PAS.0000000000001848. PMID: 34864775.
2)Supronowicz Ł, Rogalska M. Syphilitic hepatitis. Clin Exp Hepatol. 2024 Mar;10(1):9-13. doi: 10.5114/ceh.2024.136235. Epub 2024 Mar 12. PMID: 38765910; PMCID: PMC11100338.
3)Al Dallal HA, Narayanan S, Alley HF, Eiswerth MJ, Arnold FW, Martin BA, Shandiz AE. Case Report: Syphilitic Hepatitis-A Rare and Underrecognized Etiology of Liver Disease With Potential for Misdiagnosis. Front Med (Lausanne). 2021 Nov 29;8:789250. doi: 10.3389/fmed.2021.789250. PMID: 34912834; PMCID: PMC8666961.
Figure 1: Histological images of the liver biopsy
Figure 2: Abdominal CT images
Figure 3: Images of maculopapular rash

Introduction

A plethora of findings suggests the correlation between Metabolic-(Dysfunction)Associated Fatty Liver Disease (MAFLD) and long-term incorrect lifestyle behavior. The Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV2) pandemic lockdown represented a unique event forcing the entire population to suddenly change their lifestyle, favoring a drastic reduction in physical activity and an improper diet, with consequences on metabolic homeostasis never experienced before. In this study, we aimed to investigate the effects of the SARS-CoV-2 confinement and related lifestyle changes on MAFLD evolution.

Aims & Methods

A cohort of 222 MAFLD patients was followed two years before, two years during, and one year after the pandemic. At four time points [January 2018: T0; January 2020: T1; January 2022: T2; January 2023: T3], anthropometrical, biochemical, nutritional, bioelectrical impedance analysis (BIA) data, non-invasive tools for disease staging and hepatocellular carcinoma (HCC) occurrence were collected.

Results

At T2 an increase in fats and carbohydrate intake consistently with impaired weekly physical activity was demonstrated, associated with an increase in body mass index and waist-to-hip ratio (p<0.0001 for all), as well as a worsening in levels of total cholesterol, low/high-density lipoprotein, triglycerides, glucose, insulin, homeostatic model assessment for insulin resistance and transaminases (insulin: p=0.0003, glucose: p=0.0007; p<0.0001 for the others). Non-invasive tools assessments revealed a NAFLD fibrosis score, Liver Stiffness Measurement (LSM), and Controlled Attenuation Parameter impairment at T2 (p<0.0001 all). In comparison with T0 and T1, the BIA evidenced at T2 an increase in Fat Mass (FM) and a reduction of Free Fat Mass (FFM), Body Cell Mass (BCM), and Extracellular Mass (ECM). During the confinement period, the overall HCC and Milan-out staged HCC occurrence revealed HR:2.521, p=0.01, and HR:13.78, p=0.0009 respectively. Contrariwise to the modifications of the biochemical parameters, a significant association between body composition parameters modification during the study evaluations with HCC overall and HCC Milan-out criteria occurrence was highlighted (ΔFFM pre- vs during pandemic, OR: 0.704; ΔFM pre- vs during-pandemic, OR: 1.531; p <0.0001).
Receiving operator curve (ROC) analysis identified respectively -0.92 Kg (AUC:0.86) and -1.90 Kg (AUC:0.90) for FFM and +1.35 Kg (AUC:0.87) and +1.51 Kg (AUC:0.94) for FM as the best cut-off (BCO) variations (pre-pandemic vs pandemic) in the prediction of HCC overall and HCC Milan-out staged occurrence during the confinement. Time-to-time analysis revealed a higher incidence of HCC overall occurrence along the pandemic period in MAFLD patients presenting the following body modification composition “combined pattern” (BMCC) [BCO FFM decrease + BCO FM increase] in comparison to individuals presenting only one of two variations (p:0.025). At T3, compared to the pandemic period, simultaneously with improvement in physical activity as well as a decrease in fats and carbohydrate intake, the insulin levels, CAP, and FM were significantly decreased (p<0.001). Relevantly, a higher incidence of HCC overall occurrence even after the pandemic period in BMCC-MAFLD patients (p:0.048) was observed.

Conclusion

The confinement-related lifestyle changes impacted MAFLD evolution via body composition modifications, negatively influencing the HCC occurrence even after the pandemic period and the restoration of pre-existing life habits, as we are still observing the consequences of the confinement-induced "damages".

References

1. Taheri E, Bostick RM, Hatami B, et al. Dietary and Lifestyle Inflammation Scores Are Inversely Associated with Metabolic-Associated Fatty Liver Disease among Iranian Adults: A Nested Case-Control Study. J Nutr 2022;152:559-567.
2. Dallio M, Romeo M, Gravina AG, et al. Nutrigenomics and Nutrigenetics in Metabolic- (Dysfunction) Associated Fatty Liver Disease: Novel Insights and Future Perspectives. Nutrients 2021;13.
3. Ariya M, Koohpayeh F, Ghaemi A, et al. Assessment of the association between body composition and risk of non-alcoholic fatty liver. PLoS One 2021;16:e0249223.
4. Fujii H, Nakamura N, Fukumoto S, et al. Lifestyle changes during the coronavirus disease 2019 pandemic impact metabolic dysfunction-associated fatty liver disease. Liver Int 2022;42:995-1004.

Introduction

Inflammatory bowel diseases (IBDs), primarily ulcerative colitis (UC) and Crohn's disease, are complex chronic immune-mediated disorders. Although etiopathogenesis of UC is still unknown, several studies suggest a clear association to altered gut microbiota, impaired mucous layer and epithelial barrier disfunction. Fecal microbial transplantation (FMT) emerged as a promising therapeutic approach aimed at repopulating gut microbiota with beneficial taxa from a healthy donor, and indirectly influencing the recipient's immune system. At present, FMT represents a well-established effective therapy for patients suffering from recurrent C. difficile infections. Promising data suggest FMT efficacy in patients with mild to moderate UC, but mechanism of actions are still yet to be fully understood.

Aims & Methods

Our study aims to evaluate the impact that FMT, using feces from UC patients with active and inactive disease, on microbiota composition and mucosal integrity in a murine model of colitis. We used mice (n=40) that were pre-conditioned for a week with a cocktail of broad spectrum antibiotics to deplete most of the intestinal microbiota, then a 7-day DSS 3% treatment was carried out to induce the colitis and, during those days, two FMT infusion were performed. The mice were sacrificed at the end of seven days of recovery, and feces, colon and whole blood were collected.

Results

The use of antibiotics allowed the engraftment of FMT colitis in mice. Disease activity index of murine colitis was ameliorated by the infusion of feces from inactive UC patients, associated with the decrease of LPS in serum, lower levels of pro inflammatory cytokines (such as IFNgamma, TNFalpha, IL17), an increase of FOXP3 and MUC2 as a marker of intestinal integrity. A modulation of gut microbiota was assessed after each phase of treatment.
Our study suggests the infusion of fecal suspension from inactive UC patients is able to induce an anti-inflammatory response at mucosal level and to induce proliferation of those bacterial families associated with remission.

Conclusion

These data open new scenario about the use of autologous FMT in UC. Autologous FMT reduces the potential for donor-recipient microbial-interactions/incompatibilities which have been shown to influence strain engraftment outcomes.