Clinical Case Summary

Introduction: Autoimmune hepatitis(AIH)is a rare condition,the pathogen of which remains poorly understood,involving different factors:genetic,environmental and infectious,including viral agents such as Epstein-Barr(EBV).We report a case AIH triggered by EBV infection.This observation is of particular interest because the literature offers little data on this association between EBV and the onset ofAIH.
Case report: This is a 15-year-old girl,previously in good health,who was referred for the management of cholestatic jaundice,associated with fatigue,fever and pharyngitis.The history revealed no recent use of hepatotoxic drugs.Physical examination revealed an erythematous throat,mucocutaneous jaundice and hepatosplenomegaly.
Laboratory tests revealed major hepatic cytolysis,associated with cholestasis.They also revealed liver failure.There is hyperlymphocytosis, associated with monocytosis in the blood count.
An abdominal ultrasound was performed to rule out bile duct obstruction,revealing hepatosplenomegaly.Doppler excluded Budd-Chiari syndrome.Wilson's assessment was negative.Alphabetical viral serologies(A,B,and E) were all negative. However,IgM and IgG antibodies to EBV viral capsid antigen were detected,and a positive viral load.The diagnosis of acute EBV hepatitis was established,and the patient was treated symptomatically. After 10 days,the fever and pharyngitis resolved, but the liver function disturbances remained. Other explorations were carried out,and the diagnosis of autoimmune hepatitis type 1 was made based on biological arguments(anti-smooth muscle antibodies positive,a high level of immunoglobulinG)and histological .
The patient was put on corticosteroid therapy.Subsequently,after the EBV viral load was negative,Imurel was introduced.A clinical-biological remission was obtained after 2months.
Conclusion: The interest of our case is to make the practitioner aware of an outbreak of AIH,in the face of any persistent cytolysis after an episode of EBV.

References

Figure 1:portal lymphoplasmacytic infiltrate in liver biopsy with interface hepatitis (haematoxylin and eosin stain)
Figure 2:hepatic rosette formation in liver biopsy

Introduction

Endoscopy is the first-line approach for managing Zenker's Diverticulum (ZD). Various endoscopic techniques, each with its own advantages and limitations, have been described. We have proposed a new technique, which we have named Submucosal Injection-Guided septomyotomy (SING technique).

Aims & Methods

The performance of SING technique was evaluated in a prospective observational cohort of patients with ZD who underwent the procedure at two Italian hospitals: San Raffaele Hospital (Milan, Italy) and San Giovanni Bosco Hospital (Turin, Italy).
SING technique involves a classic septotomy, which consists of a mucosal incision with a Hook-Knife in the middle of the septum and a cricopharyngeal myotomy for all the length of the Zenker's Diverticulum and beyond 10 mm into the esophageal proper muscular layer. The novelty of the technique lies in the submucosal injection during the septomyotomy on both the esophageal and diverticular sides, which helps to better delineate the muscular layer and guide the complete myotomy, without the need for bilateral submucosal tunnelling.
Clinical success (CS) was defined as a Dakkak and Bennet Dysphagia Score (DBDS) of ≤1 and a Kothari-Haber Score (KHS) of <2 at 3 months. Recurrence was defined as an increase in DBDS of >1 after achieving CS or a KHS of ≥2 after CS. Follow-up included clinical evaluations at 3 and 6 months, and then annually. Adverse Events (AEs) are classified according to the AGREE Classification.

Results

42 patients with ZD underwent SING technique between March 2021 and January 2024 (median age 74 [IQR 67-80], 66.7% males, BMI 24.6 [IQR 21-27]). The median diverticula depth was 30mm (IQR 25-45) with a median septum length of 20mm (IQR 14-30). Median KHS at diagnosis was 4 (IQR 4-6), dysphagia for solids (42.9%) was the most common symptom, with a median symptom duration of 12 months (IQR 6-24). While a technical success rate was observed in all cases (42/42, 100%), a clinical success rate was observed in 40/42 patients (95.2%). In the 2/42 (4.8%) cases of clinical failure, endoscopic evaluation revealed the presence of a minimal residual muscular septum successfully treated with septomyotomy. Median procedural time was 34 minutes (IQR 29-60), with a hospital stay of 2 days (IQR 2-2). No AEs were recorded. After a median follow-up of 370 days (IQR 297-747), no cases of symptom recurrence were recorded.

Conclusion

SING technique is a safe and effective technique for the endoscopic treatment of ZD. It improves and enhances the efficacy of traditional endoscopic septotomy and can also be utilized as rescue therapy.