Evaluation of transient elastography in assessing liver fibrosis in patients with advanced schistosomiasis japonica

Schistosomiasis remains an important public health issue. The presence and extent of liver fibrosis are associated with disease progression and prognosis. The study is aimed at exploring the value of liver stiffness measurement (LSM) by transient elastography in assessing liver fibrosis in patients with advanced schistosomiasis japonica. Seventy-three patients were consecutively recruited for the purpose of this study. The correlation between noninvasive parameters and histological fibrosis stages was analyzed and an area under receiver operating characteristic curve (AUROC) was used to assess diagnostic efficacy. Our results demonstrated that there are significant differences between LSM values of patients with different stages of fibrosis (F1 vs. F2, F2 vs. F3 and F3 vs. F4, P < 0.01). The AUROC values of LSM in detecting significant fibrosis (F ≥ 2), advanced fibrosis (F ≥ 3) and cirrhosis (F = 4) were 0.96, 0.90, and 0.92 respectively. The optimal cut-off LSM values were 8.0 kPa, 9.5 kPa, and 18.0 kPa for significant fibrosis, advanced fibrosis and cirrhosis. Based on differences between AUROC values, LSM was proven to be superior to several serum models in detecting advanced fibrosis and cirrhosis. In conclusion, our study demonstrates that LSM is a reliable parameter for assessing risk of liver fibrosis in patients with advanced schistosomiasis japonica.     

A simple noninvasive index to predict significant liver fibrosis in patients with advanced schistosomiasis japonica

BackgroundSchistosoma japonicum causes marked liver fibrosis, while lethal syndromes present in advanced schistosomiasis patients. Its management depends on the degree of fibrosis present.Patients and methodsFifty-two patients were recruited to assess the diagnostic value of bio-markers in patients with advanced schistosomiasis japonica. Fibrosis was assessed in liver biopsies using METAVIR system. The correlation between conventional parameters and significant fibrosis (F2-F4) was assessed using univariate analysis and logistic regression. The method of area under receiver operating characteristic curves (AUROCs) was used as a measurement of diagnostic efficacy.ResultsWhite blood cell counts, platelet counts and albumin (all P < 0.05) were significantly lower, while prothrombin time, international normalized ratio (INR), hyaluronic acid (HA), IV collagen and ultrasound fibrosis scores (all P < 0.01) were significantly elevated in F2-F4 patients compared with F0-F1 patients. HA and INR were identified as independent predictors by multivariate analysis (P = 0.023 and P = 0.013, respectively). Of the routine laboratory tests for the diagnosis of significant fibrosis, HA gave the best AUROC of 0.875 (95% confidence interval (CI): 0.701–0.997). We constructed a new simple index (INR × HA/100) to discriminate between F2-F4 patients and F0-F1 patients. It showed the highest AUROC of 0.921 (95% CI: 0.828-1.000), and had better diagnostic values than APRI and FIB-4.ConclusionHA and INR were reliable markers for differentiating significant liver fibrosis in patients with advanced schistosomiasis japonica. And the new simple index can easily predict significant liver fibrosis with a high degree of accuracy.     

Quantifying quality of life and disability of patients with advanced schistosomiasis japonica

Background

The Chinese government lists advanced schistosomiasis as a leading healthcare priority due to its serious health and economic impacts, yet it has not been included in the estimates of schistosomiasis burden in the Global Burden of Disease (GBD) study. Therefore, the quality of life and disability weight (DW) for the advanced cases of schistosomiasis japonica have to be taken into account in the re-estimation of burden of disease due to schistosomiasis.

Methodology/Principal Findings

A patient-based quality-of-life evaluation was performed for advanced schistosomiasis japonica. Suspected or officially registered advanced cases in a Schistosoma japonicum-hyperendemic county of the People''s Republic of China (P.R. China) were screened using a short questionnaire and physical examination. Disability and morbidity were assessed in confirmed cases, using the European quality of life questionnaire with an additional cognitive dimension (known as the “EQ-5D plus”), ultrasonography, and laboratory testing. The age-specific DW of advanced schistosomiasis japonica was estimated based on patients'' self-rated health scores on the visual analogue scale of the questionnaire. The relationships between health status, morbidity and DW were explored using multivariate regression models. Of 506 candidates, 215 cases were confirmed as advanced schistosomiasis japonica and evaluated. Most of the patients reported impairments in at least one health dimension, such as pain or discomfort (90.7%), usual activities (87.9%), and anxiety or depression (80.9%). The overall DW was 0.447, and age-specific DWs ranged from 0.378 among individuals aged 30–44 years to 0.510 among the elderly aged ≥60 years. DWs are positively associated with loss of work capacity, psychological abnormality, ascites, and active hepatitis B virus, while splenectomy and high albumin were protective factors for quality of life.

Conclusions/Significance

These patient-preference disability estimates could provide updated data for a revision of the GBD, as well as for evidence-based decision-making in P.R. China''s national schistosomiasis control program.     

sTNFR-II and sICAM-1 are associated with acute disease and hepatic inflammation in schistosomiasis japonica

Soluble intracellular adhesive molecule 1 (sICAM-1) and tumour necrosis factor receptors I (TNFR-1) and II (TNFR-II) have been shown to be associated with numerous liver disorders. Shedding of these membrane proteins can be triggered by the Th1 cytokines, TNF-alpha and IFN-gamma, which are associated with susceptibility or resistance to hepatic schistosomiasis, respectively. Further, TNF-alpha receptors and sICAM-1 have been implicated in periportal fibrosis in advanced human schistosomiasis mansoni and correlate with schistosome granuloma formation in the murine model. We measured serum levels of sICAM-1, TNFR-I and TNFR-II in Chinese patients with different clinically defined stages of schistosomiasis japonica and controls; these included 35 patients with acute schistosomiasis, 45 patients with chronic schistosome infections, 34 advanced patients with evidence of severe morbidity and 20 patients with no known history of exposure to infection. Markedly elevated levels of soluble TNFRs (sTNFRs) and sICAM-1 were observed in the acute and advanced patients compared with the chronic and control groups. Mean sTNFR-II levels were significantly higher in acute patients compared with advanced (P<0.00001) and chronic patients (P<0.00001) and showed the strongest association of the markers with acute disease (odds ratio (OR)=1.099). sTNFR-II and sICAM-1 levels both correlated with infection intensity and there were significant positive correlations observed between eosinophil count and infection intensity (P=0.0072) and sICAM-1 (P=0.0014). Although there were significantly higher levels of antigen-specific IgG4 and total IgG in infected individuals compared with controls, none correlated with infection intensity. Further, no differences in IgG4 and total IgG levels were observed between the acute and chronic groups. The results suggest sTNFRs and sICAM-1 are associated with liver inflammation and disease progression. Measurement of sTNFR-II and sICAM-1 levels in serum could serve as additional markers for the diagnosis of acute stage disease and the monitoring of hepatic inflammation in human schistosomiasis japonica.     

Disappearance of specific antibodies in patients with chronic schistosomiasis japonica by treatment with praziquantel

We tested effects of praziquantel, an antischistosomal compound, on clinical and immunological parameters of chronic schistosomiasis japonica. Two Japanese patients, who had high antibody titers to Schistosoma japonicum antigens but no fecal schistosome eggs or no or mild symptoms complained, were treated with praziquantel. Within two years after treatment, anti-schistosome antibodies in sera from the patients became negative in enzyme-linked immunosorbent assay. There was no significant alteration in cellular immunity to the parasite. Although S. japonicum infection is believed to have been eradicated in Japan, our present results seem to suggest the possibility that a few Japanese individuals, who have high anti-schistosome antibody, still harbor live parasites.     

Plasminogen activator activity increases during reversal of hepatic fibrosis in murine schistosomiasis

After specific chemotherapy, granulomatous fibrosis undergoes a marked reversal in liver of Schistosoma mansoni-infected mice. We have previously shown that this fibrosis reversal was related to a high proportion of the active form of the interstitial collagenase. In vitro, plasmin has been described as a physiological activator of interstitial procollagenase. Moreover, plasmin itself degrades directly matrix components such as proteoglycans and fibronectin. We have thus followed the course of the plasminogen activator, which converts plasminogen zymogen to plasmin, in liver of S. mansoni-infected mice treated with praziquantel, as schistosomicidal drug. It was found that plasminogen activator activity in the liver increases rapidly until 5 days after treatment as compared to nontreated infected mice and then diminishes gradually. Increased plasminogen activator activity appears to be one of initial events leading to this fibrosis reversal.     

Thalidomide failed to inhibit angiogenesis and fibrosis in hepatic schistosomiasis of the mouse

The relationship between angiogenesis and fibrosis has been demonstrated in several pathological conditions, one of them being schistosomiasis. To observe whether suppression of angiogenesis would interfere with fibrosis, Thalidomide, an anti-angiogenesis drug, was administered during 30 consecutive days to mice with experimental schistosomiasis. Computerized morphometric measurements of fibrosis, and the counting of blood vessels from hepatic schistosomal lesions did not significantly differ when treated animals and their controls were compared at the end of the experiments. These rather unexpected results are presented under the understanding that they may be of interest during further studies on the anti-angiogenesis properties of thalidomide, and the relationship between angiogenesis and fibrosis.     

血清铜蓝蛋白联合透明质酸检测在肝纤维化患者诊断中的应用

目的 探讨血清铜蓝蛋白(CP)联合透明质酸(HA)检测在肝纤维化患者诊断中的应用前景。 方法 选取2015年1月至2018年12月本院收治的疑似肝纤维化患者226例为研究对象,对患者的CP、HA水平进行联合检测,根据各项指标检测水平对患者做出诊断,并与金标准诊断方法肝穿刺活检结果进行对比。对CP、HA单独检测和联合检测的诊断结果进行统计对比,并对各组检查方法的灵敏度、特异度、假阳性率、假阴性率、准确度等进行统计对比,比较不同检查方法在不同肝纤维化分级患者中的诊断正确率。 结果 226例患者中金标准诊断201例(88.94%)为肝纤维化,CP单独检测检出154例(68.14%),HA单独检测检出143例(63.27%),CP+HA联合检测检出195例(86.28%)。经Kappa一致性检验分析CP+HA联合检测与金标准结果有高度一致性,CP、HA单独检测与金标准结果为中等一致性。CP+HA联合检测的灵敏度、特异度、准确度均高于CP、HA单独检测,方法间比较差异有统计学意义(χ2=11.602、55.959、78.047,P=0.003、0.039、0.002)。在不同分级肝纤维化患者中,CP+HA联合检测在Ⅰ级、Ⅱ级纤维化检出率高于CP、HA单独检测,方法间比较差异有统计学意义(χ2=9.432、8.324,P=0.007、0.010)。 结论 CP联合HA检测在肝纤维化患者诊断中应用情况良好,有较高的诊断正确率,且对症状程度较轻的肝纤维化患者有较高的检出率,可作为肝纤维化诊断检查的主要手段加以推广应用。     

Prediction of minimal hepatic encephalopathy by using an radiomics nomogram in chronic hepatic schistosomiasis patients

ObjectiveTo construct an MR-radiomics nomogram to predict minimal hepatic encephalopathy (MHE) in patients with chronic hepatic schistosomiasis (CHS).MethodsFrom July 2017 to July 2020, 236 CHS patients with non-HE (n = 140) and MHE (n = 96) were retrospective collected and randomly divided into training group and testing group. Radiomics features were extracted from substantia nigra-striatum system of a brain diffusion weighted images (DWI) and combined with clinical predictors to build a radiomics nomogram for predicting MHE in CHS patients. The ROC curve was used to evaluate the predicting performance in training group and testing group. The clinical decisive curve (CDC) was used to assess the clinical net benefit of using radiomics nomogram in predicting MHE.ResultsLow seralbumin (P < 0.05), low platelet count (P < 0.05) and high plasma ammonia (P < 0.05) was the significant clinical predictors for MHE in CHS patients. The AUC, specificity and sensitivity of the radiomics nomogram were 0.89, 0.90 and 0.86 in the training group, and were 0.83, 0.85 and 0.75 in the training group. The CDC analysis showed clinical net benefits for the radiomics nomogram in predicting MHE.ConclusionsThe radiomics nomogram combining DWI radiomics features and clinical predictors could be useful tool to predict MHE in CHS patients.     

Proteome approach for identification of schistosomiasis japonica vaccine candidate antigen

Experimental vaccination with radiation-attenuated cercariae (RAC) confers possible practical levels of resistance to challenge infection by humoral and by cellular mechanism. Here, we aimed to identify possible vaccine antigens by using specific IgG antibody from RAC vaccinated miniature pig. Two milligrams of soluble egg antigen (SEA) or schistosomal worm antigen preparation (SWAP) was fractionated using two dimensional liquid chromatography (proteome PF 2D) consisted of high performance chromatofocusing (HPCF) and high resolution reversed phase chromatography (HPRP). Of the 42 HPCF fractions of SEA or SWAP, 26 (61.9%) or 15 (35.7%) showed positive dot blot reaction with RAC vaccinated serum respectively. The dot blot positive fractions were applied to the second HPRP column. One hundred and seven out of 26 x 96 of SEA fractions and 18 out of 15 x 96 SWAP fractions reacted with RAC vaccinated serum. From the positive fractions we chose 17 of SEA and 10 of SWAP that had no reactivity with normal cercariae infected (NCI) sera and had single peak of 214 nm; and automated N-terminal amino acid sequence based on in situ Edman Reaction was conducted. Four sequences were obtained and applied to the homology search in NCBI database. A total of eight candidate genes were listed up and their cDNA clones from schistosomula stage were obtained. Two of the recombinant proteins (AAW27472.1 and AXX25883.1) showed strong reactivity with the RAC vaccinated serum but marginal with NCI serum. This protocol using proteome PF 2D could be applicable in identifying immunoreactive proteins from crude extract for the development of vaccines or for diagnostics.     

Differential immunoregulation of granulomatous inflammation, portal hypertension, and hepatic fibrosis in murine schistosomiasis mansoni

The present study investigates the immunoregulation of hepatic fibrosis in experimental murine schistosomiasis. Disease parameters measured were portal pressure, hepatic granuloma area, hepatic interstitial collagen, and glycosaminoglycans. C57BL/6 mice were infected with 25 Schistosoma mansoni cercariae and administered splenocytes or serum derived from uninfected mice or chronically infect syngeneic mice at 6 and 7 wk of infection. Immunologically mediated modulation was noted in animals receiving splenocytes derived from chronically infected mice. Both a reduction in portal pressure and hepatic granuloma areas were noted. Hepatic collagen content but not glycosaminoglycan content was reduced by the administration of either lymphoid cells or serum from chronically infected mice. The isotypic profile of hepatic interstitial collagens was modulated by both the administration of serum or lymphoid cells. Augmented levels of type III collagen was noted on administration of serum derived from chronically infected mice, whereas type I collagen levels were relatively elevated on administration of splenocytes. The data indicate that immunomodulation of inflammation and hepatic fibrosis can occur in murine schistosomiasis but that fibrotic events and inflammatory processes are independently modulated.     

IFN-gamma polymorphisms (IFN-gamma +2109 and IFN-gamma +3810) are associated with severe hepatic fibrosis in human hepatic schistosomiasis (Schistosoma mansoni)

Schistosome infection is a major public health concern affecting millions of people living in tropical regions of Africa, Asia, and South America. Schistosomes cause mild clinical symptoms in most subjects, whereas a small proportion of individuals presents severe clinical disease (as periportal fibrosis (PPF)) that may lead to death. Severe PPF results from an abnormal deposition of extracellular matrix proteins in the periportal spaces due to a chronic inflammation triggered by eggs and schistosome Ags. Extracellular matrix protein production is regulated by a number of cytokines, including IFN-gamma. We have now screened putative polymorphic sites within this gene in a population living in an endemic area for Schistosoma mansoni. Two polymorphisms located in the third intron of the IFN-gamma gene are associated with PPF. The IFN-gamma +2109 A/G polymorphism is associated with a higher risk for developing PPF, whereas the IFN-gamma +3810 G/A polymorphism is associated with less PPF. The polymorphisms result in changes in nuclear protein interactions with the intronic regions of the gene, suggesting that they may modify IFN-gamma mRNA expression. These results are consistent with the results of previous studies. Indeed, PPF is controlled by a major locus located on chromosome 6q22-q23, closely linked to the gene encoding the alpha-chain of the IFN-gamma receptor, and low IFN-gamma producers have been shown to have an increased risk of severe PPF. Together, these observations support the view that IFN-gamma expression and subsequent signal transduction play a critical role in the control of PPF in human hepatic schistosome infection (S. mansoni).     

Diagnostic value of ferritin in the differential diagnosis of malignant effusions

The diagnostic value of ferritin in pleural effusions or ascites was studied in 151 samples from 147 patients (four patients had both kind of effusions). Samples (99 pleural effusions, 52 ascites) were evaluated in 4 groups: benign transudate (27 cases), benign nontuberculous exudate (26 cases), tuberculous exudate (47 cases) and malignant exudate (51 cases). Median ferritin levels in effusions were 67 ng/ml, 805 ng/ml, 889 ng/ml, 998 ng/ml and median effusion/serum (E/S) ratios were 0.7. 2.0, 4.9, 3.2 respectively. There was a significant difference between the concentrations of ferritin in malignant (51 cases) and nonmalignant effusions (100 cases) (p < 0.001), but the specificity and positive predictive value were low (43% and 45% respectively). Ferritin levels in transudate group were significantly lower than those in the others (p < 0.001). However, ferritin concentrations in three exudate groups were similar (p > 0.05). When compared the all inflammatory effusions (malignant, tuberculous, nontuberculous inflammatory exudates) with noninflammatory effusions (transudate and exudate), we determined a significant difference (p < 0.001). CONCLUSIONS: 1) Elevated ferritin concentration in effusions is significant indicators of exudates; 2) It is not good a parameter to discriminate the malignant effusions from the benign ones; 3) They can be useful in the differential diagnosis of the inflammatory exudations from the noninflammatory ones.     

Immunopathology of granuloma formation and fibrosis in schistosomiasis

In schistosomiasis the deposition of parasite ova within host tissues is the initial event in a complex pathophysiological cascade which is characterized by granuloma formation, and may terminate in fibrosis and related sequelae (Fig. 1). In spite of intensive study, the complex relationship between infection and morbidity remains poorly understood. In this article, Michael Phillips and Patrick Lammie review current concepts of the mechanisms of granuloma formation and its regulation in schistosome infections.