Infliximab induces remission in cryptogenic multifocal ulcerous stenosing enteritis:First case

We present the case of a 29-year-old patient with a history of abdominal pain and vomiting.Based on wireless video capsule findings he was previously diagnosed with ileal Crohn's disease at a different institution,although the clinical and radiological picture was not typical and the response to corticosteroids was poor.We performed a single-balloon enteroscopy showing a short,ulcerous stenosis 50 cm proximal from Bauhin's valve.The endoscopic and clinical histopathological findings were compatible with cryptogenic multifocal ulcerous stenosing enteritis(CMUSE).High dose corticosteroids were again started,without effect.The monoclonal tumor necrosis factor-α(TNF-α) antibody infliximab was added to the medical therapy.After induction therapy,both clinical and endoscopic amelioration was obtained.Larger case studies are needed to confirm the efficacy of TNF-α inhibition in steroid refractory CMUSE.

Patent foramen ovale closure reduces recurrent stroke risk in cryptogenic stroke:A systematic review and metaanalysis of randomized controlled trials

AIM To investigate if patent foramen ovale(PFO) closure device reduces the risk of recurrent stroke in patients with cryptogenic stroke.METHODS We searched five databases-Pub Med,EMBASE,Cochrane,CINAHL and Web-of-Science and clinicaltrials.gov from January 2000 to September 2017 for randomized trials comparing PFO closure to medical therapy in cryptogenic stroke.Heterogeneity was determined using Cochrane's Q statistics.Random effects model was used.RESULTS Five randomized controlled trials with 3440 patients were included in the analysis.Mean follow-up was 50 ± 20 mo.PFO closure was associated with a 41% reduction in incidence of recurrent strokes when compared to medical therapy alone in patients with cryptogenic stroke [risk ratio(RR): 0.59,95%CI: 0.40-0.87,P = 0.008].Atrial fibrillation was higher with device closure when compared to medical therapy alone(RR: 4.97,95%CI: 2.22-11.11,P < 0.001).There was no difference between the two groups with respect to all-cause mortality,major bleeding or adverse events.CONCLUSION PFO device closure in appropriately selected patients with moderate to severe right-to-left shunt and/or atrial septal aneurysm shows benefit with respect to recurrent strokes,particularly in younger patients.Further studies are essential to evaluate the impact of higher incidence of atrial fibrillation seen with the PFO closure device on long-term mortality and stroke rates.

Prevalence of metabolic syndrome, obesity and diabetes type 2 in cryptogenic cirrhosis

AIM: To evaluate the prevalence of metabolic syndrome (MS), obesity and type 2 diabetes mellitus (T2DM) in a group of Mexican Mestizo patients with cryptogenic cirrhosis (CC) and to compare this group with patients with cirrhosis secondary to other causes (disease controls). METHODS: Patients with CC, diagnosed between January, 1990 and April, 2005, were included in a retrospective study. Patients with cirrhosis caused by chronic hepatitis C, alcohol abuse or autoimmune hepatitis (AIH) served as disease controls. RESULTS: A total of 134 patients with CC were analyzed. Disease controls consisted of 81 patients with chronic hepatitis C, 33 with alcohol abuse and 20 with AIH. The median age of patients with CC was 57 years (range, 16-87); 83 (61.9%) patients were female; 53 (39.6%) were Child A, 65 (48.5%) Child B, and 16 (11.9%) were Child C cirrhosis. The prevalence of MS (29.1% vs 6%; P < 0.001), obesity (16.4% vs 8.2%; P = 0.04) and T2DM (40% vs 22.4%; P = 0.013) was higher in CC patients than in disease controls. There were no differences in sex, age or liver function tests between the two groups. CONCLUSION: The prevalence of MS, obesityand T2DM were higher in patients with CC than in patients with cirrhosis secondary to others causes. Our findings support the hypothesis that non-alcoholic steatohepatitis (NASH) plays an under-recognized role in CC.

Occult hepatitis B virus infection and cryptogenic chronic hepatitis in an area with intermediate prevalence of HBV infection

AIM： To assess the possible role of occult HBV infection in the pathogenesis of chronic hepatitis in Iranian patients. METHODS： After exclusion of autoimmune, metabolic and viral etiologies, 104 consecutive adult patients with histologic and biochemical features of chronic hepatitis and negative HBsAg were enrolled in the study. Qualitative PCR with a sensitivity of 150 × 10^3 copies/L, using two primers for Pre-S and core regions was applied to measure presence of HBV DNA in serum of the patients. RESULTS： All 104 patients completed the study Qualitative HBV DNA was positive in two patients （1.9%） CONCLUSION： Occult HBV infection has negligible role in the pathogenesis of cryptogenic chronic hepatitis in Iranian patients.

Cryptogenic cirrhosis in the region where obesity is not prevalent

AIM： Recent studies have demonstrated that obesity is the common feature of cryptogenic cirrhosis （CC） and non-alcoholic steatohepatitis. However, there is little information on CC in the region where obesity is not prevalent, METHODS： The clinical features, and the liver-related morbidity and mortality of CC were analyzed in Japan where the prevalence of obesity is low. Among 652 cirrhotic patients, we identified 29 patients （4.4%） with CC. Of these, 24 CC patients who were followed up for more than 6 months were compared in a case-control study with age-, sex-, and Child-Pugh score-matched controls having cirrhosis of viral etiology. RESULTS： Obesity （BMI≥25 kg/m^2）, diabetes mellitus, and hypertriglyceridemia were more frequent, and the visceral fat area was larger in the CC patients than in the controls. The indices of insulin resistance were higher and the serum aminotransferase levels were lower in the CC patients than in the controls. Logistic regression analysis identified the elevated hemoglobin A1c, BMI ≥ 25 kg/m^2, and normal aminotransferase levels as independent predictors of CC. Kaplan-Meier analysis demonstrated lower occurrence of hepatocellular carcinoma and higher survival rate in the CC than in the controls in contrast to the similar cumulatlve probability of liverrelated morbidity between those groups.CONCLUSION： CC more frequently presents with the clinical features suggestive of non-alcoholic steatohepatitis compared with controls even in the region where obesity is not prevalent. The lower occurrence of hepatocellular carcinoma and higher survival rate may indicate an indolent clinical course in CC as compared with viral cirrhosis.

Cryptogenic multifocal ulcerous stenosing enteritis: Radiologic features and clinical behavior

To investigate the characteristic radiologic findings of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) which can be differentiated from other similar bowel disease and to assess their clinical behavior. METHODSTwenty pathologically and clinically confirmed CMUSE patients (males:females = 8:12; mean age: 40.4 years) between March 2002 and August 2015 from seven academic centers in South Korea were retrospectively reviewed. We evaluated small bowel series (SBS; n = 25), computed tomography (CT) enterography (n = 21), magnetic resonance (MR) enterography (n = 2), and abdominopelvic CT (n = 18) images, focusing on enteric and perienteric manifestations. Any change in radiologic features during follow-up period was recorded. We evaluated clinical data including presenting symptoms, laboratory finding and presence of relapse from electronic medical records. Histopathologic findings were also evaluated. RESULTSThe main symptoms were abdominal pain (n = 12) and anemia (n = 10). All patients showed small bowel strictures (n = 52, mean: 2.6 per patient) on initial CT/MR, located in the ileum (n = 47) or jejunum (n = 5). Strictures showed short-length (mean: 10.44 mm) and circumferential bowel wall thickening (mean: 5.56 mm) with layered enhancement (n = 48) that were also noted on initial SBS (n = 36) with shallow ulcers (n = 10). Some ulcerative lesions or wall thickening progressed into strictures on follow-up SBS/CT, and some strictures revealed recurrent ulceration on follow-up SBS. There were no penetrating disease features like fistula or abscess and no gastrointestinal tract involvement except the small bowel. Nine patients experienced disease recurrence (median relapse-free period: 32 mo) even post-operatively. Histopathologic features of surgically resected specimens were characterized as multiple superficial ulcerations confined to mucosa or submucosa and multiple strictures. CONCLUSIONUnder characteristic radiologic findings with multiple short-segmental strictures and/or shallow ulcers of the small intestine, CMUSE should be considered when assessing patients with recurrent abdominal pain and anemia.

Evaluation of right-to-left shunt on contrast-enhanced transcranial Doppler in patent foramen ovale-related cryptogenic stroke: Research based on imaging

BACKGROUND Cardiogenic embolism caused by patent foramen ovale(PFO)is a common etiology of cryptogenic stroke(CS),particularly in young and middle-aged patients.Studies about right-to-left shunt(RLS)detection using contrast-enhanced transcranial Doppler(c-TCD)are numerous.According to the time phase and number of microbubbles detected on c-TCD,RLS can be classified and graded.We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.AIM To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.METHODS We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital.In total,111 PFO-related CS patients were divided according to whether RLS was permanent(microbubbles detected both at resting state and after the Valsalva maneuver)or latent(microbubbles detected only after the Valsalva maneuver)on c-TCD.Each group was subdivided into small,mild and large RLS according to the grade of shunt on c-TCD.A normal control group was composed of 33 patients who suffered from simple dizziness.Intragroup and intergroup differences were analyzed in terms of clinical,laboratory and diffusion-weighted imaging lesion characteristics.The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.RESULTS In 111 patients with PFO-related CS,68 had permanent RLS and 43 had latent RLS.Clinical characteristics and laboratory tests were not significantly different among the permanent RLS,latent RLS and normal control groups.The proportion of patients with multiple territory lesions in the permanent RLS group(50%)was larger than that in the latent RLS group(27.91%;P=0.021).Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group(30.23%vs 8.82%,P=0.004).Permanent-large and latent-large RLS were both more likely to be related to multiple(P_(trend)=0.017 and 0.009,respectively),small(P_(trend)=0.035 and 0.006,respectively)and cortical(P_(trend)=0.031 and 0.033,respectively)lesions.The grade of RLS evaluated by c-TCD was correlated to the size of PFO determined by transesophageal echocardiography(r=0.758,P<0.001).CONCLUSION Distribution of the infarct suggested the possible type of RLS.Multiple,small and cortical infarcts suggest large RLS induced by a large PFO.

Cryptogenic organizing pneumonia associated with pregnancy:A case report

BACKGROUND Cryptogenic organizing pneumonia(COP),formerly known as bronchiolitis obliterans organizing pneumonia,is an extremely rare disease in pregnancy.In this case,we report on COP diagnosed in recurrent pneumonia that does not respond to antibiotics in pregnant woman.CASE SUMMARY A 35-year-old woman with no prior lung disease presented with concerns of chest pain with cough,sputum,dyspnea,and mild fever at 11 wk’gestation.She was diagnosed with community-acquired pneumonia and treated with antibiotics;her symptoms improved temporarily.Four weeks after discharge,she was readmitted with aggravated symptoms.Chest computed tomography demonstrated multifocal patchy airspace consolidation and ground-glass opacities at the basal segments of the right lower lobe,at the lateral basal segment of the lower lobe,and at the lingular segment of the left upper lobe.Bronchoalveolar lavage revealed an increased lymphocyte count and a decreased CD4/CD8 ratio.Prednisolone(0.5 mg/kg/d)was administered for 10 d after the second admission.Dyspnea improved after 3 d of steroid treatment and other symptoms improved on the 5th day of steroid administration.Post-delivery transbronchial lung biopsy further revealed the presence of granulation tissue with fibroblasts in smallbronchiole lumens.CONCLUSION This case suggests that it is important to differentiate COP from atypical pneumonia in the deteriorated condition despite antibiotic treatment.

Congenital Cardiac Defects, Such as Eustachian Valve, May Increase the Risk of Cryptogenic Stroke: A Case Report

Eustachian valve is an embryonic endocardial heart structure;after birth it becomes an embryogenic residue and its persistance in adult life is unusual. The literature reports some cases of association between Eustachian valve and PFO and is known that the prominent Eustachian valve can represent a way facilitating systemic embolism.Several studies also investigated the role of Eustachian valve in the pathophysiology of both migraine and cerebral embolism. In addiction is known how Eustachian valve may increase the risk of endocarditis, which mostly affects intravenous drug abusers or those with implanted medical devices or central venous catheters. The most commonly identified organism is Staphylococcus aureus (approximately 53% of cases). We present a case of a 46-year-old woman with known migraine. She was hospitalized in Stroke Unit for a cryptogenic stroke with a right-to-left shunt detected with transcranial doppler ultrasound with “bubble test” and a patent foramen ovale with right-to-left shunt with a fenestration of atrial septum and a voluminous Eustachian valve detected with transesophageal echocardiography;she developed fever with a blood cultures positive for methicillin-resis- tant Staphylococcus aureus (MRSA), even if without evidence of endocarditis vegetations. In summary, the objective of our paper is to present an example of a correlation between the persistence of the Eustachian valve with bothcryptogenetic stroke, possible valve infection and migraine.

Patent foramen ovale closure in non-lacunar cryptogenic ischemic stroke:where are we now?

Patent foram ovale(PFO)is the most common anatomical cause of an interarterial shunt.It is usually asymptomatic but may cause paradoxical embolism and is a risk factor for non-lacunar cryptogenic cerebral ischemia in young adults.Although the first clinical trials did not show a significant superiority of PFO closure in the secondary prevention of cerebral ischemia as compared with standard antithrombotic treatment,six subsequent randomized clinical trials(CLOSURE I,PC Trial,RESPECT,CLOSE,REDUCE,and DEFENSE-PFO)performed in a sample of cryptogenic stroke in patients aged 60 years or younger provided evidence of a significant reduction of recurrent cerebral ischemia after percutaneous PFO closure.However,the use of percutaneous PFO closure cannot be generalized to the entire population of patients with cerebral ischemia and PFO,but it is indicated in highly selected patients with non-lacunar cryptogenic cerebral infarction with a large right-to-left shunt,an atrial septal aneurysm and no evidence of atrial fibrillation,as well as in association with antithrombotic treatment for an optimal secondary prevention of cerebral ischemia.

Percutaneous Patent Foramen Ovale Closure versus Medical Therapy in Cryptogenic Stroke: An Update Meta-Analysis of Randomized Controlled Trials

Objectives: Concerns regarding the real efficacy of transcatheter patent foramen ovale (PFO) closure versus medical therapy in patients with cryptogenic stroke remained unresolved. We performed a meta-analysis using the randomized controlled trials on the efficacy and safety of transcatheter PFO closure in patients with cryptogenic stroke. Methods: Web of Science, EMBASE, PubMed, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs). The primary outcome was recurrent stroke and transient-ischemic attack (TIA). Original data, hazard ratio (HR) with 95% confidence interval (95% CI) were abstracted to calculate a pooled effect size. Results: Our meta-analysis showed benefit with device closure when compared with medical therapy with an HR of 0.54 (95% CI: 0.39 - 0.74, P = 0.108) in the intention-to-treat cohort, 0.44 (95% CI: 0.24 - 0.82, P = 0.103) in the per-protocol populations, and 0.43 (95% CI: 0.31 - 0.60, P = 0.019) in the as-treated populations. There was a significantly higher incidence of new-onset atrial fibrillation in PFO closure patients (OR = 4.53, 95% CI: 2.58 - 7.97, P = 0.094). PFO Patients with an atrial septal aneurysm benefit from device closure (OR = 0.39, 95% CI: 0.22 - 0.69, P = 0.053). Patients with a substantial PFO shunt benefit the greatest with device closure with a pooled OR of 0.27 (95% CI: 0.14 - 0.56, P = 0.525). Conclusions: The meta-analysis concluded that PFO closure was associated with significantly lower risk of recurrent stroke in PFO patients with cryptogenic stroke than with medical therapy alone. The benefit of PFO closure was greater in patients with a substantial shunt and atrial septal aneurysm. PFO closure was associated with higher rates of new-onset atrial fibrillation.

The Value of c-TCD in the Diagnosis of Migraine and Cryptogenic Stroke Caused by PFO

Objective:To investigate the value of contrast-enhanced transcranial doppler(c-TCD)in the diagnosis of patent foramen ovale(PFO)of patients with migraine and cryptogenic stroke.Methods:A retrospective analysis of 160 patients undergoing c-TCD monitoring in our hospital from June 2014 to June 2019 was performed.Among them,there were 80 cases of patients with migraine(38 cases with aura and 42 cases without aura)in group A,and 80 cases of patients with cryptogenic stroke in group B.The positive detectable rate of PFO in the two groups were calculated and analyzed.Results:The detectable rate was 50.00%in group A,and 40.00%in group B.There was no statistical significance between the two groups(P>0.05).Among them,the detectable rate of PFO in migraine with aura in group A(62.50%)was higher than that in group B(37.50%).The difference was statistically significant(P<0.05);In the two groups of PFO-positive patients,the difference didn’t have statistical significance,comparing the proportion of the inherent type to that of potential type(P>0.05);There was no statistical significance of the difference between the RLS incidence of grade I and that of grade II among two groups of PFO-positive patients(P>0.05);the incidence of RLS in grade III in group B(50.00%)was higher than that in group A(25.00%),and the difference was statistically significant(P<0.05).Conclusion:c-TCD can accurately screen migraine and cryptogenic stroke caused by PFO,and grade and classify it as a clinical diagnosis of migraine and cryptogenic caused by PFO.It can also act as a objective reference of estimating the effect of treatment in different diseases and preventing cryptogenic stroke.

Clinical and Radiological Features in the Cases with Cryptogenic Brain Abscess in Association with Patent Foramen Ovale: A Case Report and Review of the Literature

Brain abscesses are commonly associated with cranial trauma, a contiguous focus of infection, or hematogenous spread from a distant focus. However, no predisposing factors are identified in approximately 4% of the cases, being recognized as a cryptogenic brain abscess (CBA). Here we report a patient with a CBA in the left occipital lobe presumably caused by a periodontal disease. The patient displayed a patent foramen ovale (PFO), through which a spontaneous right-to-left shunt was revealed with transesophageal echocardiography. A literature review indicated that in contrast to cases of general brain abscesses, patients with CBA were older and mostly had dental disorders represented by periodontal diseases and a large PFO. In these patients, the abscess was located predominantly in the posterior circulation area, and their prognosis was worse than that of general cases. Consequently, we emphasize the significance of screening for PFO in cases of advanced age with CBA in the posterior circulation region. Furthermore, to avoid neurological sequelae, we suggest immediate surgical drainage with antibiotic administration and maintenance of oral hygiene.

Clinical Utility of Procalcitonin for Differentiating between Cryptogenic Organizing Pneumonia and Community-Acquired Pneumonia

Background: Differentiating cryptogenic organizing pneumonia (COP) from community-acquired pneumonia (CAP) can be difficult in some cases. Objective: To clarify the clinical utility of procalcitonin (PCT) levels for differentiating between COP and CAP. Methods: Blood PCT levels, leukocyte count, C-reactive protein concentration, number of segments involved on computed tomography (CT) images, and pneumonia severity assessment scale were retrospectively investigated from clinical charts and chest CT images of COP and CAP patients who were admitted to our hospital from 2012 to 2014. The clinical characteristics of COP patients were compared to those of CAP patients for whom causative organisms were not detected. Results: There were 16 COP and 94 CAP patients for whom causative organisms were not detected. Blood PCT levels of all COP patients were less than 0.16 ng/dL, and significantly lower than those of CAP patients (p = 0.0004), while the number of involved segments was significantly higher than that of CAP patients (p = 0.0001). Blood PCT levels and the number of involved segments remained independently significant for differentiating between COP and CAP by multivariate analysis. Receiver operating characteristics curve analysis revealed that 7 was the best cut-off number for involved segments to differentiate between COP and CAP patients with low PCT levels (sensitivity 85.7%, specificity 94.7%). Conclusion: A combination of PCT levels and number of involved segments on CT images is useful for differentiation between COP and CAP.

Effect of Yangjing Zhongyu Decoction (养精种玉汤) on MatrixMetalloproteinase-9 Expression in Endometrium and SexHormone Regulation in Women with Cryptogenic Infertility

Objective: To investigate the effect of Yangjing Zhongyu decoction (YZD, 养精种玉汤) on metalloproteinase-9 (MMP-9) and its inhibitor-1 (TIMP-1) expression and sex hormone regulation in mid-luteal phase endometrium of women with cryptogenic infertility. Methods: Twenty-two infertile women were treated with YZD for 30 days successively. During the mid-luteal phase, in situ hybridization and reverse transcription-polymerase chain reaction method was used to detect MMP-9 and TIMP-1 mRNA, and radioimmunoassay was used to determine levels of serum estradiol (E2) and progesterone (P) synchronously. Results: After treatment, the mid-luteal serum E2 and P level were 451. 501 ± 226. 342 pmol/L and 46. 502 ± 19. 948 nmol/L respectively, significantly higher than that before treatment (304.656 ± 135.853 pmol/L and 33. 782 ± 15. 459 nmol/L respectively) , the difference was significant ( P < 0. 01). Staining of MMP-9 mRNA positive granules in cytoplasm and nuclei of adeno-epithelial cell in mid-luteal phase endometrium deepened significantly, but the change in mesenchym was insignificant. The MMP-9 mRNA expression after treatment was 0.617 ± 0.186 (grey level), significantly higher than the level before treatment (0.490 ± 0. 370), comparison between them showed significant difference ( P < 0. 05 ) . Change of TIMP-1 mRNA expression in adeno-epithelial and mesenchym before and after treatment was insignificant (0. 588 ± 0. 191 vs 0. 621 ± 0. 146,P>0. 05). Correlation analysis showed that the quantitative difference of P level before and after treatment was positively correlated with the difference of MMP-9 mRNA before and after treatment (r=0. 682, P< 0.01). Conclusion: YZD could soothen Gan(肝) and nourish Shen(肾) , raise the level of mid-luteal phase serum P, and further promote MMP-9 gene expression in endometrium to benefit the degradation of extracellular matrix of endometrium, and facilitate for blastocyst implantation.Original article on CJITWM (Chin) 2004 ;24 (4): 294

Logistic Regression Analysis of the Influencing Factors of Cryptogenic Stroke with Positive c-TCD

Objective:To explore the influencing factors and logistic regression characteristics of cryptogenic stroke in patients with positive transcranial doppler bubble test(c-TCD).Methods:A total of 134 cases of cryptogenic stroke that were diagnosed by Tianshui First People's Hospital from November 2018 to April 2020 were selected according to the TOAST(Trial of ORG 10172 in Acute Stroke Treatment)classification criteria.According to c-TCD results,there were 70 cases of right to left shunt that were included in the positive group and 64 cases without right to left shunt in the negative group.Gender,age,smoking,diabetes,hypertension,and factors affecting the positive rate of foam were analyzed.According to the abnormal embolism scale scores,logistic regression equation was used to analyze the independent influencing factors.Results:The influencing factors of cryptogenic stroke in patients with positive c-TCD were correlated with age,gender,and abnormal embolism scale scores(p<0.05).For each grade increase in age,the proportion of positive foam test was calculated to be 3.21 times,and the proportion of female to male was calculated to be 2.25 times.For each grade increase in the scores,the proportion of positive foam test was calculated to be 2.55 times.Conclusion:Female,older age,and higher scores in the abnormal embolism scale are the influencing factors for cryptogenic stroke in patients with positive c-TCD.

Progress in the treatment of elderly patients with patent foramen ovale complicated with cryptogenic stroke

Background The incidence of cryptogenic stroke(CS)accounts for about 25%of ischemic stroke.Current studies have shown that cryptogenic stroke is closely related to patent foramen ovale(PFO).Evaluating the correlation between PFO and CS needs to be combined with multidisciplinary evaluation.Many clinical studies have shown that drug therapy can reduce the risk of ischemic stroke in elderly PFO patients(>60 years old).However,whether elderly PFO patients(>60 years old)can benefit from PFO closure is still controversial.This article reviewed the research progress of drug therapy and PFO closure therapy for cryptogenic stroke associated with PFO in the elderly.[S Chin J Cardiol 2024;25(1):50-56].

Radial Probe Endobronchial Ultrasound-guided Lung Biopsy for Histopathological Diagnosis of Cryptogenic Organizing Pneumonia

INTRODUCTIONCryptogenic organizing pneumonia （COP） is a distinct type of idiopathic interstitial pneumonia with a response rate of 65 85% on corticosteroid therapy. The difficulty of COP diagnosis is that the clinical features and the radiological findings are nonspecific. The pathological hallmark of organizing pneumonia （OP） needs to be confirmed. It can also occur in a variety of other interstitial pneumonia, infectious diseases, vasculitis, and so on. To increase the pathological reliability, larger and more tissue samples are required. According to the current classification of interstitial lung disease and guidelines, the surgical lung biopsy is recommended and is considered to be the best way of obtaining a representative lung specimen However, the invasive diagnostic procedures require general anesthesia and also increase the morbidity and mortality risks; therefore, only few patients undergo such biopsy. Thus, safer and more acceptable methods for identifying COP are urgently needed.

Risk Factors of Liver Cirrhosis in Chad: Large Proportion of Cases without Clear Etiology

Background: In comparison to other forms of chronic liver diseases, cirrhosis is generally poorly studied in sub Saharan Africa. In Chad, more particularly, no data are available despite the burden of liver diseases considered as the first cause of hospitalizations in the country. Methods: We conducted a retrospective analysis of 268 patients with liver cirrhosis attending care at the University Reference Hospital between 2007 and 2016. Results: This series of liver cirrhoses was characterized by a weak mal predominance (M:F = 1.7). The age of onset occurs significantly earlier in women than in men (40.6 ± 12.0 vs. 44.4 ± 13.4, p = 0.0171). The principal risk factor was persistent infection with hepatitis B virus (49% of cases) followed distantly by infection with hepatitis C virus (13%) and excessive alcohol consumption (10%). Men were more frequently carrying HBV surface antigen than women (65.6% vs 35.9% p = 0.0019). HBV-associated liver cirrhosis was overall more severe than diseases from other causes. A large proportion of cirrhosis (30%), observed primarily in women (48.1% vs 24.1%, p = 0.0036), was considered are cryptogenic. Conclusions: The etiological spectrum of liver cirrhosis remains to be properly defined in Chad. This lack of knowledge prevents the implementation of an efficient policy of prevention. A significant effort should be secured to characterize hitherto neglected infectious, lifestyle or genetic risk factors responsible of this form of terminal disease and improve subsequently liver health of local populations.

Update on occult hepatitis B virus infection

The event of mutations in the surface antigen gene of hepatitis B virus(HBV) results in undetectable hepatitis B surface antigen with positive/negative anti-hepatitis B core(anti-HBc) antibody status in serum and this phenomenon is named occult hepatitis B infection(OBI). The presence of anti-HBc antibody in serum is an important key for OBI tracking, although about 20% of OBI cases are negative for anti-HBc antibody. The diagnosis of OBI is mainly based on polymerase chain reaction(PCR) and real-time PCR assays. However, real-time PCR is a more reliable method than PCR. OBI is a great issue for the public health problem and a challenge for the clinical entity worldwide. The persistence of OBI may lead to the development of cirrhosis and hepatocellular carcinoma. With regard to OBI complications, the screening of HBV DNA by the highly sensitive molecular means should be implemented for:(1) patients with a previous history of chronic or acute HBV infection;(2) patients co-infected with hepatitis C virus/human immunodeficiency virus;(3) patients undergoing chemotherapy or anti-CD20 therapy;(4) recipients of organ transplant;(5) blood donors;(6) organ transplant donors;(7) thalassemia and hemophilia patients;(8) health care workers;(9) patients with liver related disease(cryptogenic);(10) hemodialysis patients;(11) patients undergoing lamivudine or interferon therapy; and(12) children in time of HBV vaccination especially in highly endemic areas of HBV. Active HBV vaccination should be implemented for the close relatives of patients who are negative for OBI markers. Thus, the goal of this review is to evaluate the rate of OBI with a focus on status of high risk groups in different regions of the world.