Ibegbu A.O
Department of Human Anatomy,Faculty of Medicine, Ahmadu Bello University Zaria, Kaduna State-Nigeria. 81006.
Iduh M.U, Livinus P.P.; Eze S.M;

Department of Pathology Ahmadu Bello University Zaria, Kaduna State-Nigeria
Idoko J; Akpulu S.P; Adamu Sadeeq A.

Department of Medical Microbiology Usmanu Danfodiyo University Sokoto, Nigeria

All correspondence to: aoibegbu@yahoo.com.

ABTSRACT

The Effects of ethanolic extract of Ocimum gratissimum leaves on the liver of Adult Wistar rats were studied. Twenty four adult Wistar rats weighing between 150-250g were randomly divided into six groups of four rats each. Group 1 received 2mlv/v of distilled water, Group 2 received 54mg/kg of sodium Nitrite (NaNO2), Group 3 received 750mg/kg of extract +54mg/kg NaNO2, Group 4 received 375mg/kg of extract+54gm/kg NaNO2, Group 5 received 54mg/kg NaNO2 + 2ml/V of Olive oil while Group 6 received 2ml/V of Olive oil orally. At the end of the experiment which lasted for 21 days, the animals were sacrificed. Blood samples were collected for biochemical analysis and the liver was harvested and fixed in Bouin’s fluid for histological studies. The result showed decreased physical activities and increase rate of respiration in Group 2 and a decrease in the body weight of Groups 3 and 4 animals. The result of biochemical analyses of Liver parameters, showed a statistical significant increase in ALT, AST and a decrease in ALP in Group 2 when compared to the Control (p=0.001). The result of the histological studies of the liver showed that there was some damages in the Liver of the animals while the administration of O.gratissimum showed a mild effect in a dose dependent manner. The results from the present study suggest that O.gratissimum has the ability to ameliorate liver injury in Wistar rats.

Key Words: Osimum Gratissimum, Scent Leaves, Sodium Nitrite, Liver, Wistar Rats.

INTRODUCTION

Sodium nitrite (NaNO2) is an inorganic salt used in the manufacture of dyes and considered as one of the important food additives for fishes and meat that has been used in vivo and in vitro experiments for decades to prevent growth of Clostridium botulinum (Luca, et al., 1987). It is also used in drug industries and in medicine as antidote for cyanide poisoning (Filvo, et al., 1993). Most synthetic food additives causes health hazard such as hepatotoxicity, nephrotoxicity, endocrinal disturbances, methemoglobenemia and growth retardation (Hassan, 2007, Hassan, et al.,2008; Hassan, et al., 2009). Reactive nitrogen species produced by exposure to nitrate is considered one of the most important causes of carcinogenesis through its reaction with body tissues and triggering lipid peroxidation, DNA lesions, enzyme
inactivation and damage of different organs (Abdeen, et al., 2008; El-Wakf, et al., 2009). The high oxidative stress indicator; lipid peroxidation could be attributed to the oxidative cytotoxicity of nitrite (Patsoukis and Georgiou, 2007). These observations have been reinforced by the successful use of several endogenous and exogenous antioxidants against nitric oxide induced cellular damage.
Sidney, 1986, reported that trends in controlling and treating diseases tend to prefer natural compounds use rather than synthetic ones in scavenging produced free radicals species. Nitrite reacts with amines to produce nitrosamines and with amides to produce nitrosamides. Nitrosamines and nitrosomides constitute the N-nitroso compounds (NNC) and the reaction with nitrite is called nitrosation. Nitrosamines readily induced tumors of the liver, oesophagus, kidney, nasal cavity and pancreas and notrosamine chiefly induce tumors of glandular stomach, small intestine and nervous as well as lymphoid systems. The tissue effects depend on the species of the NNC and the system involved (Sidney, 1986). Excessive quantities of nitrate and nitrite consumption through food can be harmful to health (Leszczy-nska, et al., 2009; Chan, 2011). The ability of animals to resist the toxic effects of environmental agents is dependent on the detoxification and antioxidant systems. Several nutrients and other chemicals have been shown to be effective antioxidants, such as vitamins, trace elements, amino acids and their derivatives, fatty acids and plant phenolics (Bhattacharya, et al., 1987; Son, et al., 2004; Ayo, et al., 2006; Suteu, et al., 2007). The use of herbal products for medicinal benefits have important roles in nearly every culture on earth and herbal Medicine was practiced by the ancient people of Asia, Europe and the Americas (Wargovish, et al., 2001).
Many natural and artificial Agents possessing anti-oxidative properties have been Proposed to prevent and treat liver and kidney damages induced by Oxidative stress (Lieber, 1997; Cervinkova and Drahota,1998). There is increasing evidence for the protective role of hydroxyl and polyhydroxy-organic compounds particularly from vegetables, fruits and some herbs (Bass, 1999).
Ocimum gratissimum known as Scent leaf is a plant with root, stem and leaf systems (Iwu, 1993). O.gratissimum belongs to the family leguminocaeae, widely used local plant in Nigeria for both nutritional and Therapeutic purposes. It is naturally used in the treatment of different diseases which includes: upper respiratory tract infections, diarrhea, headache, conjunctivitis, skin disease, pneumonia, tooth and gum disorder, fever and as a mosquito repellant (Onajobi, 1986; Ilori, et al., 1996; Okigbo and Mneka, 2006). This study is aimed at evaluating the effect of ethanolic extract of Ocimum gratissimum leaves against sodium nitrite induced changes in the liver of adult Wistar rats.

MATERIALS AND METHODS
Experimental protocol:
Twenty-four apparently healthy adult Wistar rats of both sexes weighing between 150g to 250g were purchase from the Department of Human Anatomy, Faculty of Medicine, Ahmadu Bello University Zaria Kaduna State. The animals were acclimatized for three weeks in the Department Animal house. The animals were fed with standard pellet and water ad libitum throughout the experimental period. The rats were divided into six Groups of four rats each.
Fresh leaves of O.gratissimum were purchased from Sabon Gari Market Zaria Kaduna State-Nigeria. Identification and authentication was done in the herbarium of the Department of Biological Sciences, Ahmadu Bello University Zaria with voucher number 285.
The leaves were washed with distilled water and air dried for the period of one week and was extracted in the Department of Pharmacognosy, Faculty of Pharmaceutical Sciences, Ahmadu Bello University Zaria. The dried fresh leaves were grounded into coarse powder of 500g. The powder was subjected to absolute ethanol extraction using Soxhlet apparatus for 10 hours. The extract was concentrated by using evaporating dish to dryness in a Water bath regulated at 600C and 10%w/w dark green
extract was obtained.

PHYTOCHEMICAL SCREENING
The Ethanolic extracts obtained were subjected to preliminary phytochemical screening to identify the chemical constituents. The methods of analysis employed were those described by Brain and Turner (1975).

Chemicals and Reagents
12gm of sodium Nitrite manufactured by May and Baker limited Dagenhan England was purchased from Steve Moore Chemicals Limited Samaru Zaria-Nigeria. Goya Olive oil was purchased from Beautiful Gate Pharmaceutical Limited Samaru Zaria-Kaduna State, Nigeria. Growers feed from Vital feed was obtained from Samaru Market Zaria, Kaduna, Nigeria and was used to feed the animals throughout the experimental period.

Experimental Procedure
The Dose of the extract was determined using LD50 of 2500mg/kg body weight following the method of Rabelo et al., 2003. The stock solution was prepared by dissolving 12gm of the extract in 160 ml of Olive oil to form the stock solution, 30% (750mg/kg body weight) and 15% (375mg/kg body weight) of the LD50 were used in this study for the high and low dose respectively. The animals were randomly divided into six groups of four animals per group. Group 1 received 2ml/kg body weight of distilled water, Group 2 received 54mg/kg body weight of NaNO2, Group 3 received 750mg/kg body weight of the extract+54mg/kg body weight of NaNO2, Group 4 received 375mg/kg body weight of the extract+ 54gm/kg body weight of NaNO2, Group 5 received 54mg/kg body weight of NaNO2+2ml/kg body weight of Olive oil, Group 6 received 2ml/kg body weight of Olive oil.

Animal Sacrifice
After the last day of administration, the animals were left for 48 hours and were fasted overnight before sacrificed. The animals were humanely sacrificed by cervical dislocation and the blood collected through cardiac puncture for hematological and biochemical analyses.
Incisions were made through the abdomen and the liver was removed and fixed in Bouin`s fluid. The tissues were processed, sectioned and stained with hematoxylin and eosin and Cresyl fast violet methods.

STATISTICAL ANALYSIS
Data obtained from the haematological and biochemical analysis was reported as Mean ± Standard Error of Mean (SEM). One way Analysis of Variance (ANOVA) was used to compare the means w;ith values of p<0.05 was considered to be statistically significant. Sigmastat 2.0 (Systat Inc, Point Richmond, CA) was used for the statistical analysis.

PHYSICAL OBSERVATION AND WEIGHT CHANGES
Several physical observations were made during the period of administration ,except the animals in group one that received 2ml/kg body weight of distilled water and group six that received 2ml/kg body weight of Olive oil which their activities including locomotion and feeding habit were observed to be normal; The animals in group two which received 54mg/kg body weight of NaNO2 were observed to be weak and breathe faster when compared to the animals in group one and six that received distilled water and olive oil respectively. However, there was no detectable change in the animals feeding habit. Meanwhile, the animals in group five which received 54kg/body weight of NaNO2 and 2ml/kg body weight of Olive oil showed physical observations similar to the animals in group two.
The animal in group three which received 54mg/kg body weight of NaNO2 and 75mg/kg body weight of the extract were observe to be feeding very well and drink a lot of water when compared with the animals in the control group. However there was no significant difference in the physical observation of the animals in group four which received 54mg/kg body weight of NaNO2 and 375mg/kg body weight of extract when compared with the animals in group three.

The mean body weight of the animals in group One, Two, Five and Six were observed to increase during the period of administration with the animals in group six showing a more
rapid increase in weight than the others. However, there was no statistical significant different in the mean body weight of the animals across the group. In the control group, apparent increase in the final mean body weight was noticed when compared with the initial mean body weight. Meanwhile the animals in group three showed a significant decrease in the final mean body weight (213.00±30.89) when compared with the initial mean body weight (218.75±36.50). However, the animals in group four were also observed to show a significant decrease in the final mean body weight (207.25±27.09) when compared with the initial mean body weight. The decrease in the final mean body weight of the animals in group Three and four could be due to the hypoglycemic and diuretic potentials of the extract. However, there was significant increase in the final mean body weight of the animal in group five (216.00±28.44) when compared with the initial mean body weight (193.75±25.03). Meanwhile, the final mean body weight of the animals in group six showed increase in their mean body weight when compared with the animal in group five. However the increase in the mean body weight of the animals in group five and six could be due to fat accumulation as a result of the administration of Olive oil. However, there was no statistical significant difference in the mean kidney and liver weight of the animals across the group when compared with the control group.

DISCUSSION

Sodium Nitrite may react with amines of food in the stomach to produce nitrosamine and free radicals may increase lipid peroxidation which is harmful to different organs including the liver. These damages can be reduced by dietary natural antioxidant and the present study was undertaken to determine if Ocimum gratissimum could prevent or reduce NaNO2 induced liver damage by examining the different biochemical parameters in the serum. The liver play important roles in toxicity by virtue of its function both qualitatively and quantitatively. Results from the present investigation show that O. gratissimum is rich in phytochemicals and specific biologically active components have been identified in extracts from the plant by previous workers (Koche,et al., 2012; Dubey, et al., 2000; Holets, et al., 2003).

The decrease in physical activities and increase in the rate of respiration observed could be due to reduced energy generation as a result of hypoxia due to methemoglobin formation. These results of the present study are in agreement with Grant and Butler (1989) and Porter, et al. (1993).The apparent decrease in the mean body weight observed could be due to the hypoglycaemic and diuretic effect of the extract. This result is in agreement with Effriam et al. (2003) and Oguanobi et al. (2012), which showed that aqueous and ethanol extracts of Ocimum gratissimum leaves possess hypoglycaemic effects in normoglycaemic and neonatal streptozocin-induced diabetes model.

The rats treated with sodium nitrite showed significant decrease in mean body weight than the Control Group throughout the experiment periods, and this reduction may be due to the reduction of food intake (Grant and Butler, 1989) or Vitamin C deficiency (Uchida, et al.., 1990). In general, the reduction in body weight may be attributed to the decrease in food intake, the disturbance in hormonal balance and direct cytotoxic effect of sodium nitrite treatment.
Normal liver functions are characterized by balanced activities of serum enzyme markers AST, ALT and ALP. Hepatocellular necrosis leads to a very high level of AST, ALT released from the liver into the blood. ALT is the best indicator of liver injury, as liver ALT represents 90% of total enzymes presents in the body (Moss, et al., 1974). ALP activities on the other hand are related to the functioning of the hepatocytes, increase in its activity is due to increased synthesis in the presence of increased biliary pressure (Pradhu et al., 2007). Ethanolic extract of Ocimum gratissimum decreases the elevated level of AST and ALP, which suggest the protection of the structural integrity of hepatocytes cell membrane or regeneration of damaged liver cells by extract. This effect is in agreement with the view that serum level of aminotransferases returns to normal with the extract while there was a decrease in the level of ALT in Group 3.

However, there was increase in the ALT in Groups 4 and 6 which is in agreement with the view that the serum level of aminotransferases returns to normal with healing of hepatic parenchyma and regeneration of hepatocytes (Surana and Jain, 2010).
Information available showed that nitrites and nitrates are both oxidation products and ready sources of nitric oxide (NO) which reacts rapidly with superoxide to form highly reactive peroxynitrite (ONOO?) and such products may increase lipid peroxidation (LPO) which can be harmful to different organs including liver (Chow and Hong, 2002; Hassan et al., 2009; Rocha et al.; 2012). The liver is liable to injury by a variety of causes and the injury may lead to profound metabolic disorders. Liver injury induced by chemicals has been recognized as one of the most toxicological problems (Cohen, 1982).
In the histological examination of the liver, there was no lesion observed in the Control Group (one) and Groups six (Olive oil only). The characteristics of the liver lesion observed in the rats given concurrent doses of sodium nitrite and Ocimum gratissimum were congestion of central vein, necrosis of the hepatocytes, dilation of sinusoid.
The administration of sodium nitrite alone caused prominent histological damage in the liver compared with the Control and these results are in accordance with Hussein et al. (2007), Klastskin and Oconn (1993) who attributed the dilatation of the sinusoids to the direct toxic effect of the toxin leading to their dilatation. When comparing Groups 3 and 4 that were given O.gratissinum to Group 2, it showed that O. gratissimum had the ability to ameliorate the effect of NaNO2 on the liver but in a dose dependent manner of which the low dose showed a better effect of O.gratissimum on the liver histology than high dose when compared to the Control.

CONCLUSION
The present study has demonstrated the NaNO2 (sodium nitrite) induced changes in the liver and that the ethanolic extract of Ocimum gratissimum has significant beneficial role in overcoming the NaNO2 induced adverse effects which may be through its antioxidant properties.

The post Effect Of Ethanolic Extract Of Ocimum gratissimum (scent leave) Leaves On Sodium Nitrite Induced Changes In The Liver Of Adult Wistar Rats appeared first on Nigerian Biomedical Science Journal.

Isah, R.T.; Mohammed, I.
Department of Histopathology, Faculty of Medical Laboratory Science, Usmanu Danfodiyo University, Sokoto, Nigeria.
Avwioro, O.G.
Faculty of Science, Delta State University, Nigeria.
Abdullahi, K.
Department of Histopathology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria.
Bello, M.B.
Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria.

All correspondence to: Isah R.T. (tsamiyarilly@gmail.com)

ABSTRACT

The male breast in spite of being rudimentary is subject to the full spectrum of disease that affects the female breast. Male breast cancer is a rare condition globally, accounting for only 1% of all breast cancer. However, there is a wider increase in prevalence of this cancer in Africa approximately 5% – 15% as compared to developed nations. In Nigeria, several studies have shown prevalence in the range of 3.7% to 9.0% of all breast cancer cases. Mutation of BRCA 2 gene accounted for most of the cases of male breast cancer occurrence; other genetic conditions are BRCA 1 mutation, Klinefelter’s syndrome and Cowden’s disease. In addition, other risk factors associated with the disease are radiation exposure, hyperestrogenism, occupational and environmental exposure. Diagnostic methods include fairly specific techniques like routine light microscopic examination of haematoxylin and eosin stained sections of formalin fixed paraffin embedded biopsies, immunohistochemistry, fluorescent in situ hybridization and gene expression profiling. There is need for more public awareness program which focuses on behavioral modulation of diet, regular self-breast examination especially for those at risk and avoidance of exposure to environmental carcinogens.

KEY WORDS: Male breast, gynaecomastia, carcinoma, risk factors, diagnostic methods and prevention.

INTRODUCTION

Cancer can develop in any part of the body including breast of both male and females. Male breast cancer is rare compared to that of the female but they have similarities with few differences, as a result of which their diagnosis and treatment are almost similar [1, 2]. Several risk factors has been associated with development of male breast cancer which include family disposition, hyperestrogenism which may be caused by Klinefelter’s syndrome and liver cirrhosis, radiation exposure most especially at the chest region, testicular disorders, dietary source, aging and obesity [3].

Some of the signs and symptoms of breast cancer in males comprise of firm, non-painful mass located just below the nipple, skin dimpling around the breast region, nipple retraction, redness of the nipple or breast skin, bloody
discharge from the nipple and ulceration of the skin in advanced cases [4]. Pathogenesis of breast cancer in both sexes is essentially similar; much of this is linked to exposure to sex steroids (estrogen and progesterone) and activity of receptor tyrosine kinases (RTK) located on the surface of the breast parenchymal cells [5, 6].

Invasive ductal carcinoma (Not Otherwise Specified – NOS) is the most common histopathological type of breast cancer in males [7]. At least 8 out of 10 male breast cancers are invasive ductal carcinomas alone or mixed with other types of invasive or in situ breast cancer [8].

METHODOLOGY
This review paper involved gathering of already published articles and literature documents on male breast cancer. They were then extensively analyzed and presented as it affect African populace most especially Nigeria.

EPIDEMIOLOGY
Male breast cancer is a rare disease. It accounts for only about 1% of all breast cancer [9]. It was estimated that in 2013, about 2,240 new cases of breast cancer in men would be diagnosed and that breast cancer would cause approximately 410 deaths of men in United States [8]. Approximately 350-400 new cases of breast cancer in males are diagnosed annually in the United Kingdom [10]. A man’s lifetime risk of developing breast cancer is 1 in 1000, it can occur at any age, but it is mostly detected in the 60-70 years age group in developed countries [8].
The incidence of breast cancer in men has been increasing globally; one report suggested that incidence has increased 26 percent over the past 25 years [11]. In Africa, various researches conducted in the region have shown a wider increase in male breast cancer occurrence and mortality rate as compared to the developed countries. Incidence of male breast cancer is much higher in sub-Saharan Africa, approximately 5%-15% [12]. When they present, the tumours are often at advanced stages with poorer
prognoses [7]. A meta-analytical study on male breast cancer in African males indicated that the average age of occurrence was 54.6 years, which is 7 years older than the female counterparts [13]
Reasons for the differences in mortality rates between developed countries and African countries include advanced stages at presentation, worse biologic behavior, poor treatment facilities and poor patient acceptance of recommended treatments, which has been attributed to ignorance, superstition, self-denial, fear of mastectomy and unavailability of treatment facilities [14, 15].
In Tanzania for example and areas of central Africa, breast cancer accounts for up to 6 percent of cancers in men [16]. Similar researches in Uganda and Zambia Showed 5% and 15% respectively [17, 18]
Male breast cancer in Nigeria represents 3.7-8.6% of all breast cancers; this is higher than the 1% recorded from other parts of the world [19]. Majority are invasive ductal carcinoma which is characterized by late presentation at advanced stage with attendant poor prognosis [9].

RISK FACTORS
The exact cause of male breast cancer is not known but there are risk factors that make someone susceptible to develop the disease over a period of time. They include:

A. Genetic: Familial disposition just like that of the women breast cancer increases the risk of developing male breast cancer. Men that have first degree relatives with history of breast cancer tend to be susceptible to have the disease in the future. Basham et al [25] stated that 15-20% of male breast cancer cases originate from family history. Men can have mutation on breast cancer gene BRCA1 and BRCA2 but the latter is more common in this sex [26]. A male with BRCA2 mutation carries an increase 6% life time risk of having the disease than 0.1% in the normal population. Other genetic condition that increases susceptibility to the disease is Klinefelter’s syndrome [27].

B. Radiation Exposure: Frequent exposure to ionizing radiation has been associated with an increase risk of developing breast cancer in both men and women [7]. Men with history of undergoing chest x-ray or radiation therapy frequently have a greater chance of having the disease [28]. Therefore, prolong exposure to radiographs may be
harmful to individuals. Even workers that expose themselves to electromagnetic waves and other radiations daily without adequate protection are at risk [29].
C. Hyperestrogenism: Certain conditions can result in abnormally high levels of estrogen in men thereby increasing the risk of developing breast cancer. About 80-90% of male breast cancer has estrogen receptor meaning they are ER positive. Klinefelter’s syndrome and cirrhosis of the liver have been found to cause increase estrogen level in men [30]. Other conditions affecting estrogen in relation to androgen levels are taking exogenous estrogen as medication, mumps ochitis and testicular dysfunction [8]. Obesity also increases risk of breast cancer due to conversion of androgen hormone by the fat cells into estrogen; this means that obese men have higher level of estrogens in their body which subsequently may cause breast cancer [31].

DIAGNOSIS
A number of diagnostic methods are available. They include:
1. Medical history and physical examination: The medical history may give some clues about the cause of any symptom on the patient and tendency of having increase

risk factor(s) of developing breast cancer [8]. A thorough clinical breast examination will assist in locating any lumps or suspicious areas and assess the texture, size, and relationship of the breast to the skin and muscle tissue [32].

2. Biopsy: this involves removal of tissue sample from the body for examination under the microscope. There are different ways of obtaining tissue biopsy namely fine needle aspiration, core needle biopsy and surgical biopsy [33]. Majority of male breast cancers are invasive ductal carcinoma (80-90%) while ductal carcinoma in situ accounted for 10% [34, 35]. Cancer of lobular origin made up of only 1% due to lack of abundant lobules in male breast, others include Paget’s disease (1%), mucinous (1%), medullary and invasive papillary has 2% of occurrence each [36, 37, 38]. Special techniques are employed to further diagnosed breast tissue histopathologically as below:

1. Immunohistochemistry (IHC): This is a method of employing specialized antibodies against specific antigens on the cell membrane or nuclear region of the breast cancer cells. The standard tests include estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor (HER2) and Ki67 tests for invasive breast cancers [37]. About 90% of male breast cancers are ER positive and 16% of the cases over-expressed HER 2 [39].

2. Fluorescent in situ hybridization (FISH): This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted using a fluorescent microscope. Many breast cancer specialists think the FISH test gives more accurate results than IHC, but it is more expensive and takes longer to get the results. When IHC result is 2+, the HER2 status of the tumor is not clear and the tumor is then tested with FISH for confirmation [8, 40].

3. Genetic Testing: Genes are tested on the sample so as to understand the biology of the tumour. Some cancers are fast growing while others are not depending on the type of individual genes they possess. Examples of gene testing methods include Oncotype Dx and Mammaprint [38].

4. Imaging Tests: Different imaging techniques are use in assisting diagnosis of breast cancer, the methods are diagmostic mammography, ultrasound, magnetic resonance imaging [38]

5. Other Tests: There are several other tests use in assisting diagnosis of breast cancer namely nipple discharge examination, blood tests, X-ray, bone scan, computed tomography and positron emission tomography [8].

PREVENTION
There is need for men to take necessary steps in preventing themselves from having breast cancer by carrying out and observing the following steps:
1. Regular self examination: A person’s best chance of surviving breast cancer is early detection through regular self-examinations. Men should be familiar with the normal feel of their breast tissue so that they can bring any lump or change to the hospital for proper attention.

2. Active participation in exercise activities: It has been realized that increased physical activity is associated with decreased breast cancer risk. This may be because exercise lowers hormone levels, boosts the immune system, and changes metabolism while lack of exercise contributes to obesity.

3. Making healthier food choices: Several researches has shown immense important of particular food substances in preventing development of breast cancer and many other types of cancers. They contained antioxidants and other essential elements that repair and prevent cells from the damaging effects of free radicals and other carcinogens. Examples include tomatoes (lycopene), green vegetables (beta-carotene, folate, Vitamin C, E and K), berries (anthocyanins), onion (quercetin) and sweet potatoes (beta-carotene and Vitamin C).

4. Optimizing Vitamin D source: Vitamin D influences virtually every cell in the body and is one of nature’s most potent cancer fighters. This can be done by appropriate sun exposure or by using Vitamin D supplements.

5. Avoidance of unnecessary exposure to radiation/Environmental pollution: Getting medical imaging studies only when they are necessarily needed and avoidance of environmental pollutions help in cancer prevention.

6. Quitting smoking and sleeping well: Researches has shown cigarette smoking is associated with cancer development because it is injurious to the overall health of an individual. Avoidance of smoking is an essential mean of preventing cancer and having enough sleep maintain someone hormonal balance for a healthy living [41, 42, 43].

CONCLUSION:
Although cancer of the male breast is rare, when it occurs, it presents at an advanced stage especially in resource poor settings. This underscores the need for use of simple and painless preventive measures.

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The post Breast Cancer In Men: A Review of Epidemiology, Risk Factors, Diagnosis And Prevention In Africa. appeared first on Nigerian Biomedical Science Journal.

Omosigho O P
Medical Microbiology Department, Federal Medical Centre Bida. Niger State .Nigeria

Emumwen E.G, Inyinbor H.E
Medical Microbiology Dept., Federal Medical Centre Bida. Niger State Nigeria.

All correspondents to: Medical Microbiology Department, Federal Medical Centre Bida. Niger State, Nigeria. Email –omosighoop@gmail.com

ABSTRACT

Male urogenital tract infection is an important factor in the management of infertility. This study was carried out to evaluate the prevalence of bacteriospermia, antibiotic susceptibility pattern and its effect on the quality of spermatozoa in male infertility in Bida. Five hundred and six semen samples cultured in the medical microbiology laboratory for three years were analyzed. This study showed a prevalence of bacteriospermia of 39.9% with Staphylococcus aureus having the highest frequency of 30.4%. Bacterial infection has remained one of the important factor in the management of infertility ,this study showed high rate of bacteriospermia in primary infertility 27.7% which is statistically significant (P= 0.000). The prevalence of bacteriospermia in Bida was more pronounced in oligospermia 22.7%. This study found a significant statistical difference between bacteriospermia and age (P=0.000) .In conclusion, the prevalence of bacteriospermia is high in Bida, it is therefore advocated that attention should be given to the treatment of urogenital infection in the management of male factor infertility.

KEY WORDS-Bacteriospermia, Staphylococcus aureus, Antibiotic susceptibility, Male factor, Infertility.

INTRODUCTION

According to World Health Organization (WHO), seminal fluid infection was define as the presence of significant bacteriospermia (= 103 bacterial/ml ejaculate), detection of Nisseria gonorrhoae, Chlamydia trachomatis, Ureaplasma urealyticum, significant leucocytospermia (WHO 1999).
The isolation of microorganisms in seminal fluid especially of infertile men has been widely reported, while the exact role of microbial infection in the etiology of infertility is not very certain owing to the limitation in diagnostic criteria and asymptomatic nature of infection, as some possible effect on the properties of seminal fluid associated with fertility has been suggested (Gregoriov et al .,1989, Merino et al., 1995, Villanueva-Diaz et al., 1999, Purvis and Christiansen1993, Buhharin et a.,l 2000 and Rodin et al., 2003 ).
There is disagreement as to the influence of certain microbial infection on male infertility, several investigation have reported different types of organisms in seminal fluid specimens depending on the method of examination (Macleod and Gold 1951). It was reported that detection of bacteria in semen does not necessary suggest
infection since bacteria isolates in seminal fluid may represent contamination, colonization of urethral orifice or infection. Opportunistic microorganism cause classical infection of urogenital tract and subclinical reproductive tract infection, these infections of the seminal fluid leads to decrease in number of spermatozoa, the suppression of their motility, changes their morphology and fertility capacity (Buhharin et al., 2000).
This study was carried out to evaluate the prevalence of bacteriospermia, antibiotic susceptibility patterns and its effect on the quality of spermatozoa in male infertility in Bida, Niger State.

MATERIALS AND METHOD
Five hundred and six (506) seminal fluids from men investigated for infertility over a period of three years were analyzed. These were seminal fluid of patient referred to the Laboratory from the Gynecology Clinic of Federal Medical Centre, Bida.
The semen was collected after the patient had abstained from sex at least three days. Samples were collected either by self or assisted masturbation into sterile bottle. Patients were educated on proper sample collection to reduce contamination and submitted to the Laboratory within one hour of production. The semen were cultured on Blood, Chocolate and MacConkey agar media and incubated for 24 hours at 37oC while Chocolate agar were incubated under 5% Co2. Emergent colonies were identified according to standard bacteriological method.
The samples were analyzed within one hour of collection or as soon as liquefaction occurred using manual method.
Initial microscopy examination of the appearance, viscosity and volume estimation was done, after which microscopy was carried out to estimate the sperm concentration, motility and morphology according to WHO guideline (WHO 2010).

DISCUSSION

Male genital tract infection is an important etiological factor leading to deterioration of spermatogenesis, impairment of sperm function and/or obstruction of seminal tract (Owolabi et al., 2013). The prevalence of bacteriospermia among male partners of infertile couples in this study is 39.9% with Staphylococcus aureus having the highest frequency of 154(30.4%) followed by Eschericia coli 34(6.7%) and Pseudomonas aeruginosa 7(1.2%) which is in agreement with other studies in Nigeria (Ibekwe and Mbazor 2002 in Abakeliki , Ugboma et al., 2012 in Port Harcout and Emokpae et al ., 2009 in Kano).
Generally ,the risk of infertility increases by age, in this study a high bacteriospermia prevalence rate was obtained among age 36-40 years (12.4%) followed by age 26-30 years (9.2%) and 31-35 years (8.8%) this findings is statistically significant (p=0.000) and agrees with the findings in Port Harcourt Nigeria (Olutimilehin et al .,2012).

Infection has remained one of the important factors in infertility our findings showed a higher rate of bacteriospermia in primary infertile couples 27.7% compared to 12.3% in secondary infertility and it is found to be statistically significant(p=0.000) though, in contrast to the findings of Olujubu et al., (2013)who reported a higher prevalence in secondary infertility.

Bacteriospermia was more pronounced in couples with oligospermia 22.7% followed by normospermia 10.5% and azoospermia 6.7% similar to the findings in Kano by Emokpae et al .,2009, while Owolabi et al ., in Ile ife reported 50.2% seminal infection in normospermia ,20.3% in oligospermia and 4.4% in azoospermia.
Antibiotic susceptibility pattern of bacteriospermia in Bida from our study shows that all isolates are 70-90% susceptible to Levofloxacin, Ciprofloxacin, Pefloxacin and Azithromycin while many are resistant to Gentamycin , Cefuroxime, Ceftazidime and Cotrimoxazole.

In conclusion, the prevalence of bacteria in semen may affect fertility in several ways including damage of spermatozoa, hampering their motility, altering the chemical composition of fluid (Mogra et al., 1981). Bacterial infection in this study is high and we advocate that proper attention should be given to the treatment of bacteriospermia in the management of male factor cause of infertility.

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Bakari AG
Department Of Medicine Ahmadu Bello University Teaching Hospital, Zaria
Lawal N; Akuyam SA ; Anaja PO
Department of Chemical Pathology Ahmadu Bello University Teaching Hospital, Zaria

All correspondence to: Lawal N nasiruacademy@gmail.com

ABSTRACT

Type 2 diabetic patients are at an increased risk of developing liver diseases owing to the nature of the disease and its inherent complications. Elevated serum activities of the liver enzymes are the most frequent indicators of liver disease. The purpose of this study was to determine the pattern of abnormal serum liver enzymes activities in type 2 diabetic individuals. The study comprised of 170 type 2 diabetic patients attending Medical Outpatients Department of Ahmadu Bello University Teaching Hospital, Zaria. Diabetes mellitus (DM) was confirmed according to the new diagnostic criteria based on 2 fasting or 2 random plasma glucose levels of more than 7.0 mmol/L and 11.1 mmol/L respectively. A concise history of the patients, physical examination and laboratory findings were recorded on a proforma. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities were measured using the kinetic method of IFCC. Serum gamma glutamyl transferase (GGT) activities were measured using the kinetic method of SZASZ. Serum alkaline phosphatase (ALP) activities were measured using the colorimetric method of King and Amstrong. The concentrations of serum FBG and RBG were measured using glucose oxidase method of Trinder.
One hundred and eighteen (69.4 %), 46 (27.1 %), 26 (15.3 %) and 51 (30.0 %) of patients had mild increases in serum levels of AST, ALT, GGT, and ALP respectively. In addition 42 (24.5 %) patients had both mild increases of AST-ALT and 10 (5.9%) had mild increases of all the liver enzymes activities. It can be concluded from the findings of the present study that there is chronic mild increases in serum liver enzymes activities in diabetic patients therefore, liver function tests (LFTs) be included into routine laboratory investigations of DM in Nigerian hospitals.

KEY WORDS: Diabetic, Serum, Liver Enzymes

INTRODUCTION

Diabetes mellitus (DM) is a systemic disease caused by absolute or relative deficiency of insulin and is manifested by disorders of carbohydrates, lipid and protein metabolism1. The prevalence of diabetes is high in patients who have liver disease such as non alcoholic fatty liver disease (NAFLD), chronic viral hepatitis, haemochromatosis alcoholic liver disease and cirrhosis. Similar studies have shown that DM plays a significant role in the initiation and progression of liver injury (Hickman IJ and MacDonald GA, 2007).
Onyemelukwe and Bakari (1998) observed that chronic liver disease was responsible for secondary diabetes mellitus in 15 cases (2% of total and 36 % of secondary diabetes mellitus). Of this number, 10 were secondary to liver cirrhosis, 3 with schistosomal liver fibrosis and 1 case each secondary to chronic active
hepatitis and chronic persistent hepatitis. All cases except Schistosomal liver fibrosis tested positive to serum hepatitis B surface antigen.
The hallmark of the disease is fasting hyperglycemia (WHO; Geneva, 1999) and studies have shown that liver plays a critical role in carbohydrate homeostasis and insulin degradation therefore, it is not surprising that it’s function may be affected by DM (Hanley et al. 2004). Association exists between DM and liver injury (Meltzer A and Everhart JE 1997). There are evidences have revealed that patients with type 2 DM have two times the risk of developing liver diseases than their healthy counterparts (Karen Barrow, 2005). Hsiao et al;2007 reported that alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma glutamyltransferase (GGT) were associated with insulin resistance (IR) as glycaemic status progresses in the impaired fasting glucose group.

Liver disorders among diabetics is similar to that of alcoholic liver disease including fatty liver (steatosis), steatohepatitis, fibrosis and cirrhosis. Elevated serum activities of the liver enzymes such as aspartate aminotransferase (AST), alanine aminotransferase(ALT), alkaline phosphatase (ALP) and gamma glutamyltrasferase(GGT) are the most frequent indicators of liver disease and occur in diabetics more frequently than in healthy individuals Hsiao et al; 2007.The aim of the present study was to determine the pattern of abnormal liver enzyme activities in type II diabetic patients in Zaria , Northern Nigeria.

MATERIALS AND METHODS
The study was conducted in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria. This study was approved by the ethical committee of the ABUTH, Zaria in accordance with the declaration of Helsinki. A total of 170 diabetic patients attending Medical-outpatients Department (MOPD) and 80 apparently healthy individuals were studied. The criteria for diagnosis of type 2 DM was the American Diabetes Association Criteria (2004), fasting blood glucose of 7.0 mmol/L on two occasions or random blood glucose of 11.1 mmol/L with diabetic symptoms. The diabetic patients were provided with conventional diabetes care/control measures. At the MOPD, arrangement was made with the Physicians whereby subjects who satisfy the study inclusion criteria were selected. Informed consent for inclusion into the study was obtained from the subjects. The nature of the study was explained to the subjects by using an appropriate language. A full medical history was obtained from the subjects by the Physician followed by clinical examination. The findings were documented in the Proforma. Blood specimens were taken into plain tubes,
using sterile technique. The blood was centrifuged and the serum was carefully drawn into sample bottles and then stored frozen at -200C until the time for analysis. The samples were analyzed for plasma glycatedheamoglobin (GHbA1c) using the method of Triveli et al; 971 and Fasting Blood Glucose (FBG) as well as Random Blood Glucose (RBG) using the method of Trinder 1964..
Statistical analysis was performed using statistical package for social sciences (SPSS) for Windows, version 15.0. Data were presented as Mean±SEM. plasma glycated heamoglobin (GHbA1c) levels and serum Fasting Blood Glucose (FBG) as well as Random Blood Glucose (RBG) levels were compared with those of the apparently individuals using two tailed student t-test. A p-value of equal to or less than 0.05 (p=0.05) was considered as statistically significant.

RESULTS
The results of clinical parameters are presented in table I. The differences in weight and body mass index (BMI) between diabetic subjects and controls were statistically significant. Plasma GHbA1c and serum FBG as well as RBG in diabetic patients and controls are presented in table II. The mean values of plasma GHbA1c and serum FBG as well as RBG were significantly higher in diabetic patients than the control subjects (p<0.01).

The result of pattern of abnormal liver enzymes activities are presented in Table II. One hundred and eighteen (69.4 %) , 46 (27.1 %), 26 (15.3 %) and 51 (30.0 %) of patients had mild increases in serum levels of AST, ALT, GGT, and ALP respectively. Similarly, in the control subjects, 33 (41.3 %), 1 (1.3 %) 27 (36 %) 11 (13.8 %) individuals also had mild increase in serum levels of AST, ALT, GGT and ALP respectively.

DISCUSSION

The results obtained in the present study showed that the percentage prevalence of abnormal serum liver enzymes activities were significantly higher in diabetic patients than in control subjects. The finding of the present study was similar with those of Salmela et al; 1984 and Erbey et al; 2000 as seen in (table II). Even though there were variations in the values of percentage prevalence reported by the above mention authors as well as the present study however, the values were higher in diabetic patients than in control subjects.

The high percentage prevalence of elevated liver enzyme activities in type II diabetic patients seen in the present study suggest that the liver is diseased. It was reported that elevation of serum activities of the liver enzymes such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and gamma glutamyltrasferase (GGT) are the most frequent indicators of liver disease (Monica et al 2005 and Meltzer A, Everhart JE 1997) therefore, the high percentage prevalence of elevated liver enzyme activities in type II diabetic patients as well as the higher mean level liver enzyme activities in type II DM than control subjects seen in the present study further confirm the abnormalities of liver function in type II DM. The hallmark of type 2 DM is hyperglycaemia and it leads to fat accumulation in the liver14. Fat accumulation is known to be directly toxic to hepatocytes . An elevation of liver enzymes such as ALT and GGT even within the normal range, reflects deposition of excess fat in the liver (Meybodi et al 2008 and Maryam et al 2008). This may be responsible for the increased serum activities of transaminases seen in the present study. Zachary, 2007stated that fat accumulation in the liver also stimulates the release of inflammatory cytokines such as tumor necrosis factor-α (TNF) and interleukine-6 (IL-6) which may contribute to hepatocellular injury. This might also result to increased serum activities of transaminases in the present study.

Hyperglycemia leads to myoinositol depletion in several tissues susceptible to diabetic complications (for example liver), although the exact mechanism is unclear. The fall in myoinositol levels in the cell membrane alters the functioning of Na+/K+ ATPase pump and the integrity of the cell membrane is impaired (Malnick et al; 2003). Clinical observations and experimental studies have shown that subtle changes of cell membrane are sufficient to allow passage of intracellular enzymes such as AST and ALT to the extracellular space with subsequent elevation of their levels in plasma (Malnick et al; 2003). This could be another reason for increased serum activities of transaminases in the present study.

Monica et al; 2005 reported that ALT, ALP and GGT were associated with prevalent type 2 DM and AST with prevalent IGT). NAFLD is a complication in 32%-78% of patients with type 2 DM and 50% of these patients may have NASH. Some studies demonstrated that hyperglycemia and hyperinsulinaemia can promote fatty infiltration of the liver (De Marco et al 1999).
CONCLUSION
It can be concluded from the findings of the present study that there were high prevalence abnormal liver enzyme activities in diabetic patients therefore, liver function tests (LFTs) should be included into routine laboratory investigations of DM in Nigerian hospitals.

ACKNOWLEDGMENT
We acknowledged the assistance of University Board of Research of Ahmadu Bello University, Zaria. We thank Dr IS Aliyu, Head of Chemical Pathology Department of Ahmadu Bello University Teaching Hospital (ABUTH), Zaria for his constant advice and encouragement during this study. We are also grateful to Dr Muazu Babura of the Department Medicine of ABUTH, Zaria for his assistance during the course of this work. We also thank Mal. MA Auwal and of the Department of Chemical Pathology ABUTH, Zaria for his assistance in analysis and other logistics.

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Narendranath Epperla, Patrick Foy

Division of Hematology and Oncology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI, USA

Erika Peterson
Division of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA

Correspondences to: Narendranath Epperla · ·nepperla@mcw.edu

ABSTRACT
Background: Heterotaxy is a relatively uncommon congenital anomaly that is usually diagnosed incidentally on imaging studies in adults. We present an unusual case of venous thromboembolism in a 26 year old pregnant female with Heterotaxy syndrome.

Case presentation: A 26 year-old pregnant female at 13 weeks gestation suffered cardiac arrest with successful cardiac resuscitation and return of spontaneous circulation. The cardiac arrest was secondary to massive pulmonary embolism requiring thrombolytic therapy and stabilization of hemodynamics. She had extensive evaluation to determine the etiology for the pulmonary embolism and was noted to have an anatomic variation consistent with heterotaxy syndrome on imaging studies. After thrombolysis the patient was treated with UFH and then switched to enoxaparin without complication until 25 weeks of gestation when she experienced worsening abdominal pain with associated headaches, lightheadedness and elevated blood pressures needing elective induction of labor. The infant died shortly after delivery. The anticoagulation was continued for additional 3 months and she was subsequently placed on low dose aspirin to prevent recurrent venous thromboembolic episodes. She is currently stable on low dose aspirin and is into her third year after the venous thromboembolism without any recurrence.

Conclusion: To our knowledge, this is the first reported case of venous thromboembolism in pregnancy associated with heterotaxy syndrome. A discussion on pathophysiology of venous thromboembolism in pregnancy and heterotaxy syndrome has been undertaken along with treatment approach in such situations.

Keywords: Venous thromboembolism; Inferior vena cava; Low molecular weight heparin

BACKGROUND

Heterotaxy is an uncommon polymalformative syndrome characterized by congenital anomalies that arise from disorderly arrangement of asymmetric thoracic and abdominal viscera and blood vessels [1]. The estimated prevalence is approximately 1 in 10,000 live births. Morbidity and mortality rates are high approaching nearly 70 % due to major cardiac malformations (especially in heterotaxy with asplenia patients). Five to ten percent of patients with minor or no cardiac anomalies will survive to the adulthood. Some will remain asymptomatic and can be diagnosed incidentally on imaging studies. Heterotaxy has been reported to be associated with VTE and is felt to be related to abnormal lower extremity venous system. Infact in the last few years some authors considered it as a VTE risk factor. However VTE in pregnancy with heterotaxy syndrome has not been
reported.
Herein we present a case of 26 year-old pregnant female who suffered cardiac arrest related to massive pulmonary embolism requiring cardiac resuscitation. Imaging studies incidentally discovered anatomic variation consistent with heterotaxy syndrome. She was anticoagulated for 6 months with low molecular weight heparin (LMWH) and subsequently placed on low dose aspirin to prevent recurrent VTE. A detailed discussion of the pathophysiology of VTE in pregnancy and heterotaxy syndrome has been undertaken with a focus on treatment approach in such situations.

Case presentation
A 26 year old otherwise healthy, G1P0 female at 13 weeks gestation was admitted to medical intensive care unit after she experienced cardiac arrest at home. She had reported shortness of breath earlier that day and then collapsed.

During initial paramedic evaluation, she was pulseless and found to be in pulse less electrical activity (PEA). She was successfully resuscitated with return of spontaneous circulation (ROSC) in approximately 7 min and was brought to the hospital. Emergency department (ED) evaluation revealed the patient to be nonresponsive, and she was immediately intubated. Her exam was remarkable for cold and cyanotic extremities, without palpable distal pulses but strong femoral pulse. Shortly after her arrival to ED, the patient became pulse less again needing resuscitation and ROSC on 2 occasions.

Initial blood work was remarkable for severe metabolic acidosis (HCO3 of 10) and elevated troponin I (2.77 ng/ml, normal range 0–0.34 ng/ml). EKG showed right bundle branch block while bedside 2 D echocardiogram demonstrated right heart strain pattern. Bedside ultrasound (USG) showed no significant free fluid with live intrauterine gestation. Bilateral lower extremity compression venous dopplers of the entire venous system were negative for any evidence of deep venous thrombosis. She underwent computerized tomography (CT) of the chest which revealed a nearly occlusive thrombus in the bilateral lower lobar arteries extending into the segmental arteries (Fig. 1). The main pulmonary arterial trunk was noted to be enlarged with evidence of right heart strain (Fig. 2). Head CT scan was negative for any acute intracranial abnormalities. She was administered intravenous tissue plasminogen activator (TPA) (50 mg after ROSC the second time) in the ED with improvement in her hemodynamics. Hypothermia protocol was concurrently initiated. She was subsequently transferred to medical intensive care unit on unfractionated heparin (UFH), bicarbonate and norepinephrine drips. The patient was extubated two days following and was gradually weaned off blood pressure support. UFH drip was titrated based on aPTT and 6 days later she was transitioned to LMWH (dalteparin 10,000 units subcutaneously once daily in view of her insurance issues). She had aggressive supportive care and after a 2 week hospital stay, she was discharged to rehabilitation facility on Dalteparin. A month later dalteparin was changed to enoxaparin 55 mg (1 mg/kg) s/q twice daily (monitored with anti Xa levels).
At approximately 20 week’s gestation, the patient had a fetal ultrasound that revealed singleton gestation with massive hydrops, fetal contractures and ventriculomegaly/hydranencephaly. It was presumed that these findings were secondary to early hypoxic injury and she was counseled about poor prognosis. During her 25th week gestation, the patient noted worsening abdominal pain with associated headaches, lightheadedness and weakness. She had elevated blood pressures and was suspected to have mirror syndrome. Enoxaparin was discontinued 24 h prior to the planned procedure with initiation of UFH drip. The patient underwent elective induction of labor with palliative care services. The infant died shortly after delivery. The patient experienced increased vaginal bleeding secondary to retained products of conception and underwent dilatation and curettage with achievement of hemostasis. Enoxaparin at previous dosage (55 mg s/q twice daily) was restarted 24 h after the delivery without any major or untoward complication. Platelet count and anti-Xa levels were checked while the patient was on enoxaparin. Anti-Xa levels were in therapeutic range (0.8–1, goal 0.6–1.0 IU/ml) and platelet counts remained within normal limits.
In order to identify the cause of her VTE the patient had further work up including thrombophilia testing and CT chest, abdomen/pelvis. Thrombophilia testing revealed the patient to be wild type for Factor V and Prothrombin gene. Protein C and S antigen levels were normal. Antithrombin activity was initially low (71, normal range 75–125 % ACT) at the time of initial VTE but subsequently normalized (107). Antiphospholipid antibody testing including lupus anticoagulant, anti-cardiolipin antibodies and beta 2 glycoprotein I antibodies was negative. CT chest, abdomen and pelvis showed constellation of imaging findings compatible with heterotaxy syndrome. These included left-sided superior vena cava (SVC) draining into the left coronary sinus, hemiazygous vein drains into left SVC, absent azygous vein, absent (interrupted) inferior vena cava (IVC) below the hepatic IVC with persistent left IVC which drains into left coronary sinus, polysplenia, bilateral left lung and benign hepatic hemangioma (Fig. 3A-C).

The patient completed 6 month duration of anticoagulation with LMWH and was subsequently placed on ASA 81 mg. Prior to discontinuation of anticoagulation therapy the patient had CT pulmonary angiogram which showed normal diameter of the main pulmonary artery without any evidence of acute or chronic pulmonary emboli. She is currently stable on low dose ASA and is into her third year after the VTE without any recurrence. She has had no further pregnancies.

DISCUSSION
Heterotaxy or situs ambiguous refers to malposition and dysmorphism of viscera and blood vessels, often with indeterminate atrial arrangement. This abnormal arrangement of body organs is different from the orderly arrangement seen in situs solitus or situs inversus. Heterotaxy syndrome can be associated with either asplenia or polysplenia. Our patient had heterotaxy with polysplenia and hence will limit our discussion to this abnormality and hereon will be referred to as heterotaxy.
Heterotaxy implies that the patients have bilateral bilobed lungs, bilateral pulmonary atria, a centrally located liver, a stomach in indeterminate position, interrupted IVC with azygous continuation and multiple spleens. After polysplenia, the most frequent finding in heterotaxy is the hypoplasia of the IVC with absence of the intrahepatic segment and direct continuation with the azygous venous system. Heterotaxy commonly occurs as a sporadic condition but it can be inherited.
Varied timing of embryological causative factors during the development of fetus can explain the wide range of anomalies in the heterotaxy syndrome. Cardiac anomalies are mostly the result of abnormal embryological development around day 28 of embryogenesis, as it is during this period that connection between primitive heart and venous channels occurs. The failure of fusion of fetal lobules leads to individualization of multiple splenic nodules, which are located along the greater curvature of the stomach, as the spleen develops in the mesogastric region. IVC is a complex vascular structure that is developed during weeks 6–8 of embryogenesis. During this period three pairs of primitive venous channels (posterior cardinal, subcardinal and supracardinal veins) form the mature venous system (IVC) through a complex sequential process. Various malformations including partial or even complete absence of IVC can result from the failure in the developmental steps related to embryonic dysontogenesis that can affect separate segments or even the entire IVC. Thus mutations in genes that control left-right patterning and teratogenic exposures in early embryonic period underlie majority of heterotaxy cases.
The occurrence of DVT seems to be higher in patients with heterotaxy compared to the general population. It is postulated that stasis related to the abnormal venous drainage of the lower extremity venous system due to interrupted IVC, and increased platelet aggregation related to the anomalous drainage of the splenic venous system into the azygous system seems to be the possible culprits for heightened risk of pulmonary thromboembolism in these patients.
VTE is 5 times more frequent in pregnant women than in non-pregnant women of similar age. This is because pregnancy induces a state of venous stasis and
Fig. 3. A. CT scan of the chest with contrast.
Coronal section showing bilateral bilobed lungs
(yellow arrows depict the major fissure). B. CT
scan of the abdomen. The arrow points to multiple
splenic lobules suggestive of polysplenia.
C. CT scan of the abdomen. Coronal section
showing azygous continuation of inferior vena cava

hormonal and hematological changes leading to an increased risk for VTE. Venous stasis occurs from progesterone mediated increased venous distension in the first trimester and the compressive effect by the enlarging uterus on the common iliac vein in the late second and third trimesters. In addition there is an imbalance between the procoagulant (increased circulating levels of fibrinogen, von Willebrand factor, VII, VIII, IX, X and XII and increased generation of fibrin) and anticoagulant factors (decreased Protein S levels and fibrinolysis) through the pregnancy. Though pregnancy is considered to be a relative contraindication to systemic thrombolysis (recombinant TPA or streptokinase) in hemodynamically unstable patients with pulmonary embolism, the risk of complications for pregnant females treated with thrombolytic agents may be similar to that in the non-pregnant population.

In our case, the exact etiology for VTE is unclear. It may be related to pregnancy alone or mechanical factors from distorted venous system anatomy or a combination of both. Because the patient’s VTE occurred early in pregnancy, uterine enlargement is unlikely to have contributed to venous thrombosis. Effects of pregnancy in heterotaxy have been poorly described.

Challenges to the clinical management of our patient include the duration of anticoagulation and future pregnancy. Based on the 2012 American College of Chest Physicians (ACCP) guidelines, anticoagulation with LMWH is recommended for at least 3 months from the initial pulmonary embolism and 6 weeks postpartum. In our case, the patient was into her 3rd month of anticoagulation when she had induction of labor and delivery; hence the anticoagulation was continued for additional 3 months for a total of 6 months. Subsequently she was placed on low dose aspirin (81 mg) to prevent recurrent VTE (especially given her heterotaxy syndrome) based on the Warfarin and Aspirin (WARFASA) and Aspirin to Prevent Recurrent Venous Thromboembolism (ASPIRE) trials as well as the individual patient data analysis of WARFASA and ASPIRE trials performed by the INSPIRE Collaboration. Currently there is no evidence about the risk of VTE recurrence and anticoagulation duration in similar patients. According to the 2012 ACCP guidelines the decision regarding the duration of anticoagulation in a patient should be made after careful evaluation of both the risk of VTE recurrence and bleeding risk. Given the congenital prothrombotic risk factor (interrupted IVC related to heterotaxy syndrome), severity of the presentation and apparently low bleeding risk extended anticoagulation treatment with targeted oral anticoagulation maybe a suitable alternative to aspirin with periodic assessment of the bleeding risk.

Our patient had a massive pulmonary embolism with cardiac arrest that created a great sense of apprehension both in the patient and her family regarding future pregnancy. Unfortunately, there is paucity of data to either support or refute future pregnancy associated with her condition. Previous VTE alone is not a contraindication to future pregnancy provided anticoagulation is available. However patients with heterotaxy syndrome and VTE are undoubtedly at increased risk of VTE compared to other pregnant women. Hence future pregnancies in this patient group should be considered high-risk, and requires multi-disciplinary management. We recommend full intensity anticoagulation with LMWH (likely enoxaparin 1 mg/kg two times daily) with regular monitoring of anti-Xa levels prior to her pregnancy. It is important to measure anti-Xa levels 4 h after the last dose and be aware of the different targets based on which LMWH regimen is used (once-daily [goal 1.0–2.0 IU/mL] or twice-daily [goal 0.6–1 IU/mL]). In addition we recommend that there is a detailed discussion between the physician and the patient regarding the role of thrombolytic therapy in the event of recurrent VTE and possible termination of pregnancy in the worst case scenario.

CONCLUSION
To our knowledge this is the first reported case in the English literature that shows pregnancy associated VTE in a person with heterotaxy. After completion of anticoagulation therapy for the initial thrombotic event, the patient needs secondary prevention for VTE recurrence and low dose aspirin was the chosen treatment in this case. Although there are no published guidelines we believe that there are no contraindications for future pregnancy in this special group provided the patient is on anticoagulation prior to the pregnancy.

The post An Unusual Occurrence: A case of venous thromboembolism in pregnancy associated with heterotaxy syndrome appeared first on Nigerian Biomedical Science Journal.