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Hepatitis E in industrialized countries is mainly associated with genotype 3 hepatitis E virus (HEV) and normally causes a sporadic self-limiting disease in immunocompetent individuals. Unlike genotype 3, genotypes 1 and 2 circulate in developing countries, produce severe disease and occur in the epidemic form. Hepatitis E occurring in travellers returning from endemic areas in developing countries is not a novel epidemiological occurrence, however the vast majority of cases remain to be genetically studied. The present study describes two cases of severe acute hepatitis E that required hospitalization for 6 and 9 days in two individuals of Indian nationality that had recently migrated to Portugal to work. The retrieved HEV sequences both belonged to genotype 1 and had a high degree of nucleotide sequence identity, clustering with strains isolated in India and Nepal, in 2013 and 2014. Confirmed HEV genotypes of increased pathogenicity like genotype 1 are being introduced into otherwise naïve populations of industrialized countries such as European countries with consequences difficult to predict. As far as we know the present study is the first in Portugal to describe and genetically characterize imported cases of hepatitis E infection caused by HEV genotype 1.

Cryptococcal meningitis is a common opportunistic infection in HIV-infected patients and other immunocompromised people. Pregnancy, which is a state of relative immunosuppression, can also be a risk factor for the development of cryptococcal meningitis. We report a clinical case of a 41-year-old woman who developed a severe meningeal syndrome after an otherwise normal pregnancy. Cerebrospinal fluid (CSF) cytochemical analysis presented hypoglycorrhachia, high protein levels, and pleocytosis. Cryptococcal antigen tested positive in serum and CSF, and Cryptococcus neoformans was identified in the CSF culture. The diagnosis of cryptococcal meningitis was confirmed, and antifungal induction therapy was started with liposomal amphotericin B and flucytosine. After clinical improvement, induction therapy was discontinued, and the patient was discharged under maintenance therapy with fluconazole. While under antifungal maintenance therapy, the patient presented worsening of symptoms and a new brain magnetic resonance showed the development of multiple cryptococcoma. Despite sterile CSF cultures, there was a deterioration of the cytochemical parameters. The diagnosis of immune reconstitution inflammatory syndrome was assumed, and after initiation of corticotherapy, the patient improved considerably. This is a rare case of cryptococcal meningitis in a puerperal woman with a challenging management.

In this paper, an expedited multi-criteria decision analysis framework, capable of tackling several dimensions for the choice of sanitation services, at an early planning stage is presented. The approach combines geographic information systems aided analysis for onsite solutions, with a multi-criteria decision analysis tool capable of suggesting and ranking several viable offsite treatment alternatives, according to the desired criteria. The framework was applied to four coastal cities in Northern Angola, one of the sub-Saharan countries of the west coast of Africa, thus obtaining an indication for city-wide solutions, as an aid to achieve the goal of ensuring full sanitation coverage in those four locations. It included possible onsite collection and storage interfaces, namely Ventilated Improved Pit latrines, fossa alterna, septic tanks or conventional sewer systems. The study also contributed to an informed decision regarding optimal offsite treatment facility type, namely based on dedicated or combined wastewater and faecal sludge treatment (co-treatment), as well as different options for locations and sanitation technologies. Alternatives were compared and ranked according to ten main criteria concerning social, economic, technological and environmental aspects. This work helped demonstrate the usefulness of decision-aiding tools in the multi-stakeholder and complex context of sanitation in a developing country.

Hepatolithiasis (HL) or intrahepatic calculi is an uncommon condition in Western countries, with a prevalence under 1%. It is much more frequent in East Asia, reaching 20% in China and Taiwan, up to 50% of which show associated cholelithiasis [1]. The authors report a European patient with primary HL of the left hepatic lobe, 12 years after cholecystectomy for acute calculous cholecystitis, now successfully treated after left lobe hepatectomy.A 63-year-old caucasian man with a past medical history of hypertension, coronary artery disease, dyslipidaemia and urgent cholecystectomy 12 years ago (due to an acute calculous cholecystitis without ultrasonographic or perioperative evidence of bile duct dilation or choledocholithiasis, and with no cholangitis ever since) was now admitted to our ward following a 2-day course of fever (39ºC), epigastric pain, nausea, vomiting and tender right upper abdominal quadrant. Bloodwork showed mild leukocytosis with neutrophilia and low platelets; elevated C-reactive protein, GT, alkaline phosphatase and LDH; normal AST, ALT, bilirubin and amylase. Negative HBV, HCV and HIV serologies. CA19.9 was notably high (7500 U/mL), 200x above normal range (N<37). A diagnosis of acute cholangitis was assumed on clinical and laboratory basis, despite the absence of jaundice. The patient began therapy with iv ceftriaxone and improved clearly over the next few days. Raised CA19.9 in the setting of acute cholangitis, however, forced us into further study directed at the possibility of underlying biliary or pancreatic malignancy. Abdominal ultrasound disclosed multiple calcifications in the left lobe. CT displayed several left lobe intrahepatic bile duct dilations but no calcifications, thus suggesting intrahepatic cholesterol stones and cholangitis due to an obstacle before the hilum. MR-cholangiography was performed, showing marked dilation of the left intrahepatic bile duct and moderate dilation in the extrahepatic portion of the common bile duct (CBD). Neither exam showed any sign of cancer. Surgery was the therapeutic approach, and the patient underwent a left hepatectomy. Intra-operative ultrasound study unveiled severe dilation of the left intrahepatic bile duct, which was filled with gallstones, but no choledocholithiasis and no tumour whatsoever. Both the surgical procedure and the post-operative period were uneventful. Macroscopic liver section showed multiple dilated bile ductules containing fragile yellowish-green gallstones (Fig.1). Microscopy revealed cystic dilations of the left intrahepatic biliary tree packed with intraluminal gallstones (Fig.2), fibrosis and moderate chronic inflammatory infiltrate with lymphoid aggregates (Fig.3). Some areas of the epithelium displayed erosion and reactive changes. No biliary neoplasm was found. Immunocytochemistry for angiogenesis or lymphocyte membrane markers are not available in our Hospital. Soon after surgery, CA19.9 values decreased abruptly and just 4 months after the left hepatectomy they were back within reference range.Our working hyp...