from Taipei have shown 6.1% incidence of invasive amebiasis in HIV patients [8]. As against this we have just occasional case reports showing association of HIV and ALA from India [9]. There was a single case (0.7%) of ALA who was HIV positive, showed good response to standard anti amoebic therapy. Amongst 212 HIV positive patients none showed evidence of ALA. Similarly Ohinshi and Kimura have shown that ALA in HIV positive patient can be easily treated by metronidazole even with low CD4 count [10]. Toxicity due to Metronidazole has been rarely reported. One of our patients developed generalized tonic clonic seizures and stupor on the third day of treatment. On withdrawal of metronidazole, complete recovery from neuroencephalopathy was observed and was put on another amebicidal drug. Omotosa et al. from Nigeria and Gupta et al from India have also reported neuropathy associated with metronidazole which disappeared after withdrawal of drug [11,12]. In six cases where IHA titer was low, high index of suspicion with presence of space occupying lesion on USG and response to anti amoebic therapy helped us to diagnose ALA. The titers can be negative during first week after onset of symptoms and reach a peak by the second or third month. All our patients responded well to metronidazole and chloroquine. In 90% of patients clinical improvement was seen within 48–72 h. Despite the fact that ALA can almost always be treated successfully with antiamebic drugs, there has been trend for the use of percutaneous drainage [13,14]. Some investigators use antiamebicidal agents alone whereas others routinely aspirate the abscesses. Based on our experi- ence, all 131 patients responded well to metronidazole and chloroquine except 20 (15.2%) requiring aspiration. We reserved therapeutic aspiration for the occasional patients with large ALA or with complications. Mortality rate of 0–18% have been reported with ALA [15]. The rate is highest when diagnosis is delayed or in cases of compli- cations. Low mortality (0.76%) in our study reflects the fact that most patients presented with acute symptoms and diagnosis was quickly made due to clinical awareness of the conditions at our institution. In Conclusion, though radiology and serological tests have improved diagnostic accuracy, clinicians should be aware of unusual presentation of ALA. Metronidazole and chloroquine are very effective in the management of majority of ALA and therapeutic drainage is rarely required in cases of ALA. D.N. Amarapurkar 1 , N. Patel 1 , A.D. Amarapurkar 2 1 Department of Gastroenterology and Hepatology, Bombay Hospital and Medical Research Centre, Mumbai, India 2 Department of Pathology, BYL Nair Ch Hospital and TN Medical College, Mumbai, India References [1] Ayeh-kumi PF, Petri WA. Diagnosis and management of Amebiasis. Infect Med 2002;19:375–82. [2] Petri Jr WA, Singh U. Diagnosis and management of amebiasis. Clin Infect Dis 1999;29:1117–25. [3] Katzenstein D, Rickerson V, Braude A. New concepts of amebic liver abscess derived from hepatic imaging, serodiagnosis and hepatic enzymes in 67 consecutive cases in San Diego. Medicine 1982;61: 237–46. [4] Leigh PG. An unusual case of acute amebiasis. S Afr Med J 1967;10: 543–7. [5] Schwartz E, Piper-Jenks N. Simultaneous amebic liver abscess and hepatitis A infection. J Travel Med 1988;5:95–6. [6] Jain A, Kar P. HBsAg carrier with simultaneous amebic liver abscess and acute hepatitis E. Ind J Gastroenterol 1999;55:179–84. [7] Sharma MP, Sarin SK. Inferior vena caval obstruction due to amoebic liver abscess. J Assoc Physicians India 1990;30:243. [8] Hung CC, Chen PJ, Hsiesh SM, Wong JM, Fang CT, Chang SC, et al. Invasive amebiasis: an emerging parasitic disease in patients infected with HIV in an area endemic for amoebic infection. AIDS 1999;13: 2421–8. [9] Hamide A, Srimannaryana, Bhushan G, Subrahmanyam DK, Parija SC, Das AK. Amoebic liver abscess in a patient with human immunodeficiency virus infection. J Assoc Physicians India 2002;50: 832–3. [10] Ohnishi K, Kimura K. Amebic livers abscess in an elderly AIDS patient. Southeast Asian J Trop Med Public Health 1999;30:594–5. [11] Ohnishi K, Kimura K. Amebic livers abscess in an elderly AIDS patient. Southeast Asian J Trop Med Public Health 1999;30:594–5. [12] Gupta BS, Baldwa S, Verma S, Gupta JB, Singhal A. Metronidazole induced neuropathy (letter). Neurology India 2000;48:192 – 3. [13] Van Sonnenberg E, Mueller PR, Schiffman HR, Ferrucci Jr JT, Casola G, Simeone JF, et al. Intrahepatic amebic abscess: indications for and results of percutaneous catheter drainage. Radiology 1983; 156:631–5. [14] Dela Rey Nel J, Simjee AE, Patel A. Indication for aspiration of amebic liver abscess. S Afr Med J 1989;75:373–6. [15] Walsh JA. Problems in recognition and diagnosis of amebiasis: estimation of the global magnitude of morbidity and mortality. Rev Infect Dis 1986;8:228–38. doi:10.1016/S0168-8278(03)00235-6 The mechanisms underlying hepatitis C virus genotype 3-mediated liver damage To the Editor: We read with great interest the article published in the Journal of Hepatology, by Westin et al. [1], regarding the impact of steatosis on fibrosis progression in relation to hepatitis C virus (HCV) genotype. In this paper, the authors demonstrated the association between HCV genotype 3 and steatosis and showed that this association may be a risk factor for progression of fibrosis. They suggest that Letters to the Editor / Journal of Hepatology 39 (2003) 291–296 292