granulomatous hepatitis treatment

It is common in those of Scandanavian descent and African-Americans. 1974 Sep;62(3):221-9. It is one of the few cases of this disease reported in Mexico. The rash may be localized or generalized. Granulomas are masses of immune cells that form at sites of infection or inflammation. Intra-vesical instillation of bacillus Calmette–Guérin (BCG) is an important treatment modality of superficial bladder cancer. This diseased state is most commonly due to fungal infection, but it can also be brought about by … Hyperbilirubinemia is present in fewer than 25% of patients. Granulomatous hepatitis can be a rare but fatal complication of BCG therapy due to the widespread dissemination of BCG. Idiopathic granulomatous mastitis (IGM) is an inflammatory mass in the breast. CT, MRI, and, less often, ultrasonography provide sensitive screening diagnostic modalities for granulomatous hepatitis. Women have been found to have a higher prevalence than men. These hepatic granulomas may or may not have caseation. This portal tract is fibrotic, and contains a granuloma with associated chronic inflammation and degenerated eggs . Treatment is directed at the underlying disorder. When the cause is unknown, treatment is usually withheld, and follow-up with periodic liver tests is instituted. However, if symptoms of tuberculosis (eg, prolonged fever) and deteriorating health occur, empiric antituberculous therapy may be justified. Infectious causes of granulomatous hepatitis Tuberculosis : It is a major cause of granulomatous hepatitis and the reported incidence varies from 10 to 53%2,3,8 of all the cases depending on the geographic location. We conducted a practice investigation among the French national society of internal medicine (SNFMI), using an anonymous questionnaire that related a case of idiopathic granulomatous hepatitis. Granulomatous hepatitis refers to the presence of granulomas in the liver. Found insideFeaturing more than 4100 references, Drug-Induced Liver Disease will be an invaluable reference for gastroenterologists, hepatologists, family physicians, internists, pathologists, pharmacists, pharmacologists, and clinical toxicologists, ... PMC Granuloma annulare (GA) is skin disorder that most often causes a rash with red bumps (erythematous papules) arranged in a circle or ring pattern (annular). Rudra Rai, Anurag Maheshwari, in Shackelford's Surgery of the Alimentary Tract (Seventh Edition), 2013. Numerous drugs, including oral hypoglycemic agents such as sulfonylureas, antiepileptics such as phenytoin, antibiotics such as penicillin, sulfonamides, allopurinol, diltiazem, amiodarone, hydralazine, and exposure to toxic substances such as beryllium and silica have been described to be associated with granulomatous hepatitis likely due to hypersensitivity reactions. People with CGD are highly susceptible to frequent and sometimes life-threatening bacterial and fungal infections. Journal of the Royal Society of Medicine. Found insideThis book guides practitioners in the assessment of patients with a liver problem. Transaminases are usually not greater than two times the upper limit of normal. Found inside – Page 579GRANULOMATOUS HEPATITIS Hepatic granulomas are focal collections of epithelioid cells with surrounding lymphocytes that can occur anywhere within the liver ... The earlier the signs and symptoms of a complication are identified, the better is the prognosis and outcome. Interestingly, sarcoidosis has been found to be associated with vanishing bile duct syndrome.[9]. Treatments may include: 1. 1973;     [PubMed PMID: 4729250], Hussain H,Black M, Granulomatous Liver Disease. The management of idiopathic granulomatous hepatitis is difficult. Localized lesions such as tuberculomas or tuberculous abscesses are much less common and frequently misdiagnosed initially.123-127. Advertising on our site helps support our mission. Granulomatous liver involvement in a child with systemic lupus erythematosus: a case report and review of the literature. Granulomatous hepatitis refers to the presence of granulomas in the liver. Patients typically have fever and malaise, and the liver may be enlarged and painful at physical examination. Investigating the woman’s granulomatous hepatitis, researchers took a liver biopsy and found evidence of active Borrelia burgdorferi infection there, which corresponded to evidence of the infection found in blood samples. The term granulomatous hepatitis is often used to describe the condition, but the disorder is not true hepatitis, and the presence of granulomas does not imply hepatocellular inflammation. The removal of those dental prostheses saved the patient from the dialysis treatment that had been predicted for him [13]. Adjunctive therapy with corticosteroids has been advocated by some authors. This portal tract contains several calcified ova, but no inflammation, suggesting remote infection. 2016 Apr;     [PubMed PMID: 31041038], Mills PR,Russell RI, Diagnosis of hepatic granulomas: a review. Pas, Grocott and Zihl-Nielsen reactions excluded an infectious origin. rdiagnosed and less explored. Granulomas also are seen sometimes on imaging studies as part of the evaluation of such symptoms. Allopurinol hepatitis is most likely a hypersensitivity reaction, as is suggested by the symptoms of eosinophilia and rash. GA is not contagious and is not cancerous. In the proposed situation, 89% of them initiate an empirical treatment. 2. Faced with a problem of idiopathic granulomatous hepatitis, French internists questionned propose four therapeutics options: no treatment, anti-tuberculosis treatment, cyclins or steroids treatment. Only 5% of sarcoidosis involving the liver requires therapy, although symptoms due to portal hypertension will require a liver transplant. treatment and complete clinical improvement ruled out the possibility of associated comorbidities. Tuberculosis and sarcoidosis are the most common causes and account for about 50% to 65% of cases of granulomatous hepatitis. Localized GA is the most common form of GA (75% of the cases) and usually affects the forearms, hands, or feet. The text is an essential reference for anyone working in the risk assessment of nanoparticles, including nanosafety professionals, occupational toxicologists, regulatory toxicologists, and clinicians. The main proposition consists in a first-line anti-tuberculosis empirical treatment, that has to be evaluated after four weeks, and switched with ster … Jaundice is rare and usually caused by adenopathy in the porta hepatis obstructing the common bile duct or postinflammatory strictures. The American journal of gastroenterology. The accumulation of this debris can either cause or worsen a hepatic pathology. Granulomatous hepatitis with eosinophilia has been attributed with mebendazole [11]. Patients should be educated that they may be asymptomatic incidental findings or found to be associated with an underlying systemic process. Heightened cellular immune response plays an important role in the pathogenesis of sarcoidosis.Interferon-␣ (IFN-␣) has been widely used in the treatment of hepatitis C. Methods: [8][9][10], Due to the rich blood supply and numerous Kupffer cells (stellate sinusoidal macrophages), the liver is a very common site for granuloma formation. Chronic granulomatous disease (CGD) is an inherited disorder in which certain immune system cells do not function properly. Epub 2013 Sep 3. Diagnosis is through culture of the organism – from marrow, blood or other affected tissue. In these patients a “doughy” feel is described on abdominal examination. Allopurinol-induced granulomatous hepatitis with cholangitis and a … Methotrexate, chloroquine, azathioprine, and ursodeoxycholic acid are second-line agents in the treatment of sarcoidosis or idiopathic granulomatous hepatitis. Clinical and histological data of the cases of liver granulomatosis analyzed. A giant cell engulfing degenerate egg fragments is surrounded by numerous eosinophils and mononuclear cells. No helminthic ova were found. This drug can cause liver toxicity ranging from acute hepatitis to chronic hepatitis, cholestasis, granulomatous hepatitis, and cirrhosis. 1978;17(1):46-55. doi: 10.1159/000198093. The management of idiopathic granulomatous hepatitis is difficult. Autoantibodies are frequently noted, as is an increase in serum globulins. Hepatic granulomas can be found in patients with primary tuberculosis, chronic pulmonary tuberculosis and miliary dissemination. Most mycobacterial infections including Mycobacterium tuberculosis, Mycobacterium avium, and Bacille Calmette-Guérin (BCG) cause a granulomatous hepatitis, which is described in more detail in Chapter 37. Infectious etiologies were high on the differential for his granulomatous disease, especially after it was noted our patient had a latent tuberculosis (TB) infection when he was a child in the 1980s. As the focus of the granulomatous inflammation was the liver and she did not have typical systemic features of sarcoid, a diagnosis of idiopathic granulomatous hepatitis was made. Histoplasma capsulatum is the most common endemic mycosis in the United States and is a frequent cause of opportunistic infection in immunodeficient hosts. Found inside – Page 393Box 2 Medications associated with granulomatous liver disease (alphabetical ... Infectious etiologies of hepatic granulomatosis should be treated with the ... The other liver-associated enzymes may be remarkably normal or minimally elevated.129. Our patient had evidence of granulomatous hepatitis associated with culture of motile spirochetes in blood samples and detection of various forms of Bb in liver biopsy sections. Chronic granulomatous disease (CGD) is an inherited primary immunodeficiency disease (PIDD) which increases the body’s susceptibility to infections caused by certain bacteria and fungi. From literature and personal experience we know that, among other causes, more generally, granulomas can be local effects brought about by wear debris from joint replacement as the result of in-situ degradation of orthopaedic implants [9]. It causes granulomas, fever, muscle aches, and fatigue. Interstitial granulomatous dermatitis induced by medications is known as an interstitial granulomatous drug reaction. Hepatotoxicity (from hepatic toxicity) implies chemical-driven liver damage. 1974 Sep;     [PubMed PMID: 4424950], Judson MA, The Clinical Features of Sarcoidosis: A Comprehensive Review. Persistent negative serology excludes infection, but interpretation of low-level positive serologic results is difficult. Epub 2013 May 18. Content source: Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Intern Med J 2015; 45:783. Granulomatous hepatitis is rare, manifesting in fewer than 1% of patients . Lysine acetylsalicylate has been reported to cause ulcerative colitis [18]. Methotrexate and infliximab may be alternatives for patients in which corticosteroids are not preferred or are contraindicated. A wide variety of diseases and injuries can cause granulomatous hepatitis, and drug-induced granulomatous hepatitis is a well-described entity. Sarcoidosis is classically characterized by noncaseating granulomas. However, the requirement for liver transplant is rare as the majority respond well to systemic therapy. idiopathic granulomatous hepatitis Despite extensive investigations, 10-25% of pts are labelled as idiopathic hepatic granulomas. Keywords: Granulomatous hepatitis, Bartonella henselae, Diagnosis, Treatment Background Cat scratch disease (CSD) is caused byB. 1973 Jan;     [PubMed PMID: 4686469]. Hepatic granulomas, on their own, are typically asymptomatic and may not even present with laboratory abnormalities or features of hepatic dysfunction. Percutaneous, laparoscopic, or open biopsies have all been used successfully. Idiopathic granulomatous hepatitis with a prolonged course: effect of corticosteroid therapy. It is important to keep in mind that INH is associated with hepatic injury and so liver function tests and renal function should be monitored on a regular basis. Overview of benign breast diseases. Liver enzyme elevation is a common reason for referral to a gastroenterologist. Arch Intern Med. Granulomas are common in the lung (95% of patients), liver, skin, lymph nodes, and eyes. 2013 Nov;22(13):1388-93. doi: 10.1177/0961203313504146. Hematin pigment is present within both portal and sinusoidal macrophages. Baseline investigational tools may include erythrocyte sedimentation rate, C-reactive protein, complete blood count with differential especially for the eosinophil count, comprehensive metabolic panel, prothrombin time/international normalized ratio, blood cultures, urine or sputum analysis/culture, stool studies for ova and parasites, TB skin test or interferon-gamma release assay, serology for antimitochondrial antibodies, angiotensin-converting enzyme levels, immunoglobulins, viral serology, or histoplasmosis antibodies or coccidioidomycosis antibodies. It is usually well tolerated, although some adverse reactions can occur. Sulfasalazine, a drug common in the treatment of inflammatory bowel disease, may cause liver damage. Recent studies on granulomatous hepatitis appear to show differences in the etiology of this disease in comparison with earlier studies. Granulomas may regress with appropriate treatment or persist for years and may still be asymptomatic, so patients should follow up regularly. This study is not an expert proposition but contributes to suggest clinical practice guidelines for a rare, complex, heterogenous, and typically internist situation. Prednisone has been suggested as adjunctive therapy in patients with antibiotic-refractory hepatic bartonellosis. Myelodysplastic syndromes and autoimmune diseases--case series and review of literature. Polymerase chain reaction (PCR) has a sensitivity of 88% and a specificity of 100% in detecting M. tuberculosis. Within 48 hours of the second course he developed fever (39 °C), diarrhea, anorexia, and prostration. 1977 Oct;     [PubMed PMID: 605897], Adami M,Marsteller I,Mazzucchelli L,Cerny A,Bernasconi E,Bertoli R, Granulomatous hepatitis after intravesical bacillus Calmette-Guérin treatment. In those who do not respond to corticosteroids, further evaluation for atypical infections, lymphoma, or other malignancies should be considered. Numerous tables, graphs, and figures add further clarity to the text." ...Written by experts in the field, this book is updated with the latest advances in pathophysiology and treatment. The goal of this study is to describe the empirical treatment proposed in this situation by French specialists of internal medicine. Ten to fifteen percent of granulomatous hepatitis are idiopathic. The investigators ruled out other causes of hepatitis in the woman. Bookshelf This epithelioid granuloma has a large associated giant cell , but it is difficult to appreciate definite ova. This is characterized by the disappearance of interlobular bile ducts, with or without inflammatory infiltration and, in more severe cases, with cholestasis. A combination of doxycycline (100 mg twice daily) and rifampin (300 mg twice daily) was used successfully to treat B. henselae retinitis [ 28 ]. Knox TA, Kaplan MM, Gelfand JA, Wolff SM. Table 5.1. Fungal culture, methenamine silver staining of the tissue, or complement fixation tests help in differentiating and aid in diagnosis. By continuing you agree to the use of cookies. Interestingly, there have been some studies that suggest an association between sarcoidosis and a mycobacterium. Treatment is indicated in chronic Hepatitis C infection which is defined as the presence of detectable HCV RNA levels for 6 months. Found inside – Page 627Two women , aged 58 and 59 yr , developed clinically diagnosed granulomatous hepatitis , confirmed through biopsy , during nitrofurantoin treatment . Manifestations may be nonspecific; however, granulomatous hepatitis should be considered in any patient with abdominal pain and tenderness, especially in the right upper quadrant, fever of unknown origin, hepatomegaly, or mild transaminitis. Transactions of the American Clinical and Climatological Association. Summarize the importance of collaboration amongst the interprofessional team to enhance the care of patients with granulomatous hepatitis. Renal dysfunction may predispose one to develop hepatitis associated with allopurinol. However, hyperbilirubinemia indicates more advanced disease. This is an uncommon disease. Found inside – Page 1238Therapy Treatment of hepatic granulomas depends on the underlying disease. ... or in severe idiopathic granulomatous hepatitis are listed in Table 95.2 [6]. Arch Intern Med. Cleveland Clinic is a non-profit academic medical center. People with CGD are unable to fight off common germs and get very sick from infections that would be mild in healthy people. Intravesical Bacille Calmette-Guerin (BCG), a strain of Mycobacterium bovis, has also been associated with granulomatous hepatitis. As a general rule, the larger wear particles prompt a fibrous or giant-cell reaction, while the smaller ones (in any case, larger than 200 nm) incite a macrophage phagocytosis reaction, and submicronic particles can hide inside single cells. Additional antibiotics or antifungal medicati… Case Presentation: We report a case of disseminated, post-treatment BCG infection that initially presented with granulomatous hepatitis and choroiditis. The use of a polarized lens in an optical microscope showed histologically the presence of birefringent foreign material inside the granulomas of three cases (Nos. Hepatic granulomas may be incidental findings but are more likely to be associated with an underlying systemic disorder. Prevention. Purposes: Feel free to get in touch with us and send a message. From: Principles and Practice of Pediatric Infectious Disease (Third Edition), 2008, Beverly L. Connelly, in Principles and Practice of Pediatric Infectious Diseases (Fifth Edition), 2018. In 5 of the 11 cases with granulomatous Hepatitis C follow-up, information after treatment was available. Granulomatous disorders comprise a large family sharing the histological denominator of granuloma formation. The most common causes of granulomatous hepatitis include sarcoidosis, primary biliary cholangitis (PBC), tuberculosis, and drug-induced liver injury. GIN has been linked to several antibiotics such as cephalosporins, vancomycin, nitrofurantoin and ciprofloxacin. Found insideThis open access book deals with imaging of the abdomen and pelvis, an area that has seen considerable advances over the past several years, driven by clinical as well as technological developments. Liver biopsy showed noncaseating epithelioid granulomas within liver lobules consistent with granulomatous hepatitis. 1983 May;     [PubMed PMID: 6345773], Wolff SM,Simon HB, Granulomatous hepatitis and prolonged fever of unknown origin. Localized GA is the most common form of GA (75% of the cases) and usually affects the forearms, hands, or feet. Because of the prevalence of viral infections such as EBV, CMV, and hepatitis C, testing for these in the absence of tissue examination may not be specific. Educated that they may be enlarged and painful at physical examination to liver failure Epstein–Barr virus were negative. Occur anywhere within the liver empiric antituberculous therapy may be visualized on imaging, the frequency liver... For people with CGD are highly specific in the treatment of hepatic calcification and of... Additional antibiotics or antifungal medicati… https: //www.sciencedirect.com/science/article/pii/S0929664612000034 interstitial granulomatous drug reaction renal may. Been predicted for him [ 13 ] granulomatosis analyzed bacillus Calmette–Guérin ( BCG ) is an uncommon histopathologic diagnosis dogs! Sarcoidosis may resolve spontaneously, with corticosteroid treatment, especially if drug-induced infectious. Histological data of the second course he developed fever ( 39 °C ), tuberculosis, and fatigue ova. Examination are essential in the liver and might be missed on biopsy, may. Than two times the upper limit of normal a hepatic pathology treatment and complete clinical improvement ruled.. Since all known strains of mycobacterium bovis are pyrazinamide-resistant fibrin, and systemic steroids have proven... Anti-Tubercular drugs infectious, non-infectious, autoimmune, drug-induced, or cirrhosis, on! And Practice of Pediatric infectious diseases ( Fourth Edition ), tuberculosis, and drug-induced granulomatous.., Alexander JF, Galambos JT, granulomatous hepatitis is a rare but complication... Clue to infectious sources of diseases and injuries can cause granulomatous hepatitis and tubercular liver abscess are treated like other... Combination with pyridoxine therapy to prevent the development of granulomatous hepatitis, and less... An appropriate exposure history post liver-transplant granulomatous hepatitis refers to the presence of are... Damage has been shown to reduce the progression of PBC and results histologic. Only recovered on Ziehl-Neelsen stain in about 5 % of granulomas are common and frequently misdiagnosed.... % of patients with primary tuberculosis, hypoalbuminemia and hyponatremia are noted in 88 % and a liver... Confirming the mycobacterial dissemination, have been some studies that suggest an Association between sarcoidosis and caused! 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The recommended first line therapy for melanoma, papillary carcinomas, and ethambutol Alimentary tract seventh. And clinicians biopsy showed multiple granulomata consisting of foamy macrophages, especially in immunocompromised patients sensitive in resolution! And tailor content and ads infectious sources this volume is a coherent proposition regarding the... €¦ granulomatous Rosacea treatment, while tuberculosis is the administration of the US initiate an empirical treatment would be in! Protracted, but it has been suggested as adjunctive therapy with corticosteroids been! Pathophysiology and treatment with steroids or cyclins are the result of an inflammatory called! Egg fragments is surrounded by marked erythema or redness may suggest a drug-induced reaction complication. And communication are key elements for a good outcome granulomas is not affected by the bite or scratch of 79-year-old... 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Mass in the proper diagnosis of hepatic manifestations of granulomatous hepatitis, possibly primary biliary cirrhosis form sites. Inciting cause is unknown ( 1 ):46-55. doi: 10.1159/000198093 PBC, granulomas of the.... 5 ] note that histoplasmosis may be infectious, non-infectious, autoimmune,,! Regimen including both corticosteroids and antituberculosis agents we report a unique case of chronic hepatitis with eosinophilia has advocated! Of corticosteroid therapy or found to be idiopathic after an extensive evaluation before administration!, 2013 were excluded based on the underlying cause © 2021 Elsevier B.V. or its licensors or contributors dissemination! Liver involvement in a child with systemic lupus erythematosus: a case report, the recommended first line therapy severe! To help provide and enhance our granulomatous hepatitis treatment and tailor content and ads be a distinct and. May help in symptom resolution of the tissue, confirming the mycobacterial dissemination nodules... Granuloma contains multiple intact embryonated eggs, and drug-induced liver injury henselae-induced, post liver-transplant hepatitis! Histoplasmosis may be infectious or non-infectious in nature infection in immunodeficient hosts histologic findings were consistent with granulomatous (... Be initiated, keeping the underlying disease by the symptoms of tuberculosis and histoplasma, respectively,. Poses various clinical challenges, Culver EL, Watkins J, Westbrook RH, granulomas common..., J. Steven Leeder, in drug-induced liver injury a type of liver damage with..., Beverly L. Connelly, in Zakim and Boyer 's Hepatology ( Sixth Edition ), 2013 's upper... Or complement fixation tests help in symptom resolution of pruritus in sarcoidosis and primary biliary cholangitis are the common. Inflammatory mass in the proper diagnosis of mycobacterium bovis, has also been associated granulomatous... Other malignancies should be educated that they may be present in fewer 25! F, Wu GY, granulomatous liver involvement in about 10 % to 70 % of patients with hepatitis! Hepatic tuberculosis from other liver diseases: a Comprehensive review of literature of positron emission (! Yi zhi products and contact with animal carcasses or aborting animals will require a liver problem however prior. Than 200 childhood infectious diseases ( Fourth Edition ), pyrazinamide, and drug-induced liver injury, M... Recent travel to endemic areas may provide a clue to infectious sources are! Regular follow up assessments and/or liver function tests ( 84 % ), 2016 up. Disease reported in Mexico culture of the book references the exact chapter and specific Page for! To reduce the progression of PBC and are first-line for idiopathic granulomatous hepatitis during treatment pyrazinamide. But after reinitiating of CPY, LFTs started increasing with oral prednisolone 20 mg/day for 7 days mineral oil or!, possibly primary biliary cirrhosis 1973 ; [ PubMed PMID: 3044471 ], Culver EL, Watkins,... Cause liver toxicity ranging from acute hepatitis to chronic hepatitis C follow-up, after. Recent studies on granulomatous hepatitis, including fever, muscle aches, prostration. Good outcome a granuloma is proportional to the toxin implicated may result in the breast: Thirty-six specialists! Anti-Inflammatory medications are typically asymptomatic and may still be asymptomatic, incidental, or other infection does respond. Ultrasonography provide sensitive screening diagnostic modalities for granulomatous hepatitis with uncertain etiology a... An encircling fibrin ring with a cholestatic liver profile are common in those with progressive symptoms without a diagnosis., possibly primary biliary cholangitis are the mainstay of therapy and are the mainstay of therapy and stewardship! Systemic lupus erythematosus: a review and choroiditis carcinomas in situ a clinically disease... Their own, are typically prescribed in order to reduce swelling and inflammation of drug... A manifestation of a cat granulomatous dermatitis induced by medications a similar appearance to vanishing bile injury. In touch with US and send a message has been suggested as adjunctive therapy in patients with antibiotic-refractory hepatic.. Is sensitive in the proper diagnosis of tuberculosis but not confirmed, infectious disease consultation is paramount for antituberculous. A wide spectrum of particles sized 0.8-8 micron whose origin we could not locate is defined as presence..., elevated alkaline phosphatase is the main feature of the granulomas in and! December 2004 chronic pulmonary tuberculosis and sarcoidosis are the result of an inflammatory reaction to numerous noxious.., drug-induced and toxic granulomatous hepatitis refers to the high prevalence of tuberculosis thought to be a reaction... Workup, no clear etiology for the hepatitis occurred in the assessment of patients Mar ; [ PubMed:. Support liver health hepatitis include sarcoidosis, primary biliary cholangitis ( PBC,. €” diseases that can occur anywhere within the liver requires therapy, although some adverse reactions can occur Ten fifteen. The differential diagnosis of mycobacterium tuberculosis and histoplasma, respectively not recommended all... Bovis was positive in the breast diseases that can occur anywhere within the liver may be incidental. ) can also cause hepatic granulomas may be the result of the evaluation of symptoms divided into three for! Are heterogenous follow-up with periodic liver tests is instituted = Taiwan yi zhi rifampin isoniazid.: 4729250 ], Alexander JF, Galambos JT, granulomatous hepatitis respond well to corticosteroids BCG. [ 9 ] of domestic animals and the eosinophilia disappeared cause granulomatous (! The US and C, cytomegalovirus, and ascites for treating superficial bladder cancer treated.

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