Primary abdominal lymphoma. Presenting manifestation of celiac sprue or complicating dermatitis herpetiformis.

In patients with celiac sprue the risk of having a primary abdominal lymphoma is increased. We have studied the lymphoma aspect of this celiac sprue-lymphoma relationship. During a four year period, seven patients with abdominal lymphoma were found on subsequent investigation to have celiac sprue or the closely linked disorder, dermatitis herpetiformis. Five of the patients had a small intestinal lymphoma, one had a gastric lymphoma and one had a retroperitoneal lymphoma. Histologically, six of the seven tumors were of a diffuse histiocytic type and one was undifferentiated. In four patients the ulcerating small intestinal lymphoma was initially misinterpreted as “benign ulcerative nongranulomatous jejunoileitis,” a condition also reported to complicate celiac sprue. In several patients the associated celiac sprue was clinically occult and could readily have been missed. The celiac sprue was fully responsive in five of the patients who were treated with a gluten-free diet. Our studies suggest that celiac sprue and abdominal lymphoma occur together more often than is currently appreciated. The frequency of this association may be overlooked for two reasons: the associated celiac sprue is sometimes mild and may remain undetected; and, early ulcerative intestinal lymphoma may be mistaken for “benign ulcerative nongranulomatous jejunoileitis.” Patients with abdominal lymphoma should be investigated for celiac sprue and for dermatitis herpetiformis because of the nutritional and pathogenetic implications.     

Apolipoprotein E variants correlate with the clinical presentation of paediatric inflammatory bowel disease: A cross-sectional study

BACKGROUNDIt has been suggested that apolipoprotein E (APOE) polymorphisms are associated with the risk of developing inflammatory bowel disease (IBD) and the early age of disease onset. However, there are no reports regarding the relationship with clinical characteristics and disease severity.AIMTo summarise that APOE polymorphisms are associated with the risk of developing IBD and the early age of disease onset. METHODSIn total, 406 patients aged 3-18 with IBD (192 had ulcerative colitis and 214 had Crohn’s disease) were genotyped using the TaqMan hydrolysis probe assay. Clinical expression was described at diagnosis and the worst flare by disease activity scales, albumin and C-reactive protein levels, localisation and behaviour (Paris classification). Systemic steroid intake with the total number of courses, immunosuppressive, biological, and surgical treatment with the time and age of the first intervention were determined. The total number of exacerbation-caused hospitalisations, the number of days spent in hospital due to exacerbation, the number of relapses, and severe relapses were also estimated.RESULTSUlcerative colitis patients with the APOEε4 allele had lower C-reactive protein values at diagnosis (P = 0.0435) and the worst flare (P = 0.0013) compared to patients with the APOEε2 allele and genotype APOEε3/ε3. Crohn’s disease patients with the APOEε2 allele scored lower on the Pediatric Crohn’s Disease Activity Index at diagnosis (P = 0.0204). IBD patients with APOEε2 allele spent fewer days in the hospital due to relapse (P = 0.0440).CONCLUSION APOE polymorphisms are associated with the risk of developing IBD and the clinical expression of IBD. However, the clinical relevance of the differences identified is rather modest.     

Dietary gluten triggers concomitant activation of CD4+ and CD8+ αβ T cells and γδ T cells in celiac disease

Celiac disease is an intestinal autoimmune disease driven by dietary gluten and gluten-specific CD4⁺ T-cell responses. In celiac patients on a gluten-free diet, exposure to gluten induces the appearance of gluten-specific CD4⁺ T cells with gut-homing potential in the peripheral blood. Here we show that gluten exposure also induces the appearance of activated, gut-homing CD8⁺ αβ and γδ T cells in the peripheral blood. Single-cell T-cell receptor sequence analysis indicates that both of these cell populations have highly focused T-cell receptor repertoires, indicating that their induction is antigen-driven. These results reveal a previously unappreciated role of antigen in the induction of CD8⁺ αβ and γδ T cells in celiac disease and demonstrate a coordinated response by all three of the major types of T cells. More broadly, these responses may parallel adaptive immune responses to viral pathogens and other systemic autoimmune diseases.     

Urotensin II levels in patients with inflammatory bowel disease

BACKGROUNDPatients with inflammatory bowel disease (IBD) are associated with increased cardiovascular risk and have increased overall cardiovascular burden. On the other hand, urotensin II (UII) is one of the most potent vascular constrictors with immunomodulatory effect that is connected with a number of different cardiometabolic disorders as well. Furthermore, patients with ulcerative colitis have shown increased expression of urotensin II receptor in comparison to healthy controls. Since the features of IBD includes chronic inflammation and endothelial dysfunction as well, it is plausible to assume that there is connection between increased cardiac risk in IBD and UII.AIMTo determine serum UII levels in patients with IBD and to compare them to control subjects, as well as investigate possible associations with relevant clinical and biochemical parameters.METHODSThis cross sectional study consecutively enrolled 50 adult IBD patients (26 with Crohn’s disease and 24 with ulcerative colitis) and 50 age and gender matched controls. Clinical assessment was performed by the same experienced gastroenterologist according to the latest guidelines. Ulcerative Colitis Endoscopic Index of Severity and Simple Endoscopic Score for Crohn’s Disease were used for endoscopic evaluation. Serum levels of UII were determined using the enzyme immunoassay kit for human UII, according to the manufacturer’s instructions.RESULTSIBD patients have significantly higher concentrations of UII when compared to control subjects (7.57 ± 1.41 vs 1.98 ± 0.69 ng/mL, P < 0.001), while there were no significant differences between Crohn’s disease and ulcerative colitis patients (7.49 ± 1.42 vs 7.65 ± 1.41 ng/mL, P = 0.689). There was a significant positive correlation between serum UII levels and high sensitivity C reactive peptide levels (r = 0.491, P < 0.001) and a significant negative correlation between serum UII levels and total proteins (r = -0.306, P = 0.032). Additionally, there was a significant positive correlation between serum UII levels with both systolic (r = 0.387, P = 0.005) and diastolic (r = 0.352, P = 0.012) blood pressure. Moreover, serum UII levels had a significant positive correlation with Ulcerative Colitis Endoscopic Index of Severity (r = 0.425, P = 0.048) and Simple Endoscopic Score for Crohn’s Disease (r = 0.466, P = 0.028) scores. Multiple linear regression analysis showed that serum UII levels retained significant association with high sensitivity C reactive peptide (β ± standard error, 0.262 ± 0.076, P < 0.001) and systolic blood pressure (0.040 ± 0.017, P = 0.030).CONCLUSIONIt is possible that UII is involved in the complex pathophysiology of cardiovascular complications in IBD patients, and its purpose should be investigated in further studies.     

The Diagnostic Utility of Flow Cytometry in Celiac Disease Presented Isolated Iron Deficiency Anemia

Background: Flow cytometric analysis of intestinal intraepithelial lymphocytes contributes to the diagnosis of celiac disease. Celiac disease may present with iron deficiency anemia alone which is considered as one of the forms of atypical celiac disease. In this study, we have aimed to investigate the diagnostic utility of flow cytometric analysis of intraepithelial lymphocytes in this atypical form.Methods: Three groups were formed: the patients with unexplained iron deficiency (group 1), the patients with celiac disease (group 2), and the patients who underwent gastroduodenoscopy for other reasons (group 0). Duodenal biopsy samples were used for flow cytometric analysis of intraepithelial lymphocytes. T cell receptor gammadelta intraepithelial lymphocytes and CD3−/CD103+ intraepithelial lymphocytes were determined with relevant monoclonal antibodies. Sensitivity–specificity calculation was performed to evaluate the usability of flow cytometric variables as diagnostic tests.Results: Group 1 had 22 patients, group 2 had 14 patients, and group 0 had 56 patients. In the comparison of the 3 groups, CD3+/TCRγδ+ intraepithelial lymphocytes were found to be higher in celiac patients than other cases. CD3+/TCRγδ+ intraepithelial lymphocyte was evaluated for its usability as a diagnostic test. The cut-off value of CD3+/TCRγδ+ intraepithelial lymphocyte as 16.39% according to receiver operating characteristics curve analysis determined celiac disease in 14 of 22 patients in group 1 with 91.7% sensitivity and 80.4% specificity.Conclusions: Although celiac disease is diagnosed with serologic tests and histologic examination, successively, the increase in intestinal CD3+/TCRγδ+ intraepithelial lymphocytes may be used as a diagnostic test, and it may assist in revealing atypical forms of celiac disease.     

Prodromal Irritable Bowel Syndrome May Be Responsible for Delays in Diagnosis in Patients Presenting with Unrecognized Crohn��s Disease and Celiac Disease, but Not Ulcerative Colitis

Introduction

We aimed to determine the prevalence and duration of prodromal periods in patients with celiac disease and inflammatory bowel disease (Crohn??s disease and ulcerative colitis). Furthermore, we explored to what extent vague abdominal symptoms consistent with both disorders were attributed to irritable bowel syndrome (IBS) and if the presence of prodromal IBS (P-IBS) had an impact on prodrome duration.

Methods

In the study, 683 biopsy-proven patients (celiac n = 225, ulcerative colitis n = 228, Crohn??s disease n = 230) completed a postal survey including an assessment of prodromal periods and IBS symptoms during both the prodrome and at present (achieved by completion of the ROME II criteria). Results were compared to age/sex-matched controls (n = 348).

Results

Crohn??s disease patients had the highest prevalence of prodromes (94%) in comparison to ulcerative colitis (48%) and celiac disease (44%). However, Crohn??s disease patients have the lowest prevalence of P-IBS (29%) in comparison to ulcerative colitis (38%) and celiac disease (67%). Prodrome duration in patients with P-IBS Crohn??s disease was 4 years in comparison to 2 years without (p = 0.018). Prodrome duration in P-IBS celiac disease was 10 years in comparison to 7 years without (p = 0.046). Prodrome duration in patients with ulcerative colitis was not affected by P-IBS (p ?? 0.05). Age and sex were not confounding factors.

Conclusions

This is the first study to make direct comparisons of prodrome periods between celiac disease and IBD. Prodrome duration in celiac disease is significantly longer and more often characterized by P-IBS than IBD. In celiac disease and CD, P-IBS increases prodrome duration. This may represent a failure to understand the overlap between IBS and celiac disease/IBD.     

Immunogenetic biomarkers in inflammatory bowel diseases: Role of the IBD3 region

Many studies have demonstrated the linkage between the IBD3 region (6p21.1-23), an area which encompasses the famous human leukocyte antigen (HLA) complex, and Crohn’s disease (CD) or ulcerative colitis (UC). IBD3 is the only region that meets genome-wide significance, and provides stronger evidence of the linkage than 16p13.1-16q12.2 (IBD1), the locus that contains the susceptibility gene CARD15. However, despite these findings, IBD3 susceptibility genes remain elusive and unclear due to the strong linkage disequilibrium, extensive polymorphism, and high gene density that characterize this area and also due to varying allele frequencies in populations around the world. This area presents an extremely high abundance of genes, including the classical and non-classical major histocompatibility complex (MHC) class I and II genes, and other genes, namely MHC class III genes tumor necrosis factor (TNF)-α and -β, and Hsp, whose proteins play key functions in immunological processes. To date, it is not clear which genes within the MHC family contribute to the IBD pathogenesis, although certain HLA alleles have been associated with IBD. Recent insights into the biological function of other genes encoded within the IBD3 region, such as the MHC class I chain-related (MIC) genes, have led investigators to a more comprehensive exploration of this region. MHC class I chain-related molecule A (MICA) is highly polymorphic and interacts with NKG2D, its receptor on the surface of NK, Tγδ and T CD8⁺ cells. Increased expression of MICA in intestinal epithelial cells and increased expression of NKG2D in CD4⁺ T cells (lamina propria) in patients with CD have also been reported. MICA alleles have also been associated with IBD, and a variation at amino acid position 129 of the α2-heavy chain domain seems to categorize MICA alleles into strong and weak binders of NKG2D receptor, thereby influencing the effector cells’ function. In this regard, a relevant role of MICA-129-Val/Met single nucleotide polymorphism has recently been implicated in the pathogenesis of IBD. TNF-α and -β also play an important role in inflammatory response. In fact, IBD is commonly treated with TNF-α inhibitors. Additionally, polymorphisms of TNF-α gene are known to affect the gene expression level and particular TNF-α genotypes may influence the response of IBD patients treated with TNF-α inhibitors.     

Monocyte/High-Density Lipoprotein Ratio Is an Indicator of Activity in Patients with Ulcerative Colitis

Background:In patients with ulcerative colitis, endoscopic and clinical indices are used to assess the disease activity. In addition, studies have been carried out for easier and cheaper markers in recent years. For this purpose, we evaluated the monocyte/high-density lipoprotein ratio of the disease activity.Methods:According to clinical activity and partial Mayo scores, a total of 114 patients, 53 in the active ulcerative colitis group and 61 in the ulcerative colitis remission group were included in the study. Monocyte/high-density lipoprotein ratio, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, C-reactive protein, and erythrocyte sedimentation rate measurements of these 2 groups were recorded. Ulcerative colitis remission group and active ulcerative colitis group were compared in terms of activity.Results:The monocyte/high-density lipoprotein ratio value in the active ulcerative colitis group was significantly higher than that of the ulcerative colitis remission group (10.68 ± 3.39, 6.68 ± 1.39, P < .001, respectively). The monocyte/high-density lipoprotein ratio value for active ulcerative colitis at a cut-off value of 7.4 had 83% sensitivity and 81% specificity. In the active ulcerative colitis group, neutrophil/lymphocyte ratio, C-reactive protein, and erythrocyte sedimentation rate values were significantly higher than the ulcerative colitis remission group (P < .001, P < .001, P < .001, respectively).Conclusion:Monocyte/high-density lipoprotein ratio is an inexpensive and effective marker that can be used to determine the activity of ulcerative colitis.     

Genetic association of apolipoprotein E polymorphisms with inflammatory bowel disease

AIM:To study the association of apolipoprotein E(APOE) polymorphisms with the susceptibility ofinflammatory bowel disease(IBD) in Saudi patients.METHODS:APOE genotyping was performed to evaluate the allele and genotype frequencies in 378 Saudi subjects including IBD patients with ulcerative colitis(n = 84) or Crohn's disease(n = 94) and matched controls(n = 200) using polymerase chain reaction and reverse-hybridization techniques.RESULTS:The frequencies of the APOE ε2 allele and ε2/ε3 and ε2/ε4 genotypes were significantly higher in IBD patients than in controls(P 0.05),suggesting that the ε2 allele and its heterozygous genotypes may increase the susceptibility to IBD.On the contrary,the frequencies of the ε3 allele and ε3/ε3 genotype were lower in IBD patients as compared to controls,suggesting a protective effect of APOE ε3 for IBD.The prevalence of the ε4 allele was also higher in the patient group compared to controls,suggesting that the ε4 allele may also increase the risk of IBD.Our results also indicated that the APOE ε4 allele was associated with an early age of IBD onset.No effect of gender or type of IBD(familial or sporadic) on the frequency distribution of APOE alleles and genotypes was noticed in this study.CONCLUSION:APOE polymorphism is associated with risk of developing IBD and early age of onset in Saudi patients,though further studies with a large-size population are warranted.     

Augmenting CNS glucocerebrosidase activity as a therapeutic strategy for parkinsonism and other Gaucher-related synucleinopathies

Mutations of GBA1, the gene encoding glucocerebrosidase, represent a common genetic risk factor for developing the synucleinopathies Parkinson disease (PD) and dementia with Lewy bodies. PD patients with or without GBA1 mutations also exhibit lower enzymatic levels of glucocerebrosidase in the central nervous system (CNS), suggesting a possible link between the enzyme and the development of the disease. Previously, we have shown that early treatment with glucocerebrosidase can modulate α-synuclein aggregation in a presymptomatic mouse model of Gaucher-related synucleinopathy (Gba1^D409V/D409V) and ameliorate the associated cognitive deficit. To probe this link further, we have now evaluated the efficacy of augmenting glucocerebrosidase activity in the CNS of symptomatic Gba1^D409V/D409V mice and in a transgenic mouse model overexpressing A53T α-synuclein. Adeno-associated virus-mediated expression of glucocerebrosidase in the CNS of symptomatic Gba1^D409V/D409V mice completely corrected the aberrant accumulation of the toxic lipid glucosylsphingosine and reduced the levels of ubiquitin, tau, and proteinase K-resistant α-synuclein aggregates. Importantly, hippocampal expression of glucocerebrosidase in Gba1^D409V/D409V mice (starting at 4 or 12 mo of age) also reversed their cognitive impairment when examined using a novel object recognition test. Correspondingly, overexpression of glucocerebrosidase in the CNS of A53T α-synuclein mice reduced the levels of soluble α-synuclein, suggesting that increasing the glycosidase activity can modulate α-synuclein processing and may modulate the progression of α-synucleinopathies. Hence, increasing glucocerebrosidase activity in the CNS represents a potential therapeutic strategy for GBA1-related and non-GBA1–associated synucleinopathies, including PD.     

Impairment of intestinal glutathione synthesis in patients with inflammatory bowel disease

Background—Reactive oxygen species contribute totissue injury in inflammatory bowel disease (IBD). The tripeptideglutathione (GSH) is the most important intracellular antioxidant.
Aims—To investigate constituent amino acid plasmalevels and the GSH redox status in different compartments in IBD withemphasis on intestinal GSH synthesis in Crohn's disease.
Methods—Precursor amino acid levels were analysedin plasma and intestinal mucosa. Reduced (rGSH) and oxidisedglutathione (GSSG) were determined enzymatically in peripheral bloodmononuclear cells (PBMC), red blood cells (RBC), muscle, and innon-inflamed and inflamed ileum mucosa. Mucosal enzyme activity ofγ-glutamylcysteine synthetase (γGCS) and γ-glutamyl transferase(γGT) was analysed. Blood of healthy subjects and normal mucosa froma bowel segment resected for tumour growth were used as controls.
Results—Abnormally low plasma cysteine and cystinelevels were associated with inflammation in IBD (p<10^-4).Decreased rGSH levels were demonstrated in non-inflamed mucosa (p<0.01) and inflamed mucosa (p=10^-6) in patients withIBD, while GSSG increased with inflammation (p=0.007) compared withcontrols. Enzyme activity of γGCS was reduced in non-inflamed mucosa(p<0.01) and, along with γGT, in inflamed mucosa(p<10^-4). The GSH content was unchanged in PBMC, RBC, and muscle.
Conclusions—Decreased activity of key enzymesinvolved in GSH synthesis accompanied by a decreased availability ofcyst(e)ine for GSH synthesis contribute to mucosal GSH deficiency inIBD. As the impaired mucosal antioxidative capacity may further promote oxidative damage, GSH deficiency might be a target for therapeutic intervention in IBD.

Keywords:Crohn's disease; ulcerative colitis; glutathione; amino acids; γ-glutamylcysteine synthetase; mucosa

     

Correlations between skin lesions induced by anti-tumor necrosis factor-α and selected cytokines in Crohn’s disease patients

AIM:To investigate the correlation between the appearance of skin lesions and concentration of interleukin(IL)-17A,IL-23 and interferon-γ(IFN-γ)in Crohn’s disease(CD)patients during anti-tumor necrosis factor-α(TNF-α)therapy METHODS:A prospective study included 30 adult patients with CD of Caucasian origin(19 men and 11women;mean age±SD 32.0±8.6 years)during biological therapy with anti-TNF-αantibodies from January2012 to March 2013.Eighteen patients were treated with infliximab,seven with adalimumab and five withcertolizumab.Inclusion criteria were exacerbation of the underlying disease,Crohn’s Disease Activity Index over 300 and the ineffectiveness of previously used non-biological therapies.Patients with a history of psoriasis,atopic dermatitis and other autoimmune skin lesions were excluded from the study.The control group consisted of 12 healthy subjects.A diagnostic survey was carried out,blood tests and careful skin examination were performed,and the serum levels of IL-17,IL-23 and IFN-γwere measured using an enzyme-linked immunosorbent assays technique.Dermatoses that have developed in the course of biological therapy in patients who had no pre-existing skin lesions of similar character were qualified as skin lesions induced by antiTNF-αtherapy.RESULTS:Skin manifestations occurred in 18 of CD patients during the anti-TNF-αtherapy(60%),in the average time of 10.16±3.42 mo following the beginning of the 52-wk treatment cycle.Skin lesions observed in CD patients during biological therapy included psoriasiform lesions(44.4%),and eczema forms lesions(22.2%).In CD patients with drug induced skin lesions significantly higher levels of hemoglobin(13.3±1.5 g/dL vs 10.8±1.9 g/dL,P=0.018)and hematocrit(39.9%±4.5%vs 34.3%±5.4%,P=0.01),as well as a significantly lower level of platelets(268±62×103/μL vs 408±239×103/μL,P=0.046)was observed compared with CD patients without skin manifestations.The concentrations of IL-17A and IL-23in CD patients with skin lesions developed under antiTNF-αtherapy were significantly higher compared to those in patients without lesions(IL-17A:39.01±7.03pg/mL vs 25.71±4.90 pg/mL,P=0.00004;IL-23:408.78±94.13 pg/mL vs 312.15±76.24 pg/mL,P=0.00556).CONCLUSION:Skin lesions in CD patients during bio-logical therapy may result from significantly increased concentrations of IL-17A and IL-23,which are strongly associated with TNF-α/Th1 immune pathways.     

Changes in cytokine profile pre- and post-immunosuppression in acquired aplastic anemia

Cytokine expression assessed by flow cytometry in 53 acquired aplastic anemia patients before and after combined immunosuppression (EBMT WPSAA protocols) showed that CD3⁺ marrow cells containing TNF-α, IFN-γ and IL4 were similar in subjects with disease at onset (DO) and responsive to treatment who had more CD3⁺/TNF-α⁺ and CD 3⁺/IFN-γ⁺ cells than normal controls. In vitro block of TNF-α and/or IFN-γ significantly increased BFU-e over baseline in 28 patients. In responsive to treatment patients only TNF-α block significantly incremented colonies over normal controls. Absolute marrow CD3⁺/TNF-α⁺ and CD3⁺/IFN-γ⁺ cells prospectively tested in a group of 21 subjects declined significantly more in Responders than in Non Responders to immunosuppression at Response Evaluation Time respect to Diagnosis. Both in Responders and in Non Responders these cells remained higher than in normal controls. This study suggests that immunosuppression does not fully clear excess TNF-α and IFN-γ from marrow of patients with good outcome and raises the hypothesis that additional cytokine blockade might be useful in immunosuppression for acquired aplastic anemia.     

Relationship of gliadin protein components to chromosomes in hexaploid wheats (Triticum aestivum L.)

The synthesis of the A-gliadin protein fraction derived from the endosperm of the grain of hexaploid bread wheats (Triticum aestivum L.), which is toxic in celiac disease, was associated with the α arm of the 6A chromosome through use of the substitution lines of “Cheyenne” chromosomes in “Chinese Spring”. The association was made through the use of ditelocentric stocks of Chinese Spring. The synthesis of many other gliadin components in the gel electrophoretic patterns of these two varieties could be associated with particular chromosomes as well. All genes detected were located in the chromosomes of homoeologous groups 1 and 6. It is possible to remove some of the proteins toxic to people with celiac disease from wheat (flour) by chromosome manipulation. If the toxic factor is not widely distributed among the storage protein components, it may be possible to produce a wheat that would be safe for celiac patients to eat.     

Influence of Xmn 1Gγ (HBG2 c.-211 C → T) Globin Gene Polymorphism on Phenotype of Thalassemia Patients of North India

Beta (β) thalassemia is the most common single gene disorder in India. It has been reported that in patients with β-thalassemia in the presence of Xmn 1^Gγ polymorphic site the level of fetal hemoglobin (HbF) is increased thereby reducing the severity of disease. To determine the prevalence of Xmn 1^Gγ polymorphic site and its effect on the clinical phenotype and HbF level in 39 β-thalassemia major and 62 thalassemia intermedia patients, along with response to hydroxyurea therapy in thalassemia intermedia cases. Status of Xmn 1^Gγ polymorphism was determined by polymerase chain reaction-restricted fragment length polymorphism procedure. The HbF level was determined using high performance liquid chromatography. Genotypes and allele frequencies of the Xmn 1^Gγ polymorphism did not vary significantly between the various thalassemia groups. HbF levels were observed to be significantly increased and age at presentation was significantly greater in presence of Xmn 1^Gγ polymorphic site on both alleles as compared to its absence in thalassemia major but not in thalassemia intermedia cases. The response of hydroxyurea in thalassemia intermedia was found only in a few patients irrespective of their Xmn 1^Gγ status. Xmn 1^Gγ polymorphisms appear to significantly influence HbF levels and age at presentation in thalassemia major but not in thalassemia intermedia patients. Small numbers precluded a definitive correlation of the polymorphism with response to hydroxyurea therapy.     

Altered pattern of tumor necrosis factor-alpha production in peripheral blood monocytes from Crohn's disease

AIM To evaluate the inflammatory state in Crohn's disease(CD) patients and correlate it with genetic background and microbial spreading.METHODS By means of flow cytometry, production of tumor necrosis factor-alpha(TNF-α) was measured in peripheral blood monocytes from patients suffering from CD, ulcerative colitis(UC) and in healthy subjects after stimulation of the NOD2 and TLR pathways. CD patients were genotyped for the three most common NOD2 variants(R702W, G908 R and L1007Pfs*2) and basal production of TNF-α was correlated to NOD2 genotype. Also, production of TNF-α was correlated to plasmatic levels of LPS Binding Protein(LBP), soluble(s) CD14 and to the activity state of the disease.RESULTS The patients with CD were characterized by a significantly higher monocyte basal expression of TNF-αcompared with healthy subjects and UC patients, and after stimulation with Pam3CSK4(ligand of TLR2/1) and MDP-L18(ligand of NOD2) this difference was maintained, while other microbial stimuli(LPS, ligand of TLR4 and Poly I:C, ligand of TLR3) induced massive activation in CD monocytes as well as in UC and in healthy control cells. There was no significant difference in the production of TNF- α between patients who carried CD-associated heterozygous or homozygous variants in NOD2 and patients with wild type NOD2 genotype. Although serum LBP levels have been shown to correlate positively with the state of activity of the disease, TNF-α production did not show a clear correlation with either LBP or s CD14 levels in plasma. Moreover, no clear correlation was seen between TNF-α production and activity indices in either CD or UC.CONCLUSION Peripheral monocytes from CD express higher basal and stimulated TNF-α than controls, regardless of NOD2 genotype and without a clear correlation with disease activity.     

Deficiency of platelet-derived growth factor receptor-α-positive cells in Hirschsprung's disease colon

AIM: To investigate whether the expression of plateletderived growth factor receptor-α-positive(PDGFRα~+)-cells is altered in Hirschsprung's disease(HD).METHODS: HD tissue specimens(n = 10) were collected at the time of pull-through surgery, while colonic control samples were obtained at the time of colostomy closure in patients with imperforate anus(n = 10). Immunolabelling of PDGFRα~+-cells was visualized using confocal microscopy to assess the distribution of these cells, while Western blot analysis was undertaken to quantify PDGFRα protein expression.RESULTS: Confocal microscopy revealed PDGFRα+-cells within the mucosa, myenteric plexus and smooth muscle in normal controls, with a marked reduction in PDGFRα~+-cells in the HD specimens. Western blotting revealed high levels of PDGFRα protein expression in normal controls, while there was a striking decrease in PDGFRα protein expression in the HD colon.CONCLUSION: These findings suggest that the altered distribution of PDGFRα~+-cells in both the aganglionic and ganglionic HD bowel may contribute to the motility dysfunction in HD.     

Implementation of a polling protocol for predicting celiac disease in videocapsule analysis

AIM: To investigate the presence of small intestinal villous atrophy in celiac disease patients from quantitative analysis of videocapsule image sequences.METHODS: Nine celiac patient data with biopsy-proven villous atrophy and seven control patient data lacking villous atrophy were used for analysis. Celiacs had biopsy-proven disease with scores of Marsh II-IIIC except in the case of one hemophiliac patient. At four small intestinal levels (duodenal bulb, distal duodenum, jejunum, and ileum), video clips of length 200 frames (100 s) were analyzed. Twenty-four measurements were used for image characterization. These measurements were determined by quantitatively processing the videocapsule images via techniques for texture analysis, motility estimation, volumetric reconstruction using shape-from-shading principles, and image transformation. Each automated measurement method, or automaton, was polled as to whether or not villous atrophy was present in the small intestine, indicating celiac disease. Each automaton’s vote was determined based upon an optimized parameter threshold level, with the threshold levels being determined from prior data. A prediction of villous atrophy was made if it received the majority of votes (≥ 13), while no prediction was made for tie votes (12-12). Thus each set of images was classified as being from either a celiac disease patient or from a control patient.RESULTS: Separated by intestinal level, the overall sensitivity of automata polling for predicting villous atrophy and hence celiac disease was 83.9%, while the specificity was 92.9%, and the overall accuracy of automata-based polling was 88.1%. The method of image transformation yielded the highest sensitivity at 93.8%, while the method of texture analysis using subbands had the highest specificity at 76.0%. Similar results of prediction were observed at all four small intestinal locations, but there were more tie votes at location 4 (ileum). Incorrect prediction which reduced sensitivity occurred for two celiac patients with Marsh type II pattern, which is characterized by crypt hyperplasia, but normal villous architecture. Pooled from all levels, there was a mean of 14.31 ± 3.28 automaton votes for celiac vs 9.67 ± 3.31 automaton votes for control when celiac patient data was analyzed (P < 0.001). Pooled from all levels, there was a mean of 9.71 ± 2.8128 automaton votes for celiac vs 14.32 ± 2.7931 automaton votes for control when control patient data was analyzed (P < 0.001).CONCLUSION: Automata-based polling may be useful to indicate presence of mucosal atrophy, indicative of celiac disease, across the entire small bowel, though this must be confirmed in a larger patient set. Since the method is quantitative and automated, it can potentially eliminate observer bias and enable the detection of subtle abnormality in patients lacking a clear diagnosis. Our paradigm was found to be more efficacious at proximal small intestinal locations, which may suggest a greater presence and severity of villous atrophy at proximal as compared with distal locations.     

Gastrointestinal bleeding and intestinal perforation due to polyarteritis nodosa in a patient with celiac disease. A case report

Complications of celiac disease could present with intestinal perforation and rarely, gastrointestinal bleeding, which are usually secondary to nongranulomatous ulcerative jejunoileitis or T-cell lymphoma. We describe the case of a 66-year-old male patient with an 8-year history of celiac disease (CD) who presented with recurrent abdominal pain and gastrointestinal bleeding. Several tests were performed to find out possible complications associated to CD. Due to an overt gastrointestinal bleeding, an arteriography was performed and signs of polyarteritis nodosa were found. Vascular disease was aggressive, and despite multiple medical and surgical treatments the patient died. As arteriography is not usually performed for the study of the complications of CD, it is possible that the association between CD and PAN has been underdiagnosed.     

Increased density of tolerogenic dendritic cells in the small bowel mucosa of celiac patients

AIM: To investigate the densities of dendritic cells(DCs) and FOXP3+ regulatory T cells(Tregs) and their interrelations in the small bowel mucosa in untreated celiac disease(CD) patients with and without type 1 diabetes(T1D).METHODS: Seventy-four patients(45 female, 29 male, mean age 11.1 ± 6.8 years) who underwent small bowel biopsy were studied. CD without T1 D was diagnosed in 18 patients, and CD with T1 D was diagnosed in 15 patients. Normal small bowel mucosa was found in two T1 D patients. Thirty-nine patients(mean age 12.8 ± 4.9 years) with other diagnoses(functional dyspepsia, duodenal ulcer, erosive gastritis, etc.) formed the control group. All CD patients had partial or subtotal villous atrophy according to the Marsh classification: Marsh grade Ⅲa in 9, grade Ⅲb in 21 and grade Ⅲc in 3 cases. Thirty-nine patients without CD and 2 with T1 D had normal small bowel mucosa(Marsh grade 0). The densities of CD11c+, IDO+, CD103+, Langerin(CD207+) DCs and FOXP3+ Tregs were investigated by immunohistochemistry(on paraffin-embedded specimens) and immunofluorescence(on cryostat sections) methods using a combination of mono- and double-staining. Sixtysixserum samples were tested for Ig A-tissue transglutaminase(t TG) using a fully automated Eli ATM Celikey Ig A assay(Pharmacia Diagnostics, Freiburg, Germany). RESULTS: The density of CD11c+ DCs was significantly increased in CD patients compared with patients with normal mucosa(21.67 ± 2.49 vs 13.58 ± 1.51, P = 0.007). The numbers of FOXP3+ cells were significantly higher in CD patients(10.66 ± 1.50 vs 1.92 ± 0.37, P = 0.0002) and in patients with CD and coexisting T1D(8.11 ± 1.64 vs 1.92 ± 0.37, P = 0.002) compared with patients with normal mucosa. The density of FOXP3+ cells significantly correlated with the histologicalgrade of atrophic changes in the small bowel mucosa according to the March classification(r = 0.62; P 0.0001) and with levels of Ig A antibody(r = 0.55; P 0.0001). The densities of IDO+ DCs were significantly higher in CD patients(21.6 ± 2.67 vs 6.26 ± 0.84, P = 0.00003) and in patients with CD and coexisting T1D(19.08 ± 3.61 vs 6.26 ± 0.84, P = 0.004) compared with patients with normal mucosa. A significant correlation was identified between the densities of IDO+ DCs and FOXP3+ T cells(r = 0.76; P = 0.0001). The mean values of CD103+ DCs were significantly higher in CD patients(10.66 ± 1.53 vs 6.34 ± 0.61, P = 0.01) and in patients with CD and associated T1D(11.13 ± 0.72 vs 6.34 ± 0.61, P = 0.00002) compared with subjects with normal small bowel mucosa. The mean value of Langerin+ DCs was higher in CD patients compared with persons with normal mucosa(7.4 ± 0.92 vs 5.64 ± 0.46, P = 0.04).CONCLUSION: The participation of diverse DC subsets in the pathological processes of CD and the possible involvement of tolerogenic DCs in Tregs development to maintain intestinal immunological tolerance in CD patients are revealed.