Anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic antibodies as predictors of inflammatory bowel disease

BACKGROUND AND AIMS

Several antibodies have been reported in the sera of patients with Crohn's disease (CD) and ulcerative colitis (UC). The most commonly described are anti-Saccharomyces cerevisiae mannan antibodies (ASCA) in CD and perinuclear antineutrophil cytoplasm antibodies (pANCA) in UC. Familial clustering of these antibodies has been described, suggesting they might be genetic markers. Our aim was to investigate the presence of these antibodies before the emergence of overt clinical manifestations.

METHODS

Since 1980, the Israeli Defense Force (IDF) Medical Corps Serum Repository has stored serum samples obtained systematically from 5% of all recruits on enlistment, and from the same population on discharge from compulsory military service. We evaluated serum samples obtained from 32 subjects with CD and eight with UC before they were clinically diagnosed, along with samples from matched controls.

RESULTS

ASCA were present in 10/32 (31.3%) CD patients before clinical diagnosis compared with 0/95 (0%) controls (p<0.001). None of the eight patients with serum samples available before diagnosis of UC were ASCA positive. ASCA was positive in 54.5% of patients after diagnosis of CD. The mean interval between ASCA detection and diagnosis was 38 months. In 90% of patients, antibodies were detected in the first available serum sample; therefore, measurements of the average time from the presence of ASCA to diagnosis may be even longer. pANCA were present in 2/8 (25%) patients with available sera before the diagnosis of UC. None of their 24 matched controls were positive (p = 0.014).

CONCLUSIONS

ASCA and pANCA may predict development of inflammatory bowel disease years before the disease is clinically diagnosed.

Discordance between the degree of osteopenia and the prevalence of spontaneous vertebral fractures in Crohn's disease

BACKGROUND

A high prevalence of osteoporosis has been noted in Crohn's disease, but data about fractures are scarce.

METHODS

The relationship between low bone mineral density and the prevalence of vertebral fractures was studied in 271 patients with ileo-caecal Crohn's disease in a large European/Israeli study. One hundred and eighty-one currently steroid-free patients with active Crohn's disease (98 completely steroid-naive) and 90 steroid-dependent patients with inactive or quiescent Crohn's disease were investigated by dual X-ray absorptiometry scan of the lumbar spine, a standardized posterior/anterior and lateral X-ray of the thoracic and lumbar spine, and an assessment of potential risk factors for osteoporosis.

RESULTS

Thirty-nine asymptomatic fractures were seen in 25 of 179 steroid-free patients (14.0%; 27 wedge, 12 concavity), and 17 fractures were seen in 13 of 89 steroid-dependent patients (14.6%; 14 wedge, three concavity). The prevalence of fractures in steroid-naive patients was 12.4%. The average bone mineral density, expressed as the T-score, of patients with fractures was not significantly different from that of those without fractures (-0.759 vs. -0.837; P=0.73); 55% of patients with fractures had a normal T-score. The bone mineral density was negatively correlated with lifetime steroids, but not with previous bowel resection or current disease activity. The fracture rate was not correlated with the bone mineral density (P=0.73) or lifetime steroid dose (P=0.83); in women, but not in men, the fracture rate was correlated with age (P=0.009).

CONCLUSIONS

The lack of correlation between the prevalence of fractures on the one hand and the bone mineral density and lifetime steroid dose on the other necessitates new hypotheses for the pathogenesis of the former.

Osteoporosis in murine systemic lupus erythematosus--a laboratory model

The aim of this study was to assess the skeletal metabolism in a murine model of systemic lupus erythematosus (SLE). MRL/n and MRL/l mice (respectively representing a benign and a malignant form of the disease) were observed from 1.5 to 6.5 months of life. The monthly follow-up included: biochemical and histomorphometrical studies of the femoral bone, serum biochemistry, immunoglobulins and osteocalcin, and histological evaluation of the kidney tissue. The results showed a higher femoral weight (+11.5%), calcium (+4.4%) and protein bone content (+11.4%) and a significantly higher (+77%) phosphorus bone content in the MRL/n group; significantly lower (-48.9%) bone alkaline phosphatase enzymatic activity, lower bone alkaline/acid phosphatase enzymatic activities ratio (-40.8%) and lower (-38.4%) serum osteocalcin values in the MRL/l group (which might suggest reduced bone formation in these animals); markedly smaller trabecular bone volume (BV/TV) in the femoral head (-36.2%) and femoral neck (-39.8%), and smaller cortical and femoral areas in the mid-femoral shaft (-38.8% and -38.1% respectively) in the MRL/l group; higher serum immunoglobulins, increased serum blood urea nitrogen (BUN) and creatinine and a higher index of activity in the kidney histology in the MRL/l group, indicating increased activity of the disease in this substrain. The MRL mice, through their two substrains, may serve as a valuable laboratory animal model for study of the skeletal changes in SLE and of the influence of the disease activity on the skeletal metabolism.

Self-expandable metal coil stents in the treatment of benign esophageal strictures refractory to conventional therapy: a case series

BACKGROUND

Benign, refractory esophageal strictures are an important therapeutic challenge. Metallic self-expandable stents developed to treat malignant strictures have occasionally been used in the treatment of benign stenoses. This is a report of the use of 14 esophageal metallic stents in 10 patients with severe benign strictures.

METHODS

Ten patients with peptic, post-surgical, or post-radiation esophageal strictures were treated with metallic stents. All patients had previously been treated, unsuccessfully, by endoscopic dilatation. Their strictures, although benign, gave rise to the same problems as malignant ones.

RESULTS

In all patients, marked improvement of dysphagia was achieved with the use of metallic stents. They were inserted without early complications except for chest pain in one patient. Late complications were proximal and distal migration (in three patients) and a proximal stricture in one other patient. The best results were achieved in post-radiation strictures.

CONCLUSIONS

Metallic stents can be considered as a therapeutic alternative in selected patients with severe benign esophageal strictures refractory to conventional treatment.

Smitten by a kitten

Mammalian bite wounds are commonly encountered in the emergency department. When patients come early (<8 hours after injury), local infection is not usually evident. At this stage, the issue of providing prophylactic antibiotic therapy arises. We report a complication of a cat bite to the hand in a previously healthy 32-year-old man. This patient did not seek medical treatment immediately after the cat bite, and distinct local infection did not develop. Nevertheless, his course was complicated with acute Staphylococcus aureus endocarditis. We discuss the common pathogens involved in a cat bite infection, including S aureus, and delineate the indications for prophylactic antibiotic therapy after a mammalian bite wound.

The prevalence of chronic diarrhea among diabetic patients

OBJECTIVE

The prevalence of chronic diarrhea in patients with type I and type II diabetes is uncertain, most data being available from tertiary referral centers. We report the prevalence and etiology of chronic diarrhea in 861 heterogeneous diabetic patients attending a primary care diabetic outpatient clinic.

METHODS

All patients attending the clinic were asked to fill in a questionnaire relating to their bowel habits. Patients who fulfilled the criteria for chronic diarrhea underwent a comprehensive workup to define the cause of the diarrhea. Additional parameters were the mean duration of diabetes, hemoglobin-Alc levels, and the presence of autonomic neuropathy.

RESULTS

Chronic diarrhea was diagnosed in 32 patients (overall prevalence of 3.7%). The prevalence of nondiabetic diarrhea was higher among type I diabetic patients than among type II patients (3.29% vs 2.3%), although it did not reach statistical significance. Diabetic diarrhea was more common among type I than type II diabetic patients (5.2% vs 0.4%, respectively, p < 0.01). The most common cause of nondiabetic diarrhea was medication induced (metformin).

CONCLUSIONS

Chronic diarrhea is more frequent in type I diabetic patients. The higher prevalence of diarrhea in this population can be attributed to diabetic diarrhea (which is quite rare in type II patients). The most common cause of nondiabetic diarrhea is drug therapy with metformin.

Spontaneous bacterial arthritis in a cirrhotic patient

Septic arthritis is usually of hematogenous origin and is increasingly being reported in elderly patients, who often have underlying medical conditions such as diabetes or alcoholism. We report a 62-year-old patient with alcoholic liver disease who presented with Escherichia coli bacteremia and septic arthritis in a previously fractured ankle. There are scarce reports of infectious arthritis in cirrhotic patients, but this is the first report of arthritis after a primary enteric bacteremia. We believe that the patient described here developed E. coli bacteremia as a result of bacterial overgrowth and translocation related to alcoholic liver disease and cirrhosis. The resulting bacteremia resulted in the development of infection in the left ankle, which had preexisting disease and was thus vulnerable. This case provides further evidence for the mode of infection being bacteremia in cirrhotic patients. In patients with cirrhosis and fever, a high index of suspicion is required for joint infection as a potential cause of fever or deterioration in the cirrhotic's patient general condition.

Daily and seasonal variations in the concentration of melatonin in the human pineal gland

To elucidate whether pineal melatonin secretion is affected by changes in day length, we determined the concentration of melatonin in human pineal glands obtained at autopsy from 66 male subjects, aged 16-84 years over a period of 12 consecutive months. Based on the time of death, a day-night difference in pineal melatonin levels was evident only in the long photoperiod (April-September) with significantly higher melatonin concentrations occurring at night (2200-1000 h). Nighttime values in the long photoperiod were significantly higher than the nighttime values during the short photoperiod (October-March). During the short photoperiod, the data suggested a possible phase-delay in melatonin secretion. Day-night difference was evident in young subjects (30-60 years), but not in elderly subjects (61-84 years). Elderly subjects had lower total melatonin levels (day and night values) although statistically not significant. Therefore, melatonin levels did not decline with age and when the data were analyzed by age there was no significant day-night difference in melatonin levels. These data indicate that the concentration of melatonin in the human pineal is augmented only during the long photoperiod. The results suggest a partial effect of photoperiod on melatonin secretion in humans. This may result from living in an artificial light environment or due to other nonphotic signals involved in generating melatonin rhythm.

Zygomycotic gangrenous cellulitis in a patient with non-insulin dependent diabetes mellitus

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Modulation of murine systemic lupus erythematosus with peptides based on complementarity determining regions of a pathogenic anti-DNA monoclonal antibody

Experimental systemic lupus erythematosus (SLE) can be induced in naive mice by immunization with a murine monoclonal anti-DNA antibody (mAb), 5G12, that bears a major idiotype designated 16/6 Id. Strain-dependent differences were observed in the proliferative responses of lymph node cells of mice immunized with two peptides based on the sequences of the complementarity determining region (CDR) 1 and 3 of mAb 5G12. The capacity of the peptides to bind to major histocompatibility complex class II molecules correlated with the proliferative responses. Immunization of high responder strains with the CDR-based peptides led to production of autoantibodies and clinical manifestations characteristic to experimental SLE. The CDR-based peptides could prevent autoantibody production in neonatal mice that were immunized later either with the peptide or with the pathogenic autoantibody. Furthermore, the peptides inhibited specific proliferation of lymph node cells of mice immunized with the same peptide, with mAb 5G12 or with the human mAb anti-DNA, 16/6 Id. Thus, the CDR-based peptides are potential candidates for therapy of SLE.