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Alhmoud T, Gremida A, Colom Steele D, Fallahi I, Tuqan W, Nandy N, Ismail M, Aburajab Altamimi B, Xiong MJ, Kerwin A, Martin D. Outcomes of inflammatory bowel disease in patients with eosinophil-predominant colonic inflammation. BMJ Open Gastroenterol 2020; 7:e000373. [PMID: 32128230 PMCID: PMC7039632 DOI: 10.1136/bmjgast-2020-000373] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 12/28/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) is characterised by acute intestinal mucosal inflammation with chronic inflammatory features. Various degrees of mucosal eosinophilia are present along with the typical acute (neutrophil-predominant) inflammation. The effect of intestinal eosinophils on IBD outcomes remains unclear. Methods This is a retrospective study. Archived intestinal mucosal biopsy specimens of treatment-naïve IBD patients were examined by two pathologists. The number of eosinophils per high-power field was counted, and the mucosal inflammation was classified according to the eosinophilic inflammatory patterns. Clinical outcomes during the follow-up period were recorded. Results 142 treatment-naïve IBD patients were included. Mean age was 39 years. 83% of patients had ulcerative colitis, and median follow-up was 3 years. 41% of patients had disease flare(s) and 24% required hospitalisation. Eosinophil count was not associated with risk of disease flare or hospitalisation. Patients with neutrophil-predominant inflammation (>70% neutrophils) had greater risk of disease flare(s): 27(55%) versus 24(36%) and 7(28%) in patients with mixed and eosinophil-predominant inflammation, respectively (p=0.04). Overall, patients with neutrophil-predominant inflammation were more likely to have a disease flare; HR: 2.49, 95% CI (1.0 to 5.6). Hospitalisation rate was higher in patients with neutrophil-predominant inflammation: 17(35%) compared to 17(19%) in patients with eosinophil-rich inflammation (p=0.04). Kaplan-Meier analysis showed higher flare-free survival in patients with eosinophil-predominant inflammation compared to mixed and neutrophil-predominant inflammation. Conclusion IBD patients with eosinophil-predominant inflammation phenotype might have reduced risk of disease flares and hospitalisation. Larger prospective studies to assess IBD outcomes in this subpopulation are warranted.
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Affiliation(s)
- Tarik Alhmoud
- Division of Gastroenterology and Hepatology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Anas Gremida
- Division of Gastroenterology and Hepatology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Diego Colom Steele
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Imaneh Fallahi
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Wael Tuqan
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Nina Nandy
- Division of Gastroenterology and Hepatology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Mahmoud Ismail
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Barakat Aburajab Altamimi
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Meng-Jun Xiong
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Audra Kerwin
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - David Martin
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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Abstract
Physicians may encounter blood or tissue eosinophilia through a routine complete blood count with differential or a tissue pathology report. In this article, the basic biology of eosinophils is reviewed and definitions of blood eosinophilia, as well as the challenges of defining tissue eosinophilia, are discussed. Conditions associated with eosinophilia are briefly discussed as well as a general approach to evaluating eosinophilia. Future challenges include determining which eosinophil-associated diseases benefit from eosinophil-targeted therapy and identifying biomarkers for disease activity and diagnosis.
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Affiliation(s)
- Fei Li Kuang
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, 4 Memorial Drive, B1-27, Bethesda, MD 20892, USA.
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Licari A, Votto M, D'Auria E, Castagnoli R, Caimmi SME, Marseglia GL. Eosinophilic Gastrointestinal Diseases in Children: A Practical Review. Curr Pediatr Rev 2020; 16:106-114. [PMID: 31642786 DOI: 10.2174/1573396315666191022154432] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/11/2019] [Accepted: 09/18/2019] [Indexed: 12/15/2022]
Abstract
Primary eosinophilic gastrointestinal diseases (EGIDs) represent a heterogeneous group of disorders characterized by eosinophilic inflammation in the absence of known causes for eosinophilia, selectively affecting different segments of the gastrointestinal tract. While pediatric eosinophilic esophagitis (EoE) is a well-defined disease with established guidelines, Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC) remain a clinical enigma with evidence based on limited anecdotal case reports. Large cross-sectional studies in the US defined a prevalence of EoG and EoGE ranging from 1,5 to 6,4/100.000 and from 2,7 to 8,3/100.000 subjects respectively, while the prevalence of EoC ranges from 1,7 to 3,5/100.000 subjects. Regarding the pathogenesis, it is hypothesized that EGIDs result from the interplay between genetic predisposition, intestinal dysbiosis and environmental triggers. Clinically, EGIDs might present with different and nonspecific gastrointestinal symptoms depending on the involved intestinal tract and the extension of eosinophilic inflammatory infiltrate. The diagnosis of EGIDs requires: 1. recurrent gastrointestinal symptoms, 2. increased eosinophils for high power field in biopsy specimens, 3. absence of secondary causes of gastrointestinal eosinophilia. No validated guidelines are available on the clinical management of patients with EGIDs. Evidence from case reports and small uncontrolled case series suggests the use of dietary and corticosteroids as the first-line treatments. Considering the clinical follow-up of EGIDs, three different patterns of disease course are identified: single flare, recurring course-disease and chronic course-disease. This review will focus on pediatric EGIDs distal to esophagus, including Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC).
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Affiliation(s)
- Amelia Licari
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Martina Votto
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Enza D'Auria
- Department of Pediatrics, Vittore Buzzi Children's Hospital-University of Milan, Milan, Italy
| | - Riccardo Castagnoli
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Silvia Maria Elena Caimmi
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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Aceves S, Collins MH, Rothenberg ME, Furuta GT, Gonsalves N. Advancing patient care through the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). J Allergy Clin Immunol 2019; 145:28-37. [PMID: 31758958 PMCID: PMC6981250 DOI: 10.1016/j.jaci.2019.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/19/2022]
Abstract
Recent advances in rare disease research are accelerated by the work of consortia that have been supported by the National Institutes of Health. Development of such consortia rely on multidisciplinary relationships and engagement with patient advocacy groups, as well as the National Institutes of Health and industry and academic partners. In this rostrum we present the development of such a process that focuses on eosinophilic gastrointestinal diseases. Principal investigators, patient advocacy groups, research assistants, and trainees work together to perform natural history studies that promote clinical trial readiness tools, conduct clinical trials, train a new generation of investigators, and perform innovative pilot studies.
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Affiliation(s)
- Seema Aceves
- Division of Allergy Immunology, University of California, San Diego, and Rady Children's Hospital, San Diego, La Jolla, Calif
| | - Margaret H Collins
- Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colo.
| | - Nirmala Gonsalves
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Shoda T, Wen T, Caldwell JM, Collins MH, Besse JA, Osswald GA, Abonia JP, Arva NC, Atkins D, Capocelli KE, Dellon ES, Falk GW, Gonsalves N, Gupta SK, Hirano I, Mukkada VA, Putnam PE, Sheridan RM, Rudman Spergel AK, Spergel JM, Wechsler JB, Yang GY, Aceves SS, Furuta GT, Rothenberg ME. Molecular, endoscopic, histologic, and circulating biomarker-based diagnosis of eosinophilic gastritis: Multi-site study. J Allergy Clin Immunol 2019; 145:255-269. [PMID: 31738990 DOI: 10.1016/j.jaci.2019.11.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/03/2019] [Accepted: 11/06/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic gastritis (EG) is a clinicopathologic disorder with marked gastric eosinophilia and clinical symptoms. There is an unmet need among patients with EG for more precise diagnostic tools. OBJECTIVE We aimed to develop tissue- and blood-based diagnostic platforms for EG. METHODS Patients with EG and control subjects without EG were enrolled across 9 Consortium of Eosinophilic Gastrointestinal Disease Researchers-associated sites. An EG Diagnostic Panel (EGDP; gastric transcript subset) and EG blood biomarker panel (protein multiplex array) were analyzed. EGDP18 scores were derived from the expression of 18 highly dysregulated genes, and blood EG scores were derived from dysregulated cytokine/chemokine levels. RESULTS Gastric biopsy specimens and blood samples from 185 subjects (patients with EG, n = 74; control subjects without EG, n = 111) were analyzed. The EGDP (1) identified patients with active EG (P < .0001, area under the curve ≥ 0.95), (2) effectively monitored disease activity in longitudinal samples (P = .0078), (3) highly correlated in same-patient samples (antrum vs body, r = 0.85, P < .0001), and (4) inversely correlated with gastric peak eosinophil levels (r = -0.83, P < .0001), periglandular circumferential collars (r = -0.73, P < .0001), and endoscopic nodularity (r = -0.45, P < .0001). For blood-based platforms, eotaxin-3, thymus and activation-regulated chemokine, IL-5, and thymic stromal lymphopoietin levels were significantly increased. Blood EG scores (1) distinguished patients with EG from control subjects without EG (P < .0001, area under the curve ≥ 0.91), (2) correlated with gastric eosinophil levels (plasma: r = 0.72, P = .0002; serum: r = 0.54, P = .0015), and (3) inversely correlated with EGDP18 scores (plasma: r = -0.64, P = .0015; serum: r = -0.46, P = .0084). Plasma eotaxin-3 levels strongly associated with gastric CCL26 expression (r = 0.81, P < .0001). CONCLUSION We developed tissue- and blood-based platforms for assessment of EG and uncovered robust associations between specific gastric molecular profiles and histologic and endoscopic features, providing insight and clinical readiness tools for this emerging rare disease.
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Affiliation(s)
- Tetsuo Shoda
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ting Wen
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Julie M Caldwell
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margaret H Collins
- Division of Pathology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John A Besse
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Garrett A Osswald
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - J Pablo Abonia
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nicoleta C Arva
- Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, Ill
| | - Dan Atkins
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, Aurora, Colo
| | | | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine/Children's Hospital of Illinois, Peoria, Ill
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rachel M Sheridan
- Division of Pathology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amanda K Rudman Spergel
- Allergy, Asthma and Airway Biology Branch, Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Jonathan M Spergel
- Division of Allergy and Immunology, University of Pennsylvania Perelman School of Medicine/Children's Hospital of Philadelphia, Pa
| | - Joshua B Wechsler
- Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Guang-Yu Yang
- Department of Pathology and Laboratory Medicine, Northwestern University, Evanston, Ill
| | - Seema S Aceves
- Division of Allergy Immunology, University of California-San Diego, and Rady Children's Hospital, San Diego, Calif
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo
| | - Marc E Rothenberg
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Eosinophilic gastrointestinal disease below the belt. J Allergy Clin Immunol 2019; 145:87-89.e1. [PMID: 31669097 DOI: 10.1016/j.jaci.2019.10.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/08/2019] [Accepted: 10/11/2019] [Indexed: 12/19/2022]
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Kinoshita Y, Oouchi S, Fujisawa T. Eosinophilic gastrointestinal diseases - Pathogenesis, diagnosis, and treatment. Allergol Int 2019; 68:420-429. [PMID: 31000445 DOI: 10.1016/j.alit.2019.03.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic gastrointestinal diseases (EGIDs) are divided into eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE), depending on the involved gastrointestinal tract, though both are considered to be chronic Th2-type allergic diseases caused by food or environmental allergens. In development of EoE, refluxed gastric acid may also have an important role. For diagnosis of EGIDs, the presence of symptoms possibly originating from the involved gastrointestinal tract and dense eosinophil infiltration are important factors. Imaging studies, including endoscopy and computed tomography, along with histopathological examinations of biopsy specimens are useful for diagnosis, whereas laboratory testing of blood, urine, and stool samples has limited value. Three useful options for treating EoE patients are acid inhibitors, swallowed topical corticosteroids, and an elimination diet, while systemic administration of glucocorticoids is the standard treatment of EGE, though information is limited. Since the prevalence of EGIDs is increasing in Western countries as well as Japan, development of effective treatments based on sufficient evidence is becoming an urgent need.
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Grandinetti T, Biedermann L, Bussmann C, Straumann A, Hruz P. Eosinophilic Gastroenteritis: Clinical Manifestation, Natural Course, and Evaluation of Treatment with Corticosteroids and Vedolizumab. Dig Dis Sci 2019; 64:2231-2241. [PMID: 30982212 DOI: 10.1007/s10620-019-05617-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 04/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic gastroenteritis (EGE) is a rare, chronic inflammatory condition of the gastrointestinal tract. Little is known about its natural history and treatment outcomes. The aims of our analysis were to describe clinical presentation, response to current medical treatments, and to evaluate the response of refractory EGE to anti-integrin therapy. METHODS Patients with confirmed diagnosis of EGE fulfilling the diagnostic criteria: (1) the presence of gastrointestinal symptoms, (2) dense eosinophilic infiltration of the gastrointestinal mucosa, and (3) exclusion of other conditions leading to gastrointestinal eosinophilia were included in this analysis. In patients non-responding to corticosteroids and/or anti-TNF treatment the integrin blocker vedolizumab was used. RESULTS EGE patients (n = 22) were predominantly female (63%) with a median age at diagnosis of 41.5 years. The most frequent symptoms were abdominal pain (100%), diarrhea (59%), nausea/vomiting (36%), and bloating (27%). No pathognomonic endoscopic alterations were found. Eosinophilic infiltration was observed in the majority of patients in more than one segment. Patients were treated with systemic steroids, topical, and enteral release steroids in 21/22 (95%) patients, proton pump inhibitors in 7/22 (32%), TNFα inhibitors in 3/22 (14%), and vedolizumab in 4/22 (18%) patients. In 3/4 of steroid-refractory patients vedolizumab induced a clinical and histological improvement. CONCLUSIONS The combination of highly variable clinical presentation, subtle endoscopic abnormalities, and involvement of several GI segments undermines the difficulty to diagnose EGE and the need for structured biopsy sampling. Corticosteroids were efficient in the majority of patients to induce remission. Response to the integrin blocker vedolizumab suggests further assessment in refractory cases.
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Affiliation(s)
- Tanja Grandinetti
- Department of Gastroenterology and Hepatology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Alex Straumann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
- Swiss EoE Clinic, Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
| | - Petr Hruz
- Department of Gastroenterology and Hepatology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
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Loktionov A. Eosinophils in the gastrointestinal tract and their role in the pathogenesis of major colorectal disorders. World J Gastroenterol 2019; 25:3503-3526. [PMID: 31367153 PMCID: PMC6658389 DOI: 10.3748/wjg.v25.i27.3503] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/22/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
Eosinophils are currently regarded as versatile mobile cells controlling and regulating multiple biological pathways and responses in health and disease. These cells store in their specific granules numerous biologically active substances (cytotoxic cationic proteins, cytokines, growth factors, chemokines, enzymes) ready for rapid release. The human gut is the main destination of eosinophils that are produced and matured in the bone marrow and then transferred to target tissues through the circulation. In health the most important functions of gut-residing eosinophils comprise their participation in the maintenance of the protective mucosal barrier and interactions with other immune cells in providing immunity to microbiota of the gut lumen. Eosinophils are closely involved in the development of inflammatory bowel disease (IBD), when their cytotoxic granule proteins cause damage to host tissues. However, their roles in Crohn’s disease and ulcerative colitis appear to follow different immune response patterns. Eosinophils in IBD are especially important in altering the structure and protective functions of the mucosal barrier and modulating massive neutrophil influx to the lamina propria followed by transepithelial migration to colorectal mucus. IBD-associated inflammatory process involving eosinophils then appears to expand to the mucus overlaying the internal gut surface. The author hypothesises that immune responses within colorectal mucus as well as ETosis exerted by both neutrophils and eosinophils on the both sides of the colonic epithelial barrier act as additional pathogenetic factors in IBD. Literature analysis also shows an association between elevated eosinophil levels and better colorectal cancer (CRC) prognosis, but mechanisms behind this effect remain to be elucidated. In conclusion, the author emphasises the importance of investigating colorectal mucus in IBD and CRC patients as a previously unexplored milieu of disease-related inflammatory responses.
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Sunkara T, Rawla P, Yarlagadda KS, Gaduputi V. Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clin Exp Gastroenterol 2019; 12:239-253. [PMID: 31239747 PMCID: PMC6556468 DOI: 10.2147/ceg.s173130] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
Eosinophilic gastroenteritis (EGE) is a digestive disorder in children and adults that is characterized by eosinophilic infiltration in the stomach and intestine. The underlying molecular mechanisms predisposing to this disease are unknown, but it seems that hypersensitivity response plays a major role in its pathogenesis, as many patients have a history of seasonal allergies, food sensitivities, asthma, and eczema. Symptoms and clinical presentations vary, depending on the site and layer of the gastrointestinal wall infiltrated by eosinophils. Laboratory results, radiological findings, and endoscopy can provide important diagnostic evidence for EGE; however, the cornerstone of the diagnosis remains the histological examination of gastric and duodenal specimens for evidence of eosinophilic infiltration (>20 eosinophils per high-power field), and finally clinicians make the diagnosis in correlation with and by exclusion of other disorders associated with eosinophilic infiltration. Although spontaneous remission is reported in around 30%–40% of EGE cases, most patients require ongoing treatment. The management options for this disorder include both dietary and pharmacological approaches, with corticosteroids being the mainstay of therapy and highly effective. The subsequent course is quite variable. Some patients have no recurrences, while a few experience recurrent symptoms during or immediately after corticosteroid interruption. An alternative therapeutic armamentarium includes mast-cell stabilizers, leukotriene antagonists, antihistamines, immunomodulators, and biological agents. In this review, we provide a summary of the different diagnostic tools utilized in practice, as well as the different therapeutic approaches available for EGE management.
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Affiliation(s)
- Tagore Sunkara
- Division of Gastroenterology and Hepatology, Mercy Medical Center, Des Moines, IA 50314, USA.,Division of Gastroenterology, St. Barnabas Hospital Health System, New York, NY, 10457, USA
| | - Prashanth Rawla
- Department of Internal Medicine, Sovah Health, Martinsville, VA, 24112, USA
| | - Krishna Sowjanya Yarlagadda
- Division of Gastroenterology and Hepatology, Mercy Medical Center, Des Moines, IA 50314, USA.,Division of Gastroenterology, St. Barnabas Hospital Health System, New York, NY, 10457, USA
| | - Vinaya Gaduputi
- Division of Gastroenterology, St. Barnabas Hospital Health System, New York, NY, 10457, USA
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Impellizzeri G, Marasco G, Eusebi LH, Salfi N, Bazzoli F, Zagari RM. Eosinophilic colitis: A clinical review. Dig Liver Dis 2019; 51:769-773. [PMID: 31122823 DOI: 10.1016/j.dld.2019.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 12/11/2022]
Abstract
Eosinophilic colitis is a rare entity characterized by the presence of a high eosinophilic infiltrate into the colonic wall in symptomatic patients, more often presenting with abdominal pain or diarrhea. These characteristics distinguish eosinophilic colitis from primary colonic eosinophilia, in which patients are asymptomatic. Primary colonic eosinophilia does not need any therapy, while eosinophilic colitis requires a strict treatment, similar to that of the more codified chronic intestinal inflammatory diseases. To date the lack of codified guidelines regarding the diagnostic criteria and the eosinophil threshold values for each colonic segment are the main diagnostic challenge for eosinophilic colitis. In addition, eosinophilic colitis is a diagnosis of exclusion, once all other causes of colonic eosinophilia (food allergens, infections, drugs, etc.) have been excluded. Several treatment options are available for eosinophilic colitis, although the evidence for most of them is limited to case reports and small case series. We examine the epidemiology, etiology, pathophysiology, diagnostic criteria and therapeutic options of eosinophilic colitis reporting recent evidence from the current literature.
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Affiliation(s)
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | | | - Nunzio Salfi
- Histopathology Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, University of Bologna, Italy
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Ferreira CT, Vieira MC, Furuta GT, Barros FCLFD, Chehade M. Eosinophilic esophagitis – Where are we today? JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2018.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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63
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Ferreira CT, Vieira MC, Furuta GT, Barros FCLFD, Chehade M. Eosinophilic esophagitis-Where are we today? J Pediatr (Rio J) 2019; 95:275-281. [PMID: 30075121 DOI: 10.1016/j.jped.2018.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The objective of this review is to provide an overview of the practical diagnostic and therapeutic approaches to eosinophilic esophagitis and to increase the visibility of the disease among pediatricians. SOURCES A search of the MEDLINE, Embase, and CINAHL databases and recent consensus statements and guidelines were performed. SUMMARY OF THE FINDINGS The definition of eosinophilic esophagitis is based on symptoms and histology. It is important to rule out other diseases associated with esophageal eosinophil-predominant inflammation. It is not yet clear whether the increased prevalence is due to a real increase in incidence or a result of increased awareness of the disease. Various options for management have been used in pediatric patients, including proton pump inhibitors, dietary restriction therapies, swallowed topical steroids, and endoscopic dilations. More recently, proton pump inhibitor-responsive esophageal eosinophilia and eosinophilic esophagitis have been contemplated on the same spectrum, and proton pump inhibitors should be considered the initial step in the treatment of these patients. CONCLUSIONS Eosinophilic esophagitis is a relatively new disease with a remarkable progression of its incidence and prevalence in the past two to three decades, and diagnostic criteria that are constantly evolving. It is important to better understand the pathogenesis of the disease, the predisposing factors, the natural history, and the categorization of varying phenotypes to develop diagnostic and therapeutic strategies that meet the clinical needs of patients.
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Affiliation(s)
- Cristina Targa Ferreira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Pediatria, Porto Alegre, RS, Brazil; Hospital Santo Antonio, Porto Alegre, RS, Brazil.
| | - Mario Cesar Vieira
- Pontifícia Universidade Católica do Paraná (PUC-PR), Departamento de Pediatria, Curitiba, PR, Brazil; Hospital Pequeno Príncipe, Centro de Gastroenterologia Pediátrica, Curitiba, PR, Brazil
| | - Glenn T Furuta
- Children's Hospital Colorado, Hepatology and Nutrition, Digestive Health Institute, Aurora, United States; University of Colorado School of Medicine, Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Aurora, United States
| | | | - Mirna Chehade
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for Eosinophilic Disorders, New York, United States
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64
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Conrad M, Carreon C, Dawany N, Russo P, Kelsen J. Distinct Histopathological Features at Diagnosis of Very Early Onset Inflammatory Bowel Disease. J Crohns Colitis 2019; 13:615-625. [PMID: 30551128 PMCID: PMC6486490 DOI: 10.1093/ecco-jcc/jjy212] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Children with very early onset inflammatory bowel disease [VEO-IBD] represent a unique cohort, often with a severe phenotype that is refractory to conventional medications, and some cases have underlying primary immunodeficiencies. Previous work has identified distinct histopathological patterns in the gastrointestinal tract in patients with primary immunodeficiencies. The aim of this study is to characterise the diagnostic histological findings in patients with VEO-IBD as compared with older onset paediatric IBD, and determine if there are unique pathological changes that can shed light on the driving forces of the disease, particularly immunodeficiencies. METHODS Clinical retrospective chart review, including disease characteristics and endoscopic findings, was performed on all included subjects. Two paediatric pathologists reviewed biopsies from diagnostic upper endoscopies and colonoscopies of subjects with very early onset inflammatory bowel disease and older onset inflammatory bowel disease, to evaluate for the presence of 11 histological features previously associated with inflammatory bowel disease and primary immunodeficiencies. RESULTS The diagnostic gastrointestinal biopsies of subjects with very early onset inflammatory bowel disease differed from those in older onset paediatric IBD, demonstrated by increased frequency of apoptosis, severe chronic architectural changes, small intestine villous blunting, and eosinophils in the crypts, lamina propria, and surface epithelium. CONCLUSIONS The diagnostic biopsies of children with very early onset inflammatory bowel disease can identify characteristic features that may be important in guiding the diagnostic work-up in this population.
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Affiliation(s)
- Máire A Conrad
- Children’s Hospital of Philadelphia, Department of Pediatrics, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Department of Pediatrics, Philadelphia, PA, USA
- Corresponding author: Máire A. Conrad, MD, MS, Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology, and Nutrition, Wood Bldg Rm 3393, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA. Tel.: [267] 426–1495; fax: [215] 590–3606;
| | - Chrystalle Katte Carreon
- Children’s Hospital of Philadelphia, Department of Pathology and Laboratory Medicine, Philadelpha, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, PA, USA
| | - Noor Dawany
- Children’s Hospital of Philadelphia, Department of Biomedical and Health Informatics, Philadelphia, PA, USA
| | - Pierre Russo
- Children’s Hospital of Philadelphia, Department of Pathology and Laboratory Medicine, Philadelpha, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, PA, USA
| | - Judith R Kelsen
- Children’s Hospital of Philadelphia, Department of Pediatrics, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Department of Pediatrics, Philadelphia, PA, USA
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65
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Wang Z, Adachi S, Kong L, Watanabe D, Nakanishi Y, Ohteki T, Hoshi N, Kodama Y. Role of eosinophils in a murine model of inflammatory bowel disease. Biochem Biophys Res Commun 2019; 511:99-104. [DOI: 10.1016/j.bbrc.2019.02.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/10/2019] [Indexed: 02/07/2023]
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Koutri E, Papadopoulou A. Eosinophilic Gastrointestinal Diseases in Childhood. ANNALS OF NUTRITION AND METABOLISM 2019; 73 Suppl 4:18-28. [PMID: 30783041 DOI: 10.1159/000493668] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Eosinophilic gastrointestinal diseases (EGIDs) comprise a group of chronic, inflammatory diseases of the gastrointestinal (GI) tract, that are characterized, clinically, by symptoms related to the dysfunction of the involved segment(s) of the GI tract, and histologically, by dense eosinophilic inflammation, in the absence of an identifiable secondary cause. The group of EGIDs comprises eosinophilic esophagitis (EoE), eosinophilic gastritis (EG), eosinophilic gastroenteritis (EGE), and eosinophilic colitis (EC). EoE is the most common and the best described EGID compared to EG, EGE, and EC. The clinical presentation of the EGIDs differs depending on the location and the extent of the eosinophilic infiltration in the GI tract, as well as its depth through the bowel wall. In the absence of biological markers, the diagnosis is based on the combination of clinical symptoms with the histological features of EGIDs, after the exclusion of secondary causes of eosinophilic inflammation of the GI tract. Treatment is individualized and includes elimination diets (mainly empiric or elemental) and/or drugs, according to the involved GI segment: proton pump inhibitors or local steroids in EoE; local or oral systemic steroids in EG/EGE limited to the duodenum; oral systemic steroids in EGE with lower small intestine and/or colon involvement. In patients with EoE, maintenance treatment with lower doses may be considered following histological remission with the means of drugs. In patients treated with elimination diets, disease food triggers identified during food reintroduction need to be further eliminated. Esophageal stenosis despite medical treatment requires endoscopic dilation, while the use of thiopurines or anti-TNF drugs may be considered in refractory or steroid-dependent EGID (other than EoE). The aim of this review is to provide the available evidence on each of the above disorders, to aid clinicians to interpret the clinical manifestations and the laboratory findings and choose the best available treatment option.
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Affiliation(s)
- Eleni Koutri
- Division on Gastroenterology, Hepatology and Nutrition, First Department of Pediatrics, University of Athens, Children's Hospital "Agia Sofia", Athens, Greece
| | - Alexandra Papadopoulou
- Division on Gastroenterology, Hepatology and Nutrition, First Department of Pediatrics, University of Athens, Children's Hospital "Agia Sofia", Athens, Greece,
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67
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Awad HA, Abu Osba YE, Shaheen MA, Sfeira AR. Eosinophil counts in colonic tissue eosinophilia: Investigating specificity and sensitivity of cutoff points and comparing two counting methods. Saudi J Gastroenterol 2019; 26:39-45. [PMID: 31997777 PMCID: PMC7045768 DOI: 10.4103/sjg.sjg_381_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to investigate the specificity and sensitivity of eosinophil cutoff points defining the colonic tissue eosinophilia (TE) and compare the yield of reporting the highest count versus the mean of five high-power fields (HPFs). MATERIALS AND METHODS One hundred and seventy-one cases of colonic TE, including 22 primary eosinophilic colitis (PEC) cases, were compared to one hundred and twenty-one normal controls in the University of Jordan. The highest eosinophil count (EC) and the mean of five HPFs were recorded. The receiver operating characteristic curve (ROC) analysis was used to find the cutoff point with the best sensitivity and specificity. RESULTS There was no significant advantage of counting five fields over counting the most densely populated HPF. Using 30 eosinophils per HPF achieved 80% sensitivity and 65% specificity. This point is close to the mean in normal controls plus one standard deviation (SD) (29 per HPF). However, there was overlap between normal counts and TE, using 30 as a cutoff point resulted in 35% false-positive rate. There was no reliable cutoff point to differentiate PEC from secondary TE. CONCLUSION We recommend reporting the highest EC in colonic biopsies and using 30 as a cutoff point, bearing in mind the overlap with normal and correlating with the clinical team to not treat asymptomatic patients. Clinicopathological correlation is essential to separate PEC from secondary TE.
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Affiliation(s)
- Heyam A. Awad
- Department of Histopathology, Microbiology and Forensic Medicine, School of Medicine, University of Jordan, Amman, Jordan,Address for correspondence: Dr. Heyam A. Awad, Department of Histopathology, Microbiology and Forensic Medicine, School of Medicine, University of Jordan, Amman 1194, Jordan. E-mail:
| | - Yousef E. Abu Osba
- Department of Histopathology, Microbiology and Forensic Medicine, School of Medicine, University of Jordan, Amman, Jordan
| | - Mohammad A. Shaheen
- Department of Histopathology, Microbiology and Forensic Medicine, School of Medicine, University of Jordan, Amman, Jordan
| | - Ammar R. Sfeira
- Department of Histopathology, Microbiology and Forensic Medicine, School of Medicine, University of Jordan, Amman, Jordan
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DiTommaso LA, Rosenberg CE, Eby MD, Tasco A, Collins MH, Lyles JL, Putnam PE, Mukkada VA, Rothenberg ME. Prevalence of eosinophilic colitis and the diagnoses associated with colonic eosinophilia. J Allergy Clin Immunol 2019; 143:1928-1930.e3. [PMID: 30654053 DOI: 10.1016/j.jaci.2018.12.1002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/05/2018] [Accepted: 12/26/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Lauren A DiTommaso
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Chen E Rosenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael D Eby
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amy Tasco
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Margaret H Collins
- Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John L Lyles
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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The Evolving Role of Mucosal Histology in the Evaluation of Pediatric Functional Dyspepsia: A Review. GASTROINTESTINAL DISORDERS 2019. [DOI: 10.3390/gidisord1010013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Although not required to establish the diagnosis, endoscopy with mucosal biopsy is commonly performed in the evaluation of children with dyspepsia. Traditionally, esophagogastroduodenoscopy (EGD) has been performed in children with abdominal pain to identify pathology or conversely, to “rule-out” organic disease in order to establish a diagnosis of FD. In this review, we discuss the current diagnostic yield of endoscopically-obtained biopsies in identifying disease in children and adolescents with dyspepsia including an expanded discussion of common histologic diagnoses where clinical significance has not been definitively established. In turn, we discuss the transition of endoscopy from a search for disease to a search for biologic contributors to symptom generation, while considering the growing evidence linking non-diagnostic mucosal inflammation to FD, specifically mast cells and eosinophils.
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Abstract
PURPOSE OF REVIEW Eosinophilic colitis is a rare condition, with a prevalence rate in the USA of 2-3/100 000 persons (0.003%), but diagnosed in 0.1% of biopsies in those colonoscoped for diarrhoea. Secondary colonic eosinophilia is more common and associated with systemic, colonic and infectious diseases. In this review, the latest advances in diagnosis, treatment and prognosis are summarized and discussed. RECENT FINDINGS What constitutes a 'normal' count of eosinophils is poorly documented but there are recent studies that establish normal colonic eosinophil ranges as well as distinguishing histological and clinical findings in primary eosinophilic colitis and secondary colonic eosinophilia in children and adults. Primary eosinophilic colitis is rare, relatively straightforward to diagnose, but may be difficult to treat. Colonic eosinophilia may be overt in parasite infection and connective tissue disease. More subtle, secondary colonic eosinophilia is a useful biomarker for gastrointestinal diseases, such as inflammatory bowel disease, colonic spirochaetosis and collagenous colitis, but the eosinophilia may more often be overlooked. A limited number of drugs are also known to cause left sided colonic eosinophilia such as clopidogrel, ibuprofen and oestroprogestinic agents. SUMMARY Advances in our understanding of primary eosinophilic colitis and secondary colonic eosinophilia is progressing and if present, colonic eosinophilia should point the clinician and pathologist to a list of differential diagnoses worth considering to direct optimal management.
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Affiliation(s)
- Marjorie M Walker
- Faculty of Health and Medicine, School of Medicine & Public Health, University of Newcastle, Callaghan, Australia
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71
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Erkman J, Vaynblat A, Thomas K, Segal LN, Levine J, Moy L, Greifer M, Giusti R, Shah R, Kazachkov M. Airway and esophageal eosinophils in children with severe uncontrolled asthma. Pediatr Pulmonol 2018; 53:1598-1603. [PMID: 30353711 DOI: 10.1002/ppul.24180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 09/21/2018] [Indexed: 12/14/2022]
Abstract
AIM Children with severe uncontrolled asthma (SUA) have a high burden of symptoms and increased frequency of asthma exacerbations. Reflux esophagitis and eosinophilic esophagitis are important co-morbid factors for SUA. Both are associated with the presence of eosinophils in esophageal mucosa. We hypothesized that esophageal eosinophils are frequently present and correlate with the presence of airway eosinophils in children with SUA. METHOD We performed a retrospective analysis of a prospective database of children who underwent "triple endoscopy" (sleep laryngoscopy, bronchoscopy with bronchoalveolar lavage [BAL] and endobronchial biopsy [EBB], and esophagogastroduodenoscopy with esophageal biopsy [EsB]) at our Aerodigestive Center for evaluation of SUA. Children with known cystic fibrosis, primary ciliary dyskinesia, and aspiration-related lung disease were excluded. RESULT Twenty-four children (21 males) ages 2-16 years were studied. Elevated BAL eosinophils were found in 10 (42%) patients, endobronchial eosinophils in 16 (67%); 7 (29%) had endobronchial eosinophils without elevated BAL eosinophils. Esophageal eosinophils were found in 11 (46%) patients. There was a correlation between the amount of eosinophils in BAL and EBB (R = 0.43, P = 0.05) airway eosinophils, defined as elevated BAL and/or EBB eosinophils, correlated with esophageal eosinophils (R = 0.41, P = 0.047). CONCLUSION We concluded that airway and esophageal eosinophils are frequently present in children with SUA.
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Affiliation(s)
- Jessica Erkman
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Allen Vaynblat
- Department of Cardiothoracic Surgery, NYU Langone Health, New York
| | | | - Leopoldo N Segal
- Department of Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, NYU Langone Health, New York
| | - Jeremiah Levine
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Libia Moy
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Melanie Greifer
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Robert Giusti
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Rasik Shah
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Mikhail Kazachkov
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
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72
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Wright BL, Fernandez-Becker NQ, Kambham N, Purington N, Tupa D, Zhang W, Rank MA, Kita H, Shim KP, Bunning BJ, Doyle AD, Jacobsen EA, Boyd SD, Tsai M, Maecker H, Manohar M, Galli SJ, Nadeau KC, Chinthrajah RS. Baseline Gastrointestinal Eosinophilia Is Common in Oral Immunotherapy Subjects With IgE-Mediated Peanut Allergy. Front Immunol 2018; 9:2624. [PMID: 30524424 PMCID: PMC6261984 DOI: 10.3389/fimmu.2018.02624] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/25/2018] [Indexed: 12/14/2022] Open
Abstract
Rationale: Oral immunotherapy (OIT) is an emerging treatment for food allergy. While desensitization is achieved in most subjects, many experience gastrointestinal symptoms and few develop eosinophilic gastrointestinal disease. It is unclear whether these subjects have subclinical gastrointestinal eosinophilia (GE) at baseline. We aimed to evaluate the presence of GE in subjects with food allergy before peanut OIT. Methods: We performed baseline esophagogastroduodenoscopies on 21 adults before undergoing peanut OIT. Subjects completed a detailed gastrointestinal symptom questionnaire. Endoscopic findings were assessed using the Eosinophilic Esophagitis (EoE) Endoscopic Reference Score (EREFS) and biopsies were obtained from the esophagus, gastric antrum, and duodenum. Esophageal biopsies were evaluated using the EoE Histologic Scoring System. Immunohistochemical staining for eosinophil peroxidase (EPX) was also performed. Hematoxylin and eosin and EPX stains of each biopsy were assessed for eosinophil density and EPX/mm2 was quantified using automated image analysis. Results: All subjects were asymptomatic. Pre-existing esophageal eosinophilia (>5 eosinophils per high-power field [eos/hpf]) was present in five participants (24%), three (14%) of whom had >15 eos/hpf associated with mild endoscopic findings (edema, linear furrowing, or rings; median EREFS = 0, IQR 0–0.25). Some subjects also demonstrated basal cell hyperplasia, dilated intercellular spaces, and lamina propria fibrosis. Increased eosinophils were noted in the gastric antrum (>12 eos/hpf) or duodenum (>26 eos/hpf) in 9 subjects (43%). EPX/mm2 correlated strongly with eosinophil counts (r = 0.71, p < 0.0001). Conclusions: Pre-existing GE is common in adults with IgE-mediated peanut allergy. Eosinophilic inflammation (EI) in these subjects may be accompanied by mild endoscopic and histologic findings. Longitudinal data collection during OIT is ongoing.
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Affiliation(s)
- Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Nielsen Q Fernandez-Becker
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Neeraja Kambham
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Natasha Purington
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Dana Tupa
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Hirohito Kita
- Division of Allergic Diseases, Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kelly P Shim
- Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Bryan J Bunning
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Alfred D Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Elizabeth A Jacobsen
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Scott D Boyd
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Mindy Tsai
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Holden Maecker
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, United States
| | - Monali Manohar
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Stephen J Galli
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States.,Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, United States
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
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Eosinophil Counts in Mucosal Biopsies of the Ileum and Colon: Interobserver Variance Affects Diagnostic Accuracy. PATHOLOGY RESEARCH INTERNATIONAL 2018; 2018:2638258. [PMID: 30519390 PMCID: PMC6241360 DOI: 10.1155/2018/2638258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/18/2018] [Indexed: 12/26/2022]
Abstract
Primary eosinophilic gastroenteritis and colitis (EGE) is a rare entity with unspecific clinical and endoscopic findings. Validated histopathologic criteria for confirming the diagnosis are lacking, because numeric values for normal or elevated concentrations of eosinophils in mucosal biopsies are varying between observers. To quantify this interobserver variance, we had the same set of 30 slides of eosinophilic-rich mucosal biopsies from the ileum and colon systematically reviewed by a panel of six independent pathologists, each with more than a ten-year experience in the field. Using a highly standardized biopsy and slide preparation protocol, we ruled out any influence by the preparation, the patient, the endoscopist, the endoscopes and calipers used, the sampling site, the fixation and staining method, and the microscopic field sizes. Still, all numeric results differed between pathologists up to a factor greater than 30. Calculated positive or negative diagnosis of EGE differed up to a factor greater than 8. A theoretical incidence for EGE calculated from these numbers differed by a factor greater than 1500. We conclude that eosinophil counts in mucosal biopsies from the lower gastrointestinal tract are subject to a very high interobserver variance. Until further research provides objective and validated methods for standardization, all epidemiologic numbers derived from histopathologic findings may have to be questioned. When diagnosing individual patients with EGE, overall morphologic picture together with clinical and endoscopic findings is more important than numeric eosinophil count.
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74
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Lee EH, Yang HR, Lee HS. Quantitative Analysis of Distribution of the Gastrointestinal Tract Eosinophils in Childhood Functional Abdominal Pain Disorders. J Neurogastroenterol Motil 2018; 24:614-627. [PMID: 30180307 PMCID: PMC6175563 DOI: 10.5056/jnm18050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 07/13/2018] [Accepted: 07/31/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Although functional abdominal pain disorders (FAPDs) are common in children, the accurate pathogenesis of FAPDs is not known yet. Micro-inflammation, particularly tissue eosinophilia of gastrointestinal (GI) tract, has been suggested as the pathophysiology observed in several GI disorders. We aimed to evaluate eosinophilic infiltration throughout the entire GI tract in children with FAPDs, compared to those with inflammatory bowel diseases (IBD) and to normal reference values. Methods We included 56 children with FAPDs, 52 children with Crohn's disease, and 23 children with ulcerative colitis. All subjects underwent esophagogastroduodenoscopic and colonoscopic examination with biopsies. Tissue eosinophil counts were assessed in 10 regions throughout the GI tract. Results Eosinophil counts of the gastric antrum, duodenum, terminal ileum, cecum, and ascending colon were significantly higher in children with FAPDs compared to normal reference values. Eosinophil counts of the stomach and the entire colon were observed to be significantly higher in children with IBD than in those with FAPDs. Even after selecting macroscopically uninvolved GI segments on endoscopy in children with IBD, eosinophil counts of the gastric body, cecum, descending colon, sigmoid colon, and the rectum were also significantly higher in children with IBD than those with FAPDs. Conclusions Significantly high eosinophil counts of the stomach and colon were observed in the order of IBD, followed by FAPDs, and normal controls, regardless of endoscopically detected macroscopic IBD lesions in children. This suggests some contribution of GI tract eosinophils in the intrinsic pathogenesis of FAPDs in children.
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Affiliation(s)
- Eun Hye Lee
- Department of Pediatrics, Nowon Eulji Medical Center, Seoul, Korea.,Department of Pediatrics, Eulji University College of Medicine, Daejeon, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Seung Lee
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea.,Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
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Naramore S, Gupta SK. Nonesophageal Eosinophilic Gastrointestinal Disorders: Clinical Care and Future Directions. J Pediatr Gastroenterol Nutr 2018; 67:318-321. [PMID: 29851758 PMCID: PMC6743078 DOI: 10.1097/mpg.0000000000002040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Eosinophilic gastrointestinal disorders are a set of conditions with a wide range of clinical manifestations and treatment modalities. The disorders are suspected to result from an abnormal inflammatory response to allergen (s), and individuals may develop a relapsing or chronic disease, if the allergen is not eliminated. Mechanisms of disease pathogenesis, including the humoral immune response, need to be fully elucidated. A variety of therapies are used, although there is a lack of well-defined randomized, prospective studies. Other therapeutic options are needed as the current treatments have potential concerns; elimination diets may impair a child's quality of life, and corticosteroids have adverse risks with long-term use. We review what is known about nonesophageal eosinophilic gastrointestinal disorders, and discuss research investigations which need to be conducted to facilitate diagnosis and enhance treatment methods.
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Affiliation(s)
- Sara Naramore
- Sections of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Sandeep K. Gupta
- Children’s Hospital of Illinois/University of Illinois College of Medicine, Peoria, IL
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Singh V, Singh M, Schurman JV, Friesen CA. Histopathological changes in the gastroduodenal mucosa of children with functional dyspepsia. Pathol Res Pract 2018; 214:1173-1178. [DOI: 10.1016/j.prp.2018.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/12/2018] [Accepted: 06/25/2018] [Indexed: 12/17/2022]
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Eosinophils in the gastrointestinal tract: how much is normal? Virchows Arch 2018; 473:313-320. [DOI: 10.1007/s00428-018-2405-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/03/2018] [Accepted: 07/01/2018] [Indexed: 12/17/2022]
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Eosinophil Counts in the Small Intestine and Colon of Children Without Apparent Gastrointestinal Disease: A Meta-analysis. J Pediatr Gastroenterol Nutr 2018; 67:6-12. [PMID: 29394213 DOI: 10.1097/mpg.0000000000001904] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The aim of the current study was to review the available data regarding eosinophil density in healthy tissue specimen originating from lower gastrointestinal segments to support suggested diagnostic cutoffs widely used in clinical practice. A systematic search was performed in 3 different databases. Calculations were made with Comprehensive MetaAnalysis software using random-effects model. Cell number measurements were pooled using the random-effects model and displayed on forest plots. Summary point estimations, 95% confidence intervals (CIs), and 95% prediction intervals (PIs) were calculated. The cumulative mean cell numbers were 8.26 (95% CI 4.71-11.80) with PI of 0-25.32 for the duodenum, 11.52 (95% CI 7.21-15.83) with PI 0-60.64 for the terminal ileum, and 11.10/ high-power field (HPF) (95% CI 9.11-13.09) with PI of 0.96 to 21.23 in the large intestine and the rectum (HPF area = 0.2 mm). Previous studies included control patients with irritable bowel syndrome and functional gastrointestinal disorders. As mucosal eosinophils have a role in their pathomechanism, those patients should have been excluded. A critical point of interpreting reported data is that HPF is relative to the technical parameters of the microscopes; therefore, it is important to report findings in cell/mm. The present meta-analysis does not support the higher (>20) or lower (<10) cutoff values for healthy tissue eosinophil number. In contrast to the esophagus, there is no normal cutoff eosinophil density in the small intestine and the colon. A prospective, multicenter study to establish normal mucosal eosinophil density is clearly needed.
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79
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Egan M, Furuta GT. Eosinophilic gastrointestinal diseases beyond eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 121:162-167. [PMID: 29940308 DOI: 10.1016/j.anai.2018.06.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/29/2018] [Accepted: 06/14/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Eosinophilic gastrointestinal diseases (EGIDs) are a rare group of disorders that can have varied clinical presentations dependent on the involved segment within the gastrointestinal tract. Eosinophilic gastritis presents with abdominal pain or vomiting, eosinophilic gastroenteritis presents with diarrhea and anemia or hypoalbuminemia, and eosinophilic colitis can present with diarrhea or bloody stools. These nonspecific symptoms remain poorly understood in their relation to the underlying pathogenesis, but a significant percentage of patients have atopy. In this review, we discuss the current literature on EGIDs to promote a practical approach to diagnosis and care. DATA SOURCES Review of published literature. STUDY SELECTIONS Clinically relevant literature from 1900 through 2018 was obtained from a PubMed search. Those that addressed prevalence, diagnosis, clinical manifestations, natural history, and treatment of EGIDs were reviewed and are summarized in this article. RESULTS Of the 485 articles found in the search, most of which were case reports, 71 were selected for review. The natural history of EGIDs is based primarily on case series and small numbers of patients, making therapeutic decisions difficult. Treatment remains limited to dietary restriction that is not effective in many patients and topical or systemic corticosteroids whose long-term use is to be avoided if possible. CONCLUSION With the seeming increase in all types of EGIDs, phenotypic descriptions are emerging that will likely promote better understanding of the pathogenesis and identification of novel therapeutic targets.
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Affiliation(s)
- Maureen Egan
- Section of Pediatric Allergy and Immunology, Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, Colorado.
| | - Glenn T Furuta
- Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, Colorado; Digestive Health Institute, Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado
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Ferdous N, Islam MN, Ishaque SM, Akhter S, Kamal M, Rasker JJ. The colon and terminal ileum in patients with ankylosing spondylitis and controls in Bangladesh: a macroscopic and microscopic study. Rheumatol Adv Pract 2018; 2:rky016. [PMID: 31431964 PMCID: PMC6649901 DOI: 10.1093/rap/rky016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 04/24/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Little is known about gut lesions in AS patients in a developing country, such as Bangladesh. METHODS Full colonoscopy, including the terminal ileum, was performed in 60 AS patients and 20 controls, without diarrhoea, to study macroscopic and microscopic lesions. RESULTS In the colon, in 60 AS patients 17 macroscopic lesions were found, of which 11 were in the rectum; only one lesion was found in 20 controls. The prevalence of microscopic lesions in the ascending colon, sigmoid colon and rectum was 51, 44 and 50 in patients, respectively, and 13, 9 and 8 in controls. In the terminal ileum, macroscopic and microscopic lesions were seen in 21/56 and 43/56 AS patients, respectively, and in 1/20 and 9/20 controls. In the AS group, macroscopic (38.5 vs 5%, P < 0.01) and microscopic (76.8 vs 45%, P = 0.009) lesions were more frequent than in controls; no IBD was diagnosed. Findings were comparable in the axial AS group (n = 25) and the mainly peripheral group (n = 35). In AS patients, marked eosinophilic infiltration was observed in the ascending colon and sigmoid colon but not in the rectum, and this infiltration was more than in controls. The colonic mucosa in controls was otherwise comparable with western studies. Anaemia was seen in 18/60 cases. No association was found between anaemia or HLA-B27 status and gut lesions. CONCLUSION There was an equal percentage of microscopic lesions in the whole gut in AS cases and healthy controls. Previous helminth invasions might have played a role. Lesions differ significantly between AS and controls only in the ileum; therefore, the ileal lesions might be more disease related than the colonic ones.
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Affiliation(s)
- Nira Ferdous
- Modern One Stop Arthritis Care and Research Center (MOAC&RC), Dhaka, Bangladesh
| | - Md Nazrul Islam
- Modern One Stop Arthritis Care and Research Center (MOAC&RC), Dhaka, Bangladesh
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU)
| | | | | | | | - Johannes J Rasker
- Faculty of Behavioural, Management & Social sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
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Abstract
OBJECTIVE Pediatric colonic eosinophilia represents a confounding finding with a wide differential. It is often difficult to determine which children may progress to inflammatory bowel disease (IBD), which have an eosinophilic colitis (EC), and which may have no underlying pathology. There is little guidance for the practitioner on the approach to these patients. To define the clinical presentations of colonic eosinophilia and identify factors which may aid in diagnosis we reviewed patients with colonic eosinophilia and the clinicopathologic factors associated with their diagnoses. METHODS An 8-year retrospective chart review of children whose histopathology identified colonic eosinophilia (N = 72) compared to controls with normal biopsies (N = 35). RESULTS Patients with colonic eosinophilia had increased eosinophils/high-power field compared to controls (P < 0.001) and had 3 clinical phenotypes. Thirty-six percent had an inflammatory phenotype with elevated erythrocyte sedimentation rate (P < .0001), chronic inflammation on colonic biopsies (P < 0.001), and were diagnosed as having IBD. Thirty-seven percent were diagnosed as having EC, associated with male sex (P < 0.005) and peripheral eosinophilia (P = 0.041). Twenty-one percent had no significant colonic pathology. Forty-three percent of patients had >1 colonoscopy and 68% of these had change from initial diagnoses. CONCLUSIONS There are 3 main phenotypes of children with colonic eosinophilia. Signs of chronic systemic inflammation raise suspicion for IBD. Peripheral eosinophilia and male sex are associated with EC. A significant percent of children with colonic eosinophilia do not have colonic disease. Eosinophils/high-power field is not reliable to differentiate etiologies. Repeat colonoscopies may be required to reach final diagnoses.
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82
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Strozzi D, Botacin MAS, Mekdessi MA, Salustiano LX, Silva PHDP, Minasi LB, Segundo GRS, Cruz ADD. Frequency of Esophageal Eosinophilia in a Pediatric Population from Central Brazil. Sci Rep 2018; 8:5000. [PMID: 29568038 PMCID: PMC5864840 DOI: 10.1038/s41598-018-23178-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/07/2018] [Indexed: 01/21/2023] Open
Abstract
Here we report a retrospective cross-sectional study on Esophageal eosinophilia (EsEo) frequency in Brazil, for 2, 425 pediatric patients with symptoms associated with gastroesophageal diseases in 2012. EsEo is defined by ≥15 eosinophils per high power field (400x) and confirmed through histological analyses of esophageal biopsies. Overall, 126 patients had EsEo equating to a frequency of 5.2%. There was a significant difference between the endoscopic features of patients with EsEo, where 10.7% had erosive esophagitis, 3.0% had non-erosive esophagitis and 1% showed normal esophageal mucosa. According to the interaction of the variables in the Classification and Regression Tree Analysis, most patients diagnosed with EsEo were older males with erosive esophagitis. On the other hand, the lowest frequency of EsEo was found among younger females with non-erosive esophagitis/normal mucosa. Environmental conditions, including climate variation and changes, were observed in association with EsEo, supporting a potential role for environmental factors in its pathogenesis. There was an inverse correlation between the number of EsEo, rainfall and humidity. EsEo is a relatively frequent finding in the pediatric population of Brazil with symptoms of gastroesophageal diseases. Both clinical and histological examinations of patients are important for a reliable diagnostic of EsEo cases and to patient care.
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Affiliation(s)
- Daniel Strozzi
- Departamento de Medicina, Programa de Pós-Graduação em Ciências Ambientais e Saúde, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Marco Aurélio Silveira Botacin
- Departamento de Medicina, Programa de Pós-Graduação em Ciências Ambientais e Saúde, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Marilia Adriano Mekdessi
- Departamento de Medicina, Programa de Pós-Graduação em Ciências Ambientais e Saúde, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Luciana Ximenes Salustiano
- Departamento de Medicina, Programa de Pós-Graduação em Ciências Ambientais e Saúde, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Pedro H de Paula Silva
- Departamento de Ciências Biológicas, Instituto Federal de Educação, Ciência e Tecnologia do Estado de Goiás (IF Goiano), Rio Verde, Brazil
| | - Lysa Bernardes Minasi
- Programa de Pós-Graduação Mestrado em Genética, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
- Núcleo de Pesquisas Replicon, Departamento de Biologia, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Gesmar Rodrigues Silva Segundo
- Departamento de Medicina, Programa de Pós-Graduação em Ciências Ambientais e Saúde, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Aparecido Divino da Cruz
- Departamento de Medicina, Programa de Pós-Graduação em Ciências Ambientais e Saúde, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil.
- Programa de Pós-Graduação Mestrado em Genética, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil.
- Núcleo de Pesquisas Replicon, Departamento de Biologia, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil.
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83
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Collins MH, Capocelli K, Yang GY. Eosinophilic Gastrointestinal Disorders Pathology. Front Med (Lausanne) 2018; 4:261. [PMID: 29379785 PMCID: PMC5775510 DOI: 10.3389/fmed.2017.00261] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/26/2017] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic gastrointestinal disorders (EGID) are characterized pathologically by excess eosinophils in mucosal biopsies of one or multiple sites in the gastrointestinal (GI) tract, simultaneously or sequentially. Eosinophilic esophagitis (EoE) is the best characterized EGID, and in most patients it is an abnormal immune-mediated response to food antigens. Current recommendations for diagnosis include signs and symptoms of esophageal dysfunction that do not respond to proton-pump inhibitor therapy, and esophageal biopsies that exhibit at least 15 intraepithelial eosinophils in at least one high power field (HPF). Therapy consists of swallowed glucocorticoids or dietary elimination. Eosinophilic gastritis (EG) is the second most common form of EGID, but like all forms of EGID except EoE consensus recommendations for either clinical or pathological diagnosis do not exist. EG may be associated clinically with peripheral blood eosinophilia, hypoalbuminemia, and anemia, and pathologically with marked expansion of lamina propria by dense eosinophilic infiltrates. Eosinophilic enteritis (EE) may be subdivided into eosinophilic duodenitis, eosinophilic jejunitis, and eosinophilic ileitis. Most investigators believe that EE rarely, if ever, exists as a solitary form of EGID and is encountered only in patients who have at least one other affected portion of the GI tract. Eosinophilic colitis (EC) is perhaps the most enigmatic EGID. Distinction of EC from inflammatory bowel disease may be problematic especially in children. Multiple possible etiologies for EGID include hypereosinophilic syndrome, drug reactions, etc. Currently, the only etiology that can be identified histologically is parasitic infestation, if a portion of an invasive parasite is found in mucosal biopsies. This review will provide guidelines for the pathologic diagnosis of the various forms of EGID.
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Affiliation(s)
- Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Kelley Capocelli
- Department of Pathology, Children's Hospital Colorado, Aurora, CO, United States.,Department of Pathology, University of Colorado, Denver, CO, United States
| | - Guang-Yu Yang
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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84
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Abstract
Human eosinophils have characteristic morphologic features, including a bilobed nucleus and cytoplasmic granules filled with cytotoxic and immunoregulatory proteins that are packaged in a specific manner. Eosinophil production in the bone marrow is exquisitely regulated by timely expression of a repertoire of transcription factors that work together via collaborative and hierarchical interactions to direct eosinophil development. In addition, proper granule formation, which occurs in a spatially organized manner, is an intrinsic checkpoint that must be passed for proper eosinophil production to occur. In eosinophil-associated disorders, eosinophils and their progenitors can be recruited in large numbers into tissues where they can induce proinflammatory organ damage in response to local signals. Eosinophils are terminally differentiated and do not proliferate once they leave the bone marrow. The cytokine IL-5 specifically enhances eosinophil production and, along with other mediators, promotes eosinophil activation. Indeed, eosinophil depletion with anti-IL-5 or anti-IL-5Rα is now proven to be clinically beneficial for several eosinophilic disorders, most notably severe asthma, and several therapeutics targeting eosinophil viability and production are now in development. Significant progress has been made in our understanding of eosinophil development and the consequences of tissue eosinophilia. Future research efforts focused on basic eosinophil immunobiology and translational efforts to assist in the diagnosis, treatment selection, and resolution of eosinophil-associated disorders will likely be informative and clinically helpful.
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Affiliation(s)
- Patricia C Fulkerson
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
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85
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Tissue Eosinophilia and Severity of Colitis. Am J Surg Pathol 2017; 42:1127. [PMID: 29266022 DOI: 10.1097/pas.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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86
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Cheng K, Gupta SK, Kantor S, Kuhl JT, Aceves SS, Bonis PA, Capocelli KE, Carpenter C, Chehade M, Collins MH, Dellon ES, Falk GW, Gopal-Srivastava R, Gonsalves N, Hirano I, King EC, Leung J, Krischer JP, Mukkada VA, Schoepfer A, Spergel JM, Straumann A, Yang GY, Furuta GT, Rothenberg ME. Creating a multi-center rare disease consortium - the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). TRANSLATIONAL SCIENCE OF RARE DISEASES 2017; 2:141-155. [PMID: 29333363 PMCID: PMC5757645 DOI: 10.3233/trd-170016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Eosinophilic gastrointestinal disorders (EGIDs) affect various segments of the gastrointestinal tract. Since these disorders are rare, collaboration is essential to enroll subjects in clinical studies and study the broader population. The Rare Diseases Clinical Research Network (RDCRN), a program of the National Center for Advancing Translational Sciences (NCATS), funded the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR) in 2014 to advance the field of EGIDs. CEGIR facilitates collaboration among various centers, subspecialties, patients, professional organizations and patient-advocacy groups and includes 14 clinical sites. It has successfully initiated two large multi-center clinical studies looking to refine EGID diagnoses and management. Several pilot studies are underway that focus on various aspects of EGIDs including novel therapeutic interventions, diagnostic and monitoring methods, and the role of the microbiome in pathogenesis. CEGIR currently nurtures five physician-scholars through a career training development program and has published more than 40 manuscripts since its inception. This review focuses on CEGIR's operating model and progress and how it facilitates a framework for exchange of ideas and stimulates research and innovation. This consortium provides a model for progress on other potential clinical areas.
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Affiliation(s)
- Katherine Cheng
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sandeep K. Gupta
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine, Peoria, IL, USA
| | - Susanna Kantor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Denver, CO, USA
| | - Jonathan T. Kuhl
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Seema S. Aceves
- Division of Allergy and Immunology, Department of Pediatrics and Medicine, University of California San Diego, CA, USA
| | - Peter A. Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | | | - Christina Carpenter
- Health Informatics Institute, Rare Diseases Clinical Research Network, Tampa, FL, USA
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margaret H. Collins
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Evan S. Dellon
- Department of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rashmi Gopal-Srivastava
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institute of Health, Bethesda, MD, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University The Feinberg School of Medicine, Chicago, IL, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern Medicine The Feinberg School of Medicine, Chicago, IL, USA
| | - Eileen C. King
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - John Leung
- Department of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Jeffrey P. Krischer
- Departments of Pediatrics and Medicine, Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Vincent A. Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Alain Schoepfer
- Department of Gastroenterology and Hepatology, University Hospital Lausanne/CHUV, Lausanne, Switzerland
| | - Jonathan M. Spergel
- Department of Allergy and Immunology, Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Alex Straumann
- Department of Gastroenterology and hepatology, University Hospital Zuerich, Switzerland
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Glenn T. Furuta
- Gastrointestinal Eosinophilic Diseases Program, Children’s Hospital Colorado, Aurora, CO, USA
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc E. Rothenberg
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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87
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Abstract
Celiac disease features duodenal intraepithelial lymphocytosis with or without villous atrophy. Lymphocytosis without villous atrophy will be proven to represent celiac disease in 10% to 20% of cases. The differential diagnosis is broad: Helicobacter pylori gastritis, NSAID injury and bacterial overgrowth are considerations. Lymphocytosis with villous atrophy is very likely to be celiac disease, but there are mimics to consider, including collagenous sprue, tropical sprue, drug injury, and common variable immunodeficiency. Histologic clues to a diagnosis other than celiac disease include paucity of plasma cells, excess of neutrophils, granulomas, and relative paucity of intraepithelial lymphocytes.
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Affiliation(s)
- Thomas C Smyrk
- Department of Pathology, Mayo Clinic, Hilton 11, 200 First Street Southwest, Rochester, MN 55902, USA.
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88
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Classification of eosinophilic disorders of the small and large intestine. Virchows Arch 2017; 472:15-28. [DOI: 10.1007/s00428-017-2249-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/19/2017] [Accepted: 10/18/2017] [Indexed: 12/26/2022]
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89
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Histologic Correlates of Clinical and Endoscopic Severity in Children Newly Diagnosed With Ulcerative Colitis. Am J Surg Pathol 2017; 41:1491-1498. [PMID: 28863076 DOI: 10.1097/pas.0000000000000939] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
To characterize rectal histology in an inception cohort of children newly diagnosed with ulcerative colitis (UC) and to explore its relationship with clinical indices of disease severity. The PROTECT (Predicting Response to Standardized Pediatric Colitis Therapy) Study enrolled children 17 years of age and younger newly diagnosed with UC. Baseline rectal biopsies were evaluated for acute and chronic inflammation, eosinophilic inflammation (peak eosinophil count > 32 eosinophils/high powered field, eosinophilic cryptitis or abscesses), and architectural/nonarchitectural chronic changes. Correlation with clinical indices including Mayo endoscopy subscore and Pediatric Ulcerative Colitis Activity Index was performed. Rectal biopsies from 369 patients (mean age, 12.9±3.1 y, 50% female) were reviewed. Cryptitis was found in 89%, crypt abscesses in 25%, and eosinophilic inflammation in 58%. Crypt distortion/atrophy was present in 98% of specimens. Higher grades of acute and chronic inflammation were associated with the presence of basal plasmacytosis (P<0.0001), basal lymphoid aggregates (P<0.0001), and surface villiform changes (P<0.0001). A severe Mayo endoscopy subscore was most common among those with severe acute and chronic inflammation, although this relationship was not linear. Severe Pediatric Ulcerative Colitis Activity Index scores were associated with the absence of or only mild eosinophilic inflammation (<32 eosinophils/high powered field) (P<0.03) and the presence of surface villiform changes (P<0.005). Acute and chronic inflammation, eosinophilic inflammation and chronic changes are common in children newly diagnosed with UC. The clinical and biological implication of low to absent eosinophilic inflammation and the presence of surface villiform changes requires further study.
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90
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Hyams JS, Davis S, Mack DR, Boyle B, Griffiths AM, LeLeiko NS, Sauer CG, Keljo DJ, Markowitz J, Baker SS, Rosh J, Baldassano RN, Patel A, Pfefferkorn M, Otley A, Heyman M, Noe J, Oliva-Hemker M, Rufo P, Strople J, Ziring D, Guthery SL, Sudel B, Benkov K, Wali P, Moulton D, Evans J, Kappelman MD, Marquis A, Sylvester FA, Collins MH, Venkateswaran S, Dubinsky M, Tangpricha V, Spada KL, Britt A, Saul B, Gotman N, Wang J, Serrano J, Kugathasan S, Walters T, Denson LA. Factors associated with early outcomes following standardised therapy in children with ulcerative colitis (PROTECT): a multicentre inception cohort study. Lancet Gastroenterol Hepatol 2017; 2:855-868. [PMID: 28939374 PMCID: PMC5695708 DOI: 10.1016/s2468-1253(17)30252-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/25/2017] [Accepted: 07/28/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous retrospective studies of paediatric ulcerative colitis have had limited ability to describe disease progression and identify predictors of treatment response. In this study, we aimed to identify characteristics associated with outcomes following standardised therapy after initial diagnosis. METHODS The PROTECT multicentre inception cohort study was based at 29 centres in the USA and Canada and included paediatric patients aged 4-17 years who were newly diagnosed with ulcerative colitis. Guided by the Pediatric Ulcerative Colitis Activity Index (PUCAI), patients received initial standardised treatment with mesalazine (PUCAI 10-30) oral corticosteroids (PUCAI 35-60), or intravenous corticosteroids (PUCAI ≥65). The key outcomes for this analysis were week 12 corticosteroid-free remission, defined as PUCAI less than 10 and taking only mesalazine, and treatment escalation during the 12 study weeks to anti-tumour necrosis factor α (TNFα) agents, immunomodulators, or colectomy among those initially treated with intravenous corticosteroids. We identified independent predictors of outcome through multivariable logistic regression using a per-protocol approach. This study is registered with ClinicalTrials.gov, number NCT01536535. FINDINGS Patients were recruited between July 10, 2012, and April 21, 2015. 428 children initiated mesalazine (n=136), oral corticosteroids (n=144), or intravenous corticosteroids (n=148). Initial mean PUCAI was 31·1 (SD 13·3) in children initiating with mesalazine, 50·4 (13·8) in those initiating oral corticosteroids, and 66·9 (13·7) in those initiating intravenous corticosteroids (p<0·0001 for between-group comparison). Week 12 outcome data were available for 132 patients who initiated with mesalazine, 141 with oral corticosteroids, and 143 with intravenous corticosteroids. Corticosteroid-free remission with the patient receiving mesalazine treatment only at 12 weeks was achieved by 64 (48%) patients in the mesalazine group, 47 (33%) in the oral corticosteroid group, and 30 (21%) in the intravenous corticosteroid group (p<0·0001). Treatment escalation was required by nine (7%) patients in the mesalazine group, 21 (15%) in the oral corticosteroid group, and 52 (36%) in the intravenous corticosteroid group (p<0·0001). Eight patients, all of whom were initially treated with intravenous corticosteroids, underwent colectomy. Predictors of week 12 corticosteroid-free remission were baseline PUCAI less than 35 (odds ratio 2·44, 95% CI 1·41-4·22; p=0·0015), higher baseline albumin by 1 g/dL increments among children younger than 12 years (4·05, 1·90-8·64; p=0·00030), and week 4 remission (6·26, 3·79-10·35; p<0·0001). Predictors of treatment escalation by week 12 in patients initially treated with intravenous corticosteroids included baseline total Mayo score of 11 or higher (2·59, 0·93-7·21; p=0·068 [retained in model due to clinical relevance]), rectal biopsy eosinophil count less than or equal to 32 cells per high power field (4·55, 1·62-12·78; p=0·0040), rectal biopsy surface villiform changes (3·05, 1·09-8·56; p=0·034), and not achieving week 4 remission (30·28, 6·36-144·20; p<0·0001). INTERPRETATION Our findings provide guidelines to assess the response of children newly diagnosed with ulcerative colitis to standardised initial therapy and identify predictors of treatment response and failure. These data suggest that additional therapeutic interventions might be warranted to improve early outcomes, especially in patients presenting with severe disease and requiring intravenous corticosteroids. FUNDING National Institutes of Health.
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Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA.
| | - Sonia Davis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - David R Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of East Ontario, Ottawa, ON, Canada
| | - Brendan Boyle
- Gastroenterology & Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Anne M Griffiths
- Gastroenterology, Hepatology and Nutrition, Hospital For Sick Children, Toronto, ON, Canada
| | - Neal S LeLeiko
- Division of Pediatric Gastroenterology, Nutrition & Liver Diseases, Hasbro Children's Hospital, Providence, RI, USA
| | - Cary G Sauer
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - David J Keljo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James Markowitz
- Division of Pediatric Gastroenterology, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Susan S Baker
- Gastroenterology (Digestive Diseases and Nutrition), Women & Children's Hospital of Buffalo WCHOB, Buffalo, NY, USA
| | - Joel Rosh
- Pediatric Gastroenterology and Nutrition, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashish Patel
- Pediatric Gastroenterology, UT Southwestern, Dallas, TX, USA
| | - Marian Pfefferkorn
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Children's Hospital Indiana, Indianapolis, IN, USA
| | - Anthony Otley
- Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, NS, Canada
| | - Melvin Heyman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California at San Francisco, San Francisco, CA, USA
| | - Joshua Noe
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maria Oliva-Hemker
- Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Paul Rufo
- Gastroenterology, Hepatology and Nutrition, Harvard-Children's Hospital Boston, Boston, MA, USA
| | - Jennifer Strople
- Gastroenterology, Hepatology & Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Ziring
- Division of Digestive Diseases and Nutrition, UCLA Medical Center, Los Angeles, CA, USA
| | - Stephen L Guthery
- Pediatric Gastroenterology, Hepatology, Nutrition, Primary Children's Medical Center University of Utah, Salt Lake City, UT, USA
| | - Boris Sudel
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Keith Benkov
- Division of Pediatric Gastroenterology, Mt Sinai Hospital, New York City, NY, USA
| | - Prateek Wali
- Division of Pediatric Gastroenterology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Dedrick Moulton
- Division of Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr Children's Hospital of Vanderbilt, Nashville, TN, USA
| | - Jonathan Evans
- Division of Pediatric Gastroenterology and Nutrition Nemours Children's Clinic, Jacksonville, FL, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alison Marquis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Francisco A Sylvester
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margaret H Collins
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Marla Dubinsky
- Division of Pediatric Gastroenterology, Mt Sinai Hospital, New York City, NY, USA
| | - Vin Tangpricha
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - Krista L Spada
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Ashley Britt
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Bradley Saul
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Nathan Gotman
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jessie Wang
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jose Serrano
- National Institutes of Diabetes, Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - Thomas Walters
- Gastroenterology, Hepatology and Nutrition, Hospital For Sick Children, Toronto, ON, Canada
| | - Lee A Denson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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91
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Kimura M, Shimomura M, Morishita H, Meguro T. Prognosis of infantile food protein-induced enterocolitis syndrome in Japan. Pediatr Int 2017; 59:855-860. [PMID: 28432705 DOI: 10.1111/ped.13305] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/14/2017] [Accepted: 04/18/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although serum C-reactive protein (CRP) and the percentage of eosinophils in peripheral blood (Eo) are increased at onset in infants with food protein-induced enterocolitis syndrome (FPIES), the relationship of these laboratory findings to prognosis is presently unknown. METHODS Correlation of serum CRP and Eo at onset with prognosis was analyzed in 32 patients with FPIES caused by cow's milk (CM). RESULTS The rate of tolerance acquisition was 18.8%, 56.3%, 87.5%, and 96.9% at the ages of 6, 12, 24, and 36 months, respectively. Serum CRP increased in 50% of subjects at onset (median, 0.21 mg/dL; range, <0.20-18.2 mg/dL) and Eo was elevated in 71.9% of subjects at onset (median, 7.1%; range, 1.0-50.5%). Age at tolerance acquisition was significantly positively correlated with serum CRP at onset (r = 0.45, P < 0.01), and significantly negatively correlated with Eo at onset (r = -0.36, P < 0.05). Although CM-specific immunoglobulin E antibody (sIgE) was positive in nine of 32 FPIES patients at onset (median, 0.93; range, 0.38-18.9 kU/L), it decreased thereafter. CM-sIgE at onset did not correlate significantly with prognosis (r = 0.22, P > 0.05). CONCLUSIONS Serum CRP is not only an indicator of the activity of intestinal inflammation, it is also a useful parameter of poor prognosis in FPIES. In contrast, eosinophilia at onset could be used as a marker of good prognosis, suggesting that it has some beneficial effects in the pathophysiology of FPIES.
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Affiliation(s)
- Mitsuaki Kimura
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaki Shimomura
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hideaki Morishita
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Takaaki Meguro
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
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92
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Shapiro JM, Balza R, Virk Hundal NK, Hesterberg PE, Zukerberg LR. Case 23-2017. A 9-Day-Old Girl with Vomiting, Acidosis, and Azotemia. N Engl J Med 2017; 377:372-383. [PMID: 28745994 DOI: 10.1056/nejmcpc1703512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jason M Shapiro
- From the Department of Pediatrics, Rhode Island Hospital and Hasbro Children's Hospital, and the Department of Pediatrics, Warren Alpert Medical School of Brown University - both in Providence (J.M.S.); and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H., P.E.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Massachusetts General Hospital, and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Harvard Medical School - both in Boston
| | - Rene Balza
- From the Department of Pediatrics, Rhode Island Hospital and Hasbro Children's Hospital, and the Department of Pediatrics, Warren Alpert Medical School of Brown University - both in Providence (J.M.S.); and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H., P.E.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Massachusetts General Hospital, and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Harvard Medical School - both in Boston
| | - Navneet K Virk Hundal
- From the Department of Pediatrics, Rhode Island Hospital and Hasbro Children's Hospital, and the Department of Pediatrics, Warren Alpert Medical School of Brown University - both in Providence (J.M.S.); and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H., P.E.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Massachusetts General Hospital, and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Harvard Medical School - both in Boston
| | - Paul E Hesterberg
- From the Department of Pediatrics, Rhode Island Hospital and Hasbro Children's Hospital, and the Department of Pediatrics, Warren Alpert Medical School of Brown University - both in Providence (J.M.S.); and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H., P.E.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Massachusetts General Hospital, and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Harvard Medical School - both in Boston
| | - Lawrence R Zukerberg
- From the Department of Pediatrics, Rhode Island Hospital and Hasbro Children's Hospital, and the Department of Pediatrics, Warren Alpert Medical School of Brown University - both in Providence (J.M.S.); and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H., P.E.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Massachusetts General Hospital, and the Departments of Radiology (R.B.), Pediatrics (N.K.V.H.), Medicine (P.E.H.), and Pathology (L.R.Z.), Harvard Medical School - both in Boston
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Abstract
With the advent of novel therapies targeting eosinophils, there has been renewed interest in understanding the basic biology of this unique cell. In this context, murine models and human studies have continued to highlight the role of the eosinophil in homeostatic functions and immunoregulation. This review will focus on recent advances in our understanding of eosinophil biology that are likely to have important consequences on the development and consequences of eosinophil-targeted therapies. Given the breadth of the topic, the discussion will be limited to three areas of interest: the eosinophil life cycle, eosinophil heterogeneity, and mechanisms of cell-cell communication.
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Affiliation(s)
- Amy Klion
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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94
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Conner JR, Kirsch R. The pathology and causes of tissue eosinophilia in the gastrointestinal tract. Histopathology 2017; 71:177-199. [DOI: 10.1111/his.13228] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- James R Conner
- Department of Pathology and Laboratory Medicine; Mount Sinai Hospital; Toronto ON Canada
| | - Richard Kirsch
- Department of Pathology and Laboratory Medicine; Mount Sinai Hospital; Toronto ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
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95
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Sato M, Shoda T, Shimizu H, Orihara K, Futamura K, Matsuda A, Yamada Y, Irie R, Yoshioka T, Shimizu T, Ohya Y, Nomura I, Matsumoto K, Arai K. Gene Expression Patterns in Distinct Endoscopic Findings for Eosinophilic Gastritis in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1639-1649.e2. [PMID: 28526277 DOI: 10.1016/j.jaip.2017.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 02/21/2017] [Accepted: 03/17/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Eosinophilic gastritis (EG) is clinicopathologically characterized by both marked gastric eosinophilia and clinical symptoms. The endoscopic findings in EG vary among patients, leading to clinical confusion. However, little is known about the relationship between precise endoscopic findings and the pathophysiological process responsible for EG. OBJECTIVE We aimed to elucidate whether the gross endoscopic findings of EG can be classified into distinct gene expression profiles. METHODS We enrolled pediatric patients who underwent gastrointestinal endoscopy for clinical symptoms suggestive of eosinophilic gastrointestinal disorder between 2011 and 2016. EG was diagnosed when gastric eosinophilia was greater than or equal to 30 eosinophils/hpf. The gene expression profiles of gastric biopsies were assessed using microarray technology. RESULTS Patients with EG and control subjects (n = 8, each) were examined. On the microarray, 1,999 genes were differentially expressed between EG and the controls (≥2-fold difference, adjusted P value < .05), including significant upregulation of eotaxin-3 (C-C chemokine ligand 26). The endoscopic findings of patients with EG fell roughly into 2 types, namely, ulcerative and nodular lesions. Despite identifying distinct patterns of gene expression, most differentially regulated genes overlapped between the 2 endoscopic finding types. Several gene ontology terms were enriched in the substantially overlapped genes, but not in each of the distinct genes. CONCLUSIONS Our results strongly indicate that ulcerative and nodular lesions are a single disease, EG, or a variation thereof, in spite of morphological differences. Our findings may contribute to a better understanding of the pathogenesis of EG, as well as to more accurate diagnosis of this disease.
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Affiliation(s)
- Masamichi Sato
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan; Department of Pediatrics, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tetsuo Shoda
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Division of Allergy, National Center for Child Health and Development, Tokyo, Japan.
| | - Hirotaka Shimizu
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Kanami Orihara
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Waseda Institute for Advanced Study, Waseda University, Tokyo, Japan
| | - Kyoko Futamura
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Akio Matsuda
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Yoshiyuki Yamada
- Division of Allergy and Immunology, Gunma Children's Medical Center, Gunma, Japan
| | - Rie Irie
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Takako Yoshioka
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yukihiro Ohya
- Division of Allergy, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Nomura
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Division of Allergy, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Matsumoto
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
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96
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Kimura M, Shimomura M, Morishita H, Meguro T, Seto S. Eosinophilia in infants with food protein-induced enterocolitis syndrome in Japan. Allergol Int 2017; 66:310-316. [PMID: 27624222 DOI: 10.1016/j.alit.2016.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/08/2016] [Accepted: 08/01/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Many Japanese infants with food protein-induced enterocolitis syndrome (FPIES) show eosinophilia, which has been thought to be a characteristic of food protein-induced proctocolitis (FPIP). METHODS To elucidate the characteristics of eosinophilia in Japanese FPIES patients, 113 infants with non-IgE-mediated gastrointestinal food allergy due to cow's milk were enrolled and classified into FPIES (n = 94) and FPIP (n = 19). RESULTS The percentage of peripheral blood eosinophils (Eo) was increased in most FPIES patients (median, 7.5%), which was comparable with that in FPIP patients (9.0%). Among FPIES patients, Eo was the highest in patients who had vomiting, bloody stool, and diarrhea simultaneously (12.9%) and lowest in patients with diarrhea alone (3.2%). Eo showed a significant positive correlation with the incidence of vomiting (Cramer's V = 0.31, p < 0.005) and bloody stool (Cramer's V = 0.34, p < 0.0005). A significant difference was found in Eo between early- (≤10 days, n = 56) and late-onset (>10 days, n = 38) FPIES (median, 9.8% vs. 5.4%; p < 0.005). IL-5 production by peripheral blood T cells stimulated with cow's milk protein in early-onset FPIES was significantly higher than that in late-onset FPIES (67.7 pg/mL vs. 12.5 pg/mL, p < 0.01), and showed a significant positive correlation with Eo (rs = 0.60, p < 0.01). CONCLUSIONS This study demonstrated two types of eosinophilia in Japanese FPIES infants: conspicuous and mild eosinophilia in early- and late-onset FPIES patients, respectively. Conspicuous eosinophilia in early-onset FPIES is suggested to be caused by abnormally high IL-5 production.
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Affiliation(s)
- Mitsuaki Kimura
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan.
| | - Masaki Shimomura
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hideaki Morishita
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Takaaki Meguro
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Shiro Seto
- Department of Allergy and Clinical Immunology, Shizuoka Children's Hospital, Shizuoka, Japan
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97
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Liu B, Zhang GQ, Li ZY, Li J, Yu ZS, Zhu J. Diagnosis and treatment of eosinophilic gastroenteritis in children: A report of 10 cases and literature review. Shijie Huaren Xiaohua Zazhi 2017; 25:743-749. [DOI: 10.11569/wcjd.v25.i8.743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the clinical manifestations, diagnosis and treatment of eosinophilic gastroenteritis (EG) in children.
METHODS We retrospectively analyzed 10 cases of EG diagnosed at the Department of Gastroenterology of Children's Hospital of Chongqing Medical University during the past 4 years (2014-04/2016-04) and reviewed the literature to summarize the characteristics of EG, including clinical manifestations, laboratory, endoscopic, and pathological findings, treatment strategy and prognosis.
RESULTS Common symptoms were abdominal pain (40%), diarrhea (40%), abdominal distension (20%), vomiting (20%, accompanied by hematemesis), bloody stool (20%), and edema (20%). Nine (90%) had an increased peripheral white blood cell count, 7 (70%) had thrombocytosis, and 9 (90%) had a significantly increased peripheral eosinophil count. On abdominal color Doppler ultrasound, slight liver enlargement was observed in 2 cases, a small amount of ascites in 2 cases, and gastric retention and intestinal distension in 1 case. Gastroscopy was performed in 9 cases and colonoscopy in 1 case. Gastroscopy showed mucosal hyperemia, edema, spotty or patchy erosion and ulcer, and whitish coating in the stomach. Colonoscopy showed mucosal hyperemia, edema, erythema and superficial ulcer. Mucosal pathological examination showed marked mucosal eosinophil infiltration (more than 20 eosinophils per microscopic high-power field) in all cases, and a large number of eosinophils in ascites in 2 cases. Cases were classified as mucosal (n = 8) and subserosal (n = 2). Dietary intervention (amino acid formula) and/or drug therapy (glucocorticoids, leukotriene receptor antagonist, desloratadine, etc.) were administered in the 10 cases. EG-related symptoms were alleviated in 9 cases without recurrence after discontinuation of the therapy. Only 1 case was recurrent after eating fast food.
CONCLUSION Clinical manifestations of EG are diverse in children. The majority of patients have peripheral eosinophilia. Endoscopy and mucosal biopsy can provide diagnostic clues for EG. Dietary intervention is effective for the treatment of EG in some patients, while corticosteroid treatment remains the best therapy for EG.
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98
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Abstract
INTRODUCTION Eosinophilic colitis, which is a rare form of eosinophilic gastrointestinal diseases, occurs as primary and secondary allergic eosinophilic colitis of the gastrointestinal tract infection, inflammatory bowel disease, celiac disease, and vasculitis. The diagnosis is based on a significant amount of eosinophils in the inflammatory infiltrate of the colon wall. AIM To analyze the clinical picture taking into account comorbidities and endoscopic picture in children with eosinophilic colitis. MATERIAL AND METHODS The test group consisted of 43 children, the average age - 12.1 years diagnosed with eosinophilic colitis (according to the Whitington scale) hospitalized in the Gastroenterology Unit, Department of Pediatrics of the Medical University of Silesia in Katowice. Testing for food allergies, celiac disease, inflammatory bowel disease, gastrointestinal diseases and parasitic diseases was performed in the group of children and the analysis concerned the intensity of eosinophilic infiltration of the colon mucosa with the severity of clinical symptoms, endoscopic picture, the presence of inflammatory bowel disease, and food allergy. RESULTS Half of the tested children suffered from isolated eosinophilic colitis but the rest of them had eosinophilic infiltrate with inflammatory bowel disease more often, however, the Crohn's disease. The endoscopic image was uncharacteristic, and grade III in the Whitington scale was predominant in the histopathological examination, in most cases located in the entire large intestine. The higher level of total IgE was found in less than half of the patients and it did not correlate with the severity of eosinophilic infiltration. It was shown that the severity of eosinophilic infiltration correlated with exacerbation of clinical symptoms, endoscopic image, and the presence of inflammatory bowel disease. The higher level of antibodies of ASCA and ANCA was found in approximately 20% of the children with isolated eosinophilic colitis and 63% of children with Crohn's disease. CONCLUSIONS The higher concentration of total IgE in less than half of the patients with eosinophilic colitis indicates the need for improving allergy diagnosis also in terms of IgE-independent allergy. The presence of higher levels of antibodies of ASCA and ANCA in some of the patients with isolated eosinophilic colitis indicates the need for further observation for the occurrence of inflammatory bowel disease.
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100
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Katre RS, Sunnapwar A, Restrepo CS, Katabathina VS, Mumbower A, Baxi A, Sonavane S. Cardiopulmonary and Gastrointestinal Manifestations of Eosinophil- associated Diseases and Idiopathic Hypereosinophilic Syndromes: Multimodality Imaging Approach. Radiographics 2017; 36:433-51. [PMID: 26963455 DOI: 10.1148/rg.2016150145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Eosinophil-associated diseases (EADs) are a diverse group of disorders characterized by an increase in circulating or tissue eosinophils. Cardiopulmonary and gastrointestinal system involvement can be due to primary EAD with no known cause or can be secondary to known systemic disease. The cardiopulmonary spectrum of EADs comprises simple pulmonary eosinophilia, acute eosinophilic pneumonia, chronic eosinophilic pneumonia, Churg-Strauss syndrome, allergic bronchopulmonary aspergillosis, bronchocentric granulomatosis, parasitic infections, and idiopathic hypereosinophilic syndrome. Eosinophilic gastrointestinal disorders include eosinophilic esophagitis, eosinophilic gastroenteritis, and eosinophilic colitis. Diagnosis is often challenging and requires a combination of clinical and imaging features along with laboratory findings. The absolute eosinophil count in peripheral blood and the percentage of eosinophils in bronchoalveolar lavage fluid are crucial in evaluation of various eosinophilic lung diseases. Although chest radiography is the initial imaging modality used in suspected cases of pulmonary EAD, multidetector computed tomography may demonstrate more characteristic pulmonary patterns, nodules, and subtle parenchymal abnormalities. Barium esophagography is used to assess mucosal abnormalities and the length and diameter of esophageal strictures. Magnetic resonance imaging is superior in providing valuable information in select patients, especially in evaluation of cardiac and gastrointestinal system involvement. Many patients require a multimodality imaging approach to enable diagnosis, guide treatment, and assess treatment response. Knowledge of the clinical features and imaging findings of the spectrum of EADs involving the lungs, heart, and gastrointestinal tract permits optimal patient care.
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Affiliation(s)
- Rashmi S Katre
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (R.S.K., A.S., C.S.R., V.S.K., A.M., A.B.); and Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (S.S.)
| | - Abhijit Sunnapwar
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (R.S.K., A.S., C.S.R., V.S.K., A.M., A.B.); and Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (S.S.)
| | - Carlos S Restrepo
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (R.S.K., A.S., C.S.R., V.S.K., A.M., A.B.); and Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (S.S.)
| | - Venkata S Katabathina
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (R.S.K., A.S., C.S.R., V.S.K., A.M., A.B.); and Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (S.S.)
| | - Amy Mumbower
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (R.S.K., A.S., C.S.R., V.S.K., A.M., A.B.); and Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (S.S.)
| | - Ameya Baxi
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (R.S.K., A.S., C.S.R., V.S.K., A.M., A.B.); and Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (S.S.)
| | - Sushilkumar Sonavane
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (R.S.K., A.S., C.S.R., V.S.K., A.M., A.B.); and Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (S.S.)
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