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Jin M, Gong Y, Liu W, Zhong X. Clinical characteristics and management of autoimmune enteropathy in children: case reports and literature review. BMC Pediatr 2023; 23:601. [PMID: 38017413 PMCID: PMC10683148 DOI: 10.1186/s12887-023-04435-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Autoimmune enteropathy (AIE) defined by intractable diarrhoea and nonceliac enteropathy with villous atrophy, is a rare digestive disease. Case reports of this disease are sporadic and the clinical characteristics of AIE is seldom discussed. PURPOSE We evaluate the clinical, laboratory, histopathological features, response to therapy and outcome of AIE in children. METHOD We conducted a retrospective analysis of five children with AIE in our hospital. A comprehensive search of MEDLINE was performed using PubMed, through keywords of "autoimmune enteropathy, pediatric or children". The clinical manifestations, endoscopic results, pathological results, and medication therapy of these children were collected and the cases were divided into two groups, infants (≤ 1 year old) and children (> 1 year old). RESULTS Five cases treated in our department: one case took eight years to make the final diagnosis; one case was positive for anti-intestinal epithelial cell (AE) antibody; three cases showed crypt apoptosis in histopathology; and two cases showed celiac-like changes. All cases were responsive to glucocorticoid therapy in the early stage of treatment, while three cases required immunosuppressant maintenance. After reviewing the literature, we performed a statistical analysis of 50 cases with a male-to-female ratio of 31:19. Among them, 35 patients (70%) were within 1 year of age, and their clinical manifestations were mainly watery stool (43 cases, 86%), weight loss (28 cases, 56%), abdominal distension (3 cases, 6%), serum AE or anti-goblet cell (AG) antibody positivity (32 cases, 64%), other immune-related antibodies (21 cases, 42%), gene mutations (9 cases, 18%), and family history (21 cases, 42%). All the children showed different degrees of intestinal villous atrophy. Thirty-seven (74%) of the children were treated early, and their clinical symptoms were relieved. Comparing the cases between different age groups, it was found that the mortality rate of children with onset in infancy was higher (P < 0.05), and there was no difference in other autoimmune diseases, AE antibody positivity rates, and other antibodies between the two groups. In addition to survival rate between different age group (P = 0. 005), there was no difference in sex, autoantibody positivity rate, single gene mutation, or family history between the two groups (P > 0.05) through analysis of mortality and clinical remission cases. CONCLUSION Endoscopic examination and mucosal pathological examination should be performed to diagnose AIE in children with watery stool and weight loss who fail to be treated with diet therapy. Immunotherapy is the core of medical management of AIE and can improve prognosis. Children with a poor prognosis in infancy should be actively treated to reduce mortality rates associated with AIE.
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Affiliation(s)
- Meng Jin
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Youzhe Gong
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Wenwen Liu
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Xuemei Zhong
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China.
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2
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Xu M, Zhang W, Wang S, Xia M. Autoimmune enteropathy complicated with primary biliary cholangitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:667-668. [PMID: 37771301 DOI: 10.17235/reed.2023.9901/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Autoimmune enteropathy is a rare intestinal disease. Here we report an elderly female with autoimmune enteropathy and primary biliary cholangitis who presented with chronic diarrhea, malnutrition and severe hypokalemia and metabolic acidosis. Enteroscopy showed atrophied small intestinal villi with scallop-like and fissure-like changes. Hormone treatment relieved diarrhea. Four months later, she developed primary biliary cholangitis, and the liver function returned to normal after treatment with ursodeoxycholic acid, corticosteroids and immunosuppressants.
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Affiliation(s)
- Mengyue Xu
- Gastroenterology, The Affiliated Wuxi People's Hospital of Nanjing Medical University
| | - Wenjia Zhang
- Gastroenterology, The Affiliated Wuxi People's Hospital of Nanjing Medical University
| | - Sihui Wang
- Gastroenterology, The Affiliated Wuxi People's Hospital of Nanjing Medical University
| | - Min Xia
- Gastroenterology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, CHINA
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3
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Wu N, Yu J, Ding Y, Li H, Zhang JY, Huang WF. An unusual case of diarrhea: Autoimmune enteropathy. Clin Res Hepatol Gastroenterol 2023; 47:102197. [PMID: 37572789 DOI: 10.1016/j.clinre.2023.102197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/05/2023] [Accepted: 08/10/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Na Wu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361003, China
| | - Juan Yu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361003, China
| | - Yi Ding
- Department of Pathology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361003, China
| | - Hua Li
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361003, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou 35012, China
| | - Jin-Yan Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361003, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou 35012, China
| | - Wei-Feng Huang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361003, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou 35012, China.
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Amer B, Khozaig WH, Alhadad MT, Abdelrahman N. A Combination Therapy in a Rare Case of Adult-Onset Autoimmune Enteropathy. Cureus 2023; 15:e42538. [PMID: 37637519 PMCID: PMC10460121 DOI: 10.7759/cureus.42538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Autoimmune enteropathy (AIE) is a differential diagnosis of incurable chronic diarrhea, malnutrition, and weight loss. This type of diarrhea is associated with protein enteropathy that usually affects the small intestine. The diagnosis of AIE is based on chronic diarrhea, malabsorption, specific histological result, antibodies against enterocytes, and excluding similar conditions. In this case, a 28-year-old female presented with diarrhea, lower limb edema, weight loss, and electrolyte imbalances. Endoscopic examination demonstrated duodenal villous atrophy, while duodenal biopsies revealed villous blunting, scattered intraepithelial lymphocytes, and crypt hyperplasia in the lamina propria. The patient was treated with immunosuppressive treatment including methylprednisolone and azathioprine, achieving clinical remission.
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Affiliation(s)
- Bushra Amer
- Department of Family Medicine, Michigan State University College of Human Medicine, East Lansing, USA
| | - Waleed H Khozaig
- Department of Gastroenterology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, SAU
| | - Monia T Alhadad
- Department of Family Medicine, Michigan State University College of Human Medicine, East Lansing, USA
| | - Nadir Abdelrahman
- Department of Family Medicine-Geriatrics, Michigan State University College of Human Medicine, East Lansing, USA
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5
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Bruneau J, Khater S, Isnard P, Lhermitte L, Brouzes C, Sibon D, Asnafi V, Berrebi D, Rabant M, Neven B, Cellier C, Hermine O, Molina TJ. [Immunopathology of the small intestine]. Ann Pathol 2023:S0242-6498(23)00080-9. [PMID: 37156715 DOI: 10.1016/j.annpat.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 05/10/2023]
Abstract
The gastrointestinal tract is the site of exciting immunological interactions between the epithelium and the mucosa-associated lymphoid tissue, leading to the immune response to food and microbial antigens in the digestive lumen. The objective of this review is to present the main dysimmune pathologies of the digestive tract leading to an enteropathy. As examples, we describe celiac and non-celiac enteropathies to clarify a florid diagnostic framework, by identifying a spectrum of elementary lesions, which must be confronted with the clinico biological context of the patient to orient the diagnosis. The microscopic lesions observed are most often non-specific and may be encountered in several diagnostic settings. Moreover, it is a set of elementary lesions in each clinical context that will orient the diagnostic framework. Celiac disease is the main etiology of enteropathy with villous atrophy, its diagnosis is multidisciplinary and there are many differential diagnoses. We will discuss celiac disease lymphomatous complications as enteropathy associated T-cell lymphoma including refractory sprue type 2. We will then present the non-celiac enteropathies. Among these, enteropathies of unknown etiology may be associated with a primary immune deficiency that may be reflected by florid lymphoid hyperplasia of the gastrointestinal tract and/or be associated with an infectious etiology that should also be constantly sought. Finally, we will discuss of induced enteropathy by new immunomodulatory treatments.
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Affiliation(s)
- Julie Bruneau
- Service d'anatomie et de cytologie pathologique, hôpitaux universitaires Necker-Enfants Malades et Robert Debré, AP-HP, université de Paris Cité, Paris, France.
| | - Shérine Khater
- Service de gastro-entérologie, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris (AP-HP), université Paris Cité, Paris, France
| | - Pierre Isnard
- Service d'anatomie et de cytologie pathologique, hôpitaux universitaires Necker-Enfants Malades et Robert Debré, AP-HP, université de Paris Cité, Paris, France
| | - Ludovic Lhermitte
- Laboratoire d'onco-hématologie, hôpital universitaire Necker-Enfants Malades, Assistance publique-Hôpitaux de Paris (AP-HP), université Paris Cité, Paris, France
| | - Chantal Brouzes
- Laboratoire d'onco-hématologie, hôpital universitaire Necker-Enfants Malades, Assistance publique-Hôpitaux de Paris (AP-HP), université Paris Cité, Paris, France
| | - David Sibon
- Service d'hématologie, hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris (AP-HP), université Paris-Est-Créteil, Créteil, France
| | - Vahid Asnafi
- Laboratoire d'onco-hématologie, hôpital universitaire Necker-Enfants Malades, Assistance publique-Hôpitaux de Paris (AP-HP), université Paris Cité, Paris, France
| | - Dominique Berrebi
- Service d'anatomie et de cytologie pathologique, hôpitaux universitaires Necker-Enfants Malades et Robert Debré, AP-HP, université de Paris Cité, Paris, France
| | - Marion Rabant
- Service d'anatomie et de cytologie pathologique, hôpitaux universitaires Necker-Enfants Malades et Robert Debré, AP-HP, université de Paris Cité, Paris, France
| | - Bénédicte Neven
- Service d'immuno-hématologie et rhumatologie pédiatrique, hôpital universitaire Necker-Enfants Malades, Assistance publique-Hôpitaux de Paris (AP-HP), université Paris Cité, Paris, France
| | - Christophe Cellier
- Service de gastro-entérologie, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris (AP-HP), université Paris Cité, Paris, France
| | - Olivier Hermine
- Service d'hématologie, hôpital universitaire Necker-Enfants Malades, Assistance publique-Hôpitaux de Paris, AP-HP, université Paris Cité, Paris, France
| | - Thierry Jo Molina
- Service d'anatomie et de cytologie pathologique, hôpitaux universitaires Necker-Enfants Malades et Robert Debré, AP-HP, université de Paris Cité, Paris, France
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6
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Lorentsen RD, Riis LB, Steenholdt C. Adult-Onset Autoimmune Enteropathy: A Case Report. Cureus 2023; 15:e39677. [PMID: 37398811 PMCID: PMC10308144 DOI: 10.7759/cureus.39677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
Small bowel villous atrophy is most often caused by celiac disease in the Western world, but other diseases should be explored in patients without positive serology. Adult-onset autoimmune enteropathy (AIE) is a rare cause of villous atrophy first known in children with T-cell dysregulation but also seen in adults with autoimmune predispositions. Here, an 82-year-old woman with autoimmune thyroiditis was admitted with weight loss and watery diarrhoea not responding to diet change. Endoscopy revealed villous atrophy both in the duodenum and in the ileum, but no positive celiac serology. A diagnosis of autoimmune enteropathy was made based on chronic diarrhoea not responding to diet change, autoimmune predisposition, villous atrophy, typical histological findings, and no evidence of immunodeficiency or medications causing villous atrophy. The patient was treated to good effect with corticosteroids but needed total parenteral nutrition while admitted. AIE should be considered in villous atrophy without positive celiac serology.
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Affiliation(s)
- Ruben D Lorentsen
- Department of Gastroenterology, Herlev and Gentofte Hospital, Herlev, DNK
| | - Lene B Riis
- Department of Pathology, Herlev and Gentofte Hospital, Herlev, DNK
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, DNK
| | - Casper Steenholdt
- Department of Gastroenterology, Herlev and Gentofte Hospital, Herlev, DNK
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7
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Deolet E, Callewaert B, Geldof J, Van Biervliet S, Vande Velde S, Van Dorpe J, Van Winckel M, Hoorens A. Apoptotic enteropathy, gluten intolerance, and IBD-like inflammation associated with lipotoxicity in DGAT1 deficiency-related diarrhea: a case report of a 17-year-old patient and literature review. Virchows Arch 2022; 481:785-791. [PMID: 35763111 DOI: 10.1007/s00428-022-03365-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/12/2022] [Accepted: 06/17/2022] [Indexed: 10/17/2022]
Abstract
We present a long-term follow-up in a 17-year-old girl with DGAT1-related diarrhea, an autosomal recessive disorder characterized by impaired triglyceride absorption. Neonatal presentation included severe congenital diarrhea, protein-losing enteropathy, and failure to thrive requiring total parenteral nutrition. Duodenal biopsies revealed apoptotic enteropathy and acute inflammation with the presence of macrophages and Touton giant cells, related to the intake of fat. She was able to switch to enteral nutrition on a fat-free diet. However, at age 10, she developed gluten-induced enteropathy and then IBD-like inflammation 5 years later. Immunohistochemistry was able to confirm the diagnosis, while DGAT1 sequencing remained inconclusive. This highlights the role of histopathology and immunohistochemistry, despite the increasing importance of genetic analysis in the diagnostic work-up. This report also illustrates that parenteral nutrition weaning is possible in DGAT1-related diarrhea, but gut barrier dysfunction might increase the risk of autoimmune intestinal disease.
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Affiliation(s)
- Ellen Deolet
- Department of Pathology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Bert Callewaert
- Center for Medical Genetics, Ghent University Hospital, 9000, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, 9000, Ghent, Belgium
| | - Jeroen Geldof
- Department of Gastroenterology and Hepatology, Ghent University Hospital, 9000, Ghent, Belgium
| | | | - Saskia Vande Velde
- Department of Paediatric Gastroenterology, Ghent University Hospital, 9000, Ghent, Belgium
| | - Jo Van Dorpe
- Department of Pathology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Myriam Van Winckel
- Department of Paediatric Gastroenterology, Ghent University Hospital, 9000, Ghent, Belgium
| | - Anne Hoorens
- Department of Pathology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
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8
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Mulenga C, Sviben S, Chandwe K, Amadi B, Kayamba V, Fitzpatrick JAJ, Mudenda V, Kelly P. Epithelial Abnormalities in the Small Intestine of Zambian Children With Stunting. Front Med (Lausanne) 2022; 9:849677. [PMID: 35372420 PMCID: PMC8966729 DOI: 10.3389/fmed.2022.849677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/22/2022] [Indexed: 01/17/2023] Open
Abstract
Background Environmental enteropathy (EE) contributes to impaired linear growth (stunting), in millions of children worldwide. We have previously reported that confocal laser endomicroscopy (CLE) shows fluorescein leaking from blood to gut lumen in vivo in adults and children with EE. We set out to identify epithelial lesions which might explain this phenomenon in Zambian children with stunting non-responsive to nutritional support. Methods We performed confocal laser endomicroscopy (CLE) in 75 children and collected intestinal biopsies for histology in 91 children. CLE videos were evaluated, employing the Watson score to determine severity of leakiness. Morphometry was carried out on well-orientated mucosa and 3 biopsies were examined by electron microscopy. Results Confocal laser endomicroscopy demonstrated substantial leakage from circulation to gut lumen in 73 (97%) children. Histology consistently showed characteristic changes of EE: villus blunting, lamina propria and epithelial inflammation, and depletion of secretory cells (Paneth cells and goblet cells). Epithelial abnormalities included marked variability in epithelial height, disorganised and shortened microvilli, dilated intercellular spaces, pseudostratification, formation of synechiae between epithelium on adjacent villi, crypt destruction, and abundant destructive lesions which may correspond to the microerosions identified on CLE. Conclusion Epithelial abnormalities were almost universal in Zambian children with non-responsive stunting, including epithelial microerosions, cell-cell adhesion anomalies, and defects in secretory cells which may all contribute to impairment of mucosal barrier function and microbial translocation.
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Affiliation(s)
- Chola Mulenga
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sanja Sviben
- Washington University Center for Cellular Imaging, Washington University School of Medicine, St. Louis, MO, United States
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Violet Kayamba
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - James A. J. Fitzpatrick
- Washington University Center for Cellular Imaging, Washington University School of Medicine, St. Louis, MO, United States
- Departments of Cell Biology & Physiology and Neuroscience, Washington University School of Medicine, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Victor Mudenda
- Department of Pathology and Microbiology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
- *Correspondence: Paul Kelly,
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Sordo RD, Lougaris V, Bassotti G, Armuzzi A, Villanacci V. Therapeutic agents affecting the immune system and drug-induced inflammatory bowel disease (IBD): A review on etiological and pathogenetic aspects. Clin Immunol 2021; 234:108916. [PMID: 34971840 DOI: 10.1016/j.clim.2021.108916] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 01/02/2023]
Abstract
In recent years, therapeutic agents affecting the immune system have been largely implemented in the treatment of various hematological, rheumatological and dermatological disorders. Their clinical use has offered important benefits for affected patients and has also ameliorated clinical outcome and prognosis in many cases. Nonetheless, as any treatment, the use of these drugs may be associated with side effects. One of the target organs in such cases is the gastrointestinal tract. In particular, the exacerbation or the onset of inflammatory bowel disease (IBD) in treated patients is not infrequent, although the mechanism of action of these agents may be different. In this review we will focus on the use of therapeutic agents affecting the immune system and the development or exacerbation of IBD, with a mention on the possible underlying pathogenetic mechanisms.
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Affiliation(s)
- Rachele Del Sordo
- Department of Medicine and Surgery, Section of Anatomic Pathology and Histology, Medical School, University of Perugia, Perugia, Italy
| | - Vassilios Lougaris
- Pediatrics Clinic, Department of Clinical and Experimental Sciences, University of Brescia and Children's Hospital, ASST-Spedali Civili, Brescia, Italy..
| | - Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Alessandro Armuzzi
- IBD Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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10
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Thymoma-associated autoimmune enteropathy with colonic stricture: a diagnostic and histological challenge. Clin J Gastroenterol 2021; 15:112-116. [PMID: 34676508 DOI: 10.1007/s12328-021-01531-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
Thymoma-associated autoimmune enteropathy is a rare paraneoplastic syndrome that is characterized by severe chronic diarrhea, malabsorption, and specific histological findings. Because of its rarity, it is difficult to diagnose. We describe an adult patient with protracted diarrhea and weight loss that developed recurrent sepsis and progressive colonic stenosis due to thymoma-associated autoimmune enteropathy. Ultimately, the diagnosis thymoma-associated autoimmune enteropathy was established by characteristic intestinal histology, anti-enterocytes antibodies, and thorax imaging. Radical thymectomy was performed without improvement. Therapy with azathioprine and infliximab induced clinical remission with complete recovery of the colonic stenosis.
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11
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Zhou QY, Zhou WX, Sun XY, Wu B, Zheng WY, Li Y, Qian JM. Autoimmune enteropathy and primary biliary cholangitis after proctocolectomy for ulcerative colitis: A case report and review of the literature. World J Gastroenterol 2021; 27:4929-4938. [PMID: 34447236 PMCID: PMC8371508 DOI: 10.3748/wjg.v27.i29.4929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Autoimmune enteropathy (AIE) and primary biliary cholangitis (PBC) are both immune-mediated diseases. AIE or PBC complicated with ulcerative colitis (UC) are rare. There are no cases of AIE and PBC diagnosed after proctocolectomy for UC reported before, and the pathogenesis of these comorbidities has not been revealed.
CASE SUMMARY A middle-aged woman diagnosed with UC underwent subtotal colectomy and ileostomy due to the steroid-resistant refractory disease, and a restorative proctectomy with ileal pouch-anal anastomosis and proximal neoileostomy was postponed due to active residual rectal inflammation in January 2016. A few months after the neoileostomy, she began to suffer from recurrent episodes of watery diarrhea. She was diagnosed with postcolectomy enteritis and stoma closure acquired a good therapeutic effect. However, her symptoms of diarrhea relapsed in 2019, with different histological features of endoscopic biopsies compared with 2016, which showed apoptotic bodies, a lack of goblet and Paneth cells, and villous blunting. A diagnosis of AIE was established, and the patient’s stool volume decreased dramatically with the treatment of methylprednisolone 60 mg/d for 1 wk and tacrolimus 3 mg/d for 4 d. Meanwhile, her constantly evaluated cholestatic enzymes and high titers of antimitochondrial antibodies indicated the diagnosis of PBC, and treatment with ursodeoxycholic acid (16 mg/kg per day) achieved satisfactory results.
CONCLUSION Some immune-mediated diseases may be promoted by operation due to microbial alterations in UC patients. Continuous follow-up is essential for UC patients with postoperative complications.
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Affiliation(s)
- Qing-Yang Zhou
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Xun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xi-Yu Sun
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Yang Zheng
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jia-Ming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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van Wanrooij RLJ, Neefjes-Borst EA, Bontkes HJ, Schreurs MWJ, Langerak AW, Mulder CJJ, Bouma G. Adult-Onset Autoimmune Enteropathy in an European Tertiary Referral Center. Clin Transl Gastroenterol 2021; 12:e00387. [PMID: 34333499 PMCID: PMC8323799 DOI: 10.14309/ctg.0000000000000387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/28/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adult-onset autoimmune enteropathy (AIE) is a rare cause of severe chronic diarrhea because of small intestinal villous atrophy. We report on patients with adult-onset AIE in an European referral center. METHODS Retrospective study including patients diagnosed with AIE in the Amsterdam UMC, location VUmc, between January 2003 and December 2019. Clinical, serological, and histological features and response to treatment were reported. The specificity of antienterocyte antibodies (AEA) was evaluated by examining the prevalence of AEA in (i) controls (n = 30) and in patients with (ii) AIE (n = 13), (iii) celiac disease (CD, n = 52), (iv) refractory celiac disease type 2 (n = 18), and (v) enteropathy-associated T-cell lymphoma (EATL, n = 10). RESULTS Thirteen AIE patients were included, 8 women (62%), median age of 52 years (range 23-73), and 6 (46%) with an autoimmune disease. AEA were observed in 11 cases (85%), but were also found in CD (7.7%), refractory celiac disease type 2 (16.7%), and EATL (20%). Ten patients (77%) were human leukocyte antigen DQ2.5 heterozygous. Total parenteral nutrition was required in 8 cases (62%). Steroids induced clinical remission in 8 cases (62%). Step-up therapy with rituximab, cyclosporine, infliximab, and cladribine in steroid-refractory patients was only moderately effective. Four patients died (31%), but 4 (31%) others are in long-term drug-free remission after receiving immunosuppressive treatment, including 1 patient who underwent autologous stem cell transplantation. DISCUSSION Adult-onset AIE is a rare but severe enteropathy that occurs in patients susceptible for autoimmune disease. Four patients (31%) died secondary to therapy-refractory malabsorption, while immunosuppressive therapy leads to a long-lasting drug-free remission in one-third of patients.
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Affiliation(s)
- Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, the Netherlands
| | | | - Hetty J Bontkes
- Laboratory Medical Immunology, Department of Clinical Chemistry, Amsterdam UMC, AGEM Research Institute, AI & I Institute, Amsterdam, the Netherlands
| | - Marco W J Schreurs
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Anton W Langerak
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, the Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, the Netherlands
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Histopathology of non-IBD colitis practical recommendations from pathologists of IG-IBD Group. Dig Liver Dis 2021; 53:950-957. [PMID: 33712395 DOI: 10.1016/j.dld.2021.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 12/11/2022]
Abstract
Pathologists are often called upon to diagnose colitides that differ from the two main forms of inflammatory bowel disease (IBD). These non-IBD colitides include infectious colitis, microscopic colitis, ischemic colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation colitis and diversion colitis. The diagnosis of these different disease entities relies on the histopathological examination of endoscopic biopsies of the gastrointestinal tract. This paper reviews the main histomorphological characteristics of the various Non-IBD colitides.
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Hartl C, Finke J, Hasselblatt P, Kreisel W, Schmitt-Graeff A. Diagnostic and therapeutic challenge of unclassifiable enteropathies with increased intraepithelial CD103 + CD8 + T lymphocytes: a single center case series. Scand J Gastroenterol 2021; 56:889-898. [PMID: 34057863 DOI: 10.1080/00365521.2021.1931958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Chronic diarrhea, villous atrophy and/or increased intraepithelial T-lymphocytes (IEL) occur in many inflammatory disorders including celiac disease (CD). However, a definite diagnosis is difficult to make in some patients despite an extensive diagnostic work-up. Clinical outcomes and histological phenotypes of such patients we refer to as unclassifiable enteropathy (UEP) remain unclear. MATERIAL AND METHODS We performed a retrospective single-center analysis of patients with chronic diarrhea, weight loss and increased IEL. Patients with defined etiologies including infections, CD, drugs, immunodeficiencies or neoplasms were excluded. Clinical and histologic/immunophenotypic parameters were analyzed. RESULTS Nine patients with UEP were identified. Small intestinal damage ranged from minor villous abnormalities to complete atrophy while all patients displayed high numbers of CD103+ CD8+ IELs. In contrast to CD, these CD8+ T cells were not confined to the surface epithelium, but also infiltrated the crypts. Additional histological features included apoptotic crypt epithelial cells and mixed inflammatory infiltrates in the tunica propria. Involvement of other segments of the gastrointestinal tract was observed in 7/9 patients. A clonal intestinal T-cell lymphoproliferative disorder developed in 2 patients, one of which had a fatal disease course. The majority of patients responded to corticosteroids, while response to immunosuppressive medications yielded heterogeneous results. CONCLUSIONS We report a patient population with 'difficult-to-classify' enteropathies characterized by various degrees of villous atrophy and strongly increased intraepithelial CD103+ CD8+ T cells in the small intestine which harbor an increased risk for T-cell lymphoproliferative disorders. Clinical course, histology, and response to immunosuppressive therapy all suggest an autoimmune pathogenesis.
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Affiliation(s)
- Christina Hartl
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Finke
- Department of Medicine I, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Hasselblatt
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Kreisel
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Chong A, Kashani A, Ansstas M, Jamil L, Guindi M. Seronegative autoimmune enteropathy with duodenal sparing and colonic clues in an adult female. Clin J Gastroenterol 2021; 14:546-550. [PMID: 33630282 DOI: 10.1007/s12328-020-01336-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Autoimmune enteropathy (AIE) is a rare immune disorder of the gut seldom found in adults and characterized by uncontrollable diarrhea resulting in malabsorption. While AIE is known to be pan-enteric, virtually all cases have presented with altered duodenal histology following known patterns with or without macroscopic change. We describe a unique case of seronegative AIE lacking typical duodenal manifestations in a 43-year-old female. To our knowledge, this is the first report of AIE lacking usual duodenal histologic changes, which resulted in missed diagnosis for years. Ultimately, crypt epithelial apoptosis, mononuclear inflammation of the lamina propria, and goblet cell loss of intestinal mucosa besides the duodenum clinched the diagnosis of AIE. Colonic histologic abnormalities consistent with AIE in the setting of diarrhea with malnutrition despite duodenal sparing should prompt suspicion for AIE given the pan-enteric nature of this disease.
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Affiliation(s)
- Albert Chong
- Keck School of Medicine of the University of Southern California, 1975 Zonal Avenue, Keith Administration 100B, Los Angeles, CA, 90089, USA
| | - Amir Kashani
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah School of Medicine, 300 North 1900 East SOM 4R118, Salt Lake City, UT, 84132, USA
| | - Michael Ansstas
- Division of Digestive and Liver Disease, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Laith Jamil
- Section of Gastroenterology and Hepatology, Beaumont Hospital-Royal Oak, Administrative Building West, 3711 W 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Maha Guindi
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA.
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van Wanrooij RLJ, Bontkes HJ, Neefjes-Borst EA, Mulder CJ, Bouma G. Immune-mediated enteropathies: From bench to bedside. J Autoimmun 2021; 118:102609. [PMID: 33607573 DOI: 10.1016/j.jaut.2021.102609] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
Immune-mediated enteropathies are caused by excessive reactions of the intestinal immune system towards non-pathogenic molecules. Enteropathy leads to malabsorption-related symptoms and include (severe) chronic diarrhea, weight loss and vitamin deficiencies. Parenteral feeding and immunosuppressive therapy are needed in severe cases. Celiac disease has long been recognized as the most common immune-mediated enteropathy in adults, but the spectrum of immune-mediated enteropathies has been expanding. Histological and clinical features are sometimes shared among these enteropathies, and therefore it may be challenging to differentiate between them. Here, we provide an overview of immune-mediated enteropathies focused on clinical presentation, establishing diagnosis, immunopathogenesis, and treatment options.
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Affiliation(s)
- Roy L J van Wanrooij
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands.
| | - Hetty J Bontkes
- Amsterdam UMC, Laboratory Medical Immunology, Department of Clinical Chemistry, AI & I Institute, AGEM Research Institute, Amsterdam, the Netherlands
| | | | - Chris J Mulder
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands
| | - Gerd Bouma
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, the Netherlands
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Abstract
OBJECTIVES Villous atrophy (VA) is not pathognomonic of celiac disease (CD). We aimed at reporting distribution, clinical, and immunohistochemical features of seronegative VA (SNVA) in a pediatric population. METHODS We retrospectively collected data from patients who underwent intestinal biopsies between 2010 and 2017 and showed VA without serum CD-associated autoantibodies. Marsh-Oberhuber grading was used. Density of intraepithelial lymphocytes (IELs) expressing CD3 or TCRγδ+ receptor and of lamina propria CD25+ cells was assessed by immunohistochemistry. Intestinal deposits of anti-tissue tranglutaminase2 (anti-TG2) were also investigated by double immunofluorescence. RESULTS Over a 7-year period, 64 out of 1282 patients with VA had negative serum CD serology. Diagnoses were: inflammatory bowel diseases (IBD) (21/64), Gastro-Esophageal Reflux Disease (GERD) (12/64), food allergy (8/64), infections (7/64, of which 3 HIV infections), immune deficiency (3/64), short bowel syndrome (3/64), congenital diarrhea (2/64), other/inconclusive diagnosis (8/64). Forty-four, 15, and 5 showed Marsh 3a, 3b, and 3c lesion, respectively. The latter category included 2 patients with Crohn disease, 2 with immunodeficiencies, 1 with lymphohistiocytosis. In 41/46 (89%) patients, mononuclear CD25+ cells were above the cut-off, indicating mucosal inflammation but only 18/46 (39%) had IELs and TCRγδ + IELs above limits of normality. In 10 of 46 (22%) patients, a positive immunofluorescence indicated the presence of anti-TG2 mucosal antibodies. CONCLUSIONS SNVA is not rare representing up to 5% of the cases of VA. Most patients have a Marsh 3a lesion. Immunohistochemical analysis may be helpful in excluding CD, whereas the finding of mucosal anti-TG2, particularly with a weak staining, shows no absolute specificity for CD.
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Brown I, Bettington M, Rosty C. The role of histopathology in the diagnosis and management of coeliac disease and other malabsorptive conditions. Histopathology 2020; 78:88-105. [PMID: 33382496 DOI: 10.1111/his.14262] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
Most absorption of nutrients takes place in the proximal small intestine, and the most common disorders leading to malabsorption are associated with a morphological abnormality in the duodenal mucosa that is appreciable in histological sections of biopsy specimens. Coeliac disease is the most well-known example, causing intraepithelial lymphocytosis, inflammation and villous atrophy in the duodenum. Remarkably similar inflammatory changes can be induced by other processes, including medications, e.g. angiotensin II receptor blockers and immune checkpoint inhibitors, immune dysregulation disorders, e.g. common variable immunodeficiency and autoimmune enteropathy, infections, collagenous sprue, and tropical sprue. However, there are often subtle histological differences from coeliac disease in the type of inflammatory infiltrate, the presence of crypt apoptosis, and the extent and type of inflammation beyond the duodenum. The clinical setting and serological investigation usually allow diagnostic separation, but some cases remain challenging. Histopathology is also important in assessing the response to treatment, such as the change in villous architecture caused by a gluten-free diet, or the response to cessation of a potentially causative medication. This review examines the practical role that histopathology of duodenal biopsy specimens plays in the assessment and management of inflammatory malabsorptive processes of the proximal small intestine, with a particular emphasis on coeliac disease.
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Affiliation(s)
- Ian Brown
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Mark Bettington
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Christophe Rosty
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Ruiz Rebollo ML, Corrales Cruz D, Izquierdo Santervás S, Busta Nistal R, Dirá Gil M, Burgueño Gómez B. Chronic diarrhea due to autoimmune enteropathy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:348-351. [PMID: 33256418 DOI: 10.17235/reed.2020.7218/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Chronic diarrhea is a common symptom seen in the Gastroenterology clinic. Occasionally, the diagnosis is a real challenge as there are multiple entities with unremitting diarrhea as a symptom. Herein, we present a patient affected with intractable diarrhea who was transferred to our department. After many laboratory, endoscopy and radiological tests, she was diagnosed with autoimmune enteropathy (AE) and achieved clinical remission with corticosteroids and azathioprine.
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20
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Neuroendocrine Cells Are Commonly Absent in the Intestinal Crypts in Autoimmune Enteropathy. Am J Surg Pathol 2020; 44:1130-1136. [PMID: 32590456 DOI: 10.1097/pas.0000000000001516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The absence of neuroendocrine (NE) cells in the intestinal mucosa in autoimmune enteropathy (AIE) has been occasionally reported. However, the status of NE cells has not been studied in detail in AIE. Small bowel and colonic biopsies were retrospectively retrieved from 18 AIE patients (26 baseline [18 small bowel and 8 colon]; and 15 follow-up [11 duodenum and 4 colon] biopsies in 11 patients). Thirty-three common variable immunodeficiency (CVID) patients (30 small bowel and 16 colon), 15 inflammatory bowel disease patients (5 duodenum and 10 colon), 13 immunoglobulinA deficiency patients (13 duodenum and 5 colon), and 10 normal controls (5 colon and 5 duodenum) were selected as control groups. Histologic features (villous atrophy, intraepithelial lymphocytosis, acute inflammation, crypt apoptosis, and absence or presence of goblet cells, Paneth cells and plasma cells) were recorded. Chromogranin immunostain was performed and chromogranin-positive NE cells were counted per 10 consecutive, well-oriented crypts. On the basis of the number of chromogranin-positive NE cells, cases were graded as being absent (≤3 NE cells), markedly decreased (≤15), and intact (>15). The NE cell status correlated with histologic features. The median age of 18 AIE patients was 38.5 years (range: 11 to 74 y) and 14 patients were male. Fourteen of 18 (78%) patients showed loss (absent or markedly decreased) of NE cells in the small bowel and/or colon in the baseline biopsies including 12 (of 18) small bowel and 6 (of 8) colon biopsies. Follow-up biopsy was available in 11 patients. Six of 7 (85%) patients who showed loss of NE cells in the baseline biopsies regained NE cells in the follow-up biopsies, and 1 patient continued to show loss of NE cells. Four patients who showed intact NE cells in the baseline remained unchanged in the follow-up. Among the control groups, 3 of 33 (9%) CVID patients showed loss of NE cells. NE cells were not lost in the biopsies of all 15 and 13 patients with inflammatory bowel disease and immunoglobulinA deficiency, respectively, or the 10 normal controls. In all 41 biopsies (26 baseline plus 15 follow-up) with AIE, NE cell loss was significantly associated with increased crypt apoptosis and loss of goblet cells (P=0.001, both) but not with other histologic findings. In conclusion, our study suggests that NE cells may also be the target cells in AIE and commonly lost in the intestinal crypts in AIE, and consequently loss of NE cells can be used as an adjunct histologic feature for diagnosis of AIE.
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Affiliation(s)
| | - Jayanta Paul
- Department of Gastroenterology Desun Hospital and Heart Institute Kolkata India
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22
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Russo P. Updates in Pediatric Congenital Enteropathies: Differential Diagnosis, Testing, and Genetics. Surg Pathol Clin 2020; 13:581-600. [PMID: 33183722 DOI: 10.1016/j.path.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Congenital enteropathies comprise a heterogeneous group of disorders typically resulting in severe diarrhea and intestinal failure. Recent advances in and more widespread application of genetic testing have allowed more accurate diagnosis of these entities as well as identification of new disorders, provided a deeper understanding of intestinal pathophysiology through genotype-phenotype correlations, and permitted the exploration of more specific therapies to diseases that have heretofore been resistant to conventional treatments. The therapeutic armamentarium for these disorders now includes intestinal and hematopoietic stem cell transplantation, specific targeted therapy, such as the use of interleukin-1 receptor antagonists and, in some cases, gene therapy. These considerations are particularly applicable to the group of disorders identified as "very-early onset inflammatory bowel disease" (VEO-IBD), for which a veritable explosion of knowledge has occurred in the last decade. The pathologist plays a crucial role in assisting in the diagnosis of these entities and in ruling out other disorders that enter into the differential diagnosis.
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Affiliation(s)
- Pierre Russo
- Department of Pathology and Laboratory Medicine, Division of Anatomic Pathology, The University of Pennsylvania School of Medicine, The Children's Hospital of Philadelphia, 324 South 34th Street, Main Building, Philadelphia, PA 19104, USA.
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Beck A, Schulte L, Möller P. [Autoimmune enteropathy in adults : A rare and difficult but relevant differential diagnosis of chronic diarrhea]. DER PATHOLOGE 2020; 41:230-237. [PMID: 32239324 DOI: 10.1007/s00292-020-00769-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Autoimmune enteropathy (AIE) was originally believed to be a pediatric disease until there were increasing numbers of adult cases reported over the last 20 years. AIE is an autoimmune disease that manifests as severe chronic diarrhea.The histological hallmark is villous atrophy. Histology alone is not sufficiently sensitive and consistent. Four different histological patterns are known. There are many differential diagnoses to be considered relating to both histology and symptoms.We present the case of a young woman with fatal AIE and homozygous germline-mutation of the CLEC7A gene. The course of disease is documented in multiple intestinal biopsies, which show a morphological change over time.Histology and symptoms often resemble celiac disease. In order to recognize this rare disease early in its course there is a need for a special awareness among attending physicians and pathologists.
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Affiliation(s)
- A Beck
- Institut für Pathologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
| | - L Schulte
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Deutschland
| | - P Möller
- Institut für Pathologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
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24
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Moore M, Feakins RM, Lauwers GY. Non-neoplastic colorectal disease biopsies: evaluation and differential diagnosis. J Clin Pathol 2020; 73:783-792. [PMID: 32737191 DOI: 10.1136/jclinpath-2020-206794] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022]
Abstract
A wide variety of non-neoplastic conditions may be encountered on colorectal biopsy encompassing idiopathic, infectious, vascular and immune-mediated aetiologies. Although interpretation of such biopsies may be challenging, appreciation of the dominant pattern of injury and subsequent host response may allow for a more focused histological diagnosis in the correct clinical and endoscopic setting. This article aims to provide a systematic, methodical approach to the assessment of such biopsies, concentrating mainly on diagnoses other than inflammatory bowel disease.
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Affiliation(s)
- Michelle Moore
- Department of Cellular Pathology, Belfast Health and Social Care Trust, Belfast, UK
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Martín-Lagos Maldonado A, García-Consuegra Ruiz-Aragón F, Herrera Mercader MDC. Atrophic enteropathy refractory to a gluten-free diet: what should we consider? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:328-329. [PMID: 32054274 DOI: 10.17235/reed.2020.6361/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Olmesartan is an angiotensin II receptor antagonist used for the treatment of blood hypertension. Long-term use has been associated with diarrhea and sometimes intestinal involvement may mimic enteropathies such as celiac disease. Clinicians should consider drugs within the differential diagnosis of enteropathies. We report the case of a female who sought medical help for malabsorptive symptoms and was finally diagnosed with olmesartan-associated gastritis and atrophic enteropathy.
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Villanacci V, Lougaris V, Ravelli A, Buscarini E, Salviato T, Lionetti P, Salemme M, Martelossi S, De Giacomo C, Falchetti D, Pelizzo G, Bassotti G. Clinical manifestations and gastrointestinal pathology in 40 patients with autoimmune enteropathy. Clin Immunol 2019; 207:10-17. [PMID: 31279857 DOI: 10.1016/j.clim.2019.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/29/2022]
Abstract
Autoimmune enteropathy (AIE) is a rare condition that may affect pediatric and adult patients, frequently associated with primary immunodeficiencies. We performed a retrospective study on clinical and histological findings from 40 AIE patients. Histological presentation showed a prevalent celiac disease pattern (50%), followed by the mixed pattern (35%), independently of age, chronic active duodenitis (10%), and GVHD-like pattern (5%). Patients with primary immunodeficiencies (24/40) presented mainly with the celiac disease pattern (72.2% versus 22.2%; p < .0001), while patients without primary immunodeficiencies presented with a mixed histological pattern (61.1% versus 13.6%; p < .0001). Our study shows that the prevalent histological presentation is the celiac disease-like pattern, independently of age, and, for the first time, that the histological presentation of AIE differs significantly between patients with and without primary immunodeficiencies. These findings may be helpful for more precise and timely diagnosis and management of this rare disorder.
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Affiliation(s)
| | - Vassilios Lougaris
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia and ASST-Spedali Civili of Brescia, Italy.
| | - Alberto Ravelli
- Gastroenterology and GI Endoscopy Unit, University Department of Pediatrics, Children's Hospital, Brescia, Italy
| | - Elisabetta Buscarini
- Gastroenterology and Endoscopy Department, Maggiore Hospital, ASST Crema, Crema, Italy
| | - Tiziana Salviato
- Pathology Institute, Azienda Ospedaliera Universitaria, Ospedali Riuniti di Trieste, Italy
| | | | | | - Stefano Martelossi
- Marenal and Infantile Department of Pediatrics, Ospedale Ca' Foncello, Treviso, Italy
| | - Costantino De Giacomo
- Maternal and Infantile Department of Pediatrics ASST Grande Ospedale Metropolitano Niguarda Milano, Italy
| | - Diego Falchetti
- Pediatric Surgery, Maternal and Infantile Department ASST Grande Ospedale Metropolitano Niguarda Milano, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, Children's Hospital G. Di Cristina, ARNAS Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
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Consideration of Maternal Anti-enterocyte IgA Transfer With Resulting Infantile Alloimmune Enteropathy. ACG Case Rep J 2019; 6:e00093. [PMID: 31616766 PMCID: PMC6722333 DOI: 10.14309/crj.0000000000000093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 03/26/2019] [Indexed: 11/21/2022] Open
Abstract
Autoimmune enteropathy is a rare cause of infantile diarrhea. Cases typically involve infants with a protracted course of diarrhea found to have underlying autoimmune disease or immune dysfunction, leading to chronic intestinal inflammation. We describe a case of immune-mediated enteropathy in an infant with no identifiable autoimmune disease. The patient was exclusively breastfed by his mother who had Crohn's disease, and he was found to have circulating anti-enterocyte immunoglobulin A (IgA) antibody. There was no circulating anti-enterocyte immunoglobulin G or immunoglobulin M. The patient's disease and symptoms resolved with cessation of breastfeeding, and no immunomodulatory medications have been needed in 20 months of follow-up. The case raises suspicion for alloimmune disease, and it is hypothesized that intestinal injury was mediated by maternally transmitted anti-enterocyte IgA antibody.
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Bläker H. [Gastrointestinal tract diseases induced by medications]. DER PATHOLOGE 2018; 39:571-575. [PMID: 30171343 DOI: 10.1007/s00292-018-0478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Gastrointestinal symptoms are common side effects of medical drugs. They are usually mild but sometimes require diagnostic endoscopy and histologic evaluation. Due to the rapidly increasing number of drugs developed especially for cancer treatment, pathologists are faced with a spectrum of different drug-associated histologies in all segments of the gastrointestinal tract. Some medication-induced mucosal damage features may mimic classical pathologies of nondrug-associated diseases, while others result in novel phenotypes. The present article focusses on the histologic presentations of gastrointestinal diseases induced by medications that either compromise or induce immune response.
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Affiliation(s)
- H Bläker
- Pathologisches Institut, Charité Universitätsmedizin, Chariteplatz 1, 10117, Berlin, Deutschland.
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Slavik T, Potgieter FM, Brittain D. Thymoma-associated multiorgan autoimmunity with exclusive gastrointestinal tract involvement: case report and review of the literature. Virchows Arch 2018; 473:121-125. [PMID: 29374317 DOI: 10.1007/s00428-018-2304-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/13/2018] [Accepted: 01/18/2018] [Indexed: 12/25/2022]
Abstract
Thymoma-associated multiorgan autoimmunity (TAMA) is a recently delineated and rare paraneoplastic syndrome reported in patients with thymoma. The disorder is characterized by graft-versus-host disease-like pathology affecting the skin, gastrointestinal tract (GIT), and liver, and is usually associated with a poor outcome. We document a case of TAMA with exclusive GIT involvement which included the stomach, small and large bowel, presenting in a 66-year-old male patient 5 years after complete resection of a type B2 thymoma. A brief review is provided of this scarce syndrome, the GIT pathology described in the 21 TAMA cases reported to date, and the unique characteristics of patients with exclusive GIT involvement by this acquired autoimmune disorder.
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Affiliation(s)
- Tomas Slavik
- Department of Anatomical Pathology, Ampath Pathology Laboratories, Pretoria, South Africa. .,University of Pretoria, Pretoria, South Africa.
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