1
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Carroll D, Kavalukas S. Management of Complications in Crohn's Disease. Adv Surg 2024; 58:19-34. [PMID: 39089776 DOI: 10.1016/j.yasu.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Complications of Crohn's disease reach far beyond postsurgical leak, infection, and enterocutaneous fistula. Malnutrition, intestinal failure, and recurrent disease all will require ongoing attentions. The management of these patients may further be complicated by the need for chronic immunosuppression. The underlying principles continue to include optimization of nutritional status, and preservation of bowel length when possible. However, there have been several recent advances in both the medical and surgical management of the disease. Understanding the contribution of the mesentery to inflammation, new surgical techniques such as the Kono-S anastomosis and extended mesenteric resection is decreasing the need for repeated resections.
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Affiliation(s)
- Dylan Carroll
- Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40292, USA
| | - Sandy Kavalukas
- Colorectal Surgery, Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40292, USA.
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2
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Prieto Jimenez PM, Tabib S, Abbott B, Melmed G. Successful Outcome Treating Pyoderma Gangrenosum and Pouchitis With Upadacitinib. ACG Case Rep J 2024; 11:e01442. [PMID: 39139848 PMCID: PMC11319309 DOI: 10.14309/crj.0000000000001442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/07/2024] [Indexed: 08/15/2024] Open
Affiliation(s)
| | | | | | - Gil Melmed
- Cedars Sinai IBD Medical Center, New York, NY
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3
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Afarideh M, Bartoletta K, Tollefson MM. Dermatologic manifestations in pediatric patients with inflammatory bowel disease. Pediatr Dermatol 2024; 41:234-242. [PMID: 38326222 DOI: 10.1111/pde.15538] [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: 10/11/2023] [Accepted: 01/07/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Despite studies of dermatologic manifestations in adults with inflammatory bowel disease (IBD), little is known about the prevalence of IBD-associated skin lesions and their correlation with IBD severity in children. We aimed to address these knowledge gaps in our single-center cohort of children with IBD. METHODS Retrospective chart review of 528 children and adolescents (≤18 years old) with IBD and seen at Mayo Clinic (Rochester, MN) between 1999 and 2017 was conducted. The Chi-Square/Fischer's exact test (with p ≤ .05 to signify statistical significance) was applied to compare categorical outcomes between Crohn's disease (CD) and ulcerative colitis (UC) patients. RESULTS In total, 425 IBD patients (64.9% CD, 53% males) and ≥1 dermatologic diagnosis were included. Presence of ≥1 cutaneous infection was recorded in 42.8% of participants. Acne was the most common non-infectious dermatologic condition (30.8%), followed by eczema (15.8%) and perianal skin tags (14.6%). Angular cheilitis (p = .024), keratosis pilaris (KP, p = .003), and perianal skin complications (i.e., skin tags, fistula, and abscesses; all p < .001) were more frequently diagnosed among children with CD, while fungal skin infections (p = .017) were more frequently diagnosed in UC patients. Severity of IBD correlated with higher prevalence of perianal fistula (p = .003), perianal abscess (p = .041), psoriasis (p < .001), and pyoderma gangrenosum (PG, p = .003). CONCLUSIONS Both IBD-specific and IBD-nonspecific dermatologic conditions are very prevalent in childhood IBD, the most common being infectious. Children with CD are more likely to experience angular cheilitis, KP, and perianal skin findings than those with UC. Perianal disease, psoriasis, and PG are associated with more severe IBD.
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Affiliation(s)
- Mohsen Afarideh
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine Bartoletta
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megha M Tollefson
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
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4
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Gordon H, Burisch J, Ellul P, Karmiris K, Katsanos K, Allocca M, Bamias G, Barreiro-de Acosta M, Braithwaite T, Greuter T, Harwood C, Juillerat P, Lobaton T, Müller-Ladner U, Noor N, Pellino G, Savarino E, Schramm C, Soriano A, Michael Stein J, Uzzan M, van Rheenen PF, Vavricka SR, Vecchi M, Zuily S, Kucharzik T. ECCO Guidelines on Extraintestinal Manifestations in Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:1-37. [PMID: 37351850 DOI: 10.1093/ecco-jcc/jjad108] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, London, Centre for Immunobiology, Blizard Institute, Faculty of Medicine, Barts & The London Medical School, Queen Mary University of London, UK
| | - Johan Burisch
- Gastrounit, medical division, Hvidovre Hospital, University of Copenhagen, Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgos Bamias
- GI Unit, 3rd Academic Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Manuel Barreiro-de Acosta
- University Hospital Santiago De Compostela CHUS, Department of Gastroenterology - IBD Unit, Santiago De Compostela, Spain
| | - Tasanee Braithwaite
- School of Immunology and Microbiology, King's College London, The Medical Eye Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, GZO - Zurich Regional Health Center, Wetzikon, Division of Gastroenterology and Hepatology, University Hospital Lausanne - CHUV, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland; Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent; Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus Liebig University Giessen, Bad Nauheim, Germany
| | - Nurulamin Noor
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gianluca Pellino
- Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Christoph Schramm
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Soriano
- Gastroenterology Division and IBD Center, Internal Medicine Department, Azienda Unità Sanitaria Locale - IRCCS, 42122 Reggio Emilia, Italy
| | - Jürgen Michael Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt/Main, Germany
| | - Mathieu Uzzan
- Department of Gastroenterology, Hôpital Henri Mondor, APHP, Créteil, France
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
| | - Maurizio Vecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stephane Zuily
- Vascular Medicine Division and French Referral Center for Rare Auto-Immune Diseases, Université de Lorraine, INSERM, DCAC and CHRU-Nancy, Nancy, France
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Münster, Lüneburg, Germany
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5
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Tie Y, Huang Y, Chen R, Li L, Chen M, Zhang S. Current insights on the roles of gut microbiota in inflammatory bowel disease-associated extra-intestinal manifestations: pathophysiology and therapeutic targets. Gut Microbes 2023; 15:2265028. [PMID: 37822139 PMCID: PMC10572083 DOI: 10.1080/19490976.2023.2265028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic, recurrent inflammatory disease of the gastrointestinal tract. In addition to digestive symptoms, patients with IBD may also develop extra-intestinal manifestations (EIMs), the etiology of which remains undefined. The gut microbiota has been reported to exert a critical role in the pathogenesis of IBD, with a similar pattern of gut dysbiosis observed between patients with IBD and those with EIMs. Therefore, it is hypothesized that the gut microbiota is also involved in the pathogenesis of EIMs. The potential mechanisms are presented in this review, including: 1) impaired gut barrier: dysbiosis induces pore formation in the intestinal epithelium, and activates pattern recognition receptors to promote local inflammation; 2) microbial translocation: intestinal pathogens, antigens, and toxins translocate via the impaired gut barrier into extra-intestinal sites; 3) molecular mimicry: certain microbial antigens share similar epitopes with self-antigens, inducing inflammatory responses targeting extra-intestinal tissues; 4) microbiota-related metabolites: dysbiosis results in the dysregulation of microbiota-related metabolites, which could modulate the differentiation of lymphocytes and cytokine production; 5) immunocytes and cytokines: immunocytes are over-activated and pro-inflammatory cytokines are excessively released. Additionally, we summarize microbiota-related therapies, including probiotics, prebiotics, postbiotics, antibiotics, and fecal microbiota transplantation, to promote better clinical management of IBD-associated EIMs.
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Affiliation(s)
- Yizhe Tie
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yongle Huang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Clinical Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Rirong Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenghong Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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6
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Tanida S, Kubo R, Yoshii S, Takahama T, Sasoh S, Kubota Y, Ban T, Ando T, Nakamura M, Joh T. Upadacitinib Plus Intensive Granulocyte and Monocyte Adsorptive Apheresis for Ulcerative Colitis Achieved Ulcer Healing for Pyoderma Gangrenosum. J Clin Med Res 2023; 15:446-455. [PMID: 38189038 PMCID: PMC10769604 DOI: 10.14740/jocmr5005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/13/2023] [Indexed: 01/09/2024] Open
Abstract
A 44-year-old woman who had been diagnosed with ulcerative colitis (UC) at 22 years old was diagnosed with severe flare-up of UC based on endoscopic findings associated with new-onset active pyoderma gangrenosum (PG) on both lower legs after she decided to discontinue UC treatment. Systemic treatment with intravenous prednisolone at 30 mg/day had achieved insufficient response to UC and PG, resulting in a diagnosis of corticosteroid-refractory UC and PG. Combination therapy with upadacitinib at 45 mg/day plus intensive granulocyte and monocyte adsorptive apheresis (GMA) was started to achieve clinical remission of UC. Ten weeks after starting this combination therapy, clinical improvement of UC was achieved with PG ulcer healing on both lower legs. A combination of upadacitinib plus intensive GMA may offer an effective therapeutic option for patients with active PG in addition to UC but has yet to be approved for induction or maintenance treatment of PG worldwide. PG is a dermatological involvement in UC patients that requires attention.
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Affiliation(s)
- Satoshi Tanida
- Education and Research Center for Community Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Ryoji Kubo
- Division of Dermatology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Shoichiro Yoshii
- Division of Dermatology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Takuya Takahama
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Shun Sasoh
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Yoshimasa Kubota
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Tesshin Ban
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Tomoaki Ando
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Makoto Nakamura
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
| | - Takashi Joh
- Division of Gastroenterology, Gamagori City Hospital, Hirata, Gamagori, Aichi 443-8501, Japan
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7
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Kwon IJ, Park JW, Park S, Lim H, Yu J, Oh SH. Ulcerative Colitis Diagnosed through Evaluation of Underlying Diseases in a Pyoderma Gangrenosum Adolescent without Gastrointestinal Symptoms. Ann Dermatol 2023; 35:S292-S295. [PMID: 38061724 PMCID: PMC10727860 DOI: 10.5021/ad.22.101] [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: 04/18/2022] [Revised: 05/04/2022] [Accepted: 05/26/2022] [Indexed: 12/20/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, non-infectious, neutrophilic dermatosis characterized by painful ulcers with indistinct borders and peripheral erythema. The diagnosis of PG requires the exclusion of other causes of similar appearing skin manifestations, including vasculitis and infections. The pathogenesis of PG is not clear; however, dysregulation of the immune system has been suggested in previous studies. More than half of the PG patients have underlying diseases; the most common being inflammatory bowel disease (IBD). The progression of PG in IBD patients is seen after the onset of IBD, usually during its exacerbation. On the other hand, PG may follow a course independent of the intestinal disease. We present a case of an 18-year-old young male with PG that presented before being diagnosed with ulcerative colitis as an associated condition. He had a painful ulcerative lesion on his right shin with no previous gastrointestinal symptoms. This case suggests that investigating for underlying disorders is essential in PG patients despite the lack of symptoms other than the skin lesions.
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Affiliation(s)
- Il Joo Kwon
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sowon Park
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Severance Pediatric IBD Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeji Lim
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Severance Pediatric IBD Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeeun Yu
- Dr.Yu's Pediatric and Adolescence Medicine, Osan, Korea
| | - Sang Ho Oh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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8
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He R, Zhao S, Cui M, Chen Y, Ma J, Li J, Wang X. Cutaneous manifestations of inflammatory bowel disease: basic characteristics, therapy, and potential pathophysiological associations. Front Immunol 2023; 14:1234535. [PMID: 37954590 PMCID: PMC10637386 DOI: 10.3389/fimmu.2023.1234535] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disease typically involving the gastrointestinal tract but not limited to it. IBD can be subdivided into Crohn's disease (CD) and ulcerative colitis (UC). Extraintestinal manifestations (EIMs) are observed in up to 47% of patients with IBD, with the most frequent reports of cutaneous manifestations. Among these, pyoderma gangrenosum (PG) and erythema nodosum (EN) are the two most common skin manifestations in IBD, and both are immune-related inflammatory skin diseases. The presence of cutaneous EIMs may either be concordant with intestinal disease activity or have an independent course. Despite some progress in research on EIMs, for instance, ectopic expression of gut-specific mucosal address cell adhesion molecule-1 (MAdCAM-1) and chemokine CCL25 on the vascular endothelium of the portal tract have been demonstrated in IBD-related primary sclerosing cholangitis (PSC), little is understood about the potential pathophysiological associations between IBD and cutaneous EIMs. Whether cutaneous EIMs are inflammatory events with a commonly shared genetic background or environmental risk factors with IBD but independent of IBD or are the result of an extraintestinal extension of intestinal inflammation, remains unclear. The review aims to provide an overview of the two most representative cutaneous manifestations of IBD, describe IBD's epidemiology, clinical characteristics, and histology, and discuss the immunopathophysiology and existing treatment strategies with biologic agents, with a focus on the potential pathophysiological associations between IBD and cutaneous EIMs.
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Affiliation(s)
- Ronghua He
- Department of Gastroenterology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Subei Zhao
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingyu Cui
- Department of Gastroenterology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Yanhao Chen
- Department of Gastroenterology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Jinrong Ma
- Department of Gastroenterology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Jintao Li
- Department of Gastroenterology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Xiaodong Wang
- Department of Gastroenterology, The Second Hospital of Jilin University, Changchun, Jilin, China
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9
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Jatana S, Ponti AK, Johnson EE, Rebert NA, Smith JL, Fulmer CG, Maytin EV, Achkar JP, Fernandez AP, McDonald C. A novel murine model of pyoderma gangrenosum reveals that inflammatory skin-gut crosstalk is mediated by IL-1β-primed neutrophils. Front Immunol 2023; 14:1148893. [PMID: 37475852 PMCID: PMC10354730 DOI: 10.3389/fimmu.2023.1148893] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/08/2023] [Indexed: 07/22/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a debilitating skin condition often accompanied by inflammatory bowel disease (IBD). Strikingly, ~40% of patients that present with PG have underlying IBD, suggesting shared but unknown mechanisms of pathogenesis. Impeding the development of effective treatments for PG is the absence of an animal model that exhibits features of both skin and gut manifestations. This study describes the development of the first experimental drug-induced mouse model of PG with concomitant intestinal inflammation. Topical application of pyrimidine synthesis inhibitors on wounded mouse skin generates skin ulcers enriched in neutrophil extracellular traps (NETs) as well as pro-inflammatory cellular and soluble mediators mimicking human PG. The mice also develop spontaneous intestinal inflammation demonstrated by histologic damage. Further investigations revealed increased circulating low density IL-1β primed neutrophils that undergo enhanced NETosis at inflamed tissue sites supported by an increase in circulatory citrullinated histone 3, a marker of aberrant NET formation. Granulocyte depletion dampens the intestinal inflammation in this model, further supporting the notion that granulocytes contribute to the skin-gut crosstalk in PG mice. We anticipate that this novel murine PG model will enable researchers to probe common disease mechanisms and identify more effective targets for treatment for PG patients with IBD.
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Affiliation(s)
- Samreen Jatana
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - András K. Ponti
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Erin E. Johnson
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Biology, John Carroll University, University Heights, OH, United States
| | - Nancy A. Rebert
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Jordyn L. Smith
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Clifton G. Fulmer
- Department of Pathology, Pathology & Laboratory Medicine, Cleveland Clinic, Cleveland, OH, United States
| | - Edward V. Maytin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Dermatology, Dermatology & Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Jean-Paul Achkar
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Anthony P. Fernandez
- Department of Pathology, Pathology & Laboratory Medicine, Cleveland Clinic, Cleveland, OH, United States
- Department of Dermatology, Dermatology & Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Christine McDonald
- Department of Inflammation & Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States
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10
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Macleod T, Bridgewood C, McGonagle D. Role of neutrophil interleukin-23 in spondyloarthropathy spectrum disorders. THE LANCET. RHEUMATOLOGY 2023; 5:e47-e57. [PMID: 38251507 DOI: 10.1016/s2665-9913(22)00334-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 12/24/2022]
Abstract
Neutrophilic inflammation is a pervasive characteristic common to spondyloarthropathies and related disorders. This inflammation manifests as Munro's microabscesses of the skin and osteoarticular neutrophilic inflammation in patients with psoriatic arthritis, intestinal crypt abscesses in patients with inflammatory bowel disease, ocular hypopyon in anterior uveitis, and neutrophilic macroscopic and microscopic inflammation in patients with Behçet's disease. Strong MHC class I associations are seen in these diseases, which represent so-called MHC-I-opathies, and these associations indicate an involvement of CD8 T-cell immunopathology that is not yet well understood. In this Personal View, we highlight emerging data suggesting that the T-cell-neutrophil axis involves both a T-cell-mediated and interleukin (IL)-17-mediated (type 17) recruitment and activation of neutrophils, and also a sequestration of activated neutrophils at disease sites that might directly amplify type 17 T-cell responses. This amplification likely involves neutrophilic production of IL-23 and proteases as well as other feedback mechanisms that could be regulated by local microbiota, pathogens, or tissue damage. This crosstalk between innate and adaptive immunity offers a novel explanation for how bacterial and fungal microbes at barrier sites could innately control type 17 T-cell development, with the aim of restoring tissue homoeostasis, and could potentially explain features of clinical disease and treatment response, such as the fast-onset action of the IL-23 pathway blockade in certain patients. This axis could be crucial to understanding non-response to IL-23 inhibitors among patients with ankylosing spondylitis, as the axial skeleton is a site rich in neutrophils and a site of haematopoiesis with myelopoiesis in adults.
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Affiliation(s)
- Tom Macleod
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Charles Bridgewood
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals, Leeds, UK.
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11
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Kim YC, Shim HS, Jeong H, Park YJ. Pyoderma Gangrenosum Triggered by COVID-19 Vaccination in a Patient with Ulcerative Colitis: A Case Report. INT J LOW EXTR WOUND 2022:15347346221141173. [PMID: 36426538 PMCID: PMC9713538 DOI: 10.1177/15347346221141173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory skin disease that is difficult to diagnose. PG may be an extra-intestinal manifestation of ulcerative colitis (UC). In recent times, coronavirus disease (COVID-19) vaccines have caused various adverse cutaneous reactions. However, to the best our knowledge, combinations thereof have not been reported. We encountered a case of PG triggered by COVID-19 vaccination in a patient with UC. A 40-year-old woman developed severe pain and an abscess in the dorsum of the left foot after receiving the first dose of the messenger RNA (mRNA)-based Pfizer/BioNTech BNT162b2 COVID-19 vaccine. Severe painful ulcers with purulent necrosis and gaseous gangrene progressed rapidly along the extensor tendons and muscles to the toes and ankle. Although surgical debridement can worsen PG by triggering pathergy, we nonetheless performed wide debridement including partial extensor tenotomy with abscess drainage to prevent progression to pyogenic ankle arthritis and to rescue the toes. Antibiotics, corticosteroids, and anticoagulants were prescribed during surgical wound management via negative pressure therapy. After the lesion improved, the skin and soft tissue defect were covered using a superficial circumflex iliac artery perforator free flap and a split-thickness skin graft. The patient was satisfied with the foot salvage, and could walk unaided (without a brace or cane) from 8 weeks after the final surgery. PG may be rare even in UC patients, but mRNA-based COVID-19 vaccines may find an immunosuppressive niche. A high level of caution and suspicion of skin manifestations after vaccination is essential.
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Affiliation(s)
- Yoon-Chung Kim
- Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung Sup Shim
- Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Howon Jeong
- Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yune-Jung Park
- Division of Rheumatology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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12
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Martinelli VF, Martinelli Barbosa P, Dantas de Oliveira LS, de Melo LDALV, Casa Nova JM, de Brito CAA. Atypical Forms of Pyoderma Gangrenosum in Inflammatory Bowel Disease: Report of Four Cases and Literature Review. Int Med Case Rep J 2022; 15:449-456. [PMID: 36051090 PMCID: PMC9427006 DOI: 10.2147/imcrj.s376915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition. Case Presentation Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab. Conclusion PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.
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Affiliation(s)
- Valéria Ferreira Martinelli
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
| | - Pedro Martinelli Barbosa
- Department of Internal Medicine, Medical Sciences Center, Pernambucana of Health College, Recife, Pernambuco, Brazil
| | | | | | - João Manoel Casa Nova
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Carlos Alexandre Antunes de Brito
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Pernambuco, Brazil
- Department of Immunology, Autoimune Research Institute, Recife, Pernambuco, Brazil
- Correspondence: Carlos Alexandre Antunes de Brito, Department of Immunology, Autoimune Research Institute, Avenue Rui Barbosa 715, Recife, Pernambuco, 52011-040, Brazil, Tel +55 81 31480101, Email
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13
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Jena A, Sachan A, Singh AK, Sharma V. Multifocal Pyoderma Gangrenosum at Presentation in a Patient With Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2022; 28:e84-e85. [PMID: 34893838 DOI: 10.1093/ibd/izab309] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anurag Sachan
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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14
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Falloon K, Cohen B, Ananthakrishnan AN, Barnes EL, Bhattacharya A, Colombel JF, Cross RK, Driscoll MS, Fernandez AP, Ha C, Herfarth H, Horst S, Hou J, Husni ME, Kroshinsky D, Kuhn KA, Lowder CY, Martin G, Parikh D, Sayed CJ, Schocket L, Siaton BC, Vedak P, Weisman MH, Rieder F. A United States expert consensus to standardise definitions, follow-up, and treatment targets for extra-intestinal manifestations in inflammatory bowel disease. Aliment Pharmacol Ther 2022; 55:1179-1191. [PMID: 35277863 PMCID: PMC10022869 DOI: 10.1111/apt.16853] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIMS Extra-intestinal manifestations (EIMs) are a common complication of inflammatory bowel diseases (IBD), affecting up to half of the patients. Despite their high prevalence, information on standardised definitions, diagnostic strategies, and treatment targets is limited. METHODS As a starting point for a national EIM study network, an interdisciplinary expert panel of 12 gastroenterologists, 4 rheumatologists, 3 ophthalmologists, 6 dermatologists, and 4 patient representatives was assembled. Modified Delphi consensus methodology was used. Fifty-four candidate items were derived from the literature review and expert opinion focusing on five major EIMs (erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis) were rated in three voting rounds. RESULTS For use in a clinical practice setting and as part of the creation of a prospective registry of patients with EIMs, the panel developed definitions for erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis; identified the appropriate and optimal subspecialists to diagnose and manage each; provided methods to monitor disease course; offered guidance regarding monitoring intervals; and defined resolution and recurrence. CONCLUSIONS Consensus criteria for appropriate and optimal means of diagnosing and monitoring five EIMs have been developed as a starting point to inform clinical practice and future trial design. Key findings include straightforward diagnostic criteria, guidance regarding who can appropriately and optimally diagnose each, and monitoring options that include patient and physician-reported outcomes. These findings will be used in a national multicenter study network to optimise the management of EIMs.
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Affiliation(s)
- Katherine Falloon
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin Cohen
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Raymond K. Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Christina Ha
- Department of Gastroenterology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Hans Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Sara Horst
- Department of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason Hou
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center & Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - M. Elaine Husni
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Kristine A. Kuhn
- Department of Medicine, Division of Rheumatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Careen Y. Lowder
- Cleveland Clinic Foundation Cole Eye Institute, Cleveland, OH, USA
| | - George Martin
- Dr. George Martin Dermatology Associates, Kihei, HI, USA
| | - Deep Parikh
- Department of Ophthalmology New York Eye and Ear Infirmary of Mount Sinai, Department of Ophthalmology, New York University Langone Health, New York, NY, USA
| | | | - Lisa Schocket
- Department of Ophthalmology, University of Maryland, Baltimore, MD, USA
| | - Bernadette C. Siaton
- Division of Rheumatology and Clinical Immunology, University of Maryland, Baltimore, MD, USA
| | - Priyanka Vedak
- Department of Dermatology, University of North Carolina, Chapel Hill, NC, USA
| | - Michael H. Weisman
- Department of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Florian Rieder
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
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15
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Pagani K, Lukac D, Bhukhan A, McGee JS. Cutaneous Manifestations of Inflammatory Bowel Disease: A Basic Overview. Am J Clin Dermatol 2022; 23:481-497. [PMID: 35441942 DOI: 10.1007/s40257-022-00689-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2022] [Indexed: 11/30/2022]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal (GI) tract that is subdivided into Crohn's disease (CD) and ulcerative colitis (UC). CD is characterized by involvement of the entire GI tract, while UC mainly affects the distal GI tract. Moreover, both CD and UC can present with extraintestinal manifestations (EIMs) of the disease affecting multiple organ systems including the hepatobiliary tract, kidney, bones, eyes, joints, and skin. These complications can cause significant morbidity and negatively impact the quality of life for IBD patients. Although the pathogenesis of EIMs is not clearly elucidated, it is postulated that the diseased GI mucosa similarly stimulates excess immune responses at the extraintestinal sites. Cutaneous EIMs occur in up to 15% of patients with IBD, often predating their IBD diagnosis. They are categorized into (1) specific, (2) reactive, (3) associated, and (4) treatment-induced. Here, we review the epidemiological, clinical, diagnostic, and histologic features of the most commonly described cutaneous EIMs of IBD along with their respective treatment options.
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Affiliation(s)
- Kyla Pagani
- Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Danitza Lukac
- Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aashni Bhukhan
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Ft. Lauderdale, FL, USA
| | - Jean S McGee
- Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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16
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Hadji H, Bouchemal K. Advances in the treatment of inflammatory bowel disease: Focus on polysaccharide nanoparticulate drug delivery systems. Adv Drug Deliv Rev 2022; 181:114101. [PMID: 34999122 DOI: 10.1016/j.addr.2021.114101] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 02/07/2023]
Abstract
The complex pathogenesis of inflammatory bowel disease (IBD) explains the several hurdles for finding an efficient approach to cure it. Nowadays, therapeutic protocols aim to reduce inflammation during the hot phase or maintain remission during the cold phase. Nonetheless, these drugs suffer from severe side effects or poor efficacy due to low bioavailability in the inflamed region of the intestinal tract. New protocols based on antibodies that target proinflammatory cytokines are clinically relevant. However, besides being expensive, their use is associated with a primary nonresponse or a loss of response following a long administration period. Accordingly, many researchers exploited the physiological changes of the mucosal barrier for designing nanoparticulate drug delivery systems to target inflamed tissues. Others exploited biocompatibility and relative affordability of polysaccharides to test their intrinsic anti-inflammatory and healing properties in IBD models. This critical review updates state of the art on advances in IBD treatment. Data on using polysaccharide nanoparticulate drug delivery systems for IBD treatment are reviewed and discussed.
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Affiliation(s)
- Hicheme Hadji
- Institut Galien Paris Saclay, CNRS UMR 8612, Université Paris-Saclay, Faculté de Pharmacie, 5 rue J-B Clément, 92296 Châtenay-Malabry, France
| | - Kawthar Bouchemal
- Institut Galien Paris Saclay, CNRS UMR 8612, Université Paris-Saclay, Faculté de Pharmacie, 5 rue J-B Clément, 92296 Châtenay-Malabry, France.
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17
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Sawayama H, Miyamoto Y, Yoshida N, Baba H. Essential updates 2020/2021: Colorectal diseases (benign)—Current topics in the surgical and medical treatment of benign colorectal diseases. Ann Gastroenterol Surg 2022; 6:321-335. [PMID: 35634190 PMCID: PMC9130914 DOI: 10.1002/ags3.12548] [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: 10/31/2021] [Accepted: 12/27/2021] [Indexed: 11/23/2022] Open
Abstract
The development of new drugs for inflammatory bowel disease (IBD) is remarkable, and treatment strategies using multiple agents and various techniques are required; however, the treatment strategy is likely to be complex. Therefore, appropriate evaluation of traditional surgical treatment strategies and accurate knowledge of the efficacy and limitations of novel treatments are required. Total infectious complications were found to be associated with the use of corticosteroids and anti‐tumor necrosis factor‐α agents, but not with immunomodulators, anti‐integrin agents, and 5‐aminosalicylic acid. Regarding surgical procedures for IBD, conceived anastomosis methods, including Kono‐S for Crohn's disease stenosis, are associated with better outcomes than conventional techniques. Autologous cell transplantation for Crohn's fistulae has been shown to have a favorable outcome. Diverticulitis is increasing and will be treated more frequently in the future. Risk factors for the incidence of diverticulitis and differences in pathogenesis according to right or left side diverticulitis have been reported. Antibiotic therapy may be omitted for uncomplicated diverticulitis. Moreover, regarding surgical procedures, both bowel resection and anastomosis are associated with favorable short‐term outcomes, higher stoma closure rate, and superior medical economy compared to Hartmann's procedure. Risk factors for recurrence after diverticulitis surgery may provide better postoperative follow‐up. In this review, we explore the current topics of colorectal benign diseases, focusing on IBD and diverticulitis, based on clinical trials and meta‐analyses from 2020‐2021. This review consolidates the available knowledge and improves the quality of surgical procedures and perioperative management for IBD and diverticulitis.
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Affiliation(s)
- Hiroshi Sawayama
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
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18
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Laupland KB, Shekar K, Tabah A, Clement P, Edwards F, Ramanan M. Excess Burden of Critical Illness Related to Inflammatory Bowel Disease. Intern Med J 2021; 53:812-818. [PMID: 34932276 DOI: 10.1111/imj.15672] [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: 08/31/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although inflammatory bowel disease (IBD) is associated with major morbidity and mortality, few studies have evaluated its associated burden of critical illness. AIMS We sought to examine the epidemiology and outcome of ICU admission among patients with IBD in north Brisbane, Australia. METHODS A population-based cohort design was utilized. All admissions to ICUs serving the Metro North Hospital and Health Service among adult residents during 2017-2019 were included. Data were obtained from ICU clinical information systems with linkages to statewide admissions and death registries. RESULTS Among 9,011 ICU admissions, 101 (1.1%) were among patients with IBD of which 57 (0.6%) and 44 (0.5%) had UC and CD, respectively. The incidence of ICU admission was 379, 1,336, 1,514, and 1,429 per 100,000 annually among those without IBD, CD, UC and IBD, respectively. Patients with IBD were at excess risk for admission across all age groups with women at highest risk under age 50 and men thereafter. The all cause 90-day case-fatality rates following ICU admission were not significantly different among patient groups and were 18%, 12%, 15%, and 12% for CD, UC, IBD, and non-IBD, respectively. However, as compared to non-IBD patients, those with CD (151.8 vs. 39.4 per 100,000; RR 3.85; 95% CI, 1.25-9.02; p=0.013); UC (159.4 vs 39.4 per 100,000; RR 4.05; 95% CI, 1.48-8.84; p=0.005), and IBD 155.6 vs 39.4 per 100,000; RR 3.95; 95% CI, 1.96-7.10; p=0.002) were at significantly higher risk for mortality. CONCLUSIONS Patients with IBD suffer a major burden of critical illness. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia
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19
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Rogler G, Singh A, Kavanaugh A, Rubin DT. Extraintestinal Manifestations of Inflammatory Bowel Disease: Current Concepts, Treatment, and Implications for Disease Management. Gastroenterology 2021; 161:1118-1132. [PMID: 34358489 PMCID: PMC8564770 DOI: 10.1053/j.gastro.2021.07.042] [Citation(s) in RCA: 289] [Impact Index Per Article: 96.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel diseases (IBDs) are systemic diseases that manifest not only in the gut and gastrointestinal tract, but also in the extraintestinal organs in many patients. The quality of life for patients with IBD can be substantially affected by these extraintestinal manifestations (EIMs). It is important to have knowledge of the prevalence, pathophysiology, and clinical presentation of EIMs in order to adapt therapeutic options to cover all aspects of IBD. EIMs can occur in up to 24% of patients with IBD before the onset of intestinal symptoms, and need to be recognized to initiate appropriate diagnostic procedures. EIMs most frequently affect joints, skin, or eyes, but can also affect other organs, such as the liver, lung, and pancreas. It is a frequent misconception that a successful therapy of the intestinal inflammation will be sufficient to treat EIMs satisfactorily in most patients with IBD. In general, peripheral arthritis, oral aphthous ulcers, episcleritis, or erythema nodosum can be associated with active intestinal inflammation and can improve on standard treatment of the intestinal inflammation. However, anterior uveitis, ankylosing spondylitis, and primary sclerosing cholangitis usually occur independent of disease flares. This review provides a comprehensive overview of epidemiology, pathophysiology, clinical presentation, and treatment of EIMs in IBD.
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Affiliation(s)
- Gerhard Rogler
- Department of Gastroenterology & Hepatology, Department of Medicine, Zurich University Hospital, Zurich, Switzerland
| | - Abha Singh
- University of California, San Diego, La Jolla, CA, USA
| | | | - David T. Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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20
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Elsawi R, Brooks SG, Georgakopolous JR, Lansang P, Piguet V, Croitoru D. The Utility of IL-17 Inhibitors in Neutrophilic Dermatoses: A Systematic Review. J Cutan Med Surg 2021; 26:210-211. [PMID: 34498508 DOI: 10.1177/12034754211045389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rawaan Elsawi
- 12366 Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | | | - Jorge R Georgakopolous
- 12366 Temerty Faculty of Medicine, University of Toronto, ON, Canada.,12366 Division of Dermatology, Department of Medicine, University of Toronto, ON, Canada
| | - Perla Lansang
- 12366 Temerty Faculty of Medicine, University of Toronto, ON, Canada.,12366 Division of Dermatology, Department of Medicine, University of Toronto, ON, Canada.,Division of Dermatology, Sunnybrook Hospital, Toronto, ON, Canada
| | - Vincent Piguet
- 12366 Temerty Faculty of Medicine, University of Toronto, ON, Canada.,12366 Division of Dermatology, Department of Medicine, University of Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - David Croitoru
- 12366 Temerty Faculty of Medicine, University of Toronto, ON, Canada.,12366 Division of Dermatology, Department of Medicine, University of Toronto, ON, Canada
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21
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Finnin D. Young Woman with Leg Lesions. Clin Pract Cases Emerg Med 2021; 5:265-266. [PMID: 34437024 PMCID: PMC8143835 DOI: 10.5811/cpcem.2021.3.51733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/05/2021] [Indexed: 11/11/2022] Open
Abstract
Case Presentation The patient was a 33-year-old woman with inflammatory bowel disease presenting for worsening lower leg lesions with significant pain recalcitrant to oral doxycycline. Discussion Pyoderma gangrenosum is a rare ulcerative skin condition with significant pain that is often associated with other systemic diseases typically treated with immunosuppressive medications aimed at the underlying cause.
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Affiliation(s)
- Daniel Finnin
- Albany Medical Center, Department of Emergency Medicine, Albany, New York
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22
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Adjunctive Hyperbaric Oxygen Therapy in Refractory Crohn's Disease: An Observational Study. Gastroenterol Res Pract 2021; 2021:6628142. [PMID: 33995526 PMCID: PMC8096584 DOI: 10.1155/2021/6628142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 04/06/2021] [Accepted: 04/16/2021] [Indexed: 12/11/2022] Open
Abstract
Background and Aims Patients may experience complications of Crohn's disease (CD) even when treated with optimal medical therapy strategies. Previous data have shown the efficacy of hyperbaric oxygen therapy (HBOT) in the management of complicated CD. However, there is no consensus regarding the optimal number of sessions or duration of treatment regimens. The aim of the present study was to investigate the efficacy of HBOT in CD patients who were refractory to conventional medical management. Methods This study included patients who underwent HBOT for the treatment of the following complications: perianal fistulizing Crohn's disease (pCD), enterocutaneous fistulas (ECF), or pyoderma gangrenosum (PG). Complete healing was defined as the closure of external orifice and the absence of active draining (in pCD), complete wound healing (in PG), and granulation or complete wound epithelialization with no enteric draining (in ECF). The persistence of draining and the absence of wound granulation were defined as incomplete healing. Results Forty patients were included. The mean CD duration was 10.6 ± 5.8 years. pCD comprised most of the included patients (25/62.5%), followed by ECF (n = 13/32.5%) and PG (n = 6/15%). In two patients (5%), a combination of ECF and PG was diagnosed, and in one patient (2.5%), all three complications were observed. A total of 32 patients (82.5%) had complete healing. Patients with PG had the highest healing rates (100%), followed by those with ECF (84.6%) and pCD (80%). Conclusions Adjunctive HBO was associated with significant healing rates for CD-associated complications such as pCD, ECF, and PG.
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23
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Kunz J, Balakirski G, Müller S, Niebel D, Wenzel J, Bieber T. Größenprogrediente Ulzerationen beider Unterarme bei einem Patienten unter einer TNF-α-Blocker-Therapie nach Aquarienkontakt: Eine irreführende Anamnese. J Dtsch Dermatol Ges 2021; 19 Suppl 1:23-26. [PMID: 33835662 DOI: 10.1111/ddg.14477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Julia Kunz
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn
| | - Galina Balakirski
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn
| | - Svenja Müller
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn
| | - Dennis Niebel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn
| | - Jörg Wenzel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn
| | - Thomas Bieber
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn
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24
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Kridin K, Damiani G, Ludwig RJ, Tzur Bitan D, Cohen AD. Estimating the Odds of Ulcerative Colitis-Associated Pyoderma Gangrenosum: A Population-Based Case-Control Study. Dermatology 2021; 237:323-329. [PMID: 33647909 DOI: 10.1159/000512931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/04/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ulcerative colitis (UC) is a well-known underlying comorbidity of pyoderma gangrenosum (PG). However, the risk conferred by UC for the subsequent development of PG is yet to be elucidated. We aimed to estimate the magnitude of the association between UC and the subsequent occurrence of PG, which would enable us to assess the odds of PG developing in individuals with a history of UC. METHODS A population-based case-control study was conducted to compare PG patients (n = 302) and age-, sex- and ethnicity-matched control subjects (n = 1,497) regarding the presence of UC. Logistic regression models were utilized for univariate and multivariate analyses. RESULTS The prevalence of preexisting UC was greater in patients with PG than in controls (7.3 vs. 0.5%; p < 0.001). A 15-fold increase in the odds of PG in individuals with preexisting UC was observed (OR 14.62, 95% CI 6.45-33.18). The greatest risk of developing PG occurred in the first years following the diagnosis of UC (OR 35.50, 95% CI 4.35-289.60), and decreased thereafter to 10.03 (95% CI 1.83-55.03), 6.69 (95% CI 1.49-30.02), and 10.03 (95% CI 1.83-55.03) at 1-5, 5-10, and 10-15 years after the diagnosis of UC, respectively. This association retained its statistical significance following the adjustment for confounding factors (adjusted OR 10.78, 95% CI 4.55-25.52). Patients with both PG and UC were younger and had a lower prevalence of smoking than the remaining patients with PG. CONCLUSIONS UC increases the odds of developing PG by 15-fold, with the highest probability of developing PG occurring within the first year after the diagnosis of UC. Patients with UC may be advised to avoid additional precipitating factors for the development of PG.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany, .,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel,
| | - Giovanni Damiani
- Department of Dermatology, Case Western Reserve University, Cleveland, Ohio, USA.,Young Dermatologists Italian Network, GISED, Bergamo, Italy.,Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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Jo UH, Lee JY, Lee H, Kim DY, Kang S, Koh SJ, Park H. Various skin manifestations related to inflammatory bowel disease: A nationwide cross-sectional study on the Korean population. J Dermatol 2021; 48:431-438. [PMID: 33608949 DOI: 10.1111/1346-8138.15676] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/06/2020] [Indexed: 11/26/2022]
Abstract
Inflammatory bowel disease (IBD) presents with various extraintestinal manifestations. As part of them, various skin diseases are suggested to be related to IBD. We aimed to identify the epidemiology and risk of developing skin manifestations in patients with IBD. We used Korean insurance claims data and selected patients with IBD and age/sex-matched non-IBD subjects between 2013 and 2017 using the diagnosis code and prescription records of IBD-specific medications. The prevalence and risk of concurrent skin diseases were estimated. We identified 64 837 patients with IBD. Reactive skin eruptions including pyoderma gangrenosum and erythema nodosum were associated with IBD with highest odds ratios among three categories of reactive, inflammatory, and autoimmune skin diseases. Inflammatory skin diseases including rosacea, psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne conglobata were significantly associated with IBD, but the association was less marked compared to reactive skin eruptions. The patients with IBD also had a higher risk of autoimmune skin diseases including vitiligo and alopecia areata than non-IBD subjects. We determined that IBD was related to various skin diseases including reactive, inflammatory, and autoimmune skin diseases. Considering these relationships can allow better management of patients with IBD and comorbid skin diseases.
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Affiliation(s)
- Ui Hyeon Jo
- Department of Dermatology, Seoul National University Hospital, Seoul, Korea
| | - Jin Yong Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul, Korea.,Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea.,HIRA Research Institute, Health Insurance Review & Assessment Service, Wonju, Korea
| | - Hanjae Lee
- Department of Dermatology, Seoul National University Hospital, Seoul, Korea
| | - Do-Yeop Kim
- Department of Dermatology, Seoul National University Hospital, Seoul, Korea
| | - Sungchan Kang
- Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Seong-Joon Koh
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Laboratory of Intestinal Mucosa and Skin Immunology, Seoul, Korea
| | - Hyunsun Park
- Laboratory of Intestinal Mucosa and Skin Immunology, Seoul, Korea.,Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
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Kridin K, Damiani G, Cohen AD. Rheumatoid arthritis and pyoderma gangrenosum: a population-based case-control study. Clin Rheumatol 2020; 40:521-528. [PMID: 32613390 DOI: 10.1007/s10067-020-05253-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/11/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The association between pyoderma gangrenosum (PG) and rheumatoid arthritis (RA) was not investigated in the setting of controlled studies. The risk of PG among patients with RA is not established. OBJECTIVE The study aims to evaluate the magnitude of the association between RA and the subsequent development of PG. Additionally, we aimed to characterize patients with RA-associated PG relative to other patients with PG. METHODS A population-based case-control study was conducted comparing PG patients (n = 302) with age-, sex-, and ethnicity-matched control subjects (n = 1497) with respect to the presence of RA. Logistic regression models were utilized for univariate and multivariate analyses. RESULTS The prevalence of RA was greater in patients with PG than in control subjects (4.7% vs. 1.5%, respectively; P < 0.001). More than threefold increase in the odds of PG with RA (OR, 3.29; 95% CI, 1.66-6.50) was noted. This association retained its statistical significance following a sensitivity analysis excluding RA cases diagnosed up to 2 years prior to PG (OR, 2.72; 95% CI, 1.25-5.91) and after adjusting for confounding factors (adjusted OR, 2.80; 95% CI, 1.23-5.86). RA preceded the diagnosis of PG in the majority of patients by a mean (SD) latency of 9.2 (7.4) years. Patients with RA-associated PG were older relative to the remaining patients with PG (62.2 [15.0] vs. 53.4 [20.9] years, respectively; P = 0.006). CONCLUSIONS RA increases the odds of developing PG by more than threefold. Physicians managing patients with RA should be aware of this increased burden. Patients with RA may be advised to avoid additional precipitating factors of PG. Key Points • The odds of developing PG are increased by more than threefold in patients with RA. • PG followed the diagnosis of RA in the majority of patients with these coexistent conditions by an average latency of 9.2 years. • Patients with RA-associated were older relative to other patients with PG at the onset of PG.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
| | - Giovanni Damiani
- Young Dermatologists Italian Network, GISED, Bergamo, Italy.,Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Kridin K, Damiani G, Ludwig RJ, Tzur-Bitan D, Cohen AD. Quantification of the relationship between pyoderma gangrenosum and Crohn's disease: a population-based case-control study. Scand J Gastroenterol 2020; 55:814-818. [PMID: 32634344 DOI: 10.1080/00365521.2020.1786849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although Crohn's disease (CD) is an established underlying disease in pyoderma gangrenosum (PG), studies comparing patients with PG and controls with respect to the presence of CD are lacking. Consequently, the relative risk imposed by CD for the development of PG is yet to be elucidated. OBJECTIVE The study aims to quantify the magnitude of the association between CD and subsequent development of PG, thus enabling to evaluate the risk of PG with CD. METHODS A matched case-control study was conducted in Israel comparing PG patients (N = 302) with age-, sex- and ethnicity-matched control subjects (N = 1497) regarding the presence of CD. Logistic regression model was used for multivariate analysis. RESULTS The prevalence of CD was higher in patients with PG than in control subjects (7.0% vs. 0.3%, respectively; p < .001). There was a 28-fold increase in the odds of PG with CD (OR, 28.08; 95% CI, 9.56-82.41). This association was robust to a sensitivity analysis excluding CD cases diagnosed up to 3 years prior to PG (OR, 30.30; 95% CI, 8.82-104.09), and to a multivariate analysis adjusting for confounding factors (OR, 21.57; 95% CI, 7.20-64.58). The median latency between the diagnosis of CD and the development of PG was 8.08 years. Patients with both PG and CD were younger and had a higher prevalence of smoking when compared to other patients with PG. CONCLUSIONS CD increases the odds of having PG by 28-folds. Patients with CD should be advised to avoid additional precipitating factors of PG like pathergy and smoking.
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Affiliation(s)
- Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Clalit Healthcare Services, Tel-Aviv, Israel
| | - Giovanni Damiani
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA.,GISED, Young Dermatologists Italian Network, Bergamo, Italy.,Department of Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | | | - Dana Tzur-Bitan
- Department of Behavioral Sciences, Ariel University, Ariel, Israel
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Is Gout Associated with Pyoderma Gangrenosum? A Population-Based Case-Control Study. J Clin Med 2020; 9:jcm9061626. [PMID: 32481527 PMCID: PMC7356790 DOI: 10.3390/jcm9061626] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 01/27/2023] Open
Abstract
The coexistence of pyoderma gangrenosum (PG) and gout has been reported in individual patients; however, the association between these conditions has not been investigated. We aimed to assess the association between PG and gout and to examine whether the presence of gout predisposes to the development of PG. A population-based case-control study was conducted comparing PG patients (n = 302) with age-, sex-, and ethnicity-matched control subjects (n = 1497) with respect to the presence of preceding gout. Logistic regression models were utilized for univariate and multivariate analyses. The prevalence of preceding gout was greater in patients with PG than in control subjects (3.7% vs. 0.7%, respectively; p < 0.001). Gout was associated with a more than fivefold increase in the risk of PG (OR, 5.15; 95% CI, 2.21-11.98). After adjusting for confounding factors, gout emerged as a significant independent predictor of PG (adjusted OR, 4.08; 95% CI, 1.69-9.80). Gout preceded the diagnosis of PG by a median latency of 4.6 years. Patients with gout-associated PG were older, predominantly male, and had a higher prevalence of metabolic syndrome than other patients with PG. In conclusion, gout increases the risk of developing PG by more than fivefold. Physicians managing patients with gout and PG should be aware of this emerging association.
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