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van Schewick CM, Lowe DM, Burns SO, Workman S, Symes A, Guzman D, Moreira F, Watkins J, Clark I, Grimbacher B. Bowel Histology of CVID Patients Reveals Distinct Patterns of Mucosal Inflammation. J Clin Immunol 2021; 42:46-59. [PMID: 34599484 PMCID: PMC8821476 DOI: 10.1007/s10875-021-01104-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/18/2021] [Indexed: 01/22/2023]
Abstract
Diarrhea is the commonest gastrointestinal symptom in patients with common variable immunodeficiency (CVID). Different pathologies in patients' bowel biopsies have been described and links with infections have been demonstrated. The aim of this study was to analyze the bowel histology of CVID patients in the Royal-Free-Hospital (RFH) London CVID cohort. Ninety-five bowel histology samples from 44 adult CVID patients were reviewed and grouped by histological patterns. Reasons for endoscopy and possible causative infections were recorded. Lymphocyte phenotyping results were compared between patients with different histological features. There was no distinctive feature that occurred in most diarrhea patients. Out of 44 patients (95 biopsies), 38 lacked plasma cells. In 14 of 21 patients with nodular lymphoid hyperplasia (NLH), this was the only visible pathology. In two patients, an infection with Giardia lamblia was associated with NLH. An IBD-like picture was seen in two patients. A coeliac-like picture was found in six patients, four of these had norovirus. NLH as well as inflammation often occurred as single features. There was no difference in blood lymphocyte phenotyping results comparing groups of histological features. We suggest that bowel histology in CVID patients with abdominal symptoms falls into three major histological patterns: (i) a coeliac-like histology, (ii) IBD-like changes, and (iii) NLH. Most patients, but remarkably not all, lacked plasma cells. CVID patients with diarrhea may have an altered bowel histology due to poorly understood and likely diverse immune-mediated mechanisms, occasionally driven by infections.
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Affiliation(s)
- Cornelia M van Schewick
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Center for Translational Cell Research, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany
| | - David M Lowe
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Siobhan O Burns
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Sarita Workman
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Andrew Symes
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - David Guzman
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Fernando Moreira
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | | | - Ian Clark
- Pathology Department, Royal Free Hospital, London, UK.
- Department of Pathology, Health Science Center, The University of Tennessee, 930 Madison Ave, Suite 500, Memphis, TN, 38163, USA.
| | - Bodo Grimbacher
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK.
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Center for Translational Cell Research, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany.
- DZIF - German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany.
- CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany.
- RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany.
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van Schewick CM, Nöltner C, Abel S, Burns SO, Workman S, Symes A, Guzman D, Proietti M, Bulashevska A, Moreira F, Soetedjo V, Lowe DM, Grimbacher B. Altered Microbiota, Impaired Quality of Life, Malabsorption, Infection, and Inflammation in CVID Patients With Diarrhoea. Front Immunol 2020; 11:1654. [PMID: 32849570 PMCID: PMC7412961 DOI: 10.3389/fimmu.2020.01654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Diarrhoea is the commonest gastrointestinal symptom in patients with common variable immunodeficiency (CVID). Objective: The aim of this study was to describe the prevalence and clinical presentation of chronic and recurrent diarrhoea in the Royal-Free-Hospital (RFH) London CVID cohort, including symptoms, infections, level of inflammation, and microbial diversity. Methods: A cross-sectional study of adult CVID patients (139 out of 172 diagnosed with CVID completed the screening questionnaire). Those with diarrhoea ≥6 days/month had stool and blood samples analysed and completed the short Inflammatory Bowel Disease Questionnaire (sIBDQ). BMI, spleen-size, lymphocytes and gut-microbial diversity were compared. Due to logistical and clinical restraints, not all patients could be analysed on all measures. Results: 46/139 (33.1%) patients had current significant diarrhoea. In patients with past or present diarrhoea, BMI was lower (median 23.7 vs. 26, p = 0.005), malabsorption more common (57.97 vs. 35.71%, p = 0.011). CD4+ lymphocytes were higher in patients with diarrhoea (p = 0.028; n = 138), but CD4+ naïve lymphocytes were significantly higher in non-diarrhoea patients (p = 0.009, N = 28). Nine patients had confirmed or probable current gastrointestinal infections. Calprotectin was >60 μg/g in 13/29 with significant diarrhoea including 9 without infection. SIBDQ revealed a low median score of 4.74. Microbial alpha diversity was significantly lower in CVID patients compared to healthy household controls. There was no significant difference in alpha diversity in relation to antibiotic intake during the 6 weeks prior to providing samples. Conclusion: Patients with CVID and significant diarrhoea had infections, raised calprotectin, malabsorption, a lower BMI, an impaired quality of life (comparable to active IBD), and they differed from non-diarrhoea patients in their lymphocyte phenotyping. Furthermore, microbial diversity was altered. These findings strongly imply that there may be an inflammatory nature and a systemic predisposition to diarrhoea in CVID, which necessitates further investigation.
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Affiliation(s)
- Cornelia M van Schewick
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom.,Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Institute for Immunodeficiency, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Christina Nöltner
- Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Institute for Immunodeficiency, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Svenja Abel
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom.,Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Institute for Immunodeficiency, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Siobhan O Burns
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - Sarita Workman
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - Andrew Symes
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - David Guzman
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - Michele Proietti
- Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Institute for Immunodeficiency, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Alla Bulashevska
- Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Institute for Immunodeficiency, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Fernando Moreira
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - Veronika Soetedjo
- Freiburg Center for Data Analysis and Modeling (FDM), IMBI/ZKS, Freiburg, Germany
| | - David M Lowe
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - Bodo Grimbacher
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, United Kingdom.,Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Institute for Immunodeficiency, Albert-Ludwigs-University Freiburg, Freiburg, Germany.,DZIF - German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany.,CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs-University Freiburg, Freiburg, Germany.,RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
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Lizaola-Mayo BC, Rodriguez EA. Cytomegalovirus infection after liver transplantation. World J Transplant 2020; 10:183-190. [PMID: 32844094 PMCID: PMC7416364 DOI: 10.5500/wjt.v10.i7.183] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/28/2020] [Accepted: 07/01/2020] [Indexed: 02/06/2023] Open
Abstract
Human cytomegalovirus (CMV) represents the most common opportunistic infection in liver transplant recipients. CMV infections in post liver transplant patients cause significant morbidity and mortality, directly affecting post-transplant outcomes. This review will provide the framework for the surveillance, diagnosis, prophylaxis and treatment of CMV in the liver transplant population.
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Affiliation(s)
- Blanca C Lizaola-Mayo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85259, United States
| | - Eduardo A Rodriguez
- Division of Gastroenterology, Hepatology & Nutrition, University of Utah, Salt Lake City, UT 84132, United States
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A Practical Review of Cytomegalovirus in Gastroenterology and Hepatology. Gastroenterol Res Pract 2019; 2019:6156581. [PMID: 30984257 PMCID: PMC6431500 DOI: 10.1155/2019/6156581] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/05/2019] [Indexed: 02/06/2023] Open
Abstract
Human cytomegalovirus (CMV) is a ubiquitous Herpesviridae virus with a wide spectrum of pathology in humans. Host immunity is a major determinant of the clinical manifestation of CMV and can vary widely in the gastroenterology and hepatology practice setting. Immunocompetent patients generally develop a benign, self-limited mononucleosis-like syndrome whereas gastrointestinal tissue-invasive disease is more frequently seen in immunocompromised and inflammatory bowel disease patients. Additionally, liver allograft dysfunction is a significant consequence of CMV infection in liver transplant patients. While polymerase chain reaction and immunohistochemistry techniques allow for the reliable and accurate detection of CMV in the human host, the diagnostic value of different serologic, endoscopic, and histologic tests depends on a variety of factors. Similarly, latent CMV, CMV infection, and CMV disease carry different significance depending on the patient population, and the decision to initiate antiviral therapy can be complex and patient-specific. This review will focus on the pathophysiology, diagnosis, and management of CMV in patient populations relevant to the practice of gastroenterology and hepatology-liver transplant recipients, inflammatory bowel disease patients, and otherwise immunocompetent patients.
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Velidedeoğlu M, Enes Arıkan A, Kağan Zengin A. Diagnostic value of terminal ileum biopsies in patients with abnormal terminal ileum mucosal appearance. ULUSAL CERRAHI DERGISI 2015; 31:152-6. [PMID: 26504419 DOI: 10.5152/ucd.2015.2756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 12/21/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the necessity of obtaining routine ileal biopsy during colonoscopy in the patients with abnormal terminal ileum mucosal appearance if the inflammatory bowel disease is not considered. MATERIAL AND METHODS A retrospective analysis was performed for 57 patients who were referred to a private hospital for colonoscopy between January 2008 and February 2009, in whom terminal ileum intubation was achieved and an abnormal appearance was observed. RESULTS There were 33 men and 24 women; the mean age was 44.12±11.42 years. In 22 patients, the abnormality was ulcers and/or erosions. In 10 patients, there were mucosal nodularity and in 24, the finding was erythema. The time to reach to ileum from cecum was 28.78±24.30 s. The mean length of the examined ileum was 12.93±6.05 cm. There was no difference between groups according to distance covered in the ileum for diagnostic yield, but going further than 2 cm was important. CONCLUSION There should be no need to obtain routine biopsy in patients with abnormal terminal ileum mucosa appearance, when inflammatory bowel disease is not considered. In these patients, histopathology also reveals non-specific ileitis. Furthermore, in these patients, the macroscopic pathological diagnosis overlaps the histopathology, and it has a low diagnostic yield and lower clinical significance.
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Affiliation(s)
- Mehmet Velidedeoğlu
- Department of General Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - A Enes Arıkan
- Department of General Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - A Kağan Zengin
- Department of General Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
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EGAWA N, KATO H, SAKAKI N, TAJIMA T, SAKAMAKI H, AKIYAMA H, TANIKAWA S, KAKU H, HIRUMA K, KOIKE M. Endoscopic Findings of Acute Intestinal Graft‐versus‐host Disease after Bone Marrow Transplantation. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1998.tb00545.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Naoto EGAWA
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Hiroaki KATO
- Department of Endoscopy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Nobuhiro SAKAKI
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Tsuyoshi TAJIMA
- Department of Internal Medicine, Tokyo Metropolitan Ohkubo Hospital, Tokyo, Japan
| | - Hisashi SAKAMAKI
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Hideki AKIYAMA
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Syu TANIKAWA
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Hidefumi KAKU
- Department of Pediatrics, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Kiyoshi HIRUMA
- Department of Transfusion Service, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Morio KOIKE
- Department of Pathology, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
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Harewood GC, Mattek NC, Holub JL, Peters D, Lieberman DA. Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic database. Aliment Pharmacol Ther 2005; 22:571-8. [PMID: 16167974 DOI: 10.1111/j.1365-2036.2005.02632.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Terminal ileum intubation rates at colonoscopy are variable. One of the major indications for terminal ileum intubation is to identify Crohn's disease. Signs and symptoms which raise a suspicion of Crohn's include abdominal pain/bloating, anaemia and diarrhoea. AIM To determine the proportion of terminal ileal intubation in patients undergoing evaluation of abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy. METHODS The Clinical Outcomes Research Initiative national endoscopic database was analysed to determine the proportion of terminal ileum intubation in patients undergoing evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy and to characterize this population of patients. Patients with known or suspected inflammatory bowel disease were excluded from the analysis. RESULTS Between January 2000 and December 2003, 21 638 patients underwent complete colonoscopy for evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal colon findings. Overall, 3858 patients (18%) underwent terminal ileum evaluation. Intubation rates differed according to procedure indication: abdominal pain (13%), anaemia (13%), diarrhoea (28%). Terminal ileum assessment declined with advancing patient age and was least frequent in Black patients (12% vs. 18% in non-Blacks, P < 0.0001). Ileal intubation rates also varied among endoscopy site types: community (17%), academic (21%), Veterans Affairs Medical Centres (17%), P < 0.0001. Multiple logistic regression identified patients with the indication of diarrhoea (OR: 2.58) as more likely to undergo terminal ileum intubation when compared with those with abdominal pain/bloating. Patients in Veterans Affairs (OR: 1.26) and academic (OR: 1.29) sites were more likely to undergo terminal ileum intubation compared with community sites. CONCLUSION Less than one-fifth of patients with either abdominal pain/bloating, anaemia or diarrhoea underwent ileal intubation in the setting of a normal colonoscopy. Significant practice variation was observed in rates of terminal ileum evaluation. Further study is required to determine whether terminal ileum examination impacts patient management or outcome.
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Affiliation(s)
- G C Harewood
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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Torres HA, Kontoyiannis DP, Bodey GP, Adachi JA, Luna MA, Tarrand JJ, Nogueras GM, Raad II, Chemaly RF. Gastrointestinal cytomegalovirus disease in patients with cancer: a two decade experience in a tertiary care cancer center. Eur J Cancer 2005; 41:2268-79. [PMID: 16143517 DOI: 10.1016/j.ejca.2005.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2005] [Revised: 06/30/2005] [Accepted: 07/01/2005] [Indexed: 01/08/2023]
Abstract
Although gastrointestinal cytomegalovirus disease (GI-CMVd) is not common in cancer patients, it is associated with high morbidity and mortality. Herein, we review our 2-decade experience with GI-CMVd in such patient population at The University of Texas M.D. Anderson Cancer Center. Forty-seven patients were identified. Thirty-four patients (72%) had an underlying haematological malignancy, and 18 patients (38%) developed GI-CMVd following hematopoietic stem cell transplantation (HSCT). Nine (25%) of the 36 cancer patients with data available had AIDS. Upper-GI tract involvement was more common in patients with haematological malignancies than in those with solid tumours (P=0.02). Patients with AIDS were more likely to have colonic involvement than were those without AIDS (67% vs. 15%, P=0.006), and patients without AIDS were more likely to have gastric involvement (59% vs. 11%, P=0.01). The CMV-attributable mortality rate was 42%. Independent predictors of death by multivariate analysis included disseminated CMV and AIDS (P<0.01). The presentation of GI-CMVd varies according to the type of cancer, and AIDS. GI-CMVd is associated with a high mortality among cancer patients, particularly those with disseminated CMV disease or AIDS.
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Affiliation(s)
- Harrys A Torres
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas, Unit 402, M.D. Anderson Cancer Center, Houston, TX 77030-4009, USA
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Abstract
Our aim was to present a report about the usefulness of ileoscopy as an adjunct to colonoscopy, as studied in India, in the face of a dearth of such reports from the developing countries and to study the role of ileoscopy in increasing the yield of diagnosis reached and modified. In a prospective study in 66 consecutive patients undergoing colonoscopy for various indications, colonoscopy/ileoscopy was performed with a forward viewing fiberoptic colonoscope. Details of ileal mucosa, time taken to reach ileum, and length of ileum intubated were noted. Of the 66 patients undergoing colonoscopy, cecum could be reached in 62, whereas ileum was successfully intubated in 57 (86.4%). In 13 (22.5%) cases, additional information was obtained. In eight (14.4%) cases, diagnosis was established on ileoscopy. Of these, two were of lower gastrointestinal (GI) bleed (typhoid ulcer and nonsteroidal antiinflammatory drug ulcer), one had lymphoma, two had tuberculosis, and three were cases of reactive arthritis with ulcers in terminal ileum. After ileoscopy, the diagnosis was altered in five (8.7%) cases. Time taken to reach ileum from cecum was 3.3 +/- 2.5 minutes and the length of examined ileum was 17.3 +/- 7.5 cm. Ileoscopy is a useful adjunct to colonoscopy that not only helps to modify the diagnosis but also established them.
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Affiliation(s)
- D K Bhasin
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Nakase H, Itani T, Mimura J, Takeuchi R, Kawasaki T, Komori H, Hashimoto K, Chiba T. Transient protein-losing enteropathy associated with cytomegalovirus infection in a noncompromised host: a case report. Am J Gastroenterol 1998; 93:1005-6. [PMID: 9647040 DOI: 10.1111/j.1572-0241.1998.00301.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- H Nakase
- Division of Gastroenterology, Nishi-Kobe, Medical Center, Kobe, Japan
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11
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Affiliation(s)
- H M Lazarus
- Department of Medicine, Ireland Cancer Center, University Hospitals of Cleveland, Case Western Reserve University, Ohio, USA
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Galati JS, Wisecarver JL, Quigley EM. Inflammatory polyps as a manifestation of intestinal graft versus host disease. Gastrointest Endosc 1993; 39:719-22. [PMID: 8224703 DOI: 10.1016/s0016-5107(93)70233-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- J S Galati
- University of Nebraska Medical Center, Division of Digestive Diseases and Nutrition, Omaha 68198-2000
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Affiliation(s)
- D P Kotler
- Department of Medicine, St. Luke's-Roosevelt Hospital Center, New York, New York 10025
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