Intrahepatic sclerosing cholangitis associated with a familial immunodeficiency syndrome

Pediatric selective IgM immunodeficiency

Objective. Limited information exists on features of pediatric Selective IgM immunodeficiency (SIgMID). Previously published pediatric cases and 2 new cases are reviewed. Methods. English literature from PubMed and references from relevant articles were reviewed. Previously reported cases and 2 new cases from an allergy/immunology practice were analyzed. Results. Forty-nine reported cases of SIgMID presented with respiratory infections (77.6%), gastrointestinal disease (16.3%), skin disease (12.2%), and meningitis (8.2%). Mean serum IgM level was 16.5 ± 13.8 mg/dL. Two patients were identified with SIgMID among 6300 active pediatric patients (0.03%) presenting with asthma, vasomotor rhinitis, and recurrent respiratory infections. In the 51 cases reported, none developed lymphoproliferative disease nor evolved into panhypogammaglobulinemia; four fatalities were reported. Conclusions. The prevalence of SIgMID in our pediatric population was 0.03%. In general, respiratory infections are the common comorbid conditions. Death and autoimmune disease are uncommon complications of pediatric SIgMID.

Selective IgM immunodeficiency: retrospective analysis of 36 adult patients with review of the literature

OBJECTIVE

To review and compare previously reported cases of selective IgM immunodeficiency (SIgMID) with the largest adult cohort obtained from a retrospective analysis of an allergy and immunology practice.

DATA SOURCES

Publications were selected from the English-only PubMed database (1966-2005) using the following keywords: IgM immunodeficiency alone and in combination with celiac disease, autoimmune disease, malignancy, and infection. Bibliographic references of relevant articles were used.

STUDY SELECTION

Reported adult SIgMID cases were reviewed and included in a comparative database against our cohort.

RESULTS

Previously described patients with SIgMID include 155 adults and 157 patients of unspecified age. Thirty-six adult patients were identified with SIgMID from a database of 13,700 active adult patients (0.26%, 1:385). The mean +/- SD serum IgM level was 29.74 +/- 8.68 mg/dL (1 SD). The mean +/- SD age at the time of diagnosis of SIgMID was 55 +/- 13.5 years. Frequency of presenting symptoms included the following: recurrent upper respiratory tract infections, 77%; asthma, 47%; allergic rhinitis, 36%; vasomotor rhinitis, 19%; angioedema, 14%; and anaphylaxis, 11%. Serologically, 13% of patients had positive antinuclear antibodies (ANAs), 5% had serologic evidence of celiac disease, and nearly all had non-AB blood type. Patients also had low levels of IgM isohemagglutinins. No patients developed lymphoproliferative disease or panhypogammaglobulinemia, and none died of life-threatening infections, malignancy, or fulminant autoimmune-mediated diseases during a mean follow-up period of 3.7 years.

CONCLUSIONS

The prevalence of SIgMID in our adult population was 0.26% and may be more common than previously thought. Non-life-threatening respiratory disorders were common comorbid conditions.

Liver disease in children with primary immunodeficiencies

OBJECTIVE

To investigate clinical features and to establish optimal management in children with primary immunodeficiency (PID) and liver disease. Study design A retrospective analysis of medical records of 147 children with PID who presented with abnormal liver tests to a tertiary center.

RESULTS

Clinical evidence of liver disease was documented in 35 (23.8%) patients. Of these, 22 (63%) had hepatomegaly and 14 (40%) had splenomegaly. Sclerosing cholangitis (SC) was diagnosed in 21 children (60%), based on radiological and histological criteria; 4 patients with SC on cholangiography had no biliary changes in the liver biopsy. Ultrasonography demonstrated a dilated biliary system in 14 (67%) children with SC. Of 27 children investigated for Cryptosporidium parvum (CSP), 12 (44%) were positive, including 9 of 12 with SC. Overall, 7 (20%) patients died, including 3 boys with disseminated recurrent CSP infection after successful liver transplantation (LT). Temporary deterioration of liver injury was observed in 2 CSP-positive boys with CD40 ligand deficiency (CD40LD) who were undergoing nonmyeloablative hematopoietic stem cell transplantation (HSCT). Successive liver and HSCT was curative in 1 patient with CD40LD and end-stage liver disease.

CONCLUSION

SC is the most common hepatic complication of PID. Mild liver involvement could be arrested by early nonmyeloablative HSCT, whereas advanced disease may warrant combined liver and HSCT.

A patient with hereditary hemochromatosis, ulcerative colitis, and primary sclerosing cholangitis: genetic aspects

This report describes a family in which the rare combination of hereditary hemochromatosis, ulcerative colitis and primary sclerosing cholangitis was found. Subsequent to the index patient, who had all three diseases, a screening was done in his parents and siblings that included HLA-DR, HLA-DQ and HFE typing, ANCAs, liver tests and sigmoidoscopy with histology. On the basis of HLA and HFE typing, three probable haplotypes could be distinguished. The genetics of inflammatory bowel disease and hereditary hemochromatosis are discussed.

Primary sclerosing cholangitis (PSC): clinical, laboratory and survival analysis in children and adults

BACKGROUND

Primary sclerosing cholangitis (PSC) is an uncommon disorder, rarely diagnosed in children, moreover, data on its natural history and survival are still lacking.

AIM

The study was undertaken to compare clinical, laboratory and survival rates in two series of PSC: one in a pediatric group (group A) and the other in an adult population (group B).

METHODS

Group A included 9 patients (5 males, 4 females, mean age 10 yrs, range 7-15); group B included 28 patients (19 males, 9 females, mean age 32 years, range 19-60). The mean follow-up was 5.2 years in group A and 6.9 years in group B (range 1-14 years). ERCP and colonoscopy were performed in each case. Survival was analyzed using the Kaplan-Meier method.

RESULTS

At presentation children showed significantly higher levels of IgG and AST compared to adults (p<0.05); moreover, interface hepatitis occurred in 50% of children and in 14.2% in adults (p=ns). During follow-up the following major events occurred: oesophageal bleeding (n=2) in group A; progressive liver failure (n=6), cholangiocarcinoma (n=3), colonic cancer (n=1) in group B. Liver transplantation (OLTx) was performed in 4 adults (one died after a retransplantation). No deaths were observed in children. The Kaplan-Meier curve in adults shows a 65% rate of survival at 10 years.

CONCLUSIONS

The present findings on PSC suggest a more severe activity of the disease in children than in adults at presentation; nonetheless, the prognosis seems to be better in children than in adults. The Mayo score prognostic index does not predict the development of liver/colonic cancer. A poor outcome (defined as death or being listed for OLTx) only occurred in adults.

Chronic unexplained liver disease in children with primary immunodeficiency syndromes

Liver disease may be found in patients with primary immunodeficiency syndromes because of the high risk of infection with hepatotropic viruses related to the treatment with blood derivatives. The prevalence of liver disease in these patients and its etiology, however, is still not completely understood. We have evaluated the prevalence and the etiology of liver disease in children with different forms of primary immunodeficiencies. Thirty patients included in the study underwent molecular studies to detect common hepatotropic viruses, including hepatitis C and G viruses. Liver involvement was found in 11 of 30 (36.6%) patients. All patients with liver disease had deficiencies of specific immunity, with a prevalence in this subgroup of 47.8%. Liver disease was more severe in patients with T and B cell combined immune disorders than in those with a selective T cell immunodeficiency. Moreover, the severity of the disease correlated with an overall more rapid fatal outcome. A viral etiology was found in only six of these patients, whereas in the remaining five patients, no cause of liver injury was identified. In the virally infected patients, hepatitis C virus was the most common viral agent. In patients with immunodeficiencies, there is a high prevalence of liver disease not fully explained on the basis of the common viral infections.

Primary sclerosing cholangitis: a clinical review

Primary sclerosing cholangitis (PSC) is a cholestatic liver disease characterized by fibro-obliterative inflammation of the entire biliary tree. It is a slowly progressive disease with an undulating course, resulting in terminal biliary cirrhosis after a median period of about 12 years after diagnosis. The etiology of the disease is unknown and there is no effective therapy that can halt disease progression. Around 8% of PSC patients develop cholangiocarcinoma, which, by the time it is diagnosed, cannot be treated curatively. The purpose of this article is to review the current knowledge about primary sclerosing cholangitis and to speculate on future strategies to address the issues of etiology and therapy.

Immunodeficiency as a component of recognizable syndromes

Immunodeficiency occurs in numerous genetic syndromes. While it is the dominant manifestation in primary immunodeficiencies, immune deficits may also be seen in a variety of other recognizable syndromes. Immunodeficiency has been reported in 64 such conditions, adding to the 45 recognized primary immunodeficiencies. These uncommon syndromes with immune defects can present with: (a) growth deficiency (11 syndromes with disproportionate or proportionate short stature), (b) specific organ system dysfunction (18 with gastrointestinal, dermatologic, or neurologic abnormalities), (c) inborn errors of metabolism (13), (d) miscellaneous anomalies (10), or (e) chromosome anomalies (12). In most of the disorders, only some of the affected patients have immune defects. However, in 27 syndromes, immunodeficiency is a constant finding. We briefly review the clinical manifestations of each syndrome and delineate the specific associated immune defects. In most syndromes, the connection between the immune and other defects is unknown. Recognition of these conditions involving both the immune and other organ systems may facilitate accurate diagnosis and management as well as yield information regarding genes critical for the development of the involved systems.

Cholangitis associated with paroxysmal nocturnal hemoglobinuria: another instance of ischemic cholangiopathy?

Ischemia is increasingly recognized as a cause of cholangiopathy. The aim of this study was to report a case of association of paroxysmal nocturnal hemoglobinuria with abrupt-onset cholangiopathy. Anomalies resembling sclerosing cholangitis were documented in a patient suffering from recurrent biliary pain. None of the conditions that have been associated with primary sclerosing cholangitis or other forms of cholangiopathy was present, but shortly thereafter, paroxysmal nocturnal hemoglobinuria occurred. Hepatic vein thrombosis later complicated the course of the disease. Because the fortuitous coincidence of these uncommon conditions is unlikely, this case indicates that paroxysmal nocturnal hemoglobinuria is a cause of ischemic cholangiopathy. Other thrombogenic conditions may also be implicated in some instances of apparently idiopathic cholangiopathy.

Association of primary sclerosing cholangitis, thymoma and hypogammaglobulinemia

A 64-year-old Japanese woman with thymoma has been suffering from diarrhea and increased alkaline phosphatase levels without jaundice. Her serum immunoglobulin levels of IgM and IgG were less than half of the normal levels, with an increase in CD8 (suppressor/cytotoxic) T cell percentage and a decrease in CD4 (helper) T cell percentage, resulting in a lower CD4/CD8 ratio of 0.31. These immunological features are in accordance with those of hypogammaglobulinemia complicating thymoma. Cholangiography and a liver biopsy specimen disclosed the presence of primary sclerosing cholangitis (PSC). PSC has been recognized in various immunodeficiency syndromes and this case shows that thymoma complicated by hypogammaglobulinemia is associated with PSC.

AIDS-related cholangiopancreatographic changes

The cholangiographic and pancreatographic appearances of the acquired immunodeficiency syndrome (AIDS) associated cholangitis were evaluated in 26 patients. Twenty-four patients were diagnosed by retrograde cholangiography or endoscopic cholangiopancreatography (ERC or ERCP). One patient was diagnosed by T-tube cholangiography and another patient by transhepatic cholangiography. The radiographic findings ranged from intrahepatic ductal abnormalities with or without involvement of the extrahepatic biliary tree (eight patients) to irregularities and strictures involving the ampulla of Vater or the intrapancreatic portion of the common bile duct (CBD) with proximal dilatation (18 patients). Significant strictures involving the juxta-ampullary pancreatic duct were identified in six of 12 patients. Twenty-one of the 26 patients had associated infections which included: Cryptosporidium (CS), Mycobacterium avium intracellulare (MAI), cytomegalovirus (CMV), Microsporidium (MSP), and Isospora (ISP). Three patients were operated upon for acute acalculous cholecystitis. In each instance, organisms were identified in both the bile duct and the inflamed gallbladder.

Intrahepatic biliary stones in children

Intrahepatic biliary stones in seven non-Oriental patients were studied in all by sonography, in four patients by computed tomography and in four patients by percutaneous transhepatic cholangiography. For patients had extrahepatic biliary atresia treated with portoenterostomies, one patient had undergone partial liver transplantation and of the remaining two, one had cystic fibrosis and the other immunodeficiency syndrome. All sonograms were abnormal and showed echogenic foci within the liver, with or without associated signs of biliary tract dilatation. CT confirmed the biliary tract dilatation yet calculi were identified in one patient only. PTC was particularly helpful in the patient with immunodeficiency in whom features typical of sclerosing cholangitis were found. This report emphasizes the variable radiological appearance of bile stones which to our knowledge have rarely been described in children with entities other than Oriental cholangitis.

Crohn disease with sclerosing cholangitis and liver cirrhosis in adolescence

A 17-year-old patient suffering from Crohn disease (CD) and liver cirrhosis is presented. At an advanced stage of the disease, he died of a concomitant urosepsis. Autopsy showed that the liver cirrhosis was caused by sclerosing cholangitis. This very rare complication of CD in adolescence is discussed.

Advances in primary sclerosing cholangitis

Primary sclerosing cholangitis is an increasingly recognized chronic cholestatic liver disease. It frequently occurs in association with chronic ulcerative colitis and is characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts. The cause is unknown, although many mechanisms have been considered, including infectious, toxic, and immunologic. The prognosis varies. No adequate treatment exists, although a number of potential treatments have been evaluated in uncontrolled trials, and the results of controlled trials have only recently been reported. Liver transplantation has recently been shown to be an effective treatment for end-stage disease. These various advances in our understanding of primary sclerosing cholangitis are reviewed.

Papillary stenosis and sclerosing cholangitis in an immunodeficient child

Sclerosing cholangitis, an inflammatory disease of the biliary tree that occurs infrequently in childhood, has been recognized in combination with papillary stenosis in adults with the acquired immunodeficiency syndrome. A 10-yr-old child with a familial immunodeficiency syndrome characterized by defective T-cell function and deficiencies of immunoglobulins A and G developed papillary stenosis and sclerosing cholangitis associated with cryptosporidium enteritis. The patient presented with fever, jaundice, right upper quadrant pain, and elevated serum concentrations of transaminases and alkaline phosphatase. The pain and jaundice resolved after endoscopic sphincterotomy, but the biochemical abnormalities persisted. This case demonstrates that the combination of papillary stenosis and sclerosing cholangitis can occur in children as well as adults and may be associated with immunodeficiency syndromes other than the acquired immunodeficiency syndrome. Endoscopic sphincterotomy can provide symptomatic treatment for papillary stenosis in children with this condition, although the effect of sphincterotomy on the natural history of the sclerosing cholangitis is uncertain.

Primary sclerosing cholangitis associated with hyperimmunoglobulin M immunodeficiency (dysgammaglobulinemia)

Primary sclerosing cholangitis is an uncommon disorder of obliterative biliary inflammation that is exceedingly rare in childhood. Presented is a child with hyperimmunoglobulin M immunodeficiency (dysgammaglobulinemia) and primary sclerosing cholangitis. This case should focus attention on the association of primary sclerosing cholangitis and immunodeficiency syndromes, particularly in children with immune disorders and unexplained hepatic abnormalities.

Pediatric primary sclerosing cholangitis

An 11-year-old male presented with abdominal pain and emesis. Serum chemistries revealed cholestasis and an ERCP demonstrated sclerosing cholangitis. Secondary causes of this disease process were excluded. Sclerosing cholangitis is distinctly uncommon in the pediatric age group, but it should be considered in evaluation of patients of any age with cholestasis. It appears in some cases that there may be subtle histologic and radiographic features which separate the pediatric and adult forms of the disease.

Gastrointestinal complications of congenital immunodeficiency states. The surgeon's role

Ninety-one congenitally immunodeficient patients treated from 1972 to 1981 were reviewed to assess the incidence and nature of gastrointestinal complications. Thirty-three of these patients (36%) developed 59 complications. Patients with immunodeficiencies characterized by neutrophil dysfunction--chronic granulomatous disease (20 patients) and cyclic neutropenia (eight patients)--developed 22 surgical infections, 22 of which required operation. In patients with neutrophil defects, postoperative morbidity was frequent and severe. Gastrointestinal symptoms were common in patients with isolated defects of B or T lymphocytes. Ten of forty-one patients with congenital hypogammaglobulinemia developed gastrointestinal complications, as did one of four patients with DiGeorge Syndrome, and the single patient with secretory IgA deficiency. However, operation was not required for these patients with isolated disorders of lymphocyte function. Patients with combined B and T cell disorders developed gastrointestinal disease, requiring operative therapy at intermediate rates. Gastrointestinal symptoms developed in four of nine patients with severe combined immunodeficiency and three of eight with Wiskott-Aldrich syndrome. Operative therapy was required in two of these seven symptomatic patients.

Immunodeficiency-disease-associated atypical chronic hepatitis: a clinicopathologic study

Chronic hepatitis occurring in patients with primary immunodeficiency disease is an uncommonly reported phenomenon. This study describes our experience with 3 patients with various immunologic abnormalities who developed chronic atypical lymphocytic infiltrates in the liver. There was a temporal relationship to Epstein-Barr virus infection in 2 cases and hepatitis A in 1. In view of the increased incidence of malignant lymphoma in several of the primary immunodeficiency states, these cases present a difficult diagnostic challenge. The recognition of the association of infiltration of the liver with small cleaved lymphocytes and a viral infection in an immunodeficient patient should alert the pathologist to the possibility that the infiltrate does not represent malignant lymphoma. These cases may be analogous to similar virus-associated lymphoproliferative disorders described in the acquired immunodeficiency of renal transplantation.

Immunodeficiency, xanthomas and obstructive liver disease

Chronic obstructive liver disease and secondary hyperlipidemia developed in an immunodeficient boy. Sequential addition of cholestyramine and phenobarbital to his medical regimen, following an initial response to bile drainage, resulted in the disappearance of xanthomas and pruritus, and the restoration of normal serum concentrations of lipids and bile acids. This improvement may result from shifting the bile acid pool from the peripheral blood compartment to the enterohepatic circulation.

Chronic pancreatitis, sclerosing cholangitis, and sicca complex in two siblings

A new syndrome of chronic pancreatitis, sclerosing cholangitis, sicca complex, and other features was found in a brother and sister. Leucocyte-migration inhibition in the presence of a bile antigen in both patients suggested that immune mechanisms may be involved.