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Boulkroun H, Lacotte E, Angoso M, Dalle JH, Kallout J, Nolla M, Picard A, Paillard C, Plantaz D, Renard C, Rialland F, Schneider P, Buchbinder N. Late stenosis of the small intestine and colon, an atypical feature of chronic graft-versus-host disease. National retrospective study in French pediatric allograft centers. Bone Marrow Transplant 2024; 59:1316-1319. [PMID: 38886485 DOI: 10.1038/s41409-024-02330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 05/08/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Affiliation(s)
- Hana Boulkroun
- Pediatrics, Hospital Charles Nicolle CHU Rouen, Rouen, France.
| | - Edouard Lacotte
- Pediatric Gastro-Enterology CHU Caen Normandie, Caen, France
| | - Marie Angoso
- Pediatric Hematology Oncology, Center Pellingrin, CHU Bordeaux, Bordeaux, France
| | - Jean Hugues Dalle
- Pediatric Hematology Oncology and Stem Cells Transplantation, Robert Debré Hospital Paris,GH APHP-Nord, Paris University, Paris, France
| | | | - Marie Nolla
- Pediatric Hematology Oncology, CHU Toulouse, Toulouse, France
| | - Agathe Picard
- Pediatric Hematology, Oncology, Rennes South Hospital CHU, Rennes, France
| | - Catherine Paillard
- Pediatric Hematology, Oncology, Hospital Hautepierre CHU Strasbourg, Strasbourg, France
| | | | - Cécile Renard
- Pediatric Hematology, Oncology, Center Leon Berard Lyon, Lyon, France
| | - Fanny Rialland
- Pediatric Hematology, Immunology, Oncology, CHU Nantes, Nantes, France
| | - Pascale Schneider
- Pediatric Hematology, Immunology, Oncology and Stem Cells Transplantation, Rouen University Hospital Charles Nicolle CHU Rouen, Rouen, France
| | - Nimrod Buchbinder
- Pediatric Hematology, Immunology, Oncology and Stem Cells Transplantation, Rouen University Hospital Charles Nicolle CHU Rouen, Rouen, France
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2
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Schiepatti A, Sanders DS, Baiardi P, Caio G, Ciacci C, Kaukinen K, Lebwohl B, Leffler D, Malamut G, Murray JA, Rostami K, Rubio-Tapia A, Volta U, Biagi F. Nomenclature and diagnosis of seronegative coeliac disease and chronic non-coeliac enteropathies in adults: the Paris consensus. Gut 2022; 71:2218-2225. [PMID: 35676085 PMCID: PMC9554081 DOI: 10.1136/gutjnl-2021-326645] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/02/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Differential diagnosis of villous atrophy (VA) without coeliac antibodies in adults includes seronegative coeliac disease (CD) and chronic enteropathies unrelated to gluten, ie. non-coeliac enteropathies (NCEs). There is currently no international consensus on the nomenclature and diagnostic criteria for these enteropathies. In this work, a Delphi process was conducted to address this diagnostic and clinical uncertainty. DESIGN An international task force of 13 gastroenterologists from six countries was recruited at the 16th International Coeliac Disease Symposium, Paris, 2019. Between September 2019 and July 2021, a Delphi process was conducted through mail surveys to reach a consensus on which conditions to consider in the differential diagnosis of VA with negative coeliac serology and the clinical diagnostic approaches required for these conditions. A 70% agreement threshold was adopted. RESULTS Chronic enteropathies characterised by VA and negative coeliac serology can be attributed to two main clinical scenarios: forms of CD presenting with negative serology, which also include seronegative CD and CD associated with IgA deficiency, and NCEs, with the latter recognising different underlying aetiologies. A consensus was reached on the diagnostic criteria for NCEs assisting clinicians in differentiating NCEs from seronegative CD. Although in adults seronegative CD is the most common aetiology in patients with VA and negative serology, discriminating between seronegative CD and NCEs is key to avoid unnecessary lifelong gluten-free diet, treat disease-specific morbidity and contrast poor long-term outcomes. CONCLUSION This paper describes the Paris consensus on the definitions and diagnostic criteria for seronegative CD and chronic NCEs in adults.
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Affiliation(s)
- Annalisa Schiepatti
- Dipartimento di Medicina Interna e Terapia Medica, University of Pavia, Pavia, Italy .,Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Paola Baiardi
- Direzione Scientifica Centrale, Fondazione S. Maugeri, IRCCS, Pavia, Italy
| | - Giacomo Caio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy,Celiac Center and Mucosal Immunology and Biology Research Center Massachusetts General Hospital- Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina Ciacci
- AOU San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Baronissi, Italy
| | - Katri Kaukinen
- Faculty of Medicine and Health Technology, Tampere University and Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York City, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Daniel Leffler
- The Celiac Center at BIDMC, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Georgia Malamut
- Université de Paris, Department of Gastroenterology, AP-HP, Hôpital Cochin, Paris, France
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kamran Rostami
- Departments of Gastroenterology, Mid Central DHB, Palmerston Hospital, Palmerston North, Palmerston North, New Zealand
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Federico Biagi
- Dipartimento di Medicina Interna e Terapia Medica, University of Pavia, Pavia, Italy,Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
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3
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Chugh RM, Bhanja P, Olea XD, Tao F, Schroeder K, Zitter R, Arora T, Pathak H, Kimler BF, Godwin AK, Perry JM, Saha S. Human Peripheral Blood Mononucleocyte Derived Myeloid Committed Progenitor Cells Mitigate H-ARS by Exosomal Paracrine Signal. Int J Mol Sci 2022; 23:5498. [PMID: 35628308 PMCID: PMC9142131 DOI: 10.3390/ijms23105498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/28/2022] [Accepted: 05/11/2022] [Indexed: 01/27/2023] Open
Abstract
Radiation-induced loss of the hematopoietic stem cell progenitor population compromises bone marrow regeneration and development of mature blood cells. Failure to rescue bone marrow functions results in fatal consequences from hematopoietic injury, systemic infections, and sepsis. So far, bone marrow transplant is the only effective option, which partially minimizes radiation-induced hematopoietic toxicities. However, a bone marrow transplant will require HLA matching, which will not be feasible in large casualty settings such as a nuclear accident or an act of terrorism. In this study we demonstrated that human peripheral blood mononuclear cell-derived myeloid committed progenitor cells can mitigate radiation-induced bone marrow toxicity and improve survival in mice. These cells can rescue the recipient's hematopoietic stem cells from radiation toxicity even when administered up to 24 h after radiation exposure and can be subjected to allogenic transplant without GVHD development. Transplanted cells deliver sEVs enriched with regenerative and immune-modulatory paracrine signals to mitigate radiation-induced hematopoietic toxicity. This provides a natural polypharmacy solution against a complex injury process. In summary, myeloid committed progenitor cells can be prepared from blood cells as an off-the-shelf alternative to invasive bone marrow harvesting and can be administered in an allogenic setting to mitigate hematopoietic acute radiation syndrome.
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Affiliation(s)
- Rishi Man Chugh
- Departments of Radiation Oncology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (R.M.C.); (P.B.); (X.D.O.); (R.Z.); (T.A.); (B.F.K.)
| | - Payel Bhanja
- Departments of Radiation Oncology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (R.M.C.); (P.B.); (X.D.O.); (R.Z.); (T.A.); (B.F.K.)
| | - Ximena Diaz Olea
- Departments of Radiation Oncology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (R.M.C.); (P.B.); (X.D.O.); (R.Z.); (T.A.); (B.F.K.)
| | - Fang Tao
- Departments of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO 64108, USA; (F.T.); (K.S.); (J.M.P.)
| | - Kealan Schroeder
- Departments of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO 64108, USA; (F.T.); (K.S.); (J.M.P.)
| | - Ryan Zitter
- Departments of Radiation Oncology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (R.M.C.); (P.B.); (X.D.O.); (R.Z.); (T.A.); (B.F.K.)
| | - Tanu Arora
- Departments of Radiation Oncology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (R.M.C.); (P.B.); (X.D.O.); (R.Z.); (T.A.); (B.F.K.)
| | - Harsh Pathak
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (H.P.); (A.K.G.)
| | - Bruce F. Kimler
- Departments of Radiation Oncology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (R.M.C.); (P.B.); (X.D.O.); (R.Z.); (T.A.); (B.F.K.)
| | - Andrew K. Godwin
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (H.P.); (A.K.G.)
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, MO 66160, USA
| | - John M. Perry
- Departments of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO 64108, USA; (F.T.); (K.S.); (J.M.P.)
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, MO 66160, USA
- Departments of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO 64108, USA
| | - Subhrajit Saha
- Departments of Radiation Oncology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (R.M.C.); (P.B.); (X.D.O.); (R.Z.); (T.A.); (B.F.K.)
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, MO 66160, USA; (H.P.); (A.K.G.)
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Mourad N, Michel RP, Marcus VA. Pathology of Gastrointestinal and Liver Complications of Hematopoietic Stem Cell Transplantation. Arch Pathol Lab Med 2019; 143:1131-1143. [PMID: 30838881 DOI: 10.5858/arpa.2018-0282-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT.— Despite advances in therapeutic and preventive measures, hematopoietic stem cell transplant recipients remain at risk for a variety of gastrointestinal and liver complications. OBJECTIVE.— To detail the pathologic features of the various gastrointestinal and liver complications occurring after hematopoietic stem cell transplantation in relation to their clinical context. The specific complications covered include graft-versus-host disease, mycophenolate mofetil-induced injury, timeline of infections, neutropenic enterocolitis, gastrointestinal thrombotic microangiopathy, sinusoidal obstruction syndrome, hepatic iron overload, and the controversy around cord colitis syndrome. DATA SOURCES.— The content of this article is based on pertinent peer-reviewed articles in PubMed, relevant textbooks, and on the authors' personal experiences. CONCLUSIONS.— The final histopathologic diagnosis requires the integration of clinical and histologic findings and the exclusion of other competing causes of injury. Review of the clinical data, including the original disease pretransplant, the type of transplant, the timing of the gastrointestinal and/or liver manifestations, the timing of the biopsy after transplant, the presence of graft-versus-host disease in other organs and sites, the list of drug regimens, and the clinical and laboratory evidence of infection, is the key to reaching the proper histologic diagnosis.
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Affiliation(s)
- Nathalie Mourad
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - René P Michel
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - Victoria A Marcus
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
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5
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Tordjman M, Ouachee M, Bonnard A, Tilea B, Yakouben K, Viala J, Peuchmaur M, Berrebi D. Small bowel stenosis: a manifestation of chronic graft-versus-host disease in children? Hum Pathol 2018; 72:174-179. [DOI: 10.1016/j.humpath.2017.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 08/23/2017] [Accepted: 08/25/2017] [Indexed: 02/07/2023]
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6
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Motolese E, Rubegni P, Poggiali S, Motolese P, Marotta G, Russo L, D'ascenzo G, Carcagnì M, Fruschelli M, Motolese I, Fimiani M. Ocular Manifestations of Chronic Graft-Versus-Host Disease in Patients Treated with Extracorporeal Photochemotherapy. Eur J Ophthalmol 2018; 17:961-9. [DOI: 10.1177/112067210701700615] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose Eye involvement has long been appreciated in patients with chronic graft versus host disease (cGVHD). In particular, ocular complications are frequent and can be potentially severe in patients with steroid-refractory cGVHD, and therefore necessitate close monitoring. This prospective study was designed to describe eye manifestations of cGVHD in a large series of patients monitoring them before and after 1 year of extracorporeal photochemotherapy (ECP). ECP is a relatively new therapeutic approach based on the biological effects of psoralen 8-methoxypsoralen (8-MOP) and ultraviolet A light (UVA) on mononuclear cells collected by apheresis, and reinfused into the patient. Methods Only patients with steroid-refractory cGVHD under treatment with ECP, who developed cGVHD-related eye symptoms, were selected for the study. Ophthalmologic examination was repeated every 3 months. Only patients with complete recovery of the ocular manifestations and symptoms were considered responsive. Results In our study we observed eye alterations in 24 out of 140 patients (17%) with cGVHD. After 12 months of ECP, 10 out of 21 patients (48%) completely responded to the therapy. In all these cases the contribution of ECP was also essential in all the other organs subject to cGVHD. Conclusions Further studies are necessary to clarify the role of ECP in patients with cGVHD, especially in associated eye manifestations. Although our experience is limited, it suggests that ECP could be a safe and effective therapy for steroid-refractory eye manifestations of cGVHD.
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Affiliation(s)
- E. Motolese
- Department of Ophthalmology and Neurosurgery
| | - P. Rubegni
- Department of Clinical Medicine and Immunological Sciences, Section of Dermatology
| | - S. Poggiali
- Department of Clinical Medicine and Immunological Sciences, Section of Dermatology
| | | | - G. Marotta
- Department of Clinical Medicine and Immunological Sciences, Section of Hematology, University of Siena - Italy
| | - L. Russo
- Department of Ophthalmology and Neurosurgery
| | - G. D'ascenzo
- Department of Clinical Medicine and Immunological Sciences, Section of Dermatology
| | - M.R. Carcagnì
- Department of Clinical Medicine and Immunological Sciences, Section of Dermatology
| | | | - I. Motolese
- Department of Ophthalmology and Neurosurgery
| | - M. Fimiani
- Department of Clinical Medicine and Immunological Sciences, Section of Dermatology
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7
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Rieger K, Günther U, Erben U, Kühl A, Loddenkemper C, Pezzutto A, Siegmund B, Bojarski C. Confocal endomicroscopy in diagnosis of intestinal chronic graft-versus-host disease. Hematol Oncol 2017; 36:291-298. [PMID: 28547857 DOI: 10.1002/hon.2446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/30/2017] [Accepted: 04/29/2017] [Indexed: 11/10/2022]
Abstract
Graft-versus-host disease (GvHD) is a major complication of allogeneic stem cell transplantation. High-resolution in vivo histology of the intestine by confocal endomicroscopy (CEM) detects acute GvHD (aGvHD) with high sensitivity. This pilot study aims to evaluate the diagnostic value of CEM for intestinal chronic GvHD (cGvHD). The study included 20 patients with gastrointestinal symptoms and confirmed cGvHD in other organs as well as 20 patients with clinically suspected acute GvHD for control. Confocal endomicroscopy was performed as gastroscopy followed by sigmoidoscopy after intravenous injection of fluorescein (10%) and topical application of acriflavine (0.05%). Histopathology from H&E-stained biopsy samples throughout the intestinal tract complemented the survey. All histological features of intestinal cGvHD were predominantly mild to moderate. Stroma fibrosis detected by standard histology (16/20 patients) was not seen by CEM. Apoptosis assessed by histology in 12/20 patients was concordant with CEM (8/12 patients). Confocal endomicroscopy revealed esophageal manifestation of cGvHD in 3 patients. For each biopsy site, CEM correlated with intestinal histology (r = 0.64). Classical histology from intestinal biopsy samples taken under CEM monitoring confirmed the final diagnosis of cGvHD. The sensitivity of CEM with 40% in cGvHD was significantly lower compared to 70% in patients with aGvHD. Confocal endomicroscopy detected acute features of cGvHD and contributed to the diagnosis of esophageal cGvHD but failed to display stroma fibrosis in vivo. Although CEM represents a useful noninvasive tool in routine diagnostic of intestinal aGvHD, the method is not sufficient to fully establish the diagnosis of cGvHD within the intestinal tract. Confocal endomicroscopy allowed acquisition of targeted biopsies in patients suspected of having cGvHD.
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Affiliation(s)
- Kathrin Rieger
- Center of Tumor Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Günther
- Medical Department I- Gastroenterology, Infectious Diseases, Rheumatology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Erben
- Medical Department I- Gastroenterology, Infectious Diseases, Rheumatology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Kühl
- Medical Department I- Gastroenterology, Infectious Diseases, Rheumatology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Antonio Pezzutto
- Center of Tumor Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Britta Siegmund
- Medical Department I- Gastroenterology, Infectious Diseases, Rheumatology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Bojarski
- Medical Department I- Gastroenterology, Infectious Diseases, Rheumatology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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8
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Myerson D, Steinbach G, Gooley TA, Shulman HM. Graft-versus-Host Disease of the Gut: A Histologic Activity Grading System and Validation. Biol Blood Marrow Transplant 2017; 23:1573-1579. [PMID: 28533059 DOI: 10.1016/j.bbmt.2017.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/16/2017] [Indexed: 02/08/2023]
Abstract
The pathologic interpretation of gut biopsies in hematopoietic cell transplant recipients to assess graft-versus-host disease (GVHD) is well accepted and supplements clinical and endoscopic findings. However, the histologic activity grading of GVHD is controversial, with attempts to predict prognosis or response to treatment largely unsuccessful. GVHD is being diagnosed earlier in its course, raising the possibility that the pathologic grading system can be profitably modified. We developed a histologic activity grading system designed to replace the commonly used modified Lerner grading systems. Our system stratifies the low-level Lerner grade I category into 4 activity grade categories, based on the average frequency of apoptotic cells. The results are expressed as ordinal categories: GVHD of minimal, mild, moderate, severe histologic activity, or severe histologic activity with destruction (activity grades 1 to 5). In a retrospective study, we studied 87 consecutive cases with 201 post-transplantation specimens (median, 48 days; range, 18 to 1479 days) of stomach, duodenum, and colorectum, which had been activity graded at the time of the original diagnosis. Most of the biopsies diagnosed as GVHD were low grade-minimal (11%) or mild (71%) histologic activity. We hypothesized that the higher activity grades would be associated with more therapeutic intervention. The odds of increased therapy in the combined all-site specimens were increased as activity grade increased (odds ratio, 2.9 [95% confidence interval {CI}, 1.9 to 4.5]; P = < .0001). Thus, our grading system was validated. To investigate whether the activity grade was associated with therapy within the formerly undivided Lerner grade I category, the analysis was restricted to these 174 all-site specimens. The validation result was similar (odds ratio, 3.1 [95% CI, 1.3 to 7.2]; P = .009). This result interestingly suggests that there is useful information hidden in the Lerner grade I category, which could potentially guide immediately actionable treatment decisions. This histologic activity grade system has been in use at our institution for over 2 years with good acceptance.
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Affiliation(s)
- David Myerson
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pathology, University of Washington, Seattle, Washington.
| | - Gideon Steinbach
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Ted A Gooley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Howard M Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pathology, University of Washington, Seattle, Washington
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Lau MSY, Mooney P, White W, Appleby V, Moreea S, Haythem I, Elias J, Bundhoo K, Corbett G, Wong L, Tsai HH, Cross S, Hebden J, Hoque S, Sanders D. 'Pre-endoscopy point of care test (Simtomax- IgA/IgG-Deamidated Gliadin Peptide) for coeliac disease in iron deficiency anaemia: diagnostic accuracy and a cost saving economic model'. BMC Gastroenterol 2016; 16:115. [PMID: 27628523 PMCID: PMC5024457 DOI: 10.1186/s12876-016-0521-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND International guidelines recommend coeliac serology in iron deficiency anaemia, and duodenal biopsy for those tested positive to detect coeliac disease. However, pre-endoscopy serology is often unavailable, thus committing endoscopists to take routine duodenal biopsies. Some endoscopists consider duodenal biopsy mandatory in anaemia to exclude other pathologies. We hypothesise that using a point of care test at endoscopy could fill this gap, by providing rapid results to target anaemic patients who require biopsies, and save costs by biopsy avoidance. We therefore assessed three key aspects to this hypothesis: 1) the availability of pre-endoscopy serology in anaemia; 2) the sensitivities and cost effectiveness of pre-endoscopy coeliac screening with Simtomax in anaemia; 3) whether other anaemia-related pathologies could be missed by this targeted-biopsy approach. METHODS Group 1: pre-endoscopy serology availability was retrospectively analysed in a multicentre cohort of 934 anaemic patients at 4 UK hospitals. Group 2: the sensitivities of Simtomax, endomysial and tissue-transglutaminase antibodies were compared in 133 prospectively recruited patients with iron deficiency anaemia attending for a gastroscopy. The sensitivities were measured against duodenal histology as the reference standard in all patients. The cost effectiveness of Simtomax was calculated based on the number of biopsies that could have been avoided compared to an all-biopsy approach. Group 3: the duodenal histology of 153 patients presenting to a separate iron deficiency anaemia clinic were retrospectively reviewed. RESULTS In group 1, serology was available in 361 (33.8 %) patients. In group 2, the sensitivity and negative predictive value (NPV) were 100 % and 100 % for Simtomax, 96.2 % and 98.9 % for IgA-TTG, and 84.6 % and 96.4 % for EMA respectively. In group 3, the duodenal histology found no causes for anaemia other than coeliac disease. CONCLUSION Simtomax had excellent diagnostic accuracy in iron deficiency anaemia and was comparable to conventional serology. Duodenal biopsy did not identify any causes other than coeliac disease for iron deficiency anaemia, suggesting that biopsy avoidance in Simtomax negative anaemic patients is unlikely to miss other anaemia-related pathologies. Due to its 100 % NPV, Simtomax could reduce unnecessary biopsies by 66 % if only those with a positive Simtomax were biopsied, potentially saving £3690/100 gastroscopies. TRIAL REGISTRATION The group 2 study was retrospectively registered with clinicaltrials.gov. Trial registration date: 13(th) July 2016; TRIAL REGISTRATION NUMBER NCT02834429 .
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Affiliation(s)
- Michelle Shui Yee Lau
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK.
| | - Peter Mooney
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - William White
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Victoria Appleby
- Department of Gastroenterology, Bradford Royal Infirmary, Bradford, UK
| | - Sulleman Moreea
- Department of Gastroenterology, Bradford Royal Infirmary, Bradford, UK
| | - Ismail Haythem
- Department of Gastroenterology, Whipps Cross University Hospital, London, UK
| | - Joshua Elias
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
| | - Kiran Bundhoo
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
| | - Gareth Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
| | - Liam Wong
- Department of Gastroenterology, Hull Royal Infirmary, Hull, UK
| | - Her Hsin Tsai
- Department of Gastroenterology, Hull Royal Infirmary, Hull, UK
| | - Simon Cross
- Academic Unit of Pathology, Department of Neuroscience, Faculty of Medicine, Dentistry & Health, The University of Sheffield, Sheffield, UK
| | - John Hebden
- Department of Gastroenterology, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Sami Hoque
- Department of Gastroenterology, Whipps Cross University Hospital, London, UK
| | - David Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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Rozmus J, Mallhi K, Ke J, Schultz KR. Functional hyposplenism after hematopoietic stem cell transplantation. Bone Marrow Transplant 2015; 50:1343-7. [PMID: 26168071 DOI: 10.1038/bmt.2015.160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 05/26/2015] [Accepted: 05/28/2015] [Indexed: 11/09/2022]
Abstract
Functional hyposplenism is associated with chronic GvHD (cGvHD) following hematopoietic stem cell transplantation (HSCT). We hypothesized that hyposplenism measured by pitted red cell counts in cGvHD was transient and related to the severity of disease. We performed a serial, retrospective review of 36 pediatric post-HSCT patients' pit counts at BC Children's Hospital from 2005 to 2013 and compared those counts with the clinical course of patients with late acute GvHD (aGvHD)/cGvHD. Of the 36 patients, 22 had late aGvHD/cGvHD based on National Institutes of Health consensus criteria. Fourteen of 22 GvHD patients had an abnormal pitted red cell count. Ten of 14 abnormal patients had late acute or overlap GvHD syndrome, primarily gastrointestinal disease. A second cohort was prospectively evaluated in a multicenter adult HSCT biomarker trial. We identified 3 out of 10 control patients who had an abnormal pitted red cell count, 3 out of 10 with classic cGvHD and 5 out of 9 patients with overlap syndrome were abnormal. In both the retrospective and prospective studies, hyposplenism was present in patients without late aGvHD/cGvHD suggesting current guidelines regarding antibiotic prophylaxis against encapsulated bacteria after HSCT need to be re-addressed and abnormal pit counts could be used to guide prophylaxis in all HSCT patients.
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Affiliation(s)
- J Rozmus
- Division of Hematology and Oncology, Department of Pediatrics, Child & Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - K Mallhi
- Division of Hematology and Oncology, Department of Pediatrics, Child & Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - J Ke
- Division of Hematology and Oncology, Department of Pediatrics, Child & Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - K R Schultz
- Division of Hematology and Oncology, Department of Pediatrics, Child & Family Research Institute, University of British Columbia, Vancouver, BC, Canada
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11
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Abstract
The assessment of gastrointestinal (GI) specimens from transplant patients is complicated by the wide range of potentially rare pathologies that may be found in this clinical setting. Acute GI graft-versus-host disease (GvHD) is characterized by epithelial cell apoptosis, although there is increasing recognition that acute and/or chronic inflammation may also be present. By contrast, thus far there are no histological features known to be specific to chronic GI GvHD. Mycophenolate mofetil colitis may mimic both GvHD and inflammatory bowel disease, whereas both cytomegalovirus (CMV) and adenovirus infections can cause gland apoptosis. Post-transplant lymphoproliferative disorder should be considered if a Crohn's-like histological picture is seen, and granulomas in biopsies from umbilical cord blood recipients should raise a suspicion of cord colitis syndrome. Finally, the GI tract may be involved directly or indirectly by the disease that originally required haematopoietic stem cell or liver transplantation.
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Kida A, McDonald GB. Gastrointestinal, Hepatobiliary, Pancreatic, and Iron-Related Diseases in Long-Term Survivors of Allogeneic Hematopoietic Cell Transplantation. Semin Hematol 2012; 49:43-58. [DOI: 10.1053/j.seminhematol.2011.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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13
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Nieder ML, McDonald GB, Kida A, Hingorani S, Armenian SH, Cooke KR, Pulsipher MA, Baker KS. National Cancer Institute-National Heart, Lung and Blood Institute/pediatric Blood and Marrow Transplant Consortium First International Consensus Conference on late effects after pediatric hematopoietic cell transplantation: long-term organ damage and dysfunction. Biol Blood Marrow Transplant 2011; 17:1573-84. [PMID: 21963877 PMCID: PMC3215762 DOI: 10.1016/j.bbmt.2011.09.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 09/27/2011] [Indexed: 01/19/2023]
Abstract
Long-term complications after hematopoietic cell transplantation (HCT) have been studied in detail. Although virtually every organ system can be adversely affected after HCT, the underlying pathophysiology of these late effects remain incompletely understood. This article describes our current understanding of the pathophysiology of late effects involving the gastrointestinal, renal, cardiac, and pulmonary systems, and discusses post-HCT metabolic syndrome studies. Underlying diseases, pretransplantation exposures, transplantation conditioning regimens, graft-versus-host disease, and other treatments contribute to these problems. Because organ systems are interdependent, long-term complications with similar pathophysiologic mechanisms often involve multiple organ systems. Current data suggest that post-HCT organ complications result from cellular damage that leads to a cascade of complex events. The interplay between inflammatory processes and dysregulated cellular repair likely contributes to end-organ fibrosis and dysfunction. Although many long-term problems cannot be prevented, appropriate monitoring can enable detection and organ-preserving medical management at earlier stages. Current management strategies are aimed at minimizing symptoms and optimizing function. There remain significant gaps in our knowledge of the pathophysiology of therapy-related organ toxicities disease after HCT. These gaps can be addressed by closely examining disease biology and identifying those patients at greatest risk for adverse outcomes. In addition, strategies are needed for targeted disease prevention and health promotion efforts for individuals deemed at high risk because of their genetic makeup or specific exposure profile.
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Affiliation(s)
| | - George B. McDonald
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aiko Kida
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sangeeta Hingorani
- University of Washington, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Kenneth R. Cooke
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, Cleveland, OH
| | - Michael A. Pulsipher
- Primary Children’s Medical Center, Division of Hematology/BMT, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, UT
| | - K. Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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14
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Kreisel W, Dahlberg M, Bertz H, Harder J, Potthoff K, Deibert P, Schmitt-Graeff A, Finke J. Endoscopic diagnosis of acute intestinal GVHD following allogeneic hematopoietic SCT: a retrospective analysis in 175 patients. Bone Marrow Transplant 2011; 47:430-8. [PMID: 21706064 PMCID: PMC3296915 DOI: 10.1038/bmt.2011.137] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diagnosis of acute intestinal GVHD (aGVHD) following allogeneic hematopoietic cell transplantation is based on clinical symptoms and histological lesions. This retrospective analysis aimed to validate the 'Freiburg Criteria' for the endoscopic grading of intestinal aGVHD. Grade 1: no clear-cut criteria; grade 2: spotted erythema; grade 3: aphthous lesions; and grade 4: confluent defects, ulcers, denudation of the mucosa. Having excluded patients with infectious diarrhea, we evaluated 175 consecutive patients between January 2001 and June 2009. Setting a cutoff between grade 1 (no change in therapy) and grade 2 (intensification of immunosuppression), macroscopy had a sensitivity of 89.2% (95% confidence interval (CI): 80.4-94.9%), a specificity of 79.4% (95% CI: 69.6-87.1%), a positive-predictive value of 79.6% (95% CI: 70.0-87.2%) and a negative-predictive value of 89.0% (95% CI: 80.2-94.9%). In all, 20% of patients with aGVHD in the lower gastrointestinal tract (GIT) had lesions only in the terminal ileum. In all patients with aGVHD ≥2 of the upper GIT, typical lesions were also found in the lower GIT. Ileo-colonoscopy showed the highest diagnostic yield for aGVHD. In conclusion, the 'Freiburg Criteria' for macroscopic diagnosis of intestinal aGVHD provide high accuracy for identifying aGVHD ≥2.
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Affiliation(s)
- W Kreisel
- Department of Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, University Hospital Freiburg, Hugstetter Street 55, Freiburg, Germany.
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15
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Rozmus J, Schultz KR, Wynne K, Kariminia A, Satyanarayana P, Krailo M, Grupp SA, Gilman AL, Goldman FD. Early and late extensive chronic graft-versus-host disease in children is characterized by different Th1/Th2 cytokine profiles: findings of the Children's Oncology Group Study ASCT0031. Biol Blood Marrow Transplant 2011; 17:1804-13. [PMID: 21669298 PMCID: PMC3190042 DOI: 10.1016/j.bbmt.2011.05.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 05/18/2011] [Indexed: 12/15/2022]
Abstract
Numerous mechanisms underlie chronic graft-versus-host disease (cGVHD), including skewing of Th1/Th2 cytokine expression. There are biological differences between early-onset and late-onset cGVHD. To test whether different Th1/Th2 cytokines are associated with early- or late-onset cGVHD, peripheral blood was collected from 63 children enrolled on the Children's Oncology Group Phase III trial ASCT0031 evaluating hydroxychloroquine therapy for newly diagnosed extensive cGVHD. mRNA expression of interferon (IFN)-γ and interleukin (IL)-2, -4, and -10 from stimulated peripheral blood mononuclear cells was evaluated by quantitative polymerase chain reaction. Early-onset cGVHD (n = 33) was characterized by decreased expression of IFN-γ and IL-2 mRNA after nonspecific phorbol 12-myristate 13-acetate-ionomycin stimulation. In contrast, late-onset cGVHD (n = 11) was characterized by decreased expression of IL-4 and IL-2 mRNA after anti-CD3 stimulation of T cells. Receiver-operating characteristic curve analysis revealed that IFN-γ expression was correlated with the absence of early cGVHD (area under the curve [AUC] = 0.77) and that IL-4 (AUC = 0.89) and IL-2 (AUC = 0.84) expression was correlated with the absence of late cGVHD. There was no correlation between cytokine expression and a specific immune cell subset. Increased expression of Foxp3 mRNA was seen in early-onset cGVHD and late controls. The different time-dependent cytokine profiles in patients with newly diagnosed cGVHD suggests that the mechanisms underlying cGVHD are temporally regulated. Although larger validation studies are needed, our data suggest that cytokine profiles have a potential use as biomarkers for the diagnosis of cGVHD.
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Affiliation(s)
- Jacob Rozmus
- Children’s Oncology Group, Pediatric Hematology/Oncology/BMT, BC Children’s Hospital/University of British Columbia, Vancouver, BC
| | - Kirk R. Schultz
- Children’s Oncology Group, Pediatric Hematology/Oncology/BMT, BC Children’s Hospital/University of British Columbia, Vancouver, BC
- Children’s Oncology Group, Dept. Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC
| | - Kristin Wynne
- Children’s Oncology Group, Pediatric Hematology/Oncology/BMT, BC Children’s Hospital/University of British Columbia, Vancouver, BC
| | - Amina Kariminia
- Children’s Oncology Group, Pediatric Hematology/Oncology/BMT, BC Children’s Hospital/University of British Columbia, Vancouver, BC
| | - Preeti Satyanarayana
- Children’s Oncology Group, Department of Family Medicine, Sacred Heart HealthCare System, Allentown, PA
| | - Mark Krailo
- Children’s Oncology Group, Department of Preventative Medicine, University of Southern California, Los Angeles, CA
| | - Stephan A. Grupp
- Children’s Oncology Group, The Children’s Hospital of Philadelphia/University of Pennsylvania School of Medicine, PA
| | - Andrew L. Gilman
- Children’s Oncology Group, Levine Children’s Hospital, Charlotte, NC
| | - Frederick D. Goldman
- Children’s Oncology Group, Department of Pediatrics, Division of Hematology Oncology, Children’s Hospital of Alabama, Birmingham, AL
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Pimentel VN, de Matos LS, Soares TCB, Adam R, Metze K, Correa MEP, de Souza CA, Cintra ML. Perforin and granzyme B involvement in oral lesions of lichen planus and chronic GVHD. J Oral Pathol Med 2011; 39:741-6. [PMID: 20618609 DOI: 10.1111/j.1600-0714.2010.00917.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Oral lesions of lichen planus and chronic graft-vs.-host disease (cGVHD) have similar clinical and histological features, but distinct etiology. Apoptosis induced by cytotoxic T lymphocyte has been proposed as a mechanism of keratinocytes death. Cytotoxicity can be mediated by granules containing granzyme B and perforin. Since common features can reflect similarities in immunological mechanisms, we studied the role of those molecules in both diseases. METHODS We analyzed 29 cases of oral lichen planus and 27 of oral cGVHD. The sections were studied on H&E, perforin and granzyme B staining. RESULTS The total means (epithelium plus connective tissue number) of the granzyme B- and perforin-positive cells were significantly higher in cGVHD than in oral lichen planus lesions (P<0.05). Also, it was found that the higher the number of perforin+ cells, the higher the number of granzyme-B+ cells in the epithelium and in the connective tissue for both groups (P < 0.05). In oral lichen planus, the number of single apoptotic bodies had a positive correlation with connective tissue granzyme immunostaining and a negative correlation with perforin (P<0.01). On the contrary, in oral cGVHD, the number of apoptotic body clusters presented a positive correlation with connective tissue perforin (P<0.01). CONCLUSIONS Our findings indicate that apoptosis in oral lichen planus seems to be correlated with granzyme B release, while in oral cGVHD, perforin seems to be more important. Although these diseases present clinical and histological similarities, subtle differences seem to exist in their pathogenetic mechanisms.
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17
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Jabri B, Sollid LM. Tissue-mediated control of immunopathology in coeliac disease. Nat Rev Immunol 2009; 9:858-70. [PMID: 19935805 DOI: 10.1038/nri2670] [Citation(s) in RCA: 228] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coeliac disease is an inflammatory disorder with autoimmune features that is characterized by destruction of the intestinal epithelium and remodelling of the intestinal mucosa following the ingestion of dietary gluten. A common feature of coeliac disease and many organ-specific autoimmune diseases is a central role for T cells in causing tissue destruction. In this Review, we discuss the emerging hypothesis that, in coeliac disease, intestinal tissue inflammation--induced either by infectious agents or by gluten--is crucial for activating T cells and eliciting their tissue-destructive effector functions.
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Affiliation(s)
- Bana Jabri
- Department of Medicine, University of Chicago, Chicago, Illinois 60637, USA.
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18
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Shimokaze T, Mitsui T, Takeda H, Kawakami T, Arai T, Ito M, Iwaba A, Izumino H, Takahashi N, Kanno M, Sendo D, Hayasaka K. Severe hemorrhagic colitis caused by dasatinib in Philadelphia chromosome-positive acute lymphoblastic leukemia. Pediatr Hematol Oncol 2009; 26:448-53. [PMID: 19657995 DOI: 10.3109/08880010903071295] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Tomoyuki Shimokaze
- Yamagata University School of Medicine, Department of Pediatrics, Yamagata 990-9585, Japan.
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Patey-Mariaud de Serre N, Canioni D, Ganousse S, Rieux-Laucat F, Goulet O, Ruemmele F, Brousse N. Digestive histopathological presentation of IPEX syndrome. Mod Pathol 2009; 22:95-102. [PMID: 18820676 DOI: 10.1038/modpathol.2008.161] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Immunodysregulation, polyendocrinopathy, enteropathy, and X-linked inheritance (IPEX) syndrome is a well recognized and particularly severe form of autoimmune enteropathy. It has an X-linked recessive transmission, and is caused by mutations in the FOXP3 gene. We studied the intestinal morphological changes characterizing IPEX syndrome in a series of 12 children with a molecularly confirmed diagnosis. Histological examination of duodenal, gastric and colonic biopsies were retrospectively reviewed and compared by two independent experienced pathologists. In parallel, the presence of circulating anti-enterocyte antibodies was analysed using an indirect immunofluorescence technique and a quantitative radioligand assay against the 75-kDa autoantigen. The morphology of the inflammatory gut lesions could be categorized into three different entities, namely graft-vs-host disease-like changes (9/12 patients), a coeliac disease-like pattern (2/12) and an enteropathy with a complete depletion of goblet cells (1/12). Our results do not suggest any phenotype-genotype correlation. Circulating antibodies were detected in all 12 patients, with an anti-brush border pattern (11/12) and anti-goblet cell antibodies (1/12), as well as by a radioligand assay. The histological presentation of autoimmune enteropathy is rather variable. However, a graft-vs-host disease-like pattern associated with positive anti-enterocyte antibodies is the most frequent intestinal presentation of IPEX syndrome, and constitutes a very valuable tool for pathologists to suspect this diagnosis.
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Enteral budesonide in treatment for mild and moderate gastrointestinal chronic GVHD. Bone Marrow Transplant 2008; 42:541-6. [PMID: 18641680 DOI: 10.1038/bmt.2008.209] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Budesonide (BUD) is a steroid with a low bioavailability, which has been used for the treatment of oral manifestations of chronic GVHD (cGVHD). We retrospectively evaluated the efficacy of BUD in the treatment of gastrointestinal cGVHD. Thirteen patients (median age 47 years) receiving BUD for the treatment of cGVHD after allogeneic hematopoietic SCT for hematological malignancies were evaluated for response. Five patients had isolated gastrointestinal cGVHD and 8 patients had mild multiorgan involvement including gastrointestinal manifestations. Six patients received CYA at the time of onset of cGVHD, which was continued during treatment with BUD. Treatment consisted of BUD, with an initial daily dose of 3 x 3 mg orally. Complete resolution of cGVHD was achieved in seven patients, and one patient achieved partial remission of cGVHD. One patient achieved complete resolution of gastrointestinal cGVHD, while systemic manifestations of cGVHD remained stable. Four patients progressed on BUD. Owing to the predominantly local effect, relapse of symptoms of cGVHD after withdrawal of immunosuppression (n=3) as well as progression of GVHD at other sites (n=3) has been observed. BUD represents a treatment option in mild-to-moderate cGVHD, which is well tolerated and associated with a high response rate in gastrointestinal cGVHD.
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21
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Immunohistochemical and FISH analyses identify synovitis associated with chronic GVHD after allogeneic hematopoietic SCT. Bone Marrow Transplant 2008; 42:289-91. [DOI: 10.1038/bmt.2008.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Labbé AC, Su SH, Laverdière M, Pépin J, Patiño C, Cohen S, Kiss T, Lachance S, Sauvageau G, Busque L, Roy DC, Roy J. High Incidence of Invasive Aspergillosis Associated with Intestinal Graft-versus-Host Disease following Nonmyeloablative Transplantation. Biol Blood Marrow Transplant 2007; 13:1192-200. [PMID: 17889356 DOI: 10.1016/j.bbmt.2007.06.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Accepted: 06/28/2007] [Indexed: 10/23/2022]
Abstract
Invasive aspergillosis (IA) remains a major complication following allogeneic hematopoietic stem cell transplant (HSCT). In contrast to conventional HSCT, few investigators have examined risk factors of IA associated with nonmyeloablative (NMA) regimens characterized by outpatient administration, immunosuppression rather than cytoreduction, and short duration of neutropenia posttransplant. We report our results on a cohort of 125 patients treated homogenously who received a 6/6 matched sibling NMA HSCT designed to be performed on an outpatient basis. Conditioning regimen included fludarabine (30 mg/m(2) x 5 days) and cyclophosphamide (300 mg/m(2) x 5 days) followed by reinfusion of a minimum of 4 x 10(6) CD34(+) cells/kg. Acute graft-versus-host disease (aGVHD) prophylaxis consisted of tacrolimus and mycophenolate mofetil (MMF). Overall, 13 patients developed IA (5 proved, 6 probable, 2 possible) 44-791 days (median 229) after NMA HSCT, with a risk of 7% at 1, 11% at 2, and 15% at 3 years. Patients who suffered from IA had poorer overall survival (crude hazard ratio 2.3; 95% confidence interval [CI] 1.0-5.4; P = .045). Intestinal aGVHD or chronic GVHD (cGVHD) was significantly associated with IA at 1 (27% versus 3%, P = .003), 2 (27% versus 8%, P = .01), and 3 years (37% versus 10%, P = .005). The use of daclizumab was also significantly associated with IA at 3 years (47% versus 12%, P = .02). Age, sex, diagnosis, previous autologous transplant, duration of neutropenia, occurrence of cytomegalovirus viremia, duration of steroids or MMF intake, aGVHD, cGVHD, and cumulative number of days spent in hospital were not associated with IA. After multivariate analysis, intestinal GVHD remained the only statistically significant risk factor for IA at 1 (P = .003), 2 (P = .01), and 3 years (P = .005). We conclude that in NMA HSCT, the risk of IA increases over time and is significantly associated with intestinal GVHD. Because there is currently no surrogate in vitro markers of immunocompetence following NMA HSCT, this clinical finding is of particular importance to identify a population at higher risk who should be targeted for antimold prophylaxis.
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Affiliation(s)
- Annie-Claude Labbé
- Department of Microbiology and Infectious Diseases, Hôpital Maisonneuve-Rosemont and Université de Montréal, Montreal, Canada
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23
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Schultz KR, Miklos DB, Fowler D, Cooke K, Shizuru J, Zorn E, Holler E, Ferrara J, Shulman H, Lee SJ, Martin P, Filipovich AH, Flowers MED, Weisdorf D, Couriel D, Lachenbruch PA, Mittleman B, Vogelsang GB, Pavletic SZ. Toward biomarkers for chronic graft-versus-host disease: National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: III. Biomarker Working Group Report. Biol Blood Marrow Transplant 2006; 12:126-37. [PMID: 16443511 DOI: 10.1016/j.bbmt.2005.11.010] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Accepted: 11/11/2005] [Indexed: 12/22/2022]
Abstract
Biology-based markers that can be used to confirm the diagnosis of chronic graft-versus-host disease (GVHD) or monitor progression of the disease could help in the evaluation of new therapies. Biomarkers have been defined as any characteristic that is objectively measured and evaluated as an indicator of a normal biologic or pathogenic process, a pharmacologic response to a therapeutic intervention, or a surrogate end point intended to substitute for a clinical end point. The following applications of biomarkers could be useful in chronic GVHD clinical trials or management: (1) predicting response to therapy; (2) measuring disease activity and distinguishing irreversible damage from continued disease activity; (3) predicting the risk of developing chronic GVHD; (4) diagnosing chronic GVHD: (5) predicting the prognosis of chronic GVHD; (6) evaluating the balance between GVHD and graft-versus-leukemia effects (graft-versus-leukemia or GVT); and (7) serving as a surrogate end point for therapeutic response. Such biomarkers can be identified by either hypothesis-driven testing or by high-throughput discovery-based methods. To date, no validated biomarkers have been established for chronic GVHD, although several candidate biomarkers have been identified from limited hypothesis-driven studies. Both approaches have merit and should be pursued. The consistent treatment and standardized documentation needed to support biomarker studies are most likely to be satisfied in prospective clinical trials.
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Affiliation(s)
- Kirk R Schultz
- British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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Auw-Haedrich C, Potsch C, Böhringer D, Mittelviefhaus H, Maier P, Reinhard T, Freudenberg N, Finke J, Coupland SE. Histological and immunohistochemical characterisation of conjunctival graft vs host disease following haematopoietic stem cell transplantation. Graefes Arch Clin Exp Ophthalmol 2006; 245:1001-7. [PMID: 17120011 DOI: 10.1007/s00417-006-0448-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Revised: 08/29/2006] [Accepted: 09/10/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Conjunctival graft vs host disease (cnGvHD) is a complication of haematopoietic stem cell transplantation, in most cases as part of systemic GvHD. Diagnostic biopsies are commonly collected from bulbar conjunctiva only. The aims of our study were to evaluate whether additional biopsies from the tarsal conjunctiva increase sensitivity upon histopathologic evaluation and to investigate the staining profile for common immunohistochemical markers in cnGvHD. We additionally propose an adaptive histological classification for cnGvHD analogous to Lerner's GvHD skin classification for predicting patient survival. METHODS Formalin-fixed and paraffin-embedded conjunctival specimens from 23 post-mortem control eyes and 42 patients after haematopoietic stem cell transplantation (HSCT) were stained with haematoxylin and eosin (HE), periodic acid-Schiff (PAS) stain and with antibodies against CD1a, CD4, CD8, CD25, CD45RO, CD68, Fas ligand, TIA-1, HLA-DRalpha by means of immunohistochemistry. Cell counting took place in ten representative fields at 64.4 microm (length) x 21.2 microm (width). Multifactorial analysis of variance was performed to assess any influence of cnGvHD on the staining pattern for the immunohistochemical markers. Survival times were estimated by the Kaplan-Meier method. RESULTS All 42 specimens and none of the controls were diagnosed as cnGvHD. The bulbar specimens were staged according to the modified Lerner classification: grade (G) I: 0; G II: 17 (tarsal with G<or=II, 2; G>II, 8); G III: 12 (tarsal with G<or=III: 2; G>III: 1); G IV: 12 (tarsal with G<or=IV: 6); G V: 1. The number of pairs with either the tarsal or bulbar counterpart being more severely affected was almost equal (10 vs 9). A tendency towards shorter survival in advanced bulbar cnGvHD was demonstrated (G III-V vs G I-II, p =0.06). Staining for the immunohistochemical markers in cnGvHD differed significantly from that in controls (p<0.01). Proposed markers for cnGvHD (e = epithelium, s = stroma; mean cell counts +/- SD; cnGvHD vs controls) are: CD8 s (15.7 +/- 18.4 vs 6 +/- 5.6), CD25 s (2.6 +/- 2.8 vs 0.7 +/- 1.6), CD68 s (8 +/- 9 vs 3.9 +/- 3.5) at the bulbar site and CD1a e (1.2 +/- 1.6 vs 0.3 +/- 0.6) and TIA-1 e (2.2 +/- 2.2 vs 1.1 +/- 1.3) at the tarsal site. CONCLUSIONS Additional tarsal biopsy does not seem to add relevant diagnostic sensitivity for cnGvHD when the modified Lerner classification is applied. The modified Lerner classification of the bulbar cnGvHD seems to be of prognostic value.
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Affiliation(s)
- Claudia Auw-Haedrich
- Eye Hospital, Albert-Ludwigs University, Killianstrasse 5, 79106 Freiburg, Germany.
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25
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Yoshida A, Kawano YI, Kato K, Yoshida S, Yoshikawa H, Muta T, Eto T, Gondo H, Shibuya T, Ishibashi T, Yamana T. Apoptosis in perforated cornea of a patient with graft-versus-host disease. Can J Ophthalmol 2006; 41:472-5. [PMID: 16883364 DOI: 10.1016/s0008-4182(06)80010-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE REPORT Although ocular complications associated with graft-versus-host disease (GVHD) can include corneal dysfunction, corneal perforation is not common. We report the presence of apoptotic cells in a perforated cornea of a patient with GVHD. A 72-year-old man with the angioimmunoblastic type of malignant lymphoma developed chronic GVHD after allogeneic peripheral blood stem cell transplantation. Despite systemic and topical treatment, both corneas perforated, and penetrating keratoplasty with cataract extraction and intraocular lens implantation was performed on both eyes. COMMENTS The corneal button excised from the right eye was examined histologically and stained for apoptotic cells by TdT-mediated dUTP nick end labeling (TUNEL). This revealed thinning of the epithelial cell layer and stroma, with cells, including lymphocytes, infiltrating to the site of the perforation. Some of the epithelial cells and keratocytes were TUNEL positive. The presence of apoptotic cells in our case suggests that apoptosis may be involved in the perforation of the cornea in patients with GVHD.
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Affiliation(s)
- Ayako Yoshida
- Department of Opthalmology, Hamanomachi Hospital, Fukuoka, Japan.
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Zorn E, Kim HT, Lee SJ, Floyd BH, Litsa D, Arumugarajah S, Bellucci R, Alyea EP, Antin JH, Soiffer RJ, Ritz J. Reduced frequency of FOXP3+ CD4+CD25+ regulatory T cells in patients with chronic graft-versus-host disease. Blood 2005; 106:2903-11. [PMID: 15972448 PMCID: PMC1895303 DOI: 10.1182/blood-2005-03-1257] [Citation(s) in RCA: 357] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Chronic graft-versus-host disease (cGVHD) is a major complication of allogeneic hematopoietic stem cell transplantation but the immune mechanisms leading to the diverse clinical manifestations of cGVHD remain unknown. In this study, we examined regulatory T cells (Tregs) in 57 transplant recipients (30 with cGVHD and 27 without active cGVHD) and 26 healthy donors. Phenotypic studies demonstrated decreased frequency of CD4+CD25+ T cells in patients with cGVHD compared with patients without cGVHD (P < .001) and healthy individuals (P < .001). Gene expression of Treg transcription factor FOXP3 was reduced in cGVHD patients compared with patients without cGVHD (P = .009) or healthy donors (P = .01). T-cell receptor excision circle (TREC) assays for the evaluation of thymus activity revealed fewer TRECs in both transplant groups compared with healthy donors (P < .001 and P = .02, respectively) although no difference was observed between patients with or without cGVHD (P = .13). When tested in functional assays, Tregs from both patient cohorts and healthy individuals mediated equivalent levels of suppression. Collectively, these studies indicate that patients with active cGVHD have reduced frequencies of Tregs but the function of these cells remains normal. These findings support the development of new strategies to increase the number of Tregs following allogeneic hematopoietic stem cell transplantation to prevent or correct cGVHD.
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Affiliation(s)
- Emmanuel Zorn
- Department of Medical Oncology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115, USA
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Hematopoietic Stem Cell Transplantation. Clin Nutr 2005. [DOI: 10.1016/b978-0-7216-0379-7.50052-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Mazariegos GV, Abu-Elmagd K, Jaffe R, Bond G, Sindhi R, Martin L, Macedo C, Peters J, Girnita A, Reyes J. Graft versus host disease in intestinal transplantation. Am J Transplant 2004; 4:1459-65. [PMID: 15307833 DOI: 10.1111/j.1600-6143.2004.00524.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Our aim was to analyze the clinical course and outcome of patients with graft vs. host disease (GVHD) after intestinal transplantation (ITx). All patients receiving ITx between May, 1990 and December, 2003 were retrospectively reviewed for evidence of GVHD. Two hundred and fifty patients underwent ITx during the study period. Graft vs. host disease was suspected clinically in 23 patients on the clinical basis of presentation such as skin rash, ulceration of oral mucosa, diarrhea, lymphadenopathy, or native liver dysfunction. Fourteen (eight children and six adults) patients (5.6% of total patient population) had GVHD confirmed by histopathological criteria including keratinocyte necrosis (n = 9), epithelial apoptosis of the native gastrointestinal tract (n = 4), and epithelial cell necrosis of oral mucosa (n = 1). Donor-cell tissue infiltration or extensive peripheral blood donor-cell chimerism was documented on seven occasions. The majority of cases of GVHD resolved with steroid administration and optimization of tacrolimus immunosuppression. The incidence of histologically proven GVHD after clinical intestinal transplantation is 6.5% (8/122) in children and 4.7% (6/128) in adults. Successful clinical management requires a high index of suspicion to minimize morbidity and mortality. Diagnostic and treatment strategies based on this experience are proposed.
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Affiliation(s)
- George V Mazariegos
- Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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