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Abstract
Celiac disease is a gluten-triggered immune-mediated disorder, characterized by inflammation of the enteric mucosa following lymphocytic infiltration and eventually resulting in villous blunting. There have been many developments in refining diagnostic laboratory tests for celiac disease in the last decade. Biopsy-sparing diagnostic guidelines have been proposed and validated in a few recent prospective studies. However, despite these developments, histologic evaluation of duodenal mucosa remains one of the most essential diagnostic tools as it helps in the diagnosis of celiac disease in individuals who do not fulfill the biopsy-sparing diagnostic criteria and in those not responding to a gluten-free diet. Histologic evaluation also allows for the assessment of mucosal recovery after treatment and in the identification of concurrent intestinal diseases. Therefore, pathologists should be familiar with the histologic spectrum of celiac disease and need to be aware of other disorders with similar symptoms and histopathology that may mimic celiac disease. This review aims to provide pathologists with updates on celiac laboratory testing, biopsy-sparing diagnostic criteria, histopathology, complications, and differential diagnoses of celiac disease.
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Yee EU, Goldsmith JD. Diarrheal Illness in the Pediatric Population: A Review of Neonatal Enteropathies and Childhood Idiopathic Inflammatory Bowel Disease. Surg Pathol Clin 2013; 6:523-543. [PMID: 26839099 DOI: 10.1016/j.path.2013.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In the clinical context of pediatric diarrheal illness, the interpretation of endoscopic mucosal biopsies varies significantly from that in adults. This review outlines these differences by first describing a host of diarrheal illnesses that are nearly exclusive to the pediatric age group. The final portion of this article describes salient pathologic differences between adult and pediatric idiopathic inflammatory bowel disease. The goal of this review is to provide a brief description of each disease process and focus on practical aspects of diagnosis that are applicable for pathologists working in general practice settings.
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Affiliation(s)
- Eric U Yee
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Children's Hospital Boston, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jeffrey D Goldsmith
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Children's Hospital Boston, 330 Brookline Avenue, Boston, MA 02215, USA.
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3
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Abstract
Primary immunodeficiencies are important disorders because they typically cause severe illness in affected patients. In addition, these diseases provide a unique glimpse at the underpinnings of the immune system in humans. Susceptibility to infections, including those caused by parasites, is a hallmark of these immune defects. Understanding the association between primary immunodeficiencies and parasitic infections will likely improve our grasp on the mechanisms of defense against these pathogens.
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Affiliation(s)
- C S Subauste
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0560, USA.
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Ballow M. Clinical and investigational considerations for the use of IGIV therapy. Am J Health Syst Pharm 2005; 62:S12-8; quiz S19-21. [PMID: 16100383 DOI: 10.2146/ajhp050283] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Clinical uses of immunoglobulin intravenous (IGIV) therapy for a number of autoimmune and inflammatory diseases are discussed, as well as the probable mechanisms by which IGIV exerts its immunoregulatory and antiinflammatory actions. Case studies are also presented to examine practical considerations in the selection of IGIV products for patients at risk for adverse events. SUMMARY At present, the Food and Drug Administration has approved IGIV for use in six conditions, including replacement therapy for patients with antibody-deficiency disease, adjunct therapy in patients with poor antibody-producing capabilities, prophylaxis against certain types of infections, and several autoimmune disorders, including idiopathic thrombocytopenic purpura and Kawasaki disease. Numerous mechanisms have been proposed to explain the beneficial effects of IGIV, including the interaction of infused IgG with fragment crystallizable (Fc) receptors and complement proteins, the modulation of synthesis and release of cytokines and cytokine antagonists, and neutralization of circulating autoantibodies.IGIV products differ significantly in methods of production, virus elimination, formulation, and composition. These differences can potentially have an impact on safety, tolerability, and efficacy. The major features affecting tolerability include volume load, sugar and salt content, and osmolality. Case studies highlight how these product characteristics could affect patient outcomes. CONCLUSION While numerous mechanisms have been proposed to explain the beneficial effects of IGIV, the specific mechanisms remain elusive. Patient outcomes can be affected by IGIV product characteristics. The choice of an IGIV product should be matched to the patient's risk-factor profile.
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Affiliation(s)
- Mark Ballow
- Department of Pediatrics, Women and Children's Hospital of Buffalo, SUNY Buffalo School of Medicine and Biomedical Sciences, 219 Bryant Street, Buffalo, NY 14222, USA.
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Ballow M. Intravenous immunoglobulins: clinical experience and viral safety. JOURNAL OF THE AMERICAN PHARMACEUTICAL ASSOCIATION (WASHINGTON, D.C. : 1996) 2002; 42:449-58; quiz 458-9. [PMID: 12030632 DOI: 10.1331/108658002763316888] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To discuss the current procedures and processes by which viral safety is ensured for intravenous immunoglobulins (IVIGs), to place in context the current increase in clinical indications for IVIGs, and to describe the safety issues that have led to product shortages. DATA SOURCES Articles on viral safety retrieved from MEDLINE using the search terms gamma globulin, intravenous, adverse reaction, and infection and information from the manufacturers' literature and Food and Drug Administration package inserts. STUDY SELECTION AND DATA EXTRACTION Studies that specifically addressed the areas of major concern or advancement in viral safety of IVIGs, including donor selection, plasma screening, and other quality control procedures to ensure safety of source plasma; detection of viruses that may have escaped antibody screening tests through the use of polymerase chain reaction-based assays, which are capable of detecting small amounts of viral genomic material (e.g., hepatitis C virus, hepatitis B virus, and human immunodeficiency virus [HIV]) in small plasma pools; and industrial-scale, validated viral inactivation methods, such as pasteurization and solvent/detergent treatment, that have been incorporated into the manufacturing processes of immunoglobulins to further minimize the risk of viral transmission. DATA SYNTHESIS In addition to the treatment of primary immunodeficiency disorders, the clinical uses of IVIGs have expanded to include treatment of Kawasaki's syndrome, idiopathic thrombocytopenic purpura, infection following bone marrow transplantation, secondary immunologic disorders (e.g., pediatric HIV infection), hematologic disorders (e.g., chronic lymphocytic leukemia), and neurologic indications (e.g., Guillain-Barré syndrome). Although IVIG preparations are derived from human plasma, they have a long safety record and a low risk for transmitting viral infections. CONCLUSION Viral validation studies demonstrated that the processes discussed herein differ in their capabilities to inactivate lipid-enveloped and nonlipid-enveloped viruses.
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Affiliation(s)
- Mark Ballow
- Division of Pediatric Allergy/Immunology/Rheumatology, Children's Hospital of Buffalo, NY 14222, USA.
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Lee ML, Gale RP, Yap PL. Use of intravenous immunoglobulin to prevent or treat infections in persons with immune deficiency. Annu Rev Med 1997; 48:93-102. [PMID: 9046948 DOI: 10.1146/annurev.med.48.1.93] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intravenous immunoglobulin (IVIG) concentrates were originally developed as replacement therapy for individuals with primary deficiencies of the immune system. However, in various well-designed, controlled clinical trials, the ability of IVIG to prevent and possibly treat infections in patients with secondary immune deficiencies has also been considered. In this review, we briefly consider these different applications and suggest whether the data are sufficient to employ IVIG in these clinical settings.
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Affiliation(s)
- M L Lee
- International Quantitative Consultants, Inc., Glendale, California 91203, USA
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Springer SC, Key JD. Vitamin B12 deficiency and subclinical infection with Giardia lamblia in an adolescent with agammaglobulinemia of Bruton. J Adolesc Health 1997; 20:58-61. [PMID: 9007660 DOI: 10.1016/s1054-139x(96)00171-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S C Springer
- Department of Pediatrics, Medical University of South Carolina, Charleston 29425, USA
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8
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Abstract
X-linked agammaglobulinemia (XLA), characterized by a profound deficiency of B lymphocytes due to an arrest in B lymphocyte development, is caused by mutations in the gene encoding Btk (Bruton tyrosine kinase). The BTK gene has been cloned and the genomic organization determined. BTK codes for 19 exons and is expressed in all hematopoietic cell lineages but is selectively down-regulated in T lymphocytes and plasma cells. The different Btk domains include PH, TH, SH3, SH2, and the kinase (SH1) domains. Btk, a cytoplasmic protein tyrosine kinase, is involved in cell signaling, although the precise pathway remains elusive. Mutation analysis has been performed in 236 families representing 282 patients. Mutations are scattered throughout the gene and consist of missense, nonsense, and splice site mutations as well as deletions and insertions. The major consequence of nonfunctional Btk appears to be a delay or block of the development of pro-B cells to pre-B cells and then to mature lymphocytes. Because IgG is actively transported across the placenta, affected newborns have normal levels of serum IgG at birth followed by gradually decreasing IgG levels and development of hypogammaglobulinemia and increased susceptibility to infections. Bacterial infections are the most common clinical manifestation. Resistance to viral infection is intact, except for an unusual susceptibility to infections with enteroviruses that may result in vaccine-related paralytic poliomyelitis or a dermatomyositis-meningoencephalitis syndrome. The diagnosis of XLA is based on the presence of lymphoid hypoplasia, markedly reduced serum levels of all 3 major classes of immunoglobulins, failure to make antibody to antigenic stimulation, and almost complete absence of B lymphocytes in the peripheral blood. Carrier detection and prenatal diagnosis are possible. The prophylactic infusion of high-dose intravenous immunoglobulin (IVIG) and the use of antibiotics have markedly improved the long-term prognosis of patients with XLA.
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Affiliation(s)
- H D Ochs
- Department of Pediatrics, University of Washington, Seattle 98195-6320, USA
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Affiliation(s)
- P Sideras
- Department of Cell and Molecular Biology, Umeå University, Sweden
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10
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Rubin JT, Lotze MT. IMMUNE FUNCTION AND DYSFUNCTION. Radiol Clin North Am 1992. [DOI: 10.1016/s0033-8389(22)02507-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Crennan JM, Van Scoy RE, McKenna CH, Smith TF. Echovirus polymyositis in patients with hypogammaglobulinemia. Failure of high-dose intravenous gammaglobulin therapy and review of the literature. Am J Med 1986; 81:35-42. [PMID: 3728553 DOI: 10.1016/0002-9343(86)90179-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A 29-year-old man with X-linked hypogammaglobulinemia was treated with prednisone and methotrexate for polymyositis. Subsequently, it was established that disseminated echovirus 11 infection was causing the polymyositis. Treatment with large doses of intravenous gammaglobulin did not result in improvement. Viral cultures of blood, urine, and cerebrospinal fluid gave positive results throughout treatment and at postmortem examination. Multiple cultures of other tissues, including muscle, also gave positive results at postmortem examination. Severity of infection and treatment with prednisone and methotrexate prior to referral, diagnosis, and gammaglobulin treatment may explain the lack of response. A review of 23 cases of echovirus infection in patients with hypogammaglobulinemia revealed that the infection in these patients may cause meningoencephalitis or a polymyositis-like syndrome or both. Treatment with immunosuppressive agents, the standard therapy for polymyositis, is contraindicated, and intravenous or intraventricular gammaglobulin or both may be helpful.
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15
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Ament ME. Immunodeficiency syndromes and the gut. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1985; 114:127-35. [PMID: 3911369 DOI: 10.3109/00365528509093773] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The gastrointestinal tract in immunodeficiency disorders is involved with diseases similar to those seen in the immune competent. However, in some immune deficient states the incidence of gastrointestinal disease is high whereas in others it is no different than in the general population. This review clarifies the unique and specific abnormalities seen in immune deficient states and stresses the newest recognised abnormalities. It highlights the fact that the most frequent and severe abnormalities occur in patients with combined immune deficient states.
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Abstract
Intestinal parasites not only cause diarrheal illnesses but may also cause significant malabsorption in man. Separation of true malabsorption caused by a particular parasite from other factors that may coexist with and even mimic malabsorption, such as malnutrition may be very difficult. Despite these problems, it appears that giardiasis, coccidiasis, strongyloidiasis and capillariasis cause malabsorption of many important nutrients. D. latum interfere with vitamin B12 absorption.
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23
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Whitehead R, Skinner JM. Morphology of the gut associated lymphoid system in health and disease: a review. Pathology 1978; 10:3-16. [PMID: 347360 DOI: 10.3109/00313027809063475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Burke JA. The clinical and laboratory diagnosis of giardiasis. CRC CRITICAL REVIEWS IN CLINICAL LABORATORY SCIENCES 1977; 7:373-91. [PMID: 143358 DOI: 10.3109/10408367709151690] [Citation(s) in RCA: 39] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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26
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Abstract
The descriptive studies of intestinal lesions in immune deficiency and the research that has been done in order to explain their pathogenesis are reviewed. Current knowledge in this field is inadequate, and some of the intriguing phenomena described defy reasonable explanation, including the special role of Giardia lamblia and the rarity of gastrointestinal lesions in isolated IgA deficiency. Several hypotheses have been proposed regarding these phenomena.
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28
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Skinner JM, Whitehead R. Immunological aspects of gastro-intestinal pathology. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1976; 63:259-88. [PMID: 795615 DOI: 10.1007/978-3-642-66481-6_8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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30
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Rhee JW, Gryboski JD, Sheahan DG, Dolan TF, Dwyer JM. Reversible enteritis and lymphopenia in infantile X-linked agammaglobulinemia. THE AMERICAN JOURNAL OF DIGESTIVE DISEASES 1975; 20:1071-5. [PMID: 1199999 DOI: 10.1007/bf01071197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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31
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Armstrong D, Chmel H, Singer C, Tapper M, Rosen PP. Non-bacterial infections associated with neoplastic disease. Eur J Cancer 1975; 11suppl:79-94. [PMID: 176031 DOI: 10.1016/b978-0-08-019964-1.50013-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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32
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Norman ME, Hansell JR, Holtzapple PG, Parks JS, Waldmann TA. Malabsorption and protein-losing enteropathy in a child with X-linked agammaglobulinemia. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1975; 4:157-64. [PMID: 49233 DOI: 10.1016/0090-1229(75)90051-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Kettis AA, Thorén G. Inter- and intrafamilial distribution of giardia lamblia infection. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1974; 6:349-53. [PMID: 4450101 DOI: 10.3109/inf.1974.6.issue-4.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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