Antiphospholipid syndrome manifested by ischemic stroke in a patient with Crohn's disease

Increased risk of stroke among patients with Crohn's disease: a population-based matched cohort study

BACKGROUND

Crohn's disease (CD) is one type of inflammatory bowel disease (IBD) that has been speculated to share prognostic factors with the development of stroke. There is controversial information in the literature regarding the association between CD and stroke. The present cohort study estimated the risk of subsequent stroke among CD patients compared with matched comparison subjects drawn from a population-based dataset in Taiwan.

METHOD

This study drew data from the Taiwan National Health Insurance Database to conduct a historical cohort study. The study cohort comprised 3309 CD patients, and the comparison cohort comprised 13,236 subjects without an IBD. Cox proportional hazards regressions were performed to estimate the risk of subsequent stroke during the follow-up period. We also conducted additional analyses stratifying by age group and gender.

RESULTS

After adjusting for selected medical co-morbidities and recent prescriptions of selected pharmaceuticals, the hazard ratio (HR) for subsequent stroke among patients with CD was found to be 1.911 (95% confidence interval (CI) = 1.65-2.22) that of comparison subjects. While we did not detect an association between stroke and CD among patients aged 30-40 years, we did detect increased risks for stroke among CD patients aged 40-50 years (HR = 2.29) and those aged over 50 years (HR = 1.88). We also found women (HR = 2.39) to be at a greater risk than men (HR = 1.50).

CONCLUSION

This study reports an increased HR for subsequent stroke among CD patients when compared to matched comparison patients without IBD in an Asian population.

Increased risk of stroke among patients with ulcerative colitis: a population-based matched cohort study

BACKGROUND

The risk of venous thromboembolism (VTE) and the development of atherosclerosis are increased in patients with inflammatory bowel disease (IBD). Ulcerative colitis (UC) is one type of IBD; however, there is controversy in the literature regarding the association between UC and stroke. The present cohort study estimated the risk of subsequent stroke among UC patients compared with that among matched comparison subjects drawn from a population-based data set in Taiwan.

METHODS

This investigation analyzed administrative claims data sourced from the Taiwan National Health Insurance Database. Our study consisted of a study cohort comprising 516 UC patients and a comparison cohort of 2,579 subjects without IBD. Cox proportional hazards regressions were performed to estimate the risk of subsequent stroke during the follow-up period. We also conducted additional analyses investigating the risk of subsequent stroke by age group and gender.

RESULTS

After adjusting for selected medical co-morbidities and recent prescriptions of selected pharmaceuticals, the hazard ratio (HR) for subsequent stroke among patients with UC was 2.045 (95 % confidence interval (CI) = 1.374-3.043) than that among comparison subjects. While we did not detect an association between stroke and UC among patients aged 30-40 or 40-50 years, we did detect increased risks for stroke among UC patients aged over 50 years (HR = 2.045). We also found the association to remain significant for both men (HR = 2.153) and women (HR = 2.750).

CONCLUSIONS

This study detected an increased HR for subsequent stroke among Taiwanese UC patients hen compared to that among matched comparison patients without IBD.

Cerebral arterial infarction in inflammatory bowel diseases

It has been estimated that up to 10% of hypercoagulable state manifestations in patients with inflammatory bowel disease (IBD) are ischemic strokes. The literature search through MEDLINE and EMBASE highlighted 33 case reports of IBD patients complicated with cerebral arterial infarction during the course of their disease. Most of these patients presented with either left or right sided hemiparesis on admission, while the most common site of arterial infarction was either the right or the left middle cerebral artery. Thrombocytosis and anemia were the most commonly observed potential risk factors for stroke in the laboratory analysis. Other coagulation abnormalities, hereditary thrombotic mutations, hyperhomocysteinemia, hyperlipidemia, structural cardiac abnormalities, endocarditis and cerebral artery vasculitis have also been reported in some of the cases that were reviewed. Even though many of these findings are commonly observed in IBD patients, literature data is still controversial about their causal relationship to ischemic stroke. Similarly, there is also lack of steady evidence and official guidelines for stroke management in both children and adults with IBD comorbidity. Finally, an algorithm based on both the American Heart Association and European Stroke Organization guidelines for stroke management and prevention in the general population, is presented as a reference point for the treatment of IBD patients who are complicated by an ischemic cerebral event.

Inflammatory bowel disease and lupus: a systematic review of the literature

Coexistence of systemic lupus erythematosus (SLE) should be considered in patients with inflammatory bowel disease (IBD) and complex extraintestinal manifestations and the diagnosis of IBD could be established either before or after the diagnosis of SLE. Differential diagnosis of concomitant SLE and IBD is difficult and should always exclude infectious conditions, lupus-like reactions, visceral vasculitis and drug-induced lupus. The underlying mechanism by which 5-ASA/sulphasalazine induces SLE or lupus-like syndromes is not clear and high awareness for possible predictive factors is demanded for early prevention. In most cases the symptoms from drug-induced lupus have been reversible after the discontinuation of the drug and response to steroids is favorable. Treatment of patients co-diagnosed with SLE and IBD may include corticosteroids, immunosupressants and hydroxychloroquine. In severe lupus and IBD patients cyclophosphamide pulse may be of benefit while infliximab may be beneficiary in patients with lupus nephritis. However, the role TNFalpha plays in humans with SLE and IBD is controversial and data on the likely effects of blocking TNFalpha on anti-DNA autoantibody production is always of interest.

Coexistence of Crohn's disease in a patient with systemic lupus erythematosus

The concurrence of inflammatory bowel disease with systemic lupus erythematosus (SLE) is rare. The concomitant diagnosis of Crohn's disease and SLE is even more rare. The patient, a 40-year-old woman, was admitted to our hospital because of relapsing episodes of abdominal pain, diarrheas upper and lower extremities arthralgias, Raynaud's phenomenon with positive antinuclear antibodies, and fever for the last 2 years. The patient was diagnosed elsewhere with SLE and treated with hydroxychloroquine. Her medical history also included tonsillectomy and total hip replacement after a car accident. Family history was unremarkable. Physical examination was unremarkable except of very mild pain at lower left abdominal quadrant. Laboratory tests showed erythrocyte sedimentation rate at 32 mm/h, C-reactive protein at 36 mg/dl, positive rheumatoid factor, and increased C3, C4, positive antinuclear antibodies with the presence of anti-Sm and anti-RNP antibodies. Ileocolonoscopy revealed colonic inflammation with ulcers and pseudopolyps. Subsequent biopsies were diagnostic of Crohn's disease. Patient was diagnosed with Crohn's colitis concomitant to systemic lupus erythematosus and was started on therapy with azathioprine 2 mg/Kg, methylprednisolone 16 mg/d with slow tapering, mesalazine 1.5 g/day, and hydroxychloroquine. Patient is in excellent health status on the six-month follow-up.

Risk of ischemic stroke in patients with Crohn's disease: a population-based nested case-control study

BACKGROUND

Observational studies have linked Crohn's disease (CD) to an increased risk of venous thromboembolic complications. Case reports of ischemic stroke in CD patients have raised the question of a similar association, but data from observational studies are lacking.

METHODS

Using data from the UK General Practice Research Database we conducted a nested case-control analysis within a population-based cohort of 8054 patients with and 161,078 patients without CD. A total of 1748 cases of ischemic stroke were identified to whom 17,348 controls were matched on age, sex, and year of cohort entry. Adjusted odds ratios (ORs) of ischemic stroke associated with CD were calculated by conditional logistic regression. Stratified analyses were performed for age and sex.

RESULTS

While CD was not associated with an overall increased risk of ischemic stroke (OR 1.10, 95% confidence interval [CI] 0.85-1.43), stratified analyses revealed an increase in risk in younger patients (<50 years: OR 2.93; 95% CI 1.44-5.98) but not in elderly patients (> or =50 years: OR 0.99; 95% CI 0.75-1.30; P for interaction <0.01). The interaction with age remained statistically significant even after changing the cutoff value for the younger and older age group to 45, 55, or 60 years in a sensitivity analysis. There was no interaction with sex (P = 0.79).

CONCLUSIONS

The study indicates that younger patients with CD may be under an increased risk of ischemic stroke.

Neurologic presentations of gastrointestinal disease

In recent years, there has been increasing recognition of the presence of gastrointestinal (GI) dysfunction in the setting of neurologic diseases. Parkinson's disease is a particularly well-known example, but GI dysfunction also may occur in multiple sclerosis, stroke, and in various myopathic and peripheral neuropathic processes. There is much less awareness, however, that primary GI diseases may also display neurologic dysfunction as part of their clinical picture. This article focuses on some of those disease processes. Illnesses primarily targeting the GI tract are addressed and examples of primary esophageal, gastric, and intestinal disease processes are described.

[Neurological complications of inflammatory bowel disease]

Although ulcerative colitis and Crohn's disease have traditionally been considered to be inflammatory diseases limited to the gastrointestinal tract, it has been shown that both pathologies are frequently accompanied by various extraintestinal disorders. There is an increasing evidence that they may also manifest in the nervous system, including the peripheral and the central parts. Although some of these neurological complications have been known for a long time, such as cerebrovascular disease, vasculitis and autoinmune processes including neuropathies and cerebral demyelination, others have been recently described. With the exception of some of this complications such as the thromboembolism, evidence for a casual relationship relies merely on single case reports or case series. In this article, we try to review the existing evidence on neurological manifestations of both variants of inflammatory bowel disease.

The incidence of arterial thromboembolic diseases in inflammatory bowel disease: a population-based study

BACKGROUND & AIMS

We aimed to determine if there was an increased risk for arterial thromboembolic diseases (ATED) in inflammatory bowel disease (IBD).

METHODS

We used the University of Manitoba IBD Epidemiology Database (1984-2003) (n = 8060), and a matched cohort (n = 80,489) drawn from the Manitoba Health administrative database. Each IBD case and non-IBD control has a unique personal health identification number and each health system encounter is identified by a diagnostic code (International Classification of Diseases, 9th revision [ICD-9]). We compared the IBD with the non-IBD cohorts for the incidence of ATED events following the index case diagnosis of IBD including: ischemic heart disease (ICD-9-Clinical Modification [CM] codes 410-414.x), cerebrovascular disease (ICD-9-CM codes 430-436.x), and undifferentiated ATED (ICD-9-CM codes 440.x and 445.x). The incidence rate of 1 episode or more of these diseases was assessed in relation to the individual person-years of follow-up evaluation. Incidence rates and incidence rate ratios (IRRs) were computed for all IBD, and stratified by IBD diagnosis, sex, and age.

RESULTS

For ischemic heart disease, risk was increased for all IBD (IRR, 1.26; 95% confidence interval [CI], 1.11-1.44) and was increased for Crohn's disease and ulcerative colitis in both, males and females. For cerebrovascular disease, only Crohn's disease was associated with increased risk (IRR, 1.32; 95% CI, 1.05-1.66), and for undifferentiated ATED only females (IRR, 1.96; 95% CI, 1.24-3.10) and those aged 0 to 39 years (IRR, 19.95; 95% CI, 1.81-219.92) and 40 to 59 years (IRR, 3.17; 95% CI, 1.27-7.91) had significantly increased risks.

CONCLUSIONS

IBD patients are more likely to have cardiac ATED, regardless of diagnosis or sex. Crohn's disease has an increased risk for cerebral ATED. Smoking, the prothrombotic aspect of systemic inflammation, or a genetic predisposition may contribute to the risk.

Ischemic stroke and peripheral arterial thromboembolism in a patient with Crohn's disease: a case presentation

Both ischemic stroke and peripheral arterial thromboembolism have been described as extraintestinal complications of inflammatory bowel disease. Here, we present the first case with direct cooccurrence of ischemic stroke and peripheral thromboembolism in a 39-year-old patient with Crohn's disease. A pathophysiological model explaining this cooccurrence as well as the significance of prothrombotic risk factors ("hypercoaguable state") in the setting of inflammatory bowel disease and stroke are discussed.

Magnetic resonance angiography in a patient with Crohn's disease associated cerebral vasculitis

Vasculitits of the central nervous system (CNS) is a known complication of chronic inflammatory bowel diseases. We report the case of a female patient with Crohn's disease, developing vasculitis of the CNS with evidence of pathological vessel depiction on magnetic resonance angiography. To our knowledge this is the first case report regarding MRA documentation of vessel changes typical for angiitis in a patient with Crohn-associated vasculitis of the CNS.