Prevalence of Peripheral Eosinophilia at Diagnosis in Children With Inflammatory Bowel Disease

Role of peripheral and tissue eosinophils and eosinophil cationic protein in pediatric inflammatory bowel disease

OBJECTIVES

Inflammatory bowel disease (IBD), eosinophilic gastrointestinal disease (EGID), and functional abdominal pain disorder (FAPD) present with nonspecific gastrointestinal (GI) symptoms clinically and also have some similarities in pathogeneses associated with eosinophils. Therefore, we aimed to evaluate the role of eosinophils in IBD compared to EGID and FAPD by investigating eosinophils in peripheral blood and GI tissue and eosinophil cationic protein (ECP).

METHODS

Pediatric patients with chronic GI symptoms who underwent endoscopic biopsies were enrolled. Complete blood cell counts, inflammatory markers, immunoglobulin E (IgE), serum ECP levels, and endoscopic and histopathologic findings were retrospectively reviewed.

RESULTS

A total of 387 patients were included: 179 with EGID, 107 with IBDs, and 82 with FAPD. Peripheral absolute eosinophil count (AEC), total IgE, and serum ECP were significantly higher in both IBD and EGID than in FAPD (all p < 0.05). Statistically significant differences were noted among the three groups in tissue eosinophil counts in each segment of GI tract except for the esophagus (p < 0.05). Significant differences were observed in tissue eosinophil counts in the ascending, sigmoid colon, and rectum between EGID and IBD (p < 0.05). Peripheral and tissue eosinophils in the stomach and duodenum revealed positive correlation in both EGID and IBD (both p < 0.001).

CONCLUSION

Elevated eosinophil-related markers, as well as increased tissue eosinophilic infiltration in the affected areas of the GI tract in both IBD and EGID compared to FAPD, suggest that eosinophils might play a common important role in the pathogeneses of both diseases.

Hypereosinophilic Syndrome with Pulmonary Involvement in Ulcerative Colitis

Reactive eosinophilia is associated with inflammatory bowel disease and is more common in patients with ulcerative colitis (UC) compared with Crohn's disease. The prevalence rate of peripheral blood eosinophilia in patients with inflammatory bowel disease has been described to be as high as 30%-40% of patients in a pediatric study. The coexistence of hypereosinophilic syndrome (HES) and UC is uncommon. We present a 15-year-old boy with UC associated with HES who presented with chest pain and shortness of breath. Laboratory evaluation showed marked eosinophilia. Alternative causes of eosinophilia including eosinophilic leukemia, infections, or drug-induced eosinophilic pneumonia were ruled out. The patient was ultimately diagnosed with HES responsive to mepolizumab.

Prognostic Value of Colonic Tissue and Blood Eosinophils in Ulcerative Colitis

BACKGROUND

It has been suggested that eosinophils may be a prognostic marker of disease outcome in ulcerative colitis (UC), but conflicting data exist. The objective was to investigate the extent of mucosal eosinophils and peripheral blood eosinophil count in newly diagnosed UC patients and to investigate its predictive value in short- and long-term disease outcomes.

METHODS

The degree of eosinophilia in baseline colonic biopsies and blood of newly diagnosed UC patients was retrospectively analyzed. It was investigated if tissue and blood eosinophilia could be a marker of a severe phenotype of UC, defined as the need for corticosteroids or immunomodulators in the first year or treatment with therapeutic monoclonal antibodies or colectomy during follow-up. Time to therapeutic monoclonal antibodies and time to colectomy were also evaluated as outcomes.

RESULTS

There were 103 UC patients (median age 26 years) included. Median tissue peak eosinophil count (PEC) was 70.0 and median peripheral blood eosinophil count was 0.3 × 109/L at diagnosis. Tissue PEC (r = -0.161, P = .104) and blood eosinophil count (r = 0.022, P = .877) were not correlated with the severity of histologic inflammation. Logistic regression analyses did not identify PEC and blood eosinophil count as predictors of more severe disease outcomes. Tissue PEC and peripheral blood eosinophil count did not predict the time the initiation of therapeutic monoclonal antibodies or colectomy.

CONCLUSION

Baseline tissue or peripheral blood eosinophils are not markers of disease activity and cannot be used as a predictor of severe disease outcomes in both adults and children with UC.

The Clinical Significance of Eosinophils in Ulcerative Colitis: A Systematic Review

BACKGROUND AND AIMS

Ulcerative colitis [UC] is characterised by an unpredictable disease course and variable response to therapy. Recent studies suggest a role for eosinophils in both pathogenesis and predicting treatment response. The goal of this study was to determine the association between eosinophils and clinical outcomes in UC.

METHODS

A systematic review of the literature from database inception to May 2021 was performed to identify all studies evaluating the relationship between eosinophils and/or eosinophil-derived proteins [EDPs] and clinical outcomes, such as disease activity, clinical relapse, severity of disease, and response to treatment.

RESULTS

A total of 55 studies were identified. Of these, 34 studies evaluated the relationship between eosinophils in colonic tissue and outcomes and 15 in blood. Eighteen studies assessed the relationship between EDPs and outcomes. In 25 of 34 studies, a positive correlation between eosinophils and/or EDPs and disease activity was reported, three studies found a negative correlation, and nine studies found no correlation. Positive correlations between eosinophils and clinical relapse were shown in four of nine studies, and with disease outcome severity in five of seven studies. Four of 15 studies showed that subjects with higher eosinophil levels had a poor response to treatment.

CONCLUSIONS

These findings suggest that higher eosinophil levels may be associated with increased disease activity and poorer clinical outcomes and response to therapy. Future studies are needed to determine whether a distinct eosinophil-rich UC phenotype exists and whether eosinophil-targeted therapy can alter the disease course.

Hypereosinophilia with cerebral venous sinus thrombosis and intracerebral hemorrhage: A case report and review of the literature

BACKGROUND

Hypereosinophilia (HE) is defined as a peripheral blood eosinophil count of > 1.5 × 10⁹/L and may be associated with tissue damage. The clinical presentations of HE vary; however, myocardial fibrosis and thrombosis can threaten the lives of patients with sustained eosinophilia. Cerebral venous sinus thrombosis (CVST) in the setting of eosinophil-related diseases has seldom been reported. Here, we review the literature on HE with CVST to increase knowledge and encourage early diagnosis.

CASE SUMMARY

A previously healthy 41-year-old man was admitted to hospital with diarrhea and abdominal pain. He was treated with antibiotics for suspected acute colitis. Three days later, he experienced headache and vomiting. Brain computed tomography (CT) revealed thrombosis of the left jugular vein to the left transverse sinus vein. Platelet (PLT) count decreased to 60 × 10¹²/L, and absolute eosinophil count (AEC) increased to 2.41 × 10⁹/L. He was treated with low-molecular-weight heparin. PLT count progressively decreased to 14 × 10⁹/L, and we terminated anticoagulation and performed PLT transfusion. Six days after admission, he complained of a worsening headache. Brain CT revealed right temporal lobe and left centrum semiovale intracerebral hemorrhage, and AEC increased to 7.65 × 10⁹/L. We used prednisolone for HE. The level of consciousness decreased, so emergency hematoma removal and decompressive craniectomy for right cerebral hemorrhage were performed. The patient was alert 2 d after surgery. He was treated with anticoagulation again 2 wk after surgery. Corticosteroids were gradually tapered without any symptomatic recurrence or abnormal laboratory findings.

CONCLUSION

HE can induce CVST, and we need to focus on eosinophil counts in patients with CVST.

The Role of Biomarkers in Surgery for Ulcerative Colitis: A Review

Ulcerative colitis (UC) is an inflammatory condition that generally affects the rectum and extends proximally into the colon in a continuous, distal-to-proximal pattern. Surgical resection (total proctocolectomy) is the only cure for UC and is often necessary in managing complicated or refractory disease. However, recent advances in biologically targeted therapies have resulted in improved disease control, and surgery is required in only a fraction of cases. This ever-increasing array of options for medical management has added complexity to surgical decision-making. In some circumstances, the added time required to ensure failure of medical therapy can delay colectomy in patients who will ultimately need it. Indeed, many patients with severe disease undergo trials of multiple medical therapies prior to considering surgery. In severe cases of UC, continued medical management has been associated with a delay to surgical intervention and higher rates of morbidity and mortality. Biomarkers represent a burgeoning field of research, particularly in inflammatory bowel disease and cancer. This review seeks to highlight the different possible settings for surgery in UC and the role various biomarkers might play in each.

Inflammatory bowel disease presenting with pyodermatitis-pyostomatitis vegetans in a pediatric patient: A case report and review of the literature

Pyodermatitis-pyostomatitis vegetans (PD-PSV) is rarely reported in the pediatric population. Here, we provide a review of pediatric PD-PSV in the literature and report a case of widespread PD-PSV in a 15-year-old male without a previous history of inflammatory bowel disease or gastrointestinal symptoms. Clinical, histological, and immunopathological workup established PD-PSV and revealed subclinical Crohn's disease. Treatment with infliximab was effective in inducing rapid resolution of the lesions.

Peripheral Blood Eosinophilia and Long-term Severity in Pediatric-Onset Inflammatory Bowel Disease

BACKGROUND

Peripheral blood eosinophilia (PBE) is a biomarker of an aggressive multiyear natural history in adults with inflammatory bowel diseases (IBDs). Additionally, PBE at diagnosis is associated with higher disease activity in pediatric-onset IBD. We sought to determine if PBE can function as a biomarker of long-term disease severity in pediatric-onset IBD patients who are followed into adulthood.

METHODS

We analyzed a consented, prospective, natural history IBD registry at an adult tertiary center from 2009 to 2018. Prevalence of PBE was evaluated in both pediatric- and adult-onset IBD patients. Demographics, clinical characteristics, and health care utilization data were compared in patients with and without PBE.

RESULTS

Among 2800 adult IBD patients, 23.4% had pediatric-onset disease. PBE was found in 34% of the pediatric-onset patients compared with 26.8% of the adult-onset IBD patients (P < 0.001). In the pediatric-onset IBD cohort, PBE was associated with higher rates of allergies (P < 0.0001), but not of asthma, allergic rhinitis, or primary sclerosing cholangitis. In the adult IBD patients with pediatric-onset disease, PBE was associated with higher rates of C-reactive protein elevation (P < 0.0001), erythrocyte sedimentation rate elevation (P < 0.0001), higher health care utilization, and higher average health care charges per year (P < 0.00001).

CONCLUSIONS

Peripheral blood eosinophilia was more prevalent in adult IBD patients with pediatric-onset compared with adult-onset disease. Among all IBD patients with long-term follow-up, PBE defined a subgroup with more severe illness. These data suggest that PBE may be a biomarker for a high-risk subgroup with high cost trajectory and long-term severity in pediatric-onset IBD that persists into adulthood.

Pediatric Ulcerative Colitis in Kazakhstan: First Case Series from Central Asia and Current Clinical Management

The diagnoses of ulcerative colitis have increased in pediatric patients in the last two decades. Whereas there are several reports from most areas of the world, no clinical studies describing the clinical management of pediatric ulcerative colitis are currently available from Central Asia. In this article, we first describe a case series of pediatric patients affected with ulcerative colitis in Kazakhstan. This is a retrospective study including 25 consecutive pediatric patients diagnosed with ulcerative colitis in a tertiary pediatric hospital. The available demographic, clinical, hematological and inflammatory parameters at diagnosis and at the first one-year follow-up have been provided and analyzed. Most pediatric patients diagnosed with ulcerative colitis were older than 12 years, with prevalence of male gender. The analysis of clinical, laboratory, endoscopic parameters at the diagnosis suggested a significant diagnostic delay compared to developed countries; however, most of them showed clinical, laboratory and endoscopic improvements at the one-year follow-up. Even though the therapeutic approach and outcomes resulted to be consistent with other clinical studies from developed countries, several aspects of the medical follow-up should be improved, especially in pediatric patients with extensive disease.

Development of peripheral eosinophilia in inflammatory bowel disease patients on infliximab treated at a tertiary pediatric inflammatory bowel disease center is associated with clinically active disease but does not result in loss of efficacy or adverse outcomes

Introduction

Inflammatory bowel disease (IBD) consisting of Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory conditions affecting the gastrointestinal tract. Infliximab (IFX) is a chimeric anti‐tumor necrosis factor antibody used to treat moderate to severe IBD. Eosinophils are commonly found in chronically inflamed tissues in IBD. Peripheral eosinophilia (PE) was previously implicated as a marker of disease severity at diagnosis. The main aim of this study was to investigate whether in IBD patients on IFX, development of PE is associated with adverse outcomes and poor IFX efficacy.

Methods

A comprehensive retrospective chart review of IBD patients on IFX (January 2006 to July 2015) treated at a tertiary pediatric IBD center was performed. Data was collected at time specified points over a 24 month period and included demographics, atopy, disease severity, development of PE, human antichimeric antibodies (HACA), infusion reactions, cancer, psoriasis, and loss of clinical response.

Results

One hundred twenty‐one IBD patients starting IFX (67 male), mean age of 12.4 years (range 4–22 years old), met inclusion criteria. Of them, 36.3% had ≥1 PE episode (CD: 25 male, 11 female; UC: 6 male, 2 female). Mean absolute eosinophil count (AEC) did not change over time. PE was associated with clinically active disease. Among patients who developed PE, adverse outcomes were not significantly different versus those who did not have PE.

Conclusions

In a cohort of primarily pediatric IBD patients on IFX, PE was associated with clinically active disease; however, PE was not related to increased incidence of adverse outcomes or loss of drug efficacy.

Increased Prevalence of Esophageal Eosinophilia in Patients with Inflammatory Bowel Disease

Background

The overlap between eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) has not been extensively examined. We aimed to assess the prevalence of esophageal eosinophilia in patients with IBD.

Methods

We conducted a retrospective cohort study using diagnostic codes to identify adults with EoE and IBD between 2008 and 2016 at a tertiary care center. Electronic medical records were reviewed to extract clinical, endoscopic, and treatment data. Patients with esophageal eosinophilia and IBD were compared to EoE cases without IBD.

Results

Of 621 EoE patients and 4,814 IBD patients identified, 35 had a code for both diseases and 12 were confirmed to have overlapping IBD and esophageal eosinophilia. The prevalence of esophageal eosinophilia in IBD was 12/4814 (0.25%), and the prevalence of confirmed EoE in IBD was 5/4,814 (0.10%). There were no substantial clinical, endoscopic, or histologic differences between EoE patients with and without IBD. IBD was diagnosed before esophageal eosinophilia 92% of the time, with an average time between diagnoses of 9.6 years. Of the IBD patients, 71% were started on biologic anti-tumor necrosis factor-α therapy an average of 7.6 years prior to developing esophageal eosinophilia.

Conclusions

The prevalence of esophageal eosinophilia in IBD is 5 times higher than expected in the general population (0.25 vs. 0.05%) and EoE in IBD is 2 times higher than expected (0.10 vs. 0.05%). Upper gastrointestinal (GI) symptoms in patients with IBD should merit evaluation not only for upper GI Crohn's disease, but also for esophageal eosinophilia.

Diagnostic Potential of Systemic Eosinophil-Associated Cytokines and Growth Factors in IBD

Despite the acknowledged contribution of eosinophils to the disease pathogenesis, available data on cytokines closely related to the peripheral eosinophils in inflammatory bowel disease (IBD) are scattered. We assessed the concentrations of eosinophil-associated cytokines and growth factors in the group of 277 individuals (101 patients with Crohn's disease (CD), 77 with ulcerative colitis (UC), 16 with irritable bowel syndrome (IBS), and 83 healthy controls) and referred to IBD activity and the levels of hsCRP. As compared to IBS patients or healthy controls, patients with CD had significantly higher levels of IL5, IL8, IL12(p70), GM-CSF, and TNFα and patients with UC, the levels of eotaxin, IL4, IL5, IL8, IL12(p70), IL13, GM-CSF, and TNFα were also higher. As compared to CD patients, patients with UC had significantly higher levels of eotaxin, IL4, IL5, IL8, and IL1. In turn, the concentrations of hsCRP were significantly higher in CD than UC. Except for IL13, all cytokines and hsCRP positively correlated with CDAI. In UC, a positive correlation with MDAI was observed for hsCRP, GM-CSF, IL12(p70), and IFNγ and a negative one for IL8. The concentrations of hsCRP, GM-CSF, IFNγ, IL12(p70), and RANTES were higher in UC patients with active than inactive disease whereas those of IL8 and TNFα were significantly lower. Eotaxin, determined individually or in a panel with IFNγ and hsCRP, showed fair accuracy in differentiating CD from UC. If confirmed on a larger representation of IBS patients, IL8 might support differential diagnosis of organic and functional conditions of the bowel. GM-CSF, in turn, demonstrated to be an excellent indicator of bowel inflammation and may be taken into consideration as a noninvasive marker of mucosal healing. In summary, eosinophil-associated cytokines are elevated in IBD, more pronouncedly in UC, and may support the differential diagnosis of IBD and aid in monitoring of mucosal healing.

Peripheral Eosinophilia in Patients With Inflammatory Bowel Disease Defines an Aggressive Disease Phenotype

OBJECTIVES

Peripheral blood eosinophilia (PBE) in inflammatory bowel disease (IBD) is associated with ulcerative colitis (UC) and active disease. Little data exist on the long-term impact of PBE on disease course. We aimed to investigate the multi-year patterns of PBE and its impact on disease severity in a large IBD cohort.

METHODS

We performed a registry analysis of a consented, prospective, natural history IBD cohort at a tertiary center from 2009 to 2014. Demographics, comorbidities, disease activity, healthcare utilization, and time to hospitalization or surgical resection of patients who displayed PBE were compared to patients without PBE.

RESULTS

Of the 2,066 IBD patients, 19.2% developed PBE. PBE was significantly associated with UC (P<0.001), extensive colitis (P<0.001), and shorter disease duration (P=0.03). Over six years, PBE patients had more active disease (Harvey-Bradshaw Index P=0.001; ulcerative colitis activity index P<0.001), concurrent C-reactive protein elevation (P<0.001), healthcare utilization (hospitalization P<0.001, IBD surgery P<0.001), and more aggressive medical therapy (prednisone P<0.001, anti-TNF P<0.001). Patients with PBE had a significantly reduced time to hospitalization in both UC (P<0.001) and Crohn's disease (CD) (P<0.001) and reduced time to colectomy in UC (P=0.003). On multivariable modeling, PBE remained significantly associated with hospitalization and surgery in both CD and UC. New diagnosis of UC with PBE was associated with increased steroid (P=0.007) and anti-TNF (P=0.001) requirement.

CONCLUSION

This multi-year study of a large IBD cohort suggests that peripheral blood eosinophilia represents a biomarker of a distinct IBD subgroup, with a unique inflammatory signature, and at risk for worse clinical outcomes.

Eosinophils in Autoimmune Diseases

Eosinophils are multifunctional granulocytes that contribute to initiation and modulation of inflammation. Their role in asthma and parasitic infections has long been recognized. Growing evidence now reveals a role for eosinophils in autoimmune diseases. In this review, we summarize the function of eosinophils in inflammatory bowel diseases, neuromyelitis optica, bullous pemphigoid, autoimmune myocarditis, primary biliary cirrhosis, eosinophilic granulomatosis with polyangiitis, and other autoimmune diseases. Clinical studies, eosinophil-targeted therapies, and experimental models have contributed to our understanding of the regulation and function of eosinophils in these diseases. By examining the role of eosinophils in autoimmune diseases of different organs, we can identify common pathogenic mechanisms. These include degranulation of cytotoxic granule proteins, induction of antibody-dependent cell-mediated cytotoxicity, release of proteases degrading extracellular matrix, immune modulation through cytokines, antigen presentation, and prothrombotic functions. The association of eosinophilic diseases with autoimmune diseases is also examined, showing a possible increase in autoimmune diseases in patients with eosinophilic esophagitis, hypereosinophilic syndrome, and non-allergic asthma. Finally, we summarize key future research needs.

Tissue and peripheral eosinophilia as predictors for disease outcome in children with ulcerative colitis

BACKGROUND

Eosinophils are implicated in the pathogenesis of ulcerative colitis.

AIMS

To evaluate the magnitude of mucosal and blood eosinophils in newly diagnosed pediatric ulcerative colitis patients and its significance in predicting disease outcomes.

METHODS

We retrospectively evaluated colorectal biopsies of 96 pediatric patients with ulcerative colitis and 50 age- and sex-matched controls. Samples were taken from diseased areas of the colon and examined by a gastrointestinal pathologist. The most inflamed site was used for assessment of mucosal eosinophils.

RESULTS

Samples from 96 diagnostic and 70 follow-up colonoscopies were evaluated. Median age was 13.3 years (IQR 10.1-15.3). Median duration of follow-up was 12.8 years (IQR 7.2-17.1). Median number of tissue eosinophils at diagnosis was 45 (IQR 22-73) compared to 10 eosinophils (IQR 8-25) during histologic remission (p<0.0001). Peripheral absolute eosinophil counts correlated with tissue inflammation and eosinophilia (p=0.001). Mucosal eosinophilic infiltration (p=0.02) and peripheral eosinophilia (p=0.04) was associated with clinical severity at diagnosis. Multivariate analysis showed that severe eosinophilic infiltration is associated with corticosteroid therapy following diagnosis (p=0.04) but not with long-term risk for step-up therapy or colectomy.

CONCLUSION

Tissue and peripheral eosinophilia correlate with ulcerative colitis severity at diagnosis and with short-term corticosteroid requirement but not with long-term outcomes.