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Joshi R, Secondulfo C, Caputo A, Zeppa P, Iacuzzo C, Apicella L, Borriello M, Bilancio G, Viggiano D. Gut mucosa alterations after kidney transplantation: a cross sectional study. J Nephrol 2024:10.1007/s40620-024-02067-7. [PMID: 39289297 DOI: 10.1007/s40620-024-02067-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 08/08/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Kidney transplant recipients (KTRs) rely on immunosuppressants like mycophenolate to prevent organ rejection. However, mycophenolate often causes intestinal symptoms and inflammation in various organs, including the skin and the colon. While KTRs have an increased risk for skin cancer, the risk of colorectal cancer is not increased. Elucidating the histological alterations in the colon of KTRs and comparing these changes with known skin alterations would help understand how immunosuppressants influence cancer development and progression. METHODS Whole slide images from gut biopsies (Non-transplanted subjects n = 35, KTRs n = 49) were analyzed using the ImageJ and R programming environment. A total of 22,035 epithelial cells, 38,870 interstitial cells, 3465 epithelial cell mitoses, and 7477 endothelial cells, each characterized by multiple microscopy parameters, from a total of 1788 glands were analyzed. The large database was subsequently analyzed to verify the changes of inflammatory milieu in KTRs and in cancer. RESULTS KTRs without colon-cancer showed a significantly higher density of interstitial cells in the colon compared to non-transplanted patients. Moreover, the increase in interstitial cell number was accompanied by subtle modifications in the architecture of the colon glands, without altering the epithelial cell density. We could not identify significant structural modifications in cancer samples between KTRs and non-transplanted patients. CONCLUSIONS Our findings demonstrate an increased number of resident interstitial cells in the colon of KTRs, as in other patients treated with mycophenolate. These changes are associated with subtle alterations in the architecture of colon glands.
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Affiliation(s)
- Rashmi Joshi
- Department of Translational Medical Sciences, University of Campania, Via Pansini, 5, 80131, Naples, Italy
| | - Carmine Secondulfo
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | | | - Pio Zeppa
- Unit of Pathology, University Hospital of Salerno, Salerno, Italy
| | - Candida Iacuzzo
- Unit of Nephrology, Dialysis and Transplantation, University Hospital of Salerno, Salerno, Italy
| | - Luca Apicella
- Unit of Nephrology, Dialysis and Transplantation, University Hospital of Salerno, Salerno, Italy
| | | | - Giancarlo Bilancio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Davide Viggiano
- Department of Translational Medical Sciences, University of Campania, Via Pansini, 5, 80131, Naples, Italy.
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2
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Kondo M, Torisu T, Ihara Y, Kawasaki K, Umeno J, Kawatoko S, Tsuchimoto A, Nakano T, Okabe Y, Kitazono T. Clinical Features of Gastroduodenal Ulcers in Kidney Transplant Patients. Intern Med 2023; 62:3437-3443. [PMID: 37062748 PMCID: PMC10749817 DOI: 10.2169/internalmedicine.1508-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/26/2023] [Indexed: 04/18/2023] Open
Abstract
Objective The risk of developing peptic ulcers and gastrointestinal bleeding is high in patients with chronic kidney disease (CKD). Whether or not kidney transplant patients, who are treated with multiple medications, including immunosuppressive drugs, are at an increased risk of developing peptic ulcers is unclear. Methods In this retrospective study, we compared the clinical and endoscopic features of gastroduodenal ulcers between kidney transplant patients and CKD patients. The subjects underwent upper gastrointestinal endoscopy between January 2015 and March 2021. Results Gastroduodenal ulcers were observed more frequently (6.5%) in kidney transplant patients than in CKD patients (2.1%) (p=0.026). Due in part to the lower median age in the kidney transplant ulcer group than in the CKD ulcer group (59 vs. 70 years old, p=0.016), the rates of atrophic gastritis and Helicobacter pylori infection were also lower in the kidney transplant ulcer group than in the CKD ulcer group. Significantly more kidney transplant patients were treated with acid secretion inhibitors than CKD ulcer patients (100% vs. 34.8%, p=0.0005). Peptic ulcers were observed frequently in kidney transplant patients, even though common risk factors for gastroduodenal ulcers other than immunosuppressive drugs were few. All kidney transplant patients were taking immunosuppressive medications, and tacrolimus, mycophenolate mofetil, and methylprednisolone were taken more frequently than others. Conclusion Kidney transplant patients have a high risk of developing gastroduodenal ulcers. All kidney transplant patients take immunosuppressive medications, so there may be an association between immunosuppressive medications and gastroduodenal ulcer development.
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Affiliation(s)
- Masahiro Kondo
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yutaro Ihara
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Keisuke Kawasaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Shinichiro Kawatoko
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
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3
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Zhang T, Hagen CE. Gastrointestinal Biopsies in the Patient Post-Stem Cell Transplant: An Approach to Diagnosis. Surg Pathol Clin 2023; 16:745-753. [PMID: 37863563 DOI: 10.1016/j.path.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Graft-versus-host disease (GVHD) is a major complication of hematopoietic stem cell transplantation (SCT), leading to a significant morbidity and mortality. Histologically, gastrointestinal GVHD is characterized by crypt apoptosis and dropout. However, similar histologic features can also be seen in drug-induced injury and opportunistic infection. Knowledge of the timing of biopsy, patient medications, evidence of infection, and presence of GVHD at other organ sites can aid in the correct diagnosis and subsequent management of these patients. This review focuses on the pathologic differential diagnosis of apoptosis in gastrointestinal biopsies obtained from SCT patients.
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Affiliation(s)
- Tao Zhang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Catherine E Hagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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4
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Drug-induced digestive tract injury: decoding some invisible offenders. Hum Pathol 2023; 132:135-148. [PMID: 35714837 DOI: 10.1016/j.humpath.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/09/2022] [Indexed: 02/07/2023]
Abstract
There is an ever-growing list of pharmacological agents, several of which are attributed to cause clinically significant gastrointestinal (GI) injury. Many patients present with significant but nonspecific symptoms, that in conjunction with the absence of relevant drug history on the requisition slip can make the histopathologic diagnosis challenging. To complicate this, although some drugs have relatively characteristic histopathologic features (such as doxycycline), there exist many other drugs that exhibit wide and varying spectra of histopathologic findings (such as immune checkpoint inhibitors or olmesartan) and have histomorphologic overlap with many other commonly encountered disease entities. This review discusses the histopathologic features of some relatively recently described drugs causing GI tract injury, namely doxycycline, tacrolimus, mycophenolate, immune checkpoint inhibitors, and olmesartan. We also discuss the common mimics in histopathologic differential and some pearls that can help distinguish GI tract injury induced by the aforementioned drugs from its mimics. Awareness of the wide spectra of histopathologic changes associated with these drugs is crucial for practicing pathologists, to avoid misdiagnosis and guiding the clinician for an optimal patient management, which usually involves modifying or discontinuing the offending drug. Needless to say, once a diagnosis of drug-induced injury is suspected, clinicopathologic correlation including corroboration with the drug history is of utmost importance as is the exclusion of dual pathology in these patients.
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5
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Iacob S, Iacob R, Manea I, Uta M, Chiosa A, Dumbrava M, Becheanu G, Stoica L, Popa C, Brasoveanu V, Hrehoret D, Gheorghe C, Gheorghe L, Dima S, Popescu I. Host and immunosuppression-related factors influencing fibrosis occurrence post liver transplantation. Front Pharmacol 2022; 13:1042664. [PMID: 36330082 PMCID: PMC9622773 DOI: 10.3389/fphar.2022.1042664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/27/2022] [Indexed: 11/25/2022] Open
Abstract
Post liver transplantation (LT) fibrosis has a negative impact on graft function. Cytokine production in the host immune response after LT may contribute to the variable CYP3A-dependent immunosuppressive drug disposition, with subsequent impact on liver fibrogenesis, together with host-related factors. We aimed to investigate whether the cytochrome P4503A5*3 (CYP3A5*3) or TBX21 genotypes impact post-LT liver fibrogenesis. Furthermore, the impact of immunosuppressants on cellular apoptosis has been evaluated using human hepatocytes harvested from cirrhotic explanted livers. We have enrolled 98 LT recipients that were followed for occurrence of liver fibrosis for at least 12 months. There was a statistically significant higher trough level of TAC in patients with homozygous CC-TBX21 genotype (7.83 ± 2.84 ng/ml) vs. 5.66 ± 2.16 ng/ml in patients without this genotype (p = 0.009). The following variables were identified as risk factors for fibrosis ≥2: donor age (p = 0.02), neutrophil to lymphocyte ratio (p = 0.04) and TBX21 genotype CC (p = 0.009). In the cell culture model cytometry analysis has indicated the lowest apoptotic cells percentage in human cirrhotic hepatocytes cultures treated with mycophenolate mofetil (MMF) (5%) and TAC + MMF (2%) whereas the highest apoptosis percentage was registered for the TAC alone (11%). The gene expression results are concordant to cytometry study results, indicating the lowest apoptotic effect for MMF and MMF + TAC immunosuppressive regimens. The allele 1993C of the SNP rs4794067 may predispose to the development of late significant fibrosis of the liver graft. MMF-based regimens have a favourable anti-apoptotic profile in vitro, supporting its use in case of LT recipients at high risk for liver graft fibrosis.
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Affiliation(s)
- Speranta Iacob
- Gastroenterology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Razvan Iacob
- Gastroenterology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Manea
- Gastroenterology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Center for Excellence in Translational Medicine, Bucharest, Romania
| | - Mihaela Uta
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Andrei Chiosa
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Mona Dumbrava
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriel Becheanu
- Gastroenterology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Luminita Stoica
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Codruta Popa
- Gastroenterology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Vlad Brasoveanu
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Doina Hrehoret
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Cristian Gheorghe
- Gastroenterology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Liana Gheorghe
- Gastroenterology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Simona Dima
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
- *Correspondence: Simona Dima,
| | - Irinel Popescu
- Center for Excellence in Translational Medicine, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
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6
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Mycophenolic Acid Induces the Intestinal Epithelial Barrier Damage through Mitochondrial ROS. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:4195699. [PMID: 35847589 PMCID: PMC9277164 DOI: 10.1155/2022/4195699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/07/2022] [Accepted: 06/10/2022] [Indexed: 11/22/2022]
Abstract
Mycophenolic acid (MPA) may cause gastrointestinal adverse effects by damaging the intestinal epithelial barrier, the underlying mechanisms remain elusive. Studies have demonstrated that oxidative stress caused by reactive oxygen species (ROS) is linked to tight junction (TJ) proteins and apoptosis, both of which cause abnormalities in intestinal barrier function. Mitochondria, one of the main sources of ROS and abnormally high levels of ROS are linked to mitochondrial dysfunction. The aim of this study was to investigate whether MPA induces intestinal barrier dysfunction through regulation of the mitochondrial ROS. MPA-induced intestinal injury model in Kunming mice and Caco-2 cells. The effect of MPA on Caco-2 cell viability was measured by MTT; tissue diamine oxidase and endotoxin expression were determined by ELISA; expression of total proteins of ZO-1, occludin, Bax, Bcl-2, and mitochondrial proteins of Cytochrome C and Bax was measured by Western blot; and the localization of Cytochrome C with MitoTraker was observed by immunofluorescence staining. Caco-2 cell apoptosis, ROS levels, and mitochondrial membrane potential were detected by flow cytometry, while intramitochondrial ROS levels were observed by MitoSOX fluorescence staining. The results showed that MPA increased intracellular and mitochondrial ROS production to promote oxidative stress and the antioxidant NAC effectively restored ZO-1 and occludin expressions, reduced apoptosis in intestinal epithelial cells. Furthermore, we found that low concentrations of MPA caused mitochondrial damage, induced hyperpolarization of the mitochondrial membrane potential and the translocation of Cytochrome C and Bax proteins from the cytoplasm to the mitochondria. The mitochondrial protectant SS-31 reduces intracellular and intramitochondrial ROS, upregulates TJ, and reduces apoptosis. Our studies suggest that MPA-induced intestinal barrier dysfunction in vivo and in vitro is mediated, at least in part, by impairing mitochondrial function and promoting oxidative stress.
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7
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Bernal-Bello D, Serantes-Gómez D, Izquierdo-Martínez A, Morales-Ortega A, Duarte-Millán MÁ, Frutos-Pérez B. Letter to the Editor Regarding Esophageal Dysfunction and Systemic Sclerosis: Drugs Should be Kept in Mind. Rheumatol Ther 2022; 9:1237-1240. [PMID: 35716236 PMCID: PMC9314470 DOI: 10.1007/s40744-022-00459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/26/2022] [Indexed: 02/07/2023] Open
Affiliation(s)
- David Bernal-Bello
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Camino del Molino, 2. 28942, Fuenlabrada, Madrid, Spain.
| | - David Serantes-Gómez
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Camino del Molino, 2. 28942, Fuenlabrada, Madrid, Spain
| | - Aida Izquierdo-Martínez
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Camino del Molino, 2. 28942, Fuenlabrada, Madrid, Spain
| | - Alejandro Morales-Ortega
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Camino del Molino, 2. 28942, Fuenlabrada, Madrid, Spain.,Department of Medicine, Universidad de Alcalá, Madrid, Spain
| | - Miguel Ángel Duarte-Millán
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Camino del Molino, 2. 28942, Fuenlabrada, Madrid, Spain
| | - Begoña Frutos-Pérez
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Camino del Molino, 2. 28942, Fuenlabrada, Madrid, Spain
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8
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Ahmed Z, Schwartz MR, Quigley EMM. Esophageal Stricture: Not Your Usual Culprit? Gastroenterology 2022; 162:399-400. [PMID: 34688707 DOI: 10.1053/j.gastro.2021.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/18/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Zunirah Ahmed
- Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston, Texas
| | - Mary R Schwartz
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas
| | - Eamonn M M Quigley
- Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston, Texas.
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9
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Simpson JB, Sekela JJ, Graboski AL, Borlandelli VB, Bivins MM, Barker NK, Sorgen AA, Mordant AL, Johnson RL, Bhatt AP, Fodor AA, Herring LE, Overkleeft H, Lee JR, Redinbo MR. Metagenomics combined with activity-based proteomics point to gut bacterial enzymes that reactivate mycophenolate. Gut Microbes 2022; 14:2107289. [PMID: 35953888 PMCID: PMC9377255 DOI: 10.1080/19490976.2022.2107289] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023] Open
Abstract
Mycophenolate mofetil (MMF) is an important immunosuppressant prodrug prescribed to prevent organ transplant rejection and to treat autoimmune diseases. MMF usage, however, is limited by severe gastrointestinal toxicity that is observed in approximately 45% of MMF recipients. The active form of the drug, mycophenolic acid (MPA), undergoes extensive enterohepatic recirculation by bacterial β-glucuronidase (GUS) enzymes, which reactivate MPA from mycophenolate glucuronide (MPAG) within the gastrointestinal tract. GUS enzymes demonstrate distinct substrate preferences based on their structural features, and gut microbial GUS enzymes that reactivate MPA have not been identified. Here, we compare the fecal microbiomes of transplant recipients receiving MMF to healthy individuals using shotgun metagenomic sequencing. We find that neither microbial composition nor the presence of specific structural classes of GUS genes are sufficient to explain the differences in MPA reactivation measured between fecal samples from the two cohorts. We next employed a GUS-specific activity-based chemical probe and targeted metaproteomics to identify and quantify the GUS proteins present in the human fecal samples. The identification of specific GUS enzymes was improved by using the metagenomics data collected from the fecal samples. We found that the presence of GUS enzymes that bind the flavin mononucleotide (FMN) is significantly correlated with efficient MPA reactivation. Furthermore, structural analysis identified motifs unique to these FMN-binding GUS enzymes that provide molecular support for their ability to process this drug glucuronide. These results indicate that FMN-binding GUS enzymes may be responsible for reactivation of MPA and could be a driving force behind MPA-induced GI toxicity.
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Affiliation(s)
- Joshua B. Simpson
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Josh J. Sekela
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amanda L. Graboski
- Department of Pharmacology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Valentina B. Borlandelli
- Department of Bioorganic Synthesis, Leiden Institute of Chemistry, Leiden University, Leiden, The Netherlands
| | - Marissa M. Bivins
- Department of Pharmacology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Natalie K. Barker
- UNC Proteomics Core Facility, Department of Pharmacology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alicia A. Sorgen
- Department of Biological Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Angie L. Mordant
- UNC Proteomics Core Facility, Department of Pharmacology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca L. Johnson
- Center for Integrative Chemical Biology and Drug Discovery, Division of Chemical Biology and Medicinal Chemistry, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aadra P. Bhatt
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, and the Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony A. Fodor
- Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Laura E. Herring
- UNC Proteomics Core Facility, Department of Pharmacology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hermen Overkleeft
- Department of Bioorganic Synthesis, Leiden Institute of Chemistry, Leiden University, Leiden, The Netherlands
| | - John R. Lee
- Department of Medicine, Division of Nephrology and Hypertension, New York, New York, USA
| | - Matthew. R. Redinbo
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Biochemistry and Biophysics, Department of Microbiology and Immunology, and the Institute for Biological and Genome Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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10
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Xiong A, Hu Z, Zhou S, Qiang Y, Song Z, Chen H, Xiang Q, Zhang Y, Cao Y, Cui H, Luo J, Wang Y, Yang Y, Cui B, Li M, Shuai S. Cardiovascular events in adult polymyositis and dermatomyositis: a meta-analysis of observational studies. Rheumatology (Oxford) 2021; 61:2728-2739. [PMID: 34791063 DOI: 10.1093/rheumatology/keab851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/11/2021] [Accepted: 11/06/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES We aimed to review whether polymyositis (PM) and dermatomyositis (DM) patients have an increased cardiovascular (CV) risk, including ischaemic heart disease (IHD), cerebrovascular accidents (CVA), and venous thromboembolism (VTE). METHODS We searched PubMed, Embase, and the Cochrane database for relevant studies from inception to February 2021. RESULTS Twenty-two studies comprising 25,433 patients were included. With PM/DM versus general populations, the risk was significantly increased for CV events (relative risk (RR)=2.37, 95%CI:1.86-3.02). The RR of CV events for males with PM/DM was higher than for females (RR = 1.43; 95%CI:1.17-1.74). PM/DM patients followed for one to five years had a significantly higher CV risk than those followed for five to ten years (RR = 3.51, 95%CI:1.95-6.32). The risk was increased for North Americans (RR = 4.28, 95%CI:2.57-7.11), Europeans (RR = 2.29, 95%CI:1.58-3.31), and Asians (RR = 2.03, 95%CI:1.41-2.90). Our meta-analysis found that the elevated CV event risk was related to PM (RR = 2.35, 95%CI:1.51-3.66) and DM (RR = 2.55, 95%CI:1.66-3.93). Subgroup analyses showed that the risk was significantly increased for IHD (RR = 1.76, 95%CI:1.40-2.21), CVA morbidity (RR = 1.31, 95%CI:1.03-1.67), and ischaemic stroke (IS) (RR = 1.47, 95%CI:1.26-1.73), with no statistically significant increased risk of haemorrhagic stroke mortality (RR = 1.43, 95%CI:0.92-2.21). The CV event risk was increased for VTE (RR = 4.60, 95%CI:3.17-6.66), deep venous thrombosis (DVT) (RR = 5.53, 95%CI:3.25-9.39), and pulmonary embolism (PE) (RR = 5.26, 95%CI:2.62-10.55). CONCLUSION This meta-analysis found that PM/DM patients had a ∼2.37 times increased CV risk, particularly males diagnosed in the previous five years. PM/DM may be an independent risk factor for developing IHD, IS, DVT, and PE.
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China.,Inflammation and Immunology Key Laboratory of Nanchong City, Sichuan, China
| | - Ziyi Hu
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Shifeng Zhou
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Yiying Qiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Zhuoyao Song
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Huini Chen
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Qilang Xiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Yan Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Yuzi Cao
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Hongxu Cui
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Jie Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Ye Wang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China
| | - Yuan Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Beibei Cui
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Menglan Li
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China.,Inflammation and Immunology Key Laboratory of Nanchong City, Sichuan, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, China.,Inflammation and Immunology Key Laboratory of Nanchong City, Sichuan, China
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Kulak O, Gurram B, Montgomery EA, Park JY. Pediatric autoimmune gastritis: clinical correlates and histologic features. Hum Pathol 2021; 116:31-38. [PMID: 34284050 DOI: 10.1016/j.humpath.2021.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 11/24/2022]
Abstract
Autoimmune gastritis is a well-known pathologic entity, but there are few studies that examine its clinical and histologic presentation in children. This is a single institution, retrospective study performed on patients diagnosed from 2011 through 2019. Patients were identified by their pathologic diagnosis within the laboratory information system. The electronic medical record and archived slides were reviewed. Twenty-two children (3 months to 18 years; median, 10.9 years) with autoimmune gastritis were diagnosed of a total of 14,257 nonconsultation gastric biopsies from unique patients (0.15% prevalence). Patients with autoimmune gastritis were diagnosed at an average age of 10.9 years and were mostly female (68.2% women, 31.8% men). The majority had extragastric immune disorders (13/22; 59.1%). All patients in the study had gastric body mucosa with enterochromaffin-like cell hyperplasia, atrophy, and histologic features of chronic injury. Most biopsies showed gastric body metaplasia (n = 19) or active gastric inflammation. However, antral atrophy was also observed in 12 patients, and antral metaplasia was identified in one patient; four patients had active chronic antral gastritis. All biopsies were negative for Helicobacter pylori. Pediatric autoimmune gastritis is a rare disorder that should be recognized because of its systemic effects with long-term morbidity. In addition, the possibility of tandem extragastric immune disorders should be considered when a diagnosis of pediatric autoimmune gastritis is established.
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Affiliation(s)
- Ozlem Kulak
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX 75235, United States.
| | - Bhaskar Gurram
- Division of Pediatric Gastroenterology, UT Southwestern Medical Center and Children's Medical Center Dallas, Dallas, TX 75235, United States.
| | - Elizabeth A Montgomery
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL 33101, United States.
| | - Jason Y Park
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX 75235, United States; Eugene McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX 75235, United States; Department of Pathology and Laboratory Medicine, Children's Medical Center of Dallas, Dallas, TX 75235, United States.
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13
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Recalcitrant Esophageal Stricture Secondary to Mycophenolate Mofetil. Case Rep Gastrointest Med 2020; 2020:8817801. [PMID: 33299620 PMCID: PMC7704200 DOI: 10.1155/2020/8817801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022] Open
Abstract
Mycophenolate mofetil (MMF) is associated with various gastrointestinal toxicities. However, limited literature studies exist reporting MMF-related gastrointestinal toxicity manifesting as esophageal strictures. We report a case of a 62-year-old male with kidney transplant on MMF, tacrolimus, and prednisone, presenting with progressive dysphagia and odynophagia. Esophagogastroduodenoscopy revealed severe esophageal stricturing with near food bolus impaction, requiring dilations, esophageal stent, and ultimately gastrostomy tube. Biopsies revealed nonspecific inflammation with no evidence of infectious/neoplastic process; thus, our multidisciplinary esophageal group determined that the process was secondary to MMF. This case demonstrates that, though rare, MMF can result in severe esophageal strictures causing significant morbidity.
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Morris CC, Stroud SC, Golconda U, Gregoire SA, Juneman EB. Orthotopic Heart Transplant Recipient with Enteric-coated Mycophenolate Sodium (Myfortic) Induced Colitis. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e920235. [PMID: 32404861 PMCID: PMC7252833 DOI: 10.12659/ajcr.920235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient: Male, 66-year-old Final Diagnosis: Drug-induced colitis Symptoms: Abdominal discomfort • anorexia • diarrhea • weight loss Medication: Enteric-coated mycophenolate sodium (Myfortic) Clinical Procedure: Colonoscopy • colon biopsy Specialty: Cardiology • Infectious Disease
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Affiliation(s)
- Craig C Morris
- Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Steven C Stroud
- Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
| | | | - Sharon A Gregoire
- Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Elizabeth B Juneman
- Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
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Girman P, Lipár K, Kočík M, Voska L, Kožnarová R, Marada T, Lánská V, Saudek F. Sirolimus vs mycophenolate mofetil (MMF) in primary combined pancreas and kidney transplantation. Results of a long-term prospective randomized study. Am J Transplant 2020; 20:779-787. [PMID: 31561278 DOI: 10.1111/ajt.15622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/15/2019] [Accepted: 09/20/2019] [Indexed: 01/25/2023]
Abstract
The study was intended to compare pancreas graft survival rates in two groups of pancreas and kidney transplant recipients prospectively randomized to treatment either with sirolimus or MMF. From 2002 to 2013, 238 type 1 diabetic recipients with end-stage kidney disease were randomized 1:1 to sirolimus or MMF treatment. Noncensored pancreas survival at 5 years was 76.4 and 71.6% for sirolimus and MMF groups, respectively (P > .05). Death-censored pancreas survival was better in the sirolimus group (P = .037). After removal of early graft losses pancreas survival did not differ between groups (MMF 83.1% vs sirolimus 91.6%, P = .11). Nonsignificantly more grafts were lost due to rejection in the MMF group (10 vs 5; P = .19). Cumulative patient 5-year survival was 96% in the MMF group and 91% in the sirolimus group (P > .05). Five-year cumulative noncensored kidney graft survival rates did not statistically differ (85.6% in the sirolimus group and 88.8% in MMF group). Recipients treated with MMF had significantly more episodes of gastrointestinal bleeding (7 vs 0, P = .007). More recipients in the sirolimus group required corrective surgery due to incisional hernias (21 vs 12, P = .019). ClinicalTrials No.: NCT03582878.
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Affiliation(s)
- Peter Girman
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Květoslav Lipár
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Matěj Kočík
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Luděk Voska
- Clinical and Transplant Pathology Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Radomíra Kožnarová
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Tomáš Marada
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Věra Lánská
- Department for Data Analysis and Statistics, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - František Saudek
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Abstract
Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. CASE DESCRIPTION: A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. DISCUSSION: MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMF-tacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.
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Affiliation(s)
- Aamer Abbass
- Division of Gastroenterology and Hepatology, University of New Mexico, MSC 10-5550, Albuquerque, NM, 87131, USA.
| | - Sameen Khalid
- Division of Gastroenterology and Hepatology, University of New Mexico, MSC 10-5550, Albuquerque, NM, 87131, USA
| | - Vaishnavi Boppana
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Joshua Hanson
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Henry Lin
- Division of Gastroenterology and Hepatology, University of New Mexico, MSC 10-5550, Albuquerque, NM, 87131, USA
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Denis McCarthy
- Division of Gastroenterology and Hepatology, University of New Mexico, MSC 10-5550, Albuquerque, NM, 87131, USA
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Kofuji S, Hirayama A, Eberhardt AO, Kawaguchi R, Sugiura Y, Sampetrean O, Ikeda Y, Warren M, Sakamoto N, Kitahara S, Yoshino H, Yamashita D, Sumita K, Wolfe K, Lange L, Ikeda S, Shimada H, Minami N, Malhotra A, Morioka S, Ban Y, Asano M, Flanary VL, Ramkissoon A, Chow LML, Kiyokawa J, Mashimo T, Lucey G, Mareninov S, Ozawa T, Onishi N, Okumura K, Terakawa J, Daikoku T, Wise-Draper T, Majd N, Kofuji K, Sasaki M, Mori M, Kanemura Y, Smith EP, Anastasiou D, Wakimoto H, Holland EC, Yong WH, Horbinski C, Nakano I, DeBerardinis RJ, Bachoo RM, Mischel PS, Yasui W, Suematsu M, Saya H, Soga T, Grummt I, Bierhoff H, Sasaki AT. IMP dehydrogenase-2 drives aberrant nucleolar activity and promotes tumorigenesis in glioblastoma. Nat Cell Biol 2019; 21:1003-1014. [PMID: 31371825 PMCID: PMC6686884 DOI: 10.1038/s41556-019-0363-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 06/18/2019] [Indexed: 12/17/2022]
Abstract
In many cancers, high proliferation rates correlate with elevation of rRNA and tRNA levels, and nucleolar hypertrophy. However, the underlying mechanisms linking increased nucleolar transcription and tumorigenesis are only minimally understood. Here we show that IMP dehydrogenase-2 (IMPDH2), the rate-limiting enzyme for de novo guanine nucleotide biosynthesis, is overexpressed in the highly lethal brain cancer glioblastoma. This leads to increased rRNA and tRNA synthesis, stabilization of the nucleolar GTP-binding protein nucleostemin, and enlarged, malformed nucleoli. Pharmacological or genetic inactivation of IMPDH2 in glioblastoma reverses these effects and inhibits cell proliferation, whereas untransformed glia cells are unaffected by similar IMPDH2 perturbations. Impairment of IMPDH2 activity triggers nucleolar stress and growth arrest of glioblastoma cells even in the absence of functional p53. Our results reveal that upregulation of IMPDH2 is a prerequisite for the occurance of aberrant nucleolar function and increased anabolic processes in glioblastoma, which constitutes a primary event in gliomagenesis.
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Affiliation(s)
- Satoshi Kofuji
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Hirayama
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
| | - Alexander Otto Eberhardt
- Institute of Biochemistry and Biophysics, Center for Molecular Biomedicine, Friedrich Schiller University Jena, Jena, Germany
- Leibniz-Institute on Aging-Fritz Lipmann Institute, Jena, Germany
| | - Risa Kawaguchi
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Artificial Intelligence Research Center, National Institute of Advanced Industrial Science and Technology, Tokyo, Japan
| | - Yuki Sugiura
- Department of Biochemistry, Keio University School of Medicine, Tokyo, Japan
| | - Oltea Sampetrean
- Division of Gene Regulation, Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiki Ikeda
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mikako Warren
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Naoya Sakamoto
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shuji Kitahara
- Department of Anatomy and Developmental Biology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Hirofumi Yoshino
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daisuke Yamashita
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kazutaka Sumita
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kara Wolfe
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lisa Lange
- Institute of Biochemistry and Biophysics, Center for Molecular Biomedicine, Friedrich Schiller University Jena, Jena, Germany
- Leibniz-Institute on Aging-Fritz Lipmann Institute, Jena, Germany
| | - Satsuki Ikeda
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
| | - Hiroko Shimada
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Noriaki Minami
- Division of Gene Regulation, Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
| | - Akshiv Malhotra
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shin Morioka
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuki Ban
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Maya Asano
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Victoria L Flanary
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Annmarie Ramkissoon
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lionel M L Chow
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Juri Kiyokawa
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tomoyuki Mashimo
- Department of Internal Medicine; Harold C. Simmons Comprehensive Cancer Center; Annette G. Strauss Center for Neuro-Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Greg Lucey
- Division of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sergey Mareninov
- Division of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tatsuya Ozawa
- Division of Human Biology, Solid Tumor and Translational Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nobuyuki Onishi
- Division of Gene Regulation, Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
| | - Koichi Okumura
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jumpei Terakawa
- Division of Transgenic Animal Science, Advanced Science Research Center, Kanazawa University, Kanazawa, Japan
| | - Takiko Daikoku
- Division of Transgenic Animal Science, Advanced Science Research Center, Kanazawa University, Kanazawa, Japan
| | - Trisha Wise-Draper
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nazanin Majd
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kaori Kofuji
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mika Sasaki
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Masaru Mori
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
| | - Yonehiro Kanemura
- Department of Biomedical Research and Innovation, Institute for Clinical Research, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Eric P Smith
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Hiroaki Wakimoto
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Eric C Holland
- Division of Human Biology, Solid Tumor and Translational Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - William H Yong
- Division of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Craig Horbinski
- Department of Pathology, University of Kentucky College of Medicine, Lexington, KY, USA
- Departments of Pathology and Neurosurgery, Northwestern University, Chicago, IL, USA
| | - Ichiro Nakano
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ralph J DeBerardinis
- Howard Hughes Medical Institute; Children's Medical Center Research Institute; Department of Pediatrics and Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert M Bachoo
- Department of Internal Medicine; Harold C. Simmons Comprehensive Cancer Center; Annette G. Strauss Center for Neuro-Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul S Mischel
- Ludwig Institute for Cancer Research; Department of Pathology; Moores Cancer Center, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Wataru Yasui
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Makoto Suematsu
- Department of Biochemistry, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Saya
- Division of Gene Regulation, Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
| | - Tomoyoshi Soga
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
- AMED-CREST, AMED, Tokyo, Japan
| | - Ingrid Grummt
- Division of Molecular Biology of the Cell II, German Cancer Research Center, DKFZ-ZMBH Alliance, Heidelberg, Germany
| | - Holger Bierhoff
- Institute of Biochemistry and Biophysics, Center for Molecular Biomedicine, Friedrich Schiller University Jena, Jena, Germany
- Leibniz-Institute on Aging-Fritz Lipmann Institute, Jena, Germany
| | - Atsuo T Sasaki
- Division of Hematology and Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan.
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Department of Neurosurgery, Brain Tumor Center at UC Gardner Neuroscience Institute, Cincinnati, OH, USA.
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Esophagitis in patients without gastroesophageal reflux disease or eosinophilic esophagitis: diagnostic considerations. Curr Opin Gastroenterol 2019; 35:379-386. [PMID: 33216485 DOI: 10.1097/mog.0000000000000539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW A multitude of inflammatory diseases other than gastroesophageal reflux disease (GERD) and eosinophilic esophagitis can affect the esophagus. Despite the deceptively simple organization of squamous mucosa and its limited number of inflammatory responses, a wide array of histologic patterns can be seen in inflammatory disorders involving the esophagus. Each such histologic pattern is associated with a limited number of underlying conditions, and the clinician can use this information to narrow the differential diagnosis. The purpose of this review is to review and discuss the pathologic diagnosis of esophagitis caused by conditions other than GERD or eosinophilic esophagitis, with an emphasis on recent developments in the field. RECENT FINDINGS Recent studies suggest that lymphocytic esophagitis may be a histologic manifestation of esophageal motility disorders. Immunophenotypic features of infiltrating lymphocytes may be helpful in this scenario. immunoglobulin G4-related disease has been implicated as a cause of esophageal inflammation with ulceration, strictures, and mass-forming fibrosis, whereas epidermoid metaplasia has been linked molecularly to the squamous cell neoplasia pathway. SUMMARY Improved knowledge and appreciation of the pathology of esophageal inflammation are needed to better understand the pathogenesis of various types of esophagitis, and to inform new approaches to the therapy and management of inflammatory esophageal diseases.
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Review of Drug-induced Injury in Mucosal Biopsies From the Tubular Gastrointestinal Tract. Adv Anat Pathol 2019; 26:151-170. [PMID: 30870181 DOI: 10.1097/pap.0000000000000230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The use of prescription and over-the-counter medications is on the rise in the US population, especially among those aged 65 and over, with over 46% of the population taking at least 1 prescription medication. Given the frequency of medication use, and that the majority of these medications are taken orally, it has become increasingly relevant for pathologist examining endoscopically obtained gastrointestinal tract mucosal biopsies to consider and recognize patterns of mucosal injury associated with various drugs. Reports on injuries associated with certain classes of drugs can be scattered among different sources, making a comprehensive view of various injury patterns and the drugs known to cause them difficult to obtain. Herein, we provide a comprehensive overview of the drugs known to cause mucosal injuries in the tubular gastrointestinal tract organized by the organ involved and the prominent pattern of injury.
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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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21
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Kreft A, Neumann H, von Bach DS, Wagner-Drouet EM. Histologic diagnosis and grading of esophageal acute graft-versus-host disease. Virchows Arch 2019; 474:325-332. [DOI: 10.1007/s00428-018-2507-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 11/10/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022]
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22
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Celiac-like Enteropathy Associated With Mycophenolate Sodium in Renal Transplant Recipients. Transplant Direct 2018; 4:e375. [PMID: 30255135 PMCID: PMC6092177 DOI: 10.1097/txd.0000000000000812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 05/24/2018] [Accepted: 05/30/2018] [Indexed: 01/19/2023] Open
Abstract
Background Although colonic injury is a well-known complication of mycophenolic acid (MPA), the involvement of the upper gastrointestinal tract is less extensively documented. We present the occurrence of celiac-like duodenopathy manifested as a severe diarrhea syndrome in 2 renal transplant recipients on enteric-coated mycophenolate sodium. Methods The patients belong to a setting of 16 renal transplant recipients under MPA suffering from chronic diarrhea in the absence of MPA-related colitis. Results Both patients had a history of persistent diarrhea with significant weight loss. Colonic mucosa was unremarkable, whereas duodenal biopsies revealed celiac-like changes with increased epithelial cell apoptosis. Clinical symptoms completely resolved, and follow-up biopsies demonstrated normalization of histology after enteric-coated mycophenolate sodium withdrawal and switching to azathioprine. Conclusions Celiac-like enteropathy seems to represent a rare side effect of MPA-associated immunosuppressive therapy and should be taken into account in the differential diagnosis of diarrhea in transplant recipients treated with MPA particularly in the absence of MPA-related colitis. As macroscopic lesions are usually missing, blind duodenal biopsies are necessary to establish the diagnosis.
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23
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Tayyem O, Saraireh H, Al Hanayneh M, Stevenson HL. Heart transplant recipient with mycophenolate mofetil-induced colitis: the great imitator. BMJ Case Rep 2018; 2018:bcr-2017-224035. [PMID: 29930181 DOI: 10.1136/bcr-2017-224035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
In this article, we report a case of a 55-year-old male heart transplant recipient who presented with diarrhoea. An extensive workup for infectious diseases was negative. The patient had a colonoscopy with biopsies showing colitis that mimicked graft-versus-host disease on histopathology. After excluding other potential causes and excluding acute cellular rejection, mycophenolate mofetil was discontinued, and the patient had significant clinical improvement with increased appetite and weight gain.
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Affiliation(s)
- Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Hamzeh Saraireh
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Muhannad Al Hanayneh
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Heather L Stevenson
- Department of Pathology, University of Texas Medical Branch Institute for the Medical Humanities, Galveston, Texas, USA
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Flannigan KL, Taylor MR, Pereira SK, Rodriguez-Arguello J, Moffat AW, Alston L, Wang X, Poon KK, Beck PL, Rioux KP, Jonnalagadda M, Chelikani PK, Galipeau HJ, Lewis IA, Workentine ML, Greenway SC, Hirota SA. An intact microbiota is required for the gastrointestinal toxicity of the immunosuppressant mycophenolate mofetil. J Heart Lung Transplant 2018; 37:1047-1059. [PMID: 30173823 DOI: 10.1016/j.healun.2018.05.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/04/2018] [Accepted: 05/07/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is commonly prescribed after transplantation and has major advantages over other immunosuppressive drugs, but frequent gastrointestinal (GI) side-effects limit its use. The mechanism(s) underlying MMF-related GI toxicity have yet to be elucidated. METHODS To investigate MMF-related GI toxicity, experimental mice were fed chow containing MMF (0.563%) and multiple indices of toxicity, including weight loss and colonic inflammation, were measured. Changes in intestinal microbial composition were detected using 16S rRNA Illumina sequencing, and downstream PICRUSt analysis was used to predict metagenomic pathways involved. Germ-free (GF) mice and mice treated with orally administered broad-spectrum antibiotics (ABX) were utilized to interrogate the importance of the microbiota in MMF-induced GI toxicity. RESULTS Mice treated with MMF exhibited significant weight loss, related to loss of body fat and muscle, and marked colonic inflammation. MMF exposure was associated with changes in gut microbial composition, as demonstrated by a loss of overall diversity, expansion of Proteobacteria (specifically Escherichia/Shigella), and enrichment of genes involved in lipopolysaccharide (LPS) biosynthesis, which paralleled increased levels of LPS in the feces and serum. MMF-related GI toxicity was dependent on the intestinal microbiota, as MMF did not induce weight loss or colonic inflammation in GF mice. Furthermore, ABX prevented and reversed MMF-induced weight loss and colonic inflammation. CONCLUSIONS An intact intestinal microbiota is required to initiate and sustain the GI toxicity of MMF. MMF treatment causes dynamic changes in the composition of the intestinal microbiota that may be a targetable driver of the GI side-effects of MMF.
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Affiliation(s)
- Kyle L Flannigan
- Department of Physiology and Pharmacology, Cumming School of Medicine; Snyder Institute for Chronic Diseases.
| | - Michael R Taylor
- Department of Paediatrics and Alberta Children's Hospital Research Institute, Cumming School of Medicine
| | - Sheldon K Pereira
- Snyder Institute for Chronic Diseases; Department of Paediatrics and Alberta Children's Hospital Research Institute, Cumming School of Medicine
| | - Jimena Rodriguez-Arguello
- Department of Paediatrics and Alberta Children's Hospital Research Institute, Cumming School of Medicine
| | - Andrew W Moffat
- Department of Paediatrics and Alberta Children's Hospital Research Institute, Cumming School of Medicine
| | - Laurie Alston
- Department of Physiology and Pharmacology, Cumming School of Medicine; Snyder Institute for Chronic Diseases
| | - Xuemei Wang
- Department of Paediatrics and Alberta Children's Hospital Research Institute, Cumming School of Medicine; Department of Cardiac Sciences and the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine
| | - Karen K Poon
- Snyder Institute for Chronic Diseases; Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine
| | - Paul L Beck
- Department of Physiology and Pharmacology, Cumming School of Medicine; Snyder Institute for Chronic Diseases; Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kevin P Rioux
- Snyder Institute for Chronic Diseases; Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine; Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mahesh Jonnalagadda
- Laboratory of Animal Medical Services, University of Cincinnati, Cincinnati, Ohio, USA
| | - Prasanth K Chelikani
- Department of Production, Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heather J Galipeau
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Steven C Greenway
- Department of Paediatrics and Alberta Children's Hospital Research Institute, Cumming School of Medicine; Department of Cardiac Sciences and the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine; Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simon A Hirota
- Department of Physiology and Pharmacology, Cumming School of Medicine; Snyder Institute for Chronic Diseases; Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine
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Gopal P, Gibson JA, Lisovsky M, Nalbantoglu ILK. Unique causes of esophageal inflammation: a histopathologic perspective. Ann N Y Acad Sci 2018; 1434:219-226. [PMID: 29766506 DOI: 10.1111/nyas.13732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022]
Abstract
Gastroenterologists frequently perform endoscopic esophageal mucosal biopsies for pathologic diagnosis in patients experiencing symptoms of esophagitis. The more common causes of esophagitis diagnosed on esophageal mucosal biopsy include reflux esophagitis, eosinophilic esophagitis, and infectious esophagitis caused by Candida albicans, herpes simplex virus, and/or cytomegalovirus. However, there are several causes of esophagitis seen less frequently by pathologists that are very important to recognize. We discuss unique types of esophageal inflammation, including acute bacterial esophagitis, esophageal manifestations of dermatologic diseases, medication-induced esophageal injury, and sloughing esophagitis; and we review their clinical and histopathologic features.
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Affiliation(s)
- Purva Gopal
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joanna A Gibson
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Mikhail Lisovsky
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - ILKe Nalbantoglu
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
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26
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Cardona DM, Detweiler CJ, Shealy MJ, Sung AD, Wild DM, Poleski MH, Balmadrid BL, Cirrincione CT, Howell DN, Sullivan KM. Use of the National Institutes of Health Consensus Guidelines Improves the Diagnostic Sensitivity of Gastrointestinal Graft-Versus-Host Disease. Arch Pathol Lab Med 2018; 142:1098-1105. [PMID: 29697275 DOI: 10.5858/arpa.2017-0054-oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
CONTEXT - Graft-versus-host disease of the gastrointestinal tract is a common complication of hematopoietic stem cell transplant associated with significant morbidity and mortality. Accurate diagnosis can be difficult and is a truly clinicopathologic endeavor. OBJECTIVES - To assess the diagnostic sensitivity of gastrointestinal graft-versus-host disease using the 2015 National Institutes of Health (NIH) histology consensus guidelines and to analyze histologic findings that support the guidelines. DESIGN - Patients with allogeneic hematopoietic stem cell transplants were identified via a retrospective search of our electronic medical records from January 1, 2005, to January 1, 2011. Endoscopies with available histology were reviewed by 2 pathologists using the 2015 NIH guidelines. The clinical diagnosis was used as the gold standard. A nontransplant set of endoscopic biopsies was used as a control. RESULTS - Of the 250 total endoscopies, 217 (87%) had a clinical diagnosis of gastrointestinal graft-versus-host disease. Use of the NIH consensus guidelines showed a sensitivity of 86% and a specificity of 65%. Thirty-seven of 58 (64%) cases with an initial false-negative histopathologic diagnosis were diagnosed as graft-versus-host disease on our review. CONCLUSIONS - Use of the NIH histology consensus guidelines results in a high sensitivity and specificity, thereby decreasing false-negatives. Additionally, use of the NIH guidelines aids in creating uniformity and diagnostic clarity. Correlation with clinical and laboratory findings is critical in evaluating the differential diagnosis and to avoid false-positives. As expected, increased apoptosis with decreased inflammation was associated with a pathologic diagnosis of graft-versus-host disease and supports the NIH guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Keith M Sullivan
- From the Departments of Pathology (Drs Cardona, Detweiler, Shealy, and Howell) and Internal Medicine (Drs Sung, Wild, Poleski, Balmadrid, and Sullivan), Duke University Medical Center, Durham, North Carolina; and the Department of Biostatistics (Ms Cirrincione), Duke Cancer Institute, Durham, North Carolina
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Gu B, Bo GZ, Ke C. Exploration of Fecal Microbiota Transplantation in the Treatment of Refractory Diarrhea After Renal Transplantation. Transplant Proc 2018; 50:1326-1331. [PMID: 29880353 DOI: 10.1016/j.transproceed.2018.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/01/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Exploration of fecal microbiota transplantation in the treatment of refractory diarrhea after renal transplantation. METHODS Summarize the etiology of 120 cases with diarrhea after renal transplantation from 2014 to 2017 in our hospital. There were 4 recipients of refractory diarrhea who accepted fecal microbiota transplantation with informed consent, and we collected clinical data of stool and bacterial culture, gut microbiota analysis, graft function, electrolytes, immunosuppressant concentrations of prognostic evaluation of patients with fecal transplantation. RESULTS The absorption of electrolyte is slightly higher and concentration of tacrolimus and creatinine were not significantly changed compared with before. CONCLUSION Fecal microbiota transplantation provides a new choice to refractory diarrhea after renal transplantation as an innovative treatment, but the effectiveness of fecal microbiota transplantation needs long-term observation and further evaluation through large sample data.
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Affiliation(s)
- B Gu
- Department of Transplantation, Xiangya School of Medicine, Changsha, Hunan, China.
| | - G Z Bo
- Department of Transplantation, Xiangya School of Medicine, Changsha, Hunan, China
| | - C Ke
- Department of Transplantation, Xiangya School of Medicine, Changsha, Hunan, China
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Abstract
Every year many new medications are approved for clinical use, several of which can cause clinically significant gastrointestinal tract toxicity. This article emphasizes the histologic features and differential diagnosis of drug-induced injury to the gastrointestinal mucosa. Ultimately, clinical correlation and cessation of a drug with resolution of symptoms are needed to definitively confirm a drug as a causative factor in mucosal injury. Recognizing histologic features in gastrointestinal biopsies, however, can allow surgical pathologists to play a key role in establishing a diagnosis of drug-induced gastrointestinal toxicity.
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Affiliation(s)
- Heewon A Kwak
- Department of Pathology, University of Chicago, 5841 South Maryland Avenue, Chicago, IL, USA
| | - John Hart
- Department of Pathology, University of Chicago, 5841 South Maryland Avenue, MC 6101, Chicago, IL, USA.
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Talmon G, Manasek T, Miller R, Muirhead D, Lazenby A. The Apoptotic Crypt Abscess: An Underappreciated Histologic Finding in Gastrointestinal Pathology. Am J Clin Pathol 2017; 148:538-544. [PMID: 29140405 DOI: 10.1093/ajcp/aqx100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To differentiate apoptotic crypt abscesses (ACAs) from neutrophilic crypt abscesses (NCAs). METHODS Cases with crypt abscesses were classified as containing ACAs, NCAs, or mixed crypt abscesses (MCAs) by H&E staining. Sections were stained with cleaved caspase 3 and myeloperoxidase and recategorized. RESULTS Fifty-nine cases were reviewed: inflammatory bowel disease (IBD; n = 33), acute cellular rejection (n = 5), graft vs host disease (GVHD; n = 14), cytomegalovirus (n = 5), and drug reaction (n = 2). Concordance was seen in 59%, with most reclassifications resulting from a change of ACAs to MCAs. When cases were classified as having NCA vs those with apoptosis (ACA and MCA), there was 85% agreement (P < .01). NCAs were present in IBD (96%) and not in GVHD or drug injury. Crypt abscesses with apoptosis were seen in 18% of IBD and 96% of non-IBD cases. CONCLUSIONS ACAs and MCAs can be distinguished from NCAs and may be a diagnostically useful finding.
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Affiliation(s)
- Geoffrey Talmon
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha
| | - Tristan Manasek
- Department of Biology, University of Nebraska-Kearney, Kearney
| | - Ross Miller
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha
| | - David Muirhead
- Department of Pathology, City of Hope National Cancer Center, Duarte, CA
| | - Audrey Lazenby
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha
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Abstract
Gastrointestinal mucosal biopsies in the hematopoietic stem cell transplantation setting are challenging because histologic features of graft-versus-host disease (GVHD), which is treated by increasing immunosuppression, overlap with those of other conditions, such as infection, which can get worse with GVHD treatment. More than one condition can occur at the same time. It is important to understand the histologic features of GVHD, drug toxicity, infection, and clinical factors surrounding patients, including timing of biopsy in relation to transplantation, medication history, and laboratory data. Rendering a correct diagnosis and generating a pathology report with standard language that can direct clinical management ensure proper management.
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Apostolov R, Asadi K, Lokan J, Kam N, Testro A. Mycophenolate mofetil toxicity mimicking acute cellular rejection in a small intestinal transplant. World J Transplant 2017; 7:98-102. [PMID: 28280702 PMCID: PMC5324035 DOI: 10.5500/wjt.v7.i1.98] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 12/21/2016] [Accepted: 01/14/2017] [Indexed: 02/05/2023] Open
Abstract
Mycophenolate mofetil (MMF) is an important medication used for maintenance immunosuppression in solid organ transplants. A common gastrointestinal (GI) side effect of MMF is enterocolitis, which has been associated with multiple histological features. There is little data in the literature describing the histological effects of MMF in small intestinal transplant (SIT) recipients. We present a case of MMF toxicity in a SIT recipient, with histological changes in the donor ileum mimicking persistent acute cellular rejection (ACR). Concurrent biopsies of the patient’s native colon showed similar changes to those from the donor small bowel, suggesting a non-graft specific process, raising suspicion for MMF toxicity. The MMF was discontinued and complete resolution of these changes occurred over three weeks. MMF toxicity should therefore be considered as a differential diagnosis for ACR and graft-versus-host disease in SITs.
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32
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Medication-associated gastrointestinal tract injury. Virchows Arch 2017; 470:245-266. [PMID: 28133700 DOI: 10.1007/s00428-017-2077-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/05/2016] [Accepted: 01/19/2017] [Indexed: 12/18/2022]
Abstract
Medication-associated gastrointestinal (GI) tract injury has been known for centuries for some medications. The more recently introduced biologicals are a class of drugs that constantly increases, and as such, the spectrum of GI tract side effects is steadily growing. This review covers not only long-known GI tract side effects of drugs but also those more recently described. A comprehensive but concise list of medications used in daily practice and associated with GI tract injury is presented.
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Koo J, Dawson DW, Dry S, French SW, Naini BV, Wang HL. Allograft biopsy findings in patients with small bowel transplantation. Clin Transplant 2016; 30:1433-1439. [PMID: 27582272 DOI: 10.1111/ctr.12836] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 12/18/2022]
Abstract
In this study, we sought to determine the incidence of post-transplant complications including acute cellular rejection (ACR), infection, and post-transplant lymphoproliferative disease (PTLD) in mucosal allograft biopsies in patients with small bowel transplant at our institution. We retrospectively reviewed pathology reports from 5675 small bowel allograft biopsies from 99 patients and analyzed the following: indications for biopsy, frequency and grade of ACR, the presence of infectious agents, results of workup for potential PTLD, results of C4d immunohistochemistry (IHC), features of chronic mucosal injury, and findings in concurrent native bowel biopsies. Findings from 42 allograft resection specimens were also correlated with prior biopsy findings. Indeterminate, mild, moderate, and severe ACR were seen in 276 (4.9%), 409 (7.2%), 100 (1.8%), and 207 (3.6%) of biopsies, respectively. Although ACR may show histologic overlap with mycophenolate mofetil toxicity, we found the analysis of concurrent native bowel biopsies to be helpful in this distinction. Adenovirus was the most common infectious agent seen (11%), and we routinely performed adenovirus IHC on biopsies. Eighteen patients (18%) developed PTLD, 83% of which were EBV associated, but only 28% of PTLD cases were diagnosed on mucosal allograft biopsies. C4d IHC did not correlate with the presence of donor-specific antibodies in limited cases.
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Affiliation(s)
- Jamie Koo
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
| | - David W Dawson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sarah Dry
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Samuel W French
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Bita V Naini
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Lim EJ, Chin R, Nachbur U, Silke J, Jia Z, Angus PW, Torresi J. Hepatitis C-induced hepatocyte apoptosis following liver transplantation is enhanced by immunosuppressive agents. J Viral Hepat 2016; 23:730-43. [PMID: 27167351 DOI: 10.1111/jvh.12541] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 03/05/2016] [Indexed: 01/07/2023]
Abstract
In recurrent hepatitis C (HCV) post-liver transplantation (OLT), the combination of immunosuppressants and HCV is postulated to increase hepatocyte apoptosis and liver fibrosis. We evaluated hepatocyte apoptosis within the liver tissue of patients with postOLT HCV recurrence compared to HCV-negative individuals and correlated these findings with the effects of immunosuppressants on HCV-induced cell death and its inhibition in primary mouse hepatocytes (PMoH). Liver biopsies from patients with and without HCV were evaluated by immunohistochemistry for markers of apoptosis M30 CytoDEATH (M30) and cleaved PARP (clPARP). PMoH from C57BL/6 mice were infected with recombinant adenoviruses (rAdHCV) that expressed HCV proteins in hepatocytes. Infected cells were treated with cyclosporine, tacrolimus, sirolimus and/or MMF with or without pan-caspase inhibitor Q-VD-Oph. Cell viability and apoptosis were evaluated using crystal violet assays and Western immunoblots probed for cleaved caspase-3 (clCas3) and clPARP. Both M30 and clPARP were increased in the liver biopsies of patients with postOLT HCV recurrence compared to HCV-negative individuals. Treatment of rAdHCV-infected PMoH with cyclosporine, tacrolimus or sirolimus reduced cell viability and increased clCas3 and clPARP compared to rAdHCV infection alone. Addition of MMF to cyclosporine, tacrolimus or sirolimus further reduced cell viability and increased clCas3 and clPARP. Q-VD-Oph improved cell viability in HCV-infected PMoH treated with immunosuppressants alone and in combination and reduced clCas3 and clPARP by approximately 90%. Immunosuppressive agents, especially in combination, enhanced apoptosis in HCV-infected hepatocytes. The finding that Q-VD-Oph reversed hepatocyte death suggests that treatments utilizing apoptosis inhibition might reduce liver injury in postOLT HCV recurrence.
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Affiliation(s)
- E J Lim
- Liver Transplant Unit, Austin Hospital, Heidelberg, Vic., Australia.,Department of Medicine, The University of Melbourne, Austin Hospital, Heidelberg, Vic., Australia
| | - R Chin
- Department of Medicine, The University of Melbourne, Austin Hospital, Heidelberg, Vic., Australia
| | - U Nachbur
- Walter and Eliza Hall Institute, Parkville, Vic., Australia
| | - J Silke
- Walter and Eliza Hall Institute, Parkville, Vic., Australia
| | - Z Jia
- Department of Medicine, The University of Melbourne, Austin Hospital, Heidelberg, Vic., Australia
| | - P W Angus
- Liver Transplant Unit, Austin Hospital, Heidelberg, Vic., Australia.,Department of Medicine, The University of Melbourne, Austin Hospital, Heidelberg, Vic., Australia
| | - J Torresi
- Department of Medicine, The University of Melbourne, Austin Hospital, Heidelberg, Vic., Australia.,Department of Infectious Diseases, Austin Hospital, Heidelberg, Vic., Australia.,Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Parkville, Vic., Australia
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Yan TZ, Wu XQ, Rong L. A four-drug combination therapy consisting of low-dose tacrolimus, low-dose mycophenolate mofetil, corticosteroids, and mizoribine in living donor renal transplantation: A randomized study. SAGE Open Med 2016; 4:2050312116643672. [PMID: 27231549 PMCID: PMC4871204 DOI: 10.1177/2050312116643672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/15/2016] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE We compared a three-drug combination therapy (control group) consisting of tacrolimus, mycophenolate mofetil, and corticosteroids in living donor renal transplantation with a four-drug combination therapy (study group), in which the doses of tacrolimus and mycophenolate mofetil were halved and the immunosuppressive drug mizoribine was added, in order to determine whether the incidence rates of acute rejection after transplantation between the study group and the control group are similar, whether the study group regimen prevents the occurrence of calcineurin inhibitor-induced renal damage, and whether the study group regimen prevents adverse effects such as diarrhea caused by mycophenolate mofetil. METHODS We investigated the incidence of acute rejection, serum creatinine levels, and estimated glomerular filtration rate and the incidence of adverse effects such as diarrhea. RESULTS There was no significant difference between the two groups in the incidence of acute rejection. Renal function (estimated glomerular filtration rate and serum creatinine) was maintained in the control group whereas in the study group renal function gradually improved, with a statistical difference observed at 12 months. The incidence of gastrointestinal symptoms including diarrhea was significantly higher in the control group than in the study group. There was no significant difference in the incidence of cytomegalovirus infection and other adverse effects. CONCLUSION These results suggest the study group therapy is an effective regimen in preventing acute rejection and the deterioration of renal function. These results also show this therapy can reduce the incidence of adverse effects such as gastrointestinal symptoms.
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Affiliation(s)
- Tian-Zhong Yan
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Xiao-Qiang Wu
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Lu Rong
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
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36
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Hematopoietic Stem Cell Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7124099 DOI: 10.1007/978-3-319-29683-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Olmesartan-associated sprue-like enteropathy: a systematic review with emphasis on histopathology. Hum Pathol 2015; 50:127-34. [PMID: 26997446 DOI: 10.1016/j.humpath.2015.12.001] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 11/22/2015] [Accepted: 12/03/2015] [Indexed: 12/26/2022]
Abstract
Sprue-like enteropathy associated with the angiotensin II receptor blocker (ARB) olmesartan was first described in 2012, and a number of cases have since been reported. This syndrome is characterized by severe diarrhea and sprue-like histopathologic findings in the intestine, often with increased subepithelial collagen. The incidence of this adverse drug reaction is not entirely clear, although it is thought to be rare. It is also not well established if other ARBs cause such a syndrome, although case reports suggest they can. The histopathologic features of olmesartan-related injury have only been described in a limited number of cases, and there are no guidelines regarding the histopathologic distinction of olmesartan-associated enteropathy from other causes of sprue (eg, celiac disease, tropical sprue). Herein, we review the histopathologic changes and clinical observations described in recent reports of olmesartan-associated sprue-like enteropathy comprising case series and isolated reports, other relevant literature, and our experience at a referral center specializing in small intestinal disorders. We will review recent literature suggesting other ARBs can be associated with a similar phenotype. Lastly, we will discuss the histopathologic differential diagnosis and provide clues to distinguish this entity from other entities which can cause sprue-like histopathology.
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Effect of Immunosuppressive Agents on Hepatocyte Apoptosis Post-Liver Transplantation. PLoS One 2015; 10:e0138522. [PMID: 26390404 PMCID: PMC4577231 DOI: 10.1371/journal.pone.0138522] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/01/2015] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Immunosuppressants are used ubiquitously post-liver transplantation to prevent allograft rejection. However their effects on hepatocytes are unknown. Experimental data from non-liver cells indicate that immunosuppressants may promote cell death thereby driving an inflammatory response that promotes fibrosis and raises concerns that a similar effect may occur within the liver. We evaluated apoptosis within the liver tissue of post-liver transplant patients and correlated these findings with in vitro experiments investigating the effects of immunosuppressants on apoptosis in primary hepatocytes. METHODS Hepatocyte apoptosis was assessed using immunohistochemistry for M30 CytoDEATH and cleaved PARP in human liver tissue. Primary mouse hepatocytes were treated with various combinations of cyclosporine, tacrolimus, sirolimus, or MMF. Cell viability and apoptosis were evaluated using crystal violet assays and Western immunoblots probed for cleaved PARP and cleaved caspase 3. RESULTS Post-liver transplant patients had a 4.9-fold and 1.7-fold increase in M30 CytoDEATH and cleaved PARP compared to normal subjects. Cyclosporine and tacrolimus at therapeutic concentrations did not affect hepatocyte apoptosis, however when they were combined with MMF, cell death was significantly enhanced. Cell viability was reduced by 46% and 41%, cleaved PARP was increased 2.6-fold and 2.2-fold, and cleaved caspase 3 increased 2.2-fold and 1.8-fold following treatment with Cyclosporine/MMF and Tacrolimus/MMF respectively. By contrast, the sirolimus/MMF combination did not significantly reduce hepatocyte viability or promote apoptosis. CONCLUSION Commonly used immunosuppressive drug regimens employed after liver transplantation enhance hepatocyte cell death and may thus contribute to the increased liver fibrosis that occurs in a proportion of liver transplant recipients.
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Shulman HM, Cardona DM, Greenson JK, Hingorani S, Horn T, Huber E, Kreft A, Longerich T, Morton T, Myerson D, Prieto VG, Rosenberg A, Treister N, Washington K, Ziemer M, Pavletic SZ, Lee SJ, Flowers MED, Schultz KR, Jagasia M, Martin PJ, Vogelsang GB, Kleiner DE. NIH Consensus development project on criteria for clinical trials in chronic graft-versus-host disease: II. The 2014 Pathology Working Group Report. Biol Blood Marrow Transplant 2015; 21:589-603. [PMID: 25639770 DOI: 10.1016/j.bbmt.2014.12.031] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 12/17/2022]
Abstract
The 2005 National Institute of Health (NIH) Consensus Conference outlined histopathological diagnostic criteria for the major organ systems affected by both acute and chronic graft-versus-host disease (GVHD). The 2014 Consensus Conference led to this updated document with new information from histopathological studies of GVHD in the gut, liver, skin, and oral mucosa and an expanded discussion of GVHD in the lungs and kidneys. The recommendations for final histological diagnostic categories have been simplified from 4 categories to 3: no GVHD, possible GVHD, and likely GVHD, based on better reproducibility achieved by combining the previous categories of "consistent with GVHD" and "definite GVHD" into the single category of "likely GVHD." Issues remain in the histopathological characterization of GVHD, particularly with respect to the threshold of histological changes required for diagnostic certainty. Guidance is provided for the incorporation of biopsy information into prospective clinical studies of GVHD, particularly with respect to biomarker validation.
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Affiliation(s)
- Howard M Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Diana M Cardona
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Joel K Greenson
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Sangeeta Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Departments of Pediatrics, Gastroenterology and Pathology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Thomas Horn
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elisabeth Huber
- Institute of Pathology, University of Regensburg, Regensburg, Germany
| | - Andreas Kreft
- Institute of Pathology, University Medical Center Mainz, Mainz, Germany
| | - Thomas Longerich
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Thomas Morton
- Departments of Pediatrics, Gastroenterology and Pathology, University of Washington, Seattle, Washington
| | - David Myerson
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pathology, University of Washington, Seattle, Washington
| | - Victor G Prieto
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Avi Rosenberg
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Kay Washington
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee
| | - Mirjana Ziemer
- Department of Dermatology, University Hospital of Leipzig, Leipzig, Germany
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bethesda, Maryland
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kirk R Schultz
- Department of Pediatrics, BC Children's Hospital/University of British Columbia, Vancouver, British Columbia
| | - Madan Jagasia
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Georgia B Vogelsang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Kleiner
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
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Cotter MB, AbuShanab A, Merriman R, McCormick A, Sheahan K. Coeliac-like duodenal pathology in orthotopic liver transplant patients on mycophenolic acid therapy. Histopathology 2015; 66:500-7. [PMID: 25195696 DOI: 10.1111/his.12541] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 08/29/2014] [Indexed: 12/20/2022]
Abstract
AIMS Diarrhoea following orthotopic liver transplantation (OLT) is a significant clinical problem associated with mycophenolic acid (MPA). The histological injury pattern associated with MPA in the large bowel is well documented in the literature; however, that in the duodenum is less extensively documented. The aim of this study was to investigate the histological spectrum of duodenal injury specifically in symptomatic OLT patients on MPA, and to compare this with the spectrum in patients with coeliac disease and in normal controls. METHODS AND RESULTS We reviewed our pathology database for all duodenal biopsies from patients on the OLT list over a period of 19 years. Medical records, anti-tissue transglutaminase IgA serology and histology were reviewed. Of the 667 patients who underwent endoscopy, 127 had duodenal biopsies (152 biopsies). Of these, 87.5% were normal. Sixteen showed abnormal histology, and seven (43.8%) of these were on MPA at the time of biopsy. Significant features included coeliac-like changes (shortened villi and increased intraepithelial lymphocyte counts), and novel findings included increased endocrine cell counts, apoptotic counts and lamina propria eosinophil counts in comparison with normal duodenal biopsies. CONCLUSIONS Pathologists should be aware of the features of MPA-associated duodenal injury, including coeliac-like changes and increased apoptotic counts. In those with abnormal histology, discontinuation or a reduction in the dose of MPA should be discussed.
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Affiliation(s)
- Maura B Cotter
- Department of Histopathology, Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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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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42
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Bemer MJ, Risler LJ, Phillips BR, Wang J, Storer BE, Sandmaier BM, Duan H, Raccor BS, Boeckh MJ, McCune JS. Recipient pretransplant inosine monophosphate dehydrogenase activity in nonmyeloablative hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20:1544-52. [PMID: 24923537 PMCID: PMC4163086 DOI: 10.1016/j.bbmt.2014.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/30/2014] [Indexed: 10/25/2022]
Abstract
Mycophenolic acid, the active metabolite of mycophenolate mofetil (MMF), inhibits inosine monophosphate dehydrogenase (IMPDH) activity. IMPDH is the rate-limiting enzyme involved in de novo synthesis of guanosine nucleotides and catalyzes the oxidation of inosine 5'-monophosphate to xanthosine 5'-monophosphate (XMP). We developed a highly sensitive liquid chromatography-mass spectrometry method to quantitate XMP concentrations in peripheral blood mononuclear cells (PMNCs) isolated from the recipient pretransplant and used this method to determine IMPDH activity in 86 nonmyeloablative allogeneic hematopoietic cell transplantation (HCT) patients. The incubation procedure and analytical method yielded acceptable within-sample and within-individual variability. Considerable between-individual variability was observed (12.2-fold). Low recipient pretransplant IMPDH activity was associated with increased day +28 donor T cell chimerism, more acute graft-versus-host disease (GVHD), lower neutrophil nadirs, and more cytomegalovirus reactivation but not with chronic GVHD, relapse, nonrelapse mortality, or overall mortality. We conclude that quantitation of the recipient's pretransplant IMPDH activity in PMNC lysate could provide a useful biomarker to evaluate a recipient's sensitivity to MMF. Further trials should be conducted to confirm our findings and to optimize postgrafting immunosuppression in nonmyeloablative HCT recipients.
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Affiliation(s)
- Meagan J Bemer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Linda J Risler
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Brian R Phillips
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Joanne Wang
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Medicine, University of Washington, Seattle, Washington
| | - Haichuan Duan
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Brianne S Raccor
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Michael J Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Medicine, University of Washington, Seattle, Washington
| | - Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington.
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43
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Voltaggio L, Lam-Himlin D, Limketkai BN, Singhi AD, Arnold CA. Message in a bottle: decoding medication injury patterns in the gastrointestinal tract. J Clin Pathol 2014; 67:903-12. [DOI: 10.1136/jclinpath-2014-202511] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Sosin M, Woodall JD, Schultz BD, Chaudhry A, Bojovic B, Christy MR, Rodriguez ED, Drachenberg CB. Evolving Concepts of Skin and Mucosal Biopsy in Facial Vascularized Composite Allotransplantation. CURRENT TRANSPLANTATION REPORTS 2014. [DOI: 10.1007/s40472-014-0023-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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The challenging diagnosis of Cronkhite-Canada syndrome in the upper gastrointestinal tract: a series of 7 cases with clinical follow-up. Am J Surg Pathol 2014; 38:215-23. [PMID: 24418855 DOI: 10.1097/pas.0000000000000098] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cronkhite-Canada syndrome is a rare protein-losing enteropathy, classically characterized by ectodermal changes and gastrointestinal polyposis. The etiology remains obscure but immune dysregulation may be important. The diagnosis of Cronkhite-Canada syndrome in the upper gastrointestinal tract is challenging, frequently resulting in delayed patient management. In this study, we described the initial clinical presentations, upper gastrointestinal endoscopic appearances, clinical follow-up, and histologic diagnoses in 7 patients who were subsequently diagnosed with Cronkhite-Canada syndrome. Histology slides were reviewed, and IgG4 immunohistochemical analysis was performed. The most common initial endoscopic impressions were antral malignancy and gastric infection, but gastroduodenal polyposis was not described. On histologic review, the main findings in the gastric mucosa were a prominent mucosal edema, a mixed inflammatory infiltrate rich in eosinophils, and architectural changes with gland dilatation and withering. In the duodenal mucosa, total or subtotal duodenal villous atrophy, inflammation, crypt distortion, and increased apoptotic bodies were the most common features. Three patients died of the disease, and 4 patients were asymptomatic at a mean follow-up of 3.5 years. No intestinal malignancy had been diagnosed. In 2 patients foci of dysplasia in colonic polyps were identified. In only 1 patient, a significant increase in IgG4-positive plasma cells was observed in a colonic polyp. In summary, we found that patients with Cronkhite-Canada syndrome have histologic features commonly found in other immune disorders of the gastrointestinal tract that may help in establishing the diagnosis and further supports the hypothesis that Cronkhite-Canada syndrome may represent an immune dysregulation syndrome, different from IgG4-related disease.
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46
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Almashat SJ, Duan L, Goldsmith JD. Non-reflux esophagitis: a review of inflammatory diseases of the esophagus exclusive of reflux esophagitis. Semin Diagn Pathol 2014; 31:89-99. [PMID: 24815935 DOI: 10.1053/j.semdp.2014.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Esophagitis is a frequent cause of clinical symptoms and is often an indication for upper endoscopy. Mucosal biopsies are procured for diagnostic purposes and may be used to assess the efficacy of treatment, as in patients with eosinophilic esophagitis. This article outlines salient clinical and pathologic features of diseases that cause esophagitis exclusive of reflux esophagitis.
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Affiliation(s)
- Salwan J Almashat
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215; Harvard Medical School, Boston, MA 02215
| | - Lei Duan
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215; Harvard Medical School, Boston, MA 02215
| | - Jeffrey D Goldsmith
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215; Harvard Medical School, Boston, MA 02215; Department of Pathology, Children׳s Hospital Boston, Boston, MA.
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47
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Abstract
While celiac disease is the most common cause of villous remodeling and intraepithelial lymphocytosis in the proximal small bowel, there are many entities that can mimic its histologic appearance. The purpose of this review is to discuss normal small bowel histology and the differential diagnosis of celiac disease. Approaches to evaluate increased intraepithelial lymphocytes are presented, followed by a detailed discussion of the pathology of celiac disease. Particular emphasis is given to those conditions that cause intraepithelial lymphocytosis in the setting of preserved villous architecture, although other important entities, such as peptic injury, idiopathic inflammatory bowel disease, medication injury, eosinophilic (allergic) gastroenteritis, autoimmune enteropathy, common variable immunodeficiency, and infections are also reviewed.
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Affiliation(s)
- Rish K Pai
- Department of Anatomic Pathology, Robert J Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio 44195.
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48
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Qasim M, Rahman H, Ahmed R, Oellerich M, Asif AR. Mycophenolic acid mediated disruption of the intestinal epithelial tight junctions. Exp Cell Res 2014; 322:277-89. [PMID: 24509232 DOI: 10.1016/j.yexcr.2014.01.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 12/21/2013] [Accepted: 01/21/2014] [Indexed: 12/12/2022]
Abstract
Gastrointestinal toxicity is a common adverse effect of mycophenolic acid (MPA) treatment in organ transplant patients, through poorly understood mechanisms. Phosphorylation of myosin light chain 2 (MLC2) is associated with epithelial tight junction (TJ) modulation which leads to defective epithelial barrier function, and has been implicated in GI diseases. The aim of this study was to investigate whether MPA could induce epithelial barrier permeability via MLC2 regulation. Caco-2 monolayers were exposed to therapeutic concentrations of MPA, and MLC2 and myosin light chain kinase (MLCK) expression were analyzed using PCR and immunoblotting. Epithelial cell permeability was assessed by measuring transepithelial resistance (TER) and the flux of paracellular permeability marker FITC-dextran across the epithelial monolayers. MPA increased the expression of MLC2 and MLCK at both the transcriptional and translational levels. In addition, the amount of phosphorylated MLC2 was increased after MPA treatment. Confocal immunofluorescence analysis showed redistribution of TJ proteins (ZO-1 and occludin) after MPA treatment. This MPA mediated TJ disruption was not due to apoptosis or cell death. Additionally ML-7, a specific inhibitor of MLCK was able to reverse both the MPA mediated decrease in TER and the increase in FITC-dextran influx, suggesting a modulating role of MPA on epithelial barrier permeability via MLCK activity. These results suggest that MPA induced alterations in MLC2 phosphorylation and may have a role in the patho-physiology of intestinal epithelial barrier disruption and may be responsible for the adverse effects (GI toxicity) of MPA on the intestine.
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Affiliation(s)
- Muhammad Qasim
- Institute of Clinical Chemistry/UMG-Laboratories, University Medical Centre, Robert Koch Strasse 40, 37075 Goettingen, Germany; Department of Microbiology, Kohat University of Science and Technology, 26000 Kohat, Pakistan
| | - Hazir Rahman
- Institute of Clinical Chemistry/UMG-Laboratories, University Medical Centre, Robert Koch Strasse 40, 37075 Goettingen, Germany; Department of Microbiology, Kohat University of Science and Technology, 26000 Kohat, Pakistan
| | - Raees Ahmed
- Institute for Applied Science and Clinical Trials GmbH - IFS, Georg-August University, 37075 Goettingen, Germany
| | - Michael Oellerich
- Institute of Clinical Chemistry/UMG-Laboratories, University Medical Centre, Robert Koch Strasse 40, 37075 Goettingen, Germany
| | - Abdul R Asif
- Institute of Clinical Chemistry/UMG-Laboratories, University Medical Centre, Robert Koch Strasse 40, 37075 Goettingen, Germany.
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49
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Seminerio J, McGrath K, Arnold CA, Voltaggio L, Singhi AD. Medication-associated lesions of the GI tract. Gastrointest Endosc 2014; 79:140-50. [PMID: 24119504 DOI: 10.1016/j.gie.2013.08.027] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/22/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Jennifer Seminerio
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christina A Arnold
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lysandra Voltaggio
- Department of Pathology, George Washington University, Washington, District of Columbia
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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50
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Bergfeld W, Klimczak A, Stratton JS, Siemionow MZ. A four-year pathology review of the near total face transplant. Am J Transplant 2013; 13:2750-64. [PMID: 23919328 DOI: 10.1111/ajt.12379] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 01/25/2023]
Abstract
In December of 2008, our institution performed a near total face transplant. The patient was monitored for signs of rejection assessed by paired skin and mucosa biopsies. The results of histological review of 120 biopsies collected during the first 4 years posttransplant are discussed. All biopsies were stained with hematoxylin and eosin, periodic acid-Schiff, immunohistochemical and TUNEL assays and graded using the Banff 2007 classification. Grade III rejection was diagnosed clinically at weeks 45 and 66, posttransplant; week 45 was determined as folliculitis while the erythema episode at week 66 confirmed an acute rejection (AR) that required hospitalization. The mucosa frequently showed interface inflammation without clinical signs of rejection and was not present in skin biopsies. In all, 34 of the 45 mucosal biopsies (75%) showed these interface changes. Clinical symptoms concurred with skin pathology in two grade III rejections. The mucosa showed histologic signs of rejection more frequently, which may indicate: increased mucosal sensitivity to rejection, a different type or subtype of AR that is specific to the mucosa, or a nonspecific process such as a drug effect. With more data and world experience, the diagnosis of face transplant rejection will be better defined and the Banff classification enhanced.
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Affiliation(s)
- W Bergfeld
- Department of Dermatology and Pathology, Cleveland Clinic, Cleveland, OH
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