Aging, gastrointestinal infections, and mucosal immunity

Isolated Lymphoid Follicles are Dynamic Reservoirs for the Induction of Intestinal IgA

IgA is one of the most important molecules in the regulation of intestinal homeostasis. Peyer's patches have been traditionally recognized as sites for the induction of intestinal IgA responses, however more recent studies demonstrate that isolated lymphoid follicles (ILFs) can perform this function as well. ILF development is dynamic, changing in response to the luminal microbial burden, suggesting that ILFs play an important role providing an expandable reservoir of compensatory IgA inductive sites. However, in situations of immune dysfunction, ILFs can over-develop in response to uncontrollable enteric flora, resulting in ILF hyperplasia. The ability of ILFs to expand and respond to help control the enteric flora makes this dynamic reservoir an important arm of IgA inductive sites in intestinal immunity.

Bacterial translocation in the normal human appendix parallels the development of the local immune system

Experimental modes and pathological conditions may result in bacterial translocation (BT), that is, the passage of indigenous bacteria colonizing the intestine through the intestinal mucosa to mesenteric lymph nodes. Yet no data are available on BT in the normal human gut. We determined the occurrence of BT and its extent in histologically normal, incidentally removed human vermiform appendices (VA) from individuals of different ages and correlated the findings with the development with age of associated lymphatic tissue. BT appears to pertain to normal antigen-sampling processes of the GALT in the VA. It also parallels the development of the GALT and its maintenance during adulthood. In the first two weeks after birth, when bacterial colonization of the gut evolves and when the VA lacks the protection of secretory IgA, BT was not detected. Thereafter, BT occurs along with development of the local GALT, which is fully built up after the first year. A physiological uptake of, or invasion by, bacteria may be instrumental (1) for tolerance induction against the indigenous flora and (2) for the stimulation and normal development of the GALT.

Age-related decline in rectal mucosal lymphocytes and mast cells

BACKGROUND

Previous studies have shown that irritable bowel syndrome declines with age and is more common in women. Recent reports suggest that some diarrhoea predominant irritable bowel syndrome patients have low-grade inflammation with increased numbers of mucosal T lymphocytes, 5-hydroxytryptamine (5-HT) containing enteroendocrine cells and mast cells.

OBJECTIVE

To determine whether there are age or gender-related changes in mucosal T lymphocytes, mast cells or enteroendocrine cells which might explain these findings.

METHODS

Forty healthy volunteers (20 subjects below 55 years of age and 20 above 55 years) free from gastro-intestinal symptoms or disease answered detailed bowel symptom questionnaires and underwent sigmoidoscopy, rectal biopsy and colonic transit measurement. Biopsies were immunostained and quantified for lamina propria and intra-epithelial T lymphocytes, mast cells and 5-HT and peptide YY enteroendocrine cells.

RESULTS

There was a reduction in lamina propria T lymphocyte counts (P = 0.018), crypt intra-epithelial T lymphocytes (P = 0.014) and mast cells (P = 0.02) in the > 55 year group. Enteroendocrine cell numbers did not decline with age and were not related to colonic transit. There were no gender differences between any of the cells quantified.

CONCLUSIONS

Lymphocyte and mast cell numbers decline with age in normal large bowel mucosa. Reduced numbers of mucosal inflammatory cells may influence the low-grade inflammatory response to luminal antigens and contribute to the reduction of irritable bowel syndrome observed in older subjects.

The elderly and waterborne Cryptosporidium infection: gastroenteritis hospitalizations before and during the 1993 Milwaukee outbreak

We used the Temporal Exposure Response Surfaces modeling technique to examine the association between gastroenteritis-related emergency room visits and hospitalizations in the elderly and drinking water turbidity before and during the 1993 Milwaukee waterborne Cryptosporidium outbreak. Before the outbreak, the rate of such events increased with age in the elderly (p</=0.001), suggesting that the elderly are at an increased risk. During the outbreak, strong associations between turbidity and gastroenteritis-related emergency room visits and hospitalizations occurred at temporal lags of 5-6 days (consistent with the Cryptosporidium incubation period). A pronounced second wave of these illnesses in the elderly peaked at 13 days. This wave represented approximately 40% of all excess cases in the elderly. Our findings suggest that the elderly had an increased risk of severe disease due to Cryptosporidium infection, with a shorter incubation period than has been previously reported in all adults and with a high risk for secondary person-to-person transmission.

Inflammatory bowel disease

Although inflammatory bowel disease (IBD) usually presents in adolescents and young adults, both ulcerative colitis and Crohn's disease can also present in older adults. The diagnosis of IBD in the elderly is often difficult and can easily be confused with diverticulitis or ischaemic colitis. The symptoms and complications of IBD in the elderly are similar to those found in younger patients. However, when IBD presents later in life the disease is often less extensive and milder. Older IBD patients are treated with the same medications as younger patients, although the risk for drug toxicity is greater, especially with corticosteroid therapy. Comorbid illness in older patients often has a significant impact on the outcome of medical and surgical therapy for IBD but, in the absence of significant co-morbid disease, most elderly IBD patients can expect a good response to therapy.

Long-term persistence and recall of immune responses in aged mice after mucosal immunization

To evaluate the retention of memory in the mucosal immune system of aged animals, 2-year-old mice that had been immunized intragastrically at 3 months of age with Streptococcus mutans protein AgI/II coupled to the B subunit of cholera toxin (CTB) were evaluated by ELISA for antibodies to AgI/II and CT in serum, saliva, and vaginal wash. To evaluate recall responses, mice were then immunized intragastrically with AgI/II-CTB, in comparison with previously unimmunized controls. Those that had been primed in their youth showed a more rapid antibody response in serum (immunoglobulin G (IgG)) and secretions (IgA), but all animals eventually responded to a similar degree after the third dose. Mice immunized at 3 months also retained for 2 years spleen cells capable of proliferating in vitro in response to AgI/II. These data show that aged mice retain the ability to mount immune responses to mucosally presented immunogens and that memory to mucosally presented immunogens can persist for almost the whole lifetime of a mouse.

Infectious diarrhea in the elderly

Infectious diarrhea is an important disease in the elderly. Some basic principles have been outlined, as follows. In the elderly: Infectious diarrhea is an underappreciated health problem. There is a higher mortality rate and case-fatality rate compared with younger persons. Infectious diarrhea is most often associated with group settings (e.g., nursing homes and skilled nursing facilities) or antibiotic use. Infectious diarrhea may be associated with abnormal immune function (i.e., immunosenescence). Certain bacterial infections are commoner (e.g., C. difficile, E. coli O157:H7, and Salmonella). Some infections behave differently (e.g., Salmonella). Prompt and adequate rehydration measures are crucial. The institution of appropriate contact isolation and infection control measures is crucial in group settings.

Intestinal lymphocyte number, migration and antibody secretion in young and old rats

This study demonstrates that the mucosal immune response to cholera toxin (CT) is compromised in old rats in comparison with young animals. The total number of immunoglobulin A (IgA)-secreting cells is similar or higher in the intestinal inductor and effector sites in old animals. However, the number of specifically induced anti-CT IgA antibody-secreting cells is lower in these tissues in comparison with those in young animals. The kinetics of this immune response in the different gut-associated lymphoid tissues studied suggests that the age-associated decline in the number of anti-CT IgA-secreting cells in the intestinal mucosa reflects impaired IgA immunoblast migration. Our data from lymphocyte adoptive transfer studies indicate that factors intrinsic to both the donor cells and the host recipient influence the migration of immunoblasts from the Peyer's patches to the effector site. For example, donor cells from old donors transferred to either young or old recipient rats migrate slower than young donor lymphocytes transferred into old host animals. In vitro studies clearly indicate that ageing does not impair antibody secretion by intestinal mucosal plasma cells. Therefore, the age-related decline in the intestinal mucosal immune response, e.g. diminished specific antibody titres in intestinal lavage, reflects fewer antibody-secreting cells in the mucosa.

Infectious Diarrhea

Infectious diarrhea constitutes a major source of morbidity and mortality for all age groups. The focus of this article is to identify high risk host and pathogenic risk determinants of enteric infections, discuss pathophysiologic mechanisms for diarrhea, review conventional and upcoming therapeutic managements of bacterial, protozoal or viral-type diarrhea, and describe the integral role of the pharmacist in the overall care of patients having this illness.

Impact of aging on gastrointestinal mucosal immunity

There is considerable evidence that the mucosal or secretory immune response in the gastrointestinal tract is compromised by aging. The generation of a mucosal immune response is an extremely complex process that involves antigenic stimulation of a specific subpopulation of immunologically competent cells in the Peyer's patches, differentiation and migration of these cells to the small intestinal lamina propria, initiation and regulation of local antibody production in the intestinal wall, and mucosal epithelial cell receptor-mediated transport of antibodies to the intestinal lumen. Available data suggest that gastrointestinal mucosal immunosenescence reflects deficits in: (1) the differentiation and/or migration (homing) of immunoglobulin A immunoblasts to the intestinal lamina propria, and (2) the initiation and/or regulation of local antibody production. The significant age-related increases in the incidence and severity of gastrointestinal infectious diseases, coupled with the potential for immunopharmacologic manipulation of the mucosal immune compartment, substantiate the merit of studies designed to resolve the etiology of mucosal immunodeficiency in the elderly.

Correction of antigen-specific T cell defects in aged murine gut-associated lymphoid tissues an immune intervention by combined adoptive transfer of an antigen-specific immunoregulatory CD4 T cell subset and interleukin 2 administration

Gut-associated lymphoid tissues (GALT) from aged mice enterically immunized with Mycobacterium paratuberculosis protoplasmic antigen show hyperreactive humoral immune responses; this hyperresponsiveness can be corrected to a considerable extent, but not entirely, by systemic administration of interleukin 2 (IL 2) alone. The aim of the present study was to determine further whether the hyperreactivity in the antigen-specific humoral immune responses in aged GALT could be fully restored by adoptive transfer of in vitro expanded antigen-specific IL 2-dependent helper (CD4+VV-) T cells from GALT in conjunction with recombinant IL 2 administration. The results show that the age-associated hyperresponsiveness in gut mucosal antigen-specific humoral immune responses can be entirely corrected by adoptive transfer with the antigen-specific GALT T helper cells together with in vivo IL 2 administration. The mechanism of this restoration involves reversal of the decline in antigen-specific CD8+ suppressor T cell functions in aged GALT.

Infectious Gastroenteritis

Infectious gastroenteritis currently constitutes the greatest source of morbidity and mortality among various age groups. Issues of focus for this article include establishing epidemiological determinants of risk for enteric infection, describing host factors that favor survival of the infecting enteric pathogen, defining pathophysiological mechanisms of diarrhea, and reviewing the therapeutic management of bacterial, protozoal, and viral infectious diarrhea.

AIDS and HIV-1 infection: clinical entities in geriatric dentistry

The number of AIDS cases in individuals 50 years of age or older in the United States is reported to exceed 9000. Contaminated blood and blood transfusions are major contributors to HIV-1 infection in this age group. Sexual transmission and infection through intravenous drug abuse are also potential avenues of HIV-1 transmission in the older population. AIDS presents with a variety of clinical manifestations, including dementia, frequently seen in non-HIV-1-infected older people. Neurological deficiencies associated with AIDS are very common and may lead to misdiagnosis in the elderly. The observed incubation period of HIV-1 infection is longer than previously estimated, increasing the risk of older individuals exposed to HIV-1 in the past to develop AIDS. Oral manifestations may present as one of the early clinical signs of AIDS. Little is known concerning AIDS in the geriatric population. It demands consideration by dental professionals treating older individuals belonging to one of the exposure categories of the disease.

Preoperative considerations in the geriatric patient

Because of the "graying" of the population, the increasing availability of surgeons, and the improvement of surgical techniques and intensive care, more and more surgery will be done on geriatric patients. Sometimes, however, surgery will not be considered in a geriatric patient because of mistaken underestimation of life expectancy. The medical consultant is charged with confirming that surgery represents the consequence of the patient's informed decision, a task that is usually time consuming and often difficult. The medical consultant next identifies patient-related and procedure-related factors that affect surgical morbidity and mortality. General physiologic declines in all organ systems are characteristic of aging, but the most important ones affecting surgical risk are those of cardiovascular, pulmonary, immunologic, and central nervous systems. These systems must be assessed by an orderly preoperative evaluation that aims to optimize the patient's status and anticipate and minimize postoperative complication.