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Diamanti A, Trovato CM, Gandullia P, Lezo A, Spagnuolo MI, Bolasco G, Capriati T, Lacitignola L, Norsa L, Francalanci P, Novelli A. Intractable diarrhea in infancy and molecular analysis: We are beyond the tip of the iceberg. Dig Liver Dis 2024; 56:607-612. [PMID: 38044226 DOI: 10.1016/j.dld.2023.09.002] [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: 03/28/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Intractable diarrhea (ID) could be defined as a syndrome of severe chronic diarrhea associated with malnutrition not easily resolved by conventional management. AIMS To provide an overview on etiology and management of ID patients in Italy in the last 12 years. METHODS The members of Italian Society for Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) enrolled all ID patients seen between January 1, 2011 and December 31, 2022. RESULTS 69 children were enrolled (49 M, 20 F; median age at ID onset 9.5 days) from 7 tertiary care pediatric centers. Overall 62 patients had genetic diseases; 3 had infantile Inflammatory Bowel Disease and 1 autoimmune enteropathy in absence of genetic mutations; 2 undefined ID. Defects of intestinal immune-related homeostasis caused ID in 29 patients (42 %). CONCLUSION ID is a rare but challenging problem, although the potential for diagnosis has improved over time. In particular, molecular analysis allowed to identity genetic defects in 90 % of patients and to detect new genetic mutations responsible for ID. Due to both the challenging diagnosis and the treatment for many of these diseases, the close relationship between immune system and digestive tract should require a close collaboration between pediatric immunologists and gastroenterologists, to optimize epidemiologic surveillance and management of ID.
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Affiliation(s)
- A Diamanti
- Hepatology, Gastroenterology and Nutrition Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy.
| | - C M Trovato
- Hepatology, Gastroenterology and Nutrition Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - P Gandullia
- Pediatric Gastroenterology and Endoscopy, IRCCS G. Gaslini Institute, via Gerolamo Gaslini 5, Genoa, Italy
| | - A Lezo
- Dietetics and Clinical Nutrition Unit, Children's Hospital Regina Margherita, Città della Salute e della Scienza Torino, Turin, Italy
| | - M I Spagnuolo
- Department of Translation Medical Science, Pediatric Section, University Federico II, Naples, Italy
| | - G Bolasco
- Hepatology, Gastroenterology and Nutrition Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - T Capriati
- Hepatology, Gastroenterology and Nutrition Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - L Lacitignola
- Department NEUROFARBA, University of Florence. Meyer Children's Hospital, viale Gaetano Pieraccini 24, Florence, Italy
| | - L Norsa
- Regional Health Care and Social Agency Papa Giovanni XXIII, The Netherlands
| | - P Francalanci
- Hepatology, Gastroenterology and Nutrition Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - A Novelli
- Hepatology, Gastroenterology and Nutrition Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
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Go A, Lee BH, Choi JH, Jeong J, Jung E, Lee BS. Case report: a premature infant with severe intrauterine growth restriction, adrenal insufficiency, and inflammatory diarrhea: a genetically confirmed case of MIRAGE syndrome. Front Endocrinol (Lausanne) 2023; 14:1242387. [PMID: 37745698 PMCID: PMC10516543 DOI: 10.3389/fendo.2023.1242387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction MIRAGE syndrome is a rare disease characterized by myelodysplasia, infection, growth restriction, adrenal hypoplasia, genital phenotypes, and enteropathy. Herein, we report the case of a girl with MIRAGE syndrome who presented with adrenal insufficiency and chronic diarrhea. Case presentation The patient was born at 29 + 6 weeks of gestational age with a birth weight of 656 g (<3p). Her height and head circumference were also <3p. At birth, she presented with respiratory distress, meconium staining, and pneumomediastinum, which were managed with high-frequency ventilation and empirical antibiotics. Physical examination showed generalized hyperpigmentation and normal female genitalia. A few days after birth, polyuria and hypotension developed, and laboratory findings revealed hypoglycemia, hyponatremia, and hyperkalemia. Plasma adrenocorticotropic hormone levels were elevated with low serum cortisol levels and high plasma renin activity, which were suggestive of adrenal insufficiency. Hydrocortisone and fludrocortisone were introduced and maintained, and hyperpigmentation attenuated with time. Both kidneys looked dysplastic, and adrenal glands could not be traced on abdominal ultrasound. From the early days of life, thrombocytopenia and anemia were detected, but not to life-threatening level and slowly recovered up to the normal range. Despite aggressive nutritional support, weight gain and growth spurt were severely retarded during the hospital stay. Additionally, after introducing enteral feeding, she experienced severe diarrhea and subsequent perineal skin rashes and ulcerations. Fecal calprotectin level was highly elevated; however, a small bowel biopsy resulted in non-specific submucosal congestion. The patient was diagnosed with MIRAGE syndrome with SAMD9 gene mutation. She was discharged with tube feeding and elemental formula feeding continued, but chronic diarrhea persisted. By the time of the last follow-up at 15 months of corrected age, she was fortunately not subjected to severe invasive infection and myelodysplastic syndrome. However, she was dependent on tube feeding and demonstrated a severe developmental delay equivalent to approximately 5-6 months of age. Conclusion The early diagnosis of adrenal crisis and hormone replacement therapy can save the life of -patients with MIRAGE syndrome; however, chronic intractable diarrhea and growth and developmental delay continue to impede the patient's well-being.
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Affiliation(s)
| | | | | | | | | | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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De Marco G, Barabino A, Gambarara M, Diamanti A, Martelossi S, Guarino A. Network approach to the child with primary intestinal failure. J Pediatr Gastroenterol Nutr 2006; 43 Suppl 1:S61-7. [PMID: 16819404 DOI: 10.1097/01.mpg.0000226392.09978.6d] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Intestinal failure (IF) is a rare condition resulting from short gut and other heterogeneous intestinal diseases. Major centers in Italy merged in a national network to build common diagnostic and management approaches and to investigate the natural history of IF. Gastroenterological reference centers with specific expertise in intestinal morphology, diagnosis of autoimmune conditions, intestinal microbiology and parenteral nutrition were identified to act as consultants to the network. These centers of expertise provided specific diagnostic approaches while ensuring high technical standards. The approach allowed each center to learn from a larger cohort of patient samples. A database was set up to investigate etiology, epidemiology and natural history of IF. A common diagnostic algorithm for intractable diarrhea was designed. This process was largely based on electronic communication among centers and specimen shipping. Etiologic diagnosis was obtained in almost all cases of IF secondary to severe protracted diarrhea. The study of the natural history of IF showed a close association between etiology of IF and its outcome. The natural history of IF also provided the starting point for specific therapeutic approaches to its complications such as parenteral nutrition-associated cholestasis and catheter-related sepsis. The network approach to IF provides an effective model to optimize resources and prospectively investigate the natural history of IF, essential steps to design interventions, including intestinal transplantation and improve the outcome of IF.
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Affiliation(s)
- Giulio De Marco
- Department of Pediatrics, University Federico II of Naples, Naples, Italy
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Kapel N, Roman C, Caldari D, Sieprath F, Canioni D, Khalfoun Y, Goulet O, Ruemmele FM. Fecal tumor necrosis factor-alpha and calprotectin as differential diagnostic markers for severe diarrhea of small infants. J Pediatr Gastroenterol Nutr 2005; 41:396-400. [PMID: 16205505 DOI: 10.1097/01.mpg.0000178437.87546.06] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The etiology of early-onset diarrhea of neonates and small infants that persists despite bowel rest is heterogeneous. Two different categories of disorders presenting with diarrhea in the first weeks of life can be distinguished: constitutive intestinal epithelial disorders (microvillus atrophy [MVA] or epithelial dysplasia [ED]) and immune-inflammatory disorders, (autoimmune enteropathy [AIE] or inflammatory colitis [IC]). We aimed to evaluate in a prospective manner the use of fecal inflammatory markers in the differential diagnosis of severe persistent diarrhea. MATERIAL AND PATIENTS Twenty-five patients (17 males) were enrolled in this study (median age 8 months). Fourteen children had a constitutive enterocyte disorder (group 1: MVA = 8, ED = 6), and 11 patients had an immuno-inflammatory disease (group 2: AIE = 5, IC = 6). Stool samples were collected at the time of diagnosis and stored at -80 degrees until tumor necrosis factor (TNF)-alpha and calprotectin were measured by enzyme-linked immunoadsorbent assay. RESULTS No significant differences in age at onset of diarrhea or in stool volumes were observed between both groups. In group 1, fecal TNF-alpha was undetectable/normal in 14 of 14 children, whereas group 2 showed dramatically elevated TNF-alpha levels (mean 3,104, range 237-18,078 pg/g) in 8 of 11 patients. Similarly, calprotectin levels were undetectable/normal in 14 of 14 patients in group 1 and highly raised in 11 of 11 patients in group 2 (median 1,145, range 375-3,095 mug/g), P < 0.01. Under therapy, these inflammatory parameters normalized. CONCLUSIONS Determination of fecal inflammatory markers is a simple method helping to distinguish constitutive from immuno-inflammatory etiologies of severe persistent diarrhea. These data also suggest that constitutive enterocyte disorders are not accompanied by an inflammatory mucosal reaction.
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Affiliation(s)
- N Kapel
- Laboratory of Functional Coprology, Pitié-Salpétrière Hospital, Paris, France
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Guarino A, De Marco G. Natural history of intestinal failure, investigated through a national network-based approach. J Pediatr Gastroenterol Nutr 2003; 37:136-41. [PMID: 12883298 DOI: 10.1097/00005176-200308000-00010] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Intestinal failure (IF) is a condition whose treatment requires advanced knowledge and techniques and a multidisciplinary approach. Intestinal failure is the endpoint of many intestinal diseases and may result in full recovery, in life-long parenteral nutrition, or in the death of the child. The aim of this study was to evaluate the natural history of IF in children using a national network of resources. METHODS Italian centers of pediatric gastroenterology merged in a national network, developing a collaborative management approach for children with IF. A consensus definition of IF was achieved. A database was set up to investigate the cause, epidemiologic factors, and natural history of IF. RESULTS One hundred nine children were enrolled in 5 years. The cause of IF was: short bowel syndrome (n = 48), disorders of motility (n = 16), structural enterocyte defects (n = 14), multiple food intolerance (n = 10), autoimmune enteropathy (n = 7), and others or unknown (n = 14). The eventual outcome was closely related to the primary cause, ranging from full and permanent intestinal sufficiency in children with multiple food intolerance to high death rate or total dependance upon parenteral nutrition in those with structural enterocyte defects. Intermediate outcomes were observed for the other causes. Four children received intestinal transplantation. CONCLUSIONS The network approach for IF provides an effective model to optimize resources and to investigate prospectively the natural history of IF. Based on the work on this series, a European network for IF could be an effective model for fulfilling the diagnostic and management needs, including intestinal transplantation.
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Affiliation(s)
- Alfredo Guarino
- Department of Pediatrics, University Federico II of Naples, Naples, Italy.
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Affiliation(s)
- Jon A Vanderhoof
- Department of Pediatrics, University of Nebraska Medical Center, Creighton University, Omaha, Nebraska, USA.
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Croft NM, Howatson AG, Ling SC, Nairn L, Evans TJ, Weaver LT. Microvillous inclusion disease: an evolving condition. J Pediatr Gastroenterol Nutr 2000; 31:185-9. [PMID: 10941974 DOI: 10.1097/00005176-200008000-00019] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- N M Croft
- Royal Hospital for Sick Children, Yorkhill National Health Service Trust, Glasgow, United Kingdom.
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Lachaux A, Bouvier R, Loras-Duclaux I, Chappuis JP, Meneguzzi G, Ortonne JP. Isolated deficient alpha6beta4 integrin expression in the gut associated with intractable diarrhea. J Pediatr Gastroenterol Nutr 1999; 29:395-401. [PMID: 10512397 DOI: 10.1097/00005176-199910000-00005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND An infant born with pyloric atresia had development of intractable diarrhea and was found to have total epithelial detachment of gastric and small and large bowel mucosa. She had no skin abnormalities. Parental consanguinity and pyloric atresia in a sibling who died without autopsy suggest an inherited origin for this disorder. The purpose of this study was to examine defects in intestinal and skin cell adhesion. METHODS Histologic, immunohistochemical, and ultrastructural characteristics of the skin and gut of the patient were compared with that of normal control subjects. Distribution of adhesion molecules was determined. RESULTS Immunofluorescent analysis of the digestive mucosa showed alpha6beta4 integrin expression deficiency at the epithelial cell-lamina propria junction. Ultrastructural examination of the digestive mucosa revealed a complete epithelial detachment with a cleavage plane lying between the lamina densa and the basal pole of the enterocytes. Consistent with the absence of skin blistering, integrin alpha6beta4 was expressed at the dermal-epidermal junction. Electron micrographs of skin biopsy specimens showed the presence of normal hemidesmosomes and the absence of dermal-epidermal dysadhesion. CONCLUSION It was postulated that this patient had protracted diarrhea related to epithelial detachment of the digestive mucosa as a consequence of a deficiency of an integrin alpha6beta4 isoform specific to the gut.
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Affiliation(s)
- A Lachaux
- Service de Chirurgie et d'Anatomie Pathologique, Hôpital E. Herriot, Lyon, France
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Abstract
Autoimmune enteropathy (AIE) is an entity reported primarily in infancy, resulting in intractable diarrhea and associated with small bowel villous atrophy and the presence of circulating anti-enterocyte (AEA) antibodies. It is a multisystem disorder with a response, in many cases, to immunosuppressive therapy.
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Affiliation(s)
- P A Russo
- Department of Pathology, Hôpital Ste-Justine, Montréal, Québec, Canada
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Guandalini S, Dincer AP. Nutritional management in diarrhoeal disease. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1998; 12:697-717. [PMID: 10079903 DOI: 10.1016/s0950-3528(98)90004-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adequate nutritional intervention in diarrhoeal disease in children is crucial in obtaining optimal control of a disorder that may become life-threatening. During recent years, important advances have been made in our understanding of the pathophysiology of diarrhoeal states, in the formulation of oral rehydration solutions and in the role of micro- and macronutrients in diarrhoeal disorders. This chapter outlines some of the relevant concepts in the pathophysiology of diarrhoeal disease and provides a rationale for nutritional intervention. Guidelines for nutritional management in the settings of acute-onset diarrhoea, post-enteritis protracted diarrhoea and chronic non-specific diarrhoea are provided, mostly based on controlled clinical trials and meta-analyses of evidence-based medicine.
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Affiliation(s)
- S Guandalini
- University of Chicago, Department of Pediatrics, Illinois, USA
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Nau R, Lantsch M, Stiefel M, Polak T, Reiber H. Varicella zoster virus-associated focal vasculitis without herpes zoster: recovery after treatment with acyclovir. Neurology 1998; 51:914-5. [PMID: 9748063 DOI: 10.1212/wnl.51.3.914] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- R Nau
- Department of Neurology, University of Göttingen, Germany
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Candusso M, Giglio L, Faraguna D. Long-term home parenteral nutrition in children. Clin Nutr 1995; 14 Suppl 1:28-32. [PMID: 16843970 DOI: 10.1016/s0261-5614(95)80279-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- M Candusso
- Department of Paediatrics, Child Health Institute 'Burlo Garofolo', Trieste, Italy
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