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van Schewick CM, Lowe DM, Burns SO, Workman S, Symes A, Guzman D, Moreira F, Watkins J, Clark I, Grimbacher B. Bowel Histology of CVID Patients Reveals Distinct Patterns of Mucosal Inflammation. J Clin Immunol 2021; 42:46-59. [PMID: 34599484 PMCID: PMC8821476 DOI: 10.1007/s10875-021-01104-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/18/2021] [Indexed: 01/22/2023]
Abstract
Diarrhea is the commonest gastrointestinal symptom in patients with common variable immunodeficiency (CVID). Different pathologies in patients' bowel biopsies have been described and links with infections have been demonstrated. The aim of this study was to analyze the bowel histology of CVID patients in the Royal-Free-Hospital (RFH) London CVID cohort. Ninety-five bowel histology samples from 44 adult CVID patients were reviewed and grouped by histological patterns. Reasons for endoscopy and possible causative infections were recorded. Lymphocyte phenotyping results were compared between patients with different histological features. There was no distinctive feature that occurred in most diarrhea patients. Out of 44 patients (95 biopsies), 38 lacked plasma cells. In 14 of 21 patients with nodular lymphoid hyperplasia (NLH), this was the only visible pathology. In two patients, an infection with Giardia lamblia was associated with NLH. An IBD-like picture was seen in two patients. A coeliac-like picture was found in six patients, four of these had norovirus. NLH as well as inflammation often occurred as single features. There was no difference in blood lymphocyte phenotyping results comparing groups of histological features. We suggest that bowel histology in CVID patients with abdominal symptoms falls into three major histological patterns: (i) a coeliac-like histology, (ii) IBD-like changes, and (iii) NLH. Most patients, but remarkably not all, lacked plasma cells. CVID patients with diarrhea may have an altered bowel histology due to poorly understood and likely diverse immune-mediated mechanisms, occasionally driven by infections.
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Affiliation(s)
- Cornelia M van Schewick
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Center for Translational Cell Research, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany
| | - David M Lowe
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Siobhan O Burns
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Sarita Workman
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Andrew Symes
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - David Guzman
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Fernando Moreira
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | | | - Ian Clark
- Pathology Department, Royal Free Hospital, London, UK.
- Department of Pathology, Health Science Center, The University of Tennessee, 930 Madison Ave, Suite 500, Memphis, TN, 38163, USA.
| | - Bodo Grimbacher
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK.
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Center for Translational Cell Research, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany.
- DZIF - German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany.
- CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany.
- RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany.
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Reactivation of Cytomegalovirus Following Left Ventricular Assist Device Implantation: A Case-Control Study. ASAIO J 2021; 67:405-410. [PMID: 32740125 DOI: 10.1097/mat.0000000000001236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
While cytomegalovirus (CMV) reactivation occurs in immunocompetent patients who are critically ill and has been associated with worse outcomes, very few cases of CMV reactivation have been reported following left ventricular assist device (LVAD) implantation. We aimed to evaluate the incidence and risk factors for CMV reactivation following LVAD implantation. Retrospective chart review of patients who had undergone LVAD implantation between July 2004 and December 2018 was performed. Cases with CMV reactivation post-LVAD were randomly matched (1:2) by sex, LVAD type, and implant year with controls utilizing SAS macros. Fisher's exact and paired sample t-tests were performed to evaluate for differences between categorical and continuous variables, respectively. Days to reactivation post-LVAD implantation were calculated in cases, and the corresponding times post-LVAD implantation were determined in control patients for variable comparisons. Survival analysis was performed using the Kaplan-Meier method. Of the 349 patients reviewed, 208 (59.6%) patients were seropositive for CMV before LVAD implantation. Of these 208 patients, eight (3.8%) had CMV reactivation following LVAD implantation. The median time to CMV reactivation following LVAD implantation was 21.5 days (range, 6-177). Six (75%) patients had CMV viremia, and the other two had colitis and pneumonia without viremia. In comparison to controls, patients with CMV had higher creatinine levels (p = 0.039) and higher RDW (p = 0.05) and were more likely to have received steroids within the previous week (p = 0.028) and to have concurrent bacterial infection (p = 0.001). CMV reactivation following LVAD implantation is more frequent than expected. Early testing, diagnosis, and treatment in at-risk patients (i.e., renal failure, steroid use, elevated RDW) might improve clinical outcomes.
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Abohelwa MM, Hassan MA, Zahnan J, Sfeir P, El Zakhem A, Skouri H. Cytomegalovirus reactivation in left ventricular assist device patients: case series and literature review. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab090. [PMID: 33763628 DOI: 10.1093/ehjcr/ytab090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/10/2020] [Accepted: 02/19/2021] [Indexed: 11/14/2022]
Abstract
Background Cytomegalovirus (CMV) reactivation after placing left ventricular assist device (LVAD) is not a well-known entity with few cases reported in the literature. Here, we are presenting three cases of CMV reactivation after placing LVAD. A literature review of all reported cases in the literature was done. Case summary Three cases of advanced heart failure with reduced ejection fraction (Stage D9) had placed (LVAD) at the American University of Beirut Medical Center, a tertiary care centre in Lebanon. Within the first 2 weeks after LVAD implantation, the three patients spiked a high-grade fever for which sepsis workup was done, and antibiotics were initiated. Despite the escalating antibiotic regimens, the three patients had a persistent high-grade fever. The negative cultures and the continuous fever prompted an investigation for other causes of fever. Therefore, CMV polymerase chain reaction in blood was performed and revealed high titres. Patients received a full course of treatment with ganciclovir. The fever and the CMV titres declined after completing the antiviral therapy with better clinical outcomes. This raises the concern of CMV reactivation in LVAD patients. Discussion This case series and literature review highlight the epidemiology, incidence, and management of CMV reactivation among LVAD patients. Awareness about this clinical entity should be raised, especially with the increase of LVAD surgeries.
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Affiliation(s)
- Mostafa M Abohelwa
- Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Rm 3b310, Lubbock, TX 79430, USA
| | - Mona Ali Hassan
- Department of Internal Medicine, American University of Beirut Medical Center, ACC Building 6th floor, Beirut 1107-2020, Lebanon
| | - Jad Zahnan
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, ACC Building 6th floor, Beirut 1107-2020, Lebanon
| | - Pierre Sfeir
- Division of Cardiothoracic Surgery, Department of Surgery, American University of Beirut Medical Center, ACC Building 6th floor, Beirut 1107-2020, Lebanon
| | - Aline El Zakhem
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, ACC Building 6th floor, Beirut 1107-2020, Lebanon
| | - Hadi Skouri
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, ACC Building 6th floor, Beirut 1107-2020, Lebanon
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Sandkovsky U, Florescu DF, Um JY, Raichlin E, Lowes BD, Kapalis M, Hewlett A, Duncan KF, Ryan T, DiMaio D, Wedel W, Kalil AC. Cytomegalovirus reactivation and colitis after left ventricular assist device placement. Int J Infect Dis 2013; 17:e348-51. [DOI: 10.1016/j.ijid.2012.11.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 11/21/2012] [Accepted: 11/25/2012] [Indexed: 11/24/2022] Open
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