Intestinal thromboangiitis obliterans: a case report

Gene Therapy of Thromboangiitis Obliterans with Growth Factor Plasmid (VEGF165) and Autologous Bone Marrow Cells

BACKGROUND

We performed gene therapy for critical limb ischemia in thromboangiitis obliterans (TAO) by the intramuscular administration of plasmids of the vascular endothelial growth factor gene (VEGF 165) with or without bone marrow-derived stem cells.

METHODS

The 21 patients were randomly assigned to three groups: A-with dual therapy, cells and plasmid; B-plasmid only; and C-control group, where patients received intramuscular injections of saline. Serum VEGF levels, the ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), and the rest pain measured by the visual analog scale (VAS) were determined sequentially before treatment, and then 1 and 3 months after treatment.

RESULTS

In the treatment groups, serum VEGF levels increased by 4 weeks and returned to baseline values after 3 months. ABI after 12 weeks increased by an average of 0.18 in group A, and 0.09 in group B and group C. TcPO2 increased by an average of 17.3 mmHg in group A, 14.1 mmHg in group B, and 10.7 mmHg in group C. The largest pain decrease was observed in group A and averaged 5.43 less pain intensity.

CONCLUSIONS

Gene therapy using the VEGF plasmid along with or without bone marrow-derived mononuclear cells administered intramuscularly into an ischemic limb in TAO is a safe and effective therapy.

Isolated visceral manifestation of Buerger's disease presenting as intestinal obstruction: a case report

Introduction and importance

Buerger's disease is an uncommon segmental nonatherosclerotic vasculitis essentially affecting small to medium-sized arteries and veins of upper and lower extremities and can lead to limb amputation. Visceral vessel involvement is quite rare accounting for 2% of cases presenting with acute abdomen due to mesenteric ischemia. Moreover, isolated visceral involvement is even rare.

Case presentation

A 42-year-old gentleman, a chronic smoker, presented with abdominal pain associated with nausea and vomiting and loose stool of 2 months duration. Magnetic resonance enterography revealed segmental circumferential wall thickening with stricture in the mid part of the jejunum with lymphadenopathy features of possible inflammatory bowel disease (Crohn's disease). Furthermore, intraoperative surgical findings were also suggestive of Crohn's disease. However, histologic findings were consistent with thromboangiitis obliterans.

Discussion

Thromboangiitis obliterans can present with inflammatory vascular lesions without necrosis in the early stage to varying degrees of recanalisation, gangrene, and amputation in the late stage. It rarely involves the brain, heart, and abdominal viscera. The visceral involvement may be in the form of intestinal obstruction or mesenteric ischemia or can mimic Crohn's in a background of smoking.

Conclusion

This case report will help to learn more about the rarer intestinal presentation of intestinal Buerger's disease. It can present with features of bowel ischemia, obstruction or Crohn's. So, histology would play a pivotal role in differentiating the diagnostic dilemma.

Demographic Traits, Clinical Status, and Comorbidities of Patients With Thromboangiitis Obliterans in Japan

BACKGROUND

The latest demographics, clinical and living conditions, and comorbidities of patients with thromboangiitis obliterans (TAO) in Japan are unknown.

METHODS AND RESULTS

We conducted a retrospective cross-sectional survey using the annual database of the Japanese Ministry of Health, Labour and Welfare medical support system for patients with TAO between April 2013 and March 2014. This study included 3,220 patients (87.6% male), with current age ≥60 years in 2,155 patients (66.9%), including 306 (9.5%) patients aged ≥80 years. Overall, 546 (17.0%) had undergone extremity amputation. The median interval from onset to amputation was 3 years. Compared with never smokers (n=400), 2,715 patients with a smoking history had a higher amputation rate (17.7% vs. 13.0%, P=0.02, odds ratio [OR]=1.437, 95% confidence interval [CI]=1.058-1.953). A lower proportion of workers and students was seen among patients after amputation than among amputation-free patients (37.9% vs. 53.0%, P<0.0001, OR=0.542, 95% CI=0.449-0.654). Comorbidities, including arteriosclerosis-related diseases, were found even in patients in their 20-30 s.

CONCLUSIONS

This large survey confirmed that TAO is not a life-threatening but an extremity-threatening disease that threatens patients' professional lives. Smoking history worsens patients' condition and extremity prognosis. Long-term total health support is required, including care of extremities and arteriosclerosis-related diseases, social life support, and smoking cessation.

Rectourethral fistula after external beam radiotherapy for prostate cancer in a patient with thromboangiitis obliterans: A case report

INTRODUCTION

Thromboangiitis obliterans (TAO) is a rare disease of unknown cause that causes segmental vasculitis in peripheral blood vessels. It is uncertain whether its presence causes serious adverse events in patients receiving external beam radiotherapy.

PATIENT CONCERNS

A 73-year-old Japanese man with prostate cancer underwent external beam radiotherapy.

DIAGNOSIS

After completion of radiotherapy, fingertip pain occurred, leading to the diagnosis of TAO.

INTERVENTIONS

The patient was instructed to stop smoking, but was unable to do so.

OUTCOMES

Nine months after the completion of radiotherapy, fecaluria appeared, and a rectourethral fistula was diagnosed by contrast enema. The patient's TAO was poorly controlled, and the patient died from aspiration pneumonia 33 months after completion of the radiotherapy regimen. No tumor recurrence was observed during this process, and there were no risk factors other than TAO that may have formed a rectourethral fistula.

LESSONS

This is the first report of rectourethral fistula caused by external beam radiotherapy for prostate cancer in which TAO was suspected to be involved. Although little is known about the relationship between TAO and radiotherapy, it should be noted that radiotherapy itself may increase the risk of normal tissue toxicity in patients with TAO.