High faecal calprotectin levels in intestinal tuberculosis are associated with granulomas in intestinal biopsies

Primary Gastric Tuberculosis in an Immunocompetent Patient: The Truth Lying beneath the Surface

Gastrointestinal tuberculosis is an uncommon entity, in which clinical presentation can be widely variable, from mild and nonspecific symptoms to an acute abdomen and gastrointestinal bleeding. Gastric involvement by Mycobacterium tuberculosis is rare, especially when it occurs without other recognized infectious foci - primary gastric tuberculosis - with only a few reported cases. Endoscopic findings can be very heterogeneous, from areas of hyperemia to pseudotumor lesions. We present a case of primary gastric tuberculosis in an immunocompetent patient, in which the absence of an epidemiological context and nonspecific endoscopic findings led to a delay in the diagnosis. Bite-on-bite biopsies proved to be essential, allowing to obtain samples from deeper layers of the submucosa where M. tuberculosis was identified. This case aimed to increase awareness for this entity, especially in endemic countries or regions with a high prevalence of tuberculosis since the diagnosis is based mainly on a high index of suspicion.

Frequency, outcomes, and need for intervention in stricturing gastrointestinal tuberculosis: a systematic review and meta-analysis

BACKGROUND

Gastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity.

AIM

To conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT).

METHODS

We searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale.

RESULTS

Thirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07-0.20, I² = 89%) and 0.27 (95% CI 0.21-0.33, I² = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65-0.86, I² = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40-0.85, I² = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13-0.32, I² = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09-0.21, I² = 0%).

CONCLUSION

Stricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.

Intramucosal Calprotectin Expression in Inflammatory Bowel Disease (IBD) and Non-IBD Colorectal Inflammation

BACKGROUND: Inflammatory bowel disease (IBD) diagnosis remains a challenge accompanied with high numbers of misdiagnosis causing suboptimal management. Tons of trials have been conducted to improve the diagnostic accuracy, one of which is the use of biomarker such as calprotectin. Calprotectin can be detected in tissue (intramucosal) and is becoming a potential marker of IBD. AIM: This study aims to determine intramucosal calprotectin expression in IBD, non-IBD colitis, and control. METHODS: This analytic retrospective study included consecutively sampled IBD and non-IBD colitis colorectal biopsy specimens, and control group obtained from Cipto Mangunkusumo Hospital registered from 2017 to 2019. Cases were included in the study if specimens were indicative of IBD and non-IBD clinically and histopathologically and no abnormality were found histopathologically in the control group. Specimens with non-adequate data from the hospital medical records or with missing tissue slides were excluded from the study. Calprotectin immunostaining was conducted to evaluate mean intramucosal calprotectin expression (cell/HPF) in each group. RESULTS: Most of the samples from IBD and non-IBD group (45 samples each) showed mild active inflammation. Mucosal calprotectin expression in aforementioned groups was higher than that of control group (p < 0.001). Subjects with active inflammation showed higher calprotectin expression compared to those with inactive inflammation (p < 0.001). Calprotectin expression was also related to activity grade. CONCLUSION: Higher calprotectin expression showed significant association with the presence of inflammation and disease activity. However, the application of intramucosal calprotectin immunohistochemistry test to determine inflammatory etiology (IBD vs. non-IBD) still needs to be further evaluated.

Formation of Calprotectin-Derived Peptides in the Airways of Children with Cystic Fibrosis

Calprotectin is released by activated neutrophils along with myeloperoxidase (MPO) and proteases. It plays numerous roles in inflammation and infection, and is used as an inflammatory biomarker. However, calprotectin is readily oxidized by MPO-derived hypohalous acids to form covalent dimers of its S100A8 and S100A9 subunits. The dimers are susceptible to degradation by proteases. We show that detection of human calprotectin by ELISA declines markedly because of its oxidation by hypochlorous acid and subsequent degradation. Also, proteolysis liberates specific peptides from oxidized calprotectin that is present at inflammatory sites. We identified six calprotectin-derived peptides by mass spectrometry and detected them in the bronchoalveolar lavage fluid of children with cystic fibrosis (CF). We assessed the peptides as biomarkers of neutrophilic inflammation and infection. The content of the calprotectin peptide ILVI was related to calprotectin (r = 0.72, p = 0.01, n = 10). Four of the peptides were correlated with the concentration of MPO (r > 0.7, p ≤ 0.01, n = 21), while three were higher (p < 0.05) in neutrophil elastase-positive (n = 14) than -negative samples (n = 7). Also, five of the peptides were higher (p < 0.05) in the bronchoalveolar lavage fluid from children with CF with infections (n = 21) than from non-CF children without infections (n = 6). The specific peptides liberated from calprotectin will signal uncontrolled activity of proteases and MPO during inflammation. They may prove useful in tracking inflammation in respiratory diseases dominated by neutrophils, including coronavirus disease 2019.

A Challenging Case of the Forgotten Abdominal Tuberculosis in the Developed World

Differentiating abdominal tuberculosis (TB) from Crohn's disease (CD) despite the rarity of the condition remains vital to avoid catastrophic consequences of disseminated miliary TB as a result of mistakenly starting an immunosuppressive medication. We highlight a challenging pediatric abdominal TB case of a 5-year-old male that presented with failure to thrive, ascites, and diarrhea. Our case aims to shed light on a forgotten disease in our developed world by highlighting subtle clinical, endoscopic, and histologic features. Findings of caseating necrosis on biopsy, positive smear for acid-fast bacillus (AFB), AFB culture, and necrotic lymph node on imaging are diagnostic of TB but are rarely present. Clinicians should be vigilant in screening pediatric patients with elusive symptoms, history, and exam. TB should be suspected, and one should not shy away from empirical antituberculous treatment as it could be the only way of establishing the diagnosis.

Serial measurements of faecal calprotectin may discriminate intestinal tuberculosis and Crohn's disease in patients started on antitubercular therapy

BACKGROUND

Response to antitubercular therapy (ATT) is often used to differentiate intestinal tuberculosis (ITB) from Crohn's disease. Role of non-invasive biomarkers to predict mucosal response to ATT is unclear.

MATERIALS AND METHODS

A prospective study to compare faecal calprotectin and serum C-reactive protein (CRP) levels at diagnosis, 2 and 6 months of ATT in patients with suspected ITB started on ATT was done. The patients were eventually divided into two groups: ITB or alternative diagnosis (OTH). Decline of calprotectin and CRP levels was used to compute area under the receiver operating characteristic (AUROC) to predict mucosal healing at 2 months.

RESULTS

Thirty-seven patients (mean age: 34.95 ± 16.35 years, 23 males) were included and 28 (75.67%) were diagnosed as ITB while nine (24.32%) had alternative diagnosis (OTH). The median faecal calprotectin values of ITB and OTH groups at baseline, 2 months and 6 months were 216 and 282 µg/g (P = 0.466), 43 and 216 µg/g (P = 0.003), and 26 and 213 µg/g (P < 0.001), respectively. The median CRP values at baseline, 2 months and 6 months were 18 and 30 mg/L (P = 0.767), 4.7 and 15 mg/L (P = 0.025), and 3 and 10.85 mg/L (P = 0.068), respectively. The AUROC of percent decline in faecal calprotectin and serum CRP at 2 months for mucosal healing were 0.8287 [95% confidence inteval (CI) 0.6472-1] and 0.6018 (95% CI 0.4079-0.7957), respectively.

CONCLUSION

Faecal calprotectin can help in assessing response to therapy in suspected ITB patients started on empirical ATT.

Calprotectin in Lung Diseases

Calprotectin (CLP) is a heterodimer formed by two S-100 calcium-binding cytosolic proteins, S100A8 and S100A9. It is a multifunctional protein expressed mainly by neutrophils and released extracellularly by activated or damaged cells mediating a broad range of physiological and pathological responses. It has been more than 20 years since the implication of S100A8/A9 in the inflammatory process was shown; however, the evaluation of its role in the pathogenesis of respiratory diseases or its usefulness as a biomarker for the appropriate diagnosis and prognosis of lung diseases have only gained attention in recent years. This review aimed to provide current knowledge regarding the potential role of CLP in the pathophysiology of lung diseases and describe how this knowledge is, up until now, translated into daily clinical practice. CLP is involved in numerous cellular processes in lung health and disease. In addition to its anti-microbial functions, CLP also serves as a molecule with pro- and anti-tumor properties related to cell survival and growth, angiogenesis, DNA damage response, and the remodeling of the extracellular matrix. The findings of this review potentially introduce CLP in daily clinical practice within the spectrum of respiratory diseases.

Optimal cut-off value of fecal calprotectin for the evaluation of ulcerative colitis: An unsolved issue?

Introduction

There is variability in the fecal calprotectin (FCP) cut‐off level for the prediction of ulcerative colitis (UC) disease activity and differentiation from irritable bowel disease (IBS‐D). The FCP cut‐off levels vary from country to country.

Aims

We aimed to assess FCP as a marker of disease activity in patients with UC. We determined the optimal FCP cut‐off value for differentiating UC and IBS‐D.

Methods

In a prospective study, we enrolled 76 UC and 30 IBS‐D patients. We studied the correlation of FCP with disease activity/extent as well as its role in differentiating UC from IBS‐D. We also reviewed literature regarding the optimal FCP cut‐off level for the prediction of disease activity and differentiation from IBS‐D patients.

Results

Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut‐off level, 158 μg/g) for the prediction of complete mucosal healing (using Mayo endoscopic subscore) were 90, 85, 94.7, and 73.3%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut‐off level, 425 μg/g) for the prediction of inactive disease (Mayo Score ≤ 2) were 94.3, 88.7, 86.2, and 95.4%, respectively. We also found a FCP cut‐off value of 188 μg/g for the differentiation of UC from IBS‐D.

Conclusions

The study reveals the large quantitative differences in FCP cut‐off levels in different study populations. This study demonstrates a wide variation in FCP cut‐off levels in the initial diagnosis of UC as well as in follow‐up post‐treatment. Therefore, this test requires validation of the available test kits and finding of appropriate cut‐off levels for different study populations.

Serial C-reactive protein measurements in patients treated for suspected abdominal tuberculosis

BACKGROUND

Response to treatment is often used as a criterion for the diagnosis of abdominal tuberculosis.

AIM

To determine utility of serum C reactive protein (CRP) in assessment of response to anti-tubercular therapy (ATT) in abdominal tuberculosis (ATB).

METHODS

We retrospectively analysed the database of patients with suspected ATB (intestinal and/or peritoneal). Response to ATT was assessed using subjective and objective (ulcer healing or ascites resolution) parameters. Serum CRP levels were estimated at baseline and then at 2 months and 6 months of ATT.

RESULTS

One hundred and twelve patients were included in the analysis. The mean age was 36.57 ± 15.04 years and 54.46% (61/112) were males. Sixty-six patients (58.92%) had intestinal, 28 (25%) had peritoneal and 18 (16.07%) had both. Eleven patients had a normal CRP at baseline while 101 had elevated levels. The CRP levels declined in 94 patients at 6 months. One patient with increased levels at 2 months had multi-drug resistant TB. Seven patients showed elevated or plateaued CRP levels on follow-up. These patients had underlying Crohn's disease (3 patients), peritoneal carcinomatosis (1), inter-current infection (1), lymphoma (1) and non-healing ulcers (1).

CONCLUSION

Lack of decline in CRP may suggest alternative diagnosis or drug-resistant tuberculosis.

Symptomatic isolated terminal ileal ulcers: etiology and clinical significance

BACKGROUND

 With an increasing number of ileal intubations, isolated terminal ileal ulcers (ITIU) are frequently found during colonoscopies. The present study aimed at studying the etiology and clinical significance of these ulcers in patients having gastrointestinal symptoms.

METHODS

 This was a prospective observational study performed on consecutive patients who underwent ileocolonoscopy for various gastrointestinal symptoms between 1 January 2014 and 31 December 2014. Clinical, endoscopic, and histological findings of patients with ITIUs were assessed to determine the etiology and they were treated accordingly. Symptom resolution was assessed within 3 - 6 months of initial diagnosis, and colonoscopy was repeated for consenting patients.

RESULTS

 Among 74 (4.9 %) of 1497 patients who had ITIUs on ileocolonoscopy, 41 (55.4 %) had specific etiologies on initial testing. After 3 - 6 months follow-up, definitive diagnosis was ascertained in 44 (59.5 %) patients [Crohn's disease (CD): 19 (25.7 %), NSAID-induced ulcers: 11 (14.9 %), intestinal tuberculosis (ITB): 9 (12.2 %), and eosinophilic enteritis: 5 (6.8 %)], and 30 patients (40.5 %) had nonspecific ulcers. After treatment, symptomatic and endoscopic resolution were noted in 55/60 patients (91.7 %) and 28/36 patients (77.8 %), respectively. Of 5/60 patients who remained symptomatic, three were initially diagnosed with nonspecific ulcers and two with CD, and they were finally diagnosed with CD and ITB respectively, and treated accordingly.

CONCLUSIONS

 In patients with gastrointestinal symptoms, more than half of the ITIUs have specific etiologies, and timely diagnosis and appropriate treatment can prevent serious complications. Nonspecific ulcers can be managed with symptomatic treatment, but need close monitoring and re-evaluation in the case of persistence of symptoms.

Application of fecal markers in inflammatory bowel disease

Inflammatory bowel disease (IBD) includes ulcerative colitis (UC) and Crohn's disease (CD). The diagnosis and assessment of inflammation activity principally rely on endoscopy combined with pathological biopsy. Fecal biomarkers possess advantages including non-invasion, simplicity, fastness and repeatability, and they are effective in judging inflammation activity, monitoring illness status, distinguishing organic and functional diseases as well as assessing treatment outcome. Various fecal biomarkers of IBD including fecal calprotectin, lactoferrin, M-2 type pyruvate kinase, S100A12 and myeloperoxidase are summarized in this paper.