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Llera B, Hanna I, Jureller M. Eosinophilic appendicitis: an insidious and fortuitous diagnosis. J Surg Case Rep 2024; 2024:rjae380. [PMID: 38832065 PMCID: PMC11146031 DOI: 10.1093/jscr/rjae380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/16/2024] [Indexed: 06/05/2024] Open
Abstract
Eosinophilic appendicitis is a rare inflammatory condition characterized by the infiltration of eosinophils into the appendix, which is often misdiagnosed as acute appendicitis given similarities in their clinical presentation. Acute eosinophilic appendicitis: a rare cause of lower gastrointestinal hemorrhage. Within this particular report, we present a case of eosinophilic appendicitis in a 42-year-old female who underwent a laparoscopic appendectomy. The purpose of this report is to increase awareness about this unique condition and emphasize the importance of considering eosinophilic appendicitis as a differential diagnosis in patients with appendicitis-like symptoms whose clinical examination and laboratory findings may suggest otherwise.
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Affiliation(s)
- Brent Llera
- Department of Surgery, New York University Grossman School of Medicine, Mineola, NY, United States
| | - Iman Hanna
- Department of Surgery, New York University Grossman School of Medicine, Mineola, NY, United States
| | - Michael Jureller
- Department of Surgery, New York University Grossman School of Medicine, Mineola, NY, United States
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Carvalho N, Barreira AL, Henriques S, Ferreira M, Cardoso C, Luz C, Costa PM. Compilation of Evidence Supporting the Role of a T Helper 2 Reaction in the Pathogenesis of Acute Appendicitis. Int J Mol Sci 2024; 25:4216. [PMID: 38673802 PMCID: PMC11050072 DOI: 10.3390/ijms25084216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/27/2024] [Accepted: 03/31/2024] [Indexed: 04/28/2024] Open
Abstract
Despite being the most common abdominal surgical emergency, the cause of acute appendicitis (AA) remains unclear, since in recent decades little progress has been made regarding its etiology. Obstruction of the appendicular lumen has been traditionally presented as the initial event of AA; however, this is often the exception rather than the rule, as experimental data suggest that obstruction is not an important causal factor in AA, despite possibly occurring as a consequence of the inflammatory process. Type I hypersensitivity reaction has been extensively studied, involving Th2 lymphocytes, and cytokines such as IL-4, IL-5, IL-9 and IL-13, which have well-defined functions, such as a positive-feedback effect on Th0 for differentiating into Th2 cells, recruitment of eosinophils and the release of eosinophilic proteins and the production of IgE with the activation of mast cells, with the release of proteins from their granules. Cytotoxic activity and tissue damage will be responsible for the clinical manifestation of the allergy. AA histological features are similar to those found in allergic reactions like asthma. The intestine has all the components for an allergic immune response. It has contact with hundreds of antigens daily, most of them harmless, but some can potentially induce an allergic response. In recent years, researchers have been trying to assess if allergy is a component of AA, with their latest advances in the understanding of AA as a Th2 reaction shown by the authors of this article.
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Affiliation(s)
- Nuno Carvalho
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (A.L.B.); (S.H.); (M.F.); (C.L.); (P.M.C.)
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Ana Lúcia Barreira
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (A.L.B.); (S.H.); (M.F.); (C.L.); (P.M.C.)
| | - Susana Henriques
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (A.L.B.); (S.H.); (M.F.); (C.L.); (P.M.C.)
| | - Margarida Ferreira
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (A.L.B.); (S.H.); (M.F.); (C.L.); (P.M.C.)
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Carlos Cardoso
- Dr. Joaquim Chaves, Laboratório de Análises Clínicas, 1495-068 Algés, Portugal;
| | - Carlos Luz
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (A.L.B.); (S.H.); (M.F.); (C.L.); (P.M.C.)
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Paulo Matos Costa
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (A.L.B.); (S.H.); (M.F.); (C.L.); (P.M.C.)
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
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Carvalho N, Carolino E, Ferreira M, Coelho H, Santos CR, Barreira AL, Henriques S, Cardoso C, Moita L, Costa PM. Tryptase in Acute Appendicitis: Unveiling Allergic Connections through Compelling Evidence. Int J Mol Sci 2024; 25:1645. [PMID: 38338923 PMCID: PMC10855922 DOI: 10.3390/ijms25031645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
The aetiology of acute appendicitis (AA), the most frequent abdominal surgical emergency, is still unclarified. Recent epidemiologic, clinical and laboratorial data point to an allergic component in the pathophysiology of AA. Mastocytes participate in the Th2 immune response, releasing inflammatory mediators from their granules upon stimulation by IgE-specific antigens. Among the well-known mediators are histamine, serotonin and tryptase, which are responsible for the clinical manifestations of allergies. We conducted a prospective single-centre study to measure histamine and serotonin (commercial ELISA kit) and tryptase (ImmunoCAP System) concentrations in appendicular lavage fluid (ALF) and serum. Consecutive patients presenting to the emergency department with a clinical diagnosis of AA were enrolled: 22 patients with phlegmonous AA and 24 with gangrenous AA The control group was composed of 14 patients referred for colectomy for colon malignancy. Appendectomy was performed during colectomy. Tryptase levels were strikingly different between histological groups, both in ALF and serum (p < 0.001); ALF levels were higher than serum levels. Tryptase concentrations in ALF were 109 times higher in phlegmonous AA (APA) (796.8 (194.1-980.5) pg/mL) and 114 times higher in gangrenous AA (AGA) (837.4 (272.6-1075.1) pg/mL) than in the control group (7.3 (4.5-10.3) pg/mL. For the diagnosis of AA, the discriminative power of serum tryptase concentration was good (AUC = 0.825), but discriminative power was weak (AUC = 0.559) for the differential diagnosis between APA and AGA. Mastocytes are involved in AA during clinical presentations of both phlegmonous and gangrenous appendicitis, and no significant differences in concentration were found. No differences were found in serum and ALF concentrations of histamine and serotonin between histological groups. Due to their short half-lives, these might have elapsed by the time the samples were collected. In future research, these determinations should be made immediately after appendectomy. Our findings confirm the hypersensitivity type I reaction as an event occurring in the pathogenesis of AA: tryptase levels in ALF and serum were higher among patients with AA when compared to the control group, which is in line with a Th2 immune response and supports the concept of the presence of an allergic reaction in the pathogenesis of acute appendicitis. Our results, if confirmed, may have clinical implications for the treatment of AA.
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Affiliation(s)
- Nuno Carvalho
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (M.F.); (A.L.B.); (S.H.); (P.M.C.)
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Elisabete Carolino
- H & TRC—Health & Technology Research Centre, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1549-020 Lisboa, Portugal;
| | - Margarida Ferreira
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (M.F.); (A.L.B.); (S.H.); (P.M.C.)
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Hélder Coelho
- Serviço de Anatomia Patológica, Hospital Garcia de Orta, 2805-267 Almada, Portugal;
| | - Catarina Rolo Santos
- Serviço de Cirurgia Geral, Hospital de Nossa Senhora do Rosário, 2830-003 Barreiro, Portugal;
| | - Ana Lúcia Barreira
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (M.F.); (A.L.B.); (S.H.); (P.M.C.)
| | - Susana Henriques
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (M.F.); (A.L.B.); (S.H.); (P.M.C.)
| | - Carlos Cardoso
- Dr. Joaquim Chaves Laboratório de Análises Clínicas, 1495-068 Algés, Portugal;
| | - Luís Moita
- Innate Immunity and Inflammation Lab., Instituto Gulbenkian de Ciência Oeiras, 2780-156 Oeiras, Portugal;
- Instituto de Histologia e Biologia do Desenvolvimento, Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Paulo Matos Costa
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal; (M.F.); (A.L.B.); (S.H.); (P.M.C.)
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
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Zhang T, Cheng Y, Zhou Y, Zhang Z, Qi S, Pan Z. Diagnostic performance of type I hypersensitivity-specific markers combined with CRP and IL-6 in complicated acute appendicitis in pediatric patients. Int Immunopharmacol 2023; 124:110977. [PMID: 37774482 DOI: 10.1016/j.intimp.2023.110977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE In this study, the diagnostic value of C-reactive protein (CRP), interleukin-6 (IL)-6, and specific markers for type I hypersensitivity were evaluated in pediatric patients with severe acute appendicitis. METHODS A total of 140 pediatric patients with "acute appendicitis" who underwent surgery at the Department of General Surgery of the Anhui Provincial Pediatric Patients' Hospital between December 2022 and April 2023 were studied retrospectively. The data collected included the gender, age, onset time, white blood cell count (WBC), CRP, procalcitonin (PCT), serum IgE, serum IL-4, serum IL-5, serum IL-6, serum IL-9, and serum IL-13 levels. The pediatric patients were divided into two groups based on the intraoperative situation and postoperative pathology: the non-complicated acute appendicitis group (NCAA) and the complicated acute appendicitis group (CAA). We analyzed the data from both groups using univariate and multivariate logistic regression models and constructed an ROC curve. RESULTS The CAA group outperformed the NCAA group in terms of onset time, WBC, CRP, PCT, IgE, IL-6, IL-9, and IL-13 levels (P < 0.05), but there was no statistically significant difference between the two groups in terms of gender, IL-4, or IL-5 levels (P > 0.05). Then, significant independent variables were incorporated into multivariate logistic regression. According to the results, CRP, IgE, IL-6, and IL-13 are all independent risk factors for CAA. The OR and 95% CI for each factor are as follows: CRP (OR = 1.073, 95%CI: 1.010-1.140, P = 0.022), IgE (OR = 0.975, 95%CI: 0.952-0.999, P = 0.038), IL-6 (OR = 1.494, 95%CI: 1.052-2.121, P = 0.025), and IL-13 (OR = 1.310, 95%CI: 1.036-1.657, P = 0.024). The receiving operator characteristics analysis yielded area under the curve (AUC) values of 0.8187, 0.9083, 0.8947, and 0.8394, respectively, for CRP, IgE, IL-6, and IL-13, confirming their significance in the diagnosis of CAA (P < 0.05). CONCLUSION Risk factors for CAA include CRP, IgE, IL-6, and IL-13. The combination of these serological markers can be used to diagnose CAA.
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Affiliation(s)
- Tao Zhang
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China; The Fifth Clinical Medical College of Anhui Medical University, Hefei 230000, Anhui, China
| | - Yuan Cheng
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Yuliang Zhou
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Zhenqiang Zhang
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Shiqin Qi
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China
| | - Zhubin Pan
- Department of General Surgery, Anhui Provincial Children's Hospital, Children's Hospital of Fudan University Anhui Hospital, Children's Hospital of Anhui Medical University, Hefei 230000, Anhui, China; The Fifth Clinical Medical College of Anhui Medical University, Hefei 230000, Anhui, China.
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Arredondo Montero J, Torres López A, Hurtado Ilzarbe G, Antona G, Ros Briones R, López-Andrés N, Martín-Calvo N. Flow cytometric characterization of cecal appendix lymphocyte subpopulations in children: a pilot study. Pediatr Surg Int 2023; 39:274. [PMID: 37736768 PMCID: PMC10516785 DOI: 10.1007/s00383-023-05558-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Scientific literature regarding the characterization of lymphocyte subpopulations of the cecal appendix is sparse, with few precedents limited to immunohistochemical techniques. METHODS We conducted a prospective pilot study to characterize lymphocyte subpopulations of the cecal appendix in children. Participants were divided into three groups: (1) patients without histological acute appendiceal inflammation, (2) patients with histological uncomplicated acute appendicitis, and (3) patients with histological complicated acute appendicitis (gangrenous, perforated). A fresh sample of the base of the appendix was taken from all patients and a flow cytometric study was performed. Quantitative variables were compared using Kruskal-Wallis test and Mann-Whitney U test. RESULTS This study included 57 patients divided into Group 1 (n = 5), Group 2 (n = 37), and Group 3 (n = 15). Median values (IQR) of the percentage of B-lymphocytes were 67.8 [66.8-68.1] in group 1, 61.15 [53.74-66.4] in group 2, and 52.1 [33-62.02] in group 3 (p = 0.02). Median values (IQR) of the percentage of NK-lymphocytes were 0.26 [0.2-0.3] in group 1, 0.55 [0.37-0.66] in group 2, and 0.84 [0.35-1.45] in group 3 (p = 0.008). Median values (IQR) of the percentage of T-lymphocytes were 31.9 [31.7-33.1] in group 1, 37.68 [32.15-45.69] in group 2, and 46.9 [37.03-67] in group 3 (p = 0.02). Pair comparisons of groups 2 and 3 also showed significant differences in the percentage of B lymphocytes (p = 0.03) and NK-lymphocytes (p = 0.02). CONCLUSIONS Significant differences in lymphocyte subpopulations were identified according to the histologic grade of the cecal appendix. More specifically, a lower percentage of B-lymphocytes and a higher percentage of T- and NK-lymphocytes were observed in cases of acute appendicitis. These findings must be confirmed and their etiopathogenic, diagnostic, and prognostic implications elucidated in future studies with larger sample sizes.
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Affiliation(s)
- Javier Arredondo Montero
- Pediatric Surgery Department, Hospital Universitario de Navarra, Calle Irunlarrea 3, 31008, Pamplona, Navarra, Spain.
- Preventive Medicine and Public Health Department, School of Medicine, University of Navarra, Pamplona, Navarra, Spain.
| | - Andrea Torres López
- Hematology and Haemotherapy Department, Hospital Universitario de Navarra, Pamplona, Navarra, Spain
| | | | - Giuseppa Antona
- Pediatric Surgery Department, Hospital Universitario de Navarra, Calle Irunlarrea 3, 31008, Pamplona, Navarra, Spain
| | - Raquel Ros Briones
- Pediatric Surgery Department, Hospital Universitario de Navarra, Calle Irunlarrea 3, 31008, Pamplona, Navarra, Spain
| | - Natalia López-Andrés
- Cardiovascular Translational Research, NavarraBiomed (Miguel Servet Foundation), Hospital Universitario de Navarra, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Navarra, Spain
| | - Nerea Martín-Calvo
- Preventive Medicine and Public Health Department, School of Medicine, University of Navarra, Pamplona, Navarra, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Navarra, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Health Institute Carlos III, Madrid, Spain
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Carvalho N, Carolino E, Coelho H, Barreira AL, Moreira L, André M, Henriques S, Cardoso C, Moita L, Costa PM. Eosinophil Granule Proteins Involvement in Acute Appendicitis-An Allergic Disease? Int J Mol Sci 2023; 24:ijms24109091. [PMID: 37240441 DOI: 10.3390/ijms24109091] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Several pieces of evidence point to an allergic component as a trigger of acute appendicitis. As the Th2 immune response is characterized by eosinophil mobilization to the target organ and release of their cationic granule proteins, it is reasonable to investigate if the degranulation of eosinophils could be associated with the local injury. The primary aim of this study is to evaluate the participation of eosinophils granules proteins in acute appendicitis, both at local and systemic levels and the secondary aim is to evaluate the diagnostic accuracy of eosinophils granules proteins for the detection of acute appendicitis, as well as for distinguishing between complicated and uncomplicated acute appendicitis. Eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP) and eosinophil peroxidase (EP) are the most well-known eosinophil granule proteins. From August 2021 to April 2022, we present a prospective single-center study to evaluate the EDN, ECP, and EP concentrations simultaneously in appendicular lavage fluid (ALF) and the serum of 22 patients with acute phlegmonous appendicitis (APA), 24 with acute gangrenous appendicitis (AGA), and 14 normal controls. Concerning EDN, no differences were found between groups. ECP concentrations in ALF and serum were significantly higher in the histologically confirmed acute appendicitis compared to the control groups (p < 0.0001 and p < 0.0001, respectively). In ALF, no differences were found between ECP levels in APA: 38.85 ng/mL (IQR 26.50-51.77) and AGA 51.55 ng/mL (IQR 39.55-70.09) groups (p = 0.176). In the serum, no difference was found between ECP levels at APA: 39 ng/mL (IQR 21.30-56.90) and AGA: 51.30 ng/mL (IQR 20.25-62.59) (p = 0.100). For EP, the concentrations in ALF (p < 0.001) and serum (p < 0.001) were both higher in acute appendicitis compared to the control. In ALF, no difference was found between APA: 240.28 ng/mL (IQR 191.2-341.3) and AGA: 302.5 (IQR 227.7-535.85) (p = 0.236). In the serum, no differences were found between APA: 158.4 ng/mL (IQR 111.09-222.1) and AGA: 235.27 (IQR 192.33-262.51) (p = 0.179). Globally, the ALF concentrations were higher than serum concentrations, reflecting an intense inflammatory local reaction in AA. The optimal ECP cut-off for discriminating between acute appendicitis and the controls was >11.41 ng/mL, with a sensitivity of 93.5%, but with a specificity for identifying appendicitis of 21.4%, good discriminative power (AUC = 0.880). For EP, the optimal cut-off was >93.20 ng/mL, with a sensitivity of 87%, but with a specificity of 14.3% (AUC = 0.901), excellent discriminative power. For the diagnosis of perforated AA, the discriminative power of ECP and EP serum concentrations are weak (AUC = 0.562 and AUC = 0.664, respectively). Concerning the presence of peritonitis, the discriminative power of ECP and EP serum concentrations is acceptable, respectively: AUC = 0.724 and AUC = 0.735. Serum levels of EDN (p = 0.119), ECP (p = 0.586) and EP (p = 0.08) in complicated appendicitis were similar to uncomplicated appendicitis. Serum concentrations of ECP and EP can be added to decision-making AA diagnosis. A Th2-type immune response is present in AA. These data bring forward the role of an allergic reaction in the pathogenesis of acute appendicitis.
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Affiliation(s)
- Nuno Carvalho
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Elisabete Carolino
- H&TRC-Health & Technology Research Center, ESTeSL-Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1549-020 Lisboa, Portugal
| | - Hélder Coelho
- Serviço de Anatomia Patológica, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Ana Lúcia Barreira
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Luísa Moreira
- Serviço de Urologia, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Margarida André
- Serviço de Urologia, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Susana Henriques
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Carlos Cardoso
- Dr. Joaquim Chaves Laboratório de Análises Clínicas, 1495-068 Alges, Portugal
| | - Luis Moita
- Innate Immunity and Inflammation Lab, Instituto Gulbenkian de Ciência Oeiras, 2780-156 Oeiras, Portugal
- Instituto de Histologia e Biologia do Desenvolvimento, Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
| | - Paulo Matos Costa
- Serviço Cirurgia Geral, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Faculdade Medicina, Universidade Lisboa, 1649-028 Lisboa, Portugal
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