Refractory lymphocytic enterocolitis and tumor necrosis factor antagonist therapy

BACKGROUND & AIMS

Lymphocytic enterocolitis is a malabsorptive syndrome characterized by severe small-bowel villous abnormality and crypt hyperplasia and dense infiltrate of lymphocytes throughout the gastrointestinal tract.

METHODS

We present 2 patients with lymphocytic enterocolitis refractory to usual medical therapy who were treated with tumor necrosis factor antagonists.

RESULTS

Both patients had clinical improvement in diarrheal symptoms and intestinal histologic abnormalities.

CONCLUSIONS

Tumor necrosis factor-alpha antagonists such as infliximab or adalimumab may be a new treatment option for patients with severe refractory lymphocytic enterocolitis not responding to corticosteroids.

Deficiency of nicotinamide adenine dinucleotide phosphate, reduced form oxidase enhances hepatocellular injury but attenuates fibrosis after chronic carbon tetrachloride administration

Reactive oxygen species (ROS) activate hepatic stellate cells and enhance fibrogenesis. This study determined the role of nicotinamide adenine dinucleotide phosphate, reduced form (NADPH) oxidase deficiency in the development of hepatocellular necrosis, inflammation, and apoptosis in relation to fibrosis produced by chronic carbon tetrachloride (CCl(4)) administration. Wild-type (WT) mice or mice with deficiency of the gp91(phox) subunit of NADPH complex (gp91(phox(-/-) )) were subjected to biweekly CCl(4) injections over 8 weeks, whereas controls were given isovolumetric injections of olive oil. Serum aspartate aminotransferase (AST) was higher after CCl(4) administration in gp91(phox(-/-) ) than in WT mice, correlating with increased necrosis on liver histology. By contrast, more hepatocyte apoptosis was found after CCl(4) in the WT than in the gp91(phox(-/-) ) mice, which was associated with changes in components of the mitochondrial pathway of apoptosis, namely, an increase in the pro-apoptotic BAX protein in the WT, but not in the gp91(phox(-/-) ) mice and also a lower cytosolic cytochrome c in the gp91(phox(-/-) ) mice. There were fewer stellate cells and less fibrosis after CCl(4) in the gp91(phox(-/-) ) as compared with the WT mice. The increase in alpha(1)(I) collagen messenger RNA (mRNA), however, was greater after CCl(4) in the gp91(phox(-/-) ) mice. Matrix metalloproteinase-2 (MMP-2) and MMP-9 mRNA increased more in the gp91(phox(-/-) ) than in WT mice after CCl(4.) Tissue inhibitor of metalloproteinase 1 (TIMP-1) and TIMP-2 increased after CCl(4) only in the gp91(phox(-/-) ) mice.

CONCLUSION

Decreased hepatic fibrosis after chronic CCl(4) administration in mice with NADPH oxidase deficiency occurs in the setting of greater necrosis and inflammation but decreased apoptosis.

Lack of inducible nitric oxide synthase leads to increased hepatic apoptosis and decreased fibrosis in mice after chronic carbon tetrachloride administration

The role of nitric oxide (NO) in liver injury and fibrosis is unclear. The purpose of this study was to determine whether inducible NO synthase deficiency (iNOS(-/-)) affects liver injury and fibrosis produced in mice by chronic carbon tetrachloride (CCl(4)) administration. Wild-type (WT) or iNOS(-/-) mice were subjected to biweekly CCl(4) injections over 8 weeks, whereas controls were given isovolumetric injections of olive oil. Serum aminotransferases were lower after CCl(4) in the iNOS(-/-) than in the WT mice, which correlated with decreased necrosis on liver histology. There was increased apoptosis, a lower number of stellate cells, and a lesser degree of fibrosis after CCl(4) in the iNOS(-/-) as compared with the WT mice. alpha(1)(I) collagen messenger RNA (mRNA) was markedly increased after CCl(4) in the WT and to a significantly lesser extent in the iNOS(-/-) mice. Liver matrix metalloproteinase-9 (MMP-9) mRNA and MMP-2 mRNA were increased more in the WT than in the iNOS(-/-) mice after CCl(4). Also tissue inhibitor metalloproteinase 1 (TIMP-1) mRNA was increased to a much greater extent in the WT than in the iNOS(-/-) mice after CCl(4) (P < 0.05). However, MMP-9 and TIMP-1 protein, determined by western blot, were similarly increased after CCl(4) in both groups of mice.

CONCLUSION

NO protects against CCl(4)-induced apoptosis. In the absence of iNOS, there is decreased necrosis, increased apoptosis, and reduced liver fibrosis.

Human monocytic ehrlichiosis

A 56-year-old man with a history of Wegener granulomatosis presented with 6 days of sinus congestion, fever, malaise, myalgias, episcleritis, and a morbilliform rash. An exacerbation of Wegener granulomatosis was the principal concern because of the frequency of flares in that disease. The patient developed acute renal failure, thrombocytopenia, transaminitis, and, finally, severe myocarditis that led to congestive heart failure. Additional history-taking and the evolution of his clinical features led to empirical treatment with doxycycline for human monocytic ehrlichiosis (HME). The diagnosis of HME was confirmed by both a polymerase chain reaction assay for Ehrlichia chaffeensis and by the demonstration of morulae within peripheral blood mononuclear cells. The patient improved promptly following institution of doxycycline, and his cardiac function returned to normal over a period of 4 months.

Effects of extracorporeal shock wave lithotripsy on single chamber rate response and dual chamber pacemakers

This study evaluated effects of extracorporeal shock wave lithotripsy on four models of Medtronic implantable cardiac pacemakers. In vitro testing consisted of: (1) unsynchronized pacemaker strapped on the patient with extracorporeal shock synchronized to the patient's native heart rate; and (2) pacemakers suspended alone in water 6 inches from the focal point, synchronizing the extracorporeal shock to pacemaker output. Unsynchronized shocks affected each model of pacemaker differently, i.e., single chamber constant rate pacemakers experienced extended periods of inhibition for more than three pacing cycles while activity-triggered rate response pacemakers exhibited rate increases to the upper rate setting. Dual chamber synchronous pacemakers exhibited intermittently a 59% decrease and a 20% increase in ventricular rate due to inhibition and triggering, respectively, from shock oversensing. Synchronized shocks did not alter the rate of single chamber constant rate pacemakers, but did cause the rate to increase to the upper rate setting for activity-triggered rate response pacemakers. The shock was synchronized to the initial atrial output from the dual chamber pacemaker and caused frequent inhibition of the ventricular stimulus when the ventricular-safety-pace (VSP) feature was programmed off. Programming VSP on reduced the incidence of ventricular inhibition resulting in near normal pacemaker operation. There was neither observable damage to pacemaker components nor spurious reprogramming of pacemaker parameters during the tests. Our studies with one manufacturer's pacemakers suggests that lithotripsy shock effects on implantable pacemakers can be tolerated provided: (1) the single chamber pacemaker is programmed to the demand constant rate modality; (2) the dual chamber pacemaker is programmed to VSP on or to the VVI mode; and (3) the pacemaker distance to the focal point is greater than 6 inches.(ABSTRACT TRUNCATED AT 250 WORDS)

Pattern of preventable diseases in Afghanistan: suggestions to reduce the morbidity and mortality at IGICH

Over nine years period (1354-1362), 1,39,436 children were admitted in Indira Gandhi Institute of Child Health (IGICH), Kabul. Of these 51,212 (46.8%) children were hospitalised with preventable diseases. Seventy four per cent of patients were under five years of age. Among the infectious diseases, gastroenteritis accounted for nearly 70% of admissions. Tuberculosis, measles, diphtheria and typhoid fever were other common infectious diseases. Malnutrition of varying degree was the core problem among the hospitalised children and was seen in nearly two thirds of admissions. Twenty per cent of them had severe protein energy malnutrition which contributed for higher mortality. Gastroenteritis contributed for half (51.5%) of the mortality. Septicemia, tetanus neonatorum and central nervous system infections were associated with high mortality especially among the neonates. Deaths following 6-target preventable diseases accounted for nearly 1/4th of deaths (20.4-24.6%) over these years.

The effects of nuclear magnetic resonance imagers on external and implantable pulse generators

This study evaluates the effect of nuclear magnetic resonance (NMR) scanning on pacemaker function. It must be emphasized that each manufacturer's pulse generators and each pacing modality may behave differently and, therefore, require individual evaluation. According to our results, patients with pacemakers should have their pacing activity monitored continuously during scanning with the NMR 1500 gauss imaging system. External pulse generators should be set to the asynchronous mode and placed outside the NMR image volume but within the radiofrequency (RF) shield. Implanted pacemakers should be verified for type and mode of operation. All implantable pulse generators evaluated reverted from the demand to the asynchronous mode within the magnetic field of the scanner. There was no observable damage to the discrete pacemaker components that were tested. In vivo testing of implantable single-chamber pulse generators did not significantly alter the pacemaker's operating parameters. Changes in stimulation rate analogous to the RF field pulse rate were seen. In single-chamber devices the resultant rate was a multiple of the RF frequency, changing to a value less than the normal asynchronous magnetic rate. With more sophisticated dual-chamber devices the results varied. With VDD pacing during RF scanning, the cardiac stimulation rate increased to a value analogous to the RF field modulation period. More extensive in vivo testing using different models of pulse generators of various manufacturers is needed to identify specific device susceptibility to the RF, time variance and steady-state magnet fields. From these data a comprehensive statement about NMR scanning of patients with implanted pacemakers can be made.