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Khan U, Aarebrot A, Mo S, Landa S, Rösler C, Sodha OK, Bjørneklett R, Dizdar V. Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department. J Emerg Med 2024; 66:e365-e368. [PMID: 38423863 DOI: 10.1016/j.jemermed.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/27/2023] [Accepted: 10/01/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Right upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis. CASE REPORT This case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.
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Affiliation(s)
- Umael Khan
- Department of Internal Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Anders Aarebrot
- Deparment of Dermatology, Haukeland University Hospital, Bergen, Norway
| | - Solveig Mo
- Department of Surgery, Haraldsplass Hospital, Bergen, Norway
| | - Signe Landa
- Department of Radiology, Haukeland University Hospital, Bergen
| | - Cornelia Rösler
- Department of Radiology, Haukeland University Hospital, Bergen
| | - Ole Kamal Sodha
- Department of Emergency Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rune Bjørneklett
- Department of Emergency Medicine, Haukeland University Hospital, Bergen, Norway
| | - Vernesa Dizdar
- Department of Emergency Medicine, Haukeland University Hospital, Bergen, Norway
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Myrmel GM, Lunde T, Dizdar V, Larsen TH, Saeed S. Myocarditis in a Young Patient with Celiac Disease; A Case Report and Literature Review. Open Cardiovasc Med J 2021. [DOI: 10.2174/1874192402115010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Myocarditis has numerous aetiologies, and Celiac Disease (CD) has been described as a rare cause. CD has received little attention in current guidelines and may be underdiagnosed. We report a case involving a 28-year-old male with myocarditis causing severe left ventricular dysfunction and dilatation that was probably related to CD. This case highlights the importance of screening for CD in patients presenting with myocarditis and signs of malabsorption when other common causes are excluded. Besides optimal medical treatment and cardiac resynchronization therapy, a gluten-free diet and immunosuppression may also be effective measures in the management of CD-related myocarditis.
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Martínez C, Lasitschka F, Thöni C, Wohlfarth C, Braun A, Granzow M, Röth R, Dizdar V, Rappold GA, Hausken T, Langeland N, Hanevik K, Niesler B. Comparative expression profiling in the intestine of patients with Giardia-induced postinfectious functional gastrointestinal disorders. Neurogastroenterol Motil 2020; 32:e13868. [PMID: 32391639 DOI: 10.1111/nmo.13868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND A Giardia outbreak in Bergen, Norway, caused postinfectious functional gastrointestinal disorders (PI-FGIDs). Despite the devastating effects of this outbreak, it presented a unique chance to investigate the implication on the dysregulation of genetic pathways in PI-FGID. METHODS We performed the first comparative expression profiling of miRNAs and their potential target genes in microdissected rectal biopsies from 20 Giardia-induced PI-FGID patients vs 18 healthy controls by nCounter analysis. Subsequently, candidates were validated on protein level by immunostaining. KEY RESULTS miRNA profiling on rectal biopsy samples from 5 diarrhea-predominant PI-IBS cases compared to 10 healthy controls revealed differential expression in the epithelial layer. The top five regulated miRNAs were implicated in GI disease, inflammatory response, and immunological disease. Subsequently, these miRNAs and 100 potential mRNA targets were examined in 20 PI-FGID cases and 18 healthy controls in both the mucosal epithelium and the lamina propria. Although deregulation of the selected miRNAs could not be verified in the larger sample set, mRNAs involved in barrier function were downregulated in the epithelium. Pro-inflammatory genes and genes implicated in epigenetic modifications were upregulated in the lamina propria. Immunostaining for selected candidates on 17 PI-FGID cases and 16 healthy controls revealed increased tryptase levels as well as a decreased and aberrant subcellular expression of occludin. CONCLUSIONS AND INFERENCES Genes relevant to immune and barrier function as well as stress response and epigenetic modulation are differentially expressed in PI-FGIDs and may contribute to disease manifestation.
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Affiliation(s)
- Cristina Martínez
- Department of Human Molecular Genetics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.,Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Lleida, Spain.,Genes in Irritable Bowel Syndrome (GENIEUR) Research Network Europe, Heidelberg, Germany
| | - Felix Lasitschka
- Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Cornelia Thöni
- Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Carolin Wohlfarth
- Department of Human Molecular Genetics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Alexander Braun
- Department of Human Molecular Genetics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Martin Granzow
- Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Ralph Röth
- Department of Human Molecular Genetics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.,nCounter Core Facility Heidelberg, Institute of Human Genetics, Heidelberg, Germany
| | - Vernesa Dizdar
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Gudrun A Rappold
- Department of Human Molecular Genetics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.,nCounter Core Facility Heidelberg, Institute of Human Genetics, Heidelberg, Germany
| | - Trygve Hausken
- Genes in Irritable Bowel Syndrome (GENIEUR) Research Network Europe, Heidelberg, Germany.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Nina Langeland
- Genes in Irritable Bowel Syndrome (GENIEUR) Research Network Europe, Heidelberg, Germany.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kurt Hanevik
- Genes in Irritable Bowel Syndrome (GENIEUR) Research Network Europe, Heidelberg, Germany.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, National Advisory Center for Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Beate Niesler
- Department of Human Molecular Genetics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.,Genes in Irritable Bowel Syndrome (GENIEUR) Research Network Europe, Heidelberg, Germany.,nCounter Core Facility Heidelberg, Institute of Human Genetics, Heidelberg, Germany
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von Volkmann HL, Brønstad I, Tronstad RR, Dizdar V, Nylund K, Hanevik K, Hausken T, Gilja OH, Fiskerstrand T. Plasma levels of guanylins are reduced in patients with Crohn's disease. Scand J Gastroenterol 2020; 55:449-453. [PMID: 32306784 DOI: 10.1080/00365521.2020.1748224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Guanylin (GN) and uroguanylin (UGN) are endogenous ligands for the intestinal receptor guanylate cyclase C (GC-C), an important regulator of intestinal fluid homeostasis. Gene expression and protein levels of GN are suppressed in inflamed intestinal tissue from patients with inflammatory bowel disease (IBD), but knowledge about plasma levels of guanylins in these conditions is sparse. We aimed to investigate the fasting plasma levels of the prohormones proGN and proUGN in patients with Crohn's Disease (CD) and relate these to levels found in persons with other diarrheal conditions, as well as persons with normal bowel habits.Methods: Plasma from patients with CD, patients with Familial GUCY2C Diarrheal Disease (FGDS), diarrhea-predominant irritable bowel syndrome (IBS-D) and healthy controls (HC) was analyzed using ELISA assays.Results: Significantly lower fasting plasma levels of proguanylins were found in CD and FGDS patients, compared to HC. In CD patients, plasma proGN levels correlated negatively with Harvey Bradshaw Index and with number of stools/24 h.Conclusion: Our data indicate that diarrhea may be a determinant for levels of proGN in plasma, and should be further explored in studies of different diarrheal disorders.
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Affiliation(s)
- Hilde L von Volkmann
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital.,Department of Clinical Medicine, University of Bergen
| | - Ingeborg Brønstad
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital.,Department of Clinical Medicine, University of Bergen
| | - Rune R Tronstad
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Vernesa Dizdar
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital
| | - Kim Nylund
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital
| | - Kurt Hanevik
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Trygve Hausken
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital.,Department of Clinical Medicine, University of Bergen
| | - Odd Helge Gilja
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital.,Department of Clinical Medicine, University of Bergen
| | - Torunn Fiskerstrand
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway
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Dizdar V, Hausken T, Laerum OD, Gilja OH, Langeland N, Hanevik K. Prolonged Duodenal Mucosal Lymphocyte Alterations in Patients With and Without Postinfectious Functional Gastrointestinal Disorders After Giardia Infection. J Infect Dis 2020; 220:321-329. [PMID: 30500895 PMCID: PMC6581897 DOI: 10.1093/infdis/jiy690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/28/2018] [Indexed: 12/12/2022] Open
Abstract
Background Persisting low-grade inflammation is suggested to play a role in postinfectious functional gastrointestinal disorders (PI-FGIDs). The present study examined alterations in duodenal mucosal lymphocytes during and after Giardia gastroenteritis in patients who did, or did not, develop PI-FGIDs. Methods Duodenal mucosal intraepithelial lymphocytes (IELs) and lamina propria CD3, CD4, CD8, and CD20 lymphocytes were quantified in 28 patients with chronic giardiasis (CG), 66 patients with persistent abdominal symptoms after acute Giardia infection (PI-FGID), 19 recovered controls (RCs), and 16 healthy volunteers (HCs). Associations with illness duration, abdominal symptoms, and histology grade were assessed. Results Duodenal CD4 IELs were significantly elevated in CG, then decreased, followed by an upward trend after 1 year in both the PI-FGID and RC groups. Duodenal lamina propria crypt CD4 T cells were decreased in CG, and stayed low for about 14 months before normalizing in both the PI-FGID and RC groups. Lamina propria CD20 cells were persistently elevated in all 3 Giardia-exposed groups. Biopsies with microscopic inflammation showed increased lamina propria CD20 levels. Conclusions Duodenal mucosal lymphocyte alterations were prolonged after Giardia infection, but similar in patients who developed PI-FGID and recovered asymptomatic controls.
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Affiliation(s)
- Vernesa Dizdar
- Department of Medicine, Section of Gastroenterology, Department of Medicine, Bergen, Norway.,National Centre of Functional Gastrointestinal Disorders, Section of Gastroenterology, Department of Medicine, Bergen, Norway
| | - Trygve Hausken
- National Centre of Functional Gastrointestinal Disorders, Section of Gastroenterology, Department of Medicine, Bergen, Norway.,National Centre of Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Ole D Laerum
- Gade Laboratory of Pathology, Department of Clinical Research, University of Bergen, Bergen, Norway.,Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Odd Helge Gilja
- Department of Medicine, Section of Gastroenterology, Department of Medicine, Bergen, Norway.,National Centre of Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Nina Langeland
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Haraldsplass Deaconess Hospital, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Kurt Hanevik
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Brattås MK, Gjelberg HK, Dizdar V, Vetti N, Bertelsen LT, Reikvam H. A woman in her forties with pelvic pain and unclear MRI findings. Tidsskr Nor Laegeforen 2019; 139:18-0541. [PMID: 31062557 DOI: 10.4045/tidsskr.18.0541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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El-Salhy M, Vaali K, Dizdar V, Hausken T. Abnormal small-intestinal endocrine cells in patients with irritable bowel syndrome. Dig Dis Sci 2010; 55:3508-13. [PMID: 20300845 DOI: 10.1007/s10620-010-1169-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 02/11/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND General disturbances in gastrointestinal motility have been reported in patients with irritable bowel syndrome (IBS). The gastrointestinal tract hormones play an important role in regulating gastrointestinal motility. AIMS To investigate a possible abnormality in the small intestinal endocrine cells of IBS patients. METHODS Included in the study were 41 patients with irritable bowel syndrome according to Rome Criteria III and 42 healthy controls. Duodenal biopsies were obtained from both patients and controls during gastroscopy. The biopsies were immunostained by avidin-biotin-complex method for secretin, CCK, GIP, somatostatin, and serotonin cells. The cell densities were quantified by computerized image analysis. RESULTS The density of secretin- and CCK-immunoreactive cells in patients with IBS was significantly reduced. The reduction in secretin and CCK cells occurred only in IBS-diarrhea patients, but not in IBS-constipation subtype. Both GIP and somatostatin cell densities were reduced in the duodenum of IBS patients. There was no statistical difference between the subtypes of IBS patients, regarding secretin, CCK, GIP, or somatostatin cell densities. Serotonin cell density was not affected in patients with IBS. CONCLUSIONS The low densities of secretin and CCK cells in IBS-diarrhea patients may cause a functional pancreatic insufficiency as well as inadequate gall emptying, as these hormones stimulate pancreatic bicarbonate and enzyme secretion and CCK stimulates as well gall bladder contraction. Low densities of secretin, GIP, and somatostatin cells in IBS patients might result in a high secretion of gastric acid, as secretin, GIP, and somatostatin inhibit gastric acid secretion.
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Affiliation(s)
- Magdy El-Salhy
- Section for Gastroenterology, Department of Medicine, Stord Helse-Fonna Hospital, Box 4000, 54 09 Stord, Norway.
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Dizdar V, Spiller R, Singh G, Hanevik K, Gilja OH, El-Salhy M, Hausken T. Relative importance of abnormalities of CCK and 5-HT (serotonin) in Giardia-induced post-infectious irritable bowel syndrome and functional dyspepsia. Aliment Pharmacol Ther 2010; 31:883-91. [PMID: 20132151 DOI: 10.1111/j.1365-2036.2010.04251.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Post-infectious irritable bowel syndrome (PI-IBS) and functional dyspepsia (FD) have been described after both Campylobacter jejuni gastroenteritis and Giardia infection. After C. jejuni, there is increased rectal serotonin (5-HT)-containing EC cells and postprandial plasma 5-HT, while a pilot study suggested increased plasma cholecystokinin (CCK) after Giardia infection. AIM To determine changes in plasma and duodenal mucosal 5-HT and CCK in Giardia-induced PI-IBS. METHODS A total of 32 patients previously infected with Giardia and 19 who had recovered fully (controls) completed symptom questionnaires. Endoscopic duodenal biopsies were obtained from all subjects and immunohistochemically stained for CCK, 5-HT and CgA containing entero-endocrine cells and mast cells. 5-HT content was also assessed. Twenty-one of 32 patients and 19 controls consumed a high-carbohydrate meal, while fasting and postprandial plasma CCK and 5-HIAA were measured. RESULTS Post-infectious irritable bowel syndrome patients had increased numbers of CCK cells (P = 0.02), but lower numbers of EC cells (P = 0.009). Plasma CCK did not differ significantly between the groups, but correlated significantly with postprandial dyspepsia scores (r = 0.5, P = 0.05). PI-IBS patients had significantly lower plasma 5-HIAA, before and after meal (P = 0.05) as well as more dyspepsia (P < 0.0001) compared with recovered subjects. CONCLUSIONS Post-infectious bowel dysfunction following Giardia infection is associated with increased duodenal mucosal CCK. Postprandial dyspeptic symptoms correlate better with CCK than measures of 5-HT metabolism.
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Affiliation(s)
- V Dizdar
- Institute of Medicine, University of Bergen, Bergen, Norway.
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Dizdar V, Gilja OH, Hausken T. Increased visceral sensitivity in Giardia-induced postinfectious irritable bowel syndrome and functional dyspepsia. Effect of the 5HT3-antagonist ondansetron. Neurogastroenterol Motil 2007; 19:977-82. [PMID: 17973637 DOI: 10.1111/j.1365-2982.2007.00988.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In an outbreak of waterborne giardiasis where 1300 subjects were diagnosed, with Giardia lamblia, 139 continued to have abdominal symptoms of whom two of three had negative stool culture and microscopy. These were considered to have a postinfectious functional gastrointestinal disorder. We investigated visceral hypersensitivity in patients with persisting abdominal symptoms after Giardia infection and assessed the effect of 5HT(3)-antagonist ondansetron. Twenty-two patients with Giardia negative stools and 19 controls were included. A subset of patients (n = 15) had both irritable bowel syndrome (IBS) and functional dyspepsia (FD). All subjects underwent a satiety test with a soup combined with three-dimensional ultrasound. Fifteen of 22 patients underwent double-blind, randomized, placebo-controlled study with the 5-HT(3) antagonist ondansetron given orally. Drinking capacity was lower in patients than in controls (P < 0.01) and gastric emptying was reduced (P < 0.05). Patients had more symptoms both fasting and postprandially (P < 0.001) compared to controls. Ondansetron had no effect on these parameters except from less nausea postprandially (P < 0.05). In conclusion, patients with Giardia-induced gastrointestinal symptoms developed both IBS and FD. They exhibited gastric hypersensitivity with lower drinking capacity and delayed gastric emptying. The 5-HT(3) antagonist ondansetron did not improve drinking capacity, gastric emptying or symptoms except nausea.
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Affiliation(s)
- V Dizdar
- Institute of Medicine, University of Bergen, Bergen, Norway.
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