Predictors for Celiac Disease in Adult Cases of Duodenal Intraepithelial Lymphocytosis

BACKGROUND

Duodenal intraepithelial lymphocytosis (D-IEL) is an early marker for celiac disease (CD). However, the majority of cases are due to non-CD-related conditions.

GOALS

To identify the predictors of CD when presented with D-IEL.

METHODS

A total of 215 adult patients with D-IEL had undergone prospective and systematic evaluation for CD and other recognized associations.The gold-standard diagnosis of CD was based upon the presence of HLA-DQ2 and/or DQ8, persistence or progression of D-IEL following a gluten challenge, followed by symptomatic improvement on a gluten-free diet.Binary logistic regression models, adjusting for age and sex, were subsequently performed to compare presenting variables between CD and non-CD cases, and to determine their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

CD was diagnosed in 48 cases (22%) and non-CD in 167 cases (78%). There was no statistical difference in baseline demographics, clinical symptoms (ie, diarrhea, weight loss, abdominal pain), anemia, or hematinics between the CD and non-CD group.Patients with CD, in comparison with non-CD, were significantly more likely to have a positive family history of CD (21% vs. 3.6%, OR 6.73; PPV 62.5%, NPV 81%, specificity 96.4%), positive HLA-DQ status (100% vs. 49.1%; PPV 36.4%, NPV 100%, specificity 50.9%), and presence of endomysial antibody (EMA) (48% vs. 0%; PPV 100%, NPV 87%, specificity 100%); all P≤0.001.A normal tissue transglutaminase antibody (TTG) level was seen in 29.2% CD and 83.2% non-CD cases (OR 0.084, P<0.001; PPV 9.2%). There was no difference in the prevalence of TTG levels 1 to 2×upper limit of normal (ULN) between the groups (29.2% CD vs. 14.4% non-CD; PPV 33% to 38%). However, TTG levels between 3 and 20×ULN were significantly more prevalent in the CD group (33.3% vs. 2.4%, PPV 66.6% to 89%), whereas a TTG>20×ULN was exclusive to CD (8.3%, P<0.001, PPV 100%).

CONCLUSIONS

In the setting of D-IEL, only the presence of a positive EMA or TTG>20×ULN at the outset can be used to make an immediate diagnosis of CD. Gastrointestinal symptoms, family history, anemia, or other celiac serology results do not reliably distinguish CD from non-CD without further investigations.

Evolution of nonspecific duodenal lymphocytosis over 2 years of follow-up

AIM

To assess the evolution of duodenal lymphocytosis (DL), a condition characterized by increased intraepithelial lymphocytes (IELs), over 2 years of follow-up.

METHODS

Consecutive patients undergoing upper endoscopy/histology for abdominal pain, diarrhea, weight loss, weakness or other extraintestinal features compatible with celiac disease (CD) were included. Evaluation of IELs infiltrate in duodenal biopsy samples was carried out by CD3-immunohistochemistry and expressed as number of positive cells/100 enterocytes. Diagnostic agreement on the IELs count was tested by calculating the weighted k coefficient. All patients underwent serological detection of autoantibodies associated with CD: IgG and IgA anti-tissue transglutaminase and endomysium. Each patient underwent further investigations to clarify the origin of DL at baseline and/or in the course of 2 years of follow-up every six months. Autoimmune thyroiditis, intestinal infections, parasitic diseases, bacterial intestinal overgrowth, hypolactasia and wheat allergy were detected. Colonoscopy and enteric magnetic resonance imaging were performed when necessary. Risk factors affecting the final diagnosis were detected by multinomial logistic regression and expressed as OR.

RESULTS

Eighty-five patients (16 males, 69 females, aged 34.1 ± 12.5 years) were followed up for a mean period of 21.7 ± 11.7 mo. At baseline, endoscopy/duodenal biopsy, CD3 immunohistochemistry revealed: > 25 IELs/100 enterocytes in 22 subjects, 15-25 IELs in 37 and < 15 IELs in 26. They all had negative serum anti-transglutaminase and anti-endomysium, whilst 5 showed IgG anti-gliadin positivity. In the course of follow-up, 23 developed CD seropositivity and gluten sensitivity (GS) was identified in 19. Other diagnoses were: 5 Helicobacter pylori infections, 4 jejunal Crohn's disease, 1 lymphocytic colitis and 1 systemic sclerosis. The disease in the remaining 32 patients was classified as irritable bowel syndrome because of the lack of diagnostic evidence. At multivariate analysis, the evolution towards CD was associated with an IELs infiltrate > 25 (OR = 1640.4) or 15-25 (OR = 16.95), human leukocyte antigen (HLA) DQ2/8 (OR = 140.85) or DQA1*0501 (OR = 15.36), diarrhea (OR = 5.56) and weakness (OR = 11.57). GS was associated with IELs 15-25 (OR = 28.59), autoimmune thyroiditis (OR = 87.63), folate deficiency (OR = 48.53) and diarrhea (OR = 54.87).

CONCLUSION

DL may have a multifactorial origin but the IELs infiltrate and HLA are strong predictive factors for CD development and a clinical diagnosis of GS.

Cytomegalovirus pseudotumor of the duodenum in a patient with AIDS: an unrecognized and potentially treatable clinical entity

BACKGROUND

Cytomegalovirus (CMV) is a common pathogen affecting the gastrointestinal tract in patients with AIDS. We report a case of CMV-induced pseudotumor of the duodenum in a patient with AIDS and review other reported cases of CMV-induced pseudotumors in the gastrointestinal tract. CMV-induced pseudotumor in patients with AIDS is an exceptionally rare clinical entity, and to our knowledge no reports have previously summarized this clinical entity.

METHODS

All previous cases included in our literature review were found using a PubMed search (1980-November 2008) of the English-language medical literature applying the terms 'CMV infection', 'inflammatory mass', 'pseudotumor', and 'gastrointestinal tract'. The references cited in these articles were examined to identify additional reports.

RESULTS

Although CMV-induced duodenitis has been described in patients with HIV infection, to our knowledge CMV-induced pseudotumor of the duodenum has not been previously reported in the literature. We describe the first case of an AIDS patient with CMV pseudotumor responding to oral treatment with valganciclovir with complete resolution of the CMV mass. Among reports of non-duodenal pseudotumor reported in the English literature, we found only 14 cases of CMV-induced gastrointestinal pseudotumors in HIV-positive patients. The clinical manifestations, pathologic findings of the CMV pseudotumors, as well as the treatment and outcome of these HIV patients are reviewed.

CONCLUSION

CMV pseudotumor should be included in the differential diagnosis of gastrointestinal mass lesions in AIDS patients and in other immunocompromised patients. The tumor often responds to antiviral therapy, but resolution of a CMV mass as a result of oral antiviral therapy has not been previously described. Since pseudotumors secondary to CMV often respond to medical treatment, it is important that the physicians treating severely immunocompromised patients are aware of this entity.

Increased number of CCR4-positive cells in the duodenum of ovalbumin-induced food allergy model Nc/jic mice and antiallergic activity of fructooligosaccharides

BACKGROUND

Fructooligosaccharides (FOS) in prebiotic foods can alter intestinal immune responses. The combination of probiotics with oligosaccharides has been reported to alter intestinal flora and suggested to be beneficial against food allergy in humans.

METHODS

All male Nc/jic mice used in this 8-week study were 6 weeks of age and were allotted to the following three groups: (1) the nonsensitization group; (2) the ovalbumin (OVA) sensitization +5% fructose-containing control food administration group; and (3) the OVA sensitization +5% FOS-containing food administration group. Duodenal tissues were collected and then immunohistochemically stained with monoclonal antibodies to CCR4 and CCR5. The number of mast cells and the villus edema formation rate in the duodenum were determined by image analysis.

RESULTS

The number of CCR4-positive cells increased significantly in Group 2 as compared with Group 1 and tended to decrease in Group 3 as compared with Group 2. Relatively few CCR5-positive cells were observed in the duodenum. FOS tended to reduce the number of CCR4-positive cells but significantly reduced the number of mast cells and the edema formation rate in the duodenum.

CONCLUSIONS

This study demonstrated a correlation between the number of CCR4-positive cells and villus edema formation rate. Therefore, FOS, which we inferred to show antiallergic activity for food allergy in this study and which has already been established to be safe for use as food in humans, can be considered to be potentially useful for the prevention of food allergy in pediatric patients with allergy.

SUPPRESSION OF EXTRAINTESTINAL AND INTESTINAL NIPPOSTRONGYLUS BRASILIENSIS-INDUCED EOSINOPHILIA BY EIMERIA NIESCHULZI

Eosinophil responses in extraintestinal and intestinal tissues were examined in August and Sprague-Dawley rats infected with Nippostrongylus brasiliensis or Eimeria nieschulzi (or both), and in uninfected controls to test the hypothesis that E. nieschulzi suppresses the systemic N. brasiliensis-induced eosinophil response. Caudal vein blood, femoral bone marrow, bronchoalveolar lavage fluid, peritoneal lavage fluid, and duodenal and jejunal samples were collected on day 8 postinfection (PI) with E. nieschulzi, on day 16 PI of the N. brasiliensis infection, when these days coincided in the concurrently infected rats, and from uninfected controls. Differential white blood cell counts were made from blood smears and cytocentrifuged preparations, and duodenal and jejunal eosinophils per villus crypt unit were quantified. Eimeria nieschulzi significantly reduced N. brasiliensis-induced eosinophil levels in peripheral blood, lavage fluids, and duodenal and jejunal tissues in both rat strains. August and Sprague-Dawley rats monospecifically infected with N. brasiliensis and concurrently with both parasites demonstrated elevated eosinopoiesis compared with uninfected controls and rats infected with only E. nieschulzi; however, despite this, concurrently infected rats had a significantly greater level of eosinopoiesis than those infected with only the nematode. In addition, E. nieschulzi induced elevated neutrophil levels in both monospecifically and concurrently infected rats in all extraintestinal tissues examined in both rat strains, whereas lymphocyte counts decreased concomitantly. This study suggests that the intestinal coccidian E. nieschulzi has the ability to modulate the systemic inflammatory response to N. brasiliensis and that this is not a rat strain-specific phenomenon.

Duodenal intraepithelial lymphocytes in inflammatory disorders of the esophagus and stomach

BACKGROUND & AIMS

Duodenal cluster designation 3 positive (CD3+) intraepithelial T lymphocytes (IELs) are increased in gluten-sensitive enteropathy (GSE) and, because of the dispersed nature of the gut immune system, might also be increased in mucosa distant from the duodenum. Conversely, little is known about their frequency in the duodenum during inflammatory conditions of the stomach and esophagus. This study assessed whether CD3+ IELs are increased in duodenal biopsies in patients with esophagitis or gastritis relative to normal control subjects.

METHODS

Cases (n=46) with concurrent mucosal biopsies of the duodenum, stomach, and esophagus were divided into 4 groups: I, no inflammation in any site; II, active esophagitis only; III, chronic active gastritis only, with Helicobacter pylori bacteria; IV, chronic gastritis only, without H pylori bacteria. Immunostains against CD3 were performed by using standard techniques, the number of CD3+ cells/100 enterocytes in 3 well-oriented villi was recorded, and the results for the groups were compared statistically.

RESULTS

The average number of CD3+ IELs/100 enterocytes for each group was I, 6.7; II, 11.8; III, 7.2; and IV, 9.1. The differences among the groups were not statistically significant. There was no correlation between the number of duodenal IELs and severity of inflammation, patient age or sex, or symptoms.

CONCLUSIONS

Duodenal mucosal biopsies from patients with esophagitis and/or gastritis may have a slightly increased number of CD3+ IELs relative to normal control subjects. This finding may reflect an underlying mechanism of diffuse inflammation in the gastrointestinal tract.

Acute duodenal Crohn’s disease successfully managed with low-speed elemental diet infusion via nasogastric tube: A case report

Duodenal Crohn’s disease is rare, and patients without obstruction are treated medically. We herein report one case whose duodenal Crohn’s disease was successfully managed with low-speed elemental diet infusion through a nasogastric tube. A 28-year-old female developed acute duodenal Crohn’s disease. Upper GI radiologic and endoscopic examinations showed a stricture in the duodenal bulb. Using the duodenal biopsy specimens, mucosal cytokine levels were measured; interleukin (IL)-1β, IL-6, IL-8, and tumor necrosis factor-α levels were remarkably elevated. For initial 2 wk, powdered mesalazine was orally given but it was not effective. For the next 2 wk, she was treated with low-speed elemental diet therapy using a commercially available Elental^TM, which was infused continuously through a nasogastric tube using an infusion pump. The tip of the nasogastric tube was placed at an immediate oral side of the pylorus. The infusion speed was 10 mL/h (usual speed, 100 mL/h). After the 2-wk treatment, her symptoms were very much improved, and endoscopically, the duodenal stricture and inflammation improved. The duodenal mucosal cytokine levels remarkably decreased compared with those before the treatment. Although our experience was limited, low-speed elemental diet infusion through a nasogastric tube may be a useful treatment for acute duodenal Crohn’s disease.

Cytokine mRNA quantification in duodenal mucosa from dogs with chronic enteropathies by real-time reverse transcriptase polymerase chain reaction

The pathogenesis of inflammatory bowel disease (IBD) and antibiotic-responsive diarrhea (ARD) in dogs likely involves an interaction between the intestinal immune system and luminal bacterial or food antigens. German Shepherd Dogs (GSD) are particularly predisposed to both IBD and ARD. CD4+ T cells are important for the regulation of immune responses in the mucosa, and they exert their effects through the secretion of cytokines. The present study examined the role of cytokines in the pathogenesis of canine chronic enteropathies by quantification of mRNA encoding interleukin-2 (IL-2), IL-4, IL-5, IL-6, IL-10, IL-12, IL-18, interferon gamma, tumor necrosis factor-alpha, transforming growth factor-beta, and glyceraldehyde-3-phosphate dehydrogenase by real-time reverse transcriptase polymerase chain reaction in duodenal mucosal biopsies obtained from 39 dogs with chronic diarrhea and 18 control dogs. Contemporaneously collected biopsies were assessed for histologic changes with a 4-point grading system. No significant difference in the expression of cytokine mRNA (P > .01) was detected between dogs with and those without chronic diarrhea. Similarly, no significant differences in cytokine mRNA expression were observed between GSD and other breeds with chronic diarrhea, or between histologically normal duodenal mucosa and that with evidence of inflammatory change. Failure to detect a difference in mRNA expression does not rule out the possibility of a defect downstream at the level of translation or protein function. No conclusion can be drawn from these data as to the predominant CD4+ cell type in the pathogenesis of these canine chronic enteropathies.

Digestive anisakiasis: clinical manifestations and diagnosis according to localization

OBJECTIVES

Digestive anisakiasis is a parasitic disease whose clinical manifestations depend on the effect of Anisakis simplex on the digestive tract wall. Larvae are acquired by eating raw or poorly cooked fish. It is estimated that this entity is currently under-diagnosed, although publications are becoming increasingly common. We analyse our series of digestive anisakiasis checking localization and studying its relationship with symptoms and method of diagnosis.

PATIENTS AND METHOD

We review 23 cases of digestive anisakiasis registered between 1989 and 2001, and confirmed by the measurement of specific serum Ig E antibodies. We analyse clinical symptoms and method of diagnosis according to whether localization was gastro-duodenal or intestinal, evaluating whether surgical intervention was needed for a correct diagnosis. The statistical analysis is made using Fisher's test.

RESULTS

23 patients were included between 1989 and 2001, 8 with gastro-duodenal localization and 15 with intestinal localization. All patients with intestinal localization had abdominal pain. Symptoms were less severe for gastro-duodenal cases, and diagnosis was made by clinical suspicion and subsequent gastroscopy, whereas more than a half of intestinal cases required histological examination of a surgical specimen for correct diagnosis. In the remaining half, diagnosis was made by abdominal ultrasonography. We also observed that the need for surgery has decreased with time from 6/6 cases in the 1989-1996 period of time to 2/9 in the 1997-2001 period of time.

CONCLUSIONS

Clinical manifestations of anisakiasis vary depending on localization, symptoms being more severe in intestinal forms. The diagnosis of gastro-duodenal anisakiasis did not need surgery and was based mainly on gastroscopy findings, whereas intestinal forms frequently required histological examination of the surgical specimen. In our hospital, a higher index of clinical suspicion allowed us to diagnose intestinal anisakiasis without examination of surgical specimens in the last years.

[Helicobacter pylori CagA antibodies in various gastroduodenal diseases from 2 different populations]

BACKGROUND

We aimed at studying the prevalence of infection by H. pylori along with the CagA status of the strain in two populations (Spain and Cuba) and the relationship with several gastroduodenal lesions. We also studied the role of the test-and-scope strategy in the decrease of unnecessary gastroscopies.

PATIENTS AND METHOD

100 dyspeptic patients from Spain and 100 from Cuba were included. At endoscopy, antrum biopsies were obtained and H. pylori status was evaluated by rapid urease test. CagA status of the strain was assessed by Western Blot. The test-and-scope strategy was evaluated according to H. pylori infection and CagA status.

RESULTS

Mean age of Spanish and Cuban patients was 45 (16) and 46 (15) years, respectively. Dyspeptic symptoms were similar in both groups. Prevalence of infection by H. pylori was higher in Cuban (73%) than in Spaniards (40%) (p < 0.01). Prevalence of CagA+ strains was also higher in Cuban (81 vs. 27%) (p < 0.01). Among CagA+ Spanish patients, 11% had a duodenal ulcer, whereas this lesion was not found in any CagA patient (p < 0.05). Duodenal ulcer prevalence in CagA+ and CagA Cuban patients was 31 and 0%, respectively (p < 0.05). The test-and-scope strategy would have avoided endoscopy in only 24% Spanish and 15% Cuban patients.

CONCLUSIONS

The prevalence of H. pylori infection is higher in Cuban than in Spanish dyspeptic patients. H. pylori strains of Cuba seem to be more virulent than those of Spain. CagA protein is a marker of peptic ulcer in both populations. These differences could partly explain the variations in the prevalence of different gastroduodenal disorders between both countries. The test-and-scope strategy appears to avoid a low number of endoscopies.

Small intestinal mucosal immunity and morphometry in luminal overgrowth of indigenous gut flora

OBJECTIVE

The aim of this study was to investigate the separate effects of indigenous oropharyngeal- and colonic-type flora on small intestinal mucosal immunity and morphometry in small intestinal bacterial overgrowth (SIBO).

METHODS

A duodenal aspirate and random biopsies of underlying mucosa were obtained from 52 adult subjects (age range, 18-90 yr; median, 60 yr) without disorders that may otherwise disturb small intestinal histology or mucosal immunity. Villus height, crypt depth, villus/crypt ratios, counts of intraepithelial lymphocytes (IELs) and lamina propria total mononuclear cells, IgA, IgM, and IgG plasma cells, mast cells, and B and T lymphocytes were determined in relation to the presence or absence of SIBO and the nature of the overgrowth flora in all subjects. CD4+ve and CD8+ve T-cell counts were determined in 24 subjects.

RESULTS

SIBO was present in 26 of 52 (50%) subjects. Overgrowth flora included colonic-type bacteria in 20 subjects and oropharyngeal-type flora alone in 6 subjects. Lamina propria IgA plasma cell counts were significantly increased in subjects with SIBO, irrespective of whether the overgrowth flora comprised oropharyngeal-type flora alone or included colonic-type bacteria. Neither villus height, crypt depth, villus/crypt ratios, nor total or other mononuclear cell counts in lamina propria differed significantly between subjects with and without SIBO, irrespective of the nature of the overgrowth flora. IEL counts were significantly higher than in culture-negative subjects only when the overgrowth flora included colonic-type bacteria. Even then, IEL counts were within a range currently considered normal. A significant, inverse correlation between advancing age and IEL counts became apparent after adjusting for the effect of SIBO of colonic-type flora.

CONCLUSIONS

SIBO of oropharyngeal- and colonic-type flora are associated with differing disturbances of local duodenal mucosa. Nonetheless, these would not be readily apparent during routine histological assessment. Old age independently influences duodenal IEL counts.

Relative deficiency in IgA production by duodenal explants from German shepherd dogs with small intestinal disease

Matched samples of serum, saliva and tears were collected from four groups of dogs; two of the groups were German shepherd dogs (GSDs) either with (Group 1) or without (Group 4) a variety of small intestinal disorders; the remaining two groups were dogs of other breeds, again with (Group 2) or without (Group 3) small intestinal disease. Capture ELISAs were used to measure IgG, IgM, IgA and albumin concentrations within these samples; intestinal humoral immune status of clinical cases was assessed by quantifying immunoglobulin production from duodenal explant cultures.There were no significant differences in IgG, IgM or IgA concentrations in serum, saliva or tears between the different groups of dog. Moreover, no significant differences were noted between groups for IgG, IgM and IgA salivary and tear secretory indices. IgA production by 24-h explant cultures was significantly lower in GSDs compared with non-GSDs with small intestinal disease (groups 1 and 2, respectively), but the numbers of lamina propria IgA(+) plasma cells in duodenal biopsies were not different between groups. These results suggest that there may be a relative deficiency in local IgA secretion in GSDs with small intestinal enteropathies, which is not reflected in either serum IgA concentrations, or in secretion at unaffected mucosal sites. It remains to be determined whether such a deficiency is a breed-related primary defect, or whether it arises secondary to the pathological processes within the intestinal mucosa.

Cytokine mRNA expression in mucosal biopsies from German shepherd dogs with small intestinal enteropathies

German shepherd dogs (GSD) are predisposed to enteropathies such as inflammatory bowel disease (IBD) and small intestinal bacterial overgrowth (SIBO). The present study examined the role of cytokines in the immunopathogenesis of both conditions. Duodenal mucosal biopsies were taken from GSDs with small intestinal enteropathies (group 1; N = 16) or control dogs (group 2, N = 12). IL-2, IL-4, IL-5, IL-10, IL-12p40, IFN-gamma, TNF-alpha, and TGF-beta1 mRNA expression was determined by semiquantitative reverse transcriptase polymerase chain reaction. IL-2, IL-5, IL-12p40, TNF-alpha, and TGF-beta1 mRNA expression in group 1 dogs was significantly greater than in group 2 dogs (all P<0.01), but there were no significant differences between dogs with IBD or SIBO. Further, antibiotic treatment in five dogs with SIBO, resulted in reduced TNF-alpha and TGF-beta1 mRNA expression (P<0.05). Such alterations in cytokine mRNA expression suggest heightened immune responses within the duodenal mucosa in GSDs with either SIBO or IBD.

The pattern of involvement of the gastric mucosa in lymphocytic gastritis is predictive of the presence of duodenal pathology

AIM

To determine whether the pattern of involvement of the gastric mucosa in lymphocytic gastritis is predictive of the presence or absence of duodenal pathology.

METHODS

50 cases (M:F, 26:24; median age 57 years) diagnosed as lymphocytic gastritis between 1986 and 1998 with concurrent duodenal (D2) biopsies were identified from a computer search of the pathology records and validated by counting gastric intraepithelial lymphocytes. Gastric and duodenal intraepithelial lymphocyte counts were performed on haematoxylin and eosin (H&E) and anti-CD3 stained sections. D2 biopsies were assessed for villous atrophy and chronic inflammatory cell infiltration by subjective grading, and gastritis was classified and graded according to the updated Sydney system. A case was designated corpus predominant when the corpus chronic inflammation grade exceeded that of the antrum. If it was less, then the case was antrum predominant, and if they were equal it was diffuse (pan-) gastritis. The ratio between the corpus and antral intraepithelial lymphocyte count in individual patients was calculated.

RESULTS

Of 50 cases of lymphocytic gastritis, 21 were classified as corpus predominant. With one exception (a case of mild villous atrophy), all were accompanied by normal duodenal morphology. Cases with a corpus predominant gastritis had median duodenal intraepithelial lymphocyte counts of 19 (H&E) and 14.1 (CD3), whereas 29 subjects with an antrum predominant or diffuse gastritis had median counts of 39.9 (H&E) and 37.9 (CD3). Fifteen of these 29 cases (52%) showed villous atrophy; all were graded as moderate or severe. Patients with any degree of villous atrophy had a mean corpus/antrum intraepithelial lymphocyte ratio (H&E) of 0.59 (representing antral predominance), while those with normal duodenal morphology had a ratio of 2.39 (p < 0.0001).

CONCLUSIONS

The pattern of involvement of gastric mucosa in lymphocytic gastritis is closely related to the associated duodenal pathology. Those with the corpus predominant form are unlikely to have duodenal pathology, while those with an antral predominant or diffuse form should have distal duodenal biopsies taken to exclude villous atrophy.

Role of gastric mucosal cytokines in the immunopathogenesis of Helicobacter pylori infection: new hypotheses but still few certitudes

Since the recognition of Helicobacter pylori as a pathogen involved in chronic gastritis, peptic ulcers and gastric cancer, many studies have shown that clinical manifestations of H. pylori infection occur only in a minority of infected patients. Studies of the genomic diversity of this bacterium show relations of some bacterial characteristics with pathology. Imbalanced host response to infection may also play a major role in the clinical expression of H. pylori infection. Gastric epithelial cells are involved in the process, as well as lymphocytes and other immune cells of the underlying gastric tissue. A better understanding of the immunopathogenesis of H. pylori infection is required to understand the exact role of both the strain and the host.

[The probiotic correction of microecological and immune disorders in gastroduodenal pathology in children]

The state of microbiocenosis was studied and the level of immunoglobulins was determined in the gastric juice and feces of children with chronic diseases of the digestive system. In 20% of patients an increase in the contamination of the gastric biotope with opportunistic microflora was established. The isolation rate of Helicobacter pylori was 56%. The detection of H. pylori was found to be accompanied by the aggravation of the form and course of gastritis. In cases of Helicobacter-associated pathology the deficiency of Lactobacillus sp. in the stomach was established, which was accompanied by their deficiency and absence in feces. The study also revealed a decrease in the population level of Bifidobacterium sp. with a simultaneous increase in the population of opportunistic enterobacteria and changes in the state of local immunity: the decreased level of SIgA in most samples and the decreased level of IgG in the presence of H. pylori. The correction of microecological and immune disturbances with probiotic preparations, containing bifidobacteria (bifidumbacterin-forte) and lactobacilli, yielded good results.

[Epidemiology of Helicobacter pylori infection in Hungary (comparative sero-epidemiologic study)]

In the last decade pathogenetical role of Helicobacter pylori infection has been proved in development of gastroduodenal alterations. DNA-RNA hybridisation and protein profile studies proved that Helicobacter pylori is an organism distinct from other bacteria. Therefore serology became a useful method to study the epidemiology of Helicobacter pylori infection in various populations. In Hungary sera were collected from adults aged 20-60 in blood banks (Military Hospital, Tolna County Hospital) in 1993. The samples were classified in 5 year increment groups and questionnaires were filled out. Anti-H. pylori IgG were tested using Cobas Core kit (Roche Diagnostic). The overall rate of seropositivity was 63.3%. The prevalence according to age was the following: 20-24 yrs = 44%, 25-29 yrs = 40%, 30-34 yrs = 52%, 35-39 yrs = 64%, 40-44 yrs = 75%, 45-49 yrs = 73%, 50-54 yrs = 77%, 55-59 yrs = 83%. There were no statistical difference between gender, living in urban or rural areas at the time of collection or in childhood, between the level of education, type of labour or social status. However we found statistical correlation between anti-H. pylori seropositivity and epigastric symptoms. The same characteristics of Helicobacter pylori infection were found in Hungary as well as in other countries. In groups between 20 and 30 years has been proved lower prevalence in Hungary than in Poland, Bulgaria.

[Analysis of immune response to Helicobacter pylori--identification of the protein recognized by anti-Helicobacter pylori antibodies from sera of patients with gastroduodenal diseases]

HP-specific antibodies were measured in each collected fraction obtained from gel-filtrated separation method with selected patients sera by enzyme-linked immunosorbent assay (ELISA). Most of the fractions reacted with the patients sera also responded to HP urease-specific monoclonal antibodies. In addition, the fractions which showed urease activity strongly correlated with the HP antibody positive ones. Also, we could not detect any cross-reactivity to ureases of other species. Moreover, most patient sera strongly responded to the purified HP urease B subunit separated with SDS/PAGE by western blotting analysis. These findings suggest that the major target for HP-specific antibodies appears to be HP-urease, in particular around 68kd large molecule, urease B subunit and such urease-specific antibodies are isolate-species specific.

Mucosal interleukin-8 and Helicobacter pylori-associated gastroduodenal disease

OBJECTIVE

To review the role of interleukin (IL)-8 in the immunopathology of Helicobacter pylori-associated gastroduodenal disease.

METHOD

Literature review.

RESULTS

In H. pylori infection, IL-8 secretion by the gastric mucosa is increased, particularly in patients with active neutrophilic gastritis. Immunoreactive IL-8 is evident in the epithelium of histologically normal gastric mucosa but epithelial IL-8 expression is increased in H. pylori-associated chronic gastritis. Gastric epithelial cell lines constitutively express IL-8 messenger (m)RNA and IL-8 message and protein secretion can be upregulated by the cytokines tumour necrosis factor-alpha, IL-1 alpha and IL-1 beta. H. pylori also directly induces epithelial IL-8 expression in a strain-specific manner. Cytotoxic strains expressing the CagA protein upregulate IL-8 mRNA and IL-8 protein secretion.

CONCLUSION

IL-8 is an important chemotactic and activating factor for neutrophils. The secretion of IL-8 by epithelial cells is probably a key factor in host defences at mucosal sites, permitting a rapid polymorph response against infectious agents. If defence mechanisms fail and chronic infection results, continued upregulation of IL-8 and neutrophil activation could lead to mucosal damage and increased free radical formation. Mucosal IL-8 production in H. pylori infection may be an important factor in the immunopathogenesis of peptic ulcer disease and also be of relevance to gastric carcinogenesis.

Clinical significance of small-intestinal microsporidiosis in HIV-1-infected individuals

To assess the importance of microsporidiosis of the small intestine in the pathogenesis of chronic diarrhoea in HIV-1-infected individuals, duodenal biopsy samples from the following three patient groups were prospectively evaluated for bacterial, viral, and parasitic pathogens by standard methods, and for microsporidia by light microscopy: 55 consecutive HIV-1-antibody-positive subjects with unexplained diarrhoea of at least 3 weeks duration (group A); 38 HIV-1-seropositive subjects without diarrhoea (group B) who consecutively underwent upper gastrointestinal endoscopy for various reasons; and 7 patients without known risk factors for HIV infection with chronic unexplained diarrhoea (group C). In groups A and B most subjects had had previous AIDS-defining opportunistic infections and the median peripheral blood CD4 lymphocyte count was less than 0.1 x 10(9)/l. Microsporidia were detected as the single pathogen in 15 of the group A compared with 1 (in whom diarrhoea subsequently developed) of the group B patients (p = 0.001) and none of the group C patients. With the exception of 4 of the group A patients, no other intestinal pathogens were identified in any of the patients. The median peripheral blood CD4 count was significantly lower in patients with detectable microsporidia than in those without microsporidiosis (0.03 x 10(9)/l vs 0.06 x 10(9)/l; p = 0.03); in all patients with microsporidiosis, the CD4 count was equal to or less than 0.1 x 10(9)/l. 13 patients with microsporidiosis were treated with metronidazole, in 10 of whom treatment led to a substantial improvement or disappearance of diarrhoea within days of starting therapy, but did not result in eradication of the parasite in the 5 patients who underwent repeat biopsy. The findings suggest that small-intestinal microsporidiosis is an important cause of chronic unexplained diarrhoea in HIV-1-infected individuals with pronounced cellular immune deficiency. This infection should therefore be added to the list of AIDS-defining opportunistic infections.

[The prevention of gastroduodenal diseases in metallurgists]

Prophylactic treatment was carried out in 32 metallurgists suffering of gastroduodenal diseases. The treatment included Eleutherococcus, alpha-tocopherol acetate, methyuracil, milfoil, nettle leaves, wort and camomile leaves, oxygen foam cocktails. Clinical, biochemical, immunological, endoscopic and morphological examinations revealed efficiency of the prophylactic treatment.

Mucosal atrophy is associated with loss of activated T cells in the duodenal mucosa of human immunodeficiency virus (HIV)-infected patients

Gastrointestinal symptoms and malabsorption are frequent in HIV-infected patients even in the absence of opportunistic infections. In earlier studies we found indications that the gastrointestinal mucosa itself may be affected by HIV. Since there is evidence that the mucosal structure is influenced by changes in the gut-associated lymphoid tissue, we have investigated mucosal structure and immune cells in HIV-infected patients. Sixty patients (3 f, 57 m; age 21-61, median 37 years; 11 at CDC stage II or III, 49 at stage IV) with gastrointestinal complaints undergoing upper endoscopy were examined for enteric pathogens. Duodenal biopsies were labelled by immunohistology for HIV antigen p24 and for lymphocyte surface markers; mucosal architecture was studied by three-dimensional morphometry. Biopsies from HIV seronegative patients without abnormal findings served as controls. In 29 patients an enteric pathogen was identified. In 22 patients HIV-infected mononuclear cells were detected in the lamina propria. In the lamina propria CD25+ cells were decreased, CD3+ and CD8+ cells were increased in HIV-infected patients compared with controls, while the numbers of CD4+, Leu8+, and HML-1+ cells, and of macrophages were not different. Patients at stage IV had decreased numbers of CD4+ T cells compared with patients at stage II or III. Villus surface area was reduced in HIV-infected patients compared with controls. Crypt depth was increased in patients with intestinal infection compared with controls while numbers of mitotic figures were normal. Patients without intestinal infection and patients with mucosal HIV-infected cells had decreased numbers of mitotic figures and normal crypt depth compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency of occurrence of Campylobacter pylori and analysis of the systemic and local immune response

During gastroduodenoscopic examination of 225 patients, bioptic mucosal specimens were taken for bacteriological and histological examination (Table 1). Campylobacter (C.) pylori was isolated from 7 out of 9 patients (78%) with gastric ulcer, from 59 out of 60 (98%) with duodenal ulcer, from 24 out of 31 (77%) with gastric erosions, from 10 out of 10 (100%) with duodenitis, from 14 out of 16 (88%) with chronic active gastritis, from 40 out of 73 (55%) with chronic inactive gastritis and from none out of 26 patients (0%) with normal mucosa (Table 2). To study the immune response an ELISA was developed which proved to give well reproducible and specific test results (Fig. 1). IgA- and IgG-titres were strongly reduced after absorption with C. pylori, but not with other antigens (including C. jejuni and C. coli, Table 3). Some sera gave reactions at higher titres when tested with the patient's own strain than with the standard antigen which is a mixture of 4 strains (Table 4). This indicates differences of the antigen composition within the species C. pylori. Sera from patients with positive culture showed higher IgG- and IgA-titres than sera from patients without isolation of C. pylori. The IgM-titres, however, were comparable in both groups (Fig. 3). Partially, sera from patients without C. pylori also showed high IgG-titres which were positively correlated with the patient's age. About 60% of culturally positive patients had specific IgA in their gastric juice, whereas this was not so with patients without isolation of C. pylori (Fig. 6). Examination of sera from healthy children and blood donors revealed that IgG but not IgA or IgM rose significantly with increasing age (Figs. 7-9). As can be concluded from the results of cultural and serological tests, C. pylori seems to be responsible at least for a part of cases of gastritis and peptic ulcer.