A196 DIARRHEA AS A PRESENTING SYMPTOM OF RELAPSED GRANULOMATOSIS WITH POLYANGIITIS

Background

Granulomatosis with polyangiitis (GPA) is a rare, small-to-medium sized-vessel vasculitis that typically involves the sinus, respiratory, and renal systems. The gastrointestinal (GI) tract is rarely involved, but its exact frequency is poorly characterized. GI symptoms have been reported to occur in up to 10% of acute presentations, and a historic series of 56 autopsies of GPA patients found 24% to have focal necrotizing arteriolitis of the intestine (Storesund, 1998). There are few case reports of colitis associated with GPA. They commonly describe abdominal pain, rectal bleeding, and less frequently, perforation, early in the disease course in conjunction with other classic systems involvement which aid in the diagnosis of GPA.

Aims

We present the case of a 77 year-old woman with lung biopsy-proven cANCA-positive GPA who was found to have colonic vasculitis after she had been in remission for several years.

Methods

Case report and literature review

Results

The patient presented with a 1-month history of progressive back pain, followed by 1 week of severe abdominal pain and watery diarrhea. She was afebrile, with a leukocyte count of 13.8x109/L, C-reactive protein of 213 mg/L, and fecal calprotectin of 669mg/kg. cANCA was strongly positive at 5.4 AI. Computed tomography scan revealed focal inflammatory change at the cecum and terminal ileum. Stool cultures were negative. Colonoscopy showed a polypoid, inflammatory-appearing hard mass at the ileocecal valve with surrounding fragile mucosa. Ileocecal valve biopsies described fibropurulent material and granulation tissue consistent with ulcer bed with surrounding mucosa showing chronic ischemic colitis with various degrees of acute cryptitis. The most likely etiology was speculated by the pathologist to be involvement of the colon by vasculitis, as other etiologies appeared to be ruled out. The patient had mild kidney injury, but no additional lung findings, in contrast to her initial presentation of GPA. She was started on prednisone 50mg/day. Her back pain, abdominal pain, and diarrhea resolved within 1 week, and renal function improved. Currently, there is a plan to start Rituximab for chronic treatment.

Conclusions

Our case of GPA-associated colitis is unique for several reasons. First, most case reports describe rectal bleeding as the presenting symptom of GPA colitis, whereas our patient presented with non-hemorrhagic diarrhea. Second, where available, reports of colitis correlated endoscopically with colonic ulcerations, whereas our patient had an ileocecal mass. Third, most reports present colitis associated with a new diagnosis of GPA, whereas our patient presented with colitis as new GI system involvement with likely inflammatory back pain as the presenting feature of GPA relapse. While a rare feature, colitis secondary to GPA can be considered in the appropriate context.

Funding Agencies

None

THU0318 PATTERNS OF CLINICAL PRESENTATION IN TAKAYASU’S ARTERITIS

Background:

Takayasu’s arteritis (TAK) is a clinically heterogenous disease. Patterns of clinical presentation in TAK at diagnosis have not been well described, and a “triphasic pattern” of constitutional symptoms evolving into vascular inflammation and fibrosis has been reported but never systematically evaluated.

Objectives:

To describe patterns of clinical presentation in TAK at diagnosis and evaluate the presence of an antecedent triphasic disease pattern in patients with TAK who presented with a major ischemic event at diagnosis.

Methods:

Patients with TAK were prospectively recruited from the National Institutes of Health (NIH) and the Vasculitis Clinical Research Consortium (VCRC). All patients fulfilled the 1990 American College of Rheumatology (ACR) Classification Criteria for TAK. Based on clinical presentation at diagnosis, patients were divided into five groups from the different stages of the triphasic pattern of disease as follows: 1) constitutional symptoms (phase I), 2) carotidynia (phase II), 3) other vascular-associated symptoms (phase II), 4) major ischemic event (phase III) defined as CVA or TIA, retinal ischemia, MI, renovascular hypertension, or mesenteric ischemia, or 5) asymptomatic. Phase II was divided into two separate groups because patients with carotidynia reportedly have a higher rate of relapsing disease.

Associated clinical characteristics were evaluated in each group and differences among groups were assessed by chi square test and Kruskal-Wallis test, as appropriate. Preceding symptoms were also assessed to determine the presence of a triphasic disease pattern.

Results:

A total of 275 patients with TAK were included (VCRC=208; NIH=67). Similar heterogeneity of clinical presentation was identified in each cohort: constitutional symptoms (8%), carotidynia (13-15%), other vascular symptoms (43-47%), major ischemic event (28-30%), and asymptomatic (2-6%). Frequency of male gender was more common in patients who presented with constitutional symptoms or were asymptomatic at diagnosis (p<0.01). Patients who presented with constitutional symptoms and major ischemic events were youngest at diagnosis. Patients in the asymptomatic group were oldest at diagnosis and often were not treated (p<0.01). Involvement of the abdominal vasculature was associated with major ischemic events and asymptomatic presentations. Major ischemic events after diagnosis were infrequent in the groups who did not present with a major ischemic event, occurring in 10-20% cases. Relapse (p<0.01) and recurrent pharyngitis preceding diagnosis (p<0.01) was most frequent in patients who presented with carotidynia.

A total of 79 patients [VCRC=59 patients, NIH=20 patients] presented with a major ischemic event. The majority of these patients (53%) reported symptoms of active disease prior to the major ischemic event. Few patients (19%) who presented with a major ischemic event reported a triphasic pattern of disease.

Conclusion:

There is heterogeneity in clinical presentation at the time of diagnosis in TAK and this heterogeneity can be used to group patients according to pattern of disease presentation. Patients do not necessarily progress sequentially through phases of disease, but the majority of patients presenting with a major ischemic event report some preceding symptoms. Data from this study demonstrate distinct subgroups within TAK and supports the concept that TAK is possibly a heterogenous collection of multiple diseases.

References:

N/A

Disclosure of Interests:

None declared

Mammalian target of rapamycin is activated in the kidneys of patients with scleroderma renal crisis

Objectives:

Scleroderma renal crisis is a rare but serious complication affecting 2%–15% of patients with systemic sclerosis. Despite treatment with angiotensin-converting enzyme inhibitors, outcomes for scleroderma renal crisis patients are still poor. The cellular signaling mechanisms in scleroderma renal crisis are not yet known. Mammalian target of rapamycin, comprised of the subunits mTORC1 and mTORC2, has been shown to be activated in vascular lesions of renal transplant patients with anti-phospholipid antibody syndrome. Given the similarities between the pathophysiology of scleroderma renal crisis and anti-phospholipid antibody syndrome, we hypothesized that the mammalian target of rapamycin pathway would also be activated in the renal vasculature of patients with scleroderma renal crisis.

Methods:

We retrospectively analyzed renal biopsies of five patients with scleroderma renal crisis in the Canadian Scleroderma Research Group cohort. Immunostaining was performed using anti-P-S6RP antibodies to evaluate the phosphorylation of mTORC1, and anti-Rictor and anti-S473 to determine activation of mTORC2.

Results:

Four of the five patients showed mTORC1 activation in arteriolar endothelial cells, and three of the five patients showed mTORC1 activation in the arterial endothelial cells. Two of four samples showed Rictor expression in the arteriolar and arterial endothelial cells, showing mTORC2 activation. There was no expression of mTORC1 or mTORC2 in samples from two healthy controls.

Conclusion:

We demonstrate that both mTORC1 and mTORC2 are activated in renal biopsies with typical histologic features of scleroderma renal crisis. Dual mammalian target of rapamycin inhibitors are currently available and in development. These findings could inform further research into novel treatment targets for scleroderma renal crisis.

Isoelectric heterogeneity of human prorenin (inactive renin) in body fluids

Using flat bed isoelectric focusing, inactive renins from various body fluids were compared. Normal plasma inactive renin demonstrated six consistent peaks at pH 4.98, 5.14, 5.29, 5.47, 5.63 and 5.91, the largest being 5.29, 5.47 and 5.63. The isoelectric pattern of ovarian follicular fluid inactive renin was similar, with slight shifts at major peaks to a higher pH. Pregnancy plasma had inactive renin patterns like normal human plasma as did pleural fluid, lymphocoele fluid and plasma from anephric humans. Amniotic fluid inactive renin showed a markedly different pattern with major peaks at pH 5.00, 5.16 and 5.30. Fetal plasma (cord blood) also showed differences with only four peaks at 5.24, 5.40, 5.58 and 5.83. We conclude that human prorenin isoelectric patterns are similar for plasma, ovarian and most tissue fluid prorenins, but different for fetal plasma and amniotic fluid suggesting that these forms of renin do not cross the placental barrier.

Stability of imipenem and cilastatin sodium in total parenteral nutrient solution

The chemical stability and compatibility of imipenem-cilastatin sodium (Primaxin) in two different total parenteral nutrient (TPN) solutions was determined. TPN solutions consisted of 4.25% and 5% amino acids with 25% and 35% dextrose, respectively. Imipenem-cilastatin sodium was constituted with 10 ml of sterile water and admixed with 90 ml of TPN solution for a final concentration of 5 mg/ml of each drug. The final solutions were assayed at times 0 (immediately after admixture), 15 min, 30 min, 1, 4, 8, and 24 hr by a stability-indicating high-performance liquid chromatographic assay. Concurrently, test TPN solutions were monitored for pH changes, color changes, and precipitate formation. The potential effect of imipenem-cilastatin sodium on the stability of amino acids and other TPN additives was not evaluated. Imipenem and cilastatin sodium was stable (greater than or equal to 90% recovered) in each TPN solution at 15 min. A significant (greater than or equal to 10%) and steady decrease of imipenem recovery occurred at subsequent sampling times. Cilastatin appeared more stable than imipenem in both TPN solutions. A physical color change from colorless to dark orange appeared in each TPN solution over the 24-hr study period. Imipenem-cilastatin sodium is stable for 15 min in the TPN solutions studied; however, until the stability of the amino acids can be determined, the antibiotic should be administered through a separate line or Y-site while the TPN infusion is interrupted.

Sterility of total parenteral nutrient solutions stored at room temperature for seven days

The sterility of total parenteral nutrient (TPN) solutions stored at room temperature for up to seven days after preparation was studied. The study was conducted in two parts. In part 1, a positive control phase was conducted to validate that the filter set would capture bacteria or fungi in the TPN solutions. In part 2,300 unused TPN solutions were retrieved from patient-care areas within 24 hours of preparation. These solutions were randomized into three study groups of 24, 72, or 168 hours after preparation. Each TPN solution was filtered aseptically using an inline 0.22-micron filter. The filters were suspended in brain-heart infusion broth and incubated at 35 degrees C. Filters were visually evaluated for turbidity as an indicator of microbial contamination. Microbial growth was reported in 2 of 100 samples filtered 24 hours after preparation (group 1) and in 1 of 100 samples filtered 72 hours after preparation (group 2). No growth was detected in TPN solutions filtered 168 hours after preparation (group 3). Turbid samples were subcultured, and contaminants were identified as coagulase-negative Staphylococcus species and gram-positive bacilli in the group 1 samples and coagulase-negative Staphylococcus species in the group 2 samples. The difference in contamination rates among the three groups was not significant. TPN solutions may be stored after preparation at room temperature for an extended time (up to 168 hours) without increasing the risk to patient safety. However, at this institution, expiration dates are extended only to the time that supports practical recycling of standard TPN solutions (72 hours).

Stability of penicillins in total parenteral nutrient solution

The stability of ticarcillin, mezlocillin, and piperacillin in total parenteral nutrient (TPN) solutions at concentrations commonly used in adults was determined. Each antibiotic was added separately to three different amino acids-dextrose TPN solutions in two concentrations: 10 and 20 mg/mL. Amino acids concentration ranged from 25 g/L to 50 g/L. Dextrose concentration ranged from 100 g/L to 350 g/L. Solutions were assayed for antibiotic concentration immediately after mixing (time 0) and at 4, 8, 24, and 48 hours by high-performance liquid chromatography. The effect of the added penicillins on the stability of amino acids and other TPN additives was not investigated. Mezlocillin and piperacillin 10 and 20 mg/mL exhibited stability in TPN solution at 24 hours. Ticarcillin was stable for 24 hours at a concentration of 10 mg/mL, but at 20 mg/mL it was unstable at all times tested. The three antibiotics demonstrated the same characteristic stability in all three TPN solutions, suggesting that the concentrations of dextrose and amino acids did not affect stability. Ticarcillin, mezlocillin, and piperacillin are stable for 24 hours in the TPN solutions studied.

Total parenteral nutrition catheter sepsis: impact of the team approach

For a period of 32 months from the inception of the Parenteral and Enteral Nutrition (PEN) Team at the University of Michigan, the infection rate (IR) related to central venous catheters (CVCs) for total parenteral nutrition (TPN) was prospectively evaluated. Six hundred twenty-two catheters were placed in 377 patients for a total of 9,200 patient days. The length of CVC stay ranged from 2 to 108 days with a mean of 14.5. CVC longevity was longer on units where certification of nurses by the PEN team was mandatory (mean 20.4 days, IR 3.5%) vs comparable units which utilized informal instruction (mean 14.4 days, IR 3.5%). Twenty-two catheters led to patient sepsis for a rate of 3.5%, or 2.39 CVC-related infections per 1000 patient days. The preteam infection rate was 24.0%, as determined by a 6-month prospective study. Infection rates for CVCs used for TPN only and those used for parenteral nutrition (PN) plus blood products, antibiotics, and CVP measurements were identical, 3.5%. The team approach can effectively increase PN catheter longevity and reduce infection rates. Conservative cost accounting of best and worst case scenarios determined a range of $3,700 to $8,900 per episode of catheter sepsis.

Home parenteral nutrition: a hospital-based program with commercial logistic support

Since home parenteral nutrition was introduced in the 1970's, a number of medical centers have formed successful home parenteral nutrition programs which have reduced expenses to the patient and third party payers by 50 to 73% over in hospital costs. However, the cost of maintaining these programs for training and follow-up has largely been absorbed by the hospital as a nonreimbursable teaching expense. To offset the costs of our growing program in these times of budget "caps," we have established an agreement between our hospital and commercial home care company which provides for patient instruction and follow-up by the hospital parenteral and enteral nutrition team and logistic support by the home care company. We used the average cost of our first five patients to establish a fee schedule which the commercial company agreed to pay the hospital parenteral and enteral nutrition team for its services. This agreement reduces the number of nurses and pharmacists that the commercial company would otherwise have to hire for teaching and follow-up of home care patients, and supports the concept of regional care in medical centers where parenteral and enteral nutrition teams maintain quality control, continuity of care, and efficient teaching programs for patients requiring home parenteral nutrition.

Biotin deficiency in a patient with short bowel syndrome during home parenteral nutrition

A 54-year-old woman with short bowel syndrome was supported with home parenteral nutrition. Six months after receiving 2200 kcal/day of balanced home parenteral nutrition without biotin, she developed biotin deficiency with complete hair loss, eczematous dermatitis, waxy pallor, lethargy, and hypersthesias . Blood and urine samples were collected prior to treatment. Serum zinc was 64 micrograms/dl (nl 50-150 micrograms/dl), and the triene/tetraene ratio was 0.068 (nl 0.4), thereby ruling out zinc and essential fatty acid deficiencies. Serum biotin was 332 pg/ml (nl 520 +/- 220 pg/ml), and urine biotin was 5.22 ng/mg of creatinine (nl 4.3-95 with a mean of 30.2 ng/mg creatinine). The same parenteral nutrition regimen was contained and oral biotin was administered (10 mg/day). After 3 wk, serum and urine biotin levels were 650 pg/ml and 35.6 ng/mg creatinine, respectively. New hair growth was evident and all of her other symptoms resolved. Intravenous biotin was then provided (5 mg/day) for a month after which serum and urine biotin levels were 1316 pg/ml and 178 ng/mg creatine, respectively. The patient has been subsequently maintained on an intravenous multivitamin product containing 60 micrograms biotin per daily dose and remains free of signs and symptoms of biotin deficiency.