Epstein-Barr Virus-Positive T/NK-Cell Lymphoproliferative Disorders Manifested as Gastrointestinal Perforations and Skin Lesions: A Case Report

Systemic Epstein-Barr virus (EBV)-positive T-cell lymphoproliferative disorders (LPDs) of childhood is a highly aggressive EBV-positive T/natural killer (NK)-cell LPD, which emerges in the background of chronic active EBV infection (CAEBV) or shortly after primary acute EBV infection. The clinical presentations of CAEBV are varied; patients with atypical manifestations are easily misdiagnosed. We described a 14-year-old boy suffering from digestive disorders and intermittent fever for 1 year and 9 months, whose conditions worsened and skin lesions occurred 2 months before hospitalization. He was diagnosed as inflammatory bowel diseases (IBD) and treated accordingly. His other clinical features, hepatosplenomegaly, lymphadenopathy, anemia, hypoalbuminemia, and elevated inflammatory marks, were found in hospitalization. The boy suffered from repeatedly spontaneous intestinal perforations shortly after hospitalization and died of intestinal hemorrhea. The pathological results of intestine and skin both showed EBV-positive T/NK-cell LPD (lymphoma stage).There are rare studies reporting gastrointestinal perforations in EBV-positive T/NK-cell LPD, let alone repeatedly spontaneous perforations. Based on the clinical features and pathological results of this patient, the disease progressed from CAEBV (T-cell type) to systemic EBV-positive T-cell LPD of childhood (lymphoma). Not all the patients with CAEBV could have unusual patterns of anti-EBV antibodies. However, the presence of high EBV loads (EBV-encoded early small ribonucleic acid (RNA) (EBER) in affected tissues and/or EBV deoxyribonucleic acid (DNA) in peripheral blood) is essential for diagnosing CAEBV. Maybe because of his less common clinical features for CAEBV and negative anti-EBV antibodies, the boy was not diagnosed correctly. We should have emphasized the test for EBER or EBV-DNA. Meanwhile, for the IBD patients whose manifestations were not typical, and whose conditions were not improved by suitable therapies against IBD, infectious and malignant diseases should be considered.

Immunoblot analysis of sera in uncomplicated typhoid fever & with typhoid ileal perforation

BACKGROUND & OBJECTIVE

Ileal perforation is a serious complication of typhoid fever. The exact reasons for the development of perforation in only a few of those infected with Salmonella Typhi is unknown, and it is likely that immunological factors are involved. Therefore we undertook this study to compare the antibody profile in patients with uncomplicated typhoid fever with those having ileal perforation by immunoblotting.

METHODS

Two groups of patients were included in the study. Group II comprised patients with uncomplicated typhoid fever (n=47), and group I with typhoid ileal perforation (n=33). The flagellar (H), lipopolysaccharide (LPS) and outer membrane protein (OMP) antigens of Salmonella Typhi were extracted and used to test patient sera for antibodies by immunoblotting

RESULTS

Immunoblotting using S. Typhi antigens enabled the detection of S. Typhi antibodies in the two groups of patients. A significant difference was seen in the response of these two groups of patients with respect to antibodies to flagella, lipopolysaccharide and outer membrane proteins. Antibodies to flagella were more pronounced among patients with uncomplicated typhoid fever, while anti-OMP antibodies were significantly associated with typhoid ileal perforation.

INTERPRETATION & CONCLUSION

A comparison of antibodies in patients with uncomplicated typhoid fever and with ileal perforation revealed the differences in the antibody profiles of the two groups. Our study suggests that the difference in antibody response may in some way play a role in the pathogenesis of typhoid ileal perforation which can also potentially be exploited to develop suitable diagnostic tests.

Severe proctitis, perforation, and fatal rectal bleeding secondary to cytomegalovirus in an immunocompetent patient: report of a case

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. In immunocompetent individuals, the infection is usually subclinical but it can sometimes be life threatening. We describe a case of fatal CMV proctitis in a 71-year-old man following an Ivor-Lewis esophagectomy. After surgery he developed renal failure, methicillin-resistant Staphylococcus aureus pneumonia, and acute respiratory distress syndrome. He recovered but developed melena and massive fresh rectal bleeding. Sigmoidoscopy revealed severe proctitis and a biopsy was consistent with ischemia. Despite undergoing a proctectomy he continued to bleed and died despite every effort. The final histological examination of the rectum revealed a CMV infection.

The vagal nerve as a link between the nervous and immune system in the instance of polymicrobial sepsis

BACKGROUND

The role of the vagal nerve in the autonomic nervous system is widely well known. Recently, an additional function was revealed serving as a connector between the nervous and immune system. This connection is called the "cholinergic inflammatory pathway." Through stimulation of the acetylcholine receptors located upon the macrophages, the "unspecific" immune system can be directly influenced.

METHODS

The vagal nerve was completely transected directly posterior to its passage through the diaphragm. The effect of complete vagotomy was analyzed using a murine model of polymicrobial peritonitis (colon ascendens stent peritonitis, CASP). Survival and clinical course of vagotomized or sham-operated mice were analyzed in the CASP model.

RESULTS

After CASP surgery, vagotomy led to a significantly increased mortality (64.7%) in comparison to sham-vagotomized animals (34%). No difference in the bacterial load of various tissues (lung, liver, spleen, blood, lavage fluid, and kidney) from septic animals with or without vagotomy was observed. Vagotomized animals reveal elevated serum cytokine levels (TNF, IL-6, IL-10, and MCP-1) 20 h after the induction of polymicrobial peritonitis.

CONCLUSION

The vagal nerve is therefore an important modulator of the immune system.

Laparoscopic bowel injury in an animal model: monocyte migration and apoptosis

BACKGROUND

Unrecognized laparoscopic bowel injury has a delayed and covert presentation. Differences in monocyte migration and apoptosis between laparoscopic and open bowel injury were determined.

METHODS

For this study, 24 rabbits were divided into laparoscopic (n = 9) and open surgical (n = 9) bowel injury groups and a control group (n = 6) without bowel injury. Bowel injury was created using monopolar electrocautery. The animals were killed 1 day, 1 week, and 2 weeks after surgery. Monocyte migration assay was performed across a modified Boyden chamber. Apoptosis was assessed by DNA fluorescent stain H-33342.

RESULTS

In laparoscopy, monocyte apoptosis was decreased (p < 0.001), and migration was increased (p < 0.05), as compared with the open group. Apoptosis increased over time in both study groups, and was higher than in the control group (p < 0.001). Migration was decreased in both study groups as compared with the control group (p < 0.05)

CONCLUSIONS

These results suggest decreased immune system priming with laparoscopic bowel injury, which may contribute to the masking of relevant signs and symptoms of peritonitis.

PERITONEAL AND SYSTEMIC INFLAMMATORY MEDIATORS OF LAPAROSCOPIC BOWEL INJURY IN A RABBIT MODEL

PURPOSE

Unrecognized bowel injury following laparoscopy has a subtle and delayed clinical presentation compared with that after open surgery. We determined peritoneal and systemic immune function in laparoscopic and open bowel injury cases. We propose that laparoscopy does not activate immune responses to the same extent as open surgery.

MATERIALS AND METHODS

A total of 40 rabbits were divided into 4 groups. Two study groups were subjected to laparoscopic and open bowel injury, and 2 control groups underwent pneumoperitoneum and sham open surgery, respectively, without bowel injury. Animals were sacrificed 1 day, 3 days and 1 week postoperatively. Macroscopic and histological findings were analyzed. Peritoneal fluid, systemic white blood count (WBC) and differentials were done with a hemocytometer. Peritoneal fluid and serum interleukin (IL)-8 concentrations were measured by enzyme-linked immunosorbent assay.

RESULTS

Macroscopic and histological findings were indistinguishable in the 2 study groups. However, study groups demonstrated higher peritoneal WBCs than their respective controls at 1 and 3 days (p <0.05). Peritoneal WBC was lower in the laparoscopy than in the open study group at 3 days (p <0.05). There was a significant decrease in peritoneal lymphocytes and monocytes in the laparoscopic vs the open study group at 3 days. No differences were found in systemic WBC or differentials among all groups. Peritoneal IL-8 concentrations were higher in the laparoscopic bowel injury than in the laparoscopic control group at 1 and 3 days (p <0.05). However, there were no differences in peritoneal or serum IL-8 concentrations between both study groups.

CONCLUSIONS

Laparoscopic surgery seems to be unable to sustain peritoneal immune responses, which may mask reliable clinical signs and symptoms of peritonitis associated with bowel injury.

[The pathogenesis of the systemic inflammatory response syndrome and compensatory antiinflammatory response syndrome following surgical stress]

The inflammation charge cells such as the macrophages, neutrophils, endothelial cells, and fibroblasts are activated in surgical sites when tissue injury occurs due to the operation. Proinflammatory cytokines such as tumor necrosis factor alpha, interleukin (IL)-1, IL-6, and IL-8 are induced from the activated inflammation charge cells. These cytokines amplify the information by autocrine and paracrine action, induce the production of other cytokines, and send the information to the whole body. Increases in body temperature, pulse rate, and leukocyte counts are then observed. This condition is called the systemic inflammatory response syndrome (SIRS) clinically. On the other hand, the production of antiinflammatory cytokines against SIRS is induced simultaneously. The condition in which antiinflammatory cytokines are produced in excess and become dominant systemically is called the compensatory antiinflammatory response syndrome (CARS). No standard concrete diagnosis for CARS has been established, although CARS is a pathogenetic concept. However, recently the analysis of cytokine production and various types of surface molecules in the inflammation charge cells became possible with the development of molecular biological methods. As a result, it was found that the immune system is controlled by the balance between proinflammatory and antiinflammatory cytokine production, and if the compensatory antiinflammatory reaction is sufficiently severe, it will manifest clinically as anergy, with increased susceptibility to infection. In this manuscript, we explain the pathogenesis of SIRS and CARS following surgical stress by analyzing cytokine production and surface membrane molecules in the inflammation charge cells.

Immune response to laparoscopic bowel injury

BACKGROUND AND PURPOSE

Laparoscopic bowel injuries are rare but potentially fatal if recognition is delayed. Unlike the situation after open surgery, patients with unrecognized bowel injury after laparoscopy do not present with the typical "acute surgical abdomen." We investigated monocyte, neutrophil, and lymphocyte apoptosis as indicators of the immune response and whether this response is stimulated or suppressed by laparoscopic bowel injury compared with bowel injury induced during open surgery.

MATERIALS AND METHODS

After an animal protocol was approved, laparoscopy was performed in a rabbit model. A total of 44 animals were divided into four groups of 11 rabbits each. Laparoscopic bowel injury was created using 30-W electrocautery at 0 (control), 1, and 5 hours after induction of pneumoperitoneum. Bowel injury was created in the fourth group during open laparotomy. Animals were euthanized at 0, 1 day, 1 week, or 2 weeks after surgery. Apoptosis was assessed by staining the nuclei of blood cells with H-33342 dye.

RESULTS

At 1 week, neutrophil, monocyte, and lymphocyte apoptosis levels were 2.4- to 5-fold lower after laparoscopy (1-hour pneumoperitoneum) compared with open surgery. However, at 2 weeks, the percentage of apoptosis had equalized in the two groups. Interestingly, with longer laparoscopic procedures (5 hours), the percentage of apoptosis at 0 and 1 day more closely approached that seen after open surgery. At 2 weeks, there was a significant difference in apoptosis levels in all cell types between the experimental groups compared with controls (P < 0.001). No animals undergoing a 5-hour open procedure survived to 2 weeks after bowel injury.

CONCLUSIONS

Open surgery resulted in a significant increase in programmed cell death compared with controls in the immediate postoperative period following bowel injury. Laparoscopic surgery produced a delayed response and after 2 weeks with bowel perforation approached open surgery levels. The difference in the degree of cellular death may be secondary to a smaller degree of stimulation of the immune response in laparoscopic surgery.

Anti-interleukin-8 autoantibodies in patients at risk for acute respiratory distress syndrome

OBJECTIVE

To test the hypothesis that elevated concentrations of interleukin-8 associated with anti-interleukin-8 autoantibodies (anti-interleukin-8:interleukin-8 complexes) are found in patients at risk for acute respiratory distress syndrome who developed the disease.

DESIGN

Measurement of anti-interleukin-8:interleukin-8 complex concentrations in previously collected bronchoalveolar lavage fluids. These fluids were obtained from patients at risk for acute respiratory distress syndrome who subsequently either recovered or developed acute respiratory distress syndrome.

PATIENTS

A unique population of patients at risk for acute respiratory distress syndrome was studied. There were 26 patients at risk for acute respiratory distress syndrome who were divided into three groups. Group I patients had high interleukin-8 concentrations and developed acute respiratory distress syndrome, group II had high interleukin-8 concentrations and did not develop acute respiratory distress syndrome, and group III had low interleukin-8 concentrations and did not develop acute respiratory distress syndrome. These patients were selected to test the hypothesis that presence of elevated concentrations of anti-interleukin-8:interleukin-8 complexes differentiates patients at risk for acute respiratory distress syndrome who developed acute respiratory distress syndrome from patients who did not.

MEASUREMENTS AND MAIN RESULTS

Bronchoalveolar lavage fluid concentrations of interleukin-8 associated with the anti-interleukin-8 autoantibodies were significantly different between groups (p <.03). The amount of interleukin-8 bound to the anti-interleukin-8 autoantibody was higher in group I than in group II and group III.

CONCLUSIONS

Bronchoalveolar lavage fluid concentration of anti-interleukin-8:interleukin-8 complexes may serve as a marker of disease progression in patients at risk for acute respiratory distress syndrome.

Perforation of toxic megacolon in non-typhoid Salmonella enterocolitis spares young infants and is immune-mediated

Intestinal perforation, a life-threatening complication of toxic megacolon (TM) following non-typhoid Salmonella infection, is relatively uncommon in infants less than 1 year of age. The situation, also found in typhoid fever, appears to be cytokine-mediated. This finding may justify immunotherapy for older children with TM associated with non-typhoid Salmonella infection in order to prevent this complication.

Immunocytochemical analysis of cellular infiltrates in human appendicitis

This study was conducted to determine the immunologic cellular composition in human appendicitis and its association with the development of perforated appendicitis. Appendiceal specimens from 27 patients with acute appendicitis were immunostained to detect lymphocyte surface markers. Moreover, the lymphocyte surface markers of peripheral blood were analyzed by laser flow cytometry in 12 patients. Helper T lymphocytes (CD4) were present in all the patients, while B lymphocytes (CD19), natural killer (NK) cells (CD56), and cytotoxic T lymphocytes (CD8) were present in 7 (70%), 10 (100%), and 9 patients (90%) with perforated appendicitis, and in 12 (63.2%), 10 (58.8%), and 6 (54.5%) patients without perforation, respectively. There were significant differences between the patients with a perforated appendix and those without perforation, in the positivity rate for CD8 and CD56 cells (P < 0.05). The number of cells positive for CD56, being NK cells, in the blood from the patients with perforation was significantly lower than that in the blood from those without perforation (P < 0.05). The infiltration of a greater number of cytotoxic T lymphocytes and NK cells was observed in the appendices from patients with perforated appendicitis than in those from patients with nonperforated appendicitis.

Improvement of host response to sepsis by photobiomodulation

BACKGROUND AND OBJECTIVE

Late sepsis causes immunosuppression and is associated with energy depletion in lymphocytes. Adjuvant treatment with ATP-MgCL2 appears to improve cellular energetics and decrease mortality. Laser irradiation can promote cell proliferation and increase cellular ATP synthesis, which may improve the host immune response in sepsis. The purpose of this study was to determine whether laser irradiation (LI) has a stimulatory effect on the immune response in sepsis using an animal model.

STUDY DESIGN/MATERIALS AND METHODS

The cecal ligation and puncture (CLP) rat model was used. Thirty-six SD rats were divided equally among four groups: control (nonoperative), sham operation, CLP treated with laser irradiation, and CLP without laser irradiation. The peritoneal cavity of each animal in CLP/laser group was irradiated immediately after CLP using an Argon-dye laser at a wavelength of 630 nm and at a fluence of 5 J/cm2. Some animals were euthanized 24 hr following CLP and were used to evaluate the immune response (lymphocyte proliferation). In a separate experiment, the survival of septic rats was observed for 60 days. Lymphocytes isolated from normal rat spleens were used to observe for biostimulatory effects in vitro.

RESULTS

LI significantly improved ex-vivo lymphocyte proliferation of cells from septic rats (179.7 +/- 17.2 vs. 129.5 +/- 7.8; P < 0.01) and enhanced survival in septic rats (79% vs. 42%; P < 0.001). LI significantly stimulated lymphocyte proliferation in the presence of mitogenic stimuli and enhanced lymphocyte ATP synthesis (P < 0.05).

CONCLUSION

LI improves the host immune response and survival rate in sepsis in an animal model. Our studies suggest that LI may be useful as an adjuvant therapy for sepsis.

Multiple roles for IL-12 in a model of acute septic peritonitis

The present study addressed the role of IL-12 in a murine model of septic peritonitis, induced by cecal ligation and puncture (CLP). Although CLP surgery induced IL-12 production at 6 and 24 h after surgery, IL-12 immunoneutralization was clearly deleterious in this model: 54% of CLP mice receiving preimmune serum survived, whereas mice administered IL-12 antisera prior to CLP experienced a 25% survival rate. IL-12 immunoneutralization not only led to increased mortality, but also appeared to promote a shift away from IL-12 and IFN-gamma, in favor of IL-10. This cytokine shift corresponded to changes in bacterial load, as CLP mice receiving IL-12 antiserum yielded more CFUs from the peritoneal cavity at 24 h after CLP. To address the role of bacterial infection in IL-12 antiserum-induced mortality following CLP, antibiotics were administered for 4 days after surgery. Despite regular antibiotic administration, IL-12 immunoneutralization still reduced survival in CLP mice. Furthermore, histology of the ceca revealed that mice administered IL-12 antisera failed to show typical organization of the damaged cecum wall. Accordingly, Gram staining revealed bacteria within peritoneal fluids from these mice, while peritoneal fluids from CLP mice that received preimmune serum and antibiotics were free of bacteria. Altogether, these data suggested multiple important roles for IL-12 in the evolution of murine septic peritonitis.

Serologic examinations in acute appendicitis

Authors studied the formation of endotoxic antibody level in healthy adults and in patients with appendicitis with a technique (indirect haemagglutination) not used till now. They found the antibody level against endotoxin to be increased in 91% of their patients in the postoperative period. Decrease in the antibody level against endotoxin was observed in two patients with gangrenous appendicitis and two patients with perforated appendicitis. Summarizing their results, authors consider mixed (aerobic, anaerobic) infection to be of decisive importance in the development of acute appendicitis, contributing to the weakened immune response of the host.

White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis

The white blood cell (WBC) count is considered to be a useful test in the diagnosis of appendicitis. The purpose of this study was to examine the clinical features of patients with normal WBC appendicitis and also to determine whether a higher WBC count correlates with a more advanced stage of appendicitis. Patients with pathologically confirmed appendicitis from January 1989 to December 1994 were included in the study (n = 1919). The age, gender, temperature, length of hospital stay, and severity of disease (1 = acute appendicitis; 2 = gangrenous appendicitis; 3 = perforated appendicitis with abscess formation; 4 = appendicitis with diffuse peritonitis) were compared for patients with a normal WBC count (range, 3.8-10.9) versus those who had an elevated WBC count. A normal WBC count was seen in 11 per cent of patients (n = 209). There was no difference in age, temperature, gender, or severity of disease in the patients with a normal WBC count compared with those with an elevated WBC count (P > 0.05). The severity of disease of patients with a normal WBC count were: 1 = 58 per cent; 2 = 13 per cent; 3 = 7 per cent; and 4 = 22 per cent. For patients with an elevated WBC count the scores were: 1 = 57 per cent; 2 = 17 per cent; 3 = 13 per cent; and 4 = 14 per cent. The proportion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count.

Gastrointestinal perforation early after peripheral blood stem cell transplantation for AL amyloidosis

The morbidity and mortality of AL amyloidosis is caused by the deposition of Ig light chains as amyloid protein in vital organs. With conventional therapy median survival of patients with AL amyloidosis is 10-14 months. With high-dose chemotherapy clinical remissions of organ-specific disease have been reported. Here, we present a patient with high-risk AL amyloidosis who was given high-dose therapy and a peripheral blood stem cell transplant. Four days later she died of gastrointestinal perforation due to amyloid infiltrations.

Colonic perforation by ventriculoperitoneal shunt tubing: a case of suspected silicone allergy

BACKGROUND

A case of colonic perforation by a ventriculoperitoneal shunt is presented in a patient with several previous complications associated with shunt tubing.

CASE DESCRIPTION

Initially managed by intravenous antibiotics, shunt externalization, and colonoscopy, the entire ventriculoperitoneal shunt system was subsequently replaced after cerebrospinal fluid cultures had grown Propionibacterium acnes and Streptococcus sanguis organisms. The patient has had three episodes of skin breakdown over his shunt tubing (two prior and one subsequent to colonic perforation) without evidence of shunt infection or malfunction.

CONCLUSIONS

The etiology of these complications is consistent with silicone tubing allergy. Replacement with a polyurethane system produced no similar complications thus far, which further supports a possible silicone allergy to the ventriculoperitoneal shunt and possible etiology of this patient's colonic perforation.

Relative production of tumour necrosis factor alpha and interleukin 10 in adult respiratory distress syndrome

BACKGROUND

The adult respiratory distress syndrome (ARDS) may be regarded as an example of an uncontrolled or excessive inflammatory response in which tumour necrosis factor alpha (TNF-alpha) has been proposed to play a central role. Interleukin 10 (IL-10) has been identified as an important regulator of this response. The potential role for IL-10 in this context was investigated by measuring the relative production of IL-10 and TNF-alpha protein in the plasma, bronchoalveolar lavage (BAL) fluid, and alveolar macrophage culture supernatants of patients with, or at risk of developing, ARDS.

METHODS

Twenty six patients were studied from three groups at risk of or with ARDS: sepsis (n = 12), multiple trauma (n = 8), and perforated bowel (n = 6). Ten patients had ARDS. Bronchoalveolar lavage and venepuncture were performed within 24 hours of arrival on the intensive therapy unit or of diagnosis of ARDS. IL-10 and TNF-alpha protein were detected in the plasma, BAL fluid, and alveolar macrophage supernatants by sandwich enzyme linked immunoabsorbent assays.

RESULTS

The median IL-10 concentrations in the plasma and BAL fluid of patients with ARDS were significantly lower than the concentrations detectable in the plasma (median difference-17.5, 95% CI -52.4 to 1.31, p < 0.05) and BAL fluid of at risk patients (median difference -32.1, 95% CI -47.5 to 2.3, p < 0.05). There was a tendency towards enhanced concentrations of TNF-alpha detectable in the alveolar macrophage supernatants and the BAL fluid of patients with ARDS compared with at risk patients, although this did not reach statistical significance. No difference was observed in the plasma concentrations of TNF-alpha between the two groups. The ratios of TNF-alpha to IL-10 protein in the BAL fluid of patients with ARDS and at risk patients were 3.52 and 0.85, respectively (median difference 1.44, 95% CI 0.07 to 5.01, p < 0.01). There was no difference in alveolar macrophage production of IL-10 between the two groups.

CONCLUSIONS

This study highlights the potential importance of the pro-inflammatory versus the anti-inflammatory imbalance in ARDS which may be reflected by the ratio of IL-10 and TNF-alpha in the lung.

Chronological changes in the complement system in sepsis

The time courses of serum complement levels and the severity of sepsis were compared in two groups of septic patients, one in which the patients survived (surviving group) and one in which they did not (nonsurviving group). The components of the complement system, namely, C3a, C4a, C5a, CH50, C3, C4, and C5, were measured at several points in time after the diagnosis of sepsis had been established. A 2-antibody radioimmunoassay was used to measure C3a, C4a, and C5a; the latex agglutination test was used to measure C3 and C4; nephelometry was used to measure C5; and Meyer's 50% hemolysis method was used to measure CH50. Following the diagnosis of sepsis, the levels of CH50, C3, and C4 were significantly lower in the nonsurviving than the surviving group, while the levels of C3a and C4a were significantly higher in the nonsurviving than the surviving group. The C5a levels were significantly higher in the nonsurviving than the surviving group, although no significant intergroup differences were subsequently noted. These results suggest that the serum levels of C3a, C4a, C5a, CH50, C3, and C4 could serve as indices of the severity of sepsis. Thus, monitoring the complement system may be useful for predicting the outcome of patients with sepsis.

Peritoneal abscesses due to bowel perforation: effect of extent on outcome after percutaneous drainage

PURPOSE

To determine the effect of extent of peritoneal contamination in enteric abscesses on final outcome and duration of percutaneous drainage.

PATIENTS AND METHODS

Results were retrospectively reviewed for 11 patients with varying degrees of peritoneal contamination secondary to subacute bowel perforation who were primarily treated with percutaneous drainage. Stepwise linear regression analysis of duration of drainage was performed with use of patient age and immune status, the site of bowel perforation, and the number of peritoneal compartments involved in the resultant contamination as independent variables.

RESULTS

In 10 of 11 patients (91%) treatment of the resultant intraperitoneal collections with percutaneous drainage was successful irrespective of the extent of peritoneal contamination. There was no correlation between duration of drainage and extent of peritoneal contamination but good correlation with patient age and site of bowel perforation (r = 0.82, P = .02).

CONCLUSION

In patients with enteric abscesses due to subacute bowel perforation, the duration of drainage and final outcome after percutaneous drainage are independent of the extent of peritoneal contamination.

Tuberculosis of the small bowel with perforation and hematogenous spread in a renal transplant recipient

A 41-year-old male was admitted because of acute abdomen. A flat plate of the abdomen suggested pneumoperitoneum and a chest X-ray an infiltrate in the right upper lobe. The patient was a renal allograft recipient and was on immunosuppressive therapy with azathioprine, cyclosporine and steroids. At laparatomy inflammatory thickening of the bowel wall was found in the terminal ileum with necrotic areas and two sites of perforation. The involved terminal ileum was removed together with a right hemicolectomy. The resected segment showed exudative ileal tuberculosis and fibrinous and purulent peritonitis. During the postoperative period rapid hematogenous spread of tuberculosis developed with progressive reduction of respiratory function followed by ARDS. Autopsy revealed tuberculosis in all organs including the transplanted kidney.

[Clinical and immunologic characteristics of various forms of acute peritonitis]

The condition of the cellular link of the immune system was studied in 30 patients with various forms of acute peritonitis. It was found that the reaction of the immune system in peritonitis is characterized by a phase property and is manifested by processes of redistribution and activation of the immunocompetent cells and normalization of reactivity. The ratio of these phases is determined by the severity of inflammation and intoxication. It is shown that inhibition of the immune system is most marked in diffuse peritonitis, which is due to the higher absorption capacity of the peritoneum in this stage of the pathological process. It was established that the response of the immune system to the operative trauma depends on the spread of peritonitis. The number of T-helpers, T-suppressors, and activated lymphocytes and the activity of the neutrophil alkaline phosphatase are most important in the prognosis of postoperative complications. These parameters may also be used in assessment of the efficacy of immunomodulation with levamisole.

Ileal perforation in typhoid: bacteriological and immunological findings

In typhoid perforation patients, Salmonella typhi was isolated from blood in 4%, ileal contents in 23%, peritoneal pus in 13% and from mesenteric lymph nodes in 71%. While isolation of S. typhi was made from patients with less than 4 days of chloramphenicol therapy, cultures were negative from these sites after 5 days of therapy; however, S. typhi appeared to remain viable in the lymph nodes even after such therapy. All isolates of S. typhi were sensitive to chloramphenicol. Significant SAT titers (0 > or = 1/240) were obtained in only 7/21 (33%) of patients. The perforated group had lower geometric mean titers (0-1/138; H-1/46), when compared to matched patients with uncomplicated typhoid fever (0-1/476; H-1/148). This difference was significant (0- p < 0.005; H- p < 0.0025). The two groups (uncomplicated and perforated) showed no significant difference in total serum IgG, IgM and IgA or isohemagglutinin levels, indicating that the apparent hyporeactivity was not due to a generalized humoral immunodeficiency. Mesenteric lymph node histology showed hyporeactivity in both the T cell and B cell zones. These findings are discussed with the suggestion that S. typhi-specific host immunological hyporeactivity could be an explanation for these observations and a basis for the pathogenesis of perforation. Aerobic cultures of the peritoneal pus gave 39 isolates from 25 patients; the predominant isolates were Escherichia coli (24) and Klebsiella pneumoniae (12). On no occasion was S. typhi the predominant isolate. Gentamicin and kanamycin were the only two antibiotics which were consistently effective in vitro against the aerobic isolates from peritoneal pus.

Abnormal expression of secretory component in term newborns with bowel perforation--a report of two cases

Expression of secretory component (SC) in intestinal resection specimens from two term newborns with bowel perforation due to necrotizing enterocolitis (NEC) or and NEC-like syndrome was determined and compared with the SC immunoreactivity in a panel of intestinal tissues from fetuses at different ages of gestation. Expression of SC was absent in one patient, whereas in the other patient, SC immunoreactivity was observed in the basal cell part of colonic epithelium only. SC was normally expressed in a follow-up biopsy on one of these patients. In contrast, SC was present in the apical plasma membrane and brush border of colonic epithelium from 32 weeks of gestation onwards in fetuses without demonstrable intestinal disease. From these findings we conclude that the expression of SC was impaired in our patients, thus possibly playing a role in the development of the bowel perforation in these full-term newborns with an NEC-like syndrome or resulting from its pathogenesis.

Perforation of the colon associated with cytomegalovirus infection

Cytomegalovirus (CMV) inclusions were found at colonic perforation sites in three patients with clinical settings suggesting a compromised immunologic status. This could be interpreted as: (1) CMV was an etiologic agent in these perforations; or (2) CMV was an opportunistic superinfection in areas of preexisting inflammation. To determine which interpretation was more likely, we examined material from these three and ten similar patients with colonic perforations, identifying any potential causative factors present. Eleven of the 13 patients had an identifiable cause of perforation, either tumor, diverticulitis, arteritis, or pancreatic pseudocyst, while two remained unexplained. If the presence of CMV merely represented an opportunistic superinfection, then all 13 should have been at equal risk of infection. However, CMV was present in only one of the 11 cases with another identifiable cause of perforation but was present in both of the cases without another cause. This is consistent with the hypothesis that CMV was in fact an etiologic or contributing factor in those cases where it was present. Other cases of CMV infection of the gastrointestinal tract were studied to determine the mechanism by which this infection could lead to perforation of a viscus. In our three cases with perforation, four additional cases of CMV infection of the colon which we have studied, and 30 other cases in the literature, CMV inclusions were found only in areas of ulceration or perforation, never in undamaged mucosa. Thus there is as yet no evidence that CMV can be a primary cause of colonic mucosal injury. It remains likely, however, that a mucosal injury due to another cause may be followed by CMV infection of the granulation tissue which then may lead to further injury and perforation.

alpha-Chain disease causing kaliopenic nephropathy and fatal intestinal perforations

A case of alpha-chain disease (alpha-CD) is described presenting as a malabsorption syndrome complicated by severe kalipenic nephropathy. Antibiotics and cyclophosphamide were effective in controlling the malabsorption and thr renal dysfunction but did not affect the basic pathological lesion. Eventually the disease became generalized, affected lymph nodes, liver and bone marrow and caused multiple intestinal perforations. Detailed histological studies failed to demonstrate the development of reticulum-cell sarcoma as a terminal complication of the disease and are suggestive of a single malignant plasmacytic cell process.