An Investigation Into What Factors Influence Patterns of Clinical Presentation in Adult-Onset Celiac Disease.

Introduction Anxiety and depression are common in patients with celiac disease (CD), and many psychosocial explanations have been considered. However, as the gut-brain axis is becoming increasingly understood, biological mechanisms have been proposed, including vitamin or mineral deficiencies and gut inflammation. Aim To investigate associations between anxiety/depression and symptom severity, vitamin status, and gut inflammation in untreated adult patients presenting with a serologic indication of celiac disease. Methods The Hospital Anxiety and Depression Scale (HADS), Celiac Symptom Index (CSI), and Perceived Stress Scale (PSS) questionnaires were administered to 17 patients over a 14-month period. Duodenal biopsies were obtained to determine histological Marsh scores. Iron, B12, folate, vitamin D, and thyroid function tests were reviewed. Results HADS-Anxiety (HADS-A) scores correlated with symptom severity (rs = 0.62, P = 0.008), but not with any hematological investigations or degree of intestinal inflammation. No patients scored highly for depression. Iron deficiency was the most common deficiency observed (n = 6). Greater symptomatology was associated with female sex (females versus males: average CSI scores, 32.1 versus 23.6; t17 = 2.1, P < 0.05), younger age at presentation (rs = -0.55, P = 0.02), and lower Marsh score (Marsh 0 versus Marsh 3C: mean scores, 36 versus 24.5; t5 = 6.2, P = 0.009). Conclusions The anxiety experienced by patients with CD at presentation is likely a reactive form due to gastrointestinal symptoms rather than a biological process specific to CD. Older patients tend to present less symptomatically, highlighting the need for screening of at-risk individuals. The degree of villous atrophy does not correlate well with clinical presentation. Highly symptomatic patients should be screened for anxiety at presentation.

Disseminated cryptococcal infection initially presenting as cryptococcal cellulitis in an HIV-negative patient on long-term steroids.

Cryptococcosis is an invasive fungal infection caused by encapsulated yeasts of the Cryptococcus species. Inoculation usually occurs by inhalation through the respiratory tract, where it can then spread haematogenously to various sites, such as the central nervous system or the skin, in susceptible patients. We present the case of a 68-year-old male patient on long-term steroids who presented with a right upper limb cellulitis not responding to antibiotics. This was subsequently diagnosed as cryptococcal cellulitis on an urgent skin biopsy. Wound swabs and blood cultures, which were initially negative, were repeated and confirmed the presence of disseminated cryptococcal disease. The patient's neighbours kept racing pigeons and this was hypothesised as a potential source of infection.

Human-accelerated weathering increases salinization, major ions, and alkalinization in fresh water across land use.

Human-dominated land uses can increase transport of major ions in streams due to the combination of human-accelerated weathering and anthropogenic salts. Calcium, magnesium, sodium, alkalinity, and hardness significantly increased in the drinking water supply for Baltimore, Maryland over almost 50 years (p<0.05) coinciding with regional urbanization. Across a nearby land use gradient at the Baltimore Long-Term Ecological Research (LTER) site, there were significant increases in concentrations of dissolved inorganic carbon (DIC), Ca2+, Mg2+, Na+, and Si and pH with increasing impervious surfaces in 9 streams monitored bi-weekly over a 3-4 year period (p<0.05). Base cations in urban streams were up to 60 times greater than forest and agricultural streams, and elemental ratios suggested road salt and carbonate weathering from impervious surfaces as potential sources. Laboratory weathering experiments with concrete also indicated that impervious surfaces increased pH and DIC with potential to alkalinize urban waters. Ratios of Na+ and Cl- suggested that there was enhanced ion exchange in the watersheds from road salts, which could mobilize other base cations from soils to streams. There were significant relationships between Ca2+, Mg2+, Na+, and K+ concentrations and Cl-, SO42-, NO3- and DIC across land use (p<0.05), which suggested tight coupling of geochemical cycles. Finally, concentrations of Na+, Ca2+, Mg2+, and pH significantly increased with distance downstream (p<0.05) along a stream network draining 170 km2 of the Baltimore LTER site contributing to river alkalinization. Our results suggest that urbanization may dramatically increase major ions, ionic strength, and pH over decades from headwaters to coastal zones, which can impact integrity of aquatic life, infrastructure, drinking water, and coastal ocean alkalinization.

Disruption of colonic barrier function and induction of mediator release by strains of Campylobacter jejuni that invade epithelial cells.

AIM: To study the mechanisms by which Campylobacter jejuni (C. jejuni) causes inflammation and diarrhea. In particular, direct interactions with intestinal epithelial cells and effects on barrier function are poorly under-stood. METHODS: To model the initial pathogenic effects of C. jejuni on intestinal epithelium, polarized human colonic HCA-7 monolayers were grown on permeabilized filters and infected apically with clinical isolates of C. jejuni. Integrity of the monolayer was monitored by changes in monolayer resistance, release of lactate dehydrogenase, mannitol fluxes and electron microscopy. Invasion of HCA-7 cells was assessed by a modified gentamicin protection assay, translocation by counting colony forming units in the basal chamber, stimulation of mediator release by immunoassays and secretory responses in monolayers stimulated by bradykinin in an Ussing chamber. RESULTS: All strains translocated across monolayers but only a minority invaded HCA-7 cells. Strains that invaded HCA-7 cells destroyed monolayer resistance over 6 h, accompanied by increased release of lactate dehydrogenase, a four-fold increase in permeability to [(3)H] mannitol, and ultrastructural disruption of tight junctions, with rounding and lifting of cells off the filter membrane. Synthesis of interleukin (IL)-8 and prostaglandin E(2) was increased with strains that invaded the monolayer but not with those that did not. CONCLUSION: These data demonstrate two distinct effects of C. jejuni on colonic epithelial cells and provide an informative model for further investigation of initial host cell responses to C. jejuni.

Intestinal tuberculosis mimicking Crohn's disease: lessons relearned in a new era.

Over 400 000 cases of tuberculosis existed in Europe in 2002, 1% of which were intestinal tuberculosis. With population migrations on the increase, physicians may have to face an increase in intestinal tuberculosis. One of the attributes of intestinal tuberculosis is its ability to present in nonspecific ways and to mimic other disorders, in particular inflammatory bowel disease. We present a case series of intestinal tuberculosis presenting as inflammatory bowel disease and referred for management to a specialized clinic in inflammatory bowel disease, followed by a discussion of the difficulties encountered with this condition. We highlight the consequences that misdiagnosis can have, in an era where population demographics are changing in Europe and where immunomodulators and biological agents have the potential to do more harm than good.

Increased salinization of fresh water in the northeastern United States.

Chloride concentrations are increasing at a rate that threatens the availability of fresh water in the northeastern United States. Increases in roadways and deicer use are now salinizing fresh waters, degrading habitat for aquatic organisms, and impacting large supplies of drinking water for humans throughout the region. We observed chloride concentrations of up to 25% of the concentration of seawater in streams of Maryland, New York, and New Hampshire during winters, and chloride concentrations remaining up to 100 times greater than unimpacted forest streams during summers. Mean annual chloride concentration increased as a function of impervious surface and exceeded tolerance for freshwater life in suburban and urban watersheds. Our analysis shows that if salinity were to continue to increase at its present rate due to changes in impervious surface coverage and current management practices, many surface waters in the northeastern United States would not be potable for human consumption and would become toxic to freshwater life within the next century.