ABSTRACT
BACKGROUND: Histoplasma capsulatum is an endemic fungus in especially tropical areas. While mostly asymptomatic, histoplasmosis can be life-threatening in immunocompromised patients. CASE DESCRIPTION: A 60-year-old woman of Suriname origin, with a history of renal transplantation and use of mycophenolate mofetil and prednisone, presented with abdominal pain and diarrhea. Colonoscopy revealed ulcerative ileocolitis and biopsy showed active granulomatous inflammation. Morbus Crohn was considered the most plausible diagnosis after ruling out several infectious and pharmacological causes. Despite prednisone treatment, symptoms persisted and infliximab was initiated. The patient developed constitutional symptoms and radiological examination revealed disseminated granulomatous disease. Liver biopsy and re-evaluation of previous intestinal histopathology confirmed suspected histoplasmosis. CONCLUSION: Histoplasmosis should be considered in immunocompromised patients with ileocolitis who have been in endemic regions (South America). Physicians need to assess the risk of previous exposure to histoplasmosis before starting anti-TNF-α therapy.
Subject(s)
Crohn Disease/diagnosis , Histoplasma , Histoplasmosis/diagnosis , Immunocompromised Host , Intestines/microbiology , Abdominal Pain/diagnosis , Abdominal Pain/etiology , Biopsy , Colitis, Ulcerative/diagnosis , Colitis, Ulcerative/etiology , Colonoscopy/methods , Crohn Disease/complications , Crohn Disease/drug therapy , Crohn Disease/pathology , Diarrhea/diagnosis , Diarrhea/etiology , Female , Granuloma/diagnosis , Granuloma/etiology , Histoplasmosis/drug therapy , Histoplasmosis/microbiology , Histoplasmosis/pathology , Humans , Infliximab/therapeutic use , Intestines/pathology , Middle Aged , Prednisone/therapeutic use , South America , Suriname , Tumor Necrosis Factor-alphaABSTRACT
BACKGROUND: Psychotherapy is effective in treating irritable bowel syndrome, but the effect of relaxation training, a brief psychological group intervention, is not known. AIM: To determine the efficacy of relaxation training in a large cohort of irritable bowel syndrome patients. METHODS: Ninety-eight irritable bowel syndrome patients were included in this randomized controlled trial. Forty-six patients received standard medical care (CON) and 52 received four 90-min sessions of relaxation training in small groups in addition to standard medical care. Irritable bowel syndrome symptom severity, medical consumption and quality of life were assessed at baseline in patients and in 38 healthy controls and evaluated in patients at 3, 6 and 12 months after intervention. RESULTS: Irritable bowel syndrome symptom severity was significantly reduced in the relaxation training group compared to CON at 3, 6 and 12 months after treatment (time-by-treatment interaction, P = 0.002). The number needed to treat for long-term improvement was 5. Quality of life had improved (general health, P = 0.017; health change, P = 0.05). Frequency of doctor visits was reduced (P = 0.039). CONCLUSIONS: Relaxation training is a brief group intervention that significantly improves symptom severity, general health perception and medical consumption in irritable bowel syndrome patients immediately after, as well as 6 and 12 months after intervention.
Subject(s)
Irritable Bowel Syndrome/therapy , Psychotherapy, Group/methods , Relaxation Therapy , Adult , Cohort Studies , Female , Humans , Irritable Bowel Syndrome/psychology , Male , Quality of Life , Time , Treatment OutcomeABSTRACT
Motor and sensory dysfunction of the gut are present in a subset of patients with irritable bowel syndrome (IBS). Recent studies have demonstrated the presence of a recto-colonic inhibitory reflex in healthy humans. It is not known whether this reflex exists in IBS. We studied rectal compliance, perception and the recto-colonic reflex by measuring volume responses of the descending colon to rectal distentions by barostat in 26 IBS patients and 13 healthy controls under both fasting and postprandial conditions. In the fasting state, rectal distention inhibited colonic tone and phasic motility to a similar extent in health and IBS. After a meal, rectal distention inhibited colonic tone and phasic motility to a lesser degree (P < 0.05) in IBS than health. Under postprandial but not fasting conditions, rectal distentions of increasing intensity were associated with higher pain scores in IBS than in health. Rectal distention inhibits tonic and phasic motility of the descending colon in healthy controls and in IBS patients. Postprandially this recto-colonic inhibitory reflex is impaired and attenuated in IBS patients compared with controls. These findings point to an altered reflex function in IBS and have implications for pathophysiology and therapy.
Subject(s)
Colon, Descending/physiology , Irritable Bowel Syndrome/physiopathology , Rectum/physiology , Reflex, Abnormal/physiology , Aged , Colon, Descending/innervation , Compliance , Defecation/physiology , Dilatation , Fasting , Female , Gastrointestinal Motility/physiology , Humans , Male , Manometry , Middle Aged , Perception/physiology , Postprandial Period , Rectum/innervationABSTRACT
BACKGROUND: The upper small bowel is of pivotal importance for the stimulation of exocrine pancreatic secretion in response to a meal. We hypothesize that more distal delivery of nutrients into the small intestine will result in less activation of pancreatic secretion. MATERIALS AND METHODS: Eight healthy subjects (3 male, 5 female; age 23 +/- 1 years) participated in two experiments, performed in random order. Subjects were intubated with a 4-lumen tube. Duodenal outputs of pancreatic enzymes and bilirubin were measured by aspiration using a recovery marker. The distal opening was used for continuous administration of a mixed liquid meal and located at either the ligament of Treitz or 60 cm further distally. Gallbladder volume was measured and blood samples were drawn for determination of gastrointestinal hormones. The duration of each experiment was 4 h; with 1 h fasting and 3 h continuous administration of nutrients. RESULTS: During proximal jejunal feeding, pancreatic enzyme output increased significantly over basal levels. No significant increase over basal levels was observed during distal jejunal feeding. Bilirubin output and gallbladder contraction were significantly (P < 0.05) reduced during distal compared to proximal jejunal feeding. No significant differences were found in plasma levels of CCK, PYY and neurotensin between proximal and distal jejunal feeding. CONCLUSION: Continuous feeding in the distal jejunum does not stimulate exocrine pancreatic secretion but maintains gallbladder contraction, although to a lesser extent. These effects are not related to hormonal changes but probably reduced activation of the enteropancreatic reflexes.
Subject(s)
Enteral Nutrition , Jejunum/physiology , Pancreas/metabolism , Adult , Biliary Tract/metabolism , Cholecystokinin/blood , Female , Gallbladder/physiology , Humans , Male , Neurotensin/blood , Pancreatic Polypeptide/blood , Peptide YY/bloodABSTRACT
Protein engineering is a powerful tool for the improvement of the properties of biocatalysts. Previously we have applied protein engineering technologies to obtain an extremely stable variant of the thermolysin-like protease from Bacillus stearothermophilus [Van den Burg, Vriend, Veltman, Venema and Eijsink (1998) Proc. Natl. Acad. Sci. U.S.A. 95, 2056-2060]. This variant is much more resistant to denaturing conditions (temperature and denaturing agents) than the wild-type enzyme. An extensive enzymic characterization was undertaken to explore the suitability of the variant as a biocatalyst at high temperatures. By comparing a range of variants with increasing thermal stabilities we show that the additivity of the mutations is accompanied by an increase in activity at elevated temperatures in accordance with the Arrhenius law. The results suggest that the constructed protease variants could be suitable alternatives to proteases that are currently used industrially. Our studies demonstrate how protein engineering can be exploited to obtain high-performance biocatalysts.