Gammadelta T cells as a predictor of surgical relapse of Crohn's disease.

BACKGROUND: We recently demonstrated a decrease in the overall lymphocyte population in the peripheral blood of patients with CD compared to healthy controls and this decrease is more evident in γδ T lymphocytes. The percentages of T cell subsets could reflect the risk of surgical relapse in CD patients. The aim of this study is to study the correlation between αß and γδ T cell subsets in the peripheral blood of patients with CD and the risk for surgery during follow up. METHODS: A prospective study of 102 patients with CD compared with 102 healthy subjects (control group) matched by age and sex was conducted. Lymphocytic populations of CD3+, CD4+, CD8+, CD56+, and αß and γδ T cell subsets were measured in the peripheral blood of all participants. RESULTS: We found evidence of a relationship between lower γδ T cell levels and risk of surgical relapse in CD. The lowest subsets observed in CD patients with surgical relapse were CD3+γδ, CD3+CD8+γδ and CD3+CD56+γδT cells. We observed a relationship between a decrease in γδ T cells and the most severe forms of the disease. The lowest levels of CD3+γδ and CD3+CD8+γδT cells were observed in the fistulizing phenotype. CONCLUSIONS: The deficit of γδ T cells was related with the severity and the risk for surgical relapse in CD patients. Patients with CD3+γδ deficit were more prone to surgery than patients without this deficit. These results suggest that γδ T cells could be used as markers of poor prognosis of CD following the diagnosis of the disease.

Adenopatías mediastínicas y tos en paciente con enfermedad de Crohn y psoriasis. Un reto diagnóstico / Intrathoracic lymph nodes and cough in a patient with Crohn’s disease and psoriasis. A diagnostic challenge

La mesalazina está aprobada como tratamiento de primera línea para inducción y mantenimiento a largo plazo en enfermedad inflamatoria intestinal de leve a moderadamente activa. Las reacciones adversas pulmonares documentadas en ensayos clínicos se consideran muy raras (< 1/10.000 pacientes), sin embargo, existen numerosos casos publicados que relacionan el fármaco con toxicidad pulmonar. La relación temporal entre el inicio del tratamiento y la aparición de síntomas respiratorios no siempre es evidente, si bien en la mayoría de publicaciones va desde 3 a 15 meses. Realizar un diagnóstico correcto y suspender precozmente el fármaco es fundamental para evitar que la afectación pulmonar subaguda y tratable progrese a crónica con hallazgos de fibrosis irreversibles. Se presenta el caso de un paciente de 26 años con enfermedad de Crohn y psoriasis, que desarrolla neumonitis por hipersensibilidad subaguda de forma secundaria al tratamiento con mesalazina, debutando los primeros síntomas tras 31 meses de tratamiento

Mesalamine is approved as a first line treatment for induction and long term maintenance for patients with mild to moderately active inflammatory bowel disease. Pulmonary adverse reactions documented in clinical trials are considered very rare (< 1/10,000 patients), however, there are numerous published cases that relate the drug to pulmonary toxicity. The temporal relationship between the onset of treatment and the onset of respiratory symptoms is not always evident, although in most publications it goes from 3 to 15 months. Making a correct diagnosis and stopping the drug early is essential to prevent subacute and treatable pulmonary involvement from progressing to chronic with irreversible fibrosis findings. We report the case of a 26-year-old patient with Crohn’s disease and psoriasis, who develops subacute hypersensitivity pneumonitis secondary to treatment with mesalamine, starting the first symptoms after 31 months of treatment

Determination of Anti-Anisakis Simplex Antibodies and Relationship with αß and γδ Lymphocyte Subpopulations in Patients with Crohn's Disease.

BACKGROUND: The etiology of Crohn's disease (CD) is still unknown although new theories are based on defects in innate immunity. We have previously shown a decrease in γδ T cells in CD patients. Previous studies have shown a high prevalence of anti-A. simplex immunoglobulins in CD patients. The diminution of γδ T cells in the peripheral blood and intestinal mucosa of CD patients may create a state of immunosuppression that would facilitate A. simplex infection. AIMS: To study the antibody responses to Anisakis antigens in Crohn's disease patients and its relationship with αß and γδ T cell subsets. METHODS: We recruited 81 CD patients and 81 healthy controls. αß and γδ T cell subsets and anti-A. simplex antibodies were measured. RESULTS: Levels of anti-A. simplex IgG and IgM were significantly increased in CD patients. Almost 20% of CD patients were positive for IgG and IgM anti-A. simplex versus only 3.7 and 2.5%, respectively, in normal subjects. However, lower specific IgA levels were observed in the group of CD patients versus healthy subjects. We found an association between CD3 + CD8 + Î³Î´ subset and IgM anti-A. simplex levels. In ileal cases and stricturing behavior of CD, we observed the highest levels of specific antibodies with the exception of anti-A. simplex IgA. CONCLUSIONS: The relationship of specific antibodies with a γδ T cell deficiency makes these cell candidates to play a role in the immune response against Anisakis. In addition, anti-Anisakis antibodies could be considered as markers of risk of progression in CD.

Crohn's disease and Sweet's syndrome: an uncommon association.

Sweet's syndrome or acute febrile neutrophilic dermatosis (SS) is characterized by the sudden onset of painful erythematous lesions (papules, nodules, and plaques) together with fever and neutrophilia. The lesions are typically located on hands, arms, upper trunk, neck and face, showing an asymmetric distribution. Acute phase reactants are usually elevated and dermal infiltration of neutrophils without vasculitis is seen on skin biopsies. It is considered as a marker of systemic disease in over half of the cases, and is associated with infections, inflammatory bowel disease, autoimmune connective tissue disorders and various neoplasias. Its association with Crohn's disease (CD) is unusual and it appears mainly in association with colonic involvement. Fewer than 50 cases have been published in the medical literature since its first description in 1964, some concurrent with the first episode of CD. We present two patients with Crohn's disease and Sweet's syndrome diagnosed in our department at the time of CD diagnosis, as well as their response to treatment, subsequent course of the disease, and a review of the scientific literature.

Enfermedad de Crohn y síndrome de Sweet: una asociación infrecuente / No disponible

El síndrome de Sweet o dermatosis neutrofílica febril aguda(SS) se caracteriza por la aparición brusca de lesiones eritematosas,(pápulas, nódulos y placas) dolorosas, junto con fiebre y neutrofilia,siendo de presentación poco frecuente. Las lesiones se localizanpreferentemente en manos, brazos, parte superior deltronco, cuello y cara, con distribución asimétrica. Suele haber elevaciónde reactantes de fase aguda y en las biopsias cutáneas seidentifica una infiltración dérmica de neutrófilos sin vasculitis. Seconsidera un marcador de enfermedad sistémica en más de la mitadde los casos, asociándose a infecciones, enfermedad inflamatoriaintestinal, conectivopatías autoinmunes y diversas neoplasias.Su asociación con la enfermedad de Crohn (EC) es poco habitual,asociado sobre todo a afectación colónica. Se han publicadomenos de 50 casos en la literatura médica desde su primera descripciónen 1964, algunos de ellos simultáneos con el primer brotede la EC. Presentamos dos pacientes con enfermedad deCrohn y síndrome de Sweet diagnosticados en nuestro servicio enel momento del diagnóstico de la EC, así como su respuesta al tratamiento,evolución posterior y revisión de la literatura científica(AU)

The uncommon Sweet’s syndrome or acute febrile neutrophilicdermatosis (SS) is characterized by the sudden onset of painfulerythematous lesions (papules, nodules, and plaques) togetherwith fever and neutrophilia. The lesions are typically located onhands, arms, upper trunk, neck and face, showing an asymmetricdistribution. Acute phase reactants are usually elevated and dermalinfiltration of neutrophils without vasculitis is seen on skinbiopsies. It is considered as a marker of systemic disease in overhalf of the cases, and is associated with infections, inflammatorybowel disease, autoimmune connective tissue disorders and variousneoplasias.Its association with Crohn’s disease (CD) is unusual and it appearsmainly in association with colonic involvement. Fewer than50 cases have been published in the medical literature since itsfirst description in 1964, some concurrent with the first episodeof CD. We present two patients with Crohn’s disease and Sweet’ssyndrome diagnosed in our department at the time of CD diagnosis,as well as their response to treatment, subsequent course ofthe disease, and a review of the scientific literature(AU)

[Chronic diarrhea with uncommon etiology]. / Diarrea crónica de causa infrecuente.

Chronic diarrhea is a common syndrome. An etiological diagnosis is often reached through clinical history, physical examination and simple tests. In some cases, when the etiology is not found, the syndrome is called functional diarrhea, even though established criteria are often not fulfilled. We present the case of a patient with diarrhea for several months. The most common causes were ruled out through clinical history, physical examination, radiographic studies and laboratory tests, and the patient was diagnosed with functional diarrhea. Three months later, the patient presented a neck mass, and biopsy revealed medullary carcinoma of the thyroid. A review of recommendations for the systematic evaluation of chronic diarrhea is presented. A general approach should include careful history taking characteristics of diarrhea (onset, associated symptoms, epidemiological factors, iatrogenic causes such as laxative ingestion), a thorough physical examination with special attention to the anorectal region, and routine laboratory tests (complete blood count and serum chemistry). In addition, stool analysis including electrolytes (fecal osmotic gap), leukocytes, fecal occult blood, excess stool fat and laxative screening can yield important objective information to classify the diarrhea as: osmotic (osmotic gaps > 125 mOsm/Kg), secretory (osmotic gaps < 50 mOsm/Kg), inflammatory or steatorrheic. At this point in the evaluation, a specific diagnosis may be made. However, if diagnosis is not reached further specific examinations should be performed for each of the 4 types of diarrhea described above. A systematic approach to the evaluation of chronic diarrhea is warranted. Medullary thyroid carcinoma and other endocrine syndromes causing chronic diarrhea are very rare. Measurement of serum peptide concentrations should only be performed when clinical presentation and findings in stool or radiographic studies suggest this etiology.

Diarrea crónica de causa infrecuente / Chronic diarrhea with uncommon etiology

La diarrea crónica es un síndrome relativamente frecuente. El diagnóstico etiológico se realiza a menudo con anamnesis, exploración física y estudios básicos. En ciertos casos, cuando no se halla la causa, se etiqueta de diarrea funcional, muchas veces sin cumplir los criterios establecidos. Presentamos el caso de un paciente con diarrea de meses de evolución. Tras un estudio amplio, se descartaron las etiologías más frecuentes y se etiquetó de diarrea funcional. Tres meses después, presentó una masa cervical, cuya biopsia fue diagnóstica de cáncer medular de tiroides. Se presentan unas recomendaciones para la evaluación sistemática de la diarrea crónica. El abordaje inicial incluiría: una buena anamnesis que recoja las características de la diarrea, síntomas acompañantes, entorno epidemiológico, antecedentes patológicos y de toma de laxantes; exploración física completa, con examen anorrectal incluido, hemograma y bioquímica básica. Además, el estudio de heces que incluya electrólitos (hiato aniónico fecal), leucocitos, sangre oculta, grasa y laxantes permite clasificar la diarrea en osmótica (hiato aniónico > 125 mOsm/kg), secretora (hiato aniónico < 50 mOsm/kg), inflamatoria o esteatorrea. Llegado este punto podremos tener el diagnóstico etiológico de la diarrea. Sin embargo, si no lo hemos alcanzado, las siguientes exploraciones deben realizarse de acuerdo con cada uno de los 4 tipos de diarrea descritos anteriormente. Se necesita un abordaje sistemático para el diagnóstico etiológico de la diarrea crónica. El carcinoma medular de tiroides y otros síndromes endocrinos que pueden causar diarrea crónica son muy raros; sólo se debe solicitar la determinación de péptidos plasmáticos cuando la historia clínica, los hallazgos analíticos o los estudios radiológicos hagan pensar en uno de estos síndromes

Chronic diarrhea is a common syndrome. An etiological diagnosis is often reached through clinical history, physical examination and simple tests. In some cases, when the etiologyis not found, the syndrome is called functional diarrhea, even though established criteria are often not fulfilled. We present the case of a patient with diarrhea for several months. The most common causes were ruled out through clinical history, physical examination, radiographic studies and laboratory tests, and the patient was diagnosed with functional diarrhea. Three months later, the patient presented a neck mass, and biopsy revealed medullary carcinoma of the thyroid. A review of recommendations for the systematic evaluation of chronic diarrhea is presented. A general approach should include careful history taking characteristics of diarrhea (onset, associated symptoms, epidemiological factors, iatrogenic causes such as laxative ingestion), a thorough physical examination with special attention to the anorectal region, and routine laboratory tests (complete blood count and serumchemistry). In addition, stool analysis including electrolytes(fecal osmotic gap), leukocytes, fecal occult blood, excess stool fat and laxative screening can yield important objective information to classify the diarrhea as: osmotic (osmotic gaps > 125 mOsm/Kg), secretory (osmotic gaps < 50 mOsm/Kg), inflammatory or steatorrheic. At this point in the evaluation, a specific diagnosis may be made. However, if diagnosis is not reached further specific examinations should be performed for each of the 4 types of diarrhea described above. A systematic approach to the evaluation of chronic diarrhea is warranted. Medullary thyroid carcinoma and other endocrine syndromes causing chronic diarrhea are very rare. Measurement of serum peptide concentrations should only be performed when clinical presentation and findings in stoolor radiographic studies suggest this etiology