[Upper digestive tract bleeding as a clinical presentation of non-Hodgkin's lymphoma]. / Sangrado de tubo digestivo alto como presentación clínica del linfoma no Hodgkin.

Background: Non-Hodgkin's lymphoma (NHL) is a group of malignant tumors of the nodal and extranodal lymphoid tissues, and it is associated with autoimmune diseases, mainly rheumatoid arthritis (RA). Extra nodal presentation is observed in 40%, mainly affecting the gastrointestinal tract in 3% of cases, with bleeding in the digestive tract being a rare cause of clinical presentation that requires a detailed diagnostic approach. Clinical case: 55-year-old female with a history of RA, admitted to an internal medicine service due to bleeding in the digestive tract; patient presented clinical data of deep vein thrombosis in the left pelvic limb and consumptive syndrome under study. During her approach she was identified with splenic and liver infarctions, as well as multiple lymph node conglomerates, due to which it was performed an axillary lymph node biopsy reporting neoplastic proliferation of lymphoid cells, and bone marrow aspirate with presence of lymphoplasmacytic infiltration, with which a diagnosis of stage IV non-Hodgkin lymphoma was made. Patient was sent to a third-level hospital to start treatment. Conclusions: This case shows us what has already been described in literature, which is why it is of fundamental importance to carry out a comprehensive approach of clinical findings in patients with previously identified risk factors, with the aim of achieving an etiological diagnosis that allows early therapy to improve their survival.

Introducción: el linfoma no Hodgkin (LNH) es un grupo de tumores malignos de los tejidos linfoides nodales y extranodales, y está asociado a enfermedades autoinmunes, principalmente artritis reumatoide (AR). La presentación extranodal se observa en el 40% y afecta principalmente el tracto gastrointestinal en el 3% de los casos; el sangrado de tubo digestivo es una causa rara de presentación clínica que requiere un abordaje diagnóstico detallado. Caso clínico: mujer de 55 años con antecedente de AR que ingresó a un servicio de medicina interna por sangrado de tubo digestivo; presentó datos clínicos de trombosis venosa profunda en miembro pélvico izquierdo y síndrome consuntivo en estudio. Durante su abordaje se identificó con infartos esplénicos y hepáticos, así como múltiples conglomerados ganglionares, por lo que se practicó biopsia de ganglio axilar que reportó proliferación neoplásica de células linfoides y aspirado de médula ósea con presencia de infiltración linfoplasmocitaria, con lo que se determinó diagnóstico de linfoma no Hodgkin estadio IV. La paciente fue enviada a un hospital de tercer nivel para inicio de tratamiento. Conclusiones: este caso nos muestra lo ya descrito en la literatura, por lo que es de fundamental importancia hacer un abordaje integral de los hallazgos clínicos en pacientes con factores de riesgo previamente identificados, con el objetivo de lograr un diagnóstico etiológico que permita una terapéutica temprana para mejorar su sobrevida.

Quantitative myocardial perfusion evaluation with positron emission tomography and the risk of cardiovascular events in patients with coronary artery disease: a systematic review of prognostic studies.

Aims: To evaluate the prognostic value of quantitative myocardial perfusion imaging with positron emission tomography (PET) for adverse cardiovascular outcomes in patients with known or suspected coronary artery disease (CAD). Methods and results: A search in MEDLINE and Embase was conducted for studies that evaluated (i) myocardial perfusion in absolute terms with PET, (ii) prognostic value for the development of major adverse cardiovascular events (MACE), cardiac death, and/or all-cause mortality, and (iii) patients with known or suspected CAD. Studies were divided according to the radiotracer utilized and their included population (patients with and without previous infarction). Comprehensive description and a selected instance of pooling were performed. Eight studies (n = 6804) were analysed and documented clear variability in population, quantitative PET variables operationalization [stress myocardial blood flow (sMBF) and flow reserve (MFR)], statistical covariate structure, follow-up, and radiotracer utilized. MFR was independently associated with MACE in eight studies [range of adjusted hazard ratios (HRs): 1.19-2.93]. The pooling instance demonstrated that MFR significantly associates with the development of MACEs (HR: 1.92 [1.29, 2.84]; P = 0.001). sMBF was only associated with MACE in two studies that evaluated it, and only one study documented sMBF as a better predictor than MFR. Conclusion: This systematic review demonstrates the prognostic value of quantitative myocardial perfusion evaluated with PET, in the form of MFR and sMBF, for the development of major adverse cardiovascular outcomes in populations with known or suspected CAD. In the qualitative comparison, MFR seems to outperform sMBF as an independent prognostic factor. Evidence is still lacking for assessing quantitative PET for the occurrence of cardiac death and all-cause mortality. There is clear heterogeneity in predictor operationalization and study performances.

IL-17 and γδ T-lymphocytes play a critical role in innate immunity against Nocardia asteroides GUH-2.

The early host response during pulmonary nocardiosis is highly dependent on neutrophils and the successful clearance of bacteria in tissue. The data presented in this study showed that IL-17 mediated the neutrophil response following intranasal inoculation with Nocardia asteroides strain GUH-2. Flow cytometry revealed that neutrophil levels in C57BL/6 mice were increased by day 1 post inoculation and remained elevated until day 3, during which time the majority of bacterial clearance occurred. Intracellular cytokine staining for IL-17 showed a 3.5- to 5-fold increase in IL-17 producing T-lymphocytes that were predominately comprised by CD4(-)CD8(-) γδ T-lymphocytes. The importance of IL-17 and γδ T-cells was determined by the in vivo administration of antibody, capable of blocking IL-17 binding or TCR δ, respectively. Neutralization of either IL-17 or γδ T-cells in Nocardia treated mice resulted in attenuated neutrophil infiltration. Paralleling this impaired neutrophil recruitment, nearly a 10-fold increase in bacterial burden was observed in both anti-IL-17 and anti-TCR δ treated animals. Together, these data indicate a protective role for IL-17 and suggest that IL-17 producing γδ T-lymphocytes contribute to neutrophil infiltration during pulmonary nocardiosis.

The IL-23 axis in Salmonella gastroenteritis.

Non-typhoidal Salmonella (NTS) serotypes cause a localized gastroenteritis in immunocompetent individuals. In contrast, primary immunodeficiencies that impair interleukin-23 (IL-23)-dependent pathways are associated in humans with disseminated NTS bloodstream infections (bacteraemia). The recent use of animal models has helped to define the role the IL-23 axis plays during NTS gastroenteritis, but additional work is needed to elucidate how this host defence pathway prevents NTS bacteraemia.

Early MyD88-dependent induction of interleukin-17A expression during Salmonella colitis.

The development of T helper 17 (T(H)17) cells is a well-established adaptive mechanism for the production of interleukin-17A (IL-17A), a cytokine involved in neutrophil recruitment. However, pathways contributing to mucosal expression of IL-17A during the initial phase of a bacterial infection have received less attention. Here we used the mouse colitis model of Salmonella enterica serotype Typhimurium infection to investigate the contribution of myeloid differentiation primary response protein 88 (MyD88) to inflammation and mucosal IL-17A expression. Expression of IL-23 in the cecal mucosa during S. Typhimurium colitis was dependent on the presence of MyD88. Furthermore, initial expression of IL-17A at 24 h after S. Typhimurium infection was dependent on MyD88 and the receptor for IL-1ß. IL-23 and IL-1ß synergized in inducing expression of IL-17A in splenic T cells in vitro. In the intestinal mucosa, IL-17A was produced by three distinct T cell populations, including δγ T cells, T(H)17 cells, and CD4(-)CD8(-) T cells. The absence of IL-1ß signaling or IL-17 signaling reduced CXC chemokine expression but did not alter the overall severity of pathological lesions in the cecal mucosa. In contrast, cecal pathology and neutrophil recruitment were markedly reduced in Myd88-deficient mice during the initial phases of S. Typhimurium infection. Collectively, these data demonstrate that MyD88-dependent mechanisms, including an initial expression of IL-17A, are important for orchestrating early inflammatory responses during S. Typhimurium colitis.

A rapid change in virulence gene expression during the transition from the intestinal lumen into tissue promotes systemic dissemination of Salmonella.

Bacterial pathogens causing systemic disease commonly evolve from organisms associated with localized infections but differ from their close relatives in their ability to overcome mucosal barriers by mechanisms that remain incompletely understood. Here we investigated whether acquisition of a regulatory gene, tviA, contributed to the ability of Salmonella enterica serotype Typhi to disseminate from the intestine to systemic sites of infection during typhoid fever. To study the consequences of acquiring a new regulator by horizontal gene transfer, tviA was introduced into the chromosome of S. enterica serotype Typhimurium, a closely related pathogen causing a localized gastrointestinal infection in immunocompetent individuals. TviA repressed expression of flagellin, a pathogen associated molecular pattern (PAMP), when bacteria were grown at osmotic conditions encountered in tissue, but not at higher osmolarity present in the intestinal lumen. TviA-mediated flagellin repression enabled bacteria to evade sentinel functions of human model epithelia and resulted in increased bacterial dissemination to the spleen in a chicken model. Collectively, our data point to PAMP repression as a novel pathogenic mechanism to overcome the mucosal barrier through innate immune evasion.

The capsule-encoding viaB locus reduces intestinal inflammation by a Salmonella pathogenicity island 1-independent mechanism.

Salmonella enterica serotype Typhimurium elicits acute neutrophil influx in the human intestinal mucosa within 1 or 2 days after infection, resulting in inflammatory diarrhea. In contrast, no overt symptoms are observed within the first 1 or 2 weeks after infection with S. enterica serotype Typhi. Here we show that introduction of the capsule-encoding viaB locus of serotype Typhi reduced the ability of serotype Typhimurium to elicit acute intestinal inflammation in a streptomycin-pretreated mouse model. Serotype Typhimurium requires a functional invasion-associated type III secretion system (type III secretion system 1 [T3SS-1]) to elicit cecal inflammation within 48 h after infection of streptomycin-pretreated mice, and the presence of the viaB locus reduced its invasiveness for human intestinal epithelial cells in vitro. However, a reduced activity of T3SS-1 could not account for the ability of the viaB locus to attenuate cecal inflammation, because introduction of the viaB locus into an invasion-deficient serotype Typhimurium strain (invA mutant) resulted in a significant reduction of pathology and inflammatory cytokine expression in the cecum 5 days after infection of mice. We conclude that a T3SS-1-independent mechanism contributes to the ability of the viaB locus to reduce intestinal inflammation.

Interleukin-23 orchestrates mucosal responses to Salmonella enterica serotype Typhimurium in the intestine.

Salmonella enterica serotype Typhimurium causes an acute inflammatory reaction in the ceca of streptomycin-pretreated mice that involves T-cell-dependent induction of gamma interferon (IFN-gamma), interleukin-22 (IL-22), and IL-17 expression (genes Ifn-gamma, Il-22, and Il-17, respectively). We investigated here the role of IL-23 in initiating these inflammatory responses using the streptomycin-pretreated mouse model. Compared to wild-type mice, the expression of IL-17 was abrogated, IL-22 expression was markedly reduced, but IFN-gamma expression was normal in the ceca of IL-23p19-deficient mice during serotype Typhimurium infection. IL-23p19-deficient mice also exhibited a markedly reduced expression of regenerating islet-derived 3 gamma, keratinocyte-derived cytokine, and reduced neutrophil recruitment into the cecal mucosa during infection. Analysis of CD3(+) lymphocytes in the intestinal mucosa by flow cytometry revealed that alphabeta T cells were the predominant cell type expressing the IL-23 receptor in naive mice. However, a marked increase in the number of IL-23 receptor-expressing gammadelta T cells was observed in the lamina propria during serotype Typhimurium infection. Compared to wild-type mice, gammadelta T-cell-receptor-deficient mice exhibited blunted expression of IL-17 during serotype Typhimurium infection, while IFN-gamma expression was normal. These data suggested that gammadelta T cells are a significant source, but not the sole source, of IL-17 in the acutely inflamed cecal mucosa of mice. Collectively, our results point to IL-23 as an important player in initiating a T-cell-dependent amplification of inflammatory responses in the intestinal mucosa during serotype Typhimurium infection.

Simian immunodeficiency virus-induced mucosal interleukin-17 deficiency promotes Salmonella dissemination from the gut.

Salmonella typhimurium causes a localized enteric infection in immunocompetent individuals, whereas HIV-infected individuals develop a life-threatening bacteremia. Here we show that simian immunodeficiency virus (SIV) infection results in depletion of T helper type 17 (TH17) cells in the ileal mucosa of rhesus macaques, thereby impairing mucosal barrier functions to S. typhimurium dissemination. In SIV-negative macaques, the gene expression profile induced by S. typhimurium in ligated ileal loops was dominated by TH17 responses, including the expression of interleukin-17 (IL-17) and IL-22. TH17 cells were markedly depleted in SIV-infected rhesus macaques, resulting in blunted TH17 responses to S. typhimurium infection and increased bacterial dissemination. IL-17 receptor-deficient mice showed increased systemic dissemination of S. typhimurium from the gut, suggesting that IL-17 deficiency causes defects in mucosal barrier function. We conclude that SIV infection impairs the IL-17 axis, an arm of the mucosal immune response preventing systemic microbial dissemination from the gastrointestinal tract.

T cells help to amplify inflammatory responses induced by Salmonella enterica serotype Typhimurium in the intestinal mucosa.

Salmonella enterica serotype Typhimurium causes an acute inflammatory reaction in the ceca of streptomycin-pretreated mice. We determined global changes in gene expression elicited by serotype Typhimurium in the cecal mucosa. The gene expression profile was dominated by T-cell-derived cytokines and genes whose expression is known to be induced by these cytokines. Markedly increased mRNA levels of genes encoding gamma interferon (IFN-gamma), interleukin-22 (IL-22), and IL-17 were detected by quantitative real-time PCR. Furthermore, the mRNA levels of genes whose expression is induced by IFN-gamma, IL-22, or IL-17, including genes encoding macrophage inflammatory protein 2 (MIP-2), inducible nitric oxide synthase (Nos2), lipocalin-2 (Lcn2), MIP-1alpha, MIP-1beta, and keratinocyte-derived cytokine (KC), were also markedly increased. To assess the importance of T cells in orchestrating this proinflammatory gene expression profile, we depleted T cells by using a monoclonal antibody prior to investigating cecal inflammation caused by serotype Typhimurium in streptomycin-pretreated mice. Depletion of CD3+ T cells resulted in a dramatic reduction in gross pathology, a significantly reduced recruitment of neutrophils, and a marked reduction in mRNA levels of Ifn-gamma, Il-22, Il-17, Nos2, Lcn2, and Kc. Our results suggest that T cells play an important role in amplifying inflammatory responses induced by serotype Typhimurium in the cecal mucosa.