Gut Involvement Research Articles

Falling Serum Albumin Predicts Severity of Acute Graft-Vs.-Host Disease and Non-Relapse Mortality After Non-Myeloablative Allogeneic Hematopoietic Cell Transplantation.

Abstract 1146Poster Board I-168 BACKGROUNDAcute graft-vs.-host disease (aGVHD) varies in its intensity and response to therapy. Biomarkers capable of differentiating treatment-responsive from severe aGVHD at symptom onset may enable risk-stratified therapy. With the advent of prophylactic ursodiol, liver aGVHD has become rare, and gut involvement is responsible for much of the morbidity and mortality associated with severe aGVHD. Protein loss through altered epithelial tight junctions, and ultimately through mucosal necrosis, results in hypoalbuminemia in severe aGVHD (Weisdorf et al., Gastroenterology 1983 85:1076-81). We hypothesized that intestinal protein loss correlated with severity of aGVHD and thus predicted outcome. To test this hypothesis, we retrospectively evaluated changes in serum albumin as a marker of protein loss at the onset of aGVHD symptoms. To reduce the confounding effect of regimen-related gut toxicity, we restricted our analysis to patients who received non-myeloablative conditioning. PATIENTS AND METHODSAmong 708 recipients of a first non-myeloablative allogeneic HCT at our Center, 412 (58%) developed aGVHD grade II–IV. We retrospectively evaluated these 412 patients (336 grade II; 76 grade III/IV). Patients were conditioned with 2 Gy total body irradiation, with or without fludarabine 90 mg/m2. Post-grafting immunosuppression consisted of cyclosporine and mycophenolate mofetil, and corticosteroids were used as first-line treatment of aGVHD. Median patient age was 55 (range, 1–75) years. 170 patients (41%) had related donors. Among the 242 patients (59%) with unrelated donors, there were 31 HLA-allele-mismatched donors, 28 HLA-antigen-mismatched donors, and 6 allele and antigen mismatched donors. We reviewed all serum albumin values from 30 days before to 45 days after clinical onset of aGVHD. The lowest albumin value in the 30 days before HCT was considered a patient's baseline value. Trends in serum albumin before and after aGVHD onset were compared among patients with peak grade II vs. peak grade III/IV aGVHD. We also compared 6-month estimates of non-relapse mortality (NRM) associated with changes in serum albumin and the performance of falling serum albumin as a predictor of grade III/IV aGVHD. RESULTSClinical onset of aGVHD in the study cohort occurred at a median of 35 days after HCT. Patients who went on to develop severe (grade III/IV) aGVHD showed sharp decreases from baseline serum albumin levels; these decreases were already apparent at the onset of clinical aGVHD (Fig. 1). In contrast, patients whose aGVHD never exceeded grade II showed no changes on average from baseline serum albumins at aGVHD onset. Receiver-operator characteristic (ROC) curves demonstrated that among patients with new-onset symptoms of aGVHD requiring treatment, a drop from baseline in serum albumin of 0.5 g/dL optimally discriminated between those who went on to develop severe aGVHD versus those whose aGVHD peaked at grade II (ROC area under curve, 0.75). A drop from baseline albumin of 0.5 g/dL at onset of aGVHD symptoms was also associated with an increased risk of NRM at 6 months after aGVHD onset (28% vs. 8%, HR 2.13 [1.3–3.4], p=0.002; Fig. 2). CONCLUSIONA sharp decrease in serum albumin may precede and predict severe aGVHD as well as NRM. Serial measurement of serum albumin is an inexpensive and readily available potential prognostic biomarker in patients with new-onset symptoms of aGVHD after non-myeloablative allogeneic HCT. In combination with other biomarkers or clinical predictors of aGVHD severity, the kinetics of serum albumin may enable specific and risk-stratified targeting of therapies for aGVHD, reserving intensive and protracted immunosuppression for the small percentage of patients at highest risk of severe aGVHD.FIGURES: [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

HLA‐B27 Transgenic Rat

The HLA-B27 gene is strongly associated with the spondyloarthropathies (SpA), a group of chronic inflammatory diseases affecting the bowel, the joints, and the axial skeleton. Yet the basis for this association remains unknown, despite extensive study in the past years. The HLA-B27 transgenic rat spontaneously develops a disease that strikingly resembles human SpA. The purpose of this article is to review the contribution of studies on the HLA-B27 transgenic rat model aimed to elucidate the intimate relationship between gut and joint involvement in SpA.

Sirolimus as Primary Treatment of Acute Graft-versus-Host Disease following Allogeneic Hematopoietic Cell Transplantation

Glucocorticoids have gone unchallenged as an essential component of primary therapy for acute graft-versus-host disease (aGVHD) after allogeneic hematopoietic cell transplantation (HCT) despite limited complete response rates and adverse effects from this therapy. The role for alternate immunosuppressive agents as primary aGHVD treatment remains unexamined. In a series of 10 patients at high risk for corticosteroid toxicity or leukemia relapse who developed biopsy-proven grade II-III aGVHD after hematopoietic cell transplantation, we report that primary therapy with sirolimus resulted in durable complete remission of aGVHD in 5 (50%) without requirement for glucocorticoids. Mild chronic GVHD (cGVHD) developed in 4 (40%). Projected overall survival (OS) at 18 months is 79% (95% confidence interval [CI]: 38.1%-94.3%), and projected relapse-free survival (RFS) at 15 months is 70% (95% CI: 32.9%-89.2%). Sirolimus was well tolerated with mild and reversible thrombotic microangiopathy occurring in 2 patients. This experience provides preliminary evidence for the efficacy of sirolimus as a sole primary therapy in the treatment of aGVHD.

Daclizumab therapy for children with corticosteroid‐resistant acute graft‐vs.‐host disease

MAbs such as daclizumab have shown promising results in the treatment of corticosteroid-resistant aGVHD. Data describing the efficacy of MAbs in children are limited. We describe the efficacy of daclizumab in children with corticosteroid-resistant aGVHD. Seventeen children (0.4-16.2 yr) received daclizumab for aGVHD. Safety was evaluated in all 17. Response was evaluated in the 15 children who received a full course of daclizumab. A PR was defined as improvement of aGVHD symptoms in at least one organ without worsening in other organs. We observed an overall response rate (CR plus PR) of 40% (6/15). Four children had a CR and two had a PR. aGVHD involving the gut had the highest response rate (five of 10; 50%). Adverse effects attributed to daclizumab were limited to an episode of reactive arthritis. Mortality was high (47%; eight of 17) though five of the six responders to daclizumab survived. The mean length of follow-up in the surviving nine patients was 32 months (range seven to 48). We conclude that daclizumab is effective in the treatment of children with corticosteroid-resistant aGVHD, especially in patients with gut involvement.

Sirolimus and Mycophenolate Mofetil as Graft-Versus-Host Disease Prophylaxis in Myeloablative, Matched Related Donor Hematopoietic Cell Transplantation

We investigated a novel graft-versus-host disease (GVHD) prophylactic regimen, sirolimus and mycophenolate mofetil (MMF), in patients with advanced hematologic malignancies receiving myeloablative hematopoietic cell transplantation (HCT) from matched related donors (MRD). The sirolimus and MMF combination was chosen based on intriguing evidence of sirolimus, and less dramatically MMF, conserving the inhibition of T cell proliferation compared to cyclosporine (CSP) in an AGVHD murine model as well as multiple reports supporting sirolimus' preservative or augmentative effects on the T regulatory cell population (CD4+CD25+, FoxP3+) in animals and humans in comparison to cyclosporine (CSP) and a theoretical reduction in the incidence and severity of AGVHD. In addition, this regimen may cause less severe toxicities compared with standard methotrexate and/or calcineurin inhibitor (CI)-containing GVHD prophylactic regimens. Sirolimus was begun as an oral medication on day -3 with a 12 mg loading dose followed by 4 mgs daily, dose adjusted to maintain serum trough levels of 3–12 ng/ml. MMF was begun on D0 at 15 mg/kg IV every 12 hours. Mycophenolic acid (MPA) pharmacokinetics were conducted on days 2 and 21 post-HCT. Sirolimus and MMF were scheduled to be tapered simultaneously beginning 100 days post-HCT. FoxP3+ cell populations in the peripheral blood (PB) were analyzed before and after HCT in the patients receiving sirolimus and MMF GVHD prophylaxis as well as in 15 control patients with similar disease categories and preparative regimens receiving CI-containing GVHD prophylaxis. Based on pre-study stopping rules of expected grade II–IV AGVHD incidence, the trial was closed to accrual after enrollment of 11 patients. The median age of the 11 patients was 51 years (26–59). The diagnoses of the study patients included myelodysplasia (5), acute myelogenous leukemia (3) and nonhodgkin lymphoma (3). Seven patients received busulfan, etoposide and cyclophosphamide (CY); three patients received carmustine, etoposide and CY and one patient received total body irradiation, etoposide and CY as the preparative regimens. Sirolimus was discontinued in 4 patients due to concern for toxicity-related events including severe sinusoidal obstructive syndrome (1), altered mental status (1), portal vein thrombosis (1) and risk of poor wound healing after abdominal exploratory surgery (1) 9 days, 9 days, 61 days and 39 days post-HCT, respectively. Six of 11 patients developed grade II-IV AGVHD a median of 15.5 days post-HCT (range 11–25 days), 3 of the 6 with grade IV AGVHD. Two of the 3 patients with grade IV AGVHD required discontinuation of sirolimus 9 days post-HCT due to toxicity. Five of the 6 AGVHD patients had skin-only and one had liver, gut and skin involvement. All patients responded to AGVHD therapy and there were no AGVHD-related deaths. One patient died 54 days post-HCT due to complications of colonic ulceration believed related to oral MMF therapy. Two patients died of relapsed disease at 103 and 304 days post-HCT. At a median follow-up of 416 days (328–652 days), 8 of 11 patients were alive without disease, 5 with active chronic GVHD. The median MPA area under the curve (AUC) on day 2 was 12.8 mcg*hr/mL (6.4–17.4) and day 21 was 17.9 mcg*hr/mL (8–26.6). We measured a statistically significant increase in the percentage of CD4+FoxP3+ cells per total CD4+ cells in the sirolimus/MMF study group compared to the CI historical control group with a mean of the individual patient means over the first 100 days post-HCT of 16% versus 6%, respectively (p.0005). Despite the increased percentage of CD4+FoxP3+ cells per total CD4+ cells identified in the PB of the sirolimus/MMF cohort, the incidence of grade II-IV AGVHD was similar to the CI cohort (6 of 11 versus 7 of 15, respectively). However, all but one patient had skin-only AGVHD and there were no GVHD-related deaths in the sirolimus/MMF group. All patients requiring early withdrawal of sirolimus had received the busulfan-containing preparative regimen with two of these patients developing severe AGVHD. In a subsequent GVHD prophylaxis trial including sirolimus and MMF, the busulfan-containing preparative regimen will be eliminated to optimize sirolimus and MMF administration with the continued goal of reducing the incidence and severity of AGVHD.

Initial Liver Involvement in Acute Graft-Versus-Host Disease (GVHD) Predicts a Severe Acute Gvhd and Poor Long-Term Survival

Objectives: Current grading systems in acute GVHD can not effectively identify patients with poor prognosis at time of GVHD diagnosis. The aim of this study was to evaluate clinical or biological parameters at the onset of GVHD associated with poor prognosis of acute GVHD.Methods: Among 257 patients (pts) who received an allogeneic stem cell transplant (SCT) after a myeloablative conditioning regimen between 1993 and 1999, 146 pts developed acute GVHD. One hundred-day cumulative incidence of acute GVHD was 57.3% (95%CI 51.1–63.4) whereas 100-day cumulative incidence of death non related to GVHD was 5.3% (95%CI 2.5–8.1). Patients with acute GVHD were analyzed for risk factors associated with non-relapse-mortality (NRM) using proportional cause-specific hazards models.Characteristics of patients: Median age was 32 years (from 4 to 60 years). Sex ratio men/women was 1,4. Disease was defined as low risk (n=43) (acute leukemia in first remission, aplastic anemia without more than 20 blood transfusions before transplantation and chronic myeloid leukemia in first chronic phase) and high risk (n=99, all other diagnosis). Source of stem cell was bone marrow in 106, peripheral blood stem cells in 23 and cord blood in 13 pts. 87 patients received SCT from a sibling donor and 55 patients from an unrelated donor. 85 patients were HLA identical with their donor. Median follow-up was 76 months.Results: At time of diagnosis, GVHD involved a single organ in the majority of the patients (109 pts, 78%): skin for 63, gut for 35, liver for 11 pts. 37 patients had multiple organs affected by GVHD: 34 patients had 2 organs and 3 had 3 organs (liver, skin and gut). The Table 1 shows acute GVHD grade from diagnosis to maximal grade.Table 1Maximal gradeInitial gradeNo GVH1234TotalNo GVH111----111 (43%)1-311631060 (23%)2-056131483 (32%)3-00213 (1%)Total111 (43%)31 (12%)72 (28%)18 (7%)25 (10%)257Overall 1-year NRM was 54.9% (95%CI 46.6–63.2). 57 patients experienced a failure to corticosteroid treatment and were considered as “non-responders”. Covariates tested for NRM predictive factors were gender, CMV status, conditioning regimen, source of SCT, HLA match, hematological disease, initial characteristics of GVHD and response to treatment after 7 days. Significant (p < 0.05) risk factors for NRM were non sibling donor (NRM: 64.5% [51.5–77.5]), absence of methotrexate in GVHD prophylaxis (NRM: 67.3 [50.2–84.5]), initial liver involvement (NRM: 80.2% [62.2 to 98.2]) and acute GVHD resistant to corticosteroids (NRM: 78.9 % [68.1–89.8]). Patients who were responder to corticosteroids had same NRM than patients who did not develop any GVHD. Albumin level (alb) was associated with NRM in patients with initial gut involvement (NRM 21.4% [0.0–44.0] in pts with alb > or = 35 and 61.1% [37.4–84.8] in pts with alb < 35 gr/L, p=0.035). Initial grade was not significantly associated with NRM: 1-year cumulative incidence was 52.4% (39.3–65.6), 56.3% (45.3–67.4) and 66.7% (0.0–00) in patients with initial grade I, II and III, resp. as compared to 26.2% (17.4–5.0) in patients without GVHD. In multivariate analysis, initial liver involvement (HR: 2.45 (1.46 to 4.12), p=0.0007) and non sibling donor (HR: 1.58 (1.02 to 2.43, p= 0.0039) were both associated with NRM.Conclusion: In this study, classification of GVHD at time of diagnosis was not predictive for NRM. Initial liver involvement was the most important clinical predictor and may be considered in clinical management and need prospective clinical trials.

Amylose AA

Amyloidosis remains one of the three major types of multisystemic amyloidosis, with immunoglobulinic (AL) and hereditary varieties. Recently, however, its incidence has been decreasing in Western countries. Inflammatory disorders are currently the major causes of amyloid-associated (AA) amyloidosis; first of all it is rheumatoid arthritis, then ankylosing spondylarthropathy and auto-inflammatory syndromes. Some tumours may lead to amyloidosis, including Castleman's disease. Complete surgery can result in regression of amyloid. It is not exactly known why some patients develop a progressive amyloidosis, whereas others do not. A permanent acute phase response, ideally evaluated with serial measurement of serum protein SAA, the precursor of the AA protein deposited in tissues, seems to be a prerequisite to the development of inflammatory (AA) amyloidosis. Genetic factors have however been recently emphasized. Nephropathy is the main clinical manifestation of amyloidosis. Serial search for proteinuria and serum creatinine measurement remain quite useful for detecting the first sign of renal impairment during chronic inflammatory disorders. A thorough diagnosis of AA amyloidosis deserves to gather whole clinical and pathological data, including immunohistochemistry. Some pitfalls exist and another type of amyloidosis should not be misdiagnosed as the AA variety. Ultimate renal failure and gut involvement with denutrition account for the persistent poor prognosis of AA amyloidosis. Current treatment aim at decreasing the inflammatory response; drugs targeting other steps of amyloid deposition are currently developed.

Reduced-Intensity Conditioning Allogeneic Transplantation from Unrelated Donors: Evaluation of Mycophenolate Mofetil Plus Cyclosporin A as Graft-versus-Host Disease Prophylaxis

In the current study, we have analyzed the efficacy of cyclosporine A (CSA) plus mycophenolate mofetil (MMF) as graft-versus-host disease (GVHD) prophylaxis in the fludarabine plus melphalan or busulfan reduced intensity regimen (RIC) setting in a series of 44 patients receiving allogeneic transplantation from an unrelated donor. Only 23% were in the first complete remission at the time of transplant. Cumulative incidence of grades II-IV and III-IV acute GVHD (aGVHD) was 53% and 23%, respectively. Fifty-six percent had equal to or greater than grade 2 gut involvement. Cumulative incidence of overall and extensive chronic GVHD (cGVHD) was 93% and 63%, respectively. Ninety-two percent of patients who were evaluable +100 days after transplant were in complete remission. Relapse rate was 25% at 2 years. Event free (EFS) and overall survival (OS) at 2 years were 52%. Pharmacokinetic assays of mycophenolic acid (MPA) showed a therapeutic area under the curve (AUC) at the dosage of 3 g daily, although a large inter- and intraindividual variations of MPA plasma levels were found. In conclusion, the combination of CSA plus MMF in the fludarabine plus melphalan or busulfan RIC setting is feasible. Regarding GVHD, this combination allowed to control aGVHD but lead to a high incidence of cGVHD, so that newer strategies are required, especially in trying to decrease gastrointestinal involvement.

I02 GVHD and extracorporeal photopheresis

Graft-versus-host disease (GVHD) is a major cause of mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Extracorporeal exposure of peripheral blood mononuclear cells to the photosensitizing agent 8-methoxypsoralen and ultraviolet A radiation has been shown to be effective in treatment of selected T-cell mediated diseases, including cutaneous T-cell lymphoma and rejection after organ transplantation. In a phase II study on patients with steroid-refractory acute GVHD grades II to IV given adjunct ECP as secondline therapy CR was achieved in 82% of patients with cutaneous involvement, 61% with liver involvement, and 61% with gut involvement. The probability of survival was 59% among patients who responded completely to ECP compared to 11% in patients not responding completely. Thus, intensified ECP was highly effective in acute GVHD and sustained responses are associated with over 50% long-term survival. Currently, a randomized controlled multicenter study of ECP is ongoing for the treatment of patients with newly diagnosed acute GVHD. ECP given in retrospective studies to heterogeneous patient populations is associated with high response rates in chronic extensive GVHD with skin, liver and oral involvement. In a recent multicenter, prospective, phase II study in steroidintolerant, steroid-dependent or steroid-refractory chronic GVHD patients, ECP was effective in skin manifestations and steroid-sparing could be demonstrated. ECP was well tolerated with a safety profile consistent with previous studies.

Gastrointestinal Involvement in Pediatric Polyarteritis Nodosa

Gastrointestinal Involvement in Pediatric Polyarteritis Nodosa

Atypical skin graft‐vs.‐host disease following bone marrow transplantation in an infant

Herein, we describe an unusual presentation of acute graft versus host disease (GVHD) mimicking contact dermatitis in an infant who underwent 5/6 HLA-matched bone marrow transplantation (BMT) from his mother for malignant infantile osteopetrosis. The initial rash on day +32 simulated diaper rash, which progressed to a belt-shaped rash and then developed hyperkeratotic nodules on the hands. The acute GVHD was atypical and the course was progressive and fatal, with liver and gut involvement. This presentation of atypical initial skin involvement of acute GVHD may be useful for practicing clinicians in the BMT field who need to be aware of the early unusual signs of acute GVHD so that they can initiate prompt treatment.

Invasive aspergillosis localised to the colon presenting as toxic megacolon

Primary gut involvement by Aspergillus is an exceedingly rare and often a fatal complication of intensive chemotherapy in patients with acute leukaemia. We report a 46-yr-old patient with granulocytic sarcoma of the testis. He received acute myeloid leukaemia type treatment with ADE chemotherapy (Cytosine Arabinoside, Daunorubicin and Etoposide). While neutropenic he presented with pyrexia, abdominal pain and massive abdominal distention. He was treated with intravenous antibiotics and antifungals according to our usual institutional protocol without any response. He was found to have toxic megacolon on plain X-ray and subsequently underwent total colectomy and ileostomy. The colon histology showed Aspergillus fungal hyphae infiltrating the bowel wall. There was no any evidence of pulmonary, hepatic, splenic or renal lesions on the computerised tomography scan. Following colectomy, he was treated with 2 wk of antifungal treatment. He recovered well and was discharged home. The increased awareness, high degree of clinical suspicion of unusual presentation and early surgical intervention with aggressive antifungal treatment, has a key role in the management of these rare and often fatal cases.

Treatment of Steroid-Resistant Graft-Versus-Host Disease with Monoclonal Antibodies in Children.

Acute graft-versus-host disease (aGVHD) carries a major risk of morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). The prognosis is poor if aGVHD does not respond to corticosteroid treatment. Recently, monoclonal antibodies such as daclizumab, a humanized monoclonal IgG1, and infliximab, a chimeric monoclonal antibody that binds the precursor of tumor-necrosis factor-alfa, have shown promising results in the treatment of corticosteroid-resistant aGVHD. The reported response rate to monoclonal antibody therapy in adults with aGVHD reaches as high as 67%. Data describing the efficacy of monoclonal antibodies in children with corticosteroid-resistant aGVHD are limited. We conducted a retrospective analysis to evaluate the efficacy of daclizumab and/or infliximab in children diagnosed with steroid-resistant aGVHD in the Hospital for Sick Children, Toronto, from July 2002 to December 2005. Corticosteroid-resistant aGVHD was defined as aGVHD which did not respond or worsened after a minimum of 5 days of corticosteroid therapy. Complete response was defined as full recovery without any signs of aGVHD; partial response was defined as improvement of aGVHD symptoms in at least one organ without worsening in other organs. Sixteen children were treated for aGVHD, thirteen of them had aGVHD grade 3 or 4. The organs involved were gut (n=6), skin (n=4), liver (n=2) and multi-organ involvement (n=4). Thirteen children were given daclizumab; one was treated with infliximab and 2 children with their combination. Fourteen children received a full course of monoclonal antibodies for aGVHD. An additional child died after the first dose (from multi-organ failure) and one child developed reactive arthritis attributed to daclizumab. Seven of the 14 children (50%) who completed treatment responded: 5 had complete response and 2 had a partial response. Nine out of the 16 children died during the study period: 8 due to Transplant Related Mortality (TRM) and 1 due to relapse; three children developed fatal fungal infection and one had fatal adenovirus infection during or shortly after monoclonal antibody treatment. Median length of follow up in the remaining 7 patients was 18 months. We conclude that monoclonal antibodies were effective in the treatment of children with corticosteroid-resistant acute GVHD. The risk for infection, mainly fungal, was high.

Oral Beclomethasone Dipropionate for the Treatment of Gastrointestinal Acute Graft-versus-Host Disease (GVHD)

Acute graft-versus-host disease (aGVHD) remains one of the most severe complications after allogeneic transplantation; in particular, the presence of gut involvement has been related to increased mortality and poorer response. The use of systemic steroids remains the standard for first-line treatment despite its severe secondary effects. Beclomethasone dipropionate (BDP) is a topically active corticosteroid with low absorption, thereby avoiding many of the deleterious side effects associated with systemic steroids. In the present study we analyzed the efficacy of BDP in a series of 26 patients who were diagnosed with grade 1 and 2 gastrointestinal aGVHD. Twenty patients (77%) responded to BDP treatment, 17 (65.5%) reached complete remission (CR), and 3 (11.5%) showed partial response. Among those patients who reached CR, 5 relapsed, although 1 of them reached second CR after a second course of BDP; therefore, 13 (50%) of the 26 patients did not require systemic steroids to treat gastrointestinal aGVHD. CR rates in those showing gastrointestinal symptoms were 68% for patients with persistent nausea, 50% for those with vomiting, and 54% for those with diarrhea ( P = .2). No patient included in the study developed any symptom related to adrenal axis suppression. Thirteen patients (50%) developed ≥1 infectious episode during the first 100 days after transplantation. Transplant-related mortality was 0% at 100 days, and overall transplant-related mortality was 30%, with only 2 patients dying due to infectious complications. Therefore, our study shows that monotherapy with oral BDP is an effective initial therapeutic approach for mild to moderate intestinal GVHD, which avoids complications related to systemic steroids.

Fecal S100A12: A novel noninvasive marker in children with Crohnʼs disease

The calcium-binding protein S100A12 is related to calprotectin, a protein shown to be a useful marker of gut inflammation. S100A12 levels are elevated in serum and mucosa of children with inflammatory bowel disease (IBD) and may be implicated in the pathogenesis of IBD. The aims of this study were to validate an immunoassay for the detection of fecal S100A12, to assess its value as a new noninvasive marker of gut inflammation, and to investigate S100A12 levels in feces of children with IBD at diagnosis and during treatment. Feces were collected from children with active IBD at diagnosis and during treatment for IBD and from normal healthy control subjects. Fecal and serum levels of S100A12 were measured by immunoassay. A sensitivity of 96% and a specificity of 92% were observed when 10 mg/kg fecal S100A12 was used as a cutoff. S100A12 levels were evenly distributed throughout fecal samples and were stable for 7 days when stored at room temperature. Fecal S100A12 was elevated in children with IBD compared with healthy control subjects, with levels closely correlated to disease activity and other serum inflammatory markers, particularly lower gut involvement. Fecal S100A12 levels fell during therapy in children entering remission with normal C-reactive protein levels. Fecal S100A12 is a novel noninvasive marker that distinguishes children with active IBD from healthy control subjects with high sensitivity and specificity. Fecal S100A12 possesses characteristics that are desirable for a noninvasive disease marker and therefore is a suitable candidate marker for IBD. Further evaluation is required to examine this marker in additional contexts.

Improvement in orofacial granulomatosis on a cinnamon- and benzoate-free diet

Orofacial granulomatosis (OFG) is a chronic inflammatory disorder presenting characteristically with lip swelling but also affecting gingivae, buccal mucosa, floor of mouth, and a number of other sites in the oral cavity. Although the cause remains unknown, there is evidence for involvement of a dietary allergen. Patch testing has related responses to cinnamon and benzoate to the symptoms of OFG, with improvement obtained through exclusion diets. However, an objective assessment of the effect of a cinnamon- and benzoate-free diet (CB-free diet) as primary treatment for OFG has not previously been performed. Thus, this study was undertaken to investigate the benefits of a CB-free diet as first-line treatment of patients with OFG. Thirty-two patients with a confirmed diagnosis of OFG were identified from a combined oral medicine/gastroenterology clinic. All had received a CB-free diet as primary treatment for a period of 8 weeks. Each patient underwent a standardized assessment of the oral cavity to characterize the number of sites affected and the type of inflammation involved before and after diet. There was a significant improvement in oral inflammation in patients on the diet after 8 weeks. Both global oral and lip inflammatory scores improved (P<0.001), and there was significant improvement in both lip and oral site and activity involvement. However, improvement in lip activity was less marked than oral activity. Response to a CB-free diet did not appear to be site specific. A history of OFG-associated gut involvement did not predict a response to the diet. The impact of dietary manipulation in patients with OFG can be significant, particularly with regard to oral inflammation. With the disease most prevalent in the younger population, a CB-free diet can be recommended as primary treatment. Subsequent topical or systemic immunomodulatory therapy may then be avoided or used as second line.

Oral beclomethasone dipropionate for the treatment of gastrointestinal acute graft versus host disease (GVHD)

Treatment of gut GVHD relies on systemic immunosuppressive therapy such as glucocorticoids. The risk of systemic immunosuppression includes infections, hypothalamic-pituitary-adrenal axis suppression, myopathy, glucose intolerance, neuropsychiatric disease and bone demineralization, among others. Beclomethasone dipropionate (BDP) is a topically active corticosteroid with a low absorption, thus avoiding many of the deleterious side effects associated with systemic immunosuppression. In the current study we describe the safety and efficacy of DBP as a single agent in a series of 26 patients diagnosed with acute gut GVHD after allogeneic peripheral blood stem cell transplantation. All patients developed symptoms of acute GVHD with biopsy proven gut GVHD and received DBP as an oral solution in olive oil at a dose of 2 mg q6h for 28 days. Symptoms of gut involvement consisted of nausea (n = 19), vomiting (n = 12) and/or diarrhea (n = 13). Seven patients had grade 1 GI-GVHD (stage B overall aGVHD) and nineteen had grade 2 GI-GVHD (stage C aGVHD). Median day for DPB treatment was +48 after transplant. Overall response rate was 81%, 19 patients achieve complete response (70%) and 3 partial response (11%). There were no differences regarding acute gut GVHD symptoms and response rate. Only 7 did relapse among responder patients. Overall percentage of patients finally requiring steroid treatment after DPB was 41%. Cumulative incidence of TRM is this series of stage B and C aGVHD patients was 30% and overall survival 41% at 18 months. In the current study DBP was well tolerated and showed efficacy as a single agent in acute gut GVHD treatment avoiding the requirement for systemic immunosuppression in a significant proportion of patients.

Oesophageal and severe gut involvement in the haemolytic uraemic syndrome

Between 1982 and 1989, 78 children with diarrhoea-associated haemolytic uraemic syndrome (HUS) were referred to this hospital. Most presented with abdominal pain, bloody diarrhoea and vomiting. Seven had severe gastrointestinal involvement, four of whom required resection for bowel perforation or necrosis. One also developed an oesophageal stricture, a previously unreported complication of HUS. These seven children had a high incidence of other complications including hypertension, and cerebral and pancreatic involvement. One died from severe cerebral involvement, one has a residual neurological deficit and one has residual renal impairment. Severe gastrointestinal involvement did not significantly affect the long-term outcome. Simple haematological indices helped predict severe gut involvement. Four of the 78 children had undergone appendicectomy before the diagnosis of HUS was made. The operative findings were in no case typical of primary acute appendicitis, although histological examination did confirm inflammation of the appendix in two patients. Diagnosis is difficult in early disease, but increased awareness may help prevent unnecessary appendicectomy.

Lack of Detection of FIP1L1-PDGFRA Gene Fusion in a Cohort of Mastocytosis with Eosinophilia.

Mastocytosis (MCD) is a heterogeneous disorder characterized by mast cells (MC) infiltration in various organs, mostly linked to Asp816Val c-kit mutation. Idiopathic hypereosinophilic syndrome (HES) as defined by Chusid et al criteria is linked to the expression of the FIP1LI-PDFRA fusion gene. An overlap between MCD with eosinophilia and HES may exist and in some instance FIP1LI-PDFRA HES with mast cells excess and high serum tryptase has been described as MCD variant with eosinophilia. Among a cohort of 250 MCD patients we analyzed clinical, biological, and genotypic data of 14 patients who had a sustained and elevated eosinophil count> 700/mm3.Clinical data for MCD comprised symptoms related to MC infiltration and mediators release. Patients were classified following the Valent et al classification. Biological data referred to serum tryptase (nl <15 ng/mm3), blood cell count, IgE levels (nl< 200 UI). Cytopathology analysis of bone marrow. C-kit Asp816Val c-kit mutation was performed in involved skin and/or bone marrow. FIP1L1-PDGFRA fusion gene detection was performed in RNA of PBMCs and Bone marrow by PCR. Three control patients with HES without any criteria of SMCD were also investigated for FIP1L1-PDGFRA fusion gene. Fourteen patients with eosinophilia (Median 2305/mm3 (729–35000/mm3) were retrieved. Eosinophilia was detected before MCD for 7 cases (1 to 11 years), concomitantly for 6 cases and after for one case Patients characteristics were as follow: 8 females, 6 males, 56 ± 21 (18–76) years at MCD diagnosis, with flush (57%), shock (7%), urticaria pigmentosa (85%), gut involvement(74%), hepatosplenomegaly (43%), ascitis (36%), bone involvement (36%). All except two patients had systemic MCD (3 indolent, 5 aggressive, 3 associated with clonal haematological disorder (2 AMLs, 1CMML), 1 mast cell leukemia). Median serum tryptase value was a 100 ng/mm3. Haematological abnormalities were: thrombocytopenia (n=2), anemia (n=2), monocytosis (n=2). IgE levels were within normal value except for one patient with isolated cutaneous mastocytosis. Cytopathologic analysis showed mast cells in bone marrow except in two cases, and variable eosinophilic count infiltration (3 to 40%). Cytogenetic analysis found for two pts a 20q deletion and one monosomy 7. C-kit Asp816Val c-kit mutation was positive for all pts. FIP1L1-PDGFRA fusion gene detection was negative in all cases, but positive in the three HES. Four out six pts, treated for MCD with cladribine had a durable efficacy on eosinophilia count concomitantly to regression of MCD symptoms, whereas Interferon had no effect. 4 patients died as the consequence of the associated haematological disorders. In conclusion, Eosinophilia rarely occurs in MCD, but does so in all types of MCD. In contrast to HES it is not associated with FIP1L1-PDGFRA gene fusion but with D816V c-kit mutation. Therefore, it should not be treated with Glivec but with cladribine.

Risk Factor Analysis for Predicting Chronic Graft-Versus-Host Disease of Progressive or Quiescent Type in a Cohort of Patients with a History of Acute Graft-Versus-Host Disease after Allogeneic Stem Cell Transplantation.

Background: As a series of our previous investigation (Haematologica, 2005. 90: 939–48) identifying poor prognostic factors (lymphocytopenia and visceral involvement) at the onset of acute GVHD (aGVHD) in patients with a history of aGVHD after allogeneic stem cell transplantation (SCT), we tried to identify variables that could predict the development of chronic GVHD of progressive or quiescent type (pq cGVHD) and patients' outcome after the diagnosis of cGVHD in cohort of 99 patients who experienced aGVHD after allogeneic SCT.Patients and Methods: We evaluated the risk factors for cGVHD of pq cGVHD with various clinical parameters in patient group with a history of aGVHD and also the prognostic significance of various clinical parameters at diagnosis of cGVHD to determine the prognostic factor for GVHD-specific survival (GSS) in patients with pq cGVHD.Results: From 118 patient experienced aGVHD of any degree, 99 patients were evaluated for cGVHD. The cumulative incidence of overall and extensive pq cGVHD at 2 years was estimated as 84.4% and 63.1%, respectively. In univariate analyses for risk factors of pq cGVHD, severe grade 3,4 aGVHD, primary treatment failure (PTF), lymphocytopenia (≤100/μl), elevated ALP (>160IU/l), visceral involvement, hepatic or gut involvement were identified. Especially, severe aGVHD (p=0.022 and <0.001), PTF (p=0.009 and 0.010) for overall and extensive pq cGVHD, lymphocytopenia (p=0.031) for extensive pq cGVHD, and elevated ALP (p=0.001) for overall pq cGVHD were independent risk factors. The prediction model of subsequent pq cGVHD validated these risk factors with respect to the incidences of overall pq cGVHD (48.6% versus 91.9% for no risk factor versus 1~3 risk factor(s)) and of extensive pq cGVHD (34.2% versus 59.6% versus 92.2% for no / 1 / 2~3 risk factors). HLA-disparity and stem cell source did not influence on the development of pq cGVHD in this cohort. The GSS and probability of systemic immunosuppressive treatment at 2 year after diagnosis of cGVHD was estimated as 55.9% and 51.9%. The GSS was significantly associated with the performance status (p=0.004) and lymphocytopenia (≤ 1,000/μl, p=0.022) at diagnosis of cGVHD by Cox's proportional hazard model.Conclusion: Severe aGVHD, PTF, lymphocytopenia and elevated ALP may be useful predictive factors for the development of pq cGVHD in a cohort of patients who experienced a GVHD after allogeneic SCT. [Display omitted]