Alpaslan Tanoglu

Healing effects of omalizumab in a patient with cholinergic urticaria associated severe dyspeptic complaints.

To the Editor: Cholinergic urticaria (CU) is a type of physical urticaria characterized by a number of short-lasting, highly pruritic weals. The underlying pathological mechanism of CU is not fully understood.[1] Omalizumab is a humanized, monoclonal IgG anti-IgE antibody that binds specifically to circulating IgE molecules, thus interrupting the allergic cascade.[2] The efficacy of anti-IgE treatment has been shown in many disorders with complex and unclear etiology, comprising physical urticarias, chronic idiopathic urticaria, angioedema and eosinophil-associated gastrointestinal disorders.[3] n nA 38-year-old Caucasian male with severe CU was presented to GATA Haydarpasa Training Hospital in September 2014. Severe dyspeptic complaints including epigastric pain and upper abdominal fullness were accompanied the urticarial lesions for 6 months. He mentioned that approximately 20–30 min after many kind of foods and mild exercise severe pruritic hives took place, especially on the trunk and upper extremities [Figure 1]. He also indicated that the dyspeptic complaints were not improved by use of H2 receptor antagonists or proton pump inhibitors (PPIs). His physical examination was unremarkable. Laboratory tests including whole and routine blood count, liver and thyroid function tests, anti-nuclear antibody, rheumatoid factor and total tryptase levels were normal. Total IgE levels were 46 U/ml. He was prescribed various sedating and nonsedating antihistamines, leukotriene receptor antagonist and anticholinergics. Corticosteroids had a positive effect on urticarial lesions but were ceased due to severe dyspeptic complaints. He underwent an upper gastrointestinal endoscopy and was diagnosed as “eritematous pangastritis.” Histopathological examination revealed minimal to moderate chronic superficial inflammation without activation. Helicobacter pylori infection and “eosinophilic gastritis” were not detected. He was then prescribed different PPIs (lansoprazole and esomeprazole), but, unfortunately, his gastric complaints were not improved. Although using high dose antihistamines and leukotriene antagonists, his CU associated symptoms were not healed. Afterwards, he was prescribed omalizumab 150 mg solution for injection monthly. One month later he was re-evaluated. The life quality of the patient was prominently improved shortly after the first dose, as demonstrated with the dermatologic life quality index,[4] and gastric complaints almost completely disappeared. He is still given omalizumab treatment regularly. He has had minimal skin complaints, only with heavy exercise, during the period when using omalizumab, but no more gastric complaints. n n n nFigure 1 n nCholinergic urticarial lesions of this 38-year-old male patient. n n n nTo date, the therapeutic efficacy of omalizumab on CU associated resistant dyspeptic complaints has not been reported. The effectiveness of anti-IgE treatment is not only restricted to inhibition of allergen IgE interactions. It has rather complicated consequences. Stimulation of FceRI in human umbilical cord mast cells causes a substantial change in expression of many genes, including 18 cytokines, 13 chemokines, and several adhesion molecules involved in potential interactions with T cells, B cells, or dendritic cells.[5] n nIt is well-known that the gastrointestinal system plays a central role in immune system homeostasis and its relationship with the immune system is rather complicated. With current information, it is not easy to comment on how this newly emerged multi-potent immune therapeutic agent had these effects on dyspeptic complaints. In conclusion, the therapeutic spectrum of anti-IgE treatment comprises allergic disorders related to many clinical problems, including CU associated dyspeptic complaints.

Can Serum Fetuin-A Be Regarded as an Inflammatory Marker Among Patients with Familial Mediterranean Fever?

Background/AimFamilial Mediterranean fever (FMF), the most frequent periodic fever syndrome, is an autosomal recessive inherited disease that predominantly affects eastern Mediterranean populations. Fetuin-A is a well known negative acute-phase protein. Studies of this glycoprotein as a marker of inflammation in FMF are limited. We have investigated the relationship between serum levels of fetuin-A and inflammatory markers in patients with FMF before, during, and after FMF attacks.MethodsSixty-seven patients with FMF were enrolled in this study. Serum fetuin-A, seruloplasmin, fibrinogen, C reactive protein (CRP), white blood cell count (WBC), calcium, and erythrocyte sedimentation rate (ESR) were measured three times: during the attack-free period, 12xa0h after FMF attacks, and 7xa0days after FMF attacks. Plasma fetuin-A concentration was measured by use of an enzyme-linked immunoassay (ELISA) kit. Correlations and differentiation between the serum fetuin-A and other inflammatory markers in patients with FMF were investigated by use of the paired-samples T test and the Pearson correlation test (pxa0<xa00.01).ResultsSerum fetuin-A levels of all FMF patients in the attack period were significantly lower than in the attack-free period (pxa0<xa00.001). In contrast, serum seruloplasmin (pxa0<xa00.05), fibrinogen (pxa0<xa00.001), CRP (pxa0<xa00.05), WBC (pxa0<xa00.05), and ESR (pxa0<xa00.05) were all significantly higher than in the attack-free period. Plasma fetuin-A is significantly and inversely highly correlated with the other inflammatory markers.ConclusionFetuin-A might be a novel indicator of disease activity in patients with FMF and could be used as an adjunctive marker for differentiation of FMF attacks. The negative correlation between serum fetuin-A and other inflammatory markers may also be indicative of inflammation-dependent downregulation of fetuin-A expression in FMF patients.

An Extremely Uncommon Case of Parasitic Infection Presenting as Eosinophilic Ascites in a Young Patient

We report the case of a 24-year-old male patient admitted for recent ascites and splenomegaly of unknown origin. The patient was referred to our institution with complaints of diarrhea, epigastric pain, abdominal cramping and weight loss over the past three weeks. The acute onset presented with colicky abdominal pain and peritoneal effusion. History revealed reduced appetite and weight gain of 7 kg over the last one month. His past medical history and family history was negative. He had no history of alcohol abuse or viral hepatitis infection. Laboratory data revealed normal transaminases and bilirubin levels, and alkaline phosphatase and gammaglutamyltransferase were within normal range. A diagnostic laparoscopy was performed which showed free peritoneal fluid and normal abdominal viscera. Upper gastrointestinal system endoscopy performed a few days later revealed diffuse severe erythematous pangastritis and gastroduodenal gastric reflux. Duodenal biopsies showed chronic nonspecific duodenitis. Antrum and corpus biopsies showed chronic gastritis. The ascitic fluid was straw-colored and sterile with 80% eosinophils. Stool exam was negative for parasitic infection. Treatment with albendazole 400 mg twice daily for 5 days led to the disappearance of ascites and other signs and symptoms. Three months after albendazole treatment the eosinophilic cell count was normal. The final diagnosis was consistent with parasitic infection while the clinical, sonographic and histological findings suggested an eosinophilic ascites. We emphasize the importance of excluding parasitic infection in all patients with eosinophilic ascites. We chose an alternative way (albendazole treatment) to resolve this clinical picture. With our alternative way for excluding this parasitic infection, we treated the patient and then found the cause.

Association of reflux symptom index scores with gastroesophageal flap valve status

OBJECTIVEnGastroesophageal reflux disease is a chronic symptom of mucosal damage caused by gastric acid reflux. Impaired gastroesophageal flap valve (GEFV) is one of the common etiologic factors of gastroesophageal reflux. The aim of this study was to investigate the association between GEFV, RSI, and GER in patients who underwent gastroesophageal endoscopy.nnnMETHODSnTwo hundred and fifty seven consecutive patients with reflux symptoms (151 men and 106 women, mean age was 50.22 years) who underwent routine upper gastrointestinal endoscopy were enrolled to our study. GEFV was graded as I through IV according to the Hills classification. Symptoms of laryngopharyngeal and upper gastrointestinal disease and endoscopic severity of esophageal injury were correlated with GEFV status. The GEFV was classified into two groups: normal GEFV group (grade I) and the abnormal GEFV group (grades II-III and IV). The reflux symptom index (RSI) was used as a diagnostic tool for LPR.nnnRESULTSnAge, male gender, and body mass index were significantly related to an abnormal GEFV. The rate of abnormal grades of GEFV (Grade II+III+IV) was 31%. Age of normal and abnormal grades of GEFV (49.0/50.8 vs 52.9) and values of BMI (26.2/26.7 vs 26.5) were similar. RSI scores were correlated with gastroesophageal flap valve grades but RSI scores were not correlated with Los Angeles gastroesophageal reflux (GER) Classification. Moreover, gastroesophageal reflux grade of Los Angeles Classification was positively correlated with gastroesophageal flap valve grades.nnnCONCLUSIONnEndoscopic grading of GEFV is a simple and useful technique which may provide an accurate diagnosis of laryngopharyngeal and gastroesophageal reflux. Also, reflux symptom index (RSI) is a simple, economic and noninvasive diagnostic tool for gastroesophageal reflux. However, in this research, we did not find any correlation between reflux symptom index and degree of esophageal mucosal injury which was classified according to LA classification.

Serum total antioxidant capacity to discriminate benign from malignant causes of biliary obstruction

To the Editor,We have recently read with great interest the promising article by Ince et al. (1) published in your journal that evaluates the roles of serum carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), vascular en -dothelial growth factor receptor-3 (VEGFR-3), and total antioxidant capacity (TAC) in differentiating benign and malignant causes of obstructive jaundice. Although this study is important and intriguing in a number of ways, we feel that there are several issues that need to be clar -ified for a better understanding of the results presented in the authors’ report. Despite major advances in novel diagnostic modalities, the discrimination of benign from malignant causes of biliary obstruction still remains difficult. In this respect, as also suggested by the authors, TAC may be used as an adjunctive method with other laboratory markers to identify malignant causes of obstructive jaundice. Unfortunately, in the present form of the study, it is im-possible to understand whether TAC levels decreased or increased in patients with biliary obstruction. This is mainly because of the unique design of the study, in which the authors did not correlate their results with the results of a control group.The role of oxidative damage in tumoral conditions is well documented, with a large number of patho-biochemical pathways that lead to cellular neoplastic transformation and free radical DNA damage (2). As the antioxidant material in serum is a mixture of different components, TAC is generally defined as an indicator of the antioxidant capacity of the body, reflecting the sum of all antioxidant substances present in serum (3). In this respect, TAC could be a reliable biomarker for di-agnostics and prognostics, especially in malignant dis-eases (4). But, from the results of the present study, it is obvious that there is a statistically significant increase in TAC levels in malignant patients, which is contrary to current literature data. Recent studies have proven that in neoplastic conditions, serum TAC levels decrease in conjunction with elevated lipid peroxidation levels. Decreased serum TAC levels have been shown in pa-tients with breast cancer (5), hepatocellular carcinoma (6), multiple myeloma (7), gastrointestinal cancer (8), and endometrial cancer (9). From this point of view, we think that it would have been worthwhile if the authors had discussed this controversial situation in their pa-tient population. In conclusion, based on the data mentioned above, we think that it is still early for TAC to be considered a useful marker for the differential diagnosis of biliary ob-struction. Further randomized controlled studies with a larger number of participants are required to provide more evidence.

Downregulated miR-362-3p expression: a potential biomarker of colorectal cancer recurrence?

such as previous abdominal surgeries and case complexity were not significant indicators for conversion to open procedure. The anastomotic leak rate was 2.2% (11/500). The return of bowel function time for laparoscopic and open procedures were 3 and 5 days (p<0.0001); length of hospital stay for the groups was 5 and 8 days (p<0.0001). A total of 71 early postoperative complications occurred with the laparoscopic procedure vs 21 in the laparoscopic converted to open procedure (LCOP). Late complications of the laparoscopic procedure were experienced by 44 patients vs 9 in LCOP group.

Rabeprazole-Induced Tinnitus

TO THE EDITOR: Tinnitus could be defined as perception of noise sensation of sound in the absence of a corresponding external acoustic stimulus. Rabeprazole is a proton pump inhibitor used to treat acid-related gastrointestinal disorders including esophagitis, peptic ulcer, and gastroesophageal reflux disease (GERD). As a class of proton pump inhibitors, it has been implicated in several case reports as a cause of colestatic liver injury and acute interstitial nephritis. To date, rabeprazole-induced tinnitus has not been described.