Antonio Mario Scanu

Detection and Isolation of Mycobacterium avium Subspecies paratuberculosis from Intestinal Mucosal Biopsies of Patients with and without Crohn's Disease in Sardinia

OBJECTIVES:Sardinia is an island community of 1.6 million people. There are also about 3.5 million sheep and one hundred thousand cattle in which Johnes disease and Mycobacterium avium subspecies paratuberculosis infection are endemic. The present study was designed to determine what proportion of people in Sardinia attending for ileocolonoscopy with or without Crohns disease were infected with this pathogen.METHODS:Mycobacterium avium subspecies paratuberculosis was detected by IS900 PCR on DNA extracts of fresh intestinal mucosal biopsies as well as by isolation in culture using supplemented MGIT media followed by PCR with amplicon sequencing.RESULTS:Twenty five patients (83.3%) with Crohns disease and 3 control patients (10.3%) were IS900 PCR positive (p = 0.000001; Odds ratio 43.3). Mycobacterium avium subspecies paratuberculosis grew in cultures from 19 Crohns patients (63.3%) and from 3 control patients (10.3%) (p = 0.00001; Odds ratio 14.9). All patients positive by culture had previously been positive by PCR. Mycobacterium avium subspecies paratuberculosis first appeared in the liquid cultures in a Ziehl Neelsen (ZN) staining negative form and partially reverted through a rhodamine-auramine positive staining form to the classical ZN positive form. This resulted in a stable mixed culture of all 3 forms illustrating the phenotypic versatility of these complex chronic enteric pathogens.CONCLUSIONS:Mycobacterium avium subspecies paratuberculosis was detected in the majority of Sardinian Crohns disease patients. The finding of the organism colonizing a proportion of people without Crohns disease is consistent with what occurs in other conditions caused by a primary bacterial pathogen in susceptible hosts.

Contrast-enhanced ultrasonographic evaluation of inflammatory activity in Crohn's disease

BACKGROUND & AIMS We sought to test the diagnostic accuracy of ultrasound (US), color Doppler US (CD-US), and contrast-enhanced US (CE-US) in the evaluation of inflammatory activity in patients with Crohns disease (CD), and to correlate the findings of these sonographic studies with inflammatory activity, as scored by the CD activity index (CDAI). METHODS Patients with CD were enrolled in the study. Radiologists performing the scans were blinded to clinical status. Baseline US, CD-US, and CE-US examinations were conducted with high-frequency probes (8-14 and 5-7 MHz) before and after injection of sulfur hexafluoride-filled microbubbles. The diagnostic accuracy of baseline US, CD-US, and CE-US were calculated by using the endoscopic and histologic findings as reference standards and correlated with the CDAIs by using the Pearson linear correlation coefficient. RESULTS Forty-seven patients (20 men; 27 women; mean age +/- SD, 38 +/- 14 years) with a CDAI > 150 (n = 30) or < 150 (n = 17), were recruited. CE-US showed the highest performance, with 93.5% sensitivity, 93.7% specificity, and 93.6% overall accuracy. CE-US revealed 3 bowel wall perfusion patterns after microbubble injection: submucosal enhancement and inward and outward transparietal enhancement. The linear correlation coefficient for CE-US versus CDAI was 0.74 (P < .0001); for baseline US (assessing thickness, length, and multilayer appearance of the diseased bowel) versus the CDAI, the coefficients were 0.68 (P < .0001), 0.47 (P = .0009), and 0.60 (P < .0001), respectively; and for CD-US versus CDAI the coefficient was 0.73 (P < .0001). CONCLUSIONS CE-US has a high sensitivity and specificity in detecting inflammatory activity and a strong correlation with the CDAI.

Mycobacterium avium Subspecies paratuberculosis Infection in Cases of Irritable Bowel Syndrome and Comparison with Crohn's Disease and Johne's Disease: Common Neural and Immune Pathogenicities

ABSTRACT Mycobacterium avium subsp. paratuberculosis causes Johnes disease, a systemic infection and chronic inflammation of the intestine that affects many species, including primates. Infection is widespread in livestock, and human populations are exposed. Johnes disease is associated with immune dysregulation, with involvement of the enteric nervous system overlapping with features of irritable bowel syndrome in humans. The present study was designed to look for an association between Mycobacterium avium subsp. paratuberculosis infection and irritable bowel syndrome. Mucosal biopsy specimens from the ileum and the ascending and descending colon were obtained from patients with irritable bowel syndrome attending the University of Sassari, Sassari, Sardinia, Italy. Crohns disease and healthy control groups were also included. Mycobacterium avium subsp. paratuberculosis was detected by IS900 PCR with amplicon sequencing. Data on the potential risk factors for human exposure to these pathogens and on isolates from Sardinian dairy sheep were also obtained. Mycobacterium avium subsp. paratuberculosis was detected in 15 of 20 (75%) patients with irritable bowel syndrome, 3 of 20 (15%) healthy controls, and 20 of 23 (87%) people with Crohns disease (P = 0.0003 for irritable bowel syndrome patients versus healthy controls and P = 0.0000 for Crohns disease patients versus healthy controls). One subject in each group had a conserved single-nucleotide polymorphism at position 247 of IS900 that was also found in isolates from seven of eight dairy sheep. There was a significant association (P = 0.0018) between Mycobacterium avium subsp. paratuberculosis infection and the consumption of hand-made cheese. Mycobacterium avium subsp. paratuberculosis is a candidate pathogen in the causation of a proportion of cases of irritable bowel syndrome as well as in Crohns disease.

Spontaneous regression of hepatocellular carcinoma: report of a case.

The widespread use of ultrasound in screening programmes for chronic liver disease has led to early diagnosis of hepatocellular carcinoma (HCC), and to the observation of some cases of tumour spontaneous regression. This is a rare event whose underlying mechanism is still unclear. We present here a case of spontaneous regression of HCC in a 71-year-old woman with chronic hepatitis and discuss possible aetiologies. None of the causative mechanisms proposed for spontaneous regression of HCC is completely satisfactory, so further studies are necessary to improve understanding of this unusual biological event. Therefore, we stress the importance of accumulating all such cases in the literature, because the clarification of aetio-pathogenic mechanisms may lead to the development of new treatment strategies for HCC.

Visceral Aneurysm and Vascular Anomaly Involving the Splenic Artery

Visceral artery aneurysms are rare but potentially fatal.At present, they are detected with increasing frequency inasymptomatic patients because of the widespread use ofdifferent imaging modalities (1, 2). Standard treatment issurgical ligation or resection (3, 4), however, newer en-dovascular techniques have been applied with good re-sults in selected patients (5–8). We describe a case ofvisceral aneurysm and vascular anomaly involving thesplenic artery.

99mTc-Tetrofosmin Pinhole-SPECT (P-SPECT) and Radioguided Sentinel Node (SN) Biopsy and in Breast Cancer Axillary Lymph Node Staging

We compared 99mTc-Tetrofosmin P-SPECT with radioguided SN biopsy in 101 T1/T2 BC pts to predict axillary lymph node status. The day before surgery all pts underwent lymphoscintigraphy (LS) to mark the SN, following subdermal injection of 99mTc-colloidal sulphur surrounding the breast lesion. LS was combined with pre and intraoperative gamma probe. Previously, all pts had also undergone P-SPECT. ALND was performed in all cases. The SN(s) was detected in 97/101 cases (96%) by LS and gamma probe; in the 4 missed cases P-SPECT predicted lymph node status. In the 97 comparable cases, radioguided SN biopsy showed a slightly higher accuracy than P-SPECT (94.8% vs 93.8%), but a higher false-negative rate (14.3% vs 8.6%); P-SPECT had a higher NPV (95.2% vs 92.5%). The two procedures when combined achieved 100% accuracy. Radioguided SN biopsy alone had 100% accuracy only in pts with BC < 15 mm. P-SPECT had 3 false negative cases, 2 of which were micrometastatic SNs, and 3 false positives. P-SPECT identified 81.2% of cases with a single node, determined the exact number of nodes in 82.6% of cases with 1 to 3 node and correctly classified 93.7% of pts as having < or = 3 or > 3 metastatic nodes. Radioguided SN biopsy seems indicated in selected, early stage, small BC pts, while P-SPECT shows a high sensitivity independent of primary tumor size, giving additional important preoperative prognostic information. The two procedures combined provided a better axillary lymph node status prediction in T1/T2 carcinomas, and could thus improve ALND pt selection.

Labial mucosa and combined labial/bladder mucosa free graft for urethral reconstruction

One-stage urethral reconstruction was performed using a free graft of labial mucosa and combined labial/bladder mucosa. We present the results of this technique in 12 cases that had a minimum follow-up period of 3 years. Eleven patients had medium penile or posterior hypospadias and one had chordee penis without hypospadias. Urethroplasty with labial mucosa was performed by two techniques: labial mucosa used alone or combined with bladder mucosa. The labial mucosa was harvested from the inner surface of the upper and/or lower lip, depending on which method was used. Seven patients, six with medium penile or posterior hypospadias and 1 with chordee without hypospadias, were given a labial mucosa graft alone; the urethral gap was 3.5 to 6 cm. The other five cases, all with posterior hypospadias, were treated by combined labial/bladder mucosa graft urethroplasty: the urethral gap was 6 to 13 cm. Follow-up (at 3 to 4 1/2 years) showed no complications apart from a urethral fistula in one patient and mild stenosis on the anastomosis in four cases, which required urethral dilatations in the first month after surgery.

A Rare Variant of Gallstone Ileus: Bouveret’s Syndrome

IntroductionBouveret’s syndrome (gastric outlet obstruction due to impaction of a stone) is a rare variant of gallstone ileus. A recently observed case led us to review the literature, with the aim to discuss the recent advances in the management of this rare syndrome.DiscussionA 69-year-old woman was admitted with symptoms of high intestinal obstruction. Computed tomography scan of the abdomen showed a large gallstone impacted in the duodenum. One-stage surgery, consisting in enterolithotomy, cholecystectomy, and fistula repair, was carried out. Although several surgical and nonoperative procedures have been used, the optimal treatment of Bouveret’s syndrome remains controversial. Surgery still maintains a prominent position, even though nonoperative procedures have an increasing role especially in high risk patients with important comorbidities. The decision should be taken on an individual basis, after evaluating patient’s general condition and age, stone size, comorbidities influencing the operative risk, and expertise of surgical and endoscopic teams. One-stage surgery may offer definitive management in selected patients.

Molecular identification of Mycobacterium avium subspecies paratuberculosis in oral biopsies of Crohn’s disease patients

Oral lesions may be found in patients with Crohn’s disease (CD), in a percentage up to 20%. The aim of this study was to investigate a possible relationship between Mycobacterium avium subsp. paratuberculosis (MAP) and oral lesions in CD patients. 23 oral biopsies were examined performing IS900 Nested PCR; 9 of them were positive: 8 from CD patients and 1 from a control. Our purpose is to go on with this study, amplifying the number of subjects examined and testing subjects with oral lesions related to diseases other than CD to verify the specific association between MAP and oral lesions in CD patients.

NEONATAL ACUTE APPENDICITIS IN AN INGUINAL-HERNIA

Acute appendicitis is very rare in the newborn, representing only 0.1%–0.2% of childhood cases. The usual form is intra-abdominal appendicitis with perforation and diffuse peritonitis. It is exceptional to find neonatal acute appendicitis developing inside a patent processus vaginalis. We describe a case of this kind in an 18-day-old infant who survived and is doing well.