Kofi Clarke

Stopping immunomodulators and biologics in inflammatory bowel disease patients in remission.

The emergence of biologic response modifiers and earlier use of immunomodulators for inflammatory bowel disease (IBD) patients have improved outcomes. Durable remissions have been achieved in many IBD patients on these treatments, but the duration of treatment and identifying which patients may stop therapy is yet unresolved. Recently, the term very deep remission (defined as clinical remission [CDAI < 150] and endoscopic remission) has been applied to patients on immunomodulators/biologics who have no clinical symptoms or objective signs of inflammatory disease. Whether or not patients who achieve and maintain a very deep remission may successfully stop treatment is not known. This article will review the current data on stopping treatment in IBD and identify certain factors that are associated with a high relapse rate after discontinuing treatment. Where evidence-based data are lacking, the authors provide their opinion.

Rare case of entero-enteric intussusception caused by small bowel metastasis from a cardiac liposarcoma

Primary cardiac liposarcoma is exceedingly rare and its metastatic potential varies based on the actual tumor subclass. Intestinal intussusception is also an uncommon cause of abdominal pain and bowel obstruction in adults and it usually generates at a malignant lead point in this age group. We report a case of a primary cardiac dedifferentiated liposarcoma in a pregnant woman causing small bowel seeding leading to bowel intussusception.

Methicillin-resistant Staphylococcus aureus (MRSA) colitis--is there a problem?

Dear Editor: We describe a case of an unusual and perhaps underrecognized cause of colitis and draw physicians’ attention to keep this as a differential diagnosis in unusual colitides. A 60-year-old pediatric unit nurse was transferred to our center with pan colitis on both colonoscopy and computerized tomographic scan of the abdomen. Her symptoms begun 4 weeks prior to transfer with sudden onset of diarrhea and bright red rectal bleeding. She denied recent travel, antibiotic, or nonsteroidal anti-inflammatory use, or any similar prior illness. On examination at admission, she had a fever of 39.7°C, blood pressure of 102/63 mmHg, tachycardia of 105/min, and no associated extra intestinal findings. Specifically, she had no joint swelling or tenderness, no enthesitis, skin rash, red eyes, or mouth ulcers. The rest of her examination including cardiovascular, respiratory, abdominal, and neurological were normal. Initial laboratory evaluation showed normal white cell count, mild normocytic, normochromic anemia of 10.2 g/dl, C-reactive protein level of 14 times upper limit of normal, and negative blood and urine cultures. She was treated empirically for Clostridium difficileassociated diarrhea because of her work in a healthcare setting and severity of symptoms while stool studies were pending. The course of metronidazole did not improve her symptoms and stool cultures were positive for methicillinresistant Staphylococcus aureus (MRSA), negative for C. difficile, Shigella, Salmonella, and Escherichia coli and also negative for all normal enteric flora. Her treatment was changed to oral vancomycin with a rapid improvement in her symptoms. Repeat colonoscopy at our center confirmed pan colitis with ulceration predominantly in the transverse colon. Biopsies which were reviewed by gastrointestinal pathologists were consistent with acute colitis, likely infectious. Overall carriage rates of MRSA are estimated to be 9% with much higher rates in the rectum. Hospitals, other acute care facilities and long-term care facilities have protocols in place to help limit exposure and spread due to the enormous public health implications. Though the more prevalent C. difficile-associated diarrhea remains a serious and expensive cause of colitis, colonic infection with MRSA has the potential of posing a difficult and expensive problem. The nares are the primary niche of carriage for MRSA, intestinal carriage is estimated at 9%, and rectal colonization rates have been reported as high as 60%. There are reports of MRSA enteritis following abdominal surgery and antibiotic use. Other recently described risk factors include inflammatory bowel disease and prolonged hospital stay. Our report is intended to draw attention to a case of pan colitis with colonic ulceration in the setting of positive stool cultures for methicilllin-resistant S. aureus in the absence of normal enteric flora. None of the previously identified predisposing factors were present in this case. We postulate that the absence of normal enteric flora is a likely predisposing factor leading to proliferation of MRSA. Kofi Clarke reviewed the case and wrote the manuscript. Leonard Baidoo reviewed the manuscript, including references and provided supervisory editorial input. K. Clarke (*) : L. Baidoo Division of Gastroenterology, Hepatology and Nutrition, UPMC Presbyterian Hospital, University of Pittsburgh Medical Center, 200 Lothrop Street, Mezzanine Level, C-wing, Pittsburgh, PA 15213, USA e-mail: clarkek@upmc.edu

Neoterminal Ileal Polyposis and Ulceration after Restorative Proctocolectomy with a Current Review of the Literature

After ileal pouch anal anastomosis, one of the frequently encountered complications is polyposis of the pouch. We describe a case of proximal neoterminal ileal polyposis associated with deep ulceration suggestive of Crohn’s disease and review the available literature. A 36-year-old male presented with resistant pouchitis 11 years after surgery for ulcerative colitis. With all-negative initial workup, pouchoscopy showed multiple deep ulcers in the proximal ileum with some polyps. Biopsy of polyps showed inflammatory polyps with negative immunohistological staining for IgG pouchitis. With no treatable etiology for pouchitis and the presence of inflammatory polyps, there are no guidelines for surveillance of this condition. Definitive diagnosis is challenging and there is no consensus or recommended guidelines on the management.

Case of colonic mucosal Schwann cell hamartoma and review of literature on unusual colonic polyps

Mucosal Schwann cell hamartomas (MSCH) are benign mesenchymal tumours rarely seen in the gastrointestinal tract. They occasionally present as incidental sessile polyps during colonoscopy. A 55-year-old asymptomatic female patient with a medical history of multiple sclerosis presented for a screening colonoscopy. A 5 mm low-risk tubular adenoma was noted in the caecum, and a second 5 mm polyp was found in the ascending colon. Histopathology of the ascending colon polyp showed proliferation of spindle cells without ganglion cells in the lamina propria. Immunohistochemical findings are compatible with an MSCH. Surveillance colonoscopy was scheduled in 5 years based on the presence of a single low-risk tubular adenoma.

Diagnostic yield from colon biopsies in patients with inflammatory bowel disease and suspected cytomegalovirus infection: is it worth it?

Background Patients with inflammatory bowel disease (IBD) are often immunosuppressed and are at risk for reactivation of latent cytomegalovirus (CMV) infection. We examined the diagnostic yield from colon biopsies in IBD patients with suspected CMV infection. Methods Patients above 18 years of age who underwent testing for CMV on colon biopsies between January 1st, 2012, and December 31st, 2015, were identified from a pathology data base. A positive CMV result was included only if testing included both hematoxylin/eosin staining and immunohistochemistry from two or more biopsy samples. Results One hundred twenty-five patients met the inclusion criteria. Of these, 99 had a diagnosis of IBD: 30 with Crohn’s disease, 63 with ulcerative colitis, and 6 with indeterminate colitis. As regards treatment, 21.2% of the patients had biologic therapy alone, 13.1% received immunomodulators, and 11.1% were treated with combined biologic and immunomodulator therapy within 3 months of the colon biopsy. In addition, 32.3% of the patients were on steroids. Of the 99 IBD patients, only 1 had biopsy-proven CMV colitis. Conclusion The yield from colon biopsies with hematoxylin/eosin staining and immunohistochemistry to test for CMV in IBD flare is very low. Further multicenter studies with large numbers of patients are needed to compare all testing modalities in the same cohort of patients. This may help identify which subgroup of IBD patients are likely to benefit from specific modalities of CMV testing, with potential cost-saving implications.

Endoscopic Pitfalls: Adult Unrepaired Cleft Palate.

A 56-year-old woman presented with dysphagia. Upper endoscopy showed a palatal defect, with visualization of the middle and inferior nasal turbinates (arrows). After the procedure, she disclosed a history of unrepaired cleft palate. Her dental device had been modified to cover the defect, and she had been able to function normally. Although rare, identifying a history of unrepaired cleft palate in adults is key in the preprocedure evaluation. Direct visualization during endoscopy is the preferred approach, and blind intubation is discouraged.

Febrile Neutropenia with Thrombocytopenia after Infliximab Induction in a Patient with Ulcerative Colitis

A 34-year-old female with left-sided ulcerative colitis (UC) developed severe febrile neutropenia/thrombocytopenia soon after infliximab induction therapy. There was no other plausible cause of the cell line abnormalities other than an accurate temporal association with infliximab administration. Supportive care, broad-spectrum antibiotic, and single dose of filgrastim was given on day 5 of admission due to persistently low absolute neutrophil count and fevers. The cell lines recovered, fever resolved and the patient made a complete clinical recovery. Clinicians should be aware of this potential life-threatening inflixmab side effect previously unreported in adults with UC.

An isolated colonic neurofibroma.

A 52-year-old male with a past medical history of hypertension presented with a two-week history of mild right lower quadrant abdominal pain. He denied chronic nonsteroid anti-infl ammatory drug use, alcohol or tobacco abuse. No skin lesions or any areas of hypo/hyperpigmentation were noted. Abdominal exam revealed mild tenderness in the right lower quadrant. Laboratory data including serum sodium, potassium, creatinine and blood urea nitrogen were normal. Other normal tests included liver function tests, lipase and thyroid stimulating hormone levels. Urine analysis was negative. A colonoscopy was performed which showed three sessile 3 mm polyps in the splenic fl exure and proximal descending colon (Fig. 1). Polypectomy was performed and histology examination showed a thickened lamina propria arranged in a fascicular-like pattern wrapped around dispersed benign colonic glands. Immunohistochemical staining with S-100 confi rmed the diagnosis of colonic neurofi broma (Fig. 2). Isolated neurofi broma of the gastrointestinal tract was fi rst described in 1937, and remains a rare entity [1]. Since then, less than 20 such cases have been reported in the literature [2]. Clinical presentation ranges from incidental fi ndings on routine colonoscopy to massive lower gastrointestinal bleeding [2,3]. In spite of an increase in reporting of isolated colonic neurofi bromas (ICN) in the past decade, the etiology, pathogenesis, prognosis and treatment options for ICN remain unclear. In addition, there are no data on the need for follow-up colonoscopies and the appropriate intervals. Th is and other cases highlight the importance of close follow up and detailed skin exams in these patient populations to monitor for any signs of systemic neurofi bromatosis. It also raises the need for a consensus guideline on follow-up care in patients with ICN including intervals for surveillance colonoscopies.

Ultra-high C-reactive protein levels in hospitalized inflammatory bowel disease (IBD) patients predicts serious complications

Dear Editor: C-reactive protein (CRP), erythrocyte sedimentation rate, fecal lactoferrin, and fecal calprotectin have been evaluated as markers of disease activity and predictors of disease course in inflammatory bowel disease (IBD). Studies on the predictive value of CRP elevations in IBD patients are difficult to interpret or generalize because of different laboratory cutoff values. Fourteen hospitalized IBD patients with ultra-high Creactive protein (UH-CRP), defined as CRP more than ten times the upper limit of normal (ULN), were identified and followed for 6 months. Eight patients had ulcerative colitis, ages ranged between 20 and 69 years, with a mean of 37.36±17.248 (SD) years. CRP levels ranged from 14.3 to 41 times ULN, with a mean elevation of 25.66 times the ULN±8.67 (SD). Ten out of 14 patients (71.43 %) had IBD-related complications, with 50 % requiring surgery either during admission or within 6 months. Three out of five patients who were admitted with typical symptoms of abdominal pain and bloody diarrhea had severe complications, two had a perforated viscus and one had multiple intraabdominal abscesses. One in five had a bowel obstruction, and two (14.3 %) had a newly diagnosed fistula. Finally, three patients (21.4 %) had an acute severe infection; two with clostridium difficile associated colitis, and the third with enterococcus bacteremia. Compared to previously reported data, there was a non-statistically significant trend towards longer hospital stay in patients with UH-CRP elevations. AUH-CRP level in hospitalized IBD patients is associated with significant complications and should not be solely attributed to disease flare. Describing CRP elevations as multiples of the upper limit of normal from various laboratories provides an alternative way of comparing results, and may help predict serious complications. Additional prospective studies are needed.