Laura Brunetti

Is it worth investigating splenic function in patients with celiac disease

Celiac disease, an immune-mediated enteropathy induced in genetically susceptible individuals by the ingestion of gluten, is the most frequent disorder associated with splenic hypofunction or atrophy. Defective splenic function affects more than one-third of adult patients with celiac disease, and it may predispose to a higher risk of infections by encapsulated bacteria and thromboembolic and autoimmune complications, particularly when celiac patients have concomitant pre-malignant and malignant complications (refractory celiac disease, ulcerative jejunoileitis and enteropathy-associated T-cell lymphoma). However, the clinical management of patients with celiac disease does not take into account the evaluation of splenic function, and in patients with high degree of hyposplenism or splenic atrophy the prophylactic immunization with specific vaccines against the polysaccharide antigens of encapsulated bacteria is not currently recommended. We critically re-evaluate clinical and diagnostic aspects of spleen dysfunction in celiac disease, and highlight new perspectives in the prophylactic management of infections in this condition.

TCRβ clonality improves diagnostic yield of TCRγ clonality in refractory celiac disease.

Background: Refractory celiac disease (RCD) is a preneoplastic condition as many patients develop an enteropathy-type T-cell lymphoma, a mature T-cell receptor &agr;-&bgr; lymphoma arising in the gut with an ominous outcome. Recently, research focused on a population of intraepithelial intestinal lymphocytes expressing the same lymphoma T-cell receptor variable region (V)&ggr;, as shown by polymerase chain reaction (PCR) analysis and sequencing. Meanwhile, the Biomedicine and Health-2 Concerted Action has made available standardized, highly specific, and sensitive PCR assays not only for V&ggr; but also for V&bgr;. Goals: We verified whether analyzing both rearrangements in duodenal biopsies from RCD patients increases the diagnostic accuracy of this method. Study: Duodenal biopsies were analyzed from 15 RCD patients, 21 negative controls, and 2 positive controls (enteropathy-type T-cell lymphoma complicating celiac disease). Multiplex clonality analyses were performed according to the Biomedicine and Health-2 protocols. PCR products were cloned and sequenced. Results: Monoclonal rearrangements were found in 5/15 samples from patients with RCD (both rearrangements in 2 cases, V&bgr; only in 2, and only 1 solitary V&ggr; clonality). Monoclonality was found in 4/8 of the RCD patients who subsequently died, whereas only 1/7 of the patients still alive presented a monoclonal rearrangement. Positive controls revealed both monoclonal rearrangements; rearrangements were not detected in 20 of 21 negative controls. Sequencing of the amplified fragments confirmed the results. Conclusions: The combined analysis of both rearrangements allowed recognition of monoclonal populations in otherwise negative patients, with detection rates from 20% (V&ggr; only) to 33% (V&ggr; and V&bgr;), thus raising the likelihood of early identification of RCD patients at high risk of death.

Splenic hypofunction in patients with an incidental finding of small-sized spleen at abdominal ultrasound.

Splenic hypofunction is an acquired condition, ranging from a reversible mild hyposplenism to severe splenic atrophy, and may be accompanied by a reduction in spleen size. It is potentially associated with a number of different diseases, including hematological, immunological, gastroenterological and iatrogenic disorders. Functional hyposplenism, as well as asplenia, has been shown to predispose to thromboembolic events, autoimmunity and infectious complications, the latter of which are the most widely recognized risk of these states [1]. In particular, a significantly higher relative risk of pneumococcal sepsis has been demonstrated in patients affected by splenic hypofunction or atrophy [2] due to reduced levels of circulating IgM memory B cells, a unique B cell population that needs the spleen for their survival and generation [3]. Nevertheless, the relationship between splenic function and size in hyposplenic individuals is unknown. Since a small-sized spleen can be easily detected in the course of an abdominal ultrasound examination, we aimed at evaluating splenic function through pitted erythrocyte counting in patients with an incidental finding of atrophic spleen at abdominal ultrasound. Between October 2009 and January 2011, 4,585 patients were referred to the Ultrasound Unit of our Department of Internal Medicine to undergo an abdominal ultrasound evaluation. The most frequent indications were abdominal pain (49 %), malignancy (37 %), liver and biliary disorders (10 %), bowel disorders (7 %), and nephrolithiasis (5 %). All images were obtained by an expert sonographer, using an Esaote model MyLab 70 XVG, with a 1–8 MHz convex probe and an ATL model HDI 3500, a 5.2 MHz convex probe (Philips Medical Systems, Bothel, Washington). The length of the spleen, defined as the maximum distance between the dome and the tip of the spleen, was measured on a longitudinal section with the patient in the supine or right lateral decubitus position and on deep inspiration. Patients, who were diagnosed as having a small spleen: defined as a spleen length B8 cm in men and B7.5 cm in women [4], underwent peripheral blood collection for the evaluation of spleen function. Splenic function was assessed by counting the number of pitted red cells—that is, erythrocytes bearing membrane abnormalities visible under interference phase microscopy as a so-called ‘pit’. Briefly, one drop of fresh venous blood was taken and mixed with 0.5 ml 3 % buffered glutaraldehyde solution, pH 7.4, in a plastic tube. One thousand erythrocytes were examined in a wet preparation (magnification, 1,0009) with a directinterference phase microscope Leica DMLB (Leica Microsystems Wetzlar GmbH, Wetzlar, Germany) equipped with Nomarsky optics by the same experienced observer unaware of the study. The percentage of pitted erythrocytes was calculated and taken as a measure of splenic function (upper limit of normal = 4 %) [5]. A peripheral blood sample was also collected from 52 splenectomized patients, who were used as positive controls. Data were analyzed in the GraphPad Prism statistical PC program (GraphPad Software, San Diego, CA) using the paired t test and the Mann–Whitney U test. Correlations were studied by Spearman’s rank correlation test. A level of p \ 0.05 was considered statistically significant. A small spleen was found in 203 out of 4,585 patients. Only 128 (mean age 61.5 years; 90 females and 38 males) A. Di Sabatino (&) G. Carnevale Maffe L. Brunetti M. Guerci G. R. Corazza First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Piazzale Golgi 19, 27100 Pavia, Italy e-mail: a.disabatino@smatteo.pv.it

Paraneoplastic Cushing's syndrome and nephrotic syndrome in a patient with disseminated small cell lung cancer.

A 71-year-old man presented with rapid onset of edema, ascites, diffuse bone pain, systo-diastolic hypertension, and hyperglycemia (620 mg/dL). Biochemistry indicated decreased plasma proteins (5.0 g/dL), nephrotic range proteinuria (4.9 g/24 hours) with preserved kidney function, and hypokaliemia (2.8 mEq/L). Cushing syndrome related to ectopic adrenocorticotropic hormone (ACTH) production, a well-known endocrine paraneoplastic syndrome, was demonstrated by markedly elevated serum ACTH (487 pg/mL, reference interval: 6.0–57.0 pg/mL) and cortisol (59.9 g/dL, reference interval: 4.3–22.4 g/dL) basal levels, with no variation over the day and no response after high-dose dexamethasone suppression and corticotropic-releasing hormone (CRH) stimulation tests. Bone marrow biopsy and total-body computed tomography (CT) scans diagnosed disseminated small cell carcinoma of the lung (SCCL) (Fig. 1). Nephrotic syndrome was also considered paraneoplastic because of the concomitant onset with malignancy. Clinical conditions did not consent a kidney biopsy. Rapidly deteriorating general conditions with progressive marrow failure forced starting chemotherapy. Despite rhG-CSF support and reduced cisplatin and etoposide doses, grade 4 neutropenia with gram-negative septicemia occurred. Difficult control of fluids, electrolytes, and hyperglycemia because of concomitant nephrosis and hypercortisolism, made managing of the generalized blood infection very problematic, with septic shock and death 1 month after diagnosis. Ectopic ACTH secretion is a rare but sometimes important cause of morbidity and mortality in cancer patients

Un caso di epatopatia rapidamente ingravescente

Acute liver failure is a clinical syndrome characterized by the sudden onset of coagulopathy and encephalopathy. The most common aetiology are drug-induced liver failure, hepatitis, acute Wilson’s disease, acute Budd-Chiari syndrome, autoimmune hepatitis and miscellaneous. Wilson Disease is a rare inherited autosomal disorder of copper balance leading to hepatic damage and neurological disturbance of variable degree. The gene involved is ATP7B, which encodes a hepatic copper-transporting protein that plays a key role in human copper metabolism. Clinical manifestations are due to copper accumulation in particular in the liver and brain and include hepatic disease ranging from mild hepatitis to acute liver failure. Early diagnosis and therapy are essential for favorable outcome. In this article we describe a paradigmatic case of Wilson disease in a patient of 47 years marked by an acute onset which has led to acute liver failure for which she underwent orthotopic liver transplantation.