Diffuse gastroduodenitis associated with ulcerative colitis: treatment by infliximab.

Diffuse gastroduodenitis resembling ulcerative colitis in respect to macro- and microscopic findings occurs in ulcerative colitis, although it is rare. Reports of gastroduodenitis associated with ulcerative colitis treated with infliximab are rare. A 58-year-old man had tarry stool in March 2011. He had a history of ulcerative colitis that was diagnosed in 1984. He underwent subtotal colectomy in 1991. Endoscopy and radiography revealed diffuse friable mucosa throughout the duodenum and an ulcer in the middle of the descending portion, resulting in a narrow portion.In the stomach, numerous small aphthae were observed in the antrum. Biopsy specimens of the duodenum and antrum showed marked inflammatory cell infiltration in both areas and cryptitis in the duodenum. Standard induction therapy of infliximab was started in April. The ulcer in the descending portion became a scar without diffuse mucosal friability in September 2011.

Vertebral histomorphometry in a child with glucocorticoid-induced osteoporosis.

Vertebral fractures are an under-recognized problem in children with glucocorticoid-induced osteoporosis (GIO). They cause severe back pain and spinal column deformity with a decrease of quality of life. For evaluating the bone mass, bone mineral density measurements have been widely carried out using dual energy X-ray absorptiometry. However, bone histomorphometric analyses of GIO in children are scarce. Bone histomorphometric analyses of vertebral bodies have not been reported. Our aim is to report the first bone histomorphometric data for vertebrae from an autopsied child with GIO. A 15-year-old girl with systemic lupus erythematosus was started on a daily oral dose of 10 mg of prednisolone at 6 years of age. She presented with back pain from 12 years of age. Magnetic resonance imaging at 14 years of age showed a compression fracture of the first lumbar (L1) vertebral body. At 15 years of age, she died of heart failure owing to pulmonary hypertension. Collapsed (L1) and non-collapsed (seventh thoracic vertebrae; T7) vertebral bodies were autopsied for bone histomorphometry and compared. T7 showed severe osteoporosis (bone volume, 4.99%; trabecular thickness, 59 µm; trabecular separation, 1,134 µm). Compared with T7, L1 showed increased bone volume (33.9%) and trabecular thickness (77 µm), and decreased trabecular separation (156 µm) owing to the impact of the vertebral fracture. The bone formation and bone resorption parameters were comparable between the two vertebrae. These histological findings suggest that severe osteoporosis developed after long-term glucocorticoid administration, and that the remodeling activities were similar in the fractured and non-fractured vertebrae.

Early intestinal obstruction after infliximab therapy in Crohn's disease.

There is scarce knowledge on early intestinal obstruction in Crohn's disease (CD) after infliximab treatment. Therefore, we describe two cases of early intestinal obstruction in a series of 46 CD patients treated with infliximab. Both our two cases were 21-year-old men with newly diagnosed CD who were diagnosed with perianal disease 2 years previously. They were suffering from diarrhea and abdominal pain, but there were no symptoms indicating bowel obstruction. Radiographic studies revealed stenotic sites in the terminal ileum in both cases. In both cases, infliximab 300 mg was infused, after which their abnormal laboratory data as well as symptoms such as diarrhea and abdominal pain clearly improved. However, on the 11th or 13th day post-treatment, they presented abdominal distension with air-fluid levels on imaging studies. Ileocolonic resection was performed in both cases. Early intestinal obstruction after infliximab therapy is characterized by initial improvement of the symptoms and the laboratory data, which is soon followed by clinical deterioration. This outcome indicates that infliximab is so swiftly effective that the healing process tapers the stenotic site, resulting in bowel obstruction. Thus, although unpleasant and severe, the obstruction cannot be considered as a side effect but rather a consequence of infliximab's efficacy. CD patients with intestinal stricture, particularly the penetrating type with stricture, should be well informed about the risk of developing intestinal obstruction after infliximab therapy and the eventual need for surgical intervention.

Estrogen receptor alpha and beta are prognostic factors in non-small cell lung cancer.

PURPOSE: Estrogen receptor-alpha (ER-alpha) and -beta (ER-beta) play important roles in the carcinogenesis of breast tumors. Similarly, there have been several reports of ER expression in lung cancers, but the results have not been consistent, and the receptors' prognostic value remains unclear. Our goal was to investigate ER expression in non-small cell lung cancer (NSCLC) and to assess whether their expression correlates with prognosis. EXPERIMENTAL DESIGN: ER expression was examined using immunohistochemical methods with sections from 132 resected NSCLC specimens. Kaplan-Meier survival curves were analyzed to determine the significance of ER expression in the prognosis of NSCLC patients. RESULTS: ER-alpha was detected in the cytoplasm of 73% of the specimens analyzed, whereas ER-beta was detected in the nucleus of 51%. ER-alpha expression correlated with poorer overall survival (P < 0.001), as did the absence of ER-beta expression (P = 0.048). Likewise, at histopathologic stage I, ER-alpha expression (P = 0.028) or the absence of ER-beta (P = 0.037) correlated with a poorer prognosis, and ER-alpha(+)ER-beta(-) patients had a significantly worse prognosis than ER-alpha(-)ER-beta(+) patients (P = 0.00007). Multivariate Cox regression analysis revealed the absence of ER-beta to be an independent factor predictive of poor disease outcome (hazard ratio, 1.9; 95% confidence interval, 1.1-3.4; P = 0.0264). CONCLUSIONS: ER-alpha expression and the absence of ER-beta expression are associated with a poorer prognosis among NSCLC patients. In particular, the absence of ER-beta could serve as a marker identifying patients at high risk even at an early clinical stage.

Onset of Ulcerative Colitis after Helicobacter pylori Eradication Therapy: A Case Report.

In Japan, Helicobacter pylori eradication has been approved since 2013 for treatment of H pylori-induced chronic gastritis, in an attempt to reduce the prevalence of gastric cancer, a leading cancer in Japan. H pylori infection affects more than 50% of the world's population. H pylori eradication therapy is generally safe. To our knowledge, no case of newly diagnosed ulcerative colitis occurring immediately after H pylori eradication therapy has previously been reported.A 63-year-old man received a diagnosis of chronic gastritis and H pylori infection. In early March 2014, primary H pylori eradication therapy was initiated; lansoprazole, amoxicillin, and clarithromycin were administered for 1 week. Beginning on the fourth day, he had watery diarrhea twice a day. From the 11th day, bloody stools and watery diarrhea increased to 6 times a day. Colonoscopy, performed on the 40th day after termination of drug therapy, revealed diffuse inflammation in the distal aspect of the colon, with histologic findings consistent with ulcerative colitis. He was admitted to the hospital and was provided with a semivegetarian diet and metronidazole. He noticed a gradual decrease in the amount of blood in his feces then a disappearance of the blood. A fecal occult blood test on the 11th hospital day recorded 337 ng/mL. Fecal occult blood test is not indicated during macroscopic bloody stool but is indicated after disappearance of bloody stool. Therefore, he achieved clinical remission by the 11th hospital day. He was in remission on discharge.New onset of ulcerative colitis should be added to a list of adverse events of H pylori eradication therapy.

Combined overexpression of EGFR and estrogen receptor alpha correlates with a poor outcome in lung cancer.

BACKGROUND: The aim of the present study was to determine the prognostic significance of the combined overexpression of epidermal growth factor receptor (EGFR) and estrogen receptor a (ER-alpha) in non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: An immunohistochemical assessment of EGFR and ER-alpha expression was carried out in tumor specimens from 122 consecutive NSCLC patients after surgery. RESULTS: Of the 122 tumors examined, 57 (46.7%) overexpressed EGFR, 63 (51.6%) overexpressed ER-alpha, while 33 (27%) overexpressed both EGFR and ER-alpha. Univariate analyses showed that the overexpression of EGFR or ER-alpha correlated with the histological grade (p = 0.01 and p = 0.03, respectively) and a poorer prognosis (p = 0.007), while overexpression of ER-alpha also correlated with smoking (p = 0.02). Multivariate analysis showed the combined overexpression of EGFR and ER-alpha to be an independent indicator of poorer prognosis (p = 0.0006). CONCLUSION: The combined overexpression of EGFR and ER-alpha in NCLSC patients is predictive of poor outcome and, thus, represents a valuable prognostic factor.

Early intestinal obstruction after infliximab therapy in Crohn's disease

There is scarce knowledge on early intestinal obstruction in Crohn's disease (CD) after infliximab treatment. Therefore, we describe two cases of early intestinal obstruction in a series of 46 CD patients treated with infliximab. Both our two cases were 21-year-old men with newly diagnosed CD who were diagnosed with perianal disease 2 years previously. They were suffering from diarrhea and abdominal pain, but there were no symptoms indicating bowel obstruction. Radiographic studies revealed stenotic sites in the terminal ileum in both cases. In both cases, infliximab 300 mg was infused, after which their abnormal laboratory data as well as symptoms such as diarrhea and abdominal pain clearly improved. However, on the 11th or 13th day post-treatment, they presented abdominal distension with air-fluid levels on imaging studies. Ileocolonic resection was performed in both cases. Early intestinal obstruction after infliximab therapy is characterized by initial improvement of the symptoms and the laboratory data, which is soon followed by clinical deterioration. This outcome indicates that infliximab is so swiftly effective that the healing process tapers the stenotic site, resulting in bowel obstruction. Thus, although unpleasant and severe, the obstruction cannot be considered as a side effect but rather a consequence of infliximab's efficacy. CD patients with intestinal stricture, particularly the penetrating type with stricture, should be well informed about the risk of developing intestinal obstruction after infliximab therapy and the eventual need for surgical intervention

Cytomegalovirus infection associated with onset of ulcerative colitis.

BACKGROUND: In 2009, a trigger role of cytomegalovirus (CMV) was shown in the development of ulcerative colitis (UC) in mice. Fifteen cases of synchronous onset of CMV colitis and UC have been reported in literature. A careful prospective and retrospective survey identified CMV colitis in newly diagnosed UC patients at 4.5% (3/65 cases) and 8.2% (5/61 cases), respectively. This means that a majority of synchronous CMV colitis may be missed in newly diagnosed UC patients in routine practice. Such a case is presented. CASE PRESENTATION: A 50-year-old woman, with a history of right partial mastectomy two years ago, had a persistent high fever for 9 days, after which a thickness of the colonic wall was detected on abdominal ultrasonography. Laboratory data showed inflammation and 2% atypical lymphocytes with the normal number of white blood cells. Although there was no bloody stool, fecal occult blood was over 1000 ng/ml. Colonoscopy showed diffuse inflammation in the entire large bowel and pseudomembranes in the sigmoid colon. The diagnosis was UC with antibiotic-associated pseudomembranous colitis. Metronidazole followed by sulfasalazine resulted in defervescence and improvement in laboratory data of inflammation. It took one month for normalization of fecal occult blood. Endoscopic remission was simultaneously confirmed. Later, it was found that a report of positive CMV antigenaemia (2/150,000) had been missed. Reevaluation of biopsy specimens using a monoclonal antibody against CMV identified positive cells, although inclusion bodies were not found in hematoxylin and eosin sections. Finally, the case was concluded to be synchronous onset of CMV colitis and UC. CONCLUSION: Synchronous CMV colitis is not routinely investigated in newly diagnosed UC patients. Together with a recent observation in animal studies, it is plausible that a subset (a few to several per cent) of UC patients develop synchronous CMV infection. Further studies are needed to elucidate the plausibility.

Medical cure for life-threatening severe cytomegalovirus enteritis in a 71-year-old man.

The small bowel is the least common site of involvement in the gastrointestinal tract for cytomegalovirus (CMV) infection. CMV enteritis results in a high rate of emergency surgery for bleeding, perforation, or ileus and a high mortality rate. We report on successful medical treatment for a case of life-threatening severe CMV enteritis. A 71-year-old man, not known to be immunocompromised, suffered diarrhea and periumbilical abdominal pain. Diarrhea persisted and hypoalbuminemia developed, which required total parenteral nutrition. Colonoscopy revealed erosions and redness in the terminal ileum. Esophagogastroduodenoscopy revealed diffuse edema in the duodenum. Enteroclysis showed a narrow and shortened small bowel with an extremely short transit time of the small bowel of <1 min. CMV antigenemia was found on the blood sample. The biopsy specimens from both the duodenum and terminal ileum showed cell infiltration with dominance of eosinophils indicating eosinophilic enteritis. Therefore, ganciclovir 500 mg/day and prednisolone 40 mg/day were started. The diarrhea gradually improved, and a semi-vegetarian diet was started; thereafter, the patient fully recovered. Inclusion bodies were not found in routine hematoxylin-eosin stained sections of the duodenal or ileal specimens. However, a re-evaluation by immunohistochemistry using a monoclonal antibody against CMV revealed positive cells for CMV in both specimens.

Lansoprazole-associated collagenous colitis: diffuse mucosal cloudiness mimicking ulcerative colitis.

There have only been a few reports on lansoprazole-associated collagenous colitis. Colonic mucosa of collagenous colitis is known to be endoscopically normal. We present a case of collagenous colitis where the mucosa showed diffuse cloudiness mimicking ulcerative colitis. A 70-year-old woman developed watery diarrhea four to nine times a day. She had interstitial pneumonia at 67 and reflux esophagitis at 70 years. Lansoprazole 30 mg/d had been prescribed for reflux esophagitis for nearly 6 mo. Lansoprazole was withdrawn due to its possible side effect of diarrhea. Colonoscopy disclosed diffuse cloudiness of the mucosa which suggested ulcerative colitis. Consequently sulfasalazine 2 g/d was started. The patient's diarrhea dramatically disappeared on the following day. However, biopsy specimens showed subepithelial collagenous thickening and infiltration of inflammatory cells in the lamina propria, confirming the diagnosis of collagenous colitis. One month after sulfasalazine therapy was initiated, colonoscopic and histological abnormalities resolved completely. Five months later the diarrhea recurred. The findings on colonoscopy and histology were the same as before, confirming a diagnosis of collagenous colitis relapse. We found that the patient had begun to take lansoprazole again 3 mo ahead of the recent diarrhea. Withdrawal of lansoprazole promptly resolved the diarrhea. Endoscopic and histological abnormalities were also completely resolved, similar to the first episode. Retrospectively, the date of commencement of sulfasalazine and discontinuation of lansoprazole in the first episode was found to be the same. We conclude that this patient had lansoprazole-associated collagenous colitis.