[Ileocolitis in an immunocompromised patient. Crohn's disease or an infection?] / Ileocolitis bij een immuungecompromitteerde patiënte.

BACKGROUND: Histoplasma capsulatum is an endemic fungus in especially tropical areas. While mostly asymptomatic, histoplasmosis can be life-threatening in immunocompromised patients. CASE DESCRIPTION: A 60-year-old woman of Suriname origin, with a history of renal transplantation and use of mycophenolate mofetil and prednisone, presented with abdominal pain and diarrhea. Colonoscopy revealed ulcerative ileocolitis and biopsy showed active granulomatous inflammation. Morbus Crohn was considered the most plausible diagnosis after ruling out several infectious and pharmacological causes. Despite prednisone treatment, symptoms persisted and infliximab was initiated. The patient developed constitutional symptoms and radiological examination revealed disseminated granulomatous disease. Liver biopsy and re-evaluation of previous intestinal histopathology confirmed suspected histoplasmosis. CONCLUSION: Histoplasmosis should be considered in immunocompromised patients with ileocolitis who have been in endemic regions (South America). Physicians need to assess the risk of previous exposure to histoplasmosis before starting anti-TNF-α therapy.

Clinical trial: short- and long-term benefit of relaxation training for irritable bowel syndrome.

BACKGROUND: Psychotherapy is effective in treating irritable bowel syndrome, but the effect of relaxation training, a brief psychological group intervention, is not known. AIM: To determine the efficacy of relaxation training in a large cohort of irritable bowel syndrome patients. METHODS: Ninety-eight irritable bowel syndrome patients were included in this randomized controlled trial. Forty-six patients received standard medical care (CON) and 52 received four 90-min sessions of relaxation training in small groups in addition to standard medical care. Irritable bowel syndrome symptom severity, medical consumption and quality of life were assessed at baseline in patients and in 38 healthy controls and evaluated in patients at 3, 6 and 12 months after intervention. RESULTS: Irritable bowel syndrome symptom severity was significantly reduced in the relaxation training group compared to CON at 3, 6 and 12 months after treatment (time-by-treatment interaction, P = 0.002). The number needed to treat for long-term improvement was 5. Quality of life had improved (general health, P = 0.017; health change, P = 0.05). Frequency of doctor visits was reduced (P = 0.039). CONCLUSIONS: Relaxation training is a brief group intervention that significantly improves symptom severity, general health perception and medical consumption in irritable bowel syndrome patients immediately after, as well as 6 and 12 months after intervention.

Recto-colonic reflex is impaired in patients with irritable bowel syndrome.

Motor and sensory dysfunction of the gut are present in a subset of patients with irritable bowel syndrome (IBS). Recent studies have demonstrated the presence of a recto-colonic inhibitory reflex in healthy humans. It is not known whether this reflex exists in IBS. We studied rectal compliance, perception and the recto-colonic reflex by measuring volume responses of the descending colon to rectal distentions by barostat in 26 IBS patients and 13 healthy controls under both fasting and postprandial conditions. In the fasting state, rectal distention inhibited colonic tone and phasic motility to a similar extent in health and IBS. After a meal, rectal distention inhibited colonic tone and phasic motility to a lesser degree (P < 0.05) in IBS than health. Under postprandial but not fasting conditions, rectal distentions of increasing intensity were associated with higher pain scores in IBS than in health. Rectal distention inhibits tonic and phasic motility of the descending colon in healthy controls and in IBS patients. Postprandially this recto-colonic inhibitory reflex is impaired and attenuated in IBS patients compared with controls. These findings point to an altered reflex function in IBS and have implications for pathophysiology and therapy.