[Muscle weakness and early stages of liver failure in a 22-year-old man]. / Muskuläre Schwäche und beginnendes Leberversagen bei einem 22-jährigen Mann.

A 22-year-old man without pre-existing medical conditions presented to our hospital with a progressive reduction of his physical overall performance, muscle weakness of the extremities, and diarrhea for the last 2 months concomitant with elevated liver enzymes and creatine kinase activity. After ruling out infectious diseases, neoplasia, and autoimmune disorders as a cause of these symptoms, the histology of liver and muscle samples led us to suspect a diagnosis of a rare lipid metabolism disorder. Molecular biologic testing provided the diagnosis of multiple acyl-coA dehydrogenase deficiency with ubiquinone deficiency and late onset. The course of disease was complicated by liver failure and severe pneumonia requiring ventilatory assistance. With the substitution of riboflavin and ubiquinone, the patient showed a gradual recovery of his clinical presentation and an improvement of his laboratory tests. A congenital lipid metabolic disorder might be a rare cause of severe myopathy and hepatopathy in a young adult.

The V delta 1 T cell receptor repertoire in human small intestine and colon.

V delta 1 bearing T cells comprise the major population of gamma/delta T cells in the human intestinal tract. To gain insight into mechanisms involved in the generation of these cells and the diversity of their repertoire, we have characterized the junctional sequences of V delta 1 T cell receptor transcripts in the human small intestine and colon. Mucosal biopsies obtained from defined regions along the length of the small intestine or colon contained a high frequency of either one or a few identical in frame V delta 1 sequences. Less abundant sequences were also detected repeatedly throughout the length of small intestine or colon. Moreover, the intestinal V delta 1 repertoire in the small intestine and colon appeared compartmentalized and showed no overlap with the V delta 1 repertoire in peripheral blood. Dominant V delta 1 transcripts in each subject differed between the small intestine and colon, and the dominant transcripts within these sites differed among individuals. Analysis of small intestinal transcripts obtained at a 1-yr interval revealed that the V delta 1 repertoire was stable over time. The fact that the majority of V delta 1 transcripts, both dominant and rare, are distributed throughout a several meter length of the adult intestinal tract and are stable over time suggests they are not generated by an ongoing process of in situ VDJ gene rearrangement. Our results favor a model in which the repertoire of V delta 1 T cells in the intestinal tract is shaped by positive selection in response to a limited array of ligands before the migration of V delta 1 cells throughout the small intestine or colon.

The delta T cell receptor repertoire in human colon and peripheral blood is oligoclonal irrespective of V region usage.

The majority of gamma/delta T cell receptors (TCR) in the human intestinal mucosa are thought to use the TCRDV1 (V delta 1) variable region gene segment, whereas gamma/delta T cells in the circulation predominantly express the TCRDV2 (V delta 2) gene segment. delta T cell receptors that use the TCRDV2 variable region gene segment generally have been regarded as highly diverse, whereas those that use the TCRDV1 gene segment are oligoclonal, whether present in the intestinal tract or in peripheral blood. We report herein that oligoclonality is a general feature of the peripheral delta T cell receptor repertoire in healthy human adults, irrespective of the variable region used and regardless of whether gamma/delta T cells reside in the intestinal mucosa or in peripheral blood. In addition, the delta T cell receptor repertoire is shown to be highly compartmentalized between such sites as the colon and peripheral blood, relatively stable over at least a 10-16-mo period, and unique in each individual. Further, the spectrum of variable region genes used by delta T cell receptor transcripts in the human colon is greater than previously recognized. Thus, in addition to the TCRDV1 and TCRDV2 variable region gene segments, delta T cell receptors in normal intestinal mucosa can use TCRDV3 (V delta 3) and TCRAV (V alpha) gene segments which, in some individuals, comprise a significant component of the mucosal delta T cell receptor repertoire. Our studies indicate that the potential of delta T cell receptors for extensive diversity is not reflected in the mature human repertoire. Moreover, these findings suggest a model wherein the delta T cell receptor repertoire in the colon and peripheral blood is shaped by selection and clonal expansion of gamma/delta T cells that ultimately seed throughout the length of the colon mucosa and populate the circulation.

The TCR-delta repertoire in normal human skin is restricted and distinct from the TCR-delta repertoire in the peripheral blood.

The skin and the intestinal mucosa form surfaces to external environments and share similarities in anatomic structure and immunologic defense. In healthy humans, intestinal gamma/delta T cells express a highly restricted gamma/delta T cell receptor repertoire whereas gamma/delta T cells of the skin were thought to express a polyclonal repertoire. Herein we report, using complementarity-determining region 3 size spectratyping and nucleotide sequencing of T cell receptor DV1 and DV2 rearrangements, that the human skin is also composed of clonally expanded gamma/delta T cells that are widely distributed. Identical complementarity-determining region 3 profiles and T cell receptor delta rearrangements were found in two separate skin samples that were obtained as far as 2-10 cm apart. Furthermore, analysis of peripheral blood mononuclear cells of these subjects clearly demonstrated that the skin harbors a unique population of gamma/delta T cells that is distinct from that in the peripheral blood. In addition comparable data were obtained irrespective of whether DNA or RNA was analyzed, indicating that the observed oligoclonality is not secondary to the expression of large amounts of mRNA from a few activated cells. Thus, gamma/delta T cells of the skin and the intestine both express an oligoclonal repertoire that enables them to respond to a variety of deleterious antigens without the need for diverse T cell receptors, possibly by recognition of stress-induced self-antigens or of conserved foreign antigens.

Inverse PCR amplification of rare T cell receptor delta messages from mucosal biopsy specimens.

Reverse transcription (RT) PCR is an important tool in studies of the repertoire of T cell antigen receptors (TCR). In combination with inverse PCR, it can be used to amplify TCR transcripts whose V regions are unknown. Little is currently known regarding the delta TCR repertoire in human intestine. Here, RT inverse PCR was adapted to efficiently amplify low abundance delta TCR sequences from human colonic mucosal biopsy specimens. In this protocol, high yields of PCR products were obtained by optimizing the conditions at which cDNA autoligation was performed.

[Treatment and management of celiac disease]. / Therapie und Management der Zöliakie/einheimischen Sprue.

In most patients the clinical course of celiac disease is unproblematic after the diagnosis has been made and a strict gluten-free diet is established. However, in rare cases complications like refractory sprue or lymphoma can occur. Individual management is required since the clinical presentation of celiac disease can be very heterogeneous. For example, it is a matter of controversy if asymptomatic patients, who have the same typical histological changes in their small bowel like patients with symptomatic celiac disease, should adhere to a gluten-free diet. A major problem is the compliance and the unintentional intake of gluten. A 100 % gluten-free diet is not possible since most food components are contaminated with trace amounts of gluten. Fortunately most patients tolerate these contaminations. Furthermore, the threshold for gluten contamination can differ highly among patients. One central point in patient care is the monitoring of a gluten-free diet and the timely recognition of complications. Therefore, the role of antibodies and duodenal histology in monitoring the course of the disease will be discussed.

[Diagnosis of celiac disease]. / Diagnostik der Zöliakie/Sprue.

In spite of modern diagnostic possibilities, the diagnosis of celiac disease is still challenging for the physician. This is due to the great variability of the clinical presentation. Nowadays, the classical symptoms like diarrhea, weight loss and abdominal pain are seen less often. It has become evident that celiac disease is not merely a disease of the intestine but of the entire organism. Furthermore, extraintestinal manifestations can present without any gastrointestinal symptoms. It is likely that in many cases the immune system and not nutrient deficiencies play a major role. In addition, the diagnostic tests are not always unequivocal. There is a great variability of the small intestinal changes which are sometimes in contradiction to the antibody results. Since celiac disease implies a lifelong gluten-free diet, a firm diagnosis should be obtained. Thus, one should not rely on a single test but should rather consider serology, histology and clinical response altogether.

[Definitions of celiac disease--statement of an expert group from the German Society for Celiac Disease]. / Verlaufsformen und Definitionen der Zöliakie--Stellungsnahme einer Expertengruppe der Deutschen Zöliakie-Gesellschaft.

Celiac disease may have different manifestations and the clinical course can be very heterogeneous. Thus, management and treatment of celiac disease can be difficult and therefore requires individual patient care. In this article an expert group from the German Society for Celiac Disease (Deutsche Zöliakie-Gesellschaft) defines the different manifestations of celiac disease. In the past these definitions were often used differently. The consequent usage of these definitions may diminish uncertainties in clinical practice and lead to a more standardized management of the disease which is likely to improve patient care.

[Antibody diagnosis iin sprue/celiac disease]. / Antikörperdiagnostik bei Sprue/Zöliakie.

The clinical appearance of celiac disease is diverse, often times uncharacteristic and may therefore be very difficult to diagnose. Furthermore, severe inflammation of the small bowel can be present without gastrointestinal symptoms. It is estimated that most subjects with celiac disease are not diagnosed. Yet, early diagnose is desirable, since celiac disease causes growth retardation in untreated children and is potentially cancer disposing. Thus, all patients should adhere to a strict gluten-free diet. The role of antibody testing and small bowel biopsy in celiac disease will be discussed. In the future, the development of new tests may allow screening of large populations.

IgA and IgM V(H) repertoires in human colon: evidence for clonally expanded B cells that are widely disseminated.

BACKGROUND & AIMS: The mucosal immune system defends the body from pathogens to which the mucosal surfaces are continually exposed. Because lamina propria B cells should reflect the antigenic experience of the gut, we investigated their immunoglobulin (Ig) repertoire and distribution. METHODS: The junctional diversity of the IgA and IgM heavy-chain transcripts in the colon and the peripheral blood of healthy adults was analyzed by CDR3 size spectratyping and nucleotide sequencing. RESULTS: The V(H)6 and V(H)7 repertoires of intestinal IgA and IgM cells were oligoclonal, whereas the CDR3 profiles of the larger V(H)1-V(H)5 families suggested a more diverse repertoire with dominant bands superimposed on a polyclonal background. However, sequence analysis revealed multiple repetitive and clonally related transcripts at distant colonic sites from all V(H) families. This suggests that, in addition to a polyclonal B-cell pool, subsets of B cells are clonally expanded and widely distributed along the colon. Occasionally, there was evidence for B cells with the same CDR3 specificity, which exhibited an isotype switch from IgM to IgA. Circulating IgA B cells expressed a restricted V(H) repertoire that was distinct from that in the colon. CONCLUSIONS: The human colon contains widely disseminated B cells that express clonally related IgA or IgM receptors. These results are best explained by an antigen-driven process whereby intestinal memory B cells continuously recirculate.

The TCR-delta repertoire in human intestine undergoes characteristic changes during fetal to adult development.

The TCR-delta repertoire in adult human intestine is oligoclonal and unique in each individual. In the present study, changes in the junctional regions of TCR-delta transcripts in human intestine that occur during development from fetal to adult life were used to characterize fundamental changes in the TCR-delta repertoire in the human intestinal tract during ontogeny. At mid-gestation, the fetal repertoire was polyclonal, but limited, in its junctional diversity by the relative lack of N region nucleotide additions and by the frequent formation of coding region joins at regions of short sequence homology. In addition, identical TCRDV2 transcripts that resemble canonical TCR-delta sequences in mice were present in the intestine of different fetuses. In the early period after birth, the intestinal TCR-delta repertoire was polyclonal, and more diverse than the fetal repertoire, with junctional regions that contained extensive N nucleotide additions and frequently were as complex as those of adults. The intestinal TCR-delta repertoire showed increasing restriction with age and, by 14 to 17 yr, the repertoire was oligoclonal and resembled the repertoire of individuals in the sixth to seventh decade. Moreover, the adult TCR-delta repertoire was almost identical at multiple sites throughout the intestine, suggesting a model in which gammadelta T cell clones, selected by ligands in the intestinal tract, undergo expansion and recirculation before lodging throughout the small intestine or colon.

Distinct delta T cell receptor repertoires in monozygotic twins concordant for coeliac disease.

One of the hallmarks of coeliac disease, both active and treated, is an increased number and proportion of gamma/delta intraepithelial T lymphocytes in the small intestinal mucosa, and an increased number of gamma/delta T cells in the small intestinal mucosa of coeliac disease patients has been associated with the inheritance of specific HLA class II DQ alleles. Nonetheless, the contribution of genetic factors to the development of the T cell receptor (TCR) delta repertoire in coeliac disease is not known. We have assessed the contribution of genetic factors to development of the TCR delta repertoire in coeliac disease, by characterizing the junctional diversity of TCR delta transcripts expressed in the intestine and peripheral blood of a pair of monozygotic (MZ) twins concordant for coeliac disease. TCR Vdelta1, Vdelta2 and Vdelta3 transcripts from small intestinal and colon biopsies, and from peripheral blood mononuclear cells, were amplified by polymerase chain reaction (PCR) and the complementarity determining region (CDR)3 domains of TCR delta transcripts were analysed by denaturing PAGE and direct nucleotide sequencing. The repertoire of TCR delta transcripts and CDR3 amino acid motifs in the intestine and peripheral blood of MZ twins concordant for coeliac disease exhibited no overlap. The TCR delta repertoire in each twin was oligoclonal, and complexity of the junctional regions of their TCR delta transcripts was typical of the repertoire in healthy adults. Thus, genetically identical individuals with coeliac disease have distinct, non-overlapping TCR delta repertoires. Moreover, genetic factors that determine disease susceptibility do not appear to select for specific TCR delta sequences or CDR3 amino acid motifs.

[Hypertransaminasaemia and impaired liver function in a patient with oligosymptomatic celiac disease]. / Leberfunktionsstörung als Leitsymptom einer einheimischen Sprue.

Hypertransaminasaemia and impaired liver function in a patient with oligosymptomatic celiac disease. We describe the case of a 45-year-old man who was referred for evaluation of elevated aminotransferases. One year before referral the patient developed an ischemic stroke followed by a subdural hematoma three months later. In our outpatient clinic the patient presented with a malabsorption syndrome including diminished vitamin-K-dependent clotting factors. Serologic testing was positive for IgA antigliadin antibodies and IgA antiendomysial antibodies. Celiac disease was confirmed by an upper endoscopy examination and biopsies obtained from the distal duodenum. Histological examination showed villous atrophy, crypt hyperplasia and an increase in intraepithelial lymphocyte count consistent with celiac disease. After initiation of a gluten-free diet the malabsorption syndrome as well as liver dysfunction improved. Serum aminotransferase levels normalized within 6 months. The clinical course demonstrates involvement of the liver in patients with celiac disease.