A germline STAT6 gain-of-function variant is associated with early-onset allergies.

BACKGROUND: The signal transducer and activator of transcription 6 (STAT6) signaling pathway plays a central role in allergic inflammation. To date, however, there have been no descriptions of STAT6 gain-of-function variants leading to allergies in humans. OBJECTIVE: We report a STAT6 gain-of-function variant associated with early-onset multiorgan allergies in a family with 3 affected members. METHODS: Exome sequencing and immunophenotyping of T-helper cell subsets were conducted. The function of the STAT6 protein was analyzed by Western blot, immunofluorescence, electrophoretic mobility shift assays, and luciferase assays. Gastric organoids obtained from the index patient were used to study downstream effector cytokines. RESULTS: We identified a heterozygous missense variant (c.1129G>A;p.Glu377Lys) in the DNA binding domain of STAT6 that was de novo in the index patient's father and was inherited by 2 of his 3 children. Severe atopic dermatitis and food allergy were key presentations. Clinical heterogeneity was observed among the affected individuals. Higher levels of peripheral blood TH2 lymphocytes were detected. The mutant STAT6 displayed a strong preference for nuclear localization, increased DNA binding affinity, and spontaneous transcriptional activity. Moreover, gastric organoids showed constitutive activation of STAT6 downstream signaling molecules. CONCLUSIONS: A germline STAT6 gain-of-function variant results in spontaneous activation of the STAT6 signaling pathway and is associated with an early-onset and severe allergic phenotype in humans. These observations enhance our knowledge of the molecular mechanisms underlying allergic diseases and will potentially contribute to novel therapeutic interventions.

Diagnostic validity and learning curve of non-NBI expert endoscopists in gastric intestinal metaplasia diagnosis.

BACKGROUND: Endoscopists' experience influences narrow-band imaging (NBI)-guided gastric intestinal metaplasia (GIM) diagnostic performance. We aimed to evaluate the general gastroenterologists (GE) performance in NBI-guided GIM diagnosis compared to NBI experts (XP) and assess GEs' learning curve. METHODS: A cross-sectional study was conducted between 10/2019 and 2/2022. Histology-proven GIM who underwent esophagogastroduodenoscopy (EGD) were randomly assessed by 2XPs or 3GEs. Endoscopists' performance on NBI-guided diagnoses were compared to the pathological diagnosis (gold standard) in five areas of the stomach according to the Sydney protocol. The primary outcome were GIM diagnosis validity scores of GEs compared to XPs. The secondary outcome was the minimum number of lesions required for GEs to achieve an accuracy of GIM diagnosis ≥ 80%. RESULTS: One thousand one hundred and fifty-five lesions from 189 patients (51.3% male, mean age 66 ± 10 years) were examined. GEs performed EGD in 128 patients with 690 lesions. the GIM diagnosis sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of GEs compared to the XPs, were 91% vs.93%, 73% vs.83%, 79% vs.83%, 89% vs.93%, and 83% vs.88%, respectively. GEs demonstrated lower specificity (mean difference - 9.4%; 95%CI - 16.3, 1.4; p = 0.008) and accuracy (mean difference - 5.1%; 95%CI - 3.3, 6.3; p = 0.006) compared to XPs. After 100 lesions (50% GIM), GEs achieved an accuracy of ≥ 80% and all diagnostic validity scores were comparable to the XPs (p < 0.05 all). CONCLUSIONS: Compared to XPs, GEs had lower specificity and accuracy for GIM diagnosis. The learning curve for a GE to achieve comparable performance to XPs would necessitate at least 50 GIM lesions. Created with BioRender.com.

A comparison of the antegrade core trap and reverse bevel needles for EUS-guided fine-needle biopsy sampling of liver mass: a prospective randomized cross over study.

BACKGROUND: Data on the use of EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) for pathology is limited. METHODS: To prove superiority of the diagnostic rate of the newly designed modified Menghini-type needle with a beveled side-slot near the needle tip with slot cutting edge directed 20-gauge antegrade bevel (group A) over the original 22-gauge reverse bevel (group B) for EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) in a prospective crossover randomized controlled trial. RESULTS: The overall diagnostic accuracy rate of the 52 passes was 86.5% (45/52) and of group A versus B were 88.5% (23/26) versus 84.6% (22/26), respectively, p = 0.858. Tissue adequacy levels of both groups were not significantly different (grade A: B: C = 18:6:2 versus 16:7:3), p = 0.839). Grading of blood contamination of both groups was not significantly different. However, it was found that the group-A needles could biopsy tissue of significantly longer length than that of the group B; 1.3 cm (SD = 0.76) versus 0.8 cm (SD = 0.54); p = 0.007. CONCLUSION: The use of EUS-FNB of SLM is highly effective with similar levels of efficacy and number of adverse events between both types of needles. THE TRIAL REGISTRATION NUMBER: Thai Clinical Trial Registration No. TCTR2018081002.

The expression profile of Jagged1 and Delta-like 4 in hepatocellular carcinoma.

BACKGROUND: Notch signaling has been linked to many cancers. However, there is still limited information about the expression and role of the Notch ligand in hepatocellular carcinoma (HCC). OBJECTIVE: To investigate the expression of JAG1 and DLL4 in HCC tissues. METHODS: One hundred and forty-five HCC tissues in paraffin block since 2009 to 2016 at King Chulalongkorn Memorial hospital were assayed for JAG1 and DLL4 by immunohistochemistry. All the sections were separately analyzed in tumor and adjacent non-tumor tissue and scoring based on intensity and quantity of immunoreaction. Kruskal-Wallis H test examined the correlation between JAG1 and DLL4 protein expression and clinical pathology. RESULTS: The expression of JAG1 and DLL4 of tumor cells is 57.2% (83/145) and 88.9% (129/145), respectively. The expression of JAG1 is significantly higher in tumor tissues than adjacent non-tumor tissues (P = 0.002), and significantly increased in patients with age < 60 years old (P = 0.007). Interestingly, the DLL4 expression is also expressed in the normal liver tissue and DLL4 expression is not associated with any of the clinical parameters. When we performed a subgroup analysis, in HCC patients without a viral infection analysis, JAG1 is significantly increased in HCC patients with low albumin level (≤ 3.5) (P = 0.043). CONCLUSIONS: JAG1 expression is increased in HCC and seems to correlate with HCC patients with earlier onset and lower albumin level, whereas DLL4 expression did not significantly correlate with any clinical features.

Regulation of periostin expression by Notch signaling in hepatocytes and liver cancer cell lines.

Notch signaling is involved in both differentiation of hepatocyte progenitors and hepatocellular carcinoma (HCC). The mechanism whereby Notch signaling regulates cellular transformation in hepatocytes is still controversial. This study investigated the impact of overexpressing truncated intracellular Notch1 (NICD1) on transcriptomic profiles of immortalized human hepatocytes. RNA sequencing and gene ontology enrichment analysis revealed that extracellular matrix organization and hyaluronan biosynthesis process gene sets are among those affected by Notch hyperactivation. The relationship between Notch signaling and periostin, an extracellular matrix protein highly expressed in HCC, were further studied. Modulating Notch signaling through NICD1 overexpression or treatment with a gamma secretase inhibitor resulted in increased or decreased periostin expression, respectively, in HCC and liver bile duct carcinoma cell lines. Based on The Cancer Genome Atlas database, mRNA levels of NOTCH1 and POSTN are positively correlated in tumor tissues but not in nontumor tissues. Two consensus RBPJ binding motifs were identified in the -3932/-3921 and + 2522/+2533 bp of POSTN regulatory regions, and NOTCH1 is associated with these binding sites in a liver bile duct carcinoma cell line. Taken together, these results indicate that Notch signaling directly regulates transcription of POSTN in hepatocytes and liver cancer cell lines and may be a candidate for drug targeting in liver cancer.

Diseases of bile duct in children.

Several diseases originate from bile duct pathology. Despite studies on these diseases, certain etiologies of some of them still cannot be concluded. The most common disease of the bile duct in newborns is biliary atresia, whose prognosis varies according to the age of surgical correction. Other diseases such as Alagille syndrome, inspissated bile duct syndrome, and choledochal cysts are also time-sensitive because they can cause severe liver damage due to obstruction. The majority of these diseases present with cholestatic jaundice in the newborn or infant period, which is quite difficult to differentiate regarding clinical acumen and initial investigations. Intraoperative cholangiography is potentially necessary to make an accurate diagnosis, and further treatment will be performed synchronously or planned as findings suggest. This article provides a concise review of bile duct diseases, with interesting cases.

Development of a diagnostic support system for the fibrosis of nonalcoholic fatty liver disease using artificial intelligence and deep learning.

Liver fibrosis is a pathological condition characterized by the abnormal proliferation of liver tissue, subsequently able to progress to cirrhosis or possibly hepatocellular carcinoma. The development of artificial intelligence and deep learning have begun to play a significant role in fibrosis detection. This study aimed to develop SMART AI-PATHO, a fully automated assessment method combining quantification of histopathological architectural features, to analyze steatosis and fibrosis in nonalcoholic fatty liver disease (NAFLD) core biopsies and employ Metavir fibrosis staging as standard references and fat assessment grading measurement for comparison with the pathologist interpretations. There were 146 participants enrolled in our study. The correlation of Metavir scoring system interpretation between pathologists and SMART AI-PATHO was significantly correlated (Agreement = 68%, Kappa = 0.59, p-value <0.001), which subgroup analysis of significant fibrosis (Metavir score F2-F4) and nonsignificant fibrosis (Metavir score F0-F1) demonstrated substantial correlated results (agreement = 80%, kappa = 0.61, p-value <0.001), corresponding with the correlation of advanced fibrosis (Metavir score F3-F4) and nonadvanced fibrosis groups (Metavir score F0-F2), (agreement = 89%, kappa = 0.74, p-value <0.001). SMART AI-PATHO, the first pivotal artificially intelligent diagnostic tool for the color-based NAFLD hepatic tissue staging in Thailand, demonstrated satisfactory performance as a pathologist to provide liver fibrosis scoring and steatosis grading. In the future, developing AI algorithms and reliable testing on a larger scale may increase accuracy and contribute to telemedicine consultations for general pathologists in clinical practice.

Prevalence and clinicopathologic findings of conjunctival epithelial neoplasia in pterygia.

PURPOSE: To study the prevalence of conjunctival neoplasia in clinically diagnosed pterygia and the clinicopathologic characteristics of conjunctival tissues obtained from pterygium excision. DESIGN: Prospective, observational case series. PARTICIPANTS: From February through August 2007, consecutive subjects indicated for pterygium excision were enrolled from an outpatient eye clinic of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, and from the eye camp at the 6th Station of the Thai Red Cross Society, Aranyaprathet District, Sa Kaeo, Thailand. A total of 498 eyes from 482 subjects were studied. The mean age of the subjects was 56.5 ± 11.7 years. The male-to-female ratio was 3:7. METHODS: Clinical data were gathered, including age, sex, occupation, family history, and medical history. Pterygia were clinically graded as mild, intermediate, or fleshy. Tissues from surgical fields were fixed in formalin and processed using standard pathology laboratory methods. MAIN OUTCOME MEASURES: Histopathologic results were examined in a masked fashion by 3 pathologists. RESULTS: Ninety-one percent of tissue was from primary pterygia. Most lesions were classified as intermediate grade (45.2%). Histopathologic results showed that 4 eyes had conjunctival intraepithelial neoplasia. Two eyes had minimal cellular atypia at the conjunctival epithelium. Two eyes had complex choristoma. For the subjects who had conjunctival epithelial neoplasia, the mean age was 57.0 ± 8.0 years, 44.4% were male, and none had a history of carcinoma in other organs or any history of herpes virus, human papilloma virus, or human immunodeficiency virus infections. CONCLUSIONS: The prevalence of conjunctival epithelial neoplasia in clinically diagnosed pterygia is approximately 1.8%. Because the clinical characteristics of subjects who have conjunctival epithelial neoplasia apparently did not differ from those without, tissue pathologic examination may be required to diagnose the condition.

Prevalence of gastroesophageal reflux disease in children with extraesophageal manifestations using combined-video, multichannel intraluminal impedance-pH study.

BACKGROUND: Gastroesophageal reflux disease (GERD) might be either a cause or comorbidity in children with extraesophageal problems especially as refractory respiratory symptoms, without any best methods or criterion for diagnosing it in children. AIM: To evaluate the prevalence of extraesophageal GERD using conventional and combined-video, multichannel intraluminal impedance-pH (MII-pH), and to propose novel diagnostic parameters. METHODS: The study was conducted among children suspected of extraesophageal GERD at King Chulalongkorn Memorial Hospital between 2019 and 2022. The children underwent conventional and/or combined-video MII-pH. The potential parameters were assessed and receiver operating characteristic was used for the significant parameters. RESULTS: Of 51 patients (52.9% males), aged 2.24 years were recruited. The common problems were cough, recurrent pneumonia, and hypersecretion. Using MII-pH, 35.3% of the children were diagnosed with GERD by reflux index (31.4%), total reflux events (3.9%), and symptom indices (9.8%) with higher symptom recorded in the GERD group (94 vs 171, P = 0.033). In the video monitoring group (n = 17), there were more symptoms recorded (120 vs 220, P = 0.062) and more GERD (11.8% vs 29.4%, P = 0.398) by symptom indices. Longest reflux time and mean nocturnal baseline impedance were significant parameters for diagnosis with receiver operating characteristic areas of 0.907 (P = 0.001) and 0.726 (P = 0.014). CONCLUSION: The prevalence of extraesophageal GERD in children was not high as expected. The diagnostic yield of symptom indices increased using video monitoring. Long reflux time and mean nocturnal baseline impedance are novel parameters that should be integrated into the GERD diagnostic criteria in children.

H4K20me3 upregulated by reactive oxygen species is associated with tumor progression and poor prognosis in patients with hepatocellular carcinoma.

Epigenetic alteration by oxidative stress is vitally involved in carcinogenesis and cancer progression. Previously, we demonstrated that oxidative stress was increased in hepatocellular carcinoma (HCC) patients and associated with tumor aggressiveness. Herein, we immunohistochemically investigated whether histone methylation, specifically H4K20me3, was upregulated in human hepatic tissues obtained from HCC patients (n = 100). Also, we experimentally explored if the H4K20me3 was upregulated by reactive oxygen species (ROS) and contributed to tumor progression in HCC cell lines. We found that H4K20me3 level was increased in HCC tissues compared with the adjacent noncancerous liver tissues. H3K9me3 and H3K4me3 levels were also increased in HCC tissues. Cox regression analysis revealed that the elevated H4K20me3 level was associated with tumor recurrence and short survival in HCC patients. Experimentally, H2O2 provoked oxidative stress and induced H4K20me3 formation in HepG2 and Huh7 cells. Transcript expression of histone methyltransferase Suv420h2 (for H4K20me3), Suv39h1 (for H3K9me3), and Smyd3 (for H3K4me3) were upregulated in H2O2-treated HCC cells. H2O2 also induced epithelial-mesenchymal transition (EMT) in HCC cells, indicated by decreased E-cadherin but increased α-SMA and MMP-9 mRNA expression. Migration, invasion, and colony formation in HCC cells were markedly increased following the H2O2 exposure. Inhibition of H4K20me3 formation by A196 (a selective inhibitor of Suv420h2) attenuated EMT and reduced tumor migration in H2O2-treated HCC cells. In conclusion, we demonstrated for the first time that H4K20me3 level was increased in human HCC tissues, and it was independently associated with poor prognosis in HCC patients. ROS upregulated H4K20me3 formation, induced mRNA expression of EMT markers, and promoted tumor progression in human HCC cells. Inhibition of H4K20me3 formation reduced EMT and tumor aggressive phenotypes in ROS-treated HCC cells. Possibly, ROS-induced EMT and tumor progression in HCC cells was epigenetically mediated through an increased formation of repressive chromatin H4K20me3.

Cytomegalovirus infection in liver-transplanted children.

Cytomegalovirus (CMV) infection is a common complication of liver trans-plantation in children. The CMV serostatus of recipients and donors is the primary risk factor, and prophylaxis or pre-emptive strategies are recommended for high-risk patients. Graft rejection, coinfection and Epstein-Bar virus reactivation, which can lead to post-transplant lymphoproliferative disease, are indirect effects of CMV infection. Assessment of CMV infection viral load should be routinely performed upon clinical suspicion. However, tissue-invasive CMV disease is not associated with CMV viraemia and requires confirmation by tissue pathology. Oral valganciclovir and intravenous ganciclovir are equivalent treatments, and the duration of treatment depends on factors including CMV viral load, tissue pathology, and clinical response. Risk stratification by donor and recipient status prior to transplantation and post-transplantation antiviral prophylaxis or pre-emptive therapy are recommended. Adult guidelines have been established but additional study of the effectiveness of the preventive guidelines in children is needed. This review summarizes the burden, risk factors, clinical manifestations, laboratory evaluation, treatment, and prevention of CMV infection in children after liver transplantation.

Performance status of targeted biopsy alone versus Sydney protocol by non-NBI expert gastroenterologist in gastric intestinal metaplasia diagnosis.

Background and study aims According to a recent guideline, patients with gastric intestinal metaplasia (GIM) should have at least five biopsies performed under the Sydney protocol to evaluate for risk of extensive GIM. However, only narrow-band imaging (NBI)-targeted biopsy may be adequate to diagnose extensive GIM. Patients and methods A cross-sectional study was conducted between November 2019 and October 2020. Patients with histology-proven GIM were enrolled. All patients underwent standard esophagogastroduodenoscopy performed by a gastroenterology trainee. The performing endoscopists took biopsies from either a suspected GIM area (NBI-targeted biopsy) or randomly (if negative for GIM read by NBI) to complete five areas of the stomach as per the Sydney protocol. The gold standard for GIM diagnosis was pathology read by two gastrointestinal pathologists with unanimous agreement. Results A total of 95 patients with GIM were enrolled and 50 (52.6%) were men with a mean age of 64 years. Extensive GIM was diagnosed in 43 patients (45.3%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of NBI-targeted biopsy vs. the Sydney protocol were 88.4% vs.100 %, 90.3% vs. 90.3%, 88.4% vs. 89.6%, 90.3% vs. 100%, and 89.5% vs. 94.7%, respectively. The number of specimens from NBI-targeted biopsy was significantly lower than that from Sydney protocol (311vs.475, P  < 0.001). Conclusions Both NBI-targeted biopsy and Sydney protocol by a gastroenterologist who was not an expert in NBI and who has experience with diagnosis of at least 60 cases of GIM provided an NPV higher than 90%. Thus, targeted biopsy alone with NBI, which requires fewer specimens, is an alternative option for extensive GIM diagnosis.

Real-time semantic segmentation of gastric intestinal metaplasia using a deep learning approach.

BACKGROUND/AIMS: Previous artificial intelligence (AI) models attempting to segment gastric intestinal metaplasia (GIM) areas have failed to be deployed in real-time endoscopy due to their slow inference speeds. Here, we propose a new GIM segmentation AI model with inference speeds faster than 25 frames per second that maintains a high level of accuracy. METHODS: Investigators from Chulalongkorn University obtained 802 histological-proven GIM images for AI model training. Four strategies were proposed to improve the model accuracy. First, transfer learning was employed to the public colon datasets. Second, an image preprocessing technique contrast-limited adaptive histogram equalization was employed to produce clearer GIM areas. Third, data augmentation was applied for a more robust model. Lastly, the bilateral segmentation network model was applied to segment GIM areas in real time. The results were analyzed using different validity values. RESULTS: From the internal test, our AI model achieved an inference speed of 31.53 frames per second. GIM detection showed sensitivity, specificity, positive predictive, negative predictive, accuracy, and mean intersection over union in GIM segmentation values of 93%, 80%, 82%, 92%, 87%, and 57%, respectively. CONCLUSION: The bilateral segmentation network combined with transfer learning, contrast-limited adaptive histogram equalization, and data augmentation can provide high sensitivity and good accuracy for GIM detection and segmentation.

Pediatric liver transplantation outcomes from a single center in Thailand.

BACKGROUND: Liver transplantation (LT) has become an acceptable curative method for children with several liver diseases, especially irreversible acute liver failure and chronic liver diseases. King Chulalongkorn Memorial Hospital is one of Thailand's largest liver transplant centers and is responsible for many pediatric cases. AIM: To report the experience with pediatric LT and evaluate outcomes of living-related vs deceased-donor grafts. METHODS: This evaluation included children who underwent LT between August 2004 and November 2019. Data were retrospectively reviewed, including demographics, diagnoses, laboratory values of donors and recipients, the pediatric end-stage liver disease (PELD) or model for end-stage liver disease (MELD) score, graft source, wait time, perioperative course, postoperative complications, and survival rates. Continuous data were reported using the median and interquartile range. The Mann-Whitney U-test was used to compare the wait time between the living-related and deceased-donor groups. The chi-square or Fisher's exact test were used to compare the frequencies of between-group complications. Survival rates were calculated using the Kaplan-Meier method. RESULTS: Ninety-four operated pediatric liver transplant patients were identified (54% were females). The median age at transplantation was 1.2 (0.8-3.8) years. The median PELD and MELD scores were 20 (13-26.8) and 19.5 (15.8-26.3), respectively. Most grafts (81.9%) were obtained from living-related donors. The median wait time for the living donors was significantly shorter compared with the deceased donors at 1.6 (0.3-3.1) mo vs 11.2 (2.1-33.3) mo (P = 0.01). Most patients were diagnosed with biliary atresia (74.5%), and infection was the most common complication within 30 d post-transplantation (14.9%). Without a desensitization protocol, 9% of transplants were ABO-incompatible. Eight hepatitis B core antibodies (anti-HBc)-negative recipients received positive anti-HBc grafts without different observed complications. The overall survival rate was 93.6% and 90.3% at 1 and 5 years, respectively. No graft loss during follow-up was noted among survivors. CONCLUSION: A significant number of pediatric LT cases were reported in Thailand. Based on relatively comparable outcomes, ABO-incompatible and HBc antibody-positive grafts may be considered in an organ shortage situation.

Prognostic Significance of Lymphovascular Invasion Detected by D2-40 in Low-Risk Stage II Colon Cancer.

Background Lymphovascular invasion (LVI) is included in the criteria of high-risk stage II colon cancer. However, there are limitations to detecting LVI by routine hematoxylin and eosin (H&E) staining. Alternatively, immunohistochemistry (IHC) for the lymphatic endothelial marker D2-40 may help detect LVI, but its prognostic significance remains unknown. This study aimed to evaluate the prognostic significance of LVI, detected by IHC for D2-40, in low-risk stage II colon cancer.  Materials and Methods A total of 69 patients with low-risk stage II colon cancer were tested for D2-40 to assess LVI. Then, the relationships between IHC-detected LVI and clinical outcomes, including disease-free survival (DFS) and overall survival (OS), were analyzed using both univariate and multivariate analyses.  Results IHC for D2-40 revealed that 24 out of the 69 cases (34.78%) had LVI-positive tumors. IHC-detected LVI was significantly associated with adverse clinical outcomes on univariate analysis, i.e., both reduced DFS (P = 0.002) and OS (P = 0.0163). In multivariate analysis, controlling for age, IHC-detected LVI remained a significant predictor of reduced DFS with a hazard ratio (HR) of 3.37 and a 95% confidence interval (CI) of 1.39-8.15 (P = 0.007) and OS (HR, 5.66; 95% CI, 1.02-31.51; P = 0.048). Conclusions Our results demonstrated that IHC analysis for D2-40 enhanced LVI detection in patients with low-risk stage II colon cancer and that cases with a missed diagnosis of LVI by routine H&E staining had adverse clinical outcomes, that is, reduced DFS and OS.

Liver tumors in children with chronic liver diseases.

Liver tumors are rare in children, but the incidence may increase in some circumstances and particularly in chronic liver diseases. Most liver tumors consequent to chronic liver diseases are malignant hepatocellular carcinoma. Other liver tumors include hepatoblastoma, focal nodular hyperplasia, adenoma, pseudotumor, and nodular regenerative hyperplasia. Screening of suspected cases is beneficial. Imaging and surrogate markers of alpha-fetoprotein are used initially as noninvasive tools for surveillance. However, liver biopsy for histopathology evaluation might be necessary for patients with inconclusive findings. Once the malignant liver tumor is detected in children with cirrhosis, liver transplantation is currently considered the preferred option and achieves favorable outcomes. Based on the current evidence, this review focuses on liver tumors with underlying chronic liver disease, their epidemiology, pathogenesis, early recognition, and effective management.

Unremitting diarrhoea in a girl diagnosed anti-N-methyl-D-aspartate-receptor encephalitis: A case report.

BACKGROUND: Asymptomatic cytomegalovirus (CMV) infection is common in children; in contrast, in children with a weakened immune system, invasive CMV can occur. This is the first case report of a severe manifestation of CMV esophago-enterocolitis in a girl diagnosed with anti-N-methyl-D-aspartate-receptor (anti-NMDAR) encephalitis who received only a moderate dose of corticosteroid therapy. CASE SUMMARY: A 12-year-old-Thai girl presented with acute behavioural change and headache for 6 d. Electroencephalogram and positivity for NMDAR autoantibodies were compatible with anti-NMDAR encephalitis. Hence, she received pulse methylprednisolone 10 mg/kg per day for 4 d and continued with prednisolone 1.2 mg/kg per day. On day 42 of corticosteroid therapy, she developed unremitting vomiting and diarrhoea. Endoscopy showed multiple ulcers and erythaematous mucosa along the gastrointestinal tract. Tissue CMV viral load and viral-infected cells confirmed CMV esophago-enterocolitis. Therefore, the patient received ganciclovir 5 mg/kg per dose every 12 h for 3 wk and then 5 mg/kg per dose once daily for 3 wk. Unremitting diarrhoea slowly improved from stool output 1-4 L per day to 1-2 L per day after 3 wk of treatment. Pulse methylprednisolone 20 mg/kg for 5 d was initiated and continued with prednisolone 1 mg/kg per day. After this repeated pulse methylprednisolone treatment, surprisingly, diarrhoea subsided. Immunologic work-up was performed to rule out underlying immune deficiency with unremarkable results. CONCLUSION: Unremitting diarrhoea from CMV esophago-enterocolitis subsided with antiviral and methylprednisolone therapy, implying the immune and NMDAR dysregulation in anti-NMDAR encephalitis.

Detection of reflux-symptom association in children with esophageal atresia by video-pH-impedance study.

BACKGROUND: Children with esophageal atresia (EA) have risk of gastroesophageal reflux disease (GERD), suggesting reflux monitoring for prompt management. AIM: To evaluate GERD in children with EA and specific symptom association from combined Video with Multichannel Intraluminal Impedance and pH (MII-pH) study. METHODS: Children diagnosed with EA with suspected GERD and followed up at King Chulalongkorn Memorial Hospital between January 2000 and December 2018 were prospectively studied. All underwent esophagogastroduodenoscopy with esophageal biopsy and Video MII-pH study on the same day. Symptoms of GERD which included both esophageal and extra-esophageal symptom were recorded from video monitoring and abnormal reflux from MII-pH study based on the statement from the European Paediatric Impedance Group. Prevalence of GERD was also reported by using histopathology as a gold standard. Endoscopic appearance was recorded using Los Angeles Classification and esophagitis severity was graded using Esohisto criteria. RESULTS: Fifteen children were recruited with age of 3.1 (2.2, 9.8) years (40%, male) and the common type was C (93.3%). The symptoms recorded were cough (75.2%), vomiting (15.2%), irritability or unexplained crying (7.6%) and dysphagia (1.9%) with the symptom-reflux association of 45.7%, 89%, 71% and 0%, respectively. There were abnormal endoscopic appearance in 52.9%, esophagitis in 64.7% and high reflux score in 47.1%. Video MII-pH study has high diagnostic value with the sensitivity, specificity and accuracy of 72.7%, 100% and 82.4%, respectively. CONCLUSION: Prevalence of GERD in children with EA was high. Video MII-pH study to detect GERD in children with EA had high diagnostic value with the trend of specific symptom association.

Validation of models using basic parameters to differentiate intestinal tuberculosis from Crohn's disease: A multicenter study from Asia.

BACKGROUND: Data on external validation of models developed to distinguish Crohn's disease (CD) from intestinal tuberculosis (ITB) are limited. This study aimed to validate and compare models using clinical, endoscopic, and/or pathology findings to differentiate CD from ITB. METHODS: Data from newly diagnosed ITB and CD patients were retrospectively collected from 5 centers located in Thailand or Hong Kong. The data was applied to Lee, et al., Makharia, et al., Jung, et al., and Limsrivilai, et al. model. RESULTS: Five hundred and thirty patients (383 CD, 147 ITB) with clinical and endoscopic data were included. The area under the receiver operating characteristic curve (AUROC) of Limsrivilai's clinical-endoscopy (CE) model was 0.853, which was comparable to the value of 0.862 in Jung's model (p = 0.52). Both models performed significantly better than Lee's endoscopy model (AUROC: 0.713, p<0.01). Pathology was available for review in 199 patients (116 CD, 83 ITB). When 3 modalities were combined, Limsrivilai's clinical-endoscopy-pathology (CEP) model performed significantly better (AUROC: 0.887) than Limsrivilai's CE model (AUROC: 0.824, p = 0.01), Jung's model (AUROC: 0.798, p = 0.005) and Makharia's model (AUROC: 0.637, p<0.01). In 83 ITB patients, the rate of misdiagnosis with CD when used the proposed cutoff values in each original study was 9.6% for Limsrivilai's CEP, 15.7% for Jung's, and 66.3% for Makharia's model. CONCLUSIONS: Scoring systems with more parameters and diagnostic modalities performed better; however, application to clinical practice is still limited owing to high rate of misdiagnosis of ITB as CD. Models integrating more modalities such as imaging and serological tests are needed.