Parsonage-Turner syndrome due to autochthonous acute genotype 3f hepatitis E virus infection in a nonimmunocompromised 55-year-old patient.

Hepatitis E virus (HEV) infection is an emerging autochthonous disease in industrialized countries. Extra-hepatic manifestations, in particular neurologic manifestations, have been reported in HEV infection. Only a few cases of hepatitis E-associated Parsonage-Turner syndrome have been reported, and HEV genotypes were rarely determined. Here, we report the case of a Parsonage-Turner syndrome associated with an acute autochthonous HEV infection in a 55-year-old immunocompetent patient. HEV genomic RNA was detected in serum and cerebrospinal fluid samples (CSF), and molecular phylogenetic analysis of HEV was performed. The interest of this case lies in its detailed description notably the molecular analysis of HEV RNA isolated from serum and CSF. HEV infection should be considered in diagnostic investigations of neurologic manifestations associated with liver function perturbations.

Update on Anti-Saccharomyces cerevisiae antibodies, anti-nuclear associated anti-neutrophil antibodies and antibodies to exocrine pancreas detected by indirect immunofluorescence as biomarkers in chronic inflammatory bowel diseases: results of a multicenter study.

AIM: Anti-Saccharomyces cerevisiae antibodies (ASCA), anti-nuclear associated anti-neutrophil antibodies (NANA) and antibodies to exocrine pancreas (PAB), are serological tools for discriminating Crohn's disease (CrD) and ulcerative colitis (UC). Like CrD, coeliac disease (CoD) is an inflammatory bowel disease (IBD) associated with (auto) antibodies. Performing a multicenter study we primarily aimed to determine the performance of ASCA, NANA and PAB tests for IBD diagnosis in children and adults, and secondarily to evaluate the prevalence of these markers in CoD. METHODS: Sera of 109 patients with CrD, 78 with UC, 45 with CoD and 50 healthy blood donors were retrospectively included. ASCA, NANA and PAB were detected by indirect immunofluorescence (IIF). RESULTS: ASCA+/NANA- profile displayed a positive predictive value of 94.2% for CrD. Detection of ASCA was correlated with a more severe clinical profile of CrD and treatment of the disease did not influence their serum levels. ASCA positivity was found in 37.9% of active CoD. PAB were found in 36.7% CrD and 13.3% CoD patients and were not correlated with clinical features of CrD, except with an early onset of the disease. Fifteen CrD patients were ASCA negative and PAB positive. CONCLUSION: ASCA and PAB detected by IIF are specific markers for CrD although their presence does not rule out a possible active CoD. The combination of ASCA, NANA and PAB tests improves the sensitivity of immunological markers for CrD. Repeating ASCA, NANA, and PAB testing during the course of CrD has no clinical value.

Videocapsule endoscopy is useful for the diagnosis of intestinal lymphangiectasia.

We study two authentic cases of protein-losing enteropathy, the diagnosis of which was facilitated using Given M2A videocapsule endoscopy. The first case corresponded to a primary intestinal lymphangiectasia confirmed by jejunum biopsies and the second one to a protein-losing enteropathy with lymphatic abnormalities secondary to a chronic constrictive pericarditis. In the first case, the mucosa of jejunum presented with a diffuse oedematous aspect, whitish villi, white curved lines probably related to submucosal dilated lymphatics and lacteal juice. In the second case, capsule endoscopy showed oedematous aspect of jejunum mucosa associated with white curved lines similar to those observed in the first case. Videocapsule endoscopy is useful in cases of protein-losing enteropathy to identify presence of intestinal lymphangiectasia and to specify their localisation after ruling out other disorders liable to induce protein-losing gastrointestinal syndrome.

Delta-opioid receptor agonists inhibit neuromuscular transmission in human colon.

The present study was undertaken to investigate the possible role of delta-opioid receptors in the neuroregulation of human colonic motility by using a superfusion model. Spontaneous mechanical activity and responses to electrical transmural nerve stimulation of both longitudinal and circular muscle strips from the human sigmoid colon were studied. Exogenously added delta-opioid receptor agonists did not modify spontaneous contractile activities of either type of strip. Nerve stimulation induced a triphasic response composed of an initial contraction followed by a relaxation and an off-contraction. This response was mediated by cholinergic excitatory nerves and non-adrenergic, non-cholinergic excitatory and inhibitory nerves. [Met5]Enkephalin and the synthetic delta-opioid receptor agonist [D-Pen2,D-Pen5]enkephalin (DPDPE) significantly decreased the amplitude of the initial contraction and of the off-contraction. The effects of both delta-opioid receptor agonists were reduced in the presence of either the delta-opioid receptor antagonist, ICI 174864, or another delta-opioid receptor antagonist, naltrindole. ICI 174864 prevented neither the effects of a natural kappa-opioid receptor agonist, dynorphin-(1-13) nor those of the mu-opioid receptor agonist, PL017. Therefore, these data suggest that delta-opioid receptors might be involved in the neuroregulation of smooth muscle of human colon and may mediate inhibition of cholinergic and non-cholinergic excitatory transmission within the myenteric plexus.

Regulatory role of enteric kappa opioid receptors in human colonic motility.

The effects of different kappa opioid agonists and antagonists on spontaneous mechanical activities and responses to electrical transmural nerve stimulation of both longitudinal and circular muscle strips from the human sigmoid colon were studied. A superfusion apparatus was used to record isometric contractions. Exogenously added kappa agonists did not modify spontaneous contractile activities on either type of strip. Nerve stimulation induced a triphasic response composed of a first contraction (C1) followed by a relaxation (C2) and an off-contraction (C3); this response was mediated by cholinergic excitatory nerves and non-adrenergic, non-cholinergic excitatory and inhibitory nerves. Dynorphin 1-13 and the synthetic kappa agonist trans-3,4-dichloro-N-methyl-N-(2- [1pyrolidinyl]-cyclohexyl) dramatically decreased the amplitude of the excitatory components C1 and C3. The effects of both kappa agonists were blocked in presence of the kappa antagonist Nor-Binaltorphimine. The delta antagonist ICI 174864 did not prevent the inhibition of the contractions C1 and C3 induced by dynorphin. Therefore, these data suggest that kappa receptors are involved in the neuroregulation of smooth muscle of human colon and mediate inhibition of cholinergic and non-cholinergic excitatory transmission within myenteric plexus.

Antral and fundic D-cell numbers in Helicobacter pylori infection.

OBJECTIVES: Helicobacter pylori infection is associated with an exaggeration of gastrin release following meals or bombesin stimulation attributed to a defect of somatostatin secretion of antral D-cells. Nevertheless, these modifications of gastric physiology do not explain the increase of gastric acid secretion which is only observed in duodenal ulcer patients. The inhibitory effect of somatostatin secretion of fundic D-cells on parietal cells is well known. The aim of our prospective study was to compare the number of fundic D-cells and likewise the number of antral G-cells and D-cells between patients with duodenal ulcer and healthy subjects with and without H. pylori infection. METHODS: The numbers of D-cells and G-cells were compared between 19 infected patients with duodenal ulcer and 20 healthy subjects, 10 with and 10 without H. pylori infection. Fundic mucosal biopsy specimens were examined using immunohistochemical techniques specific for the presence of somatostatin, antral mucosal biopsy specimens for the presence of gastrin and somatostatin. RESULTS: The number of G-cells was significantly lower (P = 0.0012) in duodenal ulcer patients by comparison with infected subjects and controls. The number of antral D-cells was significantly less (P < 0.0001) in duodenal ulcer patients (mean of 10 random fields = 0.45 +/- 0.04) than in either asymptomatic infected patients (0.65 +/- 0.07) or uninfected controls (0.88 +/- 0.10). The number of fundic D-cells was significantly lower (P < 0.0001) in duodenal ulcer patients (mean = 0.20 +/- 0.03) than in either asymptomatic infected subjects (0.29 +/- 0.05) or controls (0.73 +/- 0.09); here the difference between the two groups of infected subjects was not significant. Multivariate analysis showed that the presence of H. pylori infection of the fundic mucosa did not influence the number of fundic D-cells. CONCLUSION: Changes in the number of fundic and antral D-cells induced by H. pylori infection did not explain abnormalities of gastric acid secretion usually observed in duodenal ulcer patients; it is suggested that pre-existing abnormalities in the regulation of parietal cell or increase of parietal cell mass are involved.

Prothrombin fragment 1 + 2 and thrombin-antithrombin III complex as markers of activation of blood coagulation in inflammatory bowel diseases.

OBJECTIVES AND METHODS: The aims of the present work were to assess the presence of thrombin generation in Crohn's disease and in ulcerative colitis by using the prothrombin fragment 1 + 2 and the thrombin-antithrombin III complex assays and to study the possible relationships between these markers and disease activity. RESULTS: Prothrombin fragment 1 + 2 and thrombin-antithrombin III complex were significantly raised in patients with Crohn's disease (n = 69) and with ulcerative colitis (n = 25) as compared with healthy controls (n = 50). In Crohn's disease these two markers of thrombin generation were correlated with the Van Hees index (P < 0.05 and P < 0.001, respectively); values were significantly different from controls even in the patient group displaying the lowest disease activity (P < 0.001). No correlation was found with tumour necrosis factor alpha and C-reactive protein; nevertheless patients with C-reactive protein less than or equal to 10 mg/l had significant lower values of prothrombin fragment 1 + 2 (P < 0.03). In ulcerative colitis prothrombin fragment 1 + 2 and thrombin-antithrombin III complex were significantly increased by comparison with controls, were higher in patients with pancolitis and correlated with C-reactive protein (P < 0.002 and P < 0.009, respectively). CONCLUSION: These data show that prothrombin fragment 1 + 2 and thrombin-antithrombin III complex are increased in inflammatory bowel diseases and suggest that thrombin generation might be an early event in their pathogenesis.

[Biological manifestations of a prethrombotic state in developmental Crohn's disease]. / Manifestations biologiques d'un état préthrombotique au cours de la maladie de Crohn évolutive.

The authors have studied 21 patients with Crohn's disease and have looked for signs of platelet and blood coagulation activation, by measuring platelet factor 4, beta thromboglobulin and fibrinopeptide A: a fibrinolytic system study with tissue plasminogen activator assessment has also been made. Beta thromboglobulin, platelet factor 4 and fibrinopeptide A were increased in 80 per cent, 100 per cent and 60 per cent of cases respectively. Beta thromboglobulin was significantly correlated with the Van Hees activity index. Plasminogen before venous stasis was significantly decreased and 9 patients had a plasminogen release defect. The relationship between Crohn's disease and thrombosis might partially be explained by a release of inflammation mediators and/or endotoxins: these mediators might induce thrombosis by interfering with the antithrombogenic properties of the endothelial cell. In conclusion these data prove that active Crohn's disease is currently associated with a prethrombotic state, present biologic tests that might predict a venous or arterial thrombosis at short term are not available.

[Arterial thrombotic complications in Crohn's disease]. / Accidents thrombotiques artériels au cours de la maladie de Crohn.

In a series of 230 observations of Crohn's disease, the authors describe 4 cases of arterial thrombosis; two of them involving cerebral arteries. These complications occurred in young women without any notable risk factor for atheroma. All patients had highly active Crohn's disease when arterial thrombosis occurred: two of them had several episodes of thrombosis and three, extraintestinal manifestations. As the arterial thromboses are often severe, rarely foreseeable and the venous thromboses frequent, the point is whether to use anticoagulants. When Crohn's disease is highly active, but only if there are no hemorrhagic lesions, anticoagulants at prophylactic doses may be recommended. How to define more exactly a high risk thromboses population deserves further investigation.

[Diagnostic value of high resolution sonography in Crohn's disease and ulcerative colitis]. / Valeur diagnostique de l'échographie de haute fréquence au cours de la maladie de Crohn et de la rectocolite hémorragique.

OBJECTIVE: To evaluate the diagnostic accuracy of high resolution sonography in patients with inflammatory bowel disease (MICI). PATIENTS AND METHODS: In patients with Crohn's disease (n = 48), ulcerative colitis (n = 23), indeterminate colitis (n = 3), inflammatory (n = 21) and non-inflammatory (n = 23) controls, high resolution sonography was performed and compared to colonoscopy (+/- retrograde ileoscopy) and/or baryum studies of the small bowel and the colon. RESULTS: Diagnosis of intestinal inflammation or not was correct in 69/74 MICI patients (sensitivity: 94.4%, specificity: 66.7%, global accuracy: 93.2%). Segment location was accurate in 58/74 (sensitivity: 80.3%, specificity: 66.7%, global accuracy: 79.7), more frequently in Crohn's disease, than in ulcerative colitis. Five out of six complications of Crohn's disease were diagnosed. In Crohn's disease, the method was more accurate in case of colonic or ileocolonic involvement. CONCLUSION: High resolution sonography is a reliable diagnostic tool for the detection of intestinal inflammation and related complications in MICI. In can be of value in the follow-up and seems particularly interesting in the case of temporary contraindication of invasive methods.

[Mononuclear cell activation in Crohn's disease. Evaluation using serum assay of neopterin and interleukin-2 soluble receptors]. / Activation des cellules mononucléées dans la maladie de Crohn. Evaluation par le dosage sérique de la néoptérine et des récepteurs solubles de l'interleukine-2 (RS-IL-2).

To determine the degree of mononuclear blood cell activation in Crohn's disease (CD), 65 patients were prospectively investigated (22 with mild, 26 with moderate and 17 with severe disease). Serum levels of soluble receptors for interleukin-2 (SR-IL-2) were measured by ELISA. In CD patients SR-IL-2 levels were significantly higher (m = 707 +/- 326 U/ml) than in three other groups: 70 controls (m = 258 +/- 87 U/ml, p less than 0.0001); 8 patients with acute infectious colitis (m = 405 +/- 216 U/ml, p less than 0.0001); 101 HIV seropositive subjects (m = 564 +/- 216 U/ml, p less than 0.002). There was a positive correlation between SR-IL-2 level and the Van Hees activity index (r = 0.595, p less than 0.0001). On the other hand, the numbers of activated T cells (CD 3+, HLA DR+), CD 4+, CD 8+ and NK cells did not differ according to the CD activity groups. Furthermore, CD patients treated with steroids (n = 39) did not differ from those without any medication. As a marker of monocyte activation, serum neopterin level was determined by RIA. All CD patients considered as a group, serum neopterin level was 2.89 +/- 1.44 ng/l (n less than 2.5 ng/l). Neopterin level increased with disease activity (1.97 +/- 0.92 vs 3.10 +/- 1.46 vs 3.74 +/- 1.36, p less than 0.01), and was positively correlated with SR-IL-2 (r = 0.609, p less than 0.0001). These results suggest a monocyte-macrophage activation in CD, which parallels disease activity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Socioprofessional consequences of Crohn disease]. / Répercussions socio-professionnelles de la maladie de Crohn.

To evaluate evolutivity and social repercussions of Crohn's disease, the same gastroenterologist interviewed 151 out of 197 patients with Crohn's disease (77.5 percent) who had been hospitalized from 1964 to 1986 in our unit. The other 46 could not be traced or refused to participate. There was no difference regarding age, sex, duration of illness, pattern of lesions and operations between the two groups. At the time of observation, mean follow-up was 7.8 years and two thirds of the patients had inactive disease. During the previous year, the course of the disease was quiescent in 50 percent of all patients; this rate increased with duration of follow-up and time from surgery. A constant rate of stable course was observed (20 percent) irrespective of duration of disease and time of surgery. The interviews were compared with those obtained from an age and sex-matched group of 70 previously healthy subjects admitted to the hospital for less than one month. The education and socioeconomic levels were higher in patients with Crohn's disease than in controls, in spite of the fact that 25 percent of patients whose disease begun during scholarship complained of difficulties at school, and nearly 20 percent of all patients were partially or totally unable to work. Sports and cultural activities were the same in Crohn's disease and in the control group. Tobacco intake was slightly higher at time of diagnosis but it was equal in both groups at the time of the interview. Non allopathic advice or treatment were sought by 48 percent of Crohn's disease patients (7 percent in controls).(ABSTRACT TRUNCATED AT 250 WORDS)

[Monoclonal anti-AFP immunoscintigraphy of human hepatocellular carcinoma. Influence of biological, anatomical and vascular factors]. / Immunoscintigraphie monoclonale anti-AFP du carcinome hépatocellulaire humain. Influence des facteurs biologiques, anatomiques et vasculaires.

The actual interest of immunoscintigraphy for the detection of alphafetoprotein-producing liver tumors was investigated by both visual examination and quantitative analysis in 61 patients with either hepatocellular carcinoma (39 patients, group I), secondary liver cancer (11 patients, group II), or non tumoral liver (9 cirrhosis, 2 healthy liver, group III): All patients received injections of 123I-anti-alphafoetoprotein monoclonal antibodies and planar scans were performed after 28 hours. Only 18 out of 39 hepatocellular carcinoma-bearing patients had a positive scan (46 p. 100). Such a moderate sensibility was due to a striking inhibitory influence of cirrhosis: the positivity rate was 6/24 and 12/15 respectively when hepatocellular carcinoma was and was not associated with cirrhosis (p less than 0.01). Specificity was also moderate (55 p. 100) for detection of hepatocellular carcinoma in tumor-bearing patients (group I and II). In the absence of cirrhosis, the intensity of the tumoral uptake was highly correlated with high serum alphafoetoprotein level (p less than 0.001) and tumor arterial hypervascularization (p less than 0.01). Anti-alphafoetoprotein monoclonal antibody uptake by the extratumoral liver was found to be very specific of hepatocellular carcinoma since it was high in 23 out of 39 patients of group I but in only 1 out of 22 in groups II and III (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of lithiasis of the common bile duct by endoscopic sphincterotomy and laparoscopic cholecystectomy]. / Le traitement de la lithiase de la voie biliaire principale par sphinctérotomie endoscopique et cholécystectomie laparoscopique.

This paper evaluates the treatment of common bile duct stones by endoscopic sphincterotomy (SE) and laparoscopic cholecystectomy (CL). 733 patients presenting with symptomatic cholelithiasis were operated on between March 1990 April 1993; 131 (18%) of them had a preoperative suspicion of common bile duct stones (LVBP): jaundice for 41, biliary acute pancreatitis for 27 and altered liver function tests for 63. 131 retrograde cholangiographies (CPRE) were attempted with an associated SE (113 cases) in the presence of LVBP, biliary pancreatitis, enlargement of common bile duct and appearance of forced papilla. CL was performed 24 to 48 hours later. CPRE +/- SE had no mortality; 1 patient presented a retroduodenal perforation of CBD, requiring surgery. 58 cases (44.2%) of LVBP were diagnosed, without a statistically significant difference according to the clinical pattern. In the group with altered liver function tests only alkaline phosphatase was significantly predictive of LVBP. There was no mortality or morbidity related to CL; conversion rate was 9.8%; 4 of 12 cases of conversion were related to persistence of stones in the common bile duct, without any possibility of laparoscopic extraction. Mean hospital stay was 7.4 days. Efficacy of this sequential method of treatment of LVBP was 91.3%: this method seems satisfactory, not dangerous and minimally invasive, and should be indicated for pre-operative suspected common bile duct stones.