Hyperbaric oxygen therapy for perianal Crohn's disease.

I read with great interest the letter by Calderón et al., who clearly described effectiveness of hyperbaric oxygen therapy (HBOT) for refractory ischemic ulcer at the ileorectal anastomosis in Crohn's disease (CD). I congratulate them on their efforts in achieving a favorable long-term outcome. I would like to share my experience of HBOT for perianal CD (PCD). In addition, I discuss recent trials of HBOT for PCD.

Reply to the comments on "Coffee bean sign, steel pan sign and whirl sign in sigmoid volvulus".

We thank Prof. Atamanalp and colleagues for their interest and valuable comments on our article. The authors have highlighted important considerations in the diagnosis of sigmoid volvulus (SV). We would like to respond to their comments. Firstly, although we agree with their opinion that CT, MRI, and endoscopy are more reliable diagnostic tools than plain radiography, we still emphasize that diagnostic imaging for SV is initially based on plain radiography, as recommended by the WSES consensus guidelines. Since SV is the third most common cause of colonic obstruction worldwide, the accessibility of plain radiography is crucial. Among the many plain radiographic signs of SV, Levsky et al. reported that the most sensitive signs were absence of rectal gas, followed by inverted-U appearance and coffee bean sign. Understanding these signs may lead to early detection of SV and further CT evaluation for ischemia or perforation. Despite the high value of plain radiography, there is a global tend to use CT instead from the outset. Secondly, we agree with their opinion that endoscopy is not only a therapeutic, but also a diagnostic procedure to assess mucosal viability. In addition, we believe that endoscopy is also useful in ruling out other obstructive lesions, including colorectal neoplasia and complicated sigmoid diverticular disease. In the clinical setting, endoscopy is performed after the diagnosis of SV by plain radiography or CT and serves as the first line of decompression of SV when ischemia or perforation is not suspected. Finally, we congratulate Prof. Atamanalp and colleagues for their dedicated contribution to the large-scale SV studies in Eastern Anatolia, Turkey, where SV is endemic.

Strongyloides stercoralis hyperinfection presenting pneumatosis intestinalis and acute respiratory distress syndrome after treatment for COVID-19.

A 91-year-old man was admitted with vomiting and abdominal pain. He had had COVID-19 pneumonia a month before and the treatment had consisted of remdesivir, dexamethasone and baricitinib. CT scans showed pneumatosis intestinalis. His respiratory condition rapidly deteriorated and chest CT scans showed ground-glass opacity and Strongyloides stercoralis was identified in the sputum, making a diagnosis of hyperinfection syndrome associated acute respiratory distress syndrome. Treatment of ivermectin was not achieved in time and he died of multiple organ failure. S. stercoralis is a soil-transmitted helminth endemic to tropical and subtropical areas. Immunosuppressive conditions can cause hyperinfection syndrome and life-threatening conditions. Our case highlights the importance of assessing for untreated chronic strongyloidiasis in COVID-19 patients requiring steroid treatment in endemic areas.

Rapid formation of aortoesophageal fistula complicated by mycotic thoracic aortic aneurysm secondary to infective endocarditis.

A 73-year-old man was admitted with four weeks of intermittent fever. He had a history of total aortic arch replacement for aortic arch aneurysm four years prior. CT scans showed no abnormalities before admission. Repeated blood cultures yielded Streptococcus anginosus and Prevotella melaninogenica, suggesting infective endocarditis (IE). Transesophageal echocardiography revealed a vegetation on the aortic valve, confirming IE. He suddenly presented with massive hematemesis and hypotension. Endoscopy revealed an elevated lesion with a laceration but no active bleeding in the esophagus. CT scans showed a thoracic aneurysm involving the esophagus. A diagnosis of aortoesophageal fistula (AEF) complicated by mycotic thoracic aortic aneurysm (MTAA) was made, and he underwent stent graft interpolation followed by minimally invasive esophagectomy. MTAAs are more prone to rupture than arteriosclerotic aneurysms as they are usually not true but pseudoaneurysms. Antecedent infection, including endocarditis, sepsis, predisposes to MTAA. AEF is a rare but life-threatening cause of gastrointestinal bleeding characterized by Chiari's triad. There have been no reports of such rapid formation of AEF after the graft replacement, as shown here. A recent article reported a rapid formation (16 days) of AEF after thoracic endovascular aortic repair, emphasizing prosthetic infection as the most important risk factor. Our case underscores the importance of suspecting AEF and conducting repeated appropriate examinations even if initial examinations do not reveal any aneurysms.

Endoscopic findings of radiation ileitis.

I herein report a case of radiation ileitis. Ileocolonoscopy disclosed villous edema and multiple patchy lymphangiectasias in the terminal ileum. While observing, active bleeding occurred from the numerous telangiectasias and friable atrophic mucosa. Clinical manifestations of radiation ileitis are briefly discussed.

Ulcerative colitis exacerbated by strongyloidiasis.

We herein report a case of ulcerative colitis (UC) exacerbated by strongyloidiasis. Parasites including Strongyloides stercoralis and Entamoeba histolytica can cause chronic gastrointestinal inflammation and long-lasting symptoms resembling UC. On the other hand, it is not well-known that such organisms can trigger the exacerbation of pre-existing UC. We would like to highlight the importance of recognition of strongyloidiasis in the management of UC patients who have lived in or migrated from endemic regions, such as Asia, Africa, and South America.

Duodenal nodularity with villous flattening in common variable immunodeficiency.

We herein report a case of common variable immunodeficiency (CVID). Endoscopy with biopsies disclosed duodenal nodularity with villous flattening associated with CVID. CVID-associated enteropathy is briefly discussed.

Chinese dragon sign of ulcerative colitis.

We present a case of a 17-year-old woman with ulcerative colitis (UC) presented with abdominal pain and hematochezia. A CT scan showed active bowel inflammation, presenting the Chinese dragon sign. A diagnosis of exacerbation of UC was made. This sign refers to tortuous thick-walled sigmoid colon and rectum with narrow lumen resembles the body of the dragon and hypervascularity of the involved mesenteric vessels as bright dots next to the outer wall resemble the legs and skin spikes. Although this sign is nonspecific and may appear in ischemic colitis, ischemic colitis usually does not have rectal involvement and can be differentiated from typical UC.

Comb sign in Crohn's disease.

We present a case of a 13-year-old boy with Crohn's disease (CD) who presented with abdominal pain and diarrhea. On examination, there was tenderness on the lower abdomen. Laboratory examinations showed elevated inflammatory parameters. A CT scan showed active inflammation of the ileum and rectosigmoid colon with the comb sign. A diagnosis of exacerbation of CD was made. The comb sign refers to hypervascularity of the mesentery with vascular dilatation, tortuosity, and wide spacing of the vasa recta that are aligned as the teeth of a comb. This sign is not always pathognomonic for CD; however, it may help identification of acute exacerbation in known CD and differentiating active CD from hypovascular disease such as lymphoma. The comb sign can be highly correlated with the endoscopic severity rather than mural thickening in CD.

Jejunal lymphangioma.

We herein report a case of jejunal lymphangioma. A CT scan showed non-enhancing cystic masses in the jejunum. Enteroscopy revealed multiple cystic swelling with whitish carpet-like villi. Histopathology disclosed dilated lymphatic channels, lined by a single layer of endothelial cells, which were positive for the lymphatic endothelial marker by the immunohistochemical staining. Clinical manifestations of intestinal lymphangioma are briefly discussed.

Transparent cap-assisted endoscopic retrieval of a sharp foreign body in the esophagus.

We herein report an 80-year-old woman who accidentally ingested a sharp foreign body. Transparent cap-assisted endoscopy disclosed an impacted press-through package (PTP) in the upper esophagus. The PTP was grasped by the forceps, inserted into the cap, and removed carefully without complication. Ingestion of sharp-pointed foreign bodies has serious risks of gastrointestinal perforation and hemorrhage; therefore, emergent endoscopic removal has been recommended. Transparent cap-assisted endoscopy is a simple, safe, and effective method with a shorter procedure time and clearer visual field compared with conventional endoscopy. We wish to emphasize that this method has advantages and a potential to be used for endoscopic retrieval of small sharp foreign bodies.

Coffee bean sign, steel pan sign, and whirl sign in sigmoid volvulus.

A 66-year-old man presented with abdominal distension. A plain radiograph showed the coffee bean sign, suggesting sigmoid volvulus (SV). The CT scans disclosed the steel pan sign, the whirl sign, and the beak-shaped transition point, confirming SV. He improved with colonoscopic decompression and detorsion. Characteristic radiographic signs of SV are briefly discussed.

Jejunal schwannoma detected by video capsule endoscopy.

We present a rare case of a 60-year-old woman with jejunal schwannoma. This is the first case of intestinal schwannomas detected by video capsule endoscopy. Characteristic endoscopic and immunohistochemical pictures are presented with a brief literature review.

Confounding effects of microbiome on the susceptibility of TNFSF15 to Crohn's disease in the Ryukyu Islands.

Crohn's disease (CD) involves chronic inflammation in the gastrointestinal tract due to dysregulation of the host immune response to the gut microbiome. Even though the host-microbiome interactions are likely contributors to the development of CD, a few studies have detected genetic variants that change bacterial compositions and increase CD risk. We focus on one of the well-replicated susceptible genes, tumor necrosis factor superfamily member 15 (TNFSF15), and apply statistical analyses for personal profiles of genotypes and salivary microbiota collected from CD cases and controls in the Ryukyu Islands, southernmost islands of the Japanese archipelago. Our association test confirmed the susceptibility of TNFSF15 in the Ryukyu Islands. We found that the recessive model was supported to fit the observed genotype frequency of risk alleles slightly better than the additive model, defining the genetic effect on CD if a pair of the chromosomes in an individual consists of all risk alleles. The combined analysis of haplotypes and salivary microbiome from a small set of samples showed a significant association of the genetic effect with the increase of Prevotella, which led to a significant increase of CD risk. However, the genetic effect on CD disappeared if the abundance of Prevotella was low, suggesting the genetic contribution to CD is conditionally independent given a fixed amount of Prevotella. Although our statistical power is limited due to the small sample size, these results support an idea that the genetic susceptibility of TNFSF15 to CD may be confounded, in part, by the increase of Prevotella.

Pulmonary strongyloidiasis: assessment between manifestation and radiological findings in 16 severe strongyloidiasis cases.

BACKGROUND: Strongyloidiasis is a chronic parasitic infection caused by Strongyloides stercoralis. Severe cases such as, hyperinfection syndrome (HS) and disseminated strongyloidiasis (DS), can involve pulmonary manifestations. These manifestations frequently aid the diagnosis of strongyloidiasis. Here, we present the pulmonary manifestations and radiological findings of severe strongyloidiasis. METHODS: From January 2004 to December 2014, all patients diagnosed with severe strongyloidiasis at the University of the Ryukyus Hospital or affiliated hospitals in Okinawa, Japan, were included in this retrospective study. All diagnoses were confirmed by the microscopic or histopathological identification of larvae. Severe strongyloidiasis was defined by the presence of any of the following: 1) the identification of S. stercoralis from extra gastrointestinal specimens, 2) sepsis, 3) meningitis, 4) acute respiratory failure, or 5) respiratory tract hemorrhage. Patients were assigned to either HS or DS. Medical records were further reviewed to extract related clinical features and radiological findings. RESULTS: Sixteen severe strongyloidiasis cases were included. Of those, fifteen cases had pulmonary manifestations, eight had acute respiratory distress syndrome (ARDS) (53%), seven had enteric bacterial pneumonia (46%) and five had pulmonary hemorrhage (33%). Acute respiratory failure was a common indicator for pulmonary manifestation (87%). Chest X-ray findings frequently showed diffuse shadows (71%). Additionally, ileum gas was detected for ten of the sixteen cases in the upper abdomen during assessment with chest X-ray. While, chest CT findings frequently showed ground-glass opacity (GGO) in 89% of patients. Interlobular septal thickening was also frequently shown (67%), always accompanying GGO in upper lobes. CONCLUSIONS: In summary, our study described HS/DS cases with pulmonary manifestations including, ARDS, bacterial pneumonia and pulmonary hemorrhage. Chest X-ray findings in HS/DS cases frequently showed diffuse shadows, and the combination of GGO and interlobular septal thickening in chest CT was common in HS/DS, regardless of accompanying pulmonary manifestations. This CT finding suggests alveolar hemorrhage could be used as a potential marker indicating the transition from latent to symptomatic state. Respiratory specimens are especially useful for detecting larvae in cases of HS/DS.

Clinical evaluation of high mobility group box 1 protein in Legionella pneumophila pneumonia.

High mobility group box 1 (HMGB-1) protein is involved in acute lung injury due to various etiologies. We evaluated HMGB-1 levels in sera and bronchoalveolar fluids in patients with pneumonia caused by Legionella pneumophila. Levels of HMGB-1 in the sera of patients with L. pneumophila pneumonia (32 cases) and control subjects (24 cases) were determined. Serum HMGB-1 levels in Legionella pneumonia were similar to those of the control subjects. No significant correlation between HMGB-1 levels and other biomarkers and the outcome of cases was observed. In contrast, HMGB-1 levels, as well as interferon-γ, in bronchoalveolar (BA) fluids from severe L. pneumophila pneumonia (7 cases) were significantly higher than those in the sera of identical patients. HMGB-1 levels in BA fluids were relatively higher in pneumonia cases with ALI than those without ALI. Our findings suggest that intra-pulmonary HMGB-1 may be involved in the pathophysiology of pneumonia caused by L. pneumophila.

Role of Brevundimonas vesicularis in supporting the growth of Legionella in nutrient-poor environments.

In 1986, we encountered the first case of Legionella micdadei pneumonia in Japan. In the follow-up study to determine the infection route of L. micdadei, we isolated Brevundimonas vesicularis from the shower hose of the patient�s home. This motivated us to explore the symbiosis between B. vesicularis and Legionella in this study. B. vesicularis type strain, B. vesicularis Kobe strain, Legionella pneumophila serogroup 1 type strain, and L. micdadei Kobe strain were used. B. vesicularis was inoculated into 0.01 M phosphate buffer solution containing artificial sand, and varying concentrations of glucose at 0.1%, 0.01%, and 0.001%. Legionella was added to the cultures after ten days of incubation, and Legionella viable counts were monitored over time. After three days of incubation, Legionella counts increased approximately twofold in flasks containing 0.001% glucose, but Legionella counts decreased in both B. vesicularis inoculated and non-inoculated flasks containing higher concentrations of glucose. The counts were significantly higher in flasks inoculated with B. vesicularis than in non-inoculated flasks throughout the experiments. Under the nutrient-poor conditions, the presence of B. vesicularis was found to aid a further increase in Legionella counts. Further research is necessary to understand the symbiotic conditions most supporting the growth of L. micdadei.