Human cytomegalovirus and Epstein-Barr virus infection in inflammatory bowel disease:Need for mucosal viral load measurement

AIM:To evaluate the best diagnostic technique and risk factors of the human Cytomegalovirus(HCMV)and Epstein-Barr virus(EBV)infection in inflammatory bowel disease(IBD).METHODS:A cohort of 40 IBD patients(17 refractory)and 40 controls underwent peripheral blood and endoscopic colonic mucosal sample harvest.Viral infection was assessed by quantitative real-time polymerase chain reaction and immunohistochemistry,and correlations with clinical and endoscopic indexes of activity,and risk factors were investigated.RESULTS:All refractory patients carried detectable levels of HCMV and/or EBV mucosal load as comparedto 13/23(56.5%)non-refractory and 13/40(32.5%)controls.The median DNA value was significantly higher in refractory(HCMV 286 and EBV 5.440 copies/105cells)than in non-refractory(HCMV 0 and EBV 6copies/105 cells;P<0.05 and<0.001)IBD patients and controls(HCMV and EBV 0 copies/105 cells;P<0.001 for both).Refractory patients showed DNA peak values≥103 copies/105 cells in diseased mucosa in comparison to non-diseased mucosa(P<0.0121 for HCMV and<0.0004 for EBV),while non-refractory patients and controls invariably displayed levels below this threshold,thus allowing us to differentiate viral colitis from mucosal infection.Moreover,the mucosal load positively correlated with the values found in the peripheral blood,whilst no correlation with the number of positive cells at immunohistochemistry was found.Steroid use was identified as a significant risk factor for both HCMV(P=0.018)and EBV(P=0.002)colitis.Finally,a course of specific antiviral therapy with ganciclovir was successful in all refractory patients with HCMV colitis,whilst refractory patients with EBV colitis did not show any improvement despite steroid tapering and discontinuation of the other medications.CONCLUSION:Viral colitis appeared to contribute to mucosal lesions in refractory IBD,and its correct diagnosis and management require quantitative real-time polymerase chain reaction assay of mucosal specimens.

Role of the advanced glycation end products receptor in Crohn's disease inflammation

AIM:To investigate the level of mucosal expression and the involvement of the receptor for the advanced glycation end products(RAGE)in delayed apoptosis and tumor necrosis factor(TNF)-αproduction in Crohn’s disease(CD).METHODS:Surgical and endoscopic specimens from both inflamed and non-inflamed areas of the ileum and/or colon were collected from 20 and 14 adult CD patients,respectively,and used for the assessment of RAGE expression by means of immunohistochemistry and western blotting analysis.Normal tissues from 21 control subjects were used for comparison.The same polyclonal anti-human RAGE antibody(R and D System)was used in all experimental conditions.RAGE staining was quantized by a score including both the amount of positive cells and intensity of immunoreactivity;cellular pattern was also described.The effects of RAGE blocking on apoptotic rate and TNF-αproduction were investigated on immune cells freshly isolated from CD mucosa and incubated both with and without the muramyl dipeptide used as antigenic stimulus.Statistical analysis was performed via the test for trend,with regression models to account for intra-patient correlations.A 2-sided P<0.05 was considered significant.RESULTS:In inflamed areas,RAGE expression in both the epithelial and lamina propria compartments was higher than control tissues(P=0.001 and 0.021,respectively),and a cluster of positive cells were usually found in proximity of ulcerative lesions.Similar results were obtained in the lamina propria compartment of non-inflamed areas(P=0.025).The pattern of staining was membranous and granular cytosolic at the epithelial level,while in the lamina propria it was diffuse cytosolic.When evaluating the amount of protein expression by immunoblotting,a significant increase of both surface area and band intensity(P<0.0001 for both)was observed in CD inflamed areas compared to control tissue,while in non-inflamed areas a significant increase was found only for band intensity(P<0.005).Moreover,a significantly lower expression in noninflamed areas in comparison with inflamed areas was found for both surface area and band intensity(P<0.0006 for both).Finally,RAGE blocking largely affects both the apoptotic rate of mucosal cells(towards an increase in both non-inflamed and inflamed areas of P<0.001 and<0.0001,respectively)and TNF-αsecretion(towards a decrease in both non-inflamed and inflamed areas of P<0.05 and<0.01,respectively),mainly in the presence of antigenic stimulation.CONCLUSION:RAGE is up-regulated in CD,especially in inflamed areas,and it appears to play a role in the mechanisms involved in chronic inflammation.

Is it worth investigating splenic function in patients with celiac disease?

Celiac disease, an immune-mediated enteropathy induced in genetically susceptible individuals by the ingestion of gluten, is the most frequent disorder associated with splenic hypofunction or atrophy. Defective splenic function affects more than one-third of adult patients with celiac disease, and it may predispose to a higher risk of infections by encapsulated bacteria and thromboembolic and autoimmune complications, particularly when celiac patients have concomitant pre-malignant and malignant complications (refractory celiac disease, ulcerative jejunoileitis and enteropathy-associated T-cell lymphoma). However, the clinical management of patients with celiac disease does not take into account the evaluation of splenic function, and in patients with high degree of hyposplenism or splenic atrophy the prophylactic immunization with specific vaccines against the polysaccharide antigens of encapsulated bacteria is not currently recommended. We critically re-evaluate clinical and diagnostic aspects of spleen dysfunction in celiac disease, and highlight new perspectives in the prophylactic management of infections in this condition.

Validation of the Italian translation of the perceived stigma scale and resilience assessment in inflammatory bowel disease patients

BACKGROUND Stigmatization is the separation of an individual from a group due to aspects that make them different.Resilience may in turn influence the perception of stigma.Patients with inflammatory bowel disease(IBD)are susceptible to stigma,although data are very limited.AIM To validate an Italian translation of the IBD perceived stigma scale(PSS)in relation to patients’resilience.METHODS Consecutive IBD outpatients were prospectively enrolled(December 2018-September 2019)in an Italian,tertiary referral,IBD center.Clinical and demographic data were collected.Stigma and resilience were evaluated through the IBD-PSS and the 25-item Connor-Davidson Resilience Scale,respectively.The International Quality of Life Assessment Project approach was followed to translate the IBD-PSS into Italian and to establish data quality.Higher scores represent greater perceived stigma and resilience.Multivariable analysis for factors associated with greater stigma was computed.RESULTS Overall,126 IBD patients(mean age 46.1±16.9)were enrolled.The International Quality of Life Assessment criteria for acceptable psychometric properties of the scale were satisfied,with optimal data completeness.There was no ceiling effect,whilst floor effect was present(7.1%).The discriminant validity and the internal consistency reliability were good(Cronbach alpha=0.87).The overall internal consistency was 95%,and the test-retest reliability was excellent 0.996.The median PSS score was 0.45(0.20-0.85).Resilience negatively correlated with perceived stigma(Spearman’s correlation=-0.18,95%confidence intervals:-0.42-0.08,P=0.03).CONCLUSION We herein validated the Italian translation of the PSS scale,also demonstrating that resilience negatively impacts perceived stigma.