Frequency and chronology of extraintestinal manifestations in the Swiss Inflammatory Bowel Disease Cohort

Background: Data on the frequency of extraintestinal manifestations (EIM) in inflammatory bowel disease (IBD) is scarce, especially the one evaluating the time of occurrence of the EIM relative to IBD diagnosis. Aim: To assess the type and frequency of EIM in IBD patients and to evaluate when EIMs occur relative to IBD diagnosis. Methods: Analysis of data from the Swiss Inflammatory Bowel Disease Cohort (SIBDCS) which collects data on a large sample of IBD patients from hospitals and private practices across Switzerland starting in 2005. While parametric data are shown as mean ± SD, non-parametric data are presented as median and interquartile range (IQR). Results: A total of 1143 patients were analyzed (572 (50%) female, mean age 42.1 ± 14.4 years): 629 (55%) with Crohn's disease (CD), 501 (44%) with ulcerative colitis (UC), and 13 (1%) with indeterminate colitis (IC). Of 1143 patients, 374 (32.7%) presented with EIM (65% with CD, 33% with UC, 2% with IC). Of those patients suffering from EIMs, 37.4% presented with one, 41.7% with two, 12.4% with three, 5.3% with four, and 3.2% with five EIM during their lifetime. The IBD patients initially presented with the following EIMs: peripheral arthritis (PA) 63.4%, ankylosing spondylitis (AS) 8.1%, primary sclerosing cholangitis (PSC) 6.0%, uveitis 5.7%, oral aphthosis 5.7%, erythema nodosum (EN) 5.0%, pyoderma gangrenosum 1.8%, psoriasis 0.7%. While 92.9% of EIM occurred once IBD diagnosis was established (median 72 months, IQR 9-147 months, p < 0.001), 7.1% of EIMs preceded IBD diagnosis (median time 28 months before IBD diagnosis, IQR 7-60 months). Over a course of a lifetime, IBD patients presented with the following EIM (total exceeds 100 due to potential presence of multiple EIM): peripheral arthritis 69.3%, oral aphthosis 23%, ankylosing spondylitis 19.4%, uveitis 15.5%, erythema nodosum 14.5%, PSC 7.8%, pyoderma gangrenosum 6%, psoriasis 2.8%. Conclusion: EIMs frequently occur in a lifetime of IBD patients. The vast majority of patients present with EIMs once IBD diagnosis has been established. IBD patients most often present with peripheral arthritis, ankylosing spondylitis and PSC as their first EIM. However, peripheral arthritis, oral aphthosis, and ankylosing spondylitis are the most common EIMs in a lifetime of IBD patients.

Extraintestinal manifestations in inflammatory bowel disease: frequency and associated risk factors in the nationwide Swiss IBD cohort study (SIBDCS)

Background: Data on the frequency of extraintestinal manifestations (EIM) in Crohnʼs disease (CD) and ulcerative colitis (UC) are scarce. Goal: to evaluate prevalences, forms of EIM and risk factors in a large nationwide IBD cohort. Methods: Data from validated physician enrolment questionnaires of the adult Swiss IBD cohort were analyzed. Logistic regression models were used to identify EIM risk factors. Results: 950 patients were included, 580 (61%) with CD (mean age 43yrs) and 370 (39%) with UC (mean age 49yrs), of these, 249 (43%) of CD and 113 (31%) of UC patients had one to 5 EIM. The following EIM were found: arthritis (CD 33%, UC 21%), aphthous stomatitis (CD 10%, UC 4%), uveitis (CD 6%, UC 4%), erythema nodosum (CD 6%, UC 3%), ankylosing spondylitis (CD 6%, UC 2%), psoriasis (CD 2%, UC 1%), pyoderma gangrenosum (CD and UC each 2%), primary sclerosing cholangitis (CD 1%, UC 4%). Logistic regression in CD identified the following items as risk factors for ongoing EIM: active disease (OR 1.95, 95% CI 1.17-3.23, P=0.01), positive IBD family history (OR 1.77, 95% CI 1.07-2.92, P=0.025). No risk factors were identified in UC patients. Conclusions: EIM are a frequent problem in CD and UC patients. Active disease and positive IBD family history are associated with ongoing EIM in CD patients. Identification of EIM prevalence and associated risk factors may result in increased awareness for this problem and thereby facilitate their diagnosis and management.

Chronological order of appearance of extraintestinal manifestations relative to the time of IBD diagnosis in the Swiss Inflammatory Bowel Disease Cohort

BACKGROUND: Data evaluating the chronological order of appearance of extraintestinal manifestations (EIMs) relative to the time of inflammatory bowel disease (IBD) diagnosis is currently lacking. We aimed to assess the type, frequency, and chronological order of appearance of EIMs in patients with IBD. METHODS: Data from the Swiss Inflammatory Bowel Disease Cohort Study were analyzed. RESULTS: The data on 1249 patients were analyzed (49.8% female, median age: 40 [interquartile range, 30-51 yr], 735 [58.8%] with Crohn's disease, 483 [38.7%] with ulcerative colitis, and 31 [2.5%] with indeterminate colitis). A total of 366 patients presented with EIMs (29.3%). Of those, 63.4% presented with 1, 26.5% with 2, 4.9% with 3, 2.5% with 4, and 2.7% with 5 EIMs during their lifetime. Patients presented with the following diseases as first EIMs: peripheral arthritis 70.0%, aphthous stomatitis 21.6%, axial arthropathy/ankylosing spondylitis 16.4%, uveitis 13.7%, erythema nodosum 12.6%, primary sclerosing cholangitis 6.6%, pyoderma gangrenosum 4.9%, and psoriasis 2.7%. In 25.8% of cases, patients presented with their first EIM before IBD was diagnosed (median time 5 mo before IBD diagnosis: range, 0-25 mo), and in 74.2% of cases, the first EIM manifested itself after IBD diagnosis (median: 92 mo; range, 29-183 mo). CONCLUSIONS: In one quarter of patients with IBD, EIMs appeared before the time of IBD diagnosis. Occurrence of EIMs should prompt physicians to look for potential underlying IBD.

Extraintestinal Manifestations of Inflammatory Bowel Disease.

Extraintestinal manifestations (EIM) in inflammatory bowel disease (IBD) are frequent and may occur before or after IBD diagnosis. EIM may impact the quality of life for patients with IBD significantly requiring specific treatment depending on the affected organ(s). They most frequently affect joints, skin, or eyes, but can also less frequently involve other organs such as liver, lungs, or pancreas. Certain EIM, such as peripheral arthritis, oral aphthous ulcers, episcleritis, or erythema nodosum, are frequently associated with active intestinal inflammation and usually improve by treatment of the intestinal activity. Other EIM, such as uveitis or ankylosing spondylitis, usually occur independent of intestinal inflammatory activity. For other not so rare EIM, such as pyoderma gangrenosum and primary sclerosing cholangitis, the association with the activity of the underlying IBD is unclear. Successful therapy of EIM is essential for improving quality of life of patients with IBD. Besides other options, tumor necrosis factor antibody therapy is an important therapy for EIM in patients with IBD.

Parasitos de aves e mamíferos silvestres em cativeiro no estado de Pernambuco

Resumo: Os animais silvestres são hospedeiros de uma grande variedade de parasitos que podem interferir em sua conservação ex situ. O objetivo deste estudo foi identificar os parasitos gastrointestinais (PGI) e ectoparasitos dos animais do Centro de Triagem de Animais Silvestres (CETAS) do Instituto Brasileiro de Meio Ambiente e Recursos Naturais Renováveis (IBAMA) de Recife, Pernambuco, além de determinar os aspectos do manejo em cativeiro que possam estar relacionados com os parasitos identificados. Foram coletados ectoparasitos e amostras fecais de 223 aves e mamíferos, as quais foram processadas pelos métodos: microscopia direta, flutuação e sedimentação. Helmintos e/ou protozoários foram detectados em 91 (40,8%) amostras fecais, sendo 64 (70,3%) de aves e 27 (29,7%) de mamíferos. Ovos de Capillaria sp., Ascaridida, Spirurida e oocistos de Eimeria sp. foram detectados nas amostras fecais das aves, enquanto ovos de Trichuris trichiura, Strongyloides sp., Toxocara canis, Ancylostoma sp., Strongylida e oocistos de Coccídios foram encontrados nas amostras fecais de mamíferos. Os ectoparasitos identificados em aves foram Colpocephalum turbinatum, Kurodaia (Kurodaia) fulvofasciata, Halipeurus sp., Naubates sp., Saemundssonia sp., Austromenopon sp., Paragoniocotes sp., Brueelia sp., Myrsidea sp. and Pseudolynchia sp., enquanto em mamíferos os ectoparasitos identificados foram Rhipicephalus sanguineus, Amblyomma varium, A. calcaratum, A. nodosum, Ornithodoros talaje e Ctenocephalides felis felis. A. calcaratum e O. talaje são registrados pela primeira vez em Pernambuco e T. tetradactyla é apresentado como novo hospedeiro de O. talaje. Nenhum dos animais estudados apresentou sinais clínicos em decorrência da infecção/infestação parasitária. Parasitos com potencial zoonótico como T. trichiura, Strongyloides sp., T. canis e Ancylostoma sp. foram identificados em primatas não humanos e carnívoros. Precárias condições estruturais e sanitárias do CETAS-PE estão relacionadas com os parasitos identificados neste estudo e devem ser levadas em consideração para a adoção de medidas adequadas de controle. Os resultados deste estudo contribuirão de maneira significativa para a conservação de animais selvagens no CETAS-PE e para a saúde dos profissionais responsáveis pela manutenção destes animais.

Double-blind trial of the efficacy of pentoxifylline vs thalidomide for the treatment of type II reaction in leprosy

Type II reaction in leprosy, or erythema nodosum leprosum (ENL), is often characterized by severe clinical symptoms together with nerve function impairment leading to permanent disabilities. Thalidomide has been shown to be a highly effective drug for the treatment of ENL. It is, however, contraindicated for women of childbearing age due to its teratogenicity. On the other hand, pentoxifylline, used to treat hypercoagulable states, is not teratogenic and, like thalidomide, can inhibit the synthesis of tumor necrosis factor-a and other cytokines. In the present randomized double-blind clinical study we compared the effectiveness of orally administered pentoxifylline vs thalidomide in treating type II reaction in 44 patients. Daily doses of 300 mg thalidomide or 1.2 g pentoxifylline were administered for 30 days to multibacillary leprosy patients undergoing type II reaction. Randomly chosen patients were included in the study before, during, and after specific multidrug therapy. Clinical evaluations were performed on the 1st, 7th, 14th, 21st, and 30th days of treatment and laboratory tests were carried out on the 1st and 30th days. As expected, overall, thalidomide proved to be more effective in the treatment of type II leprosy reaction. Nevertheless, continuous treatment with pentoxifylline was effective in relieving the clinical signs of ENL, especially limb edema and systemic symptoms, in 62.5% of the patients.

Evidencia actual sobre características demográficas en mastitis granulomatosa idiopática

Introducción: La mastitis granulomatosa idiopática es una enfermedad crónica benigna, rara y de etiología desconocida; tiende a confundirse con otras enfermedades debido a síntomas similares. Este estudio pretende identificar y cuantificar las características demográficas, los antecedentes ginecoobstétricos relevantes y las manifestaciones clínicas prediagnósticas de esta enfermedad Metodología: Se realizó una revisión sistemática con análisis agrupado de datos tipo meta análisis. Se utilizó una estrategia de búsqueda en PubMed. Todos los estudios relacionados con la definición, manifestaciones clínicas, diagnóstico, tratamiento y pronóstico de la mastitis granulomatosa idiopática fueron elegibles. Las variables de interés fueron edad, país, antecedente de contracepción hormonal, tiempo de evolución, tiempo desde el último embarazo, diagnóstico inicial, y manifestaciones clínicas previas a la consulta. No hubo restricción en fechas de publicación. Resultados: Fueron incluidas 641 mujeres con diagnóstico de MGI reportadas en 68 publicaciones que cumplieron los criterios de selección. La edad media fue 35.9 años, 14.1% de ellas estaba embarazada o lactando, el antecedente de consumo de anticonceptivos hormonales fue 21% y el tiempo promedio desde el último parto fue de 3.9 años. La afectación ocurre principalmente en mama izquierda y en cuadrante superoexterno. El cáncer de mama y el absceso mamario son diagnósticos diferenciales en la consulta. Discusión: El diagnóstico de MGI es un reto para el ginecólogo desde la consulta inicial. Debido a que sus manifestaciones clínicas no son específicas, su diagnóstico parece apuntar a la necesidad de un proceso de descarte de otras patologías más frecuentes e incluso de peor pronóstico. Palabras clave mastitis granulomatosa idiopática

Anti-neutrophil cytoplasmic antibodies (ANCA) in the clinical forms of leprosy

Anti-neutrophil cytoplasmic antibodies (ANCA) are autoantibodies against enzymes present in primary granules of neutrophils and lysosomes of monocytes detected in systemic vasculitis and in other diseases, including infections, ANCA are markers of active Wegener granulomatosis, which presents some anatomo-pathologic and immune response features similar to those of leprosy. Thus, we raised the hypothesis that ANCA may be present in leprosy as markers specifically linked to the presence of vasculitis. The aim of this study was to determine the presence of ANCA in leprosy and its correlation with the clinical forms of the disease. Sera from 60 normal individuals and from 59 patients with different clinical forms of leprosy were studied. The patients were also allocated into reactional and nonreactional groups. By indirect immunofluorescence, ANCA were positive, an atypical pattern A-ANCA, in 28.8% of the patient sera. A-ANCA predominated, although not significantly (p >0,05), in the reactional groups (37.9% vs 20.0%), and in those at the lepromatous pole (41.6% vs 20.0%). There was no correlation between ANCA positivity and either disease duration, disease activity, or therapeutic regimen (p >0.05), An interesting finding was the correlation between ANCA and gender: 94.1% of ANCA-positive patients were males (p <0.01), a feature that so far has not been reported in ANCA-related diseases and for which there is no explanation at the moment. By ELISA, the sera of the lepromatous leprosy patients did not show activity against either PR3, MPO, HLE, the most common ANCA antigens. Because A-ANCA are nonspecific, this finding requires further investigation for the determination of the responsible antigen(s), in conclusion, A-ANCA are present in 28.8% of leprosy patients but are not related to vasculitis in the erythema nodosum leprosum reaction and are not a marker of a specific clinical form.

Renal lesions in leprosy: A retrospective study of 199 autopsies

In the present work, 199 patients with leprosy who underwent autopsy between 1970 and 1986 were retrospectively studied to determine the prevalence, types, clinical characteristics, and etiologic factors of renal lesions (RLs) in leprosy. Patients were divided into two groups: 144 patients with RLs (RL+) and 55 patients without RLs (RL-), RLs observed in 72% of the autopsied patients were amyloidosis (AMY) in 61 patients (31%), glomerulonephritis (GN) in 29 patients (14%), nephrosclerosis (NPS) in 22 patients (11%), tubulointerstitial nephritis (TIN) in 18 patients (9%), granuloma in 2 patients (1%), and other lesions in 12 patients (6%), AMY occurred most frequently in patients with lepromatous leprosy (36%; nonlepromatous leprosy, 5%; P < 0.01), recurrent erythema nodosum leprosum (33%; P < 0.02), and trophic ulcers (27%; 0.05 < P < 0.10), Ninety-seven percent of AMY was found in patients with lepromatous leprosy, 88% showed recurrent trophic ulcers, and 76% presented with erythema nodosum leprosum, NPS was found in older patients with arterial hypertension, neoplastic diseases, infectious diseases, and vasculitis associated with GN, Most patients with AMY presented with proteinuria (95%) and renal failure (88%), the most frequent causes of death were renal failure in patients with AMY (57%), infectious diseases in patients with GN (41%) and TIN (45%), and cardiovascular diseases in patients with NPS (41%), No difference in survival rates was observed among RL- patients and those with AMY, GN, NPS, or TIN. (C) 2001 by the National Kidney Foundation, Inc.

Ticks associated with armadillo (Euphractus sexcinctus) and anteater (Myrmecophaga tridactyla) of Emas National Park, State of Goias, Brazil

This study was conducted in October 1998 and November 1999 in the Emas National Park (131,868 ha), a savanna-type cerrado region situated in the far south of Goias State, Brazil, near the geographic center of South America (15degrees-23degrees S; 45degrees-55degrees W). Animals were captured with the aid of nets and anesthetized (15 mg/kg ketamine + 1 mg/kg xylasine) in order to collect ticks for identification and to establish laboratory colonies. They included giant anteaters (Myrmecophaga tridactyla) (n = 4) and yellow armadillos (Euphractus sexcinctus) (n = 6). Free-living ticks (larvae, nymphs, and adults) were collected from the field by using a 1 X 2-m flannel cloth. Free-living ticks were identified as Amblyomma sp., A. cajennense, and A. triste. Adult ticks collected from anteaters were identified as Amblyomma cajennense and A. nodosum and from armadillos as A. pseudoconcolor and A. nodosum. The relevance of these host-tick relationships to possible mechanisms underlying emergence of tick-borne pathogens of importance to public health is discussed.

A REAPPRAISAL OF GENERIC AND SUBGENERIC CLASSIFICATION IN THE BATRACHOSPERMACEAE (RHODOPHYTA)

The generic and subgeneric classification of the family Batrachospermaceae (Rhodophyta) has long been recognized as ambiguous and often inconsistent. One of the prime features used to delineate sections of Batrachospermum, trichogyne shape, is variable even within given species. However, characters associated with the carposporophyte and the carpogonial branch, as well as carpogonial symmetry, are practical and consistent taxonomic criteria. These features have been used to redefine sectional delineation in Batrachospermum. Based on phylogenetic reasoning and practicality, it is proposed that the three genera Nothocladus, Sirodotia and Tuomeya be reduced to sectional level within Batrachospermum. The genus Batrachospermum would thus become the sole member of the Batrachospermaceae and would include two subgenera, Batrachospermum and Acarposporophytum, the former with nine clearly defined sections (Aristata, Batrachospermum, Contorta, Hybrida, Nothocladus (Skuja) stat. nov., Sirodotia (Kylin) stat. nov., Tuomeya (Harvey) stat. nov., Turficola and Viridia). As a result, the following nomenclatural changes are proposed: Batrachospermum lindaueri (Skuja) comb. nov., B. nodosum (Skuja) comb. nov., B. delicatulum (Skuja) comb. nov., B. fennicum (Skuja) comb. nov., B. suecicum (Kylin) comb. nov. and B. americanum (Kutzing) comb. nov.

Species diversity and seasonality of free-living ticks (Acari : Ixodidae) in the natural habitat of wild Marsh deer (Blastocerus dichotomus) in Southeastern Brazil

This study evaluated the presence and seasonal activity of free-living ticks in remaining marsh areas by the Parana river, in Brazil. Eight field trips (once per season) for collection of ticks were performed during 2 years. Using CO2 traps, dragging, and visual inspection of vegetation, five free-living tick species were collected, in the following order of abundance: Amblyomma cajennense, Amblyom\ma dubitatum, Amblyomma triste, Amblyomma coelebs, and Amblyomma nodosum. The seasonal pattern of A. cajennense was characterized by the highest peaks for adult ticks in the summer/spring months, for nymphs in the winter and for larvae in the autumn and winter. A. dubitatum and A. triste presented similar seasonal patterns characterized by peaks of adult ticks in the autumn. Nymphs of A. dubitatum peaked in the winter of the first year and in the winter/spring of the second year. A. triste was the only species to be collected in significantly higher numbers in the marsh than in surrounding drier areas such as forest patches. Among domestic animals living close the marsh areas, horses were infested by Anocentor nitens, A. cajennense, and Boophilus microplus, bovines were infested solely by B. microplus, and dogs were infested by Rhipicephalus sanguineus. Adults of A. triste showed to be well adapted to the marsh environment. This result, at least partially, explains local previous observations on the association of A. triste with marsh deer, as this vertebrate host inhabits mainly the marsh area. (c) 2006 Published by Elsevier B.V.

Ticks (Acari: Ixodidae) associated with wild animals in the Pantanal region of Brazil

This paper describes the identification of ticks from wild animals of the Pantanal region in Brazil as part of a comprehensive study about established and emerging tick-host relationships and related pathological aspects. Eighty-one animals were captured (representing 13 species six orders), and ticks were found on 63 (78%). Tick species identified included Boophilus microplus (Canestrini), Amblyomma cajennense (F.), Amblyomma parvum Aragão, Amblyomma pseudoconcolor Aragão, Amblyomma scalpturatum Neumann, Amblyomma nodosum Neumann, Amblyomma ovale Koch, and Amblyomma tigrinum Koch. Dragging from grasslands yielded negative results compared with the high concentration of ticks that were collected from leaves in the forests.

Ticks associated with wild animals in the Nhecolândia Pantanal, Brazil

A study of ticks associated with wild animals was carried out from September 1996 to April 1998 at the Fazenda Alegria (21,000 ha), in the Nhecolândia Pantanal, State of Mato Grosso do Sul, Brazil, a sunken plain bordering the upper Paraguay river, located 19 × 08′S; 56 × 46′W. A total of 81 wild animals (13 species, 6 orders) were captured with the aid of nets, and ticks were found on 63 (78%). Tick species identified included Boophilus microplus (Canestrini), Amblyomma cajennense (F.), A. parvum (Aragão), A. pseudo-concolor (Aragão), A. scalpturatum (Neumann), A. nodosum (Neumann), A. ovale (Koch), and A. tigrinum (Koch). Dragging from grasslands (campos) yielded negative results compared to the high concentration of ticks, mainly nymphs, that were collected from leaves in the forests (capão). Predominance of immature instars (Amblyomma genera) was observed in the end of winter (August-September). Ticks were associated mainly with coatis, deer (Mazama gouazoubira) and anteater, and these animals may play a role in the epidemiology of tick-transmitted pathogens in the Pantanal if one considers their coexistence with local domestic animals.