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Yang AH, Sullivan B, Zerbe CS, De Ravin SS, Blakely AM, Quezado MM, Marciano BE, Marko J, Ling A, Kleiner DE, Gallin JI, Malech HL, Holland SM, Heller T. Gastrointestinal and Hepatic Manifestations of Chronic Granulomatous Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1401-1416. [PMID: 36646382 DOI: 10.1016/j.jaip.2022.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/02/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
Chronic granulomatous disease (CGD) is a rare inborn error of immunity, resulting from a defect in nicotinamide adenine dinucleotide phosphate oxidation and decreased production of phagocyte reactive oxygen species. The main clinical manifestations are recurrent infections and chronic inflammatory disorders. Current approaches to management include antimicrobial prophylaxis and control of inflammatory complications. Hematopoietic stem cell transplantation or gene therapy can provide definitive treatment. Gastrointestinal and hepatic manifestations are common in CGD and include structural changes, dysmotility, CGD-associated inflammatory bowel disease, liver abscesses, and noncirrhotic portal hypertension. The findings can be heterogeneous, and the management is complex in light of the underlying immune dysfunction. This review describes the various clinical findings and the latest studies in management of gastrointestinal and hepatic manifestations in CGD, as well as the management experience at the National Institutes of Health.
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Affiliation(s)
- Alexander H Yang
- Digestive Diseases Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
| | - Brigit Sullivan
- Office of the Director, National Institutes of Health, Bethesda, Md
| | - Christa S Zerbe
- Immunopathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Suk See De Ravin
- Genetic Immunotherapy Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Andrew M Blakely
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Martha M Quezado
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Beatriz E Marciano
- Immunopathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Jamie Marko
- Department of Radiology, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Alexander Ling
- Department of Radiology, Clinical Center, National Institutes of Health, Bethesda, Md
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - John I Gallin
- Clinical Pathophysiology Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Harry L Malech
- Genetic Immunotherapy Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Steven M Holland
- Immunopathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md.
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Wu EY, Ehrlich L, Handly B, Frush DP, Buckley RH. Clinical and imaging considerations in primary immunodeficiency disorders: an update. Pediatr Radiol 2016; 46:1630-1644. [PMID: 27655432 PMCID: PMC5083248 DOI: 10.1007/s00247-016-3684-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/20/2016] [Accepted: 08/02/2016] [Indexed: 01/16/2023]
Abstract
Primary immunodeficiencies are a group of genetically determined disorders with diverse presentations. The purpose of this review is to provide a practical and brief description of a select number of these diseases and to discuss the important role the radiologist can have in making an early diagnosis and in detecting and following disease complications. The role of diagnostic imaging and informed performance and interpretation are vital in the diagnosis, surveillance and management of all primary immunodeficiency disorders.
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Affiliation(s)
- Eveline Y Wu
- Department of Pediatrics, University of North Carolina at Chapel Hill, 030 MacNider Hall, CB#7231, Chapel Hill, NC, 27599, USA.
| | - Lauren Ehrlich
- Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Brian Handly
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald P Frush
- Division of Pediatric Radiology, Duke University Medical Center, Durham, NC, USA
| | - Rebecca H Buckley
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.,Department of Immunology, Duke University School of Medicine, Durham, NC, USA
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Leopard Skin-Like Colonic Mucosa: A Novel Endoscopic Finding of Chronic Granulomatous Disease-Associated Colitis. J Pediatr Gastroenterol Nutr 2016; 62:56-9. [PMID: 26164846 DOI: 10.1097/mpg.0000000000000905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Chronic granulomatous disease (CGD) is a rare inherited disorder in which phagocytes are unable to eradicate pathogens because of a deficit of nicotinamide adenine dinucleotide phosphate oxidase. Among CGD patients, ∼ 30% to 50% develop severe gastrointestinal tract symptoms. Although characteristic histologic findings of CGD-associated colitis have been reported, information on endoscopic features remained vague. METHODS A total of 8 male patients with CGD (ages 2-23 years) from 2 Japanese institutions underwent colonoscopy for the evaluation of their fever, diarrhea, bloody stool, and abdominal pain. The endoscopic and histologic findings were retrospectively reviewed. RESULTS The endoscopic findings of CGD-associated colitis appeared varied. Notably, brownish dots over a yellowish edematous mucosa were observed in 3 of the 8 patients. Prominent pigment-laden macrophages were noted histologically on the mucosa. CONCLUSIONS Although nonspecific endoscopic findings of CGD-associated colitis have been reported before, our observation of brownish dots spread across a yellowish edematous mucosa, termed "leopard sign," could be a unique feature of this condition.
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Abstract
Interventional radiology is a rapidly growing discipline in paediatrics. Many non-vascular interventional techniques may be used in the gastrointestinal tract in children. The technically simpler and more common of these may be adopted by any paediatric radiologist with an interest in interventional radiology. Other rarer and more complex techniques are currently restricted to specialist centres with a higher overall caseload. This review emphasizes the common procedures such as oesophageal dilatation, gastrostomy, insertion of transgastric jejunal feeding tubes and biopsy. Less common salivary, hepatobiliary, pancreatic and intestinal interventions are also described.
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Affiliation(s)
- Derek J Roebuck
- Department of Radiology, Great Ormond Street Hospital, London, WC1N 3JH, UK.
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Abstract
OBJECTIVE Chronic granulomatous disease is a rare clinical entity characterized by recurrent infective and inflammatory complications. Patients are usually assigned to specialist centres, but nonspecialist clinicians may be required to treat these patients in the emergency setting. This review serves as a management guide to those clinicians who are faced with patients presenting with gastrointestinal manifestations of chronic granulomatous disease. METHODS This review is based on a literature search (Medline and NLM PubMed) with manual cross-referencing of all articles related to gastrointestinal chronic granulomatous disease. RESULTS Gastrointestinal tract involvement is present in most affected patients. Clinical presentation can mimic common surgical complications such as colitis, perianal sepsis, gastric outlet obstruction and liver abscess. A history of recurrent infections during childhood is common. Management involves haematological, microbiological, endoscopic and radiological investigations. Treatment modalities include early aggressive empirical antimicrobial therapy for sepsis, immunomodulation for inflammatory complications and surgical drainage of abscesses. CONCLUSION Early involvement of a centre with immunological expertise combined with aggressive management of complications significantly improves morbidity and mortality from this rare condition.
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Affiliation(s)
- A Huang
- Wycombe General Hospital, High Wycombe, UK
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Agudelo-Flórez P, Prando-Andrade CC, López JA, Costa-Carvalho BT, Quezada A, Espinosa FJ, de Souza Paiva MA, Roxo P, Grumach A, Jacob CA, Carneiro-Sampaio MMS, Newburger PE, Condino-Neto A. Chronic granulomatous disease in Latin American patients: clinical spectrum and molecular genetics. Pediatr Blood Cancer 2006; 46:243-52. [PMID: 16123991 DOI: 10.1002/pbc.20455] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic granulomatous disease (CGD) is a primary immunodeficiency characterized by early onset of recurrent and severe infections. The molecular defects causing CGD are heterogeneous and lead to absence, low expression, or malfunctioning of one of the phagocyte NADPH oxidase components. The aim of this study was to analyze the clinical features and to investigate the molecular genetic defects of Latin American patients with CGD. PROCEDURES The study included 14 patients. The diagnosis was based on a history of recurrent severe infections, impaired respiratory burst, and the demonstration of an underlying mutation by single strand conformation polymorphism (SSCP) or RT-PCR analysis, followed by genomic DNA or cDNA sequencing. RESULTS Seven unrelated patients were found to have the X-linked form of CGD (X-CGD). Heterogeneous mutations affected the CYBB gene: two insertions, one substitution, and four splice site defects; two of them are novel. Seven patients presented with one of the autosomal recessive forms of CGD (A47-CGD); all had the most common mutation, a DeltaGT deletion in exon 2 of the NCF1 gene. Pneumonia was the most frequent clinical feature, followed by pyoderma, sinusitis, otitis, and liver abscess. Patients with X-CGD were more likely to have initial infections before age 2 years and to have inflammatory obstructive granulomas later. None of the patients had severe adverse reactions to BCG immunization. CONCLUSIONS X-CGD patients from Latin America showed a high degree of molecular heterogeneity, including two novel mutations. Their clinical characteristics included early onset of infections and eventual obstructive granulomas. A47-CGD represented 50% of the reported cases, a higher prevalence than reported in other series.
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Affiliation(s)
- Piedad Agudelo-Flórez
- Center for Investigation in Pediatrics and Department of Pediatrics, State University of Campinas Medical School, Campinas, Sao Paulo, Brazil
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Rojo P, Ruiz-Contreras J, Gonzalez-Tome M, Serrano C, Marin MA. Outpatient treatment with corticosteroids and antibiotics for acalculous cholecystitis in chronic granulomatous disease. Acta Paediatr 2005; 94:1684-6. [PMID: 16303712 DOI: 10.1080/08035250500201648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
UNLABELLED We report the outpatient management of acalculous colecistitis in an 18-y-old male with X-linked chronic granulomatous disease. The patient complained of abdominal pain and the initial ultrasound showed a gallbladder with a thickened wall. CONCLUSION In chronic granulomatous disease, pain from a thickened gallbladder disappears after oral treatment with glucocorticoids and antibiotics.
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Affiliation(s)
- Pablo Rojo
- Department of Paediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain.
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Levine S, Smith VV, Malone M, Sebire NJ. Histopathological features of chronic granulomatous disease (CGD) in childhood. Histopathology 2005; 47:508-16. [PMID: 16241999 DOI: 10.1111/j.1365-2559.2005.02258.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To describe the spectrum of histopathological features encountered in children with chronic granulomatous disease (CGD) at a specialist centre. METHODS AND RESULTS The histopathological findings of 88 surgical pathology requests from a range of organ systems including upper and lower gastrointestinal tract biopsy series, liver, bladder, bone, lung, skin, soft tissue, bone marrow and lymph node biopsy specimens, in 32 patients aged 4 months to 18 years (median 7 years) with CGD were reviewed. In most tissues the features were those of active chronic inflammation, with or without abscess or granuloma formation, often associated with fungal infection. In some tissues, more characteristic findings were identified, including the presence of pigmented macrophages, especially in hepatic sinusoids and colonic mucosa, where active chronic eosinophil predominant colitis was also observed. CONCLUSIONS Chronic granulomatous disease may present to histopathologists in a wide range of tissue specimens most often demonstrating features of active chronic inflammation with or without granuloma formation. The presence of numerous pigmented macrophages in association with such inflammation should raise suspicion of the diagnosis. In addition, diffuse granulomatous inflammation of the lung and hepatic abscess formation should be regarded as suggestive of the diagnosis.
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Affiliation(s)
- S Levine
- Department of Paediatric Histopathology, Great Ormond Street Hospital, London, UK
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McCabe RP. Gastrointestinal Manifestations of Non-AIDS Immunodeficiency. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:17-25. [PMID: 11792234 DOI: 10.1007/s11938-002-0003-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Most primary immunodeficiencies are diagnosed in children and, therefore, are managed by pediatricians and pediatric specialists. Generally, internists and adult gastroenterologists only rarely encounter patients with primary immunodeficiency, and have little or no involvement in actual treatment. However, gastroenterologists should be familiar with primary immunodeficiency because 1) current and future therapy for immunodeficiency will allow more patients to survive into adulthood, 2) some primary immunodeficiencies, particularly common variable immunodeficiency, may have their first clinical manifestation in adolescence or early adulthood, and 3) recently it has been hypothesized that Crohn's disease may be an immunodeficiency. Detailed treatment recommendations are not included in this review, as subspecialists in pediatrics, immunology, and hematology manage such treatments. Of far greater importance, even in this treatment-oriented forum, is the enhancement of our awareness of these disorders.
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Affiliation(s)
- Robert P. McCabe
- Minnesota Gastroenterology, PA, 2545 Chicago Avenue South, Suite 700, Minneapolis, MN 55404, USA.
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Abstract
Chronic granulomatous disease (CGD) is a group of hereditary disorders of impaired intracellular destruction of phagocytosed bacteria. Gastrointestinal manifestations are present, with hepatic abscess being the most common. In this case report, we present an adult with CGD with esophageal involvement, which has been described in only one other adult. The clinical history, modalities of diagnosis (including endoscopy, barium radiography, and esophageal manometry), and therapeutic strategies pertaining to the esophageal manifestations of CGD are discussed. A review of the pertinent available literature is provided.
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Affiliation(s)
- M Golioto
- Division of Gastroenterology Duke University Medical Center, Durham, North Carolina 27710, USA
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Yin EZ, Frush DP, Donnelly LF, Buckley RH. Primary immunodeficiency disorders in pediatric patients: clinical features and imaging findings. AJR Am J Roentgenol 2001; 176:1541-52. [PMID: 11373230 DOI: 10.2214/ajr.176.6.1761541] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- E Z Yin
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Ruiz-Contreras J, Bastero R, Serrano C, Benavent MI, Martinez A. Oesophageal narrowing in chronic granulomatous disease. Eur J Radiol 1998; 27:149-52. [PMID: 9639141 DOI: 10.1016/s0720-048x(97)00049-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A 14 year-old boy with X-linked chronic granulomatous disease (CGD) developed a long smooth narrowing at the mid oesophagus with severe dysphagia. Endoscopy revealed a normal mucosa and biopsy showed non-specific acute inflammatory changes. Bacterial cultures of the biopsy specimens were sterile. Combined treatment with antibiotics and steroids resulted in a transitory remission, but symptoms recurred after 2.5 months. One second course of steroids and antibiotics lead to a long-term remission. Oesophagogram was more useful than endoscopy to evaluate the severity of the stricture.
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Affiliation(s)
- J Ruiz-Contreras
- Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain.
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