Histoplasma capsulatum infection in refractory Crohn's disease of the pouch on anti-TNF biological therapy

Histopathology of Pouch and Para-Pouch Inflammatory and Neoplastic Disorders

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is used to treat patients with ulcerative colitis or familial adenomatous polyposis who need colectomy. While this procedure substantially improves patient's quality of life and reduces cancer risk, it is associated with a variety of sequelae' including surgical complications, inflammatory disorders, and neoplasia. Pouchitis, cuffitis, and Crohn's disease of the pouch are the most common inflammatory disorders of the pouch and para-pouch.

OBJECTIVE

This study aimed to elaborate on the histopathology of common inflammatory and neoplastic disorders of the pouch and para-pouch.

DATA SOURCES

A Medline search for English language studies published between 1981 and 2021 using the PubMed search engine. The terms "ileal pouch-anal anastomosis," "pouchitis," "pouchitis activity score," "secondary pouchitis," "Crohn's disease of the pouch," "Crohn's-like conditions of the pouch," "pre-pouch ileitis," "cuffitis," "pouch adenocarcinoma," and "pouch neoplasia" were used.

STUDY SELECTION

The published human studies that reported histopathology of common inflammatory and neoplastic disorders of the ileal pouch were selected and reviewed.

CONCLUSIONS

Histologic examination plays an essential role in confirming inflammation in pouchitis, identifying etiology and clues for secondary pouchitis, and diagnosing neoplasia. A standardized, simple, and reproducible histologic grading system for pouchitis is needed. Pouch and para-pouch glandular dysplasia diagnosis is challenging and should always be reviewed by at least one gastrointestinal pathologist.

Common Inflammatory Disorders and Neoplasia of the Ileal Pouch: A Review of Histopathology

Ileal pouch-anal anastomosis (IPAA) is the standard restorative procedure after proctocolectomy in patients with ulcerative colitis (UC) who require colectomy. The ileal pouch is susceptible to a variety of insults including mechanical injury, ischemia, fecal stasis, and infectious agents. In addition, the development of recurrent and idiopathic inflammatory bowel disease and neoplasia may occur in the ileal pouch. Although clinical, endoscopic, and radiographic examination can diagnose many ileal pouch diseases, histologic examination plays an essential role in diagnosis and management, particularly in cases with antibiotic refractory chronic pouchitis and pouch neoplasia.

Could Histoplasma capsulatum Be Related to Healthcare-Associated Infections?

Healthcare-associated infections (HAI) are described in diverse settings. The main etiologic agents of HAI are bacteria (85%) and fungi (13%). Some factors increase the risk for HAI, particularly the use of medical devices; patients with severe cuts, wounds, and burns; stays in the intensive care unit, surgery, and hospital reconstruction works. Several fungal HAI are caused by Candida spp., usually from an endogenous source; however, cross-transmission via the hands of healthcare workers or contaminated devices can occur. Although other medically important fungi, such as Blastomyces dermatitidis, Paracoccidioides brasiliensis, and Histoplasma capsulatum, have never been considered nosocomial pathogens, there are some factors that point out the pros and cons for this possibility. Among these fungi, H. capsulatum infection has been linked to different medical devices and surgery implants. The filamentous form of H. capsulatum may be present in hospital settings, as this fungus adapts to different types of climates and has great dispersion ability. Although conventional pathogen identification techniques have never identified H. capsulatum in the hospital environment, molecular biology procedures could be useful in this setting. More research on H. capsulatum as a HAI etiologic agent is needed, since it causes a severe and often fatal disease in immunocompromised patients.

Chronic cavitary pulmonary histoplasmosis in a non-HIV and immunocompromised patient without overseas travel history

Korea is not known as an endemic area for Histoplasma. However, we experienced a case of histoplasmosis in a person who had never been abroad. A 65-year-old female was admitted to the hospital for evaluation of multiple lung nodules. A computed tomography (CT) scan of the chest showed multiple ill-defined consolidations and cavitations in all lobes of both lungs. The patient underwent a CT-guided lung biopsy, and a histopathology study showed findings compatible with histoplasmosis. Based on biopsy results and clinical findings, the patient was diagnosed with chronic cavitary pulmonary histoplasmosis. The patient recovered completely following itraconazole treatment. This is the first case report of pulmonary histoplasmosis unconnected with either HIV infection or endemicity in Korea.

Infection risk associated with anti-TNF-α agents: a review

INTRODUCTION

TNF-α is a pro-inflammatory cytokine known to a have a key role in the pathogenesis of chronic immune-mediated diseases. TNF-α inhibitors can be administered either as monotherapy or in combination with other anti-inflammatory or disease-modifying anti-rheumatic drugs (DMARDs) to treat chronic immune-mediated diseases.

AREAS COVERED

Patients receiving TNF-α inhibitors are at high risk of infections. Based on our experience, in this paper, we discuss the risk of infections associated with the administration of TNF-α inhibitors and the strategies for mitigating against the development of these serious adverse events.

EXPERT OPINION

Infliximab more so than etanercept appears to be responsible for the increased risk of infections. Re-activation of latent tuberculosis (LTB) infection and the overall risk of opportunistic infections should be considered before beginning TNF-α inhibitor therapy. A careful medical history, Mantoux test and chest-x-ray should always be performed before prescribing TNF-α inhibitors. Particular attention should be paid to risk factors for Pneumocystis jirovecii infection. Hepatitis B and C virological follow-up should be considered during TNF-α inhibitor treatment. Finally, patients who are at high risk of herpes zoster (HZ) reactivation would benefit from a second vaccination in adulthood when receiving TNF-α inhibitors.