Obstructive Jaundice in a Patient with Ulcerative Colitis, Sjögren's Syndrome and Sarcoidosis

Cardiac sarcoidosis in a patient with ulcerative colitis: A case report and literature review

RATIONALE

Both ulcerative colitis (UC) and sarcoidosis are chronic inflammatory diseases with unknown etiologies and are rare. However, the odds ratio in UC patients has been reported to range from 1.7 to 2.1, suggesting a potential etiology between sarcoidosis and UC. Furthermore, the underlying etiologies of UC and sarcoidosis remain unidentified. Sharing the experience of a UC patient with cardiac sarcoidosis could provide valuable insights to prevent sudden death in UC patients.

PATIENT CONCERNS

A 71-year-old Japanese woman was diagnosed with UC at 58-year-old and maintained remission on mesalazine treatment. She complained of just palpitation; therefore, she consulted a cardiologist.

DIAGNOSES

The patient received a diagnosis of cardiac sarcoidosis with complicating ulcerative colitis based on the results of N-terminal prohormone of the brain natriuretic peptide (NT-proBNP), imaging examinations, and histology.

INTERVENTION

The patient was treated with prednisolone and methotrexate. The prednisolone was then tapered, and the methotrexate dose was adjusted based on her symptoms, imaging results, and laboratory findings.

OUTCOME

She no longer had any symptoms, and the abnormal FDG uptake had disappeared after 2 years.

LESSON

In UC patients, periodic or additional (in case of symptomatic) electrocardiography and NT-proBNP are recommended for the early detection of cardiac sarcoidosis, a life-threatening complication.

Gastrointestinal and hepatic manifestations of Sjogren syndrome

Sjogren syndrome (SS) is an autoimmune disease that affects exocrine glands and therefore may affect the gastrointestinal system, from the mouth, esophagus, and bowel to the liver and pancreas. Oral involvement in SS is mainly characterized by dryness, with a wide spectrum of symptoms, from mild-to-severe xerostomia with dysgeusia and tooth decay. The dysphagia, although common, does not correlate with the reduced salivary flow rate or the dysmotility that may be present. Dyspepsia, found in up to 23% of patients, may be associated with gastritis, reduced acid production, and antiparietal cell antibodies, but rarely pernicious anemia. Pancreatic involvement, although rare, includes pancreatitis and pancreatic insufficiency. The most common causes of liver disease are primary biliary cirrhosis, autoimmune hepatitis, nonalcoholic fatty liver disease, and hepatitis C virus (HCV). Although abnormal liver tests are found in up to 49% of patients, they are usually mild. Although sicca syndrome, abnormal histology of the salivary glands, and abnormal sialograms are common in primary biliary cirrhosis, the antibodies to Ro/SSA or La/SSB antigens are infrequent. Xerostomia, sialadenitis, abnormal salivary flow rates, and abnormal Schirmer test in HCV vary widely among the studies, although the antibodies to Ro/SSA or La/SSB are only 1%. Several studies show that HCV is in saliva, although how this may impact sicca syndrome or SS in HCV is unclear. SS as a disease of exocrine glands affects many parts of the gastrointestinal system.

Sjogren's syndrome in a patient with ulcerative colitis and primary sclerosing cholangitis: Case report and review of the literature

Inflammatory bowel disease has been reported to co-exist with other autoimmune diseases. Sjogren's syndrome is an autoimmune disorder characterized by xerostomy and/or xerophthalmy. Sjogren's syndrome occurring in IBD has been very rarely reported. A 45-year old woman diagnosed ten years ago with ulcerative pancolitis and primary sclerosing cholangitis was referred to our outpatient IBD clinic because of xerostomy but not for xerophthalmy for the previous three months. The patient had been under azathioprine maintenance treatment (2 mg/kg) and achieved long-term disease remission for the past 4 years. Patient clinical examination and laboratory tests were unremarkable. Salivary gland biopsy and complete ophthalmologic investigation were performed and the patient was diagnosed with Sjogren's syndrome. Understanding sicca manifestations in IBD is difficult since the pathogenesis of this intestinal disorder is not yet clear. Of these complex autoimmune phenomena which occur along with IBD it is quite difficult to categorize concomitant Sjogren's syndrome as primary or secondary and literature is conflicting. The possibility of Sjogren's syndrome should always be considered and properly investigated in patients diagnosed with inflammatory bowel disease who develop a constellation of constitutional sicca symptoms.

Idiopathic fibrosing pancreatitis associated with ulcerative colitis

Idiopathic fibrosing pancreatitis has been associated with Sjögren's syndrome, primary biliary cirrhosis and primary sclerosing cholangitis. This condition frequently develops in childhood and youth, and has also been related to ulcerative colitis and pericholangitis. Pancreatic complications have been rarely described as systemic complications of ulcerative colitis. A 25-year-old man presented with epigastric pain and jaundice. Abdominal ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) revealed a diffuse enlargement of the pancreas, filiform distal stenosis of the common bile duct and intrahepatic bile ducts, and pancreatic duct dilatation. At operation, a rock-hard and nodular pancreas was noted. Cholecystectomy and Roux-en-Y hepaticojejunostomy, with an access loop, was successfully performed. Idiopathic fibrosing pancreatitis should be considered in young patients with obstructive jaundice, especially those affected with chronic inflammatory or autoimmune diseases. Glucocorticoid therapy would be the first-line treatment, although many patients require operation.

A matrix metalloproteinase inhibitor to treat unresectable cholangiocarcinoma

Matrix metalloproteinases (MMPs) are implicated in tumour invasion and metastasis. We report the first use of an MMP inhibitor to treat unresectable cholangiocarcinoma. Four men with stage IV cholangiocarcinoma received oral Marimastat (10 mg bd) indefinitely following relief of obstructive jaundice. Monthly measurements of the tumour marker CA 19-9 were used as an indicator of disease response and activity. CA 19-9 levels dropped sharply and stayed low in the two patients who appeared to respond. Mean survival of the four patients was 21.5 months (range 4-48 months). Side effects were well tolerated. A more extensive and detailed examination of MMP inhibitors to treat cholangiocarcinoma is indicated.

Pancreatic involvement in systemic sarcoidosis. A case report

We report a case of serum pancreatic hyperenzymemia as a primary manifestation of sarcoidosis; pancreatic involvement was confirmed by endoscopic ultrasonography which revealed a notable glandular fibrosis of the pancreas. It is important that patients with systemic sarcoidosis who have increased serum levels of amylase and lipase be checked in order to detect the presence of possible pancreatic involvement. Endoscopic ultrasonography represents the technique of choice used to confirm the clinical suspicion of pancreatic inflammation.

Mesalamine-related lung disease: clinical, radiographic, and pathologic manifestations

Lung injury related to mesalamine (5-aminosalicylic acid) has rarely been reported in patients with inflammatory bowel diseases. Patients present with progressive respiratory symptoms and radiographic abnormalities whose genesis may occur from days to years after initiation of therapy. Although pathologic features overlap with other pulmonary disorders, findings of chronic interstitial pneumonia and poorly formed nonnecrotizing granulomas should prompt consideration of mesalamine-related lung disease in a patient receiving this medication. The authors describe the clinical, radiographic, and pathologic manifestations of mesalamine-related lung disease in three patients and review the literature related to this topic.

Coexisting Sjögren's syndrome and sarcoidosis in the lung

CONTEXT

Sjögren's syndrome (SS) and sarcoidosis are diseases of unknown origin that are considered to result from abnormal regulation of the immune system. Pulmonary involvement by SS and sarcoidosis may have similar clinical and radiographic manifestations, making it difficult for the clinician to distinguish between these diseases.

OBJECTIVES

This study was undertaken to analyze the characteristics of SS and sarcoidosis in the lung to identify distinguishing features that may assist clinicians in the differentiation of these conditions.

DESIGN

We present two cases with severe pulmonary impairment in which the distinction between SS and sarcoidosis required lung tissue biopsy. The literature regarding the pulmonary manifestations of these diseases is reviewed.

RESULTS

The clinical, pathological, radiographic, and physiological characteristics of lung disease in the setting of SS and sarcoidosis can be very similar, preventing a diagnosis solely on clinical grounds. This is exemplified in the two cases reported. In one patient who carried the diagnosis of sarcoidosis, examination of lung tissue revealed lymphocytic interstitial pneumonitis consistent with SS. In the other patient, who had previously been diagnosed with SS on clinical grounds, examination of lung tissue showed lymphocytic interstitial pneumonitis with scattered noncaseating granulomas, suggesting the possibility of coexisting SS and sarcoidosis. A literature review indicated that lung involvement by SS may be difficult to distinguish from that of sarcoidosis. Furthermore, several cases have been reported in which both diseases coexisted.

CONCLUSIONS

Because SS and sarcoidosis may coexist and present with similar pulmonary manifestations, aggressive evaluation including tissue biopsy may be required. However, even tissue biopsy may not distinguish between these entities unless noncaseating granulomas are seen (in the case of sarcoidosis) or isolated lymphocytic interstitial pneumonitis is detected (in the case of SS). When both features (ie; noncaseating granuloma and lymphocytic interstitial pneumonitis) are encountered in the same organ, we believe these diseases are coexisting. Distinguishing both conditions may have prognostic implications, because sarcoidosis may present as an autolimiting process and frequently resolves spontaneously without significant residual functional impairment. In contrast, pulmonary involvement with SS often leads to permanent defects and may progress to incapacitating disease.

Primary Sjögren's syndrome, ulcerative colitis and selective IgA deficiency

A 24-year-old man with primary Sjögren's syndrome presented with xerophthalmia, xerostomia, and marked parotid swelling. He had a previous history of selective IgA deficiency and ulcerative colitis treated with sulphasalazine. Immunosuppression and withdrawal of sulphasalazine resulted in rapid resolution of the parotitis and disappearance of autoantibodies. A possible role for sulphasalazine in the induction of autoimmunity in this case is discussed.

Association between inflammatory bowel disease and sarcoidosis. Report of two cases and review of the literature

BACKGROUND

Common etiopathogenic factors may explain the association of systemic sarcoidosis with inflammatory bowel disease.

METHODS

We report two cases of such an association: one of sarcoidosis that developed 2 years after proctocolectomy for ulcerative colitis and one of sarcoidosis and Crohn's colitis. Factors like increased cellular immunity or circulating immunocomplexes or autoantibodies may have a role. Exogenous agents or familiarity may also be involved.

CONCLUSIONS

It is postulated that the association between sarcoidosis and inflammatory bowel disease (both ulcerative colitis and Crohn's disease) does not occur by chance alone and that the two conditions may share some genetic or immunologic alterations. The two diseases, however, follow an independent clinical course.

Sarcoidosis in autoimmune disease

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Sarcoidosis coexisting with connective tissue diseases, once considered rare, complicates various such disorders, including rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, Sjögren's syndrome, and the spondyloarthropathies. Symptoms common to sarcoidosis and autoimmune disease include keratoconjunctivitis sicca, weight loss, fever, lymphadenopathy, pulmonary complaints, and cutaneous lesions. Consequently, the diagnosis of sarcoidosis in association with connective tissue disease is often difficult and may require biopsy of the lung, liver, skin, lymph node, muscle, or bone marrow for pathological confirmation. Abnormalities of immune function as well as autoantibody production, including rheumatoid factor and antinuclear antibodies, are seen in sarcoidosis and in connective tissue diseases, suggesting a common immunopathogenic mechanism. The severity and course of sarcoidosis associated with autoimmune disease is variable. The incidence of sarcoidosis in association with rheumatic disease may be underestimated if new symptoms of sarcoidosis are attributed to the primary rheumatic disease and a secondary diagnosis is not pursued.