Gut Microbiota Modulation of Short Bowel Syndrome and the Gut-Brain Axis

Short bowel syndrome (SBS) is a condition that results from a reduction in the length of the intestine or its functional capacity. SBS patients can have significant side effects and complications, the etiology of which remains ill-defined. Thus, facilitating intestinal adaptation in SBS remains a major research focus. Emerging data supports the role of the gut microbiome in modulating disease progression. There has been ongoing debate on defining a "healthy" gut microbiome, which has led to many studies analyzing the bacterial composition and shifts that occur in gastrointestinal disease states such as SBS and the resulting systemic effects. In SBS, it has also been found that microbial shifts are highly variable and dependent on many factors, including the anatomical location of bowel resection, length, and structure of the remnant bowel, as well as associated small intestinal bacterial overgrowth (SIBO). Recent data also notes a bidirectional communication that occurs between enteric and central nervous systems called the gut-brain axis (GBA), which is regulated by the gut microbes. Ultimately, the role of the microbiome in disease states such as SBS have many clinical implications and warrant further investigation. The focus of this review is to characterize the role of the gut microbiota in short bowel syndrome and its impact on the GBA, as well as the therapeutic potential of altering the microbiome.

Primary Mixed Cellularity Classical Hodgkin lymphoma of the Lumbar spine - An unusual presentation

Primary spinal epidural lymphoma (PSEL) is a subset of lymphoma. For the diagnosis of PSEL there should be no other recognizable sites of lymphoma other than the spine at the time of diagnosis. The incidence of this subset of lymphomas is very low. Hodgkin lymphoma (HL) usually presents with painless enlargement of peripheral lymph nodes and only a small percentage arises from extra nodal regions.Very few patients with HL develops spinal cord compression due to an epidural tumor at some time during the course of their disease. But patients with HL presenting with isolated primary involvement of the epidural spinal region is very rare with very few reports available in the literature.

CASE

A 19-year-old male presented to the local hospital with history of low back pain for almost one year. An initial biopsy was non-contributory and was reported as showing inflammatory change. The patient was empirically started on antituberculosis medication but his condition worsened and within weeks he developed paraplegia. MRI of the spine showed a large paraspinal mass with compression of L1 vertebral body. Urgent surgical decompression was done and final histopathology showed a mixed cellularity classical Hodgkin lymphoma (MCCHL). Systemic work-up did not show evidence of nodal disease. Following surgery, he received chemotherapy.

CONCLUSION

We report this case because of the unusual presentation of HL as a primary spinal mass. We would also like to highlight that apart from common causes, a differential diagnosis of HL should also be entertained while dealing with spinal masses. Otherwise diagnosis can be missed leading to delay in treatment and complications.

Isolated renal mucormycosis: an unusual cause of acute renal infarction in a boy with aplastic anaemia

Mucormycosis is an opportunistic fungal infection occurring most often in immunocompromised patients. The most common clinical presentation of infection with the fungus is rhinocerebral, followed by primary pulmonary, disseminated, gastrointestinal and cutaneous manifestations. Renal involvement in disseminated mucormycosis is well described, however, there are only few case reports describing the isolated renal mucormycosis in literature. We present an unusual case of renal mucormycosis in a patient of aplastic anaemia who presented with right flank pain and, on imaging, was found to have renal infarction and thrombosis of renal vessels. Histopathology revealed fungal hyphae infiltrating the entire kidney, renal vessels and perinephric space.

Fludarabine, cyclophosphamide and horse antithymocyte globulin conditioning regimen for allogeneic peripheral blood stem cell transplantation performed in non-HEPA filter rooms for multiply transfused patients with severe aplastic anemia

Multiply transfused patients of severe aplastic anemia are at increased risk of graft rejection. Five such patients underwent peripheral blood stem cell transplantation from HLA-identical siblings with a fludarabine-based protocol. The conditioning consisted of fludarabine 30 mg/m(2)/day x 6 days, cyclophosphamide 60 mg/kg/day x 2 days and horse antithymocyte globulin (ATG) x 4 days. Two different ATG preparations were used: ATGAM (dose 30 mg/kg/day x 4 days) or Thymogam (dose 40 mg/kg/day x 4 days). Engraftment: median time to absolute neutrophil count (ANC) >0.5 x 10(9)/l was 11 days (range: 8-17) and median time to platelet count >20 x 10(9)/l was 11 days (range: 9-17). At a median follow-up of 171 days (range: 47-389), there has been no graft rejection and all patients are in complete remission. Acute GVHD (grade 1) occurred in one patient only. Chronic GVHD developed in two patients (extensive in one and limited in another). The transplants were performed in non-HEPA filter rooms. In only one patient, systemic antifungal therapy (voriconazole) was used. The use of Thymogam brand of ATG for conditioning is being reported for the first time. Our experience suggests that this fludarabine-based protocol allows rapid sustained engraftment in high-risk patients without significant immediate toxicity.