Management of IBD Patients with Current Immunosuppressive Therapy and Concurrent Infections

2015 ◽  
Vol 33 (Suppl. 1) ◽  
pp. 50-56 ◽  
Author(s):  
Jean-François Rahier
Keyword(s):  
Current Practice ◽  
Opportunistic Infections ◽  
Safety Issue ◽  
Case Reports ◽  
Careful Monitoring ◽  
Increased Risk ◽  
Before And After ◽  
Concurrent Infections ◽  
Inflammatory Bowel ◽  
Work Up

In an era of increasing use of immunomodulator therapy and biologics, opportunistic infections (OI) have emerged as a pivotal safety issue in patients with inflammatory bowel disease (IBD). Clinical studies, registries and case reports warn about the increased risk for infections, particularly OIs. Today, the challenge for a physician is not only to manage IBD, but also to recognize, prevent and treat common and uncommon infections. The 2014 European Crohn's and Colitis Organisation (ECCO) guidelines on the management and prevention of OIs in patients with IBD provide clinicians with guidance on the prevention, detection and management of OIs. Proposals may appear radical, potentially changing the current practice, but we believe that the recommendations will help optimize patient outcomes by reducing the morbidity and mortality related to OIs. In this ongoing process, prevention is by far the first and most important step. Prevention of OIs relies on recognition of risk factors for infection, the use of primary or secondary chemoprophylaxis, careful monitoring (clinical and laboratory work-up) before and during the use of immunomodulators, vaccination and education of the patient. Special recommendations should also be given to patients before and after travel.

Lithium toxicity after bariatric surgery

2017 ◽  
Vol 41 (S1) ◽  
pp. S491-S491
Author(s):  
L. De Jonge ◽  
S. Petrykiv ◽  
J. Fennema ◽  
M. Arts
Keyword(s):  
Bariatric Surgery ◽  
Drug Absorption ◽  
Case Reports ◽  
Lithium Toxicity ◽  
Vertical Sleeve Gastrectomy ◽  
Careful Monitoring ◽  
Lithium Level ◽  
Before And After ◽  
Life Threatening ◽  
Competing Interest

IntroductionBariatric surgery is globally increasingly being applied in patients with morbid obesity to achieve permanent weight reduction. More than fifty percent of these patients have a psychiatric disorder in their history and over thirty percent take psychotropic medication. The prevalence of bipolar disorder in patients who undergo bariatric surgery is around four percent, and most of them are treated with lithium.Objectives & aimsTo report and discuss the effect of bariatric surgery on changes in lithium absorption.MethodsWe present all published case studies and literature review on lithium toxicity after bariatric surgery.ResultsTo date; only two case-reports were published with dramatic changes in lithium level after vertical sleeve gastrectomy and Roux-en-Y bariatric surgery. Within a period of two to five weeks, the patients were presented to the emergency department with signs of dehydration and acute kidney failure.ConclusionClinicians should be aware of dramatic and possibly even life-threatening pharmacokinetic changes in drug absorption that may occur after bariatric surgery. Careful monitoring and even reduction of lithium dosage before and after surgery could potentially prevent serious complications.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Biologic-Induced Infections in Inflammatory Bowel Disease: The TNF-α Antagonists

2018 ◽  
Vol 52 (6) ◽  
pp. 571-579 ◽  
Author(s):  
Sean M. McConachie ◽  
Sheila M. Wilhelm ◽  
Ashish Bhargava ◽  
Pramodini B. Kale-Pradhan
Keyword(s):  
Risk Factors ◽  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Opportunistic Infections ◽  
Case Series ◽  
Infectious Risk ◽  
Increased Risk ◽  
Tnf Α ◽  
Inflammatory Bowel ◽  
Meta Analyses

Objective: To review the mechanism and association of infectious risk among the tumor-necrosis factor α (TNF-α) antagonists used in inflammatory bowel disease. Data Sources: A PubMed literature search was performed using the following search terms: infliximab, adalimumab, certolizumab, golimumab, inflammatory bowel disease, crohn’s, ulcerative colitis, adverse effects, adverse events, safety, and infection. Study Selection and Data Extraction: Meta-analyses and cohort studies with outcomes pertaining to quantitative infectious risk were reviewed. Case reports and case series describing association between TNF-α inhibitors and infection were also reviewed. Data Synthesis: A total of 7 recent meta-analyses of randomized trials demonstrate inconclusive association of infection with TNF-α antagonists. Registry data suggest that medications carry an independent risk of opportunistic infections. Risk factors for infection include older age, malnutrition, diabetes, and possibly combination therapy. Reported infections vary widely but include intracellular and granulomatous bacteria, viruses, and fungi. Conclusion: TNF-α antagonists are associated with an increased risk of opportunistic infection, although this risk has not been demonstrated conclusively in randomized controlled trials. Knowledge of concomitant risk factors, mechanism of infectious risk, and available treatment options can improve patient care in the clinical setting.

scholarly journals Lethal disseminated tuberculosis in patients under biological treatment – two clinical cases and a short review

2018 ◽  
Vol 46 (7) ◽  
pp. 2961-2969 ◽  
Author(s):  
Elena Dantes ◽  
Doina Ecaterina Tofolean ◽  
Ariadna Petronela Fildan ◽  
Liviu Craciun ◽  
Elena Dumea ◽  
...  
Keyword(s):  
Biological Treatment ◽  
Biological Therapy ◽  
Opportunistic Infections ◽  
Short Review ◽  
Rapid Progression ◽  
Disseminated Tuberculosis ◽  
Increased Risk ◽  
Tnf Α ◽  
Bowel Diseases ◽  
Inflammatory Bowel

Tumour necrosis factor (TNF)-α inhibitors are highly used in Romania for the treatment of autoimmune disorders, such as rheumatoid arthritis (RA), psoriasis, inflammatory bowel diseases, and ankylosing spondylitis. Biological therapy using TNF-α inhibitors is very effective but is associated with an increased risk of opportunistic infections, including active tuberculosis. Here, two cases are presented of patients with RA and psoriasis under biological therapy who developed very aggressive forms of disseminated tuberculosis, with a rapid progression to death. The authors conclude that patients undergoing biological therapy require thorough evaluation prior to initiating treatment, followed by continuous and rigorous monitoring by a multidisciplinary team during biological treatment, particularly in countries with a high incidence of tuberculosis.

scholarly journals The Use of Checkpoint Inhibitors before and after Allogeneic Stem Cell Transplantion: A Double-Edged Sword

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5722-5722 ◽  
Author(s):  
Ali Younas Khan ◽  
Awais Ijaz ◽  
Muhammad Usman ◽  
Muhammad Junaid Tariq ◽  
Muhammad Asad Fraz ◽  
...  
Keyword(s):  
Stem Cell ◽  
Mortality Risk ◽  
Checkpoint Inhibitors ◽  
Case Reports ◽  
Sinusoidal Obstruction Syndrome ◽  
Allogenic Stem Cell Transplantation ◽  
Safety And Efficacy ◽  
Increased Risk ◽  
Before And After ◽  
Overall Mortality

Abstract Introduction: Allogenic stem cell transplantation (allo-SCT) is a potentially curative option for hematological malignancies. Checkpoint inhibitors (CPI) have been successful in achieving remission for patients that relapse after allo-SCT. CPI can help relapsed/refractory (RR) patients to respond and bridge towards allo-SCT after achieving remission. Check point inhibition after allo-SCT carries an increased benefit of graft vs malignancy effect (GvL) but it may exaggerate the risk of immune system related toxicity such as graft versus host disease (GvHD). Methods: To assess the safety and efficacy of CPI use in conjunction with allo-SCT, after a comprehensive literature search, we included data (n=283) from a total of twenty-four studies (11 original manuscripts, 13 case reports or case series) and analysed the results. Results: Most common indication for CPI use was Hodgkin lymphoma (n=182). CPIs used in various studies included CTLA-4 inhibitors (ipilimumab, n=93) and PD-1 inhibitors (nivolumab, n=167 and pembrolizumab, n= 27). In patients who were exposed to CPI before allo-SCT (n=107), 56% patients developed acute (a) GvHD and 29% patients developed chronic (c) GvHD. The overall mortality risk (11/107) associated with GvHD was 11%. Interval between last dose of CPI and allo-SCT ranged from 28-62 days. Median cycles of CPI therapy ranged from 4-9 cycles. The overall response rate (ORR) was observed (42/62) to be 68% patients with complete remission (CR) in 47% patients and partial remission (PR) in 21% patients. Most common adverse events reported were non-infectious febrile syndrome (12%), infections (5%), hepatic sinusoidal obstruction syndrome (4%) and encephalitis (3%). In patients (n=150) who received CPI after allo-SCT for treatment of disease relapse, 13% patients developed aGvHD and 11% patients developed cGvHD. The overall mortality risk with GvHD was around 7% in this population. The interval between allo-SCT and first dose of CPI ranged from 12.5 months to 29 months. Nivolumab was given at doses 1 mg/kg to 3 mg/kg, weekly or two-weekly. Ipilimumab dose ranged from 0.1 mg/kg to 5 mg/kg. A combination with lenalidomide was also tried. Pembrolizumab was administered at 200 mg/kg every three weeks. An ORR of 48% (59/123) was observed with CR in 34 (28%), PR in 25 (20%) and disease stabilization in 7 (6%) patients. Complications, other than GvHD, include hematological side effects (22%), most notably neutropenia followed by respiratory and hepatic complications (16% and 14% respectively). Thirteen case reports evaluated safety and efficacy of CPIs after allo-SCT. Among 26 cases, the reported ORR was 85% with fifteen and seven patients achieving CR and PR, respectively. Of the four patient deaths that occurred during the study period, one died of GvHD. Most common adverse reactions noted were in the GI tract, notably hepatitis (32%), followed by skin (25%) and pulmonary disease (25%). Conclusion: CPI use before and after allo-SCT can be highly effective for relapse disease control. For patients who received Allo-SCT, CPI exposure can lead to significantly increased risk of GvHD, GvHD related morbidity and mortality. There is need for caution while making decision for CPI use in this population. Prospective well-designed clinical trials are required to further explore the safety of CPIs in allo-SCT setting. Disclosures No relevant conflicts of interest to declare.

scholarly journals Microscopic Ileitis in Clinically Suspected Inflammatory Bowel Disease Patients- Can It Predict the Future?

2019 ◽  
Author(s):  
Fadi Abu Baker ◽  
Jesus Alonso Z'cruz De La Garza ◽  
Smadar Nafrin ◽  
Amir Mari ◽  
Muhammed Suki ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Clinical Outcome ◽  
Bowel Disease ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
And Gender ◽  
Diagnostic Work ◽  
Work Up

Abstract Background: The implication of microscopic ileitis finding in patients referred for ileocolonoscopy for clinically suspected inflammatory bowel disease is not well defined and its correlation with clinical outcome has not been fully studied. The current study aims to determine the prognostic yield of biopsies in this setting, and to evaluate the correlation of microscopic ileitis with long-term clinical outcome. Methods: Endoscopic reports of patients referred to our department for ileocolonoscopy in the years 2010-2016, as part of a diagnostic work-up for suspected IBD were revised. Patients with normal ileocolonoscopy were included, provided that terminal ileum biopsies were performed. Accordingly, patients were divided into normal (normal or reactive changes) and microscopic ileitis (inflammation or ileitis of any severity) groups. Both groups were followed prospectively to determine clinical outcome. Results: 439 patients met the inclusion criteria. 64 (14.6%) had inflammation on biopsy and were included in the microscopic ileitis group. Age and gender didn't differ significantly between groups. Overall follow up period was 6.1±2.3 years. Patients in the microscopic ileitis group were significantly associated with Crohn's diagnosis during follow-up period compared to normal (19% vs 2%, OR=11.98, 95%CI=4.48-32.01; p<0.01). Patients with granuloma or moderate-severe ileitis on biopsy were significantly associated with Crohn's development (100% vs 11%; P<0.01) compared to mild or nonspecific inflammation. Conclusion: Microscopic ileitis finding in clinically suspected IBD is associated with increased risk of future diagnosis of crohn's disease.

scholarly journals P304 Extranodal primary intestinal lymphoma in inflammatory bowel disease: An ECCO CONFER multi-centre case series

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S305-S305
Author(s):  
F Phillips ◽  
B Verstockt ◽  
D Ribaldone ◽  
I Guerra ◽  
N Teich ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Intestinal Inflammation ◽  
Case Reports ◽  
Case Series ◽  
B Cell Lymphoma ◽  
Case Report Form ◽  
Intestinal Lymphoma ◽  
Increased Risk ◽  
Inflammatory Bowel

Abstract Background There is a small but measurable increased risk of lymphoma in inflammatory bowel disease (IBD). Evidence coming from case reports and small case series of primary intestinal lymphoma in IBD suggest an association with inflamed tissue and immunosuppressant use, mainly thiopurines. Methods This was a multicentre case series supported by the European Crohn’s and Colitis Organisation (ECCO) and performed as part of the Collaborative Network of Exceptionally Rare case reports (CONFER) project. A call was made to report on cases of intestinal lymphoma in IBD and clinical data were recorded in a standardised case report form. Results Fifteen patients with intestinal lymphoma from 8 centres were included [12 males and 3 females, mean age 47.8 ( ± 16.4 SD, range 26–76) years at lymphoma diagnosis]. Eleven patients had Crohn’s disease: 7 had diffuse large B-cell lymphoma (DLBCL), 2 had Hodgkin’s disease and 2 had MALT lymphoma. Four patients had ulcerative colitis: DLBCL, MALT, indolent T-cell and immunoblastic lymphoma with plasma cell differentiation were diagnosed as a single case in each. Nine patients presented with symptoms of bowel obstruction, two presented with a non-obstructing mass, and there were single cases of isolated weight loss, symptoms resembling disease flare, indolent jaundice (from a duodenal lymphoma) and an incidental finding. The location of lymphoma was rectum in 3 cases, colon in 3 cases, small intestine in 4 cases, ileocolonic anastomosis in one case, stomach in one case and in multiple upper and lower GI sites in 3 cases. Lymphoma was located within the area affected from IBD in 10 patients, with four of these having active intestinal inflammation at the time of diagnosis. At lymphoma diagnosis, 7 patients were on azathioprine (one of whom also had adalimumab for 3 months), one was on infliximab for 1 month, one was on low dose steroids, one was on an aminosalicylate and 5 had not received IBD-related medications. Lymphoma was diagnosed at a mean time of 10.4 ( ± 7.07 SD, 1–24) years after IBD diagnosis in 11 patients, prior to IBD in one and concurrently with IBD in 3. Remission was achieved in 11 patients after treatment, 2 died from their lymphoma despite treatment and 2 are being monitored without therapy. Conclusion This case series of primary intestinal lymphomas in IBD illustrates a strong male predilection and a wide histological type range, with the majority being DLBCL. More than half of the cases cannot be attributed to IBD-related treatment whilst in a third of patients, lymphoma developed at a distant site from the area affected from IBD, thereby questioning the role of active inflammation or medication use in its development. The majority of cases successfully recovered after appropriate treatment.

Infections and inflammatory diseases as risk factors for venous thrombosis

2012 ◽  
Vol 107 (05) ◽  
pp. 827-837 ◽  
Author(s):  
Hanneke J. C. Kluin-Nelemans ◽  
Karina Meijer ◽  
Y. I. G. Vladimir Tichelaar
Keyword(s):  
Risk Factors ◽  
Venous Thrombosis ◽  
Inflammatory Diseases ◽  
Case Reports ◽  
Epidemiological Studies ◽  
Increased Risk ◽  
Immunodeficiency Virus ◽  
Virus Pneumonia ◽  
Inflammatory Bowel ◽  
Tract Infections

SummaryInflammation and venous thrombosis are intertwined. Only in the recent 15 years clinical epidemiological studies have focussed on inflammatory or infectious diseases as risk factors for venous thrombosis. Although a few reviews and many case reports or studies on these topic has been written, a review reporting relative or absolute risks for venous thrombosis has not been published yet. We performed a systematic review using Medline, Pubmed and Embase and found 31 eligible articles. Inflammatory bowel disease, ANCA-associated vasculitis, infections in general and more specifically, human immunodeficiency virus, pneumonia and urinary tract infections are associated with an increased risk of venous thrombosis.

Cardiac Cephalalgia: Case Reports and Review

Cephalalgia ◽  
2008 ◽  
Vol 28 (8) ◽  
pp. 892-896 ◽  
Author(s):  
J-H Wei ◽  
H-F Wang
Keyword(s):  
Case Reports ◽  
Legal Issues ◽  
Atypical Presentation ◽  
Medline Search ◽  
Coronary Syndrome ◽  
Exertional Headache ◽  
Increased Risk ◽  
Potential Risks ◽  
Cardiac Cephalalgia ◽  
Work Up

Diagnosis of myocardial infarction or acute coronary syndrome is difficult, especially in atypical presentation at an emergency department, and sometimes results in serious legal issues. Symptoms of atypical presentation include shortness of breath, dyspnoea on exertion, toothache, abdominal pain, back pain and throat pain. As of now, reports of a headache, especially exertional headache, as the only presentation of acute cardiac ischaemia are rare and only have case reports. We present two patients with a cardiac source of headache and analyse 32 patients with similar situations from MEDLINE search from 1966 to the present. Cardiac cephalalgia is benign in general, but potential risks for death should be considered. If the patient has increased risk of atherosclerosis with exertional headache, anginal headache should be highly suspected and further work-up should be undertaken.

scholarly journals Acute appendicitis in people living with HIV: What does the emergency surgeon needs to know?

2021 ◽  
Vol 9 ◽  
pp. 205031212098246
Author(s):  
Arshad Mahmood ◽  
Syed H Raza ◽  
Elamin Elshaikh ◽  
Dushyant Mital ◽  
Mohamed H Ahmed
Keyword(s):  
Acute Appendicitis ◽  
Opportunistic Infections ◽  
White Cell Count ◽  
Abdominal Tuberculosis ◽  
High Rate ◽  
People Living With Hiv ◽  
Alvarado Score ◽  
Increased Risk ◽  
Before And After ◽  
Hiv Aids

Acute appendicitis is among the commonest surgical emergencies seen in an acute setting. Individuals living with the Human Immunodeficiency Virus (HIV) and/or the Acquired Immunodeficiency Syndrome (AIDS) have an increased risk of encountering complications with acute appendicitis. We conducted a literature search using the words appendicitis and HIV in google scholar, Medline, Scopus and PubMed. The search also extended to cover HIV presented with acute appendicitis, their outcome during and following the management of acute appendicitis. Several studies showed that HIV is associated with a higher rate of acute appendicitis than the general population. HIV can directly affect the appendix, through opportunistic infections, immune reconstitution inflammatory syndrome associated with start of antiretroviral medication. High index of suspicion is needed to exclude conditions that mimic acute appendicitis (abdominal tuberculosis, pyelonephritis, cytomegalovirus, cryptosporidium, pneumococcus, Amoebic appendicitis and pill impaction). The clinical presentation may not be typical of acute appendicitis and can be associated with low white cell count and variable fever. The Alvarado score for predicting acute appendicitis can be used and more research is needed to establish cut-off point value. Computed tomography scan and ultrasound are widely used in clinical diagnosis. Importantly, acute appendicitis with HIV/AIDS can be associated with high rate of post-surgical complications like infections, delay of healing, perforation, peritonitis, intra-abdominal abscess and longer hospital stay. HIV/AIDS with acute appendicitis is complex condition. Therefore, we conclude that patients with known HIV and acute appendicitis should also be managed in close liaison with HIV physicians during, before and after surgical treatment.

scholarly journals Drug Targeting of Inflammatory Bowel Diseases by Biomolecules

Nanomaterials ◽  
2021 ◽  
Vol 11 (8) ◽  
pp. 2035
Author(s):  
Joana Costa Antunes ◽  
Catarina Leal Seabra ◽  
Joana Margarida Domingues ◽  
Marta Oliveira Teixeira ◽  
Cláudia Nunes ◽  
...  
Keyword(s):  
Opportunistic Infections ◽  
Inflammatory Diseases ◽  
Treatment Options ◽  
Stimuli Responsive ◽  
Triggered Release ◽  
Healthy State ◽  
Increased Risk ◽  
Bowel Diseases ◽  
Inflammatory State ◽  
Inflammatory Bowel

Inflammatory bowel disease (IBD) is a group of disabling, destructive and incurable immune-mediated inflammatory diseases comprising Crohn’s disease (CD) and ulcerative colitis (UC), disorders that are highly prevalent worldwide and demand a large investment in healthcare. A persistent inflammatory state enables the dysfunction and destruction of healthy tissue, hindering the initiation and endurance of wound healing. Current treatments are ineffective at counteracting disease progression. Further, increased risk of serious side effects, other comorbidities and/or opportunistic infections highlight the need for effective treatment options. Gut microbiota, the key to preserving a healthy state, may, alternatively, increase a patient’s susceptibility to IBD onset and development given a relevant bacterial dysbiosis. Hence, the main goal of this review is to showcase the main conventional and emerging therapies for IBD, including microbiota-inspired untargeted and targeted approaches (such as phage therapy) to infection control. Special recognition is given to existing targeted strategies with biologics (via monoclonal antibodies, small molecules and nucleic acids) and stimuli-responsive (pH-, enzyme- and reactive oxygen species-triggered release), polymer-based nanomedicine that is specifically directed towards the regulation of inflammation overload (with some nanosystems additionally functionalized with carbohydrates or peptides directed towards M1-macrophages). The overall goal is to restore gut balance and decrease IBD’s societal impact.

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