Very Early-Onset Inflammatory Bowel Disease (VEO-IBD) Presenting with Recurrent Leukocytoclastic Vasculitis Preceded by Streptococcal Pharyngitis

Inflammatory bowel disease (IBD) that presents in children <6 years of age is known as very early-onset IBD (VEO-IBD). Extraintestinal manifestations in IBD, such as erythema nodosum (EN), pyoderma gangrenosum (PG), and, less likely, leukocytoclastic vasculitis (LV), are more commonly present in Crohn’s disease. Association between LV and ulcerative colitis (UC) is not commonly seen. We report a case of a 6-year-old female with a VEO-IBD UC phenotype presenting with multiple episodes of leukocytoclastic vasculitis, each preceded by streptococcal pharyngitis. Prior to the diagnosis of VEO-IBD, a skin biopsy was obtained and had shown leukocytoclastic vasculitis with a negative IgA stain. Initial laboratory results were remarkable for leukocytosis and increased anti-strep O and anti-DNase B titers. Gastrointestinal panel PCR demonstrated Clostridium difficile toxin A/B. Treatment for LV consisted of methylprednisolone IV 20 mg for four days with a weaning schedule of prednisolone for two weeks and naproxen 250 mg BID for three days. Clostridium difficile was treated with metronidazole 250 mg TID for ten days. She remained stable for three years until she presented with continuous bloody stools, newly onset chest pain, and shortness of breath. Computed tomography angiogram (CTA) was normal. Stool calprotectin was elevated at 658 mcg/gm. Abdominal magnetic resonance enterography (MRE), esophagogastroduodenoscopy, and colonoscopy confirmed a VEO-IBD ulcerative colitis phenotype. She was started on infliximab 10 mg/kg every four weeks after infliximab titers, and antibodies were obtained. Currently, the patient remains on clinical and biochemical remission, with no recent LV episodes or recurrence of streptococcal pharyngitis. Our patient is unique as no case report has been published with multiple episodes of leukocytoclastic vasculitis in association with a VEO-IBD UC phenotype.

P151 Validation of the MaRIA Score in pediatric patients

Background To validate the Magnetic Resonance Index of Activity (MaRIA Score) in the pediatric population and determine if it would be possible to monitor inflammatory bowel disease (IBD) without invasive tests in some cases. Methods A cross-sectional and descriptive study of paediatric patients with previously diagnosed or suspected IBD who underwent upper endoscopy (EGD) and colonoscopy, blood tests, stool analysis and MR Enterography (MRE) in a 15 days range, from October 2018 to February 2020. The clinical and endoscopic situation were assessed with the activity indices PUCAI/PCDAI/shPCDAI and the activity scores UCEIS/Mayo/SES-CD respectively, according to the underlying pathologies. We considered analytical remission as FC&lt; 250 mcg/g, ERS&lt; 20 mm and CRP&lt; 1 mg/dl. The MRE results were assessed with the MaRIA Score, that is validated for adults. Results Amongst 21 patients, 12 (57%) were males. 12 patients had Crohn ́s disease (CD) (57%), 3 had ulcerative colitis (UC) (14%), 6 had IBD unclassified (IBDu) (28%). The mean age at diagnosis was 14.2 ± 0.7 and the progression time of the disease was 3.9 ± 0.6 years. A total of 16 patients showed clinical remission (76%), 6 of them (28%) also had endoscopic and histological remission. Eight patients were receiving biological treatment (38%). The measured acute phase reactants (APR) were: CRP 0.9 ± 0.5 mg/dl, ESR 13.7 ± 2.6 mm, α1 acid glycoprotein 95.5 ± 1.1 mg/dl and fecal calprotectin (FC) of 1154.3 ± 254.8 mcg/g. Rotavirus, adenovirus, Clostridium difficile toxin analysis and stool culture were performed in 14 patients, all of them negative. The MaRIA Score values were 54.3 ± 53.3, being 0 in 11 cases. We found no differences between the MaRIA Score and the analytical remission. We found a significant correlation between the MaRIA Score and the PUCAI value (p &lt; 0.05), but not with other clinical scores. Patients in clinical remission showed a tendency to have a lower MaRIA Scores, but these differences were not statistically significant (p = 0.09). The MaRIA Score showed lower values for those with endoscopic and histological remission (p &lt; 0.05), All the patients with MaRIA Score&gt; 0 were CD except one, diagnosed with UC. Out of the 15 patients with endoscopic/histological involvement, 10 presented a MaRIA Score&gt; 0. Five of the 11 patients (45%) in whom the MaRIA Score was 0 did not have endoscopic and histological remission, only one of them had a diagnosis of CD. Conclusion The MaRIA Score was significantly correlated with endoscopic scores in pediatric IBD patients, especially in CD. However, based on the results of this study, the MRE should not replace the EGD and colonoscopy in order to thoroughly evaluate the disease activity.

Clostridium difficile toxin A-mediated Caco-2 barrier damage was attenuated by insect-derived fractions and corresponded to increased gene transcription of cell junctional and proliferation proteins

Pathogenesis of C. difficile in the intestine is associated with the secretion of toxins which can damage the intestinal epithelial layer and result in disease, such as diarrhoea. Treatment for...

Amoxicillin-Clavulanate-Induced Ischaemic Colitis

Ischaemic colitis (IC) is the most frequent form of ischaemia of the digestive tract. Due to the worldwide increasing use of medications, there is a growing interest in drug-induced IC. This study reports a rare case of IC directly due to amoxicillin-clavulanate intake. The objective of the study was to describe the evolution of this novel manifestation. An 18-year-old man, non-smoker, with an insignificant medical history, presented with diarrhoea and cramping abdominal pain that started the day following the end of a 10-day amoxicillin-clavulanate course for recent upper respiratory tract infection. Stool cultures including Clostridium difficile toxin testing were negative. Colonoscopy documented an erosive-ulcerative colitis of the sigmoid and the descending colon. Histological examination of the colon biopsies revealed an IC with focal pseudomembranous areas in the descending-sigmoid colon. Thrombophilia screening tests were negative. The patient was discharged from the hospital without symptoms, and another colonoscopy was performed 3 weeks after the previous one, which documented normal endoscopic and histological findings. Amoxicillin-clavulanate IC is a very rare condition and should be suspected once infectious diseases, vascular/haemodynamic causes and a prothrombotic/hypercoagulable state have been excluded. Immediate discontinuation of the antibiotic leads to rapid disease remission.