romanian journal of internal medicine

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SAIKI A., OYAMA T., ENDO K., EBISMO M., OHIRA M., KOIDE N., MURANO T., MIYASHITA Y., SHIRAI K.,. Preheparin serum lipoprotein lipase mass might be a ...


No. 2, 2008

CONTENTS REVIEWS M. CUCUIANU, IOANA BRUDAŞCĂ, Lipolytic enzymes, metabolic syndrome and atherosclerosis (Revisiting and revising a 40 years old study) ......................................................................................................................................................... MARIA MOŢA, SIMONA POPA, E. MOŢA, I. DIACONESCU, I. GHEORGHIŢOIU, M. PANDURU, Impact of host insulin resistance on fibrosis and response to Interferon in chronic hepatitis C ............................................................... I.B. IAMANDESCU, ALEXANDRA MIHĂILESCU, Bronchial asthma with psychogenic trigger .......................................... CRISTINA HOŢOLEANU, CRISTINA JURJ, The involvement of genetic factors in chronic venous insufficiency ................ MARIA GREABU, M. BATTINO, MARIA MOHORA, R. OLINESCU, ALEXANDRA TOTAN, ANDREEA DIDILESCU, Oxygen, a paradoxical element? .......................................................................................................................................

99 105 113 119 125

ORIGINAL ARTICLES LUCIA AGOŞTON-COLDEA, L.D. RUSU, D. ZDRENGHEA, M.L. RUSU, DANA POP, ALEXANDRA CRĂCIUN, LAURA POANTĂ, M. GATFOSSÉ, SOPHIE ROSENSTINGL, TEODORA MOCAN, Lipoprotein(a) and lipid and non-lipid risk factors in coronaries risk assessment ......................................................................................................... TEODORA MOCAN, LUCIA AGOŞTON-COLDEA, M. GATFOSSÉ, SOPHIE ROSENSTINGL, L.C. MOCAN, D.L. DUMITRAŞCU, A new prediction score for myocardial infarction: MINF SCORE .............................................. I.ST. GYALAI-KORPOS, MIRELA TOMESCU, ANTOANELA POGOREVICI, Hypertensive acute pulmonary œdema as expression of diastolic heart failure .................................................................................................................................. DIANA LORETA PĂUN, MARIA MOHORA, CARMEN DUŢĂ, C. DUMITRACHE, Genetic testing for multiple endocrine neoplasia type 2 ............................................................................................................................................... INIMIOARA MIHAELA COJOCARU, M. COJOCARU, R. TĂNĂSESCU, CECILIA BURCIN, ADINA NICOLETA ATANASIU, ANDREEA CRISTINA MITU, IULIANA ILIESCU, LAURA DUMITRESCU, Some clinicoimmunological aspects in patients with ocular myasthenia gravis associated with inflammatory bowel disease .............

137 145 153 159


CASE REPORTS MARIA MAGDALENA TĂMAŞ, CORINA BAICAN, SIMONA REDNIC, Hyperimmunoglobulin E syndrome (Job’s syndrome) ......................................................................................................................................................................... I. COPACI, C. RUSU, C. JURCUŢ, MIHAELA ENACHE, V. DUŢESCU, MIRELA ANGHEL, MARIA GĂLĂMAN, Giant iliac artery aneurysm – A rare cause of hydronephrosis ......................................................................................... SABINA ZURAC, GIANINA MICU, ALEXANDRA BASTIAN, ELIZA GRĂMADĂ, LUCIANA LAVRIC, R. ANDREI, FLORICA STĂNICEANU, R. VOIOSU, A. CROITORU, Malignancy and overdiagnosis of malignancy in Peutz Jeghers polyposis...............................................................................................................................................................

ROM. J. INTERN. MED., 2008, 46, 2, 97–184

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Lipolytic Enzymes, Metablic Syndrome and Atherosclerosis (Revisiting and Revising a 40 Years Old Study) M. CUCUIANU1, IOANA BRUDAŞCĂ2 1 Medical Clinic I, 2Biochemistry Department “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

More than 40 years ago, our laboratory reported that post-heparin lipolytic activity was decreased in patients with severe atherosclerotic disease, while values recorded in obese and hyperlipidemic subjects without clinically detectable atherosclerotic lesions did not significantly differ from normal weight normolipidemic controls. Because in 1967 data on pathophysiology of lipolytic enzymes were rather scarce, and mainly because our information facilities were limited in those years, we had difficulties in interpreting these results, and the study was to some extent awkwardly approached, as the investigated subjects were not considered according to their gender, body fat patterning and type of hyperlipoproteinemia, and the lipolytic activities of lipoprotein lipase and hepatic lipase had not been selectively assessed. Reviewing recent data in the literature it was noted that pre-heparin lipoprotein lipase mass assessed by ELISA was indeed significantly lower in insulin resistant coronary patients than in patients with no lesions, and correlated negatively with the severity of atherosclerotic lesions. Noteworthy hypoadiponectinemia, a hallmark of insulin resistance, was associated with decreased lipoprotein lipase and increased hepatic lipase activities. Clustering of increased plasma VLDL-triglyceride, cholesteryl-ester transfer protein and hepatic lipase would remodel HDL and LDL particles, generating an atherogenic lipoprotein profile. In opposition to atherogenic dyslipidemia related to an enhanced hepatic secretion of VLDL, cases with important hypertriglyceridemia subsequent to deficient lipolytic clearance are at a rather low risk for coronary artery disease. It may therefore be suggested that the decreased lipoprotein lipase noted in atherosclerotic patients is not a major pathogenic link, being rather related to the inflammatory component of the disease, its expression being reduced by proinflammatory cytokines. Key words: lipoproteinlipase, hepatic lipase, atherosclerosis.

Presuming that a decreased lipoprotein lipase activity could be a pathogenic link in atherogenesis or at least a marker of such a process, the behavior of post-heparin lipolytic activity had been investigated 40 years ago in our laboratory, in patients with atherosclerotic disease as well as in subjects at high risk (obese and/or hyperlipidemic) [1]. Seemingly this should have been a rather unfortunate working hypothesis, because in most cases atherogenic dyslipidemia is related to an enhanced hepatic synthesis of VLDL, while an inherited severe lipoprotein lipase deficit does not seem to be atherogenic, although being associated with excessive hypertriglyceridemia [2] [3]. It could nevertheless be reported that, when compared to the 49 normal weight normolipidemic control subjects, post heparin lipolytic activity was significantly lower in the 44 patients with clinically detectable severe atherosclerotic disease (survivors of myocardial infarction, or peripheral atherosclerotic arteriopathies ROM. J. INTERN. MED., 2008, 46, 2, 99–104

in a rather advanced stage), while lipolytic activity did not significantly differ from normal values in the 14 obese subjects without hyperlipidemia and in the 42 hyperlipidemic subjects without clinically detectable atherosclerotic changes [1]. Because in 1967 data on pathophysiology of lipolytic enzymes were rather scarce and mainly because in those years our access to information was limited, we encountered difficulties in interpreting the results, and the study was to some extent awkwardly approached, namely: a) the obese subjects were not considered in relation to gender and body fat patterning (android or gynoid). Actually 11 of the 14 obese were women. b) the hyperlipidemic subjects had not been divided according to their type of hyperlipoproteinemia c) lipolytic activities of lipoprotein lipase and hepatic lipase had not been selectively assessed.


M. Cucuianu, Ioana Brudaşcă

It was only much later that lipoprotein lipase could be selectively measured by inhibiting hepatic lipase with goat IgG raised against human hepatic lipase. Selective measurement of hepatic lipase may be more easily achieved by inhibiting lipoprotein lipase with 1 mol/l NaCl solution [4]. d) post – heparin lipolytic activity is based on the release of lipolytic enzymes anchored at the surface of endothelial cells membrane. Because lipolytic activity would depend not only on the amount of releasable enzymes, but also on the rate of release and the subsequent removal of active enzymes from the plasma, the time interval between the intravenous heparin injection and the obtention of the postheparin plasma is critical and would influence the results. Evidence was however recently accumulated that a small amount of lipoprotein lipase exists in the serum in inactive form, being commonly called preheparin lipoprotein lipase mass (preheparin LPL mass) which can be accurately measured by an ELISA procedure and was found to be stable during the day time, thereby providing a practical marker for the lipoprotein lipase status [5][6]. Noteworthy preheparin LPL mass was found to be decreased in insulin – resistant patients and the values recorded in patients with coronary atherosclerosis were indeed significantly lower than in patients with no lesions. Also preheparin LPL mass was negatively correlated with the severity of atherosclerotic lesions [7]. Such findings could be perhaps circumstantially connected to data emphasizing that proinflammatory cytokines (TNFα and IL-6) reduce the expression of lipoprotein lipase [8][9]. Improved knowledge on the physiology and pathophysiology of lipolytic enzymes is now allowing and also require to reconsider the pathogenic relevance of their abnormal behavior for the development of metabolic syndrome, atherogenic dyslipidemia and atherosclerosis. MECHANISMS REGULATING LIPOLYTIC ENZYMES

Lipoprotein lipase (LPL) has been found in the adipose tissue, heart, diaphragm, skeletal muscle, lung, spleen, renal medula, the lactating mammary


gland and the neonatal liver. It is not active in the adult liver. From the cells involved in its synthesis, LPL molecules are translocated to the surface of capillary endothelial cells anchored to the cell membrane by heparan sulfate proteoglycans, where it would exert its physiologic activity, namely the hydrolysis of triglycerides in lipoproteins and chylomicra. Endothelial anchored LPL may be released into the circulating blood by intravenous injection of heparin. This is an artefact allowing the assessment of LPL activity in the plasma, and is not a physiological process [10]. The released enzyme would then act on the plasma triglyceride, this activity being enhanced by apoCII bound to phospholipids, and is inhibited by apoCIII. Normal blood contains only minute amounts of inactive LPL, the “preheparin LPL”, detectable by sensitive immunoassays, being nevertheless a marker and a measure of LPL mass [5][6]. LPL – lipolytic activity of a tissue is correlated to the tissue’s ability to take up and incorporate the fatty acids released from lipoprotein triglyceride. There is therefore a high degree of tissue specificity and synergism in the regulation of LPL activity. Actually, feeding and insulin are known to stimulate the synthesis of LPL in adipose cells, as well as its translocation to the luminal surface of capillary endothelial cells, while myocardial and muscular LPL expression would increase when these tissues are functionally active and would decrease in sedentary subjects [10][11]. Interestingly, stress, food deprivation and proinflammatory cytokines would decrease LPL activity in adipose tissue but not in the heart and the skeletal muscle. It was also found that a decrease in the concentration of plasma triglyceride substrate leads to a decreased adipose tissue LPL activity, while heart and muscle LPL activities would increase. Actually, the Km is 10 times higher for the adipose tissue LPL than for heart LPL. Hepatic lipase (HL) also hydrolyses triglyceride, yet its functional relevance differs from that of LPL. It preferentially acts on smaller VLDL particles and may also hydrolyse the triglyceride in triglyceride-enriched HDL and LDL particles. HL is primarily synthesized in hepatocytes, being mainly expressed at the surface of these cells microvilli [12][13]. More recently the macrophage was identified as another site of synthesis of HL [14]. The synthesized enzyme molecules are then


Metabolic syndrome and atherosclerosis

further transported in the circulation to be bound to heparan sulfate on the surface of hepatic synusoid endothelia as well as on ovarian and adrenal blood vessels. Like LPL, HL may be released from the endothelial surface by intravenous injection of heparin. To be noted the preferential location of HL in the liver, which is involved in cholesterol uptake for elimination in the bile and for the synthesis of bile acids, as well as in steroid hormones producing ovarian and adrenal cells. Such locations are highly suggestive that HL is involved in the uptake of cholesterol into these cells. Actually HL expression was found to be increasd in cholesterol depleted cells [15]. It is also known that estrogens depress HL activity while androgens and thyroid hormones exert a stimulating effect [12][13]. In most cases, high insulin levels were shown to be associated with high HL activity and low HDL cholesterol [16], but this association does not necessarily imply that insulin would stimulate the synthesis of HL. One may rather suspect that increased insulin and HL levels could be different effects of a common cause, presumably insulin resistance. In support of such an interpretation, it is worth mentioning that hypoadiponectinemia, a hallmark of insulin resistance, is associated with increased HL [17] and decreased LPL [18] activities in vivo. One should remember that adiponectin, a collagen-like protein exclusively synthesized by adipocytes, is the only adipokine obviously decreasing in both obesity and lipoatrophy, and its primary action appears to be the limitation of nonesterified fatty acids (NEFA) release from the adipose tissue. Decreased adiponectin would therefore lead to an excessive release of NEFA from an enlarged intraabdominal adipose tissue into the portal flow [19][20]. Overloading of the liver with fatty acids was reported to stimulate the hepatic synthesis not only of triglyceride but also of protein [21], thus providing a reasonable explanation for the increased plasma levels of several liver secreted enzymes and proteins such as serum cholinesterase, γ glutamyl transferase, lecithin cholesterol acyltransferase, factor XIII subunit B, vitamin K dependent clotting factors, protein C, protein S, fibronectin, cholesteryl ester transfer protein and plasminogen activator inhibitor (PAI-1 [22]. NEFA may act as ligands for genes and a fatty acid responsive region could be actually identified and localized in human PAI-1 gene [23]. One may therefore presume that the decreased adiponectin and the increased NEFA in the portal flow would also stimulate the synthesis of HL.


Endothelial lipase (EL), a more recently described lipolytic enzyme, shares a great homology with LPL and HL, being however located and acting inside endothelial cells, its synthesis by these cells being stimulated by proinflammatory cytokines. EL appears to preferentially hydrolyse phospholipids being thereby involved in the remodelling of HDL particles [24]. PATHOGENIC RELEVANCE OF ABNORMAL LIPOLYSIS

Because lipolytic enzymes exert multiple effects on lipoprotein metabolism and transport, it is rather difficult to distinguish between beneficial and deleterious effects of their increased or decreased activities. Severe genetic LPL deficit is not atherogenic, as the exceedingly large triglyceride rich chylomicra do not penetrate the arterial wall. Affected individuals with hyperchylomicronemia may nevertheless experience abdominal pain, bouts of acute pancreatitis and retinal impregnation with lipids [3]. Noteworthy, the lipoprotein and chylomicron remnants resulting from LPL activity are highly atherogenic when they are not taken up and degraded into the liver as in cases of dysbetalipoproteinemia (type III), subsequent to deficient or abnormal apolipoprotein E [3]. It had appeared reasonable to consider that an excessive and prolonged postprandial hyperlipidemia should be attributed to an impaired LPL activity. This concept has recently been critically considered in insulin resistant patients. Actually, the postprandial hyperlipidemia noted in patients with type 2 diabetes after a fatty meal was found to be significantly greater than in control subjects, although both patients and controls displayed a similar reactive increase of LPL activity in their adipose tissue [25], thereby casting doubts about the importance of the lipolytic enzymes for the clearance of postprandial elevation of plasma triglyceride. It should be rememebered that an efficient clearance of chylomicra implies not only lipolysis of the triglyceride, but also a removal of the resulting free fatty acids and of the partially delipidated chylomicra and lipoproteins remnants. An impaired uptake of fatty acids into the adipose tissue, or in the muscle for oxidation would drive excess fatty acids to the liver, leading to an


M. Cucuianu, Ioana Brudaşcă

increased hepatic synthesis and secretion of VLDL triglyceride. Noteworthy the peripheral (gynoid) adipocytes are more apt to take up the fatty acids released by a LPL mediated lipolysis than the visceral (android) insulin resistant adipocytes [26]. In android obese the increased plasma levels of fatty acids resulting from an enhanced release from the enlarged intraabdominal adipose tissue in fasting conditions would be further amplified postprandially [27]. Consistent evidence is thereby provided that impaired lipolysis may not be the only mechanism involved in the development of postprandial hyperlipidemia. Severe genetic HL deficit was reported to be atherogenic [28], yet an increased HL activity occurring in insulin resistant patients displaying moderately increased plasma VLDL triglyceride levels would favour the development of an atherogenic dyslipidemia [29]. Such apparently surprising aspects may however be explained by the dual effects of HL on lipoprotein metabolism and transport. An important beneficial mechanism is represented by the HL mediated binding of lipoprotein particles to the hepatocyte membrane surface thereby facilitating the translocation of cholesteryl esters into the hepatocyte through a lipid-lipid interaction named transcytosis [30]. On the other hand, a deleterious effect of HL may be exerted in certain peculiar conditions clustering increased plasma levels of triglyceride rich lipoproteins, cholesteryl ester transfer protein (CETP) and hepatic lipase. Such a situation occurs in patients with the metabolic syndrome involving the following mechanisms: a) an increased level of fatty acids in the portal flow would enhance the synthesis of VLDL triglyceride as well as CETP and HL b) a CETP – mediated transfer of cholesteryl ester from HDL and from LDL towards VLDL and IDL in exchange for triglyceride would occur [31] c) HL would then hydrolyse the acquired triglyceride in HDL, thereby resulting smaller


less efficient and more readily degradable particles, and in LDL thereby generating smaller and denser LDL particles [32], which are more atherogenic because they more easily penetrate the vascular wall, are more tightly bound to the extracellular matrix of the arterial wall and are more prone to oxidation. The lipid triad (high triglyceride, low HDL cholesterol and the presence of small dense LDL) is thus constituted, being an important component of the metabolic syndrome, also known as the atherogenic dyslipidemia or as the atherogenic lipoprotein profile [33]. Studies in Third World populations at low risk for atherogenesis have reported that carbohydrate-rich, lipid-very poor-diets are often accompanied by increased plasma triglyceride. This increase is primarily attributable to a deficient clearance of triglycerides whereas the elevation of the triglycerides observed in the insulin resistant patients appears to be caused by the increased fatty acids in the portal flow and the subsequent enhanced hepatic synthesis and secretion of VLDLtriglyceride and proteins. Noteworthy endothelial dysfunction is seen only in those hypertriglyceridemic patients who are insulin resistant and it is absent in subjects genetically deficient in LPL. It was therefore suggested that the high plasma triglyceride levels in Western populations are a marker of insulin resistance rather than an inherent pathogenic role of the triglyceride per se [34]. One may also presume that the decreased LPL mass and activity occurring in patients with the metabolic syndrome and clinically detectable atherosclerosis lesions are subsequent to the inflammatory component of atherogenesis, being therefore only a marker of this process and not a major pathogenic link. The main conclusion of this mini-review is that there is a lot to be learned by critically analyzing one of your own studies in the light of recent achievements in the respective field.

În urmă cu mai bine de 40 de ani, cercetări efectuate în laboratorul nostru au evidenţiat o scădere a activităţii lipolitice postheparină la pacienţii cu atreoscleroză clinic manifestă, în timp ce valorile înregistrate la subiecţii obezi şi la cei hiperlipidemici fără leziuni aterosclerotice detectabile clinic nu au diferit faţă de valorile găsite la subiecţii de control normolipidemici şi normoponderali. Deoarece în 1967 erau relativ puţine date privitoare la fiziopatologia enzimelor lipolitice şi mai ales datorită posibilităţilor noastre de informare destul de limitate


Metabolic syndrome and atherosclerosis


în acei ani, s-au întâmpinat dificultăţi în interpretarea rezultatelor, iar abordarea studiului a fost grevată de stângăcii, în sensul că subiecţii nu au fost grupaţi în funcţie de sex şi tipul de obezitate şi de hiperlipoproteinemie, iar activitatea lipolitică a lipoproteinlipazei şi cea a lipazei hepatice nu au fost determinate în mod diferenţiat. Urmărind datele recente din literatură, s-a observat că masa lipoproteinlipazei pre-heparină, dozată prin tehnica ELISA este de fapt mai scăzută la pacienţii insulinorezistenţi afectaţi de ateroscleroza coronarelor decât la cei fără leziuni, iar valorile enzimei s-au corelat negativ cu severitatea leziunilor aterosclerotice. De notat că hipoadiponectinemia, o caracteristică a rezistenţei la insulină, s-a asociat cu creşterea activităţii lipazei hepatice şi scăderea activităţii lipoproteinlipazei. Asocierea unor nivele plasmatice crescute de VLDL – trigliceride cu creşteri ale proteinei de transfer a esterilor de colesterol şi a lipazei hepatice duce la o remodelare a particulelor de HDL şi LDL şi la dezvoltarea unei dislipidemii aterogene. Spre deosebire de acest tip de dislipidemie produs prin creşterea sintezei hepatice de VLDL, s-au semnalat cazuri cu hipertrigliceridemii importante, cauzate de un deficit de lipoliză şi care au un risc redus pentru boala arterelor coronare. Datele sugerează că scăderea activităţii lipoproteinlipazei la pacienţii aterosclerotici nu constituie o verigă patogenetică importantă, fiind mai degrabă o consecinţă a componentei inflamatorii a bolii, expresia enzimei reducându-se sub acţiunea citokinelor proinflamatorii. Corresponding author: M. Cucuianu, Professor Str. Donath bl. MX3, ap. 3, 400290 Cluj-Napoca e-mail: [email protected]

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Impact of Host Insulin Resistance on Fibrosis and Response to Interferon in Chronic Hepatitis C MARIA MOŢA1,*, SIMONA POPA1, E. MOŢA2, I. DIACONESCU3, I. GHEORGHIŢOIU4, M. PANDURU1 1

Department of Diabetes, Nutrition and Metabolic Disease, 2Department of Nephrology-Internal Medicine, Department of Infectious Diseases, University of Medicine and Pharmacy, Craiova, Romania, 4Department of Gastroenterology, County Emergency Hospital, Târgu-Jiu, Romania


Chronic hepatitis C and obesity inflict significant health and economic burdens on the world. Insulin resistance associated to obesity is the key factor in this disease, mainly because it has been related to fibrosis extension and non-response to antiviral therapy. The mechanism underlying this correlation is not fully explained yet. Leptin, adiponectin, TNF alfa, the hepatic expression of suppressor of cytokine signalling 3 (SOCS3), and hyperinsulinemia have been considered as heavily influencing fibrosis extension and nonresponsiveness to the IFN-α. The adipokines increased hepatic expression of SOCS3, and hyperinsulinemia has been proposed as heavily influencing non-responsiveness to the IFNα and fibrosis extension by maintaining the hepatic stellate cells activated phenotype in patients with chronic hepatitis C and insulin resistance-related obesity. We shall review the mechanisms by which obesity-related insulin resistance may be associated with fibrosis extension and decreased efficacy of IFN-α based therapies in obese individuals with chronic hepatitis C and the therapeutic strategies that may increase the effectiveness of these therapies. Consequently, being aware of the role of obesityrelated insulin resistance in chronic hepatitis C, it will be possible to elaborate new therapeutic strategies for chronic hepatitis C obese patients. Also, it will be possible to elaborate new criteria for the initiation of antiviral therapy by including parameters such as body weight, abdominal circumference, HOMA-IR, the dosage of adipokines in order to more accurately define the groups of patients with a higher risk of non-responsiveness to antiviral therapy, thus lowering long-term costs.

Hepatitis C and obesity inflict significant health and economic burdens on the world. Insulin resistance (IR) is the key factor in these disease processes mainly because it has been related to fibrosis extension and nonresponse to antiviral therapy. Complex interplay between these conditions results in the ultimate phenotype of liver disease. It is estimated that 170 million of people or 3% of the world population is infected with the hepatitis C virus and that yearly, 3–4 million count as more [1]. In Romania, statistics show that 1 million persons (4.5% of the Romanian population) are infected with the same virus [2]. The current standard of care for the treatment of chronic hepatitis C virus infection is combination therapy with interferon alpha (IFN-α) and ribavirin [3]. Although the use of a dual combination of IFN-α/ ribavirin has improved the treatment efficacy of chronic hepatitis C virus infection, many patients still fail to eradicate the virus. At the international level, sustained virological response (SVR) – defined as RNA hepatitis C virus undetectable for 24 weeks beyond the completion ROM. J. INTERN. MED., 2008, 46, 2, 105–112

of treatment – is globally estimated to 54–55%, whereas for genotype 1, responsiveness rates range between 42–46% [4]. In Romania the global SVR is estimated to 51.5% [2]. Taking into consideration the high transforming rate in hepatic cirrhosis (2–3% yearly) [5] or hepatic carcinoma (1.5–2% yearly) [6], the identification of nonresponsiveness factors and the elaboration of well-defined criteria for antiviral therapy are the main objectives for therapy efficacy and prevention of complications as well as for lower costs in patients with obesity-related IR and chronic hepatitis C (CHC). IR emerges as a very important host factor in patients with CHC, mainly because it has been related with non-response to antiviral therapy [7–11] and the progression of fibrosis [7][8][12][13]. The main deleterious effect of IR in CHC is the ability to promote fibrosis progression [14–16]. Maintenance of the activated hepatic stellate cells (HSC) phenotype by both proliferation and inhibition of apoptosis is a key feature in the molecular pathogenesis of liver [17]. Several


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mechanisms have been proposed relating obesityassociated IR to fibrosis extension in CHC. IR appears as a consequence of the inability of insulin to induce the effect on glucose metabolism and an abnormally large amount of insulin is secreted to achieve a biological response [18]. The adipose tissue has been more recently recognized as an active participant in numerous physiological and pathophysiological processes. Several adipose-derived cytokines (adipokines) act as a link between accumulated fat mass and altered insulin sensitivity [18–21]. Most of them are overproduced during obesity, including leptin, tumor necrosis factor alpha (TNF-α); conversely, expression and plasma levels of adiponectin are down-regulated during obesity. TNF-α alter insulin sensitivity by triggering different key steps in the insulin signaling pathway [20], conversely, leptin and adiponectin both exert an insulin-sensitizing effect, at least in part, by favoring tissue fatty-acid oxidation through activation of AMP-activated kinase [19]. In obesity, IR has been linked to leptin resistance and decreased plasma adiponectin [18][19]. Leptin could modulate TNF-α production and adiponectin counteracts the pro-inflammatory effects of TNF-α [20]. Several lines of evidence have suggested that IR in obesity is a component mediated by the overexpression of the suppressor of cytokine signaling 3 (SOCS3) proteins in insulin-sensitive tissues, which is induced by TNF-α overproduced from excessive adipose tissue [22–25]. Because SOCS molecules have been recognized to be powerful inhibitors of cytokine signaling via the Janus kinase/ signal transducers and activators of transcription (Jak/STAT) pathway, overexpression of these molecules should be an efficient instrument to counteract the cellular response toward IFN-α, an essential part of first line antiviral immune response. The mechanism underlying the correlation of IR, associated with obesity, with the response to antiviral therapy and with fibrosis extension is not fully explained yet. Leptin, adiponectin, TNF-α, the hepatic expression of SOCS3, and hyperinsulinemia have been proposed as heavily influencing fibrosis extension and nonresponsiveness to the IFN-α in patients with CHC and insulin resistance related obesity. This review outlines the recent findings that highlight the mechanisms by which obesity-related IR may be associated with fibrosis extension and decreased efficacy of IFN-α-based therapies in individuals with CHC and the therapeutic strategies


that may increase the effectiveness of these therapies in obese individuals. IMPACT OF INSULIN RESISTANCE ASSOCIATED OBESITY ON RESPONSE TO ANTIVIRAL THERAPY IN CHRONIC HEPATITIS C (Fig. 1)

The immunomodulatory effects of IFN-α are dependent on host nutritional and metabolic conditions and on the ability of the host immune system to respond [7][9]. In order to increase the number of patients achieving a SVR, there is a need to identify modifiable risk factors that have impact on treatment efficacy. Several studies have demonstrated that SVR rates are lower in patients with coexistent IR [7][12][26][27]. The pathogenic mechanisms for this are not fully understood.

Fig. 1. – Impact of insulin resistance associated obesity on fibrosis in chronic hepatitis C.

Interaction of IFN-α with a cell surface receptor leads to a series of intracellular reactions that result in transcriptional induction of several antiviral and immunoregulatory genes [9]. The action of IFN-α is largely mediated via the Jak/STAT signal transducing cascade, a key signaling system involved in the signal transduction of a


Host insulin resistance on fibrosis

number of interleukins, IFN-α s, and a range of growth and differentiation factors [28][29]. Binding these ligands to their respective receptors activates tyrosine kinases of the Janus kinase family, followed by tyrosine phosphorylation, dimerization, and nuclear translocation of STATs. In the nucleus, activated STAT-dimers bind to specific enhancer sequences and modulate transcription of target genes [30][31]. In hepatitis C virus-infected individuals, IFN-α is thought to induce a cascade of gene expression that leads to the synthesis of certain proteins in hepatocytes, including the enzyme 2,5-oligoadenylate synthetase, which can interfere with viral replication [7][32]. Numerous studies have demonstrated that IFN-α-activated signaling is negatively regulated by a number of inhibitory factors [9][33]. Recent evidence suggests that one of the most important mechanisms for the negative regulation of signal transduction via Jak/STAT is the induction of SOCS3 [7][24][34]. Up-regulation of hepatic SOCS3 mRNA and proteins has been observed in various insulin resistant animal models [22][25]. These molecules affect cytokine signaling by binding to the tyrosine kinases of the Janus family, which results in reduced enzymatic activity and inhibition of the tyrosine phosphorylation of Jak and STAT factors [28][30][32]. SOCS3 have been shown to inhibit the tyrosine phosphorylation and nuclear translocation of STAT1 in response to IFN-α stimulation and this inhibition occurs at very low levels of SOCS3 protein expression [35]. In addition, some authors suggest that SOCS3 proteins contribute to IFN-α resistance probably by the inhibition of expression of the antiviral proteins 2,5oligoadenylate synthetase [32].Several studies have found that patients with high TNF-α levels have a poor response to IFN-α therapy [36][37] and this may occur via induction of SOCS proteins [24]. Elevated levels of TNF-α are known to be associated with obesity and insulin resistance [18][34]. A marked decrease in SOCS3 expression was found in obese mice lacking TNF-α signaling, supporting the premise that elevated levels of SOCS3 in obesity may be related to increase of TNF-α expression [25]. Recent research on patients with HCV infection shows a striking correlation between TNF-α and SOCS3 mRNA levels, consistent with a role for this cytokine in induction of SOCS3 expression in vivo [34]. Hong et al. have shown in a mouse model that injection of TNF-α markedly induced expression of SOCS3, resulting in inhibition of IFN-α signaling in hepatic cells [24].


Some authors have indicated the independent and predictive role of adiponectine, an adipocyte hormone, in the response to antiviral therapy for CHC [7][10][11]. Nevertheless, Lu et al. carried out an experiment on a small number of patients and concluded that there is no correlation between the level of adiponectine and the SVR [38]. Eguchi et al. think that leptin may be an independent predictive factor of non-responsiveness to the IFN-α therapy in CHC [39]. Evidence suggests that it is likely that leptin resistance rather than hyperleptinemia contributes to decreased SVR in obese patients [40]. It is not clearly defined yet the mechanism through which leptin affects responsiveness to antiviral therapy in patients with chronic hepatitis C. The induction of the hepatic expression of SOCS3 by leptin may explain it [7](Fig. 1). IR has been shown to be associated with increased fibrosis, and the degree of IR correlates with progression of fibrosis [41]. The mechanism linking IR to collagen deposition is thought to involve the stimulation of HSC. A key feature in the molecular pathogenesis of liver fibrosis requires maintenance of the activated HSC phenotype by both proliferation and inhibition of apoptosis [17]. Activation of HSC, also known as Ito cells, perisinusoidal cells, and liver pericytes, is supposed to be one of the most important steps in development of liver fibrosis [8][12][17][41]. The adipokines play multiple roles in the pathogenesis of liver fibrosis in patients with insulin resistance-related obesity and chronic hepatitis C. It was thought that HSC is the common target cells shared by adipokines [15][16][42–44]. Hyperleptinemia has been usually found in patients with IR, also HSC showed specific leptin receptors, thus leptin could play a role in the activation of HSC and fibrosis progression [45][46]. Piche et al. reported that leptin is an independent metabolic factor associated with the severity of liver fibrosis in patients with CHC and higher body mass index [47]. Up-regulation of leptin signaling in CHC could contribute to enhanced fibrogenesis, particularly in states in which leptin levels are high like obesity-associated IR. Leptin is a 16-kd hormone that mediates a range of metabolic effects by using a transduction pathway from the leptin receptor through JakSTAT signaling components [30,42,48]. Several studies provide evidence that leptin is a potent HSC mitogen and dramatically inhibits stellate cell


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apoptosis, so leptin acts as a direct HSC survival agonist [17] 42][47]. Saxena NK. et al. demonstrate that leptin receptor phosphorylation and HSC mitogenesis are linked to Erk and Akt phosphorylation, two key signal transduction elements associated with cell growth [17]. It has been reported that leptin promotes liver fibrosis by activating known extracellular matrix response genes [49][50], but it also perpetuates the fibrogenic process by directly inducing stellate cell proliferation and resistance to a timely death by apoptosis [17]. An increasing body of evidence from both experimental and clinical studies suggests that HSC apoptosis may contribute to liver fibrogenesis [51][55]. Resistance to apoptosis provides an important escape mechanism by which stellate cells in CHC continue to promote fibrotic change. Therefore, the elimination of activated HSCs by apoptosis might be an important mechanism of stopping and potentially reversing liver fibrosis [51][53]. Leptin abolished-apoptosis appears to be mediated by a PI-3 kinase-dependent pathway [17]. HSCs express death receptor and its stimulation results in apoptosis [54]. Tumor necrosis factor-related apoptosis-inducing ligand receptors (TRAIL) are an important family of death receptors [55]. A few recent studies have shown that leptin not only reduced apoptotic activity, but more importantly, leptin could rescue stellate cells from highly potent HSC pro-apoptotic stimulus-TRAIL [17]. Specific induction of apoptosis in human HSC may represent a realistic objective for cell targeted therapy in liver fibrosis. It has been recently demonstrated that leptin can bind to cultured rat HSC in vitro, activate STAT3 phosphorylation through leptin receptor, and increase total mRNA for the α2[I] collagen gene [42]. Similarly, Eguchi et al. show that in HSC culture leptin induced an increased expression of transforming growth factor-β [56]. This data suggest that leptin may be considered a novel multi-faceted profibrogenic cytokine. Numerous studies have demonstrated that adiponectin is, on the contrary, anti-fibrogenic. Adiponectin is a relatively abundant 30-kd plasma protein that until present has been felt to be secreted specifically from adipose tissue. There was demonstrated that adiponectin may be critical to either maintaining the HSC quiescent phenotype or reverse hepatic fibrosis by induction of activated HSC apoptosis [14][51][53]. Adiponectin receptors


were detected in both activated and quiescent HSCs, but only activated HSCs produced significant apoptosis after treatment with adiponectin [14]. Adiponectin can induce activated HSC apoptosis by caspase activation and inhibit activated HSC proliferation, failing to do so in quiescent HSCs [14][51]. The data suggest that adiponectin may have important therapeutic implications in liver fibrosis. TNF-α production is enhanced in hepatitis C associated with obesity-related IR. TNF-α levels were related to fibrosis progression, because of the ability to activate HSC and promote collagen deposits [16][43][44][53]. The mechanism by which TNF-α could contribute to tissue fibrosis is thought to involve the apoptosis/proliferation of HSC. Saile et al. indicate that TNF-α inhibit proliferation and also apoptosis in activated HSC in vitro [44]. TNFα has pleiotropic functions in hepatitis, but its role in liver fibrosis remains elusive. The association between fibrosis in CHC and IR induced by obesity may be due to the elevated levels of insulinemia [7]. Hyperinsulinemia may enhance fibrosis through the stimulation of the growth factor of the conjunctive tissue in the HSC [57](Fig. 2).

Fig. 2. –Proposed mechanisms by which host insulin resistance might contribute to hepatic stellate cells apoptosis and proliferation in chronic hepatitis C. HSC:hepatic stellate cells TNF-α:tumor necrosis factor α.


Host insulin resistance on fibrosis CONCLUSIONS

In conclusion, being aware of the role of IR associated with obesity, in the responsiveness to antiviral therapy, in the proliferation of HSC and fibrosis severity we shall be able to elaborate new therapeutic strategies for CHC obese patients. Also, we shall be able to elaborate new criteria for the initiation of antiviral therapy by including parameters such as body weight, abdominal circumference, HOMA-IR, the dosage of adipokines in order to more accurately define the groups of patients with a higher risk of non-responsiveness to antiviral therapy, thus lowering long-term costs. The treatment of patients that have IR associated to obesity could induce higher rates of SVR. The optimal and cost-effective approach is to encourage physical exercise and weight loss prior and during the ongoing antiviral therapy. Decreasing


the levels of leptin and TNF-α and increasing the level of adiponectin via the administration of omega polyunsaturated fatty acids [7][58–60] are new therapeutic strategies for a better responsiveness rate to antiviral therapy and for the regression of fibrosis. The achievement of the SVR in the largest number of patients has several advantages: it prevents patients from developing cirrhosis or hepatic carcinoma and consequently, it lowers the costs triggered by these severe complications. With respect to these findings we shall be able to set new selection criteria, by including body weight, abdominal circumference, HOMA-IR, and adipokines at the beginning of the IFN-α therapy in CHC patients in order to more accurately define the groups of patients with a higher risk of nonresponsiveness to antiviral therapy.

Hepatita cronică C şi obezitatea sunt afecţiuni ce implică importante consecinţe clinice, terapeutice şi socio-economice. Insulinorezistenţa asociată obezităţii constituie factorul cheie care stă la baza asocierii obezităţii cu hepatita cronică C, în special datorită corelaţiei acesteia cu extensia fibrozei şi cu nonresponsivitatea la terapia antivirală. Mecanismul care stă la baza acestei corelaţii este incomplet elucidat. Leptina, adiponectina, TNF-α, SOCS3, hiperinsulinemia au fost propuse ca factori determinanţi ai extensiei fibrozei şi ai nonresponsivităţii la tratamentul cu IFN-α. Se consideră că adipokinele cresc expresia hepatică a SOCS3, iar hiperinsulinemia se pare că are o influenţă importantă asupra nonresponsivităţii la terapia cu IFN-α şi asupra extensiei fibrozei prin menţinerea fenotipului activ al celulelor stelate hepatice la pacienţii cu hepatită cronică C şi insulinorezistenţa asociată obezităţii. În acest articol vom evalua mecanismele prin care insulinorezistenţa asociată obezităţii se corelează cu extensia fibrozei şi scaderea eficienţei terapiei cu IFN-α, cât şi strategiile terapeutice care pot creşte responsivitatea la terapia antivirală la pacienţii obezi cu hepatită cronică C. În concluzie, cunoscând rolul insulinorezistenţei asociată obezităţii în hepatita cronică C se vor putea elabora noi strategii terapeutice la pacienţii obezi cu hepatită cronică C. De asemenea se vor putea elabora noi criterii pentru iniţierea terapiei antivirale incluzând parametri ca: greutatea, circumferinta abdominală, HOMA-IR, dozarea adipokinelor, în vederea delimitării clare a grupelor de pacienţi cu risc mare de nonresponsivitate la terapia antivirală şi, astfel, reducerii costurilor pe termen lung. Corresponding author: Maria Moţa, MD, PhD, Professor of Diabetes, Nutrition, Metabolic Disease. University of Medicine and Pharmacy, 2–4 Petru Rareş St, Craiova, Dolj County, Romania E-mail: [email protected] Tel.: + 40 744 624 664, Fax: + 40 251 502 246


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58. TAKASHI I.D.E., Interaction of Fish Oil and Conjugated Linoleic Acid in Affecting Hepatic Activity of Lipogenic Enzymes and Gene Expression in Liver and Adipose Tissue. Diabetes, 2005, 54(2):412–23. 59. BERGER A., ROBERTS M.A., HOFF B., How dietary arachidonic- and docosahexaenoic-acid rich oils differentially affect the murine hepatic transcriptome. Lipids Health Dis., 2006, 5: 10. 60. BERGER A., MUTCH D.M., GERMAN J.B., ROBERTS M.A., Dietary effects of arachidonate-rich fungal oil and fish oil on murine hepatic and hippocampal gene expression. Lipids Health Dis., 2002, 1: 2. Received April 20, 2008

Bronchial Asthma with Psychogenic Trigger I.B. IAMANDESCU1, ALEXANDRA MIHĂILESCU2 1

“Carol Davila” University of Medicine and Pharmacy, “Colentina” Hospital, Clinic of Allergology, Bucharest, Romania 2 “Carol Davila” University of Medicine and Pharmacy,“Al. Obregia” Hospital of Psychiatry, Bucharest, Romania

The authors present several personal studies in accordance with other published data which contest the existence of purely psychogenic bronchial asthma, as it was considered 30-50 years ago. Although psychological stimuli could trigger the occurrence of attacks of bronchial asthma, they are not an exclusive etiological factor (Iamandescu, 1980, 1985). In the context of large groups of asthma with allergic or other etiology, forms of asthma that are triggered by an additional psychogenic factor could be identified. These are noted in 62.5% of hospitalized patients, most cases with a prolonged and more severe evolution of the disease, but in only 30% of light and moderately severe cases that are followed up in outpatient (Iamandescu, 1980, 1984). The percent of psychological trigger is maximum (86%) in corticodependent asthma patients (Iamandescu, 1996). Somatic and psychological background of asthma with psychogenic triggering is represented by the following: 1) an obvious relationship between psychological stimuli and the onset of asthma attacks, and a psychological terrain “endowed” with an increased vulnerability to stress. These patients present a diminished rate of cortisol response to stress compared with asthma patients without psychogenic triggering; 2) reversibility to broncho-dilator agents, in contrast with resistance to systemic corticoid therapy; 3) sensitivity to aspirin; 4) endocrine dysfunctions (high estrogen and thyroid hormones secretion); 5) multi-factorial triggering of the attacks (especially non-specific respiratory irritants, including physical-chemical factors and meteorological changes) (1985); 6) variable response to psychotherapy and psychotropic drugs, suggesting – in case of therapeutic failure – the predominance of the chronic inflammation determined by other etiologic agents, different from psychological stress. Key words: Bronchial asthma, psychological trigger, stress, depression.


In many cases the bronchial asthma is, at least initially, of allergic or intrinsic (non-allergic) origin, and the psychogenic triggering is a “supplemental factor”. It should be stressed that the study of the role played by psychogenic factors in the triggering of bronchial asthma attacks has two aspects: − The relationship between the psychological stress – as a rule extending over a long period of the patient’s life, and having a variable intensity and duration – and the occurrence of the first bronchial asthma attacks, corresponding to the onset of the disease. − The relationship between common, daily psychological excitants and the triggering of asthma attacks after the onset of the disease. The legitimacy of purely psychogenic asthma had been suggested (with some reserves) by authors like Hansen, Findeisen, Seropian, Graham ROM. J. INTERN. MED., 2008, 46, 2, 113–118

and Mathov, based on clinical observations of BA attacks without any explanation: allergic or infectious (the two main etiologies admitted at that time, 1970–1980). Oehling [1] believed that psychological factors – just like physical, chemical or neural factors – play a secondary role in inducing disturbances leading to bronchial asthma. Mathov [2] expressed in 1981 a series of reserves with regard to the exclusive psychogenic etiology of asthma, and the so-called “psychogenic asthma”. The author invoked, just as we do, the fact that patients with “psychogenic asthma” had either personal or family antecedents of allergy and a high level of total IgE, suffering in fact from allergic asthma. These patients had a quasi-constant evolution of asthma in the spring or in the autumn, and did not respond favorably to anxiolytic medication. Mathov restricts the sphere – already limited – of purely psychogenic asthma to those cases that are triggered by psychogenic causes in the absence of a demonstrated allergy or infection. Klaper (cited by Klumbies) [3] did not find a single patient with pure psychogenic asthma out


I.B. Iamandescu, Alexandra Mihăilescu

of 100 cases, even if a psychogenic etiology was identified in 53 of these. Of the 120 patients that have been investigated in a personal study by Iamandescu (1980) [4], none had pure psychological asthma, which is triggering of asthma attacks exclusively by psychological factors. 89 of these patients had a purely allergic etiology (to dust, pollen, daphnia, moulds) confirmed by challenge testing, while 31 had intrinsic asthma. In the context of large groups of asthma with allergic or other etiology, forms of asthma that are triggered by an additional psychogenic factor could be identified. These are noted in 62.5% of hospitalized patients, most cases with a prolonged and more severe evolution of the disease, but in only 30% of light and moderately severe cases that are followed up in outpatients [4]. The percent of psychological trigger is maximum (86%) in corticodependent asthma patients [5]. To conclude, although psychological stimuli could trigger the occurrence of attacks of bronchial asthma, they are not an exclusive etiological factor [4][6] and this is in accordance with more recent opinions. While contesting a purely psychogenic bronchial asthma, it is necessary to isolate those forms of BA, either allergic or intrinsic, in which the onset of attacks is provoked also by the psychological factors. 2. INCIDENCE

With regard to the incidence of psychogenic triggering of allergic asthma attacks, this varies – according to the data in the literature – in relation with the severity of the disease, but also with the age of the patient [7]. The percentages of old statistics vary from 8% [8] in a group of 441 patients with asthma, to 54% (Pearson, 1958) in a lot of 375 patients. More recently (1992) Richter and Dahme [9] evaluated the appreciations in this regard made by physicians (60%) and psychosomaticians (68%). Since we have examined these problems in the context of a doctoral thesis, and in several later studies (1996, 1998, 2006), we are in a position to present our personal data in the light of experience of the other authors. An analytical study presented in a paper published in 1985 tried to establish the relationship between psychological stress and the trigger of asthma attacks. We studied a sample of 120 asthma patients and two control groups


including patients with psychosomatic diseases (60 patients with urticaria and 50 with digestive ulcers). All groups of patients with psychosomatic diseases were compared between them and with a group of healthy controls. The analysis of these results disclosed the following major aspects: 1) The presence of traumatic psychological events in the period preceding the first attacks of asthma was detected in approximately 66% of the asthma patients, a percentage that is significantly different statistically (pT genotype may present a 16 fold increased risk for venous thrombosis. A recent study showed a prevalence of hyperhomocysteinemia of 39% (significantly statistical P 0.21 >9 >144 >122 >–0.3

Se (%) 89 61 68 80 50 80

Sp (%) 39 76 74 53 75 62.5

PPV (%) 59 72 72 63 57 65

NPV (%) 78 66 70 73 60 78

AUC=area under ROC curve; Se=Sensitivity; Sp=Specificity; PPV=Positive Predictive Value; NPV=Negative Predictive Value; Lp(a)=lipoprotein (a);CRP=C-reactive protein; sBP=systolic blood pressure; non-HDL-C=non-HDL-Cholesterol

The utility of regression formulas has already been proven in evaluating risk in cardiology, due to multifactorial etiopathogeny of this system. Several scoring systems have been developed [16–21]. However, included predictors were different for each study. Framingham Study proposes a formula for coronary risk estimate including: sBP, smoking, TC/HDL-C ratio, presence of electrocardiography left ventricular hypertrophy, age, as well as presence of diabetes [16]. PROCAM Study proposes several risk formulas. The stroke score generated by the study authors is based on: age, sex, diabetes mellitus presence, smoking status and sBP [17]. Other studies (Dundee) propose formulas based on: age, sBP, cholesterol level and smoking with considering gender interference in risk difference [18]. British Regional Heart Study also generates a modified score based on: smoking, mean blood pressure, previous diagnosis of ischemic heart disease, evidence of angina, parental death of heart trouble, presence of diabetes [19]. Another study (AMORIS) propose scores based on: apoB/apoA-I ratio, proinsulin, systolic pressure, family risk of CHD and smoking [20] [21]. Our study proposes a new predictive combination of 5 parameters including: age, Lp(a), CRP, non-HDL-C, sBP. Many regression formulas have been proposed to evaluate both the coronary events and the death risk in patients [16–21]. The predictive performance of our score is higher in terms of AUROC. We obtained an area under curve of 74.5%. Results were superior to Dundee formula (AUROC=66%), Framingham Score (AUROC=61%) or PROCAM Score (AUROC=63%) [22]. Our study has several unique features. First, it introduces multivariate risk prediction formula Lp(a) and CRP values. Although recent studies have demonstrated correlation of Lp(a) with coronary events [23][24], as far as we know there

have been no prediction scores with inclusion of the recently validated marker. CRP has also been proved to be correlated with coronary events [25], but we found no prediction score with inclusion of CRP in the model. Our formula also comprised a small number of predictors by including the two markers mentioned above. Another interesting observation is that although apoA-I is a strong predictor it does not add a great variability in prediction formula. Similar observations have been published regarding apoB/apoA-I ratio in Epik-Norfolk study results [26]. Those results impose apolipoproteic markers as tools to be applied independently in risk prediction rather than integrated components in scoring systems. We are, however, aware of the limitations of our score. The formula still needs to be validated on a different database coming from a different population than the original sample. Such validation could confirm the initially calculated performance or could reveal unexpected distributions due to variables not considered. A recalibration could then be necessary to maintain the utility of the score. A larger sample could also be necessary to test the full efficacy of such a formula. CONCLUSIONS

Our study proposes a new predictive system for myocardial infarction that can become a useful tool in clinical practice. Although it still needs further analyses to determine whether adding new variables to the model can increase accuracy, the proposed model draws attention to potential of markers such as Lp(a) or CRP to become integral part of regression formulas and to increase accuracy of multivariate prediction solutions.


Teodora Mocan et al.


Lucrarea de faţă îşi propune generarea unui sistem simplu şi fiabil de predicţie non-invazivă a apariţiei infarctului miocardic precum şi de evaluare a performanţei noului sistem de predicţie generat. Material şi metodă. Au fost incluşi în studiu 208 pacienţi (bărbaţi şi femei) cu vârste între 37–75 ani, internaţi în Centre Hospitalier Coulommiers, France. Pacienţii au fost stratificaţi în două grupuri în funcţie de prezenţa (104 pacienţi, 63,7±9,2 ani) sau absenţa infarctului miocardic (104 pacienţi, 58,1±12,4 ani). Rezultate. În urma analizelor univariate şi multivariate, au fost selectaţi următorii parametri pentru a forma modelul de predicţie: vârsta, lipoproteina (a), proteina C reactivă, tensiunea arterială sistolică, non-HDL-Colesterolul. S-a obţinut un scor validat cu valoarea ariei de sub curbă ROC de 0.745 ±0.034 (95%CI=0.681–0.804), p–0.3), s-a obţinut o sensibilitate=80%, specificitate=62.5%,valoarea predictivă pozitivă=65%,valoarea predictivă negativă=78%. Valorile menţionate au fost superioare fiecărui component al scorului analizat individual. Concluzie. Noul sistem generat poate deveni o unealtă utilă în evaluarea riscului de noi evenimente coronariene, cu aplicare directă în practica clinică. Lucrarea de faţă îşi propune generarea unui sistem simplu şi fiabil de predicţie non-invazivă a apariţiei infarctului miocardic precum şi de evaluare a performanţei noului sistem de predicţie generat. Material şi metodă. Au fost incluşi în studiu 208 pacienţi (bărbaţi şi femei) cu vârste între 37–75 ani, internaţi în Centre Hospitalier Coulommiers, France. Pacienţii au fost stratificaţi în două grupuri în funcţie de prezenţa sau absenţa infarctului miocardic. Rezultate. În urma analizelor univariate şi multivariate, au fost selectaţi următorii parametri pentru a forma modelul de predicţie: vârsta, lipoproteina (a), proteina C reactivă, tensiunea arterială sistolică, non-HDL-Colesterolul. S-a obţinut un scor validat cu valoarea ariei de sub curbă ROC de 0.745 ±0.034 (95%CI=0.681–0.804), p–0.3), s-a obţinut o sensibilitate=80%, specificitate=62.5%,valoarea predictivă pozitivă=65%,valoarea predictivă negativă=78%. Valorile menţionate au fost superioare fiecărui component al scorului analizat individual. Concluzie. Noul sistem generat poate deveni o unealtă utilă în evaluarea riscului de noi evenimente coronariene, cu aplicare directă în practica clinică. Corresponding author: Teodora Mocan, MD, MA “Iuliu Haţieganu” University of Medicine and Pharmacy 1–3 Clinicilor, 400006, Cluj-Napoca, Romania Telephone: +0264/598575; Fax: 0264/599817; 0264/597257 E-mail: [email protected]


TUNSTALL-PEDOE H., Value of the Dundee coronary risk-disk: a defence. Br. Med. J., 1992, 305: 231–232. ANTMAN E.M., ANBE D.T., ARMSTRONG P.W. et al., ACC/AHA guidelines for the management of patients with STelevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 2004, 110: 82–292. GIBBONS R.J., BALADY G.J., BRICKER J.T. et al., ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J. Am. Coll. Cardiol., 2002, 40:1531–1540.

7 4.


6. 7.

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13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.


A new prediction system for MI


CHEITLIN M.D., ARMSTRONG W.F., AURIGEMMA G.P. et al., ACC/AHA/ASE guideline update for the clinical application of echocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J. Am. Soc. Echocardiogr., 2003, 16:1091–1110. SMITH S.C. JR, FELDMAN T.E., HIRSHFELD J.W. JR. et al., ACC/AHA/SCAI guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 2006, 113:156–175. SILBER S., ALBERTSSON P., AVILES F.F. et al., Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur. Heart J., 2005, 26:804–847. GRUNDY S.M., BECKER D., CLARK L.T. et al., Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Circulation, 2002, 106:3143–3421. GRUNDY S.M., CLEEMAN J.I., MERZ N.B. et al., Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation, 2004, 110:227–293. MARCOVINA S.M., ALBERS J.J., HENDERSON L.O. et al., International Federation of Clinical Chemistry standardization project for measurements of apolipoproteins A-I and B. III. Comparability of apolipoprotein A-I values by use of international reference material. Clin. Chem., 1993, 39:773–781. MARCOVINA S.M., ALBERS J.J., KENNEDY H. et al., International Federation of Clinical Chemistry standardization project for measurements of apolipoproteins A-I and B. IV. Comparability of apolipoprotein B values by use of International Reference Material. Clin. Chem., 1994, 40:586–592. MARCOVINA S.M., ALBERS J.J., SCANU A.M. et al., Use of a reference material proposed by the International Federation of Clinical Chemistry and Laboratory Medicine to evaluate analytical methods for the determination of plasma lipoprotein(a). Clin. Chem., 2000, 46:1956–1967. PEARSON T.A., MENSAH G.A., ALEXANDER R.W. et al., Centers for Disease Control and Prevention; American Heart Association. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation, 2003, 107:499–511. MANCIA G., ROSEI E.A., CIFKOVA R. et al., European Society of Hypertension-European Society of Cardiology. Guidelines for the management of arterial hypertension. J. Hypertens., 2003, 21:1011–1053. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care, 2003, 26: 3160–3167. FAWCETT T., An introduction to ROC analysis. Pattern Recognition Letters 2006, 27:861–874. BRINDLE P.M., MC CONNACHIE A., UPTON M.N. et al., The accuracy of the Framingham risk-score in different socioeconomic groups: a prospective study. Br. J. Gen. Pract., 2005, 55: 838–845. ASSMANN G., SCHULTE H., CULLEN P. et al., Assessing risk of myocardial infarction and stroke: new data from the Prospective Cardiovascular Münster (PROCAM) study. Eur. J. Clin. Invest., 2007, 37:925–932. TUNSTALL-PEDOE H., The Dundee coronary risk-disk for management of change in risk factors. Br. Med. J., 1991, 303: 744–747. SHAPER A.G., POCOCK S.J., PHILLIPS A.N. et al., Identifying men at high risk of heart attacks: strategy for use in general practice. Br. Med. J., 1986, 293:474–479. LUC G., BARD J.M., ARVEILER D. et al., Lipoprotein (a) as a predictor of coronary heart disease: the PRIME Study. Atherosclerosis, 2002, 163:377–384. WALLDIUS G., JUNGNER I., HOLME I. et al., High apolipoprotein B, low apolipoprotein A-I, and improvement in the prediction of fatal myocardial infarction (AMORIS study): a prospective study. Lancet, 2001, 358:2026–2033. WALLDIUS G., AASTVEIT A.H., JUNGNER I., Stroke mortality and the apoB/apoA-I ratio: results of the AMORIS prospective study. J. Intern. Med., 2006, 259:259–66. WALLDIUS G., JUNGNER I., The apoB/apoA-I ratio: a strong, new risk factor for cardiovascular disease and a target for lipid-lowering therapy-a review of the evidence. J. Intern. Med., 2006, 259:493–519. VON ECKARDSTEIN A., SCHULTE H., CULLEN P. et al., Lipoprotein (a) further increases the risk of coronary events in men with high global cardiovascular risk. J. Am. Coll. Cardiol., 2001, 37:434–439. BOEKHOLDT S.M., HACK C.E., SANDHU M.S. et al., C-reactive protein levels and coronary artery disease incidence and mortality in apparently healthy men and women: the EPIC-Norfolk prospective population study 1993–2003. Atherosclerosis, 2006, 187:415–422. VAN DER STEEG W.A., BOEKHOLDT S.M., STEIN E.A. et al., Role of the apolipoprotein B-apolipoprotein A-I ratio in cardiovascular risk assessment: a case control analysis in EPIC-Norfolk. Ann. Intern. Med., 2007, 146:677–679.

Received April 24, 2008


Teodora Mocan et al.


Hypertensive Acute Pulmonary Oedema as Expression of Diastolic Heart Failure I.ST. GYALAI-KORPOS, MIRELA TOMESCU, ANTOANELA POGOREVICI “V. Babeş” University of Medicine and Pharmacy, Cardiology Clinic, City Hospital, Timişoara, Romania

In part of hypertensive acute pulmonary oedema patients we can determine normal ejection fraction (EF) after remission of symptomatology and pulmonary congestion. In most cases echocardiography is performed after the disappearance of pulmonary oedema (APO). Methods. Echocardiography was performed in standard views. The EF was measured by arealength monoplane method in apical 4-chamber and 2-chamber view, the final figure being an arithmetical mean of the two values. Measurement of the EF was made during APO and immediately after disappearance of symptoms and pulmonary congestion. Color, pulsed and continued Doppler were used for quantification of mitral regurgitation in apical 4-chamber and 2-chamber view. Results. The study included 61 patients with hypertensive APO, with systolic blood pressure (BP) >160 mmHg. From the total, 37(60.65%) were men and 24 (39.34%) female and the mean age was 65.02±12.17 years. The systolic blood pressure (SBP) during APO was 196.97±18.89 mmHg and after treatment 132.38±11.78 with significant statistical power (p160 mmHg. From the total, 37(60.65%) were men and 24(39.34%) females and the mean age was 65.02±12.17 years. The systolic blood pressure (SBP) during EPO was 196.97± 18.89 mmHg and after treatment 132.38±11.78 with significant statistical power (p 160 mmHg. Din totalul pts, 37 au fost bărbaţi (60,65%) şi 24 femei (39,34%), vârsta medie fiind de 65,02±12,17. Tensiunea arterială sistolică (TAS) în timpul EPA, a fost de 196,97±18,89, iar după tratament (132,38±11,78), având putere statistică semnificativă (p < 0,0001, cu intervalul de confidenţă 95%, de la –71,083 la –57,553).


Hypertensive acute pulmonary edema


Fracţia de ejecţie determinată în timpul EPA (FE-EPA) a fost de 49,84±10,7 iar după remiterea simptomatologiei şi congestiei pulmonare (FE-NonEPA), de 48,9±8,47. Distribuţia valorilor de FE la numărul de pts este ilustrată în figură. Valoarea FE-EPA se corelează cu valorile FE-NonEPA (p< 0.0001, r2 = 0.9093), corelaţia fiind semnificativă (alpha = 0.05). Regresia liniară a valorilor FE în timpul şi după EPA este semnificativă (r2 = 0.91, panta fiind semnificativă statistic p de 50%. Din aceştia, cu FE normală după remiterea EPA, 31 de pts (91,17 %) au avut FE-EPA normală şi în timpul edemului pulmonar acut hipertensiv. Niciunul din pts studiaţi n-au prezentat insuficienţă mitrală acută semnificativă în timpul EPA. Concluzii. Studiul nostru a arătat că la pts cu edem pulmonar acut hipertensiv, fracţia de ejecţie măsurată în timpul EPA este similară cu cea determinată după normalizarea tensiunii arteriale şi remiterea congestiei pulmonare. O FE normală, înregistrată la un pacient după remiterea EPA hipertensiv, indică, cu o mare probabilitate, faptul că aceasta s-a datorat insuficienţei diastolice izolate tranzitorii întrucât insuficienţa sistolică tranzitorie sau/şi insuficienţa mitrală severă sunt rare la aceşti pts în criză. Corresponding author: Dr. I.St. Gyalai-Korpos City Hospital 12, Revoluţiei Blvd. Timişoara, Romania


GIELEN S., SANDRI M., SCHULER G.C., Acute heart failure: rational diagnostics in clinical practice and the emergency department. Herz, 2006, 31(8), 736–47. 2. MARTIN J.F., HIGASHIAMA E., GARCIA E., LUIZON M.R., CIPULLO J.P., Hypertensive crisis profile. Prevalence and clinical presentation. Arg. Bras Cardiol., 2004, 83(2), 131–6, 125–30. 3. D’ALOIA A., FIORINA C., VIZZARDI E., FAGGIANO P., DEI CAS L., Hypertensive crisis and acute, reversible, left ventricular systolic dysfunction: a case report. Eur. J. Heart Fail., 2002, 4(5), 655–60. 4. PHILLIPS R.A., DIAMOND J.A., Diastolic function in hypertension. Curr. Cardiol. Rep., 2001, 3(6), 485–97. 5. GOTTDIENER J.S., ARNOLD A.M., AURIGEMMA G.P. et al., Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study. J. Am. Coll. Cardiol., 2000, 35, 1628–37. 6. AUMONT M.C., MORISSON-CASTAGNET J.F., Diastolic heart failure and pulsed pressure. Arch. Mal. Coeur Vaiss, 2003, 96 (2), 125–30. 7. PHILLIPS R.A., GREENBLATT J., KRAKOFF L.R., Hypertensive emergencies: diagnosis and management. Prog. Cardiovasc. Dis., 2002, 45 (1), 33–48. 8. VASAN R.S., LEVY D., Defining diastolic heart failure: a call for standardized diagnostic criteria. Circulation, 2000, 101, 2118–21. 9. GANDHI S.K., POWERS J.C., NOMEIR A.M. et al., The pathogenesis of acute pulmonary edema associated with hypertension. N. Engl. J. Med., 2001, 344, 17–22. 10. LEEMAN M., Hypertensive crisis: when and how to treat? Rev. Med. Brux., 2004, 25 (2), 73–8. Received April 26, 2008


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Genetic Testing for Multiple Endocrine Neoplasia Type 2 DIANA LORETA PĂUN1, MARIA MOHORA2, CARMEN DUŢĂ2, C. DUMITRACHE1 1 “C.I. Parhon” National Institute of Endocrinology “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania


Multiple endocrine neoplasia type 2 (MEN 2) represents a complex autosomal dominant inherited syndrome characterized by occurrence of distinct proliferative disorders of endocrine tissues. The identification of RET proto-oncogene mutations in MEN 2 and FMCT has provided a precise method for identifying gene carriers. 30 subjects (9 males, 21 females, age range 11–63 years) with multiple endocrine neoplasia type 2 have been investigated from 1998 till 2006. 20 patients were considered as index cases and 10 patients were identified after a screening programme for MEN 2. Tumoral associations permitted the MEN 2A diagnosis in 21 cases, MEN 2A with cutaneous lichen amyloidosis in 6 cases and FMCT in 3 cases. We selected 22 patients from 14 families to investigate mutations in the RET proto-oncogene. In 7 subjects no mutations could be detected in the exons 10 and 11 of the RET proto-oncogene. Heterozygous missense mutations in exon 11 were found in 15 subjects consisting of three different mutations in codon 634 (TGC → TGG, TGC → GGC, TGC → CGC). We conclude that our 15 patients have the most frequent mutations described in MEN 2A families. Because the testing for exons 10 and 11 is negative for other 7 patients, the remaining 13, 14, 15 and 16 exons should be sequenced in these cases. Key words: multiple endocrine neoplasia, RET proto-oncogene, gene analysis.

Multiple endocrine neoplasia (MEN) is characterized by the occurrence of tumours involving two or more endocrine glands and two major forms referred as a MEN 1 and MEN 2 are recognized. MEN 1 is characterized by parathyroid, pancreatic islet and anterior pituitary tumours and MEN 2 is characterized by medullary thyroid carcinoma (MTC) in association with phaeochromocytoma. MEN 2 was first defined as a syndrome in 1961 [1] and in the subsequent decades, subvariants have been defined. MEN 2A or Sipple syndrome is the most common form of hereditary MTC accounting for approximately 80% of MEN2 [2]. Individuals with this variant develop MTC, unilateral or bilateral phaeochromocytomas and hyperparathyroidism. There are three variants of MEN 2A, two of which are distinctive. The first is MEN 2A with Hirschprung disease, a second variant, found in approximately 20–30 families is the association of MEN2A and cutaneous lichen amyloidosis [3] and familial MTC (FMTC) is the variant of MEN2A characterized by MTC, but no other manifestations of MEN 2 [4]. The boundaries between MEN 2A and FMCT can be difficult to define. In general, FMCT tends to be the least aggressive form of hereditary MTC. MEN 2B, less ROM. J. INTERN. MED., 2008, 46, 2, 159–163

common than MEN 2A, is characterized by the presence of distinctive mucosal neuromas located over the distal tongue, in the eyelids and throughout the gastrointestinal tract. Before the possibility of performing genetic tests, first degree relatives of affected members in MEN 2 kindreds were clinically screened every year for MTC, phaeochromocytoma and hyperparathyroidism by performing measurements of pentagastrin-stimulated levels of calcitonin, 24 h urinary catecholamines excretion and serum values of both calcium and parathyroid hormone. Actually, since identification of RET protooncogene as the susceptibily gene, clinical screening has to be limited only to mutant gene carriers. Identification of mutations of the RET proto-oncogene in MEN 2 has provided us with a unique opportunity to determine whether prophylactic thyroidectomy can prevent morbidity and death from hereditary MTC. The RET gene was identified as a protooncogene in 1985 [6] by finding it rearranged in a NIH3T3 transfection assay, hence its name: REarranged during Transfection. It has already been shown that RET gene played a role in papillary thyroid carcinoma [7]. RET proto-oncogene encodes


Diana Loreta Păun et al.

a tyrosine kinase receptor with cadherin-like and cystein-rich extracellular domains and a tyrosine kinase intracellular domain. The activating mutations that have been identified in this gene in MEN 2 and FMTC are of two types. In approximately 96% of MEN 2A and FMCT families any of five cystein residues (609, 611, 618, 620, 634) was found to be


mutated [8][9] (Table I). The abrogation of one of the extracellular cystein residues that occurs in MEN 2A and FMCT possibly results in ligandindependent auto-dimerization of the RET protein with constitutive activation as the oncogenic consequence. Genotype-phenotype relationships exist in MEN-2A, althought they are not absolute.

Table I Description of main RET proto-oncogene mutations described in patients affected by MEN 2A and FMCT syndromes Exons Exon 10 Codon 609

Codon 611 Codon 618

Codon 620 Exon 11 Codon 634


Amino acid mutation


Cys → Arg Cys → Gly Cys → Tyr Cys → Trp Cys → Arg Cys → Tyr Cys → Phe Cys → Ser Cys → Arg Cys → Phe


Cys → Arg Cys → Trp Cys → Ser Cys → Gly Cys → Tyr Cys → Phe

In a large study, comprising 477 MEN 2 and FMCT families [10], mutations in codon 634 were found strongly associated with the occurrence of medullary thyroid carcinoma in combination with phaeochromocytoma. In 95% of the MEN 2B families a methionine to threonine mutation was identified in the codon 918 [11] and this replacement has been shown to affect the substrate specificity of the kinase activity [12]. Mutational analysis of the RET gene has been used in the diagnosis and management of patients with MEN 2 variants. The mutational analysis of RET proto-oncogene can be easily performed by PCR techniques. Genetic tests are very accurate and easily reproductible and provide identification of asymptomatic affected members (Table I). MATERIAL AND METHOD

Since 1998 till 2006 we studied 30 patients with MEN 2 (Table II); there were 20 patients representing index-cases and 10 cases who belonged to MEN 2A families, all of them having

surgery for MTC and/or pheochromocytoma. Medullary thyroid carcinoma, pheochromocytoma and parathyroid tumors occurred in 90%, 73% and 17%, respectively. 21 patients had MEN 2A, 6 cases MEN2A and cutaneous lichen amyloidosis and 3 cases familial MTC (FMTC). There were no patients with MEN 2A and Hirschprung disease or with MEN 2B syndrome. Medullary thyroid carcinoma were the first manifestation of MEN 2 in 57% of patients, pheochromocytoma in 40% of cases and hyperpathyroidism in 3% of cases only. Table II Patient characteristics Patient characteristics MEN 2 patients Male/female Age at diagnosis First tumor detected: MCT Pheo Parathyroid adenoma Diagnosis by symptoms Diagnosis by screening

MEN 2A 30 9/21 33.63±2.5 (11–63) 17 12 1 20 10


Multiple endocrine neoplasia type 2 MUTATION ANALYSIS OF THE RET PROTOONCOGENE

Genomic DNA was obtained by extraction from the 20 patients peripheral blood leukocytes using a Promega minikit and standard procedures. Two fragments covering exons 10 and 11 (a 300-nucleotide PCR product corresponding to exon


10 and a 161-nucleotide PCR product corresponding to exon 11) of the RET proto-oncogene were amplified by polymerase chain reaction using specific oligonucleotide primers (Table III), according to the following protocol: 95 CX10 min followed by 30 cycles of 95 CX1 min, 64 CX1 min, 72 CX1 min and the final extension at 72 C for 7 min.

Table III Oligonucleotide primers Exon Exon 10 Exon 11


The resulting fragments were sequenced directly with the Big Dye R Terminator v 3.1 cycle sequencing kit using a ABI Prism 310 Genetic Analyser (BCMU – Bucharest University). RESULTS

In 15 of 22 examined MEN 2A patients missense mutations in the RET proto-oncogene were detected. All of them were represented by mutation of codon 634 from exon 11 (Table IV). We cannot find mutations occurring in exon 10. Table IV Mutations of the RET proto-oncogene in patients with MEN 2A Exon Codon Amino acid sequence changes: Cys →

11 (N=16) 634 Trp (nine patients) Gly (four patients) Arg (two patients)

Nine of MEN 2 samples proved to have an identical base sequence change TGC-TGG, resulting in the substitution of Cys with Trp, four of the samples have the change TGC-GGC resulting in the substitution of Cys with Gly and two samples have the change TGC-CGC resulting in the substitution of Cys with Arg (Table IV). DISCUSSION

MEN 2 is an autosomal dominant syndrome identified to date in 1000 kindreds [13][14]. All variants of MEN 2 show a high penetrance for medullary thyroid carcinoma, in fact, 90% of MEN


2 carriers show evidence for MTC [15]. MEN 2A is a syndrome of MTC in 90% of adults gene carriers, unilateral or bilateral pheochromocytoma in 50% and multigland parathyroid tumors in 20–30% [16]. In our patients medullary thyroid carcinoma, pheochromocytoma and parathyroid tumors occurred in 90%, 73% and 17%, respectively. MEN 2A accounts for over 75% of MEN 2 [13][14]. Several rare variants of MEN 2 include familial MTC [4], MEN 2 with cutaneous lichen amyloidosis [3] and MEN 2A with Hirschsprung’s disease [17]. MEN 2B is the most distinctive and aggressive of the MEN 2 variants [18]. In our series 21 patients had MEN 2A, 6 cases MEN2A and cutaneous lichen amyloidosis and 3 cases familial MTC (FMTC). There were no patients with MEN 2A and Hirschprung disease or with MEN 2B syndrome. All MEN 2 variants are caused by germline mutation in the RET proto-oncogene [9][13]. MEN 2 carrier determination is one of the few examples of a genetic test that mandates a highly effective clinical intervention [20–22]. DNA testing for presymptomatic identification of gene carriers of affected families provides the most reliable indication for prophylactic thyroidectomy if the mutation in the family can be identified [23]. We can say that the discovery of RET protooncogene mutations in 1993 ushered in the next stage in management of the hereditary MTC or MEN2 [8][9]. Mutation of codon 634 accounts for 90% of all mutations identified in MEN 2A [10]. Between 10% and 15% of kindreds with MEN 2A have mutations of codons 609, 611, 618 or 620; kindred of these mutations may have either MEN 2A or one of its variants [24]. The most common mutations associated with MEN 2B affect codons


Diana Loreta Păun et al.

883, 918 and 922 and account 3–5% of all RET mutations [11]. The remainder of the mutations are uncommon. Codon 768 and 804 mutations have been associated with FMCT [25]. In our 15 examined MEN 2A patients missense mutations in the RET proto-oncogene were detected in codon 634 from exon 11. We cannot find mutations occurring in exon 10. Nine of MEN 2 patients proved to have an identical base sequence change TGC-TGG, resulting in the substitution of Cys with Trp, four of the samples have the change TGC-GGC resulting in the substitution of Cys with Gly and two samples have the change TGC-CGC resulting in the substitution of Cys with Arg. In addition to the 30 years of study experience, coalescence of mutational information between 1993 and 2000 has allowed practitioners and researchers within the field to achieve a consensus on use of this information as the basis for determining gene carrier status [26][27].


We conclude that in all families with MEN 2, mutational analysis of RET proto-oncogene should be performed both to identify specific mutations and to prove gene carrier status for MEN 2. Our 15 patients have the most frequent mutations described in MEN 2A families (in codon 634 exon 11). Because the testing for exons 10 and 11 is negative for other 7 patients, the remaining 13, 14, 15 and 16 exons should be sequenced in these cases. The introductions of genetic testing into the clinical management of MEN 2 and other endocrine tumor syndromes has provided greater precision regarding diagnosis of the syndrome and has greatly increased the likelihood that individuals with this syndrome will live full and normal lives. Acknowledgement. The authors are grateful for technical support of Prof. Marieta Costache and Catalina Luca from the Faculty of Biology, Bucharest University.

Neoplazia endocrină multiplă reprezintă o entitate caracterizată prin neoplazia a mai mult de un organ endocrin şi se transmite genetic după un model autozomal dominant. Identificarea mutaţiilor proto-oncogenei RET în sindromul MEN 2 şi carcinomul medular tiroidian familial a reprezentat baza depistării purtătorilor de genă mutantă în aceste sindroame. În perioada 1998–2006 au fost investigaţi în Institutul Naţional de Endocrinologie 30 de pacienţi cu sindrom MEN 2 (9 bărbaţi şi 21 de femei cu vârste cuprinse între 11 şi 63 de ani) dintre care 20 au fost cazuri index iar 10 au fost depistaţi în urma unui program de screening familial prospectiv. Asocierile tumorale au permis încadrarea în sindrom MEN 2A în 21 de cazuri, MEN 2A cu amiloidoză lichen cutanată în 6 cazuri şi carcinom medular tiroidian familial în 3 cazuri. Analiza genetică a protooncogenei RET a fost realizată la 22 de pacienţi din 14 familii. În 7 cazuri nu s-au putut detecta mutaţii în exonii 10 şi 11 ai protooncogenei RET. 15 pacienţi au prezentat trei tipuri de mutaţii la nivelul codonului 634 din exonul 11(TGC → TGG, TGC → GGC, TGC → CGC), de altfel cel mai frecvent afectat în sindromul MEN 2A. Pentru detectarea mutaţiilor protooncogenei RET în celelalte 7 cazuri este utilă scanarea exonilor 13, 14, 15 şi 16. Corresponding author: Diana Loreta Păun, MD “C.I. Parhon” National Institute of Endocrinology Bucharest, Romania E mail: [email protected]


SIPPLE J.H., The association of pheochromocytoma with carcinoma of the thyroid gland. American Journal of Medicine. 1961, 31:163–6. GAGEL R.F., MARX S., Multiple endocrine neoplasia, In: Book Multiple Endocrine Neoplasia, Tenth Ed., PR. Larsen, H. Kronenberg, S. Melmed, K.S. Polonsky (Eds.), W.B. Saunders, Philadelphia, 2003, pp.1762–1771.

5 3. 4. 5. 6. 7. 8. 9. 10.

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

23. 24. 25. 26. 27.

Multiple endocrine neoplasia type 2


GAGEL R.F., MARX S., LEVY D.T., DONOVAN D.T., ALFORD B.R. et al., Multiple endocrine neoplasia type 2A associated with cutaneous lichen amyloidosis. Ann. Int. Med., 111, 1989, 802–806. FARNDORN J.R., LEIGHT G.S., DILLEY W.G. et al., Familial medullary thyroid carcinoma without associated endocrinopathies: a distinct clinical entity. Br. J. Surg., 1986; 73:278. WILLIAMS E.D., POLLOCK D.J., Multiple mucosal neuromata with endocrine tumours: a syndrome allied to Von Recklinghausen’s disease. J. Pathol. Bacteriol., 1966, 91, 71–80. TAKAHASHI M., RITZ J., COOPER G.M., Activation of a novel human transforming gene, RET, by DNA rearrangement. Cell., 1985, 42: 581. SANTORO M., CARLOMAGNO F., HAY I.D. et al., RET oncogene activation in human thyroid neoplasms to the papillary cancer subtype. J. Clin. Invest., 1992, 89: 1517. DONIS-KELLER H., DOU S., CHI D. et al., Mutations in the RET proto-oncogene are associated with MEN 2A and FMCT. Hum. Mol. Genet., 1993, 2: 851. MULLIGAN L.M., KWOK J.B.J., HEALEY C.S. et al., Germline mutation of RET proto-oncogene in multiple endocrine neoplasia type 2A. Nature, 1993, 363: 458. ENG C., CLAYTON D., SCHUFFENECKER I. et al., The relationship between specific RET proto-oncogene mutation and disease phenotype in multiple endocrine neoplasia type 2. International RET mutation consortium analysis. JAMA, 1996, 276:1575–9. HOFSTRA R.M., LANDSVATER R.M., CECCHERINI I. et al., A mutation in the RET proto-oncogene associated with multiple endocrine neoplasia type 2B and sporadic thyroid carcinoma. Nature, 1994, 3: 367–75. SANTORO M., CARLOMAGNO F., ROMANO A. et al., Activation of RET as a dominant transforming gene by germline mutations of MEN 2A and MEN 2B. Science, 1995, 267: 381. ENG C., SMITH D.P., MULLIGAN L.M. et al., Point mutation within the tyrosine kinase domain of the RET proto-oncogene in multiple endocrine neoplasia type 2B and related sporadic tumors. Hum. Mol. Genet., 1994, 3: 237. PONDER B.A.J., Multiple endocrine neoplasia type 2. In: The metabolic and molecular bases of inherited disease, 8th edit. Scriver CR Beaudet A., Sly W.S., Valle D., eds. McGraw-Hill, New York, 2001, 931–42. PONDER B.A.J., PONDER M.A., COFFEY R. et al., Risk estimation and screening in families of patients with medullary thyroid carcinoma. Lancet, 1988, 1, 397–401. GAGEL R.F., TASHJIAN A.H., CUMMINGS T. et al., The clinical outcome of prospective screening for multiple endocrine neoplasia type 2A: a 18-year experience. N. Engl. J. Med., 1988, 318: 478–84. RAKOVER Y., DHARAN M., LUBOSHITSKY R., Hirschsprung’s disease associated with isolated familial medullary carcinoma of the thyroid. Journal of Pediatric Endocrinology, 1994, 7(4): 373–77. DAHIA P.L.M., ENG C., Genetic disorders of endocrine neoplasia. In Frontiers of hormone research, ed. Grossman A., vol. 28, Karger, 2001. ENG C., SMITH D.P., MULLIGAN L.M. et al., Point mutation within the tyrosine kinase domain of the RET proto-oncogene in multiple endocrine neoplasia type 2B and related sporadic tumors. Hum. Mol. Genet., 1994, 3: 237. NICCOLI-SIRE P., CONTE-DEVOLX B., Groupe d’etude des Tumeurs Endocrines – RET mutations and preventive treatment of medullary thyroid cancer. Ann. Endocrinol., 2005, 66 (3): 168–175. WELLS S.A., CHI D., TOSHIMA K. et al., Predictive DNA testing and prophylactic thyroidectomy in patients at risk for multiple endocrine neoplasia type 2A. Ann. Surg., 1994, 220: 237. LIPS C.J.M., Clinical management of the multiple endocrine neoplasia syndromes: results of a computerized opinion poll at the Sixth International Workshop on Multiple Endocrine Neoplasia and von-Hippel-Lindau disease. J. Intern. Med., 1998, 243: 589–594. LIPS C.J.M., LANDSVATER R.M., HOPPENER J.W.M. et al., Clinical screening as compared with DNA analysis in families with multiple endocrine neoplasia type2A. N. Engl. J. Med., 1994, 331: 828. SANTORO M., MELILO R.M., CARLOMANGO F., VECCHIO G., FUSCO A., Minireview: RET: normal and abnormal functions. Endocrinology, 2004, 145(12): 5448–51. BLAUGRUND J.E., JOHNS M.M., EBYL Y.J. et al., RET proto-oncogene mutations in inherited and sporadic medullary thyroid cancer. Hum. Mol. Genet., 1994, 3:1895. BRANDI M.L., GAGEL R., ANGELI A., BILEZIKIAN J.P., BECK-PECCOZ P. et al., Guidelines for Diagnosis and Therapy of MEN Type 1 and Type 2 (Consensus). J. Clin. Endocrinol. Metab., 2001, 86(12): 5658–71. SKINNER M.A., MOLEY J.A., DILLEY W.G., OWZAR K., DEBENEDETTI M.K. and WELLS S.A. Jr., Prophylactic thyroidectomy in multiple endocrine neoplasia Type 2A. N. Engl. J. Med., 2005, 353: 1105–1113.

Received May 11, 2008


Diana Loreta Păun et al.


Some Clinico-Immunological Aspects in Patients with Ocular Myasthenia Gravis Associated with Inflammatory Bowel Disease INIMIOARA MIHAELA COJOCARU1, M. COJOCARU2, R. TĂNĂSESCU1, CECILIA BURCIN3, ADINA NICOLETA ATANASIU3, ANDREEA CRISTINA MITU3, IULIANA ILIESCU3, LAURA DUMITRESCU3 1

“C. Davila” University of Medicine and Pharmacy, Clinic of Neurology, “Colentina” Clinical Hospital 2 Department of Clinical Immunology, 3Clinic of Neurology, “Colentina” Clinical Hospital, Bucharest, Romania

The link between inflammatory bowel disease (IBD) and ocular myasthenia gravis (OMG) is thought to be related to the production of autoantibodies. The aim of this study was to determine the incidence of some antibodies in OMG patients with IBD. Sixty-four patients with IBD and neurological symptoms were examined neurologically and immunologically (41 men and 23 women, mean age 43±5.4 years); mean duration of IBD before the diagnosis of OMG was 7.5 years. The following immunological investigations were performed: anti-acetylcholine receptor antibodies (AChR Abs) (ELISA), anti-smooth muscle antibodies (ASMA) (indirect immunofluorescence), perinuclear anti-neutrophilic cytoplasmic antibodies (p-ANCA) (indirect immunofluorescence), carcinoembryonic antigen (CEA) (ELISA), Saccharomyces cerevisiae antibodies IgA and IgG (ASCA) (ELISA), peripheral lymphocyte counts, immature CD4, CD4/CD8 ratio. Five patients out of 64 with IBD presented OMG. The following antibodies were observed: anti-AChR in 4 OMG patients, ASMA in 4 OMG patients, p-ANCA in 4 OMG patients, CEA in 5 OMG patients, ASCA IgA and IgG in 3 OMG patients. Of 5 OMG patients 4 were positive for >3 antibodies. The peripheral lymphocytic counts were reduced in 5 OMG patients, a decline in CD8 cells and an increase in immature CD4 cells in 5 OMG patients, an increased CD4/CD8 ratio in 5 OMG patients were observed. The association of IBD with OMG was rare. Autoimmune dysregulation is the central defect in both MG and IBD. Further studies are required to define the nature of this association.

Inflammatory bowel disease (IBD) frequently presents with other autoimmune diseases. Myasthenia gravis is also associated with other autoimmune diseases. The link between IBD and ocular myasthenia gravis (OMG) is thought to be related to the production of autoantibodies. The aim of this study was to determine the OMG in patients with IBD and neurologic complications. MATERIAL AND METHODS

Sixty-four patients with IBD and neurologic complications were neurologically examined and immunologically investigated (39 with ulcerative colitis (UC) and 25 with Crohn’s disease (CD), 41 men and 23 women, mean age 43±5.4 years, duration of IBD before the diagnosis of OMG was 7.5 years. The following immunological investigations were performed: anti-acetylcholine receptor antibodies (AChR Abs) (enzyme immunosorbent assay, ELISA), anti-smooth muscle antibodies (ASMA) ROM. J. INTERN. MED., 2008, 46, 2, 165–168

(indirect immunofluorescence, IIF), perinuclear anti-neutrophilic cytoplasmic antibodies (p-ANCA) (IIF), carcinoembryonic antigen (CEA) (ELISA), Saccharomyces cerevisiae antibodies IgA and IgG (ASCA) (ELISA), peripheral lymphocyte counts, immature CD4, CD4/CD8 ratio (flow cytometry) [1–6]. RESULTS

Five patients out of 64 patients with IBD presented OMG (3 with UC and 2 with CD). The following antibodies were observed: AChR Abs in 4 OMG patients (2 with UC and 2 with CD), ASMA in 4 OMG patients (3 with UC and 1 with CD), p-ANCA in 4 OMG patients (3 with UC and 1 with CD), CEA in 5 OMG patients (3 with UC and 2 with CD), ASCA (IgA and IgG) in 3 OMG patients (1 with UC and 2 with CD). Of 5 OMG patients 4 were positive for more than 3 antibodies.


Inimioara Mihaela Cojocaru et al.

The peripheral lymphocytic counts were reduced in 5 OMG patients (3 with UC and 2 with CD), a decline in CD8 cells and an increase CD4 cells in 5 OMG patients (3 with UC and 2 with CD), an increase in immature CD4 cells in 5 OMG patients, and an increased ratio of CD4/CD8 in 5 OMG patients (3 with UC and 2 with CD) were observed (Table I). Table I Some immunological investigations in patients with OMG and IBD Total cases AChR Abs ASMA p-ANCA CEA ASCA IgA and IgG Reduced peripheral lymphocytic counts Decline in CD8 cells Increased CD4/Cd8 ratio

OMG 5 4 4 4 5 3 5

UC 3 2 3 3 3 1 3

CD 2 2 1 1 2 2 2

5 5

3 3

2 2

It was no evidence of thymic mass on CT of the chest. The thyroid function studies were normal. DISCUSSION

MG and IBD are autoimmune disorders. It is known that MG may be associated with other autoimmune disorders: systemic lupus erythematosus, vitiligo, alopecia, lichen planus [7]. IBD may be also associated with autoimmune disorders; it was observed a 9.4% prevalence of these disorders in UC including thyroid disorders, type 1 diabetes mellitus, pernicious anemia, sclerosing cholangitis, vitiligo [7][8]. There are some reports regarding the association of OMG and IBD [8–12].


The various neurological manifestations of UC reported in literature are myelopathy, peripheral neuropathy, myopathy, cerebral venous thrombosis, cerebrovascular disease, myasthenia gravis and multiple sclerosis [13–23]. There are some data concerning a patient with both MG and CD who improved in perineal and perianal disease following thymectomy for severe incontrolled MG [8]. Another case with both MG and UC demonstrated regression of MG following proctolectomy [24]. Both IBD and MG may be associated with an elevated CEA and decreased peripheral lymphocyte counts that subsequently normalize following thymectomy [25]. It was shown abnormal thymic involution and the presence of increased ratio of T helper to T suppressor cells in both MG and UC; other authors have observed a decline in suppressor T cells and an increase in immature helper T cells suggesting migration without normal maturation [26][27]. Autoimmune disregulation is a central defect in both MG and IBD. The link between IBD and MG is thought to be related to the production of autoantibodies [28][29]. We have not observed differences regarding the type of autoantibodies and the type of IBD in patients with OMG. CONCLUSION

The association of IBD with OMG was rare. Autoimmune disregulation is a central defect in both MG and IBD. The link between IBD and MG is thought to be related to the production of autoantibodies. Further studies are required to define the nature of this association.

Se consideră că asocierea dintre bolile inflamatorii intestinale şi miastenia gravis oculară este în legătură cu producerea de autoanticorpi. Scopul acestui studiu a fost determinarea incidenţei unor autoanticorpi la pacienţii cu miastenie gravis oculară şi boli inflamatorii intestinale. Şasezeci şi patru pacienţi cu boli inflamatorii intestinale şi complicaţii neurologice au fost examinaţi neurologic şi investigaţi imunologic (41 bărbaţi şi 23 femei cu vârsta medie 43±5,4 ani); durata medie a bolii inflamatorii intestinale înaintea diagnosticului de miastenie gravis oculară a fost 7,5 ani. S-au efectuat următoarele investigaţii imunologice: anticorpi anti-receptor acetilcolină (AChR) (ELISA), anticorpi anti-muşchi neted (ASMA) (imunofluorescenţă indirectă), anticorpi anti-citoplasmă polimorfonuclear


Some clinico-immunological aspects in ocular myasthenia gravis


neurofil tipul perinuclear (p-ANCA) (imunofluorescenţă indirectă), antigenul carcinoembrionar (CEA) (ELISA), anticorpi anti-Saccharomyces cerevisiae IgA şi IgG (ASCA) (ELISA), numărul limfocitelor circulante, numărul CD4 şi CD8, raportul CD4/CD8. Cinci pacienţi din 64 cu boli inflamatorii intestinale au prezentat miastenie gravis oculară. Au fost observaţi următorii anticorpi: AChR la 4 pacienţi cu miastenia gravis oculară, ASMA la 4 pacienţi cu miastenia gravis oculară, p-ANCA la 4 pacienţi cu miastenie gravis oculară, CEA la 5 pacienţi cu miastenie gravis oculară, ASCA IgA and IgG la 3 miastenie gravis oculară. Din 5 pacienţi cu miastenie gravis oculară, 4 au prezentat mai mult decât 3 pacienţi cu tipuri de anticorpi. Numărul limfocitelor circulante a fost scăzut la 5 pacienţi cu miastenie gravis oculară, numărul celulelor CD8 a fost scăzut, iar numărul celulelor CD4 imature a fost crescut la 5 pacienţi cu miastenia gravis oculară, raportul CD4/CD8 a fost anormal la 5 pacienţi cu miastenia gravis oculară. Asocierea bolilor inflamatorii intestinale cu miastenia gravis, oculară este rară. Dereglarea autoimună este perturbarea centrală, atât în miastenia gravis cât şi în bolile inflamatorii intestinale. Se consideră că legătura dintre bolile inflamatorii intestinale şi miastenia gravis este determinată de producerea autoanticorpilor. Se impun studii suplimentare pentru a defini această asociere. Corresponding author: Inimioara Mihaela Cojocaru, MD, PhD, Senior lecturer Colentina Clinical Hospital, Clinic of Neurology 19–21, Şos. Ştefan cel Mare 020125, Bucharest, Romania e-mail: [email protected]

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SANDBORN W.J., Serologic markers in inflammatory bowel disease: state of the art. Rev. Gastroenterol. Disord., 2004, 4(4): 167–74. BARTA Z., CSIPO J., SABO G.G. et al., Seroreactivity against Saccharomyces cerevisiae in patients with Crohn’s disease and celiac disease. World J. Gastroenterol., 2003, 9(10): 2308–12. ANDREANI M.I., FRASCA G., BRUSCO G. et al., Antineutrophil cytoplasmic antibodies in inflammatory bowel disease: diagnostic tool or research procedure? Ann. Ital. Med. Int., 1996, 11(4): 2547. JASKOWSKI T.D., LITWIN C.M., Analysis of serum antibodies in patients suspected of having inflammatory bowel disease. Clin. Vaccine Immunol., 2006, 16(6): 655–60. ALLENSPACH K., LUCKSCHANDER N., STYNER M. et al., Evaluation of assays for perinuclear antineutrophilic cytoplasmic antibodies and antibodies to Saccharomyces cerevisiae in dogs with inflammatory bowel disease. Am. J. Vet. Res., 2004, 65(9): 1279–83. BEAWEN S.W., ABREN M.T., Biomarkers in inflammatory bowel disease. Curr. Opin. Gastroenterol., 2004, 20(4): 318–27. MILLER T.N., Myasthenia gravis, ulcerative colitis and lichen planus. Proc. R. Soc. Med., 1971, 64: 806. TAN R.S., Ulcerative colitis, myasthenia gravis, lichen planus, alopecia areata, vitiligo. Proc. R. Soc. Med., 1974, 67: 195–6. LOSSOS A., RIVER Y., ELIAKIM A. et al., Neurologic aspects of inflammatory bowel disease. Neurology, 1995, 45: 416–21. FINNIC I.A., SCHIELDS R., SUTTON R. et al., Crohn’s disease and myasthenia gravis: a possible role for thymectomy. Gut., 1994, 35: 278–9. MARTIN R.W., SHAH A., Myasthenia gravis coexistent with Crohn’s disease. J. Clin. Gastroenterol., 1991, 13: 112–13. FOROOZAN R., SAMBURSKY R., Ocular myasthenia gravis and inflammatory bowel disease: a case report and literature review. Br. J. Ophthalmol., 2003, 87(9): 1186–87. PERKIN G.D., MURRAY-LYON I., Neurology and the gastrointestinal system. J. Neurol. Neurosurg. Psychiatry, 1998, 65(3): 291–300. OKIYAMA R., YAMADA M., TAMAKI M., Mononeuropathy multiplex with ulcerative colitis. Internal Medicine, 1993, 32: 651–54. OYANAGI H., ISHIHATA R., ISHIKAWA H. et al., Ulcerative colitis associated with Takayasus disease. Internal Medicine, 1994, 33: 127–29. MILANDRE L., MONGES D., DOR V. et al., Phlebite cerebrale et maladie de Crohn. Rev. Neurol. (Paris), 1992, 148(2): 139–44.


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17. AL-MALIK H., GREEN M.R., Cerebral venous thrombosis as a complication of Crohn disease: a case report. J. Pediatr. Gastroenterol. Nutr., 2001, 32(2): 209–11. 18. SAMAL S.C., PATRA S., REDDY D. C. et al., Cerebral venous thrombosis as presenting feature of Crohn’s disease. Indian J. Gastroenterol., 2004, 23(4): 148–9. 19. RANG E.H., BROOKE B.N., TAYLOR J.H., Association of ulcerative colitis with multiple sclerosis. Lancet, 1982, 2: 55. 20. MINUK G.Y., LEWKONIA R.M., Possible familial association of multiple sclerosis and inflammatory bowel disease. N. Engl. J. Med., 1986, 314: 586. 21. SADOVNICEK A.D., PATY D.W., YANNAKOULIAS G., Concurrence of multiple sclerosis and inflammatory bowel disease. N. Engl. J. Med., 1989, 321: 762–3. 22. KIMURA K., HUNTER S. F., THOLLANDER M.S. et al., Concurrence of inflammatory bowel disease and multiple sclerosis. Mayo Clin. Proc., 2000, 75: 802–6. 23. PANDIAN J.D., PAWAR G., SINGH G.S. et al., Multiple sclerosis in a patient with chronic ulcerative colitis. Neurol. India, 2004, 52: 282–3. 24. GOWER-ROUSSEAU C., REUMAUX D., BELLARD M. et al., Remission of myasthenia gravis after proctolectomy in a patient with ulcerative colitis. Am. J. Gastroenterol., 1993, 88: 1136–8. 25. PAPATESTAS A.E., KIM U., GENKINS G. et al., The association of carcinoembryonic antigen and peripheral lymphocytes. Surgery., 1974, 78: 343–8. 26. SOUADIJIAN J.V., ENRIQUEZ P., SILVERSTEIN M. et al., The spectrum of disease associated with thymoma. Coincidence or syndrome? Arch. Intern. Med., 1974, 134: 374–9. 27. AISO S., YOSHIDA T., WATANABE M. et al., Characterization of thymus cells in hyperplastic thymus cells in patients with myasthenia gravis and ulcerative colitis with monoclonal antibodies. J. Clin. Lab. Immunol., 1984, 13: 137–9. 28. ROXANIS I., MICKLEM K. et al., Thymic myoid cells and germinal center formation in myasthenia gravis. Possible roles in pathogenesis. J. Neuroimmunol., 2002, 125(1–2): 185–97. 29. SHIONO H., ROXANIS I. et al., Scenarios for autoimmunization of T and B cells in myasthenia gravis. Ann. N.Y. Acad. Sci., 2003, 998: 237–56. Received March 20, 2008



Department of Rheumatology, Department of Dermatology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania


“And Satan caused Job to have spots on his body. The spots were sore. And the spots were on every part of Job’s body.” Book of Job, Old Testament

Hyperimmunoglobulin E (Hyper IgE) syndrome, also described as Job’s syndrome, is a rare primary immunodeficiency disease characterized by recurrent skin and respiratory tract infections, chronic eczematous dermatitis, skeletal abnormalities associated with markedly elevated serum IgE levels. Variable impaired T cell function is described in this disease, but no direct association between IgE levels or clinical manifestations with these abnormalities does exist. We report a case of a patient with recurrent staphylococcal cold abscesses, eczematous dermatitis and high serum IgE levels in which the treatment with Cyclosporine A seems to have a favorable effect. Key words: hyperimmunoglobulin E, Staphylococcus aureus, Cyclosporine A.


A 28-year old patient presents painful lesions of both legs with fluctuant evolution which first appeared during childhood. Over time, the patient has had repeated episodes of skin infections with Staphylococcus aureus, as well as eczematous dermatitis. He did not have any other signs of infection or fever and he had a forearm fracture during adolescence. The results of cutaneous biopsies in previous hospitalizations showed nontypical aspects. The Doppler ultrasound did not show any abnormality of the venous or arterial system. One year before admission to our department, the serological determination of immunoglobulins was performed and high levels of IgE were found at 2800 UI/ml, 20 times greater than normal. The diagnosis of Job’s syndrome was considered. Steroids, antibiotics and the plastic surgery he was subjected to only had temporary and mild positive effects as the dermatological manifestations reappeared. At the time of admission, the clinical examination revealed erithema of both legs, cold abscesses, ulcers of different sizes and necrotic lesions, eczematous lesions of the right foot and left leg (Fig. 1), mild prognatism, small inferior ROM. J. INTERN. MED., 2008, 46, 2, 169–171

incisors, broad nasal bridge. The patient had no fever or any signs of systemic infection, and no signs of arthritis, bleeding or other atopic symptoms. Laboratory data collected included a moderate inflammatory syndrome, mild eosinophilia, hyper IgE (1340 UI/mL), without any other abnormalities. Immunological investigations were performed in order to exclude the possibility of a systemic vasculitis, but the only positive result was a low titer of antinuclear antibodies (ANA 1/80). Bacterial cultures from the plagues were positive for Staphylococcus aureus. X-rays were performed to rule out osteomyelitis, but the results were negative. The mineral bone density was investigated by Dual Energy X-ray absorptiometry (DXA) and the results were between the normal limits. Diagnosis of Hyperimmunoglobulin E syndrome or Job’s syndrome is made on the basis of clinical manifestations (recurrent skin infections with Staphylococcus aureus, cold abscesses, eczematous dermatitis) and biological findings (persistent high levels of IgE, together with the slight facial and dental abnormalities). The treatment consisted in local care of the skin, steroid administration (topical steroids together with oral Prednisone 0.5 mg/kg/24h, with slight decrease of the dose over 3 weeks), antibiotic therapy


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based on the results of bacterial cultures. Anti-H1 medication (Claritine) and C vitamin were added. The immunomodulatory therapy with Cyclosporine A 0.3 mg/kg/day was started with a favorable outcome, regarding as well the clinical and the biological aspects (Fig. 2). No adverse reactions were found and he did not have any relapse of the disease over one year and a half of treatment. DISCUSSION

Hyper IgE syndrome is a multisystemic disease of unknown etiology that affects the connective tissue, the skeleton and the immune system. T-cell abnormalities have been described, with a decrease in production of Th1, interferon γ (IFN γ) and an increased production of Th2. Decreased neutrophilic chemotaxis may be another immunological feature responsible for the inadequate inflammatory response and consequently for the delay in the recognition of infections [1]. Most cases are sporadic, but autosomal dominant (AD) or autosomal recessive (AR) inheritance have been described. The skeletal, dental and soft tissue abnormalities are seen in AD cases, while severe viral infections as well as neurological complications are frequent in AR Hyper IgE syndrome [2][3]. There are no diagnostic criteria for hyper IgE syndrome, but recurrent skin and infections, the eczematoid rashes in the presence of high levels serum IgE, without any other defect in the immune system, are commonly found in Job’s syndrome. The rash in hyper IgE syndrome is that of atopic dermatitis, but with an atypical distribution and no other atopic symptoms are present [4]. Nonimmunologic features include multiple bone fractures, coarse facies, retained primary dentition and joint hyper extensibility, and they can be as frequent as the immunologic manifestations [2]. Unexpectedly, frequent fractures are due to osteoporosis which is induced by a cytokinemediated bone resorption by overexpression of


prostaglandin E2 (PGE2) [5]. But fractures were also documented in subjects with normal bone density [4]. At the time of presentation, the aspect of our patient’s skin raised the possibility of a cutaneous vasculitis. Systemic lupus erythematosus [6], systemic vasculitis [7], dermatomyositis [8] have been reported in Hyper IgE syndrome, but the absence of suggestive clinical or biological features ruled out these conditions. The absence of other atopic symptoms excludes an atopic dermatitis. High levels of IgE may also be present in Wiscott-Aldrich syndrome, together with an atopic-like dermatitis and recurrent pyogenic infections, but the absence of the characteristic thrombocytopenia and bleeding excluded the possibility of this disease. Treatment consists of intensive skin care and use of topical agents: moisturizing creams, antibacterials, topical steroids. Prophylactic antibiotics are given in order to reduce severe infections. Ascorbic acid and anti-H1 are prescribed in order to improve the chemotactic responsiveness of neutrophils. Other therapeutic options have been tried in several studies, with different results: Methotrexate [9], Interferon γ [10], intravenous gamma-globulin [7], plasmapheresis [11] and bone marrow transplant [12]. In two studies, Cyclosporine A was followed by a dramatic improvement of clinical manifestations and IgE serum levels, without side effects, but with a relapse at the time of discontinuation and with clinical and laboratory improvement after reintroducing this therapy [13][14]. Exacerbations and remissions are known in Hyper IgE syndrome. The prognosis depends upon the efficacy of anti-infectious measures and the careful management of the chronic dermatosis. The duration of treatment with Cyclosporine A still remains a problem due to the possible recrudescence of the disease at the end of the period considered appropriate for treatment. A close follow-up is needed also because the imbalance between Th1 and Th2 lymphocytes could lead to malignant transformation.

Sindromul hiperimunoglobulinelor E, descris sub numele de sindromul Job, este o afeţiune rară din spectrul imunodeficienţelor primare, caracterizată de infecţii recurente ale tegumentului şi tractului respirator superior, leziuni de dermatită cronică eczematiformă şi anomalii scheletale asociate cu valori crescute ale IgE serice. S-au descris diverse funcţii deficitare ale limfocitelor T, fără a se găsi însă o asociere directă cu nivelurile IgE ori cu manifestările clinice ale bolii.


Job’s syndrome


Prezentăm cazul unui pacient cu infecţii stafilococice recurente şi abcese reci, dermatita exematiformă şi hiper-IgE, la care tratamentul cu Ciclosporina A a avut un efect favorabil. There are no conflicts of interest and no financial support for this research. Correspondence author: Dr. Maria-Magdalena Tamas Department of Rheumatology 2–4, Clinicilor Str, 400006 Cluj, Romania Tel: +40 722 352052, Fax: +40 264431040 [email protected]

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

NETEA M.G., SCHNEEBERGER P.M., DE VRIES E. et al., Th1/Th2 cytokine imbalance in a family with hyper-IgE syndrome. Neth. J. Med., 2002, 60, 349–353. GRIMBACHER B., HOLLAND S.M., GALLIN J.I. et al., Hyper-IgE syndrome with recurrent infections – an autosomal dominant multisystem disorder. N. Engl. J. Med., 1999, 340, 692–702. GRIMBACHER B., HOLLAND S.M., PUCK J.M., Hyper-IgE syndromes. Immunological Reviews, 203, 244–250. LAJEUNESSE E., Hyperimmunoglobulin-E syndrome with recurrent infection: a review of current opinion and treatment. Pediatr. Allergy Immunol., 2000, 11, 133–141. COHEN-SOLAL M., PRIEUR A.M., PRIN L. et al., Cytokine-mediated bone resorption in patients with the hyperimmunoglobulin E syndrome. Clin. Immunol. Immunopathol., 1995, 76, 75–81. SCHOPFER K., FELDGES A., BAERLOCHER K. et al., Systemic lupus erythematosus in Staphylococcus aureus hyperimmunoglobulinemia E syndrome. BMJ, 1983, 287, 524–526. KIMATA H., High-dose intravenous gamma globulin treatment for hyperimmunoglobulinaemia e syndrome. J. Allergy Clin. Immunol., 1995, 95, 771–774. MIN J.K., CHO M.L., KIM S.C. et al., Hyper immunoglobulin E-recurrent infection syndrome in a patient with juvenile dermatomyositis. Korean J. Intern. Med., 1999, 14, 95–98. PHERWANI A.V., MADNANI N.A., Hyperimmunoglobulin E syndrome. Indian Pediatrics, 2001, 38, 1029–1034. KING C.L., GALLIN J.I., MALECH H.L. et al., Regulation of immunoglobulin production in hyperimmunoglobulin E recurrent-infection syndrome by interferon gamma. Proc. Natl. Acad. Sci. USA., 1989, 86, 10085–10089. DAU P.C., Remission of hyper-IgE syndrome treated with plasmapheresis and cytotoxic immunosuppression. J. Clin. Apher., 1988, 4, 8–12. GENNERY A.R., FLOOD T.J., ABINUN M., CANT A.J., Bone marrow transplantation does not correct the hyper IgE syndrome. Bone Marrow Transplant, 2000, 25, 1303–1305. ETZIONI A., SHEHADEH N., BRECHER A. et al., Cyclosporin A in hyperimmunoglobulin E syndrome. Ann. Allergy Asthma Immunol., 1997, 78, 413–414. WOLACH B., ELIAKIM A., POMERANZ A. et al., Cyclosporin treatment of hyperimmunoglobulin E syndrome. Lancet, 1996, 347, 67.

Received April 25, 2008


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Giant Iliac Artery Aneurysm – a Rare Cause of Hydronephrosis I. COPACI1, C. RUSU1, C. JURCUŢ1, MIHAELA ENACHE1, V. DUŢESCU1, MIRELA ANGHEL2, MARIA GĂLĂMAN3 1 rd

3 Internal Medicine Department, “Carol Davila” Central Clinical Emergency Military Hospital, Bucharest, Romania 2 National Institute of Aeronautical and Space Medicine, Bucharest, Romania 3 Imaging Department, “Carol Davila” Central Clinical Emergency Military Hospital, Bucharest, Romania

The presence of arterial aneurysm – an abnormal dilatation of an arterial segment due to various causes – might lead to compression effects and to various symptoms. Finding an etiology for unilateral hydronephrosis represents in some cases a real challenge for the clinician and targeted investigations must be ordered for the diagnostic approach. The abdominal ultrasound examination is one of the first imaging modalities but the abdominal computed tomography is helpful for definitive conclusions. We present a rare case of unilateral hydronephrosis due to a giant left iliac artery aneurysm in a 77-year-old male with history of peripheral artery disease. Key words: hydronephrosis, iliac artery aneurysm, ultrasonography, computed tomography.

A 77-year-old male was addressed to our department for moderate pain in left iliac fossa and left flank, starting 5 weeks before admission. A standard abdominal echography performed in another department revealed a severe hydronephrosis on the left kidney, without any other abnormalities and without the visualization of an obstructive level. The medical history of the patient consists in a chronic severe peripheral arterial disease, necessitating bilateral foot amputation and sympathectomy 30 years ago. He was a smoker and he is severely obese with a BMI (body mass index) of 36 kg/m2. The patient was receiving oral anticoagulation and vasodilator therapy. He did not have any complaints of urinary symptoms, diarrhea, constipation or fever, and no history of trauma was obtained. The appetite was normal and there was no history of weight loss. PHYSICAL EXAMINATION

Cardiovascular and pulmonary examinations were unremarkable. The blood pressure was normal on presentation. At the level of the left abdomen (left flank and iliac fossa), the physical examination revealed a non-tender mass with solid aspect, non-pulsatile, without bruits. The femoral and popliteal arteries were pulsatile. Both feet are amputated for chronic peripheral artery disease. ROM. J. INTERN. MED., 2008, 46, 2, 173–178

There were no palpable lymph nodes, no hepatomegaly and the bowel sounds were audible. PARACLINIC INVESTIGATIONS

The chest radiography and the electrocardiogram were normal. The biological tests revealed an INR of 1.78, a slight normocytic anemia with hemoglobin at 11.1 g/dl and mild renal failure with creatinine of 1.92 mg/dl. The standard abdominal ultrasound examination confirms the severe hydronephrosis (Fig. 1) and revealed a mass at the level of the left abdomen, just below the kidney (Figs. 2 and 3). The abdominal mass presented a transonic structure with thick and inhomogeneous walls with discrete pulsatility and with turbulent flow at color Doppler. We suspected an aortic aneurysm and the patient was referred for computed tomography. Computed tomography showed a 13 cm ovoid mass, with the great diameter vertically oriented, inseparable at the native examination from the psoas and ileopsoas muscles and from the left iliac vessels and with iliac bone atrophy (Fig. 4). After the intravenous contrast injection (Fig. 5), the mass appeared better delimited with vascular lumen and with massive circumferential thrombosis. The abdominal aorta and right iliac artery were normal and the mass could be identified as being a giant aneurysm of the left iliac artery. The left


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Fig. 1. – Hydronephrosis and pyelocaliceal dilatation on the left kidney.

Fig. 2. – Transverse ultrasound examination of the left flank showing the hypoechoic mass (118/67 mm) with extensive thrombosis of the walls (36 mm maximal thickness).

ureter was compressed in the mid and inferior segments leading to hydronephrosis (Fig. 6). We could also observe aortic and iliac artery wall calcifications reflecting a widespread atherosclerotic vascular process. The bowel structures were displaced by the mass which has a longitudinal diameter (Fig. 7) of 17.5 cm beginning just below the left renal pedicle.

We performed an abdominal radiography 15 minutes after the injection of the contrast substance, and we noted the left hydronephrosis and the delay of the secretion and of the excretion compared with the right kidney. The patient was addressed to the vascular surgeon, who proposed the angiography and the surgical repair, but the patient chose to delay these


Giant iliac artery aneurysm

Fig. 3. – Superior pole of aneurysm with thrombosis (white arrow) and the left kidney with hydronephrosis (interrupted white arrow).

Fig. 4. – Native abdominal computed tomography with transverse dimensions of the aneurysm (130/101 mm).



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Fig. 5. – Abdominal computed tomography with contrast showing the aneurysm and the circumferential thrombosis of the walls.

Fig. 6. – Hydronephrosis on the left kidney (white arrow).




Giant iliac artery aneurysm

Fig. 7. – Computed tomography reconstruction showing the longitudinal dimensions of the aneurysm (interrupted black arrow).

interventions. We recommended the continuation of the oral anticoagulant and vasodilatatory therapy as well as weight control.


The obstruction of the ureters by aneurysms was cited especially in the case of aortic aneurysms [1], and there are few reports in the literature describing iliac artery aneurysms of great dimensions having a compressive effect on the urinary tract [2][3]. The clinical presentation encompasses various patterns between the asymptomatic hydronephrosis to anuric acute renal failure [2], to fatal or non-fatal aneurysm rupture [4] or arteriovesical fistula with hematuria [5]. In our case, the presentation was determined by the occurrence of hydronephrosis, associated with left flank pain and mild renal failure. The impressive dimensions of an iliac artery aneurysm with massive wall thrombosis determined a compressive effect on the left ureter, explaining the renal complication. The clinical examination was not suggestive for a vascular mass because of the wall thrombosis which could explain the absence of

pulsatility of the abdominal mass. Only a thorough and combined imaging exploration could bring detailed information regarding the nature of the compressive mass and its anatomical boundaries. The surgical repair of the aneurysm is the most used method to restore the urinary flow and renal function and to avoid the complications as rupture or peripheral embolism. There are some reports that used the endovascular repair techniques in the treatment of iliac artery aneurysms [6]. Given the high prevalence of associated vascular pathology, in patients with the peripheral vascular disease the screening for aortic or other abdominal artery aneurysms is appropriate. In the present case, the history of smoking and of peripheral vascular disease increased the risk for the development of vascular aneurysms.


We present a rare case of unilateral hydronephrosis due to a giant iliac artery aneurysm in a 77-year-old male with a history of peripheral artery disease, reflecting the value of combined imaging techniques in the evaluation of abdominal masses.


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Prezenţa anevrismelor arteriale – dilataţii anormale ale segmentelor vasculare de diverse cause – poate determina efecte compresive şi manifestări clinice legate de acestea. Diagnosticul etiologic al hidronefrozei unilaterale este dificil în unele cazuri şi necesită utilizarea tehnicilor imagistice. Explorarea ultrasonografică este de cele mai multe ori investigaţia de primă alegere, dar examenul prin tomografie computerizată este adeseori util în diagnosticul pozitiv. Lucrarea prezintă un caz rar de hidronefroză unilaterală datorată unui anevrism gigant de arteră iliacă stângă la un pacient în vârstă de 77 de ani, cu istoric de boală vasculară periferică. Corresponding author: I. Copaci, MD, PhD 3rd Internal Medicine Department, “Carol Davila” Central Clinical Emergency Military Hospital, Bucharest, Romania 88, Mircea Vulcanescu St., Bucharest, Romania E-mail: [email protected]

REFERENCES 1. 2. 3. 4. 5. 6.

SAITO S., Evaluation of cases where the right kidney is higher than the left kidney. Int. J. Urol., 2003, 10:359–363. VLASIC-MATAS J., KARELOVIC D., BUKOVIC D., HRGOVIC I., HRGOVIC Z., Differential diagnosis of urinary retention: aneurysm of the iliac artery. Aktuelle Urol., 2004, 35:62–64. SHINDO S., KUBOTA K., KOJIMA A., IYORI K., ISHIMOTO T. et al., Inflammatory solitary iliac artery aneurysms: a report of two cases. Cardiovasc. Surg., 2001, 9:615–619. GURU K.A., SARLE R.C., REDDY D., PEABODY J.O., Iliac artery aneurysm: a fatal cause of urinary retention. J. Endourol., 2003, 17:221–222. GOFF C.D., DAVIDSON J.T., TEAGUE N., CALLIS J.T., Hematuria from arteriovesical fistula: unusual presentation of ruptured iliac artery aneurysm. Am. Surg., 1999, 65:421–422. BOULES T.N., SELZER F., STANZIALE S.F., CHOMIC A., MARONE L.K. et al., Endovascular management of isolated iliac artery aneurysms. J. Vasc. Surg., 2006, 44:29–37.

Received April 4, 2008

Malignancy and Overdiagnosis of Malignancy in Peutz Jeghers Polyposis SABINA ZURAC1,2, GIANINA MICU1, ALEXANDRA BASTIAN1, ELIZA GRĂMADĂ1, LUCIANA LAVRIC2, R. ANDREI1, FLORICA STĂNICEANU1,2, R. VOIOSU2,3, A. CROITORU4 Note: Sabina Zurac and Gianina Micu should be regarded as first author in equal contribution 1

Department of Pathology, Colentina University Hospital 2 “Carol Davila” University of Medicine and Pharmacy 3 Department of Gastroenterology, Colentina University Hospital 4 Department of Surgery, Colentina University Hospital Bucharest, Romania

Peutz Jeghers (PJ) polyps are rare hamartomatous tumors of the gastrointestinal tract frequently associated with skin and mucosal pigmentation. Despite their benign nature there is a certain increased risk of progression to malignancy in some cases, justifying a sustained follow-up of the patients. We present 3 cases of Peutz Jeghers syndrome (PJS) diagnosed in our hospital on gastrointestinal specimens obtained by endoscopy and opened surgery. We analyzed different degrees of dysplastic changes, epithelial intussusception, association with other types of polypoid lesions and other various aspects possibly related with disease progression. Clinico-pathological correlations were made. Two of these cases were related (mother and daughter); both of them were operated in another hospital for small bowel tumors with a subsequent diagnosis of adenocarcinoma. The daughter (28 years old) was referred to our hospital for endoscopic follow-up; a small polyp of the transverse large bowel was excised by colonoscopy with a histopathologic diagnosis of PJ polyp; a careful histopathologic reevaluation of both specimens of enterectomy (slides and paraffin blocks) revealed an overdiagnosis of cancer due to the epithelial cystic dilatation and pseudoinvasion in both patients. The other case showed diagnostic changes of PJS and also various aspects of adenomatous polyps some of them with mild and moderate dysplastic changes. When a PJ polyp is diagnosed, the possibility of pseudoinvasion should be kept in mind, in order to avoid overdiagnosis of malignancy; also, due to the fact that the malignant transformation of a PJ polyp is still on debate (hamartoma – dysplasia – carcinoma sequence versus malignant transformation of an adenomatous aria of a hamartoma versus coincidental association of a digestive cancer due to genetic aberrations of PJS), all the other associated microscopic aspects of the lesion should be carefully analyzed. Key words: Peutz Jeghers polyps, Peutz Jeghers syndrome, malignancy overdiagnosis.

Peutz Jeghers (PJ) polyps are rare hamartomas with gastrointestinal localization; most frequently they involve small bowel – mainly jejunum 65–95%, less frequently colon and rectum 30–60% or stomach 25–50% and occasionally esophagus and duodenum. The first mention of the hamartomatous nature of PJ polyps dates since 1949 [1]. Most of the cases with PJ polyps associate melanic mucocutaneous pigmentation (most often of the oral mucosa) in Peutz Jeghers syndrome (PJS); despite the characteristic appearance of the mucocutaneous pigmentation, the presence of the polyps represents the cardinal sign of the syndrome (Table I) [2]. PJS (synonyms – periorificial lentiginosis, polyps and spots syndrome) is an autosomal dominant hereditary disease. ROM. J. INTERN. MED., 2008, 46, 2, 179–184

Table I Criteria of positive diagnosis in PJS − − − −

Minimum two histopathologic confirmation of PJ polyps OR Any number of histopathologic confirmed PJ polyps + familial history of PJS OR Prominent characteristic mucocutaneous pigmentation + familial history of PJS OR Any number of histopathologic confirmed PJ polyps + characteristic mucocutaneous pigmentation

First case of PJS was reported in 1895 by JRT Connor who described pigmentation of oral and labial mucosa in two 12-years-old twin sisters with anemia and premature death. Peutz (1921) was the first author who described the association between the mucocutaneous pigmentation and


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gastrointestinal polyposis; in 1949 Jeghers associated the clinical features of the syndrome with the risk of invasive cancer. The “Peutz Jeghers syndrome” name was coined in 1954 (Brunner, Mayo clinic) [3][4]. PJS has a low incidence (one case in 200 000 births); both sexes are equally affected. The morbidity in PJS is represented by chronic anemia (secondary to repeated digestive hemorrhages) and intestinal obstruction (subsequent to intestinal intussception or to mucinous cysts sometimes present in PJ polyps). Most of the PJS are asymptomatic (at least in the beginning) because the polyps are small in size and their growth rate is low. Only the mucocutaneous pigmentation (when present) might be the only sign that raises the suspicion of PJS diagnosis. Once manifest, the clinical signs of the syndrome belong to digestive area, most frequent in the first decade of life: abdominal pain (colics or cramps), nausea, vomiting (sometimes the patients vomit polyps – when torsion and autoamputation occur in pediculated polyp with long and thin pedicle) [5]. Digestive complications (bleedings with secondary feriprive anemia, intestinal occlusion, billiary obstruction – due to periampullary located polyps, rectal prolaps) most often occur in the first two or three decades of life and usually require emergency surgical treatment (median age of first surgical intervention – 11 years) [6]. Rarely, early puberty or gynecomastia or feminization in boys were noticed. In what concerns hyperpigmentation, it consists in brown maculae (melanin accumulation) of 1 to 5 mm in diameters with maximal intensity in the first 5 years of life with a pronounced tendency to attenuate in the adult life; rarely it may completely disappear. The most affected areas are perioral region (with oral mucosa involvement), rarely periocular, fingers or perianal region. There are cases without cutaneous pigmentation, usually this situation being the reason for a delay in diagnosis [4]. The polyps can be solitary or multiple (dozens or even thousands) – most often multiple. There is certain variability in term of size (usually 0.5 to 5 cm) and shape (rounds or ovoids with smooth or cauliflower-like surface, sessile or pediculated). In terms of microscopic features, they appear as hamartomas with villous pattern consisting in normal mucosa covering finely


arborescent smooth muscle core. In up to 10% of the polyps, mucosal foldings and invaginations are present. It is the pathologist role to discern between different types of polyps which may occur in GI tract (Table II) [2–4]. Table II Differential diagnosis of PJ polyps − − −

Hyperplastic polyp Adenocarcinoma Other polyposis: FAP; HNCP; juvenile polyposis, Gardner syndrome, Laugier-Hunziker syndrome


We report three cases of PJS occurring in two females and in one male. The female patients, 54 and 28 years old, were mother and daughter. Both of them were operated for an “adenocarcinoma” of the small bowel in another hospital. The daughter was submitted for endoscopic follow-up to the Department of Gastroenterology of our hospital; during a colonoscopy, a small polyp was resected and submitted for histopathologic examination. The microscopic appearance has been suggestive of PJ polyp. The histopathologic slides from the previous surgical intervention of both patients were reviewed in our department. Both of the cases presented small bowel polyps with villous pattern and finely arborescent smooth muscle core covered by intestinal mucosa with absorptive and goblet cells (Fig. 1). Inside of the intestinal wall – both in the submucosa and muscularis propria epithelial structures, mucinous cysts and hemosiderin deposits were identified (Fig. 2). The epithelial inclusions in the intestinal wall (previously interpreted as “carcinomatous invasion”) consisted in normal looking intestinal epithelium with absorptive cells, alternating in a relatively orderly manner with goblet cells (Fig. 3). Limited areas of tachychromatic nuclei with mild pleomorphism were noted in the endoluminal protrusive polypoidal mass, most of them in conjunction with inflammation and ulceration (Fig. 4). Both of the cases were interpreted as ulcerated PJ polyps with epithelial herniation in the submucosa and muscularis propria. The daughter has two histo-pathologic confirmations of PJ polyps (one in the reexamined slides from the open surgery specimen, the other in the colonoscopic resected polyp); her case was interpreted as PJS. Her mother


Peutz Jeghers syndrome

has positive history of PJS (her daughter) and a histopathologic confirmed PJ polyp – according to the criteria for PJS diagnosis, she also has PJS. The third case, a 69 yrs old male, presented for gastric polyposis. Total gastrectomy was performed in our hospital. The surgical specimen enclosed the whole stomach (20 cm in length on the greater curvature and 15 cm on the lesser curvature). Multiple corporeal and antral polyps were present. They were small (0.5 to 1cm in diameters), sessile or pediculated, soft consistency, gray color with congestive areas (Fig. 5). Microscopic examination revealed PJ polyps with arborescent vascular and smooth muscle stromal stalks covered by normal gastric epithelial structures (gastric mucosa of antral or corporeal type, according to the localization of each polyp) with areas of ulceration and/or supurative foci (Fig. 6); moderate polymorphous inflammatory infiltrate, edema, hyperemia and mild stromal fibrosis were present; cystic dilatations and areas of intestinal metaplasia were identified. Some polyps associated areas of tubular adenoma (Fig. 7), sometimes with low grade intraepithelial neoplasia (mild dysplasia) (Fig. 8). DISCUSSIONS

Today it is common knowledge that PJ polyps are benign lesions [7]; some clinicopathologic data reveal a proportion up to 5% of precancerous associated lesions and malignant evolution [8][9]. On the other hand, there are authors who reject the hypothesis that PJ polyps might represent premalignant lesion per se, in favor of a coincidental association of gastrointestinal carcinomas. Hamartomas are not considered precancerous lesions. However, there is an increased frequency of digestive carcinomas in PJS patients. Even so, two hypotheses may be discussed – there is a malignant transformation of PJ polyps, or the same genetic alteration incriminated in PJS occurrence induces the development of a digestive cancer, but at different levels, comparing with those of PJ polyps. The possibility of a malignant transformation of a PJ polyp is supported by the simple analysis of localization of PJ polyps versus the localization of cancer in PJS patients and general population [10]: − −

small bowel cancer is exceedingly rare in general population cancer in PJS patients has the highest incidence in small bowel


the most frequent localization of PJ polyps is represented by the small bowel

Also, in PJ polyps, at least in 3–6% of cases, a sequential evolution hamartoma – adenoma – adenocarcinoma was proposed as a possible hypothesis of malignant transformation (9, 11). In favor of this scenario, several data were collected: − −

there are dysplastic lesions in PJ polyps digestive cancers in PJS may occur in the vicinity of PJ polyps (there are areas of PJ polyps in contiguity with carcinomatous proliferation on histopathologic slides) loss of heterogeneity of STK 11 gene was identified both in PJ polyps and in intestinal cancers occurred in PJS patients

Even the syndrome is known by decades, the genetic basis of this disease remained unclear for many years; not until 1997, a mutation in the short arm of chromosome 19 was identified in some patients with PJS. There are two types of PJS: − −

“familial” type (autosomal dominant inheritance – genetic transmission from an affected parent) [5] “sporadic” type (10–20% of the cases with no hereditary transmission – most probably due to a spontaneous mutation during conception [12]

Recent studies demonstrated as the determinant cause for PJS a mutation of STK 11 (LKB1) gene (located on the short arm of chromosome 19) – 19p13.3 (13). Up to 70% of familial type of PJS presents STK11 mutation. However, there is a genetic heterogeneity of PJS with other gene mutations yet to be discovered. STK 11 gene controls both cellular growth and death. Because STK 11 is located on a somatic chromosome, either mother or father, since affected, might transmit the disease. STK 11 seems to have a double role – it induces the hamartomatous polyp formation and represents a blockage in the course of malignant transformation [14]. For a STK11-related malignant course it is mandatory to associate the first STK 11 mutation (germ-line mutation) with a second mutation (for example, in order to initiate a breast cancer, a secondary mutation of BRCA 1 gene is required). There is not known which is the cause of this additional mutation; environmental factors (chemical, physical or biological ones) might be incriminated [15][16].


Sabina Zurac et al.

This is the reason why many generations of a family with germ-line mutation alone do not develop cancer (even the STK 11 mutation is transmitted to the descendents in 50/50 proportion). STK 11 overexpression is noted in tumorigenesis and apoptosis suppression; similar findings characterized COX2 (with an overexpression of 82– 85% in PJS) [17]. Statistic data show that there is a certain predisposition in PJS patients to develop an extradigestive cancer. It is not clear yet if the association of PJS with an extradigestive malignancy is a real fact (genetic modifications of PJS increasing the risk of cancer development) or mere coincidence (cancer appears in similar proportion in PJS patients as in general population with an apparent overestimation due to the rarity of the syndrome). Some authors consider this association not relevant. Several studies reveal a higher incidence of extradigestive cancers in PJS, mainly bilateral breast cancers and genital cancers [8]; the best-documented extradigestive localizations of cancer in PJS patients are ovaries, uterine cervix, testicles, pancreas and breast [7][18][19]. There is a marked predisposition of PJS patients to develop digestive or extradigestive cancers with younger ages of onset (93% risk of developing a certain malignancy before 64 years). Due to the rarity of the syndrome, there is little documentation on the prognosis. Chronic anemia and intestinal obstruction benefit of curative treatment and rarely put the patient on vital risk. The risk of malignancy remains the main problem of PJS patients. Usually, cancer (digestive or extradigestive) occurs in younger patients than the median age in general population for similar cancers, but the time between the PJS diagnosis and the occurrence of a malignancy may vary from 5 to 45 years. The overall risk of death by cancer in PJS patients is about 50% at 58 years of age. The presence of more than 4 polyps, the size of the polyps larger than 1 cm (or 2–3 cm, according to different authors) and the presence of dysplastic lesions in PJ polyps, increase the risk of malignancy. In regard of treatment, surgery is required when complications occur (hemorrhage, obstruction) – small bowel excisions; when multiple polyps are present, the repeated surgical excisions – even of small segments of small bowel – may provoque a “syndrome of short small bowel” with subsequent


morbidity). Polypectomy/endoscopic polypectomy is recommended, especially when polyps are pediculated [20][21]. Prophylactic treatment is possible – the levels of COX 2 are higher in PJS patients; COX2 inhibitors (Cerebrex, Vioxx, acetylsalycilic acid) reduce the rhythm of growing of the PJ polyps and tumorigenesis. When cancer occurs, specific oncologic treatment is mandatory, according to localization, type and stage of the tumor. If there is no simultaneity between the diagnosis of PJS and the diagnosis of cancer (i.e. patient diagnosed with PJS without any cancer yet), careful follow-up is recommended (Table III) [22][23]. Table III Prophylaxis − −

genetic consultation for parents with positive history for PJS careful follow-up of PJS patients: – blood test (hemoglobin) and abdominal and pelvic ultrasonography 1/yr – superior and inferior digestive endoscopy and small bowell radiography with contrast2/yr – mamography and cervical examination – patients younger than 40 yrs 1/3yr – 40–50 yrs 1/2yr – over 50 yrs 1/yr

In conclusion, debating the issue of malignancy in PJS, two aspects should be emphasized: – PJS may associate malignancies Malignancy may appear in PJS; there is a significant risk of developing malignancy both in digestive and extradigestive localizations; if digestive malignancy in PJS occurs as a progression to cancer of a PJ polyp (possible via an adenomatous transformation) or in separate location than PJ polyps (in conjunction with the genetic alterations responsible for both PJ polyp formation and malignant transformation) is still a matter of debate. In our cases, we report the presence of adenomatous areas in some of the gastric polyps. Also, in both of the cases with small bowel polyps, we recorded some “atypical” areas in the protrusive mass of the polyp, but the presence of inflammation in the vicinity was suggestive of a rather regenerative nature of the “atypia” than of a dysplastic one. More molecular data are necessary in order to solve this problem.


Peutz Jeghers syndrome

– Malignancy may be overestimated in PJS This matter has a considerable importance in routine practice; due to the rarity of the cases, a pathologist may encounter maybe one case of PJS in a lifetime career; if the patient has a long history of intussceptions without previous clinical recognition, there is higher risk of presenting epithelial inclusions in the intestinal wall (in submucosa, muscularis propria or even subserosa). These lesions, especially in those patients without a diagnosis of PJS which present symptoms of intestinal occlusion in adulthood, are very easily mistaken as “carcinomatous invasion” and a diagnosis of carcinoma may be established (24). In our cases, the two female patients, mother and daughter, had previous overestimated diagnosis of


malignancy, based on an erroneous interpretation as invasion of herniated epithelial structures in the intestinal muscularis, in conjunction with some cellular alterations, most probably secondary to the inflammatory ulcerative process present in the examinated PJ polyps. Most often, the presence of mucinous cysts and hemosiderin deposits in the areas of pseudoinvasion, correlated with the absence of cytologic atypia and desmoplasia, help the pathologist to exclude malignancy. Even so, the occasional presence of dysplastic lesions in the invaginated epithelium complicates the differential diagnosis and augments the risk of overdiagnosis as malignancy; immunohistochemical fenotyping may be useful in these cases.

Polipii Peutz Jeghers (PJ) sunt tumori hamartomatoase rare ale tractului gastrointestinal frecvent asociate cu pigmentare cutanată şi mucoasă. În ciuda naturii lor benigne, în unele cazuri există un risc crescut de progresie către malignitate, situaţie care justifică o urmărire periodică susţinută a pacienţilor. Prezentăm 3 cazuri de sindrom Peutz Jeghers (SPJ) diagnosticate în spitalul nostru pe piese gastrointestinale obţinute endoscopic sau chirurgical. Am analizat diferitele grade de modificări displazice, intususcepţie epitelială, asociere cu alte leziuni polipoide şi alte aspecte variate posibil legate de progresia bolii. Au fost efectuate corelaţii clinico-patologice. Două din aceste cazuri erau înrudite (mamă şi fiică); ambele au fost operate în alt spital pentru tumori de intestin subţire cu diagnostic ulterior de adenocarcinom. Fiica (în vârstă de 28 de ani) a fost trimisă în spitalul nostru pentru urmărire endoscopică; în cursul colonoscopiei a fost rezecat un mic polip de pe colonul transvers, diagnosticul histopatologic fiind de polip PJ; reevaluarea atentă a ambelor piese de enterectomie (lame şi blocuri de parafină) a arătat o supraevaluare a diagnosticului de cancer datorită prezenţei de dilatări epiteliale chistice şi pseudoinvazie la ambele paciente Celălalt caz a prezentat modificări diagnostice pentru SPJ precum şi diferite aspecte de polipi adenomatoşi, unii dintre ei cu modificări displastice uşoare şi moderate. Când se diagnostichează un polip PJ, trebuie avută în vedere posibilitatea pseudoinvaziei, pentru a evita supradiagnosticarea malignităţii; de asemenea, datorită faptului că transformarea malignă a unui polip PJ este o ipoteză încă în dezbatere (secvenţa hamartom – displazie – carcinom versus transformare malignă a unei arii adenomatoase a unui hamartom versus asociere coincidentală a unui cancer digestiv datorită aberaţiilor genetice ale SPJ), toate celelalte aspecte microscopice trebuie analizate cu grijă. Corresponding author: Sabina ZURAC, MD Department of Pathology, Colentina University Hospital 19–21, Şos. Ştefan cel Mare 020125 Bucharest, Romania Tel (004 021) 317 2354/5612, Fax (004 021) 316 55 12 e-mail: [email protected]


Sabina Zurac et al.


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Received May 28, 2008