Nci 2018 / 2 by KAREPUBLISHING

P ISSN 2148–4902 E ISSN 2536–4553

NORTHERN CLINICS OF ISTANBUL • İSTANBUL KUZEY KLİNİKLERİ NORTHERN CLINICS OF ISTANBUL • İSTANBUL KUZEY KLİNİKLERİ

Vol. 5 • No. 2 • Year 2018

INDEXED IN WEB OF SCIENCE, EMERGING SOURCES CITATION INDEX, PUBMED, PUBMED CENTRAL, EUROPE PMC, EBSCO, DOAJ, TUBITAK TR INDEX, AND TURKIYE CITATION INDEX.

Journal Abbreviation: North Clin Istanb

Vol. 5 • No. 2 • Year 2018

KARE

Intracellular trafficking of diphtheria toxin and its mutated form, CRM197, in the endocytic pathway • Role of the monocyte-to-highdensity lipoprotein ratio in predicting atrial high-rate episodes detected by cardiac implantable electronic devices • The relationship between serum leptin level

and disease activity and inflammatory markers in fibromyalgia patients • Evaluation of hepatitis A, B, and C serology in patients with cirrhosis and intensive alcohol consumption • Comparison of cutaneous manifestations in diabetic and nondiabetic obese patients: A prospective,

previous HBV infection • Single-sided sinonasal mass: A retrospective study • Ultrasound diagnosis of a pathological fracture of the phalanx in a patient with chronic kidney disease: After a 2-month diagnostic delay • Peripartum cardiomyopathy and ventricular thrombus: A case report and review

controlled study • Determination of colistinrelated nephrotoxicity and risk factors in intensive care unit • Violence and related factors among high school students in semirural areas of Eskisehir • Anti-HDV seroprevalance among patients with

of literature • Solitary cecal diverticulitis, a rare cause of right lower quadrant pain: Four cases • Neuro-Behcet’s disease in a case with papilledema and intracranial hypertension as the initial presentation • An unusual complication of posterior packing in epistaxis • Successful

percutaneous coronary intervention for chronic total occlusion via the radial artery • Underlying factors of recurrent infections in patients with down syndrome • Endoscopic retrograde cholangiopancreaticography in elderly patients: A reliable alternative in sepsis

NORTHERN CLINICS OF ISTANBUL İSTANBUL KUZEY KLİNİKLERİ Editor

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NORTHERN CLINICS OF ISTANBUL İSTANBUL KUZEY KLİNİKLERİ YEAR 2018 VOLUME 5 NUMBER 2

p ISSN 2148 - 4902 e ISSN 2536 - 4553

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Northern Clinics of Istanbul (NCI) is a peer-reviewed journal published triannually. Materials published in the Journal is covered by copyright ©2018 NCI. All rights reserved. This publication is printed on paper that meets the international standard ISO 9706:1994. National Library of Medicine recommends the use of permanent, acid-free paper in the production of biomedical literature.

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Press date: June 2018 Circulation: 1000 Type of publication: Periodical

CONTENTS Vol. 5 • No. 2 • Year 2018 IV

Instructions for the authors

O R I G I N A L A RT I C LE S

89–95

Intracellular trafficking of diphtheria toxin and its mutated form, CRM197, in the endocytic pathway B. Ozerman Edis, E. Haciosmanoglu, B. Varol, M. Bektas

96-101

Role of the monocyte-to-high-density lipoprotein ratio in predicting atrial high-rate episodes detected by cardiac implantable electronic devices S. Satilmis

102-108 The relationship between serum leptin level and disease activity and inflammatory markers in fibromyalgia patients S. Ataoglu, H. Ankarali, R. Samanci, M. Ozsahin, O. Admis 109-113 Evaluation of hepatitis A, B, and C serology in patients with cirrhosis and intensive alcohol consumption S. Vatansever, Z. B. Pakoz, B. Unsal 114-119 Comparison of cutaneous manifestations in diabetic and nondiabetic obese patients: A prospective, controlled study E. Ozlu, T. K. Uzuncakmak, M. Takır, N. Akdeniz, A. S. Karadag 120-124 Determination of colistin-related nephrotoxicity and risk factors in intensive care unit A. Inci, M. Korkmaz Toker, I. G. Bicer, A. Derbent, Z. Salihoglu 125-131 Violence and related factors among high school students in semirural areas of Eskisehir B. Isiktekin Atalay, E. Unal, M. F. Onsuz, B. Isikli, C. Yenilmez, S. Metintas 132-138 Anti-HDV seroprevalance among patients with previous HBV infection A. Sahin, S. Gurocak, N. Tunc, U. Demirel, O. K. Poyrazoglu, H. Akbulut, M. Yalniz, Z. Asci Toraman, I. H. Bahcecioglu 139-143 Single-sided sinonasal mass: A retrospective study S. Belli, M. Yildirim, S. Eroglu, F. Kaya Emre

O RI G I N A L I M A G E

144

Ultrasound diagnosis of a pathological fracture of the phalanx in a patient with chronic kidney disease: After a 2-month diagnostic delay S. Sayilir

C A SE RE PO RTS 145-147 Peripartum cardiomyopathy and ventricular thrombus: A case report and review of literature U. Aksu, S. Topcu, O. Gulcu, I. H. Tanboga 148-152 Solitary cecal diverticulitis, a rare cause of right lower quadrant pain: Four cases A. Yuksel, O. Civil, M. K. Colakoglu, F. Sumer, A. T. Eruyar 153-156 Neuro-Behcet’s disease in a case with papilledema and intracranial hypertension as the initial presentation S. Aydin Kurna, A. Altun, N. Cakir, A. Karatay Arsan 157-159 An unusual complication of posterior packing in epistaxis M. O. Erdogan, E. Ozturk, B. Erdogan, M. A. Afacan, I. Tayfur, K. Yusufoglu, S. Colak, A. Algin 160-162 Successful percutaneous coronary intervention for chronic total occlusion via the radial artery M. A. Tatlisu

I N V I T E D RE V I E W

163-168 Underlying factors of recurrent infections in patients with down syndrome T. Patiroglu, M. Cansever, F. Bektas

Let t er to t he E di tor

169-170 Endoscopic retrograde cholangiopancreaticography in elderly patients: A reliable alternative in sepsis E. Tarikci Kilic, L. Doganay, K. Ozdil

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Orıgınal Article

BASIC MEDICAL SCIENCES

North Clin Istanb 2018;5(2):89–95 doi: 10.14744/nci.2017.55798

Intracellular trafficking of diphtheria toxin and its mutated form, CRM197, in the endocytic pathway Bilge Ozerman Edis,1 Ebru Haciosmanoglu,2 Basak Varol,1 Muhammet Bektas1 Department of Biophysics, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

Department of Physiology, Istanbul Bilim University, Faculty of Medicine, Istanbul, Turkey

ABSTRACT OBJECTIVE: Diphtheria toxin (DTx) is a well-characterized bacterial toxin. However, the endocytic pathway of the mutant of DTx, CRM197, which is used as an immunological adjuvant, has not yet been fully explained. The aim of this study was to investigate the intracellular trafficking of CRM197-loaded endosomes. METHODS: Human umbilical vein endothelial cells (HUVECs) were used in a cell culture. The effective incubation time was determined by transmission electron microscopy in toxin-treated cells. Density gradient centrifugation and ADP-ribosylation assay were used to isolate and detect toxin-loaded endosomal fractions. Endosomal fractions from CRM197-treated cells were elicited after 15 minutes of incubation and the presence of fragment A was demonstrated using Western blot. Immunofluorescence microscopy was used to identify endosomes in CRM197-treated endothelial cells. RESULTS: DTx-loaded endosomes were detected as enlarged vesicles in the perinuclear area with 15 minutes of toxin treatment. DTx-loaded endosomal fractions were determined by ADP-ribosyltransferase activity test and Western blot analysis. Enzymatic activity of the toxin-loaded endosomal fraction increased by 20% in actin cytoskeletal-damaged cells treated with cytochalasin D. The steps for the toxin treatment of HUVECs with DTx and obtaining endosomal fractions were repeated for CRM197. In the CRM197-loaded endosomal fraction, actin and Hsp90 were identified in addition to fragment A. Fluorescent images revealed that CRM197-loaded endosomes were co-localized with actin filaments and that Rab11, which signals the return to the plasma membrane, was more prominent than Rab7, the lysosomal pathway indicator. CONCLUSION: These results suggest that CRM197-loaded endosomes participate in the recycling pathway. Keywords: Actin cytoskeleton; CRM197; diphtheria toxin; endosome; Human umbilical vein endothelial cells.

Cite this article as: Ozerman Edis B., Haciosmanoglu E., Varol B., Bektas M. Intracellular trafficking of diphtheria toxin and its mutated form, CRM197, in the endocytic pathway. North Clin Istanb 2018;5(2):89–95.

iphtheria toxin (DTx) is a well- characterized bacterial toxin, which induces inhibition of protein synthesis by ADP-ribosylation of eukaryotic elongation factor 2 (eEF2). In the presence of specific receptors, DTx enters into cells via endocytosis, and passes into cytosol then ADP-ribosylates eEF2 over histidin (715. amino acid). Inhibition of protein synthesis, destruction of actin cytoskeleton and activation of nuclease are fol-

lowed by induction of apoptotic process in the cell [1]. However mutant forms of diphtheria toxin (CRM197, CRM228) cannot inhibit protein synthesis [2]. Among cross-reactive mutants, CRM197 is used as a carrier molecule in pediatric conjugated vaccines [3]. Mutant diphtheria toxin CRM197 which functions as carrier protein in vaccines developed against bacterial infections, and also used for the construction of immuno-

Received: May 30, 2017 Accepted: August 12, 2017 Online: April 19, 2018 Correspondence: Dr. Bilge OZERMAN EDIS. Department of Biophysics, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey. Phone: +90 212 414 24 82 e-mail: bilge.edis@istanbul.edu.tr © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

logical adjuvant has the same number (n=535) of amino acids with natural toxin. Because of a single amino acid substitution in fragment A (FA) CRM197 carries glutamic acid in position 52 instead of glycine [4]. DTx enters into cell, ADP-ribosylates eEF2 with its FA component in the presence of NAD, and triggers inhibition of protein synthesis, and activation of apoptotic pathways [5]. Mutation in CRM197 induces loss of enzymatic activity of FA so CRM197 does not lead to any change in intracellular protein synthesis. CRM197 enters into cell via binding of its fragment B (FB) to DTx receptor. The precursor (pro-HB-EGF) of heparin-binding epidermal growth factor like growth factor (HB-EGF) anchored on the cell surface functions as a receptor for the toxin [6]. Varol et al. have presented endocytosis of DTx, and stages of activation of FA in cytosol in detail [1]. Currently, diverse hypotheses have been suggested concerning exit of FA from endosome, and its way of access into targeted region. According to a supportive model, entry of FA into cytosol requires presence of compounds as, Hsp90 chaperone, cytosolic translocation factors as thioredoxin reductase 1, and cytosolic factors as ATP and Î˛-COP [7]. In addition to cytosolic translocation factors, eEF2 which is one of the components of protein synthesis mechanisms, and actin from components of cytoskeleton have been found to be effective in delivery of FA of both DTx and mutant CRM197 through endosomes into cytosol [8]. In studies performed on DTx, and CRM197, it has been determined that as a result of interactions between FA-eEF2-actin, ADP-ribosylation of eEF2 occurs, but actin filaments are also depolymerized, and finally destroyed [9]. Just as the case in FAactin interaction, under the impact of CRM197, actin filaments are also depolymerized [10]. From molecular dynamics simulations approach (homology modelling) the potential interaction site between FA of DTx and actin has been determined [11]. Loss of intercellular contacts was observed as a result of depolymerization of actin filaments of endothelial cells incubated with CRM197 for 24 hours in cell culture media [12]. In the same study the interaction between CRM197, and G-actin was determined using chromatographic methods, and as a result of thermodynamic calculations of molecular dynamics simulations an interaction interface was proposed. On the interaction interface, three areas where amino acids in CRM197 (lysin 48, cysteine 218, and cysteine 233) may interact with respective amino acids of G-actin (glycin 197, arginin 62, and serine 60) were determined. Besides limited number

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of studies have been performed concerning intracellular pathway of CRM197. As is also known, actin cytoskeleton supports intracellular movements of endosomes. Besides, interactions between actin and toxin tend to direct intracellular trafficking of CRM197. Endosomal migration signal, a process regulated by Rac-GTP, is transferred to actin cytoskeleton by Rab5 signal peptide carrying early endosomes [13]. Late endosomal Rab7 transmits the signal of cargo digestion, while Rab peptides in recycling (Rab4, Rab11) direct endosomes to plasma membrane. Endosomes carrying Rab4 signal peptide on their surface rapidly, but endosomes loaded with signal peptide Rab11 slowly fuses with plasma membranes [13]. For the delivery of toxin into cytosol endosomes attach Tâ&#x2C6;&#x2019; domain which is identified with 200-387 amino acids of FB part of the toxin transported into the cell, then the toxin is subjected to proteolytic degradation. [14]. Following this stage, the pathway of endocytic process for CRM197 has not been definitively identified yet. In this study, in order to investigate the pathway selected by CRM197-loaded endosomes toxin infected cells were examined. Firstly DTx was used to the determine application time of CRM197 then ultrastructural analysis and ADP-ribosylation assay were carried out in toxin loaded endosomes. Incubation of cell suspension was limited to 15 minutes so as to obtain CRM197 loaded endosomes. Western Blot analysis determined that within this specified time interval FA of CRM197 was not delivered from endosomes into cytosol. Immunofluorescent labeling detected that Rab 11 peptide in early endosomes of CRM197 treated cells exposed a more powerful fluorescent signal than other Rab peptides. MATERIALS AND METHODS Chemicals In this study anti-Rab7 (Sigma), anti-Rab11, and anti-Hsp90 (Abcam), anti-Actin (Santa Cruz), anti-FA (7F2) (Abcam), and anti-EEA1 (Abcam) were used as primary antibodies. Secondary antibody, and fluorescent (TRITC) labeled phalloidin were purchased from Santa Cruz, and Sigma, culture materials from Nunc, and Falcon firms, DTx, and CRM197 from Calbiochem, and ProLong Gold Antifade Mountant Invitrogen firms. For ADP-ribosylation assay [Adenosine-14C]NAD (NENDupont) with a specific activity of 535 Ci/mol was used.

Ozerman Edis et al., Intracellular trafficking of CRM197-loaded endosomes

Cell culture Human umbilical vein endothelial cells (HUVECs) were used in the study. Under standard culture conditions, Dulbecco’s Modified Eagle’s medium (DMEM F-12) which contained 10% Fetal Bovine Serum (FBS) and antibiotic (100 µg/ml streptomycin, and 100 U/ ml penicillin) was used, and cellular proliferation was achieved at 37°C with a 5% CO2 content. Trypan blue was used for viability of cells which were incubated on 6-well plates (1x106 cell/ml) containing coverslip, and treated with CRM197 (0.8 nM) for 15 minutes. Ultrastructural analysis DTx (0.8 nM)–treated cells, and control cells were incubated at 37°C, and on 5% CO2 containing culture media for 15 minutes to make fine structural examination using electron microscope (TEM). Cells (3x106 cells/ ml) were washed, with phosphate–buffer saline (PBS) and centrifugated (2000 rpm, for 3 minutes). Cells in pellet were fixed in 2.5% glutaraldehyde, and 1% osmium tetroxide. Cells were wrapped with egg white, and left overnight in 70% alcohol to harden them. After routine dehydration processing in a graded alcohol series, cells were blocked, and embedded in Epon® resin. Small slices were cut from blocks using ultramicrotome (C. Reichert OM U3), and transferred on copper grids. Grids were stained with contrasting agents as uranyl acetate and Reynolds solutions, and were examined with TEM ( JEOL JEM 1011). Isolation of endosomes HUVECs cell suspension was incubated in the presence of CRM197 (0.8 nM) for 15 minutes. Endothelial cells (107 cells/ml) were precipitated while centrifuging them at 4°C, and 270×g for 5 minutes. The cells were suspended in PBS, and precipitated again. Cells in the pellet were suspended in 1 ml homogenization buffer (0.25 M sucrose, 3 mM imidazole, 0.5 mM potasium4’,6-diamidino-2-phenylindole (K-EDTA) pH:7.3), and centrifuged at 750×g for 7 minutes. The precipitated cell fraction was lysed in the same homogenization buffer (200 µL) using insulin syringe [15]. The lysate was centrifuged at 750×g for 7 minutes. The lysate pellet obtained was suspended in homogenization buffer (500 µl) (17% Percoll, and 10% Iodixanol-Opti-Prep kit). A 17% Percoll phase on the 65% sucrose bed added into ultracentrifuge tube, suspension (500 µl) was layered. At the end of 1 hour-long precipitation process at 59,000×g using

Sorvall AH 650 rotor, endosomal fraction was pipetted over Percoll phase. ADP-ribosylation assay DTx (0.8 nM) treated cells were used to determine ADPribosyltransferase activity of FA-loaded endosomal fractions in the absence or in the presence of cytochalasin D, a membrane permeable compound causing the disruption of actin filaments [8]. ADP-ribosylation assay was realized at 20°C within 10 minutes in the presence of 25 μl reaction mixture containing 50 mM Tris-HCl, pH: 7, 4, 7 mM 2-mercaptoethanol, 5 μM [Adenosin-14C] NAD, in addition to 20 pmol eEF2. After incubation, 5 µl samples were passed through GF/A Whatman filters, and washed with cold TCA. After drying, the filters were transferred to vials containing 5 ml 2,5-difenyloxalose (PPO) in toluene. Radioactivity was determined in a liquid scintillation counter (Packard Tri-Carb1000 TR). Endosomal fractions were isolated in the presence of 1% Triton X-100 (400 µl). For ADP-ribosylation assay 20 µl of sample, and for electrophoresis 10 µl of sample (20 µg endosomal protein mixture) were used. Electrophoretic analysis Sodyum dodecyl sulphate–polyacrilamide gel electrophoresis (SDS-PAGE) was performed based on Laemmli method [16]. For determination of molecular weight standards prestained 10-170 kDa protein kit (Page Ruler, Pierce) was used. Endosomal proteins subjected to electrophoretic analysis were stained with Coomassie brilliant blue, and excess stain was removed by solution containing 10% acetic acid, and 5% methanol. Western Blot After electrophoresis, proteins loaded gel was used for Western blotting. For this procedure SDS-PAGE gel was placed on nitrocellulose membrane, and between 3MM Whatman filter papers. This sandwich system was saturated with transfer buffer in semi-dry transfer device. Proteins were transferred onto nitrocellulose membrane at 150-200 mA, and lasted for half an hour. The membrane was incubated with Tris Buffered Salt Solution containing 5% bovine serum albumin to prevent nonspecific bindings so as to saturate the membrane. Membrane was washed twice with TBST solution, and incubated under room temperature for two hours with primary monoclonal antibody solution. Membrane was washed

Immunofluorescence microscopy During fluorescence microscopic examination, actin cytoskeleton was labeled with phalloidin-TRITC in mutant toxin-treated cells. CRM197 was identified with anti-FA. Anti-Rab4 was used for early endosome marker that regulates classification of endosomes in cells, and return of the receptor to the cell membrane, for late endosomes anti-Rab7, and for endosomes in the return cycle anti-Rab11 was used. Visualization of antibodies was ensured using anti-mouse or anti-rabbit IgG-FITC. Intracellular location of CRM197-treated cells was visualized using primary anti-FA antibody, and secondary anti-mouse IgG-FITC antibody. Cell nuclei were labeled using 4’,6-diamidino-2-phenylindole (DAPI). For immunofluorescence microscopy cells on coverslip were washed with PBS, and incubated in 0.01% Triton X-100 for 10 minutes. For fixation, the cells were incubated in 2% paraformaldehyde/PBS media at 4oC for 1 hour. Then primary antibodies diluted with 1% PBSBSA were incubated for 2 hours. Fluorescence labeled secondary antibodies were diluted in 1% PBS-BSA at a ratio of 1:2000, and incubated for one hour. Slides were examined under oil immersion objective of fluorescence microscope with triple filter (Olympus BX51) at 100x magnification. The images were photographed using Olympus DP-72 camera system, and DP2-TWAIN software program. RESULTS DTx untreated (control) and treated endothelial cells were examined under TEM for their ultrastructural details, and sizes of endosomes were compared (Fig. 1A). Increase in the diameter of early endosomes was detected (Fig. 1B). Increase in the size of endosomes of the endothelial cells at the end of 15 minutes of incubation was consistent with previous findings in literature. Following

this time of DTx incubation, endosomal fractions were obtained with density gradient centrifugation (Figure 2). Endosomal fractions were prepared from cells in the absence or presence of cytochalasin D then ADP–ribosyltransferase activity was analyzed. In cases where actin A

Figure 1. Transmission electron micrographs of endothelial cells: The magnified part of the cells was indicated in the lower left checkbox. When compared with the endosomes of the cells of control group (A) number, and size of the endosomes in diphtheria toxin–loaded cells markedly increased (B) (magnification 20,000x). On the micrograph some endosomes are shown in rings, while nuclei and mitochondria with asterixes (*), and ( ) signs, respectively (Scale bar: 1μm).

100 % ADP-ribosylation

three times with TBST solution, then it was incubated for one hour under room temperature in the presence of alkaline phosphatase conjugated secondary Ig-G antibody. Membrane was rewashed three times with TBST solution, under room temperature, it was incubated at dark for the formation of bands in the presence of alkaline phosphatase substrate BCIP (150 μg/ml), and NBT (300 μg/ml). Membrane was placed in 20 mM EDTA, and the reaction was stopped. Bands in nitrocellulose membrane were analyzed.

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6 160 kDa

21 kDa

40 20 0

6 7 8 9 Fraction Number

10 11 12 13

Figure 2. Examination of endosomal fractions obtained from DTx -treated cells. (A) The level of ADP-ribosyltransferase activity of endosomal FA was shown in diphtheria toxintreated cells (dark-colored columns) or in cytochalasin D (2 µM) added cells before toxin treatment (light-colored columns). Assay of ADP-ribosylation was repeated three times. (B) In the Western Blot analysis, anti- EEA1 (160 kDa) (1:500), and anti-FA (21 kDa) (1:500) were used to determine early endosomes and FA respectively in DTxtreated cells incubated previously with cytochalasin D. FA was detected in endosomes obtained from the 3rd fraction which had the highest ADP-ribosyl transferase activity.

Ozerman Edis et al., Intracellular trafficking of CRM197-loaded endosomes

A Pellet

kDa

59.000xg

1 hour

55 40 Fractionation

100

Ultracentrifugation

% 17 Percoll % 64 Sucrose

CRM197 Hsp90

(-)

35 25

(+) FA

Actin

Figure 3. Western Blot analysis of endosomal fractions obtained from CRM197 treated cells. Endosomal fractions were obtained using density-gradient centrifugation (A). Endosomal fractions were observed with SDS-PAGE, and transferred on nitrocellulose membrane (B). Endosomal proteins on gel (line #1) were identified using Coomassie brilliant blue dye and FA on membrane was labelled with anti-FA (1:200) (line #3). Colored protein standard solutions are seen in lines # 2, and 4. Anti-actin antibody (1:100), and anti-Hsp90 beta antibody [5G4] (1:1000) were used to identify actin and Hsp90 in endosomal fractions of CRM197 treated (+) and untreated (-) cells (C).

cytoskeleton was damaged, enzymatic activity of the FAloaded endosomal fractions was detected 20% higher (Fig. 2A). FA-loaded early endosomes were detected at the 3rd. fraction significantly in Western Blot analysis (Fig. 2B). Thus, it was determined that the FA had not yet completely delivered from endosomes into the cytosol of A

DTx-treated cells and the endosomal fraction was still cargo-loaded within this incubation time period. Starting from these findings we concluded that for isolation of endosomal fraction from CRM197-treated cells, and follow-up of endocytic process, it should be appropriate to limit the incubation time to 15 minutes. As indicated in the ‘Method’ section, early endosomes were obtained from CRM197-treated endothelial cell lysate (Fig. 3). At the last stage of isolation of early endosomes, density gradient centrifugation was used (Fig. 3A). CRM197-loaded early endosomes were determined by FA labeling in Western Blot analysis of endosomal fractions (Fig. 3B).On the other hand, Western Blot method was also used to determine the presence of actin, and Hsp90 that support the entry of cargo molecule carried with endosomes into cytosol (Fig. 3C). Cells were incubated with CRM197 in culture media for 15 minutes so as to analyze intracellular trafficking of mutant toxin. Intracellular distribution of CRM197 was showed using immunofluorescence method (Fig. 4). FA of CRM197 was labeled and widespread distribution of CRM197 in endothelial cells was determined (Fig. 4A). Actin filaments of cells were labeled with phalloidin-TRITC so as to make actin cytoskeleton visible (Fig. 4B). As a result of triple labeling overlapping FA and actin filaments were observed (Fig. 4C). Endosomal markers and actin filaments were labeled to determine the intracellular pathway followed by CRM197-loaded endosomes. In control (Fig. 5A) and CRM197-treated cells (Fig. 5B) endosomal marker Rab11of the recycling pathway which regulates return of receptors onto plasma C

Figure 4. Intracellular trafficking of CRM197. Endothelial cells were treated with CRM197 (0.8 nM) for 15 minutes. The cells fixed on the slides to identify FA (green) were incubated with anti-FA monoclonal 7F2 primary antibody (1:1000) for 2 hours, and marked with FITC-labeled secondary antibody specific to this antibody (1:2000) (A). TRITC-labeled phalloidin (1:1000) was added into wells, and incubated for 1 hour to label actin cytoskeleton (red) (B). Cell nuclei (blue) were labeled with DAPI. Prepared slides were covered with ProLong Gold Antifade (C). As is seen in Figure 4, CRM197 is widely distributed in HUVEC, and localized on actin filaments (Scale bar: 10 µm).

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Rab11

F-actin

Control

CRM197

Figure 5.

Transport of CRM197 along recycling pathway. For Rab11 whose receptor-mediated transporters were directed to recycling pathway, endothelial cells were labelled with anti-Rab11 (1:200) antibodies, and made visible with the aid of FITC-conjugated secondary antibodies (green). Actin filaments were labelled with phalloidin-TRITC (red). Prepared slides were covered with protective ProLong Gold Antifade. As shown in Figure 5, when control HUVEC (A) cells were compared with CRM197â&#x20AC;&#x201C;treated endothelial cells (B) early endosomes carrying Rab11 peptide emitted stronger fluorescence signal in endothelial cells incubated with CRM197, and endosomes positioned together with actin filaments are detected (Scale bar: 10 Âľm).

membrane was labeled. When compared with control endosomes, Rab11 signal was detected stronger in CRM197loaded endosomes that were observed localized on actin filaments. As a result of labeling Rab7 which is the signal peptide for lysosomal pathway, any difference between the control, and CRM197-loaded endosomes could not be detected. DISCUSSION Actin plays an important role in the endocytic pathway during endocytosis of some pathogens, and their transport to targeted organelle or cell compartment. It has been suggested that actin cytoskeleton may act as a precursor in the very rapid transport of diphtheria toxin into perinuclear area with the aid of endosomes, and also considered that actin-FA-eEF2 interactions regulate ADP-ribosyltransferase activity. In our previous studies, the impact of both eEF2, and actin on transport of FA into cytosol was detected [8]. As a result of actin-FA-eEF2 interactions, it

has been determined that ADP-ribosylation of eEF2 limits translocation of FA. Moreover depolymerization, and then degradation of actin filaments were demonstrated [9, 10]. Following our previous investigations performed concerning the interaction between diphtheria toxin, and actin, in this study endocytic process of, CRM197, used in the production of pediatric vaccine, was analyzed. Intracellular trafficking of CRM197 was investigated in HUVECs. To determine the incubation time with CRM197, and then to show CRM197-loaded endosomal fraction at first stage DTx was used. In ultrastructural analysis, clustering of enlarged endosomes was determined around the nuclei of DTx-treated endothelial cells [17]. It has been revealed that FA in endosomal fractions obtained from cells incubated with DTx for 15 minutes, did not pass into cytosol, or even in conditions where actin cytoskeleton degraded, FA was trapped in early endosomes. Immunofluorescence method demonstrated that cargo-loaded endosomes spread through all of endothelial cells during endocytic process of CRM197. By the means of Western Blot it is determined that in CRM197-loaded endosomes, during the stage where FA does not leave endosomes, Hsp90, and actin molecules which will support entry of FA into cytosol also accompany endosomes. Findings indicate that early endosomes fused with CRM197-loaded endocytic vesicles tend to lead to recycling pathway. During endocytic process, delivery of FA from endosomes depends on the presence of eEF2 as for both DTx, and CRM197 was shown [8]. Additionally, as demonstrated in many studies, cytosolic factors as Hsp90, and thioredoxin reductase also support translocation of FA [18]. Besides under the impact of VEGF in vascular endothelial cells, the role of Hsp90 played in the transmission of the cell migration signals into focal adhesion kinases has been also determined [19]. In our studies on CRM197-actin interaction it has been detected that 18 hours of contact with CRM197 caused disruption of 65% of F-actin in post-microsomal pellets, and intercellular contacts decreased in HUVECs when incubation time with CRM197 extended to 24 hours [1,12]. Simulation modelling of molecular dynamics has demonstrated that cysteins, localized on T-domain of CRM197 are amino acids most probably interact with actin [12]. Interaction between T-domain and actin tends to support FA delivery over endosomal membrane into cytosol. Actin and Hsp90 identified on cell lysate fractions where CRM197-loaded endosomes are localized signify that FA has not been delivered from endosomes yet. Rab11 was reported as one of the Rab proteins which direct intracellular trafficking of endosomes, also regu-

Ozerman Edis et al., Intracellular trafficking of CRM197-loaded endosomes

late dynamics of actin cytoskeleton developed during cellular movements, and activity of RAC (small GTPase) [20]. More powerful signals produces by Rab11 peptide in CRM197-treated endothelial cells suggest that endosomes are directed again towards cell membrane by means of recycling pathway. Cargo-loaded early endosomes in CRM197-treated HeLa cells enlarged with successive fusions, but they did not transform into late endosomes which indicate lysosomal pathway [21]. In studies where CRM197 was used as drug delivery fusion protein, it was demonstrated that in common cell cultures, liposomes conjugated with CRM197 passed through from brain endothelial cell into astrocytes [22]. Drugs delivered by CRM197 carrier protein from endothelial cells which form blood-brain barrier are directed from apical towards basal lobes, thus delivery of drugs into brain tissue is achieved through transcytosis has been accepted. Delivery of lopermide into neurons was observed with in vivo studies by means of the strategy of overpassing blood-brain barrier using CRM197 nanoparticles [23]. CRM197-actin interaction, and leading of CRM197loaded endosomes towards cell membrane, before lysosomal pathway demonstrate compliance with the delivery strategy of drugs transported from brain endothelial cells by CRM197. In conclusion, we suggest that endocytic process of CRM197-loaded early endosomes in HUVECs progresses on the recycling pathway. Acknowledgement: We would like to thank L. Ebru Akyon working at Department of Histology and Embryology, Istanbul Faculty of Medicine for her support in ultrastructural analysis. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: This work was supported by the Scientific Research Project Coordination Unit of Istanbul University. Projects number: 21270, 39536 and 24735. Authorship contributions: Concept – B.O.E., B.V; Design – B.O.E, E.H., M.B.; Supervision – M.B.; Materials – B.O.E, E.H.; Data collection &/or processing – B.O.E, E.H., B.V.; Analysis and/or interpretation – B.O.E., E.H., M.B.; Writing – B.O.E, E.H., B.V.; Critical review – M.B.

REFERENCES 1. Varol B, Özerman Edis B, Bektaş M. Toxin Structure, Delivery and Action. In: Burkovski A, editor. Corynebacterium diphtheriae and Related Toxigenic Species. Dordrecht: Springer Netherlands; 2014. p. 83–94. 2. Uchida T, Pappenheimer AM Jr, Greany R. Diphtheria toxin and related proteins. I. Isolation and properties of mutant proteins serologically related to diphtheria toxin. J Biol Chem 1973;248:3838–44. 3. Shinefield HR. Overview of the development and current use of CRM(197) conjugate vaccines for pediatric use. Vaccine 2010;28:4335–9.

4. Giannini G, Rappuoli R, Ratti G. The amino-acid sequence of two nontoxic mutants of diphtheria toxin: CRM45 and CRM197. Nucleic Acids Res 1984;12:4063–9. 5. Van Ness BG, Howard JB, Bodley JW. ADP-ribosylation of elongation factor 2 by diphtheria toxin. NMR spectra and proposed structures of ribosyl-diphthamide and its hydrolysis products. J Biol Chem 1980;255:10710–6. 6. Naglich JG, Metherall JE, Russell DW, Eidels L. Expression cloning of a diphtheria toxin receptor: identity with a heparin-binding EGF-like growth factor precursor. Cell 1992;69:1051–61. 7. Lemichez E, Bomsel M, Devilliers G, vanderSpek J, Murphy JR, Lukianov EV, et al. Membrane translocation of diphtheria toxin fragment A exploits early to late endosome trafficking machinery. Mol Microbiol 1997;23:445– 57. 8. Bektaş M, Hacıosmanoğlu E, Ozerman B, Varol B, Nurten R, Bermek E. On diphtheria toxin fragment A release into the cytosol--cytochalasin D effect and involvement of actin filaments and eukaryotic elongation factor 2. Int J Biochem Cell Biol 2011;43:1365–72. 9. Bektaş M, Varol B, Nurten R, Bermek E. Interaction of diphtheria toxin (fragment A) with actin. Cell Biochem Funct 2009;27:430–9. 10. Varol B, Bektaş M, Nurten R, Bermek E. The cytotoxic effect of diphtheria toxin on the actin cytoskeleton. Cell Mol Biol Lett 2012;17:49–61. 11. Unlü A, Bektaş M, Sener S, Nurten R. The interaction between actin and FA fragment of diphtheria toxin. Mol Biol Rep 2013;40:3135–45. 12. Özerman Edis B, Varol B, Hacıosmanoğlu E, Ünlü A, Bektaş M. Crossreacting material 197 (CRM197) affects actin cytoskeleton of endothelial cells. Gen Physiol Biophys 2017;36:383–9. 13. Scita G, Di Fiore PP. The endocytic matrix. Nature 2010;463:464–73. 14. Oh KJ, Senzel L, Collier RJ, Finkelstein A. Translocation of the catalytic domain of diphtheria toxin across planar phospholipid bilayers by its own T domain. Proc Natl Acad Sci U S A 1999;96:8467–70. 15. Tjelle TE, Brech A, Juvet LK, Griffiths G, Berg T. Isolation and characterization of early endosomes, late endosomes and terminal lysosomes: their role in protein degradation. J Cell Sci 1996;109:2905–14. 16. Laemmli UK. Cleavage of structural proteins during the assembly of the head of bacteriophage T4. Nature 1970;227:680–5. 17. Morris RE, Gerstein AS, Bonventre PF, Saelinger CB. Receptor-mediated entry of diphtheria toxin into monkey kidney (Vero) cells: electron microscopic evaluation. Infect Immun 1985;50:721–7. 18. Ratts R, Zeng H, Berg EA, Blue C, McComb ME, Costello CE, et al. The cytosolic entry of diphtheria toxin catalytic domain requires a host cell cytosolic translocation factor complex. J Cell Biol 2003;160:1139–50. 19. Rousseau S, Houle F, Kotanides H, Witte L, Waltenberger J, Landry J, et al. Vascular endothelial growth factor (VEGF)-driven actin-based motility is mediated by VEGFR2 and requires concerted activation of stress-activated protein kinase 2 (SAPK2/p38) and geldanamycin-sensitive phosphorylation of focal adhesion kinase. J Biol Chem 2000;275:10661–72. 20. Ramel D, Wang X, Laflamme C, Montell DJ, Emery G. Rab11 regulates cell-cell communication during collective cell movements. Nat Cell Biol 2013;15:317–24. 21. Antignani A, Youle RJ. Endosome fusion induced by diphtheria toxin translocation domain. Proc Natl Acad Sci U S A 2008;105:8020–5. 22. Gaillard PJ, de Boer AG. A novel opportunity for targeted drug delivery to the brain. J Control Release 2006;116:e60–2. 23. Tosi G, Vilella A, Veratti P, Belletti D, Pederzoli F, Ruozi B, et al. Exploiting Bacterial Pathways for BBB Crossing with PLGA Nanoparticles Modified with a Mutated Form of Diphtheria Toxin (CRM197): In Vivo Experiments. Mol Pharm 2015;12:3672–84.

Orıgınal Article

CARDIOLOGY

North Clin Istanb 2018;5(2):96–101 doi: 10.14744/nci.2017.35761

Role of the monocyte-to-high-density lipoprotein ratio in predicting atrial high-rate episodes detected by cardiac implantable electronic devices Seckin Satilmis Department of Cardiology, Acibadem Atakent University Hospital, Istanbul, Turkey

ABSTRACT OBJECTIVE: Technological advances have allowed cardiac implantable electronic devices (CIEDs) to detect, analyze, and store atrial high-rate episodes (AHREs), which are surrogate for the term silent atrial fibrillation (AF). The association of AHREs with adverse clinical events has been demonstrated in several recent studies, implying that morbidity and mortality can be significantly prevented by prompt recognition and intervention. Inflammation and oxidative stress are among several mechanisms that contribute to the pathogenesis of AF. The monocyte-to-high-density lipoprotein ratio (M/H ratio) is a novel indicator of both inflammation and oxidative stress. In this study, we aimed to investigate the value of the M/H ratio for predicting AHREs detected by CIEDs. METHODS: A total of 203 patients (mean age: 57.5+9.1 years, 60.1% male) implanted with a dual pacemaker because of sick sinus syndrome were included. Blood samples were obtained from the patients after 12 h of fasting for the analysis of routine biochemistry tests and the lipid panel in the morning of device implantation. At a clinical visit 6 months after CIED implantation, the devices were interrogated to detect the occurrence of AHREs. AHREs were defined as atrial episodes faster than 220 bpm and lasting longer than 5 min. The patients were divided into two groups depending on the presence of AHREs during pacemaker interrogation: Group 1 (AHRE present) and Group 2 (AHRE absent). RESULTS: At the clinical visit 6 months after CIED implantation, 51 (25.1%) patients had at least one AHRE. The M/H ratio was significantly higher in patients in Group 1 (11.41±1.24) than in those in Group 2 (8.17±1.02) (p<0.01). On performing multivariate Cox regression analysis, the M/H ratio was found to be associated with the occurrence of AHREs in patients with CIEDs (OR: 22.813, 95% CI: 6.852–75.953, p<0.01). CONCLUSION: The M/H ratio is an indicator of inflammation and oxidative stress, both of which play an important role in the pathogenesis of AF. This ratio was found to be statically higher in patients with AHREs detected by CIEDs than in those without AHREs. Keywords: Atrial high-rate episodes; cardiac implantable electronic devices; monocyte-to-high-density lipoprotein ratio; inflammation; oxidative stress

Cite this article as: Satilmis S. Role of the monocyte-to-high-density lipoprotein ratio in predicting atrial high-rate episodes detected by cardiac implantable electronic devices. North Clin Istanb 2018;5(2):96–101.

trial fibrillation (AF) is the most common cardiac rhythm disturbance in the adult population. The prevalence of AF has reached up to 10% in people over 80 years old 1. AF is associated with a 5-fold increase in the stroke risk and 2-fold increase in the mortality rate 2, which has necessitated prompt diagnosis and interven-

tion to prevent significant morbidity and mortality. In recent years, several studies have demonstrated the poor correlation between AF and symptoms 3. Until recently, difficulties in the diagnosis of asymptomatic AF have resulted in its importance to be unknown. Technological advances have allowed cardiac implantable electronic

Received: August 17, 2017 Accepted: September 06, 2017 Online: April 12, 2018 Correspondence: Dr. Seckin SATILMIS. Department of Cardiology, Acibadem Atakent University Hospital, Istanbul, Turkey. Phone: +90 532 634 89 77 e-mail: drseckin50@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Satilmis, AHREs detected by CIEDs

devices (CIEDs) to detect, analyze, and store atrial highrate episodes (AHREs) with high sensitivity and specificity 4, which led to emergence of the term “silent AF.” Subsequent studies have demonstrated that silent AF is not only a harbinger of the development of clinical AF but also increases the risk of ischemic stroke and death 5. The prediction of AHREs detected by CIEDs and the necessity of anticoagulation therapy for silent AF remain as some of the most controversial issues at present. Inflammation and oxidative stress are among several mechanisms contributing to the pathogenesis of AF. The activation of leukocytes and subsequent release of various pro-inflammatory and pro-oxidant cytokines and chemokines have led to pathological structural and electrical remodeling in the left atrium; this remodeling is considered to be an important prerequisite for the development of AF 6. High-density lipoprotein (HDL) exhibits anti-inflammatory and anti-oxidant properties by several pathways; these include inhibition of the transmigration of monocytes in response to oxidized low-density lipoprotein (LDL), expression of endothelial adhesion proteins, and promotion of the reverse transport of oxidized molecules 7. Due to these protective effects, a low HDL level is associated with more frequent AF occurrence 8. Recently, several studies have demonstrated the importance of the serum monocyte count-to-HDL ratio (M/H ratio) as a reliable predictor of AF recurrence after catheter ablation 9 and a prognostic marker in chronic kidney disease 10. To best of our knowledge, to date, no study has evaluated the role of the M/H ratio as a predictor of AHREs using CIEDs. Therefore, the aim of the present study was to investigate the use of the M/H ratio as a predictor of AHREs in patients with CIEDs. MATERIALS AND METHODS We prospectively enrolled 210 patients who were implanted with a dual chamber pacemaker because of sinus node dysfunction between January 2014 and December 2014. In all patients, the choice of device manufacturer was left to the discretion of the attending physician. Patients with a previous history of atrial arrhythmias, renal failure, valvular heart disease, valvuloplasty, or valve replacement procedure and patients on pacemaker rhythm were excluded. The final study population was 203 patients. All patients participating in the study provided written consent and signed the consent form. The study

was approved by the Institutional Ethical Committee. Baseline demographic characteristics and relevant clinical information of each patient were recorded at the time of implantation. All patients were implanted with a dual-chamber pacemaker, which was programmed to the DDDR mode. The atrial tachycardia detection mode was enabled, and the AF suppression feature was programmed off by performing atrial overdrive pacing. Bipolar atrial leads sensitivity and post-ventricular atrial blanking period was interrogated properly to reduce P-wave sensitivity and far-field R-wave over-sensing to identify atrial activities during AHREs. At a clinical visit 1 month later, the patients underwent transthoracic echocardiographic (TTE) by an expert in the field of cardiovascular imaging; 6 months after CIED implantation, the devices were interrogated to detect and classify the patients on the basis of the occurrence of AHREs. AHREs were defined as episodes faster that 220 bpm and lasting longer than 5 minutes on the basis of a previous study that demonstrated their significance via an increased rate of stroke and thromboembolic events and the exclusion of R-wave over-sensing episodes that were frequently found at periods of less than 5 min 11. The termination of AF was defined as the occurrence of 20 beats below the AHRE detection rate to ensure the exclusion of short episodes of atrial premature beats. The patients were divided into two groups on the basis of the presence of AHRE (Group 1) or absence (Group 2) of AHREs at the time of device interrogation. Blood samples were obtained from the patients after 12 h of fasting for the analysis of routine biochemistry tests and the lipid panel in the morning of device implantation. At the same time, samples for complete blood count analysis were collected in ethylene-diaminetetraacetic acid-anticoagulated tubes. The reference value for monocyte count in our laboratory was 2–10% of the total white blood cell count. All data were evaluated using IBM SPSS 22 (IBM SPSS, USA). Mean and standard deviation were used for quantitative variables; Student’s t-test was used for normally distributed variables in both groups, and the Mann–Whitney U test was used for variables that were not normally distributed. Qualitative variables were evaluated by Pearson’s chi-squared test and Yates’ correction for continuity. The logistic regression model was used in multivariate analysis to identify risk factors related to mortality. A p-value of <0.05 was considered to be statistically significant.

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Table 1. Demographic features of the study population Parameters

Total (n:203)

AHRE (-) (n:152)

AHRE (+) (n:51)

Age (years) Women Body Mass Index (kg/m2) Coronary Artery Disease Diabetes Mellitus Hypertension Dyslipidemia Alcohol intake Current smoker

67.51±9.17 81 (39.9%) 26.03±2.90 23 (11.3%) 85 (41.9%) 86 (42.3%) 41 (20.2%) 19 (8.8%) 59 (29.1%)

67.24±9.09 57 (37.5%) 25.98±2.90 17 (11.2%) 63 (41.7%) 63 (41.7%) 30 (19.7%) 14 (9.2%) 43 (28.3%)

68.31±9.43 24 (47.1%) 26.19±2.92 6 (11.8%) 22 (44%) 23 (45.1%) 11 (21.6%) 5 (9.8%) 16 (31.4%)

0.751 0.250 0.896 0.910 0.869 0.744 0.778 0.900 0.675

AHREs: Atrial high-rate episodes

Table 2. Echocardiographic and laboratory parameters Parameters

Total (n:203)

AHRE (-) (n:152)

AHRE (+) (n:51)

Ejection Fraction (%) Left Atrial Diameter (cm) Left ventricle end-diastolic diameter (cm) Left ventricle end-systolic diameter (cm) Hemoglobin (g/dl) Creatinine (mg/dl) Na(mEq/L) K (mEq/L) White Blood Cell Count (x109/L) Monocyte (x109/L) LDL Cholesterol (mg/dl) HDL Cholesterol (mg/dl) Monocyte/HDL ratio

60.64±4.98 3.86±0.26 4.5±0.3 2.65±0.39 13.51±1.76 0.95±0.25 138.30±3.04 4.16±0.56 7375±1.57 365.8±50.32 112.97±26.8 41.18±3.86 8.98±1.77

60.63±4.99 3.86±0.27 4.5±0.3 2.64±0.34 13.65±1.74 0.93±0.23 138.2±3.03 4.11±0.53 7344±1.35 344.2±34.07 111.53±25.6 42.28±3.39 8.17±1.02

60.69±5.00 3.87±0.25 4.5±0.3 2.67±0.48 13.10±1.75 0.99±0.27 139.32±2.12 4.31±0.60 7469±2.10 430.1±32.95 117.23±30.14 37.92±3.21 11.41±1.24

0.949 0.565 0.621 0.106 0.750 0.797 <0.001 0.094 0.623 <0.001 0.191 <0.001 <0.001

AHREs: Atrial high-rate episodes, HDL: High-density lipoprotein cholesterol, LDL: Low-density lipoprotein cholesterol, Na: Sodium, K: Potassium

RESULTS Between January 2014 and December 2014, 203 patients (mean age: 57.5+9.1 years, 60.1% male) with a dual pacemaker were included in the study. They were divided into two groups on the basis of presence of AHRE in their pacemaker interrogation at a clinical visit 6 months after device implantation. Fifty one (25.1%) patients with AHRE were in Group 1 and 152 (74.1%) patients without AHRE were in Group 2. Both groups were similar in terms of baseline characteristics and demographic features (Table 1). Echocardiographic and laboratory data of the study population are given in Table 2. As shown in Table-2, serum sodium

levels were statistically higher in Group 1 (p<0.01). Serum potassium and serum calcium levels were similar in both groups. Although the total white blood cell count was similar in both groups, serum monocyte levels were significantly higher in Group 1 (p<0.01). Serum high density lipoprotein levels were significantly lower in Group 1 (p<0.01). When comparing the M/H ratio in both groups, Group 1 showed significantly higher M/H values (11.41±1.24) than Group 2 (8.17±1.02) (p<0.01) (Fig. 1). TTE findings including left atrial diameter, left ventricular end-diastolic and systolic diameters, and ejection fraction were similar in both groups. According to univariate Cox proportional hazard

Satilmis, AHREs detected by CIEDs

Table 3. Univariate and multivariate Cox proportional Hazard modeling results of the occurrence of AHREs in patients with CIED

P value

Monocyte/HDL ratio LDL WBC Monocyte HDL Hemoglobin level

<0.01 0.899 0.702 <0.01 <0.01 0.265

Univariate analysis OR %95CI P value 22.813 1.001 0.946 1.079 0.617 0.863

6.852-75.953 0.986-1.016 0.711-1.259 1.051-1.108 0.521-0.730 0.667-1.118

Multivariate analysis OR %95CI

<0.01

3.768

0.123-0.392

<0.01

2.601

0.010-0.070

HDL: High-density lipoprotein cholesterol, LDL: Low-density lipoprotein cholesterol, WBC: White blood cell count

16.00 153

Monocyte-to-HDL ratio

14.00

12.00

10.00

8.00

6.00 Absent

Present

Figure 1. Atrial High Rate Episode regression analysis, serum monocyte count, HDL level, and M/H ratio were significantly associated with AHRE (p<0.01) (Table 3). Multivariate Cox proportional hazard regression analysis revealed that the M/H ratio (OR=3.768, 95% CI=0.123â&#x20AC;&#x201C;0.392, p<0.01) and serum HDL level (OR=2.601, 95% CI=0.01â&#x20AC;&#x201C;0.07, p<0.01) were independent predictors of AHRE in patients with CIEDs (Table 3). DISCUSSION In this prospective study, we aimed to focus on the association between the M/H ratio and AHRE occurrence in patients with CIEDs. After the follow-up visit, we

demonstrated that patients with a high M/H ratio before the procedure were more likely to develop AHREs. To the best of our knowledge, this is the first study reporting the value of the M/H ratio in predicting the occurrence of AHREs in this population. Electrical and structural remodeling is a complex mechanism underlying the pathogenesis of AF. Electrical remodeling includes an increased atrial refractory period and atrial conductivity prolongation, whereas structural remodeling includes left atrial dilation and increased connective tissue deposition within the atrial wall, leading to atrial fibrosis. Functional changes within the atria occurring after the development of AF perpetuate the arrhythmia via these complex mechanisms (AF begets AF). Over the past years, electrical remodeling has been considered to be the main pathway leading to the occurrence and persistence of AF. However, recent reports, including studies on atrial biopsies of patients with AF, have demonstrated that structural remodeling caused by inflammation and oxidative damage occurs in parallel with electrical remodeling 12. There is strong evidence on the association of inflammation with various cardiovascular conditions including coronary artery disease, diabetes mellitus and hypertension. Similarly, recent studies have demonstrated that inflammatory processes are involved in the pathogenesis of AF 13. C-reactive protein (CRP) is a highly specific biomarker of systemic inflammation. AF incidence is higher in post-operative patients. The peak incidence of AF occurs during the second and third day postoperatively, which is similar to the time when the CRP level peaks 14. Inflammatory markers, including IL-6, IL-8,

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IL-10, VEGF, and CRP, levels were found to be higher in patients with AF than in those with sinus rhythm 15. The activation of leukocytes is considered to be the key initiating step that leads to various inflammatory cascades. Leukocytes are the main source of inflammatory cytokines, including TNF-α, IL-6, and IL-8, which are found to be present in higher levels in the blood samples of patients with AF than in the samples of those with sinus rhythm 16. Yamashita et al. studied the left atrial appendage specimens of patients with AF undergoing the maze procedure and repair of non-rheumatic mitral valve regurgitation or atrial septal defect 16. Immunohistochemistry of specimens revealed more prominent leucocyte infiltration in the endo/sub-endocardium in patients with AF. Leucocytes were positive for CD45 and CD68, which are specific for monocytes and macrophages. In addition, leucocytes were activated during their transmigration from the endo/sub-endocardium to the mid-myocardium. The adhesion and transmigration of immune cells were regulated by various adhesion molecules and chemokines. Immunohistochemical analysis revealed that the expression of adhesion molecules, including ICAM-1 and VCAM-1, was high in the endocardium of patients with AF; however, the expression of these molecule was low in patients with sinus rhythm. Monocyte chemotactic protein-1 (MCP-1) is known to be a chemotactic molecule that regulates the transmigration of immune cells following activation and adhesion. MCP-1 expression was higher in patients with AF than in those with sinus rhythm. Locally expressed IL-6 and TGF-ß propagate inflammation and increase extracellular matrix deposition and fibrosis. Yamashita et al. demonstrated that monocytes and macrophages within atrial specimens of patients with AF highly expressed these cytokines, leading to electrical and structural remodeling. These observations suggested the presence of “occult myocarditis” within atrial layers with the recruitment of immune cells predominantly monocytes/macrophages 16. Dyslipidemia is associated with atherosclerosis and a risk factor for various cardiovascular conditions including coronary artery disease and stroke. However, there are conflicting results on the role of dyslipidemia in the occurrence of AF 17. Reverse cholesterol transport is the best recognized mechanism by which HDLs exert their anti-atherogenic function. However, recent studies have revealed other functions of HDLs, including anti-inflammatory and

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anti-oxidant functions, which can guide its association with AF 18. HDLs exert anti-oxidant functions via various mechanisms. They bind and transport oxidant molecules such as lipid hydroperoxides in different cell types 18. In addition, HDLs possess several enzymes that degrade lipid hydroperoxides, which oxidize the cell membrane components of LDL. HDL exhibits anti-inflammatory effects on several steps in the inflammation process. HDL inhibits the adhesion of immune cells via reduced expression of activated endothelial adhesion molecules including VCAM1, ICAM-1, and E-selectin 19. In addition, HDLs inhibit MCP-1, which is a chemokine for monocytes/ macrophages, in response to LDL oxidation 19. These observations led researchers to investigate the possible association of HDL with AF occurrence. Watanabe et al. investigated the association of lipid profile and new-onset AF in the general population. According to the result of that study, a lower HDL plasma level is a risk factor for AF occurrence, particularly in women 8. Recently, Canpolat et al. investigated the impact of the M/H ratio before the procedure in predicting AF recurrence after successful cryoballoon-based catheter ablation. They demonstrated that an increased M/H ratio is an independent and strong predictor of AF recurrence after successful cryoablation 9. A cut-off M/H ratio of >11.48, which is slightly higher than ours (>9.48), has been established for the prediction of AF recurrence. In addition, Kanbay et al. reported that higher M/H ratios are associated with poorer cardiovascular outcome in patients with chronic kidney diseases 10. The term “silent AF” has emerged in accordance with advances in CIED technology. In several studies, researchers have concluded that AHREs are harbingers of mortality and morbidity, particularly in terms of stroke and future AF 20. In light of these data, patients with AHREs constitute an important group of patients for anti-coagulants to prevent fatal and non-fatal thromboembolic complications. To date, a screening method to predict AHRE in patients with CIEDs is absent. In our study, the M/H ratio predicted AHREs with high sensitivity and specificity. However, prospective double-blind studies are needed to confirm this prediction. Our study should be evaluated with its inherent limitations. Firstly, this was a single-center study with a limited number of patients. Secondly, measuring of the

Satilmis, AHREs detected by CIEDs

serum HDL level and monocyte count once may not be sufficient for use as a parameter. Thirdly, we defined AHRE as episodes faster than 220 bpm and longer than 5 min; different definitions of AHREs in terms of atrial rate and duration are present in the literature. Using other AHRE definitions would lead to results that are different from those in our present study. CONCLUSION AHREs detected by CIEDs are harbingers of ischemic stroke and future AF. The M/H ratio is a novel biomarker representing both inflammation and oxidative stress. Our results indicate that an elevated M/H ratio can predict AHREs in patients with CIEDs. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:2370–5. 2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991;22:983–8. 3. Page RL, Wilkinson WE, Clair WK, McCarthy EA, Pritchett EL. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation 1994;89:224–7. 4. Jędrzejczyk-Patej E, Lenarczyk R, Mazurek M, Liberska A, Przybylska-Siedlecka K, Podolecki T, et al. Can we rely on machines? Devicedetected atrial high rates correspond well with atrial arrhythmias in cardiac resynchronization recipients. Europace 2016;18:436–44. 5. Glotzer TV, Hellkamp AS, Zimmerman J, Sweeney MO, Yee R, Marinchak R, et al. Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: report of the Atrial Diagnostics Ancillary Study of the MOde Selection Trial (MOST). Circulation 2003;107:1614–9.

101 6. Psychari SN, Apostolou TS, Sinos L, Hamodraka E, Liakos G, Kremastinos DT. Relation of elevated C-reactive protein and interleukin-6 levels to left atrial size and duration of episodes in patients with atrial fibrillation. Am J Cardiol 2005;95:764–7. 7. Barter PJ, Baker PW, Rye KA. Effect of high-density lipoproteins on the expression of adhesion molecules in endothelial cells. Curr Opin Lipidol 2002;13:285–8. 8. Watanabe H, Tanabe N, Yagihara N, Watanabe T, Aizawa Y, Kodama M. Association between lipid profile and risk of atrial fibrillation. Circ J 2011;75:2767–74. 9. Canpolat U, Aytemir K, Yorgun H, Şahiner L, Kaya EB, Çay S, et al. The role of preprocedural monocyte-to-high-density lipoprotein ratio in prediction of atrial fibrillation recurrence after cryoballoon-based catheter ablation. Europace 2015;17:1807–15. 10. Kanbay M, Solak Y, Unal HU, Kurt YG, Gok M, Cetinkaya H, et al. Monocyte count/HDL cholesterol ratio and cardiovascular events in patients with chronic kidney disease. Int Urol Nephrol 2014;46:1619–25. 11. Pollak WM, Simmons JD, Interian A Jr, Atapattu SA, Castellanos A, Myerburg RJ, et al. Clinical utility of intraatrial pacemaker stored electrograms to diagnose atrial fibrillation and flutter. Pacing Clin Electrophysiol 2001;24:424–9. 12. Frustaci A, Chimenti C, Bellocci F, Morgante E, Russo MA, Maseri A. Histological substrate of atrial biopsies in patients with lone atrial fibrillation. Circulation 1997;96:1180–4. 13. Boos CJ, Anderson RA, Lip GY. Is atrial fibrillation an inflammatory disorder? Eur Heart J 2006;27:136–49. 14. Guo Y, Lip GY, Apostolakis S. Inflammation in atrial fibrillation. J Am Coll Cardiol 2012;60:2263–70. 15. Li J, Solus J, Chen Q, Rho YH, Milne G, Stein CM, et al. Role of inflammation and oxidative stress in atrial fibrillation. Heart Rhythm 2010;7:438–44. 16. Yamashita T, Sekiguchi A, Iwasaki YK, Date T, Sagara K, Tanabe H, et al. Recruitment of immune cells across atrial endocardium in human atrial fibrillation. Circ J 2010;74:262–70. 17. Annoura M, Ogawa M, Kumagai K, Zhang B, Saku K, Arakawa K. Cholesterol paradox in patients with paroxysmal atrial fibrillation. Cardiology 1999;92:21–7. 18. Christison J, Karjalainen A, Brauman J, Bygrave F, Stocker R. Rapid reduction and removal of HDL- but not LDL-associated cholesteryl ester hydroperoxides by rat liver perfused in situ. Biochem J 1996;314:739– 42. 19. Cockerill GW, Rye KA, Gamble JR, Vadas MA, Barter PJ. High-density lipoproteins inhibit cytokine-induced expression of endothelial cell adhesion molecules. Arterioscler Thromb Vasc Biol 1995;15:1987–94. 20. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, et al; ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012;366:120–9.

Orıgınal Article

PHYSICAL THERAPY & REHABILITATION

North Clin Istanb 2018;5(2):102–108 doi: 10.14744/nci.2017.31644

The relationship between serum leptin level and disease activity and inflammatory markers in fibromyalgia patients Safinaz Ataoglu,1 Handan Ankarali,2 Rumeysa Samanci,1 Mustafa Ozsahin,1 Ozlem Admis3 Department of Physical Medicine and Rehabilitation, University of Duzce, Medical Faculty, Duzce, Turkey

Department of Biostatistics and Medical Informatics, University of Istanbul Medeniyet, Medical Faculty, Istanbul, Turkey

Department of Biochemistry, University of Duzce, Medical Faculty, Duzce, Turkey

ABSTRACT OBJECTIVE: The aim of this study was to investigate whether there is a correlation between serum leptin level, disease activity and inflammation markers in patients with fibromyalgia syndrome (FMS). METHODS: A total of 48 patients with FMS diagnosed according to the 1990 American College of Rheumatology criteria were included in the study, as well as 36 healthy women as controls. The Visual Analogue Scale was used to gauge pain severity, the Fibromyalgia Impact Questionnaire was used to assess physical function, the 36-Item Short Form Health Survey was used to examine quality of life, and depression was measured with the Beck Depression Inventory. Blood samples were examined for erythrocyte sedimentation rate (ESR), C-reactive protein level (CRP), high-sensitivity CRP level (hsCRP), the neutrophil-tolymphocyte ratio (NLR), and the serum leptin level was determined using the enzyme-linked immunosorbent assay method. RESULTS: The serum leptin level in patients with FMS was significantly higher than in the healthy group. However, no significant relationship was found between leptin level and clinical and inflammatory parameters. In addition, there were no significant differences between the patients and the control group in measurements of ESR, CRP, hsCRP, or NLR. CONCLUSION: A higher serum leptin level in patients with FMS suggested that leptin may play role in the pathogenesis of FMS, yet there was no relationship between leptin and clinical and inflammatory parameters, suggesting that leptin is not an indicator of disease activity in FMS. Additional research should be performed with larger patient groups. Keywords: Fatigue syndrome; fibromyalgia; inflammation; leptin.

Cite this article as: Ataoglu S., Ankarali H., Samanci R., Ozsahin M., Admis O. The relationship between serum leptin level and disease activity and inflammatory markers in fibromyalgia patients. North Clin Istanb 2018;5(2):102–108.

ibromyalgia syndrome (FMS), is a complex clinical entity characterized by widespread body pain and may be associated with numerous symptoms [1]. FMS is a frequently encountered clinical entity, with a prevalence of 2% to 8%, and an important public health problem, as it causes labor loss, a deterioration in the quality of life of the patient, and significant treatment expenditures [2, 3].

Though the etiopathogenesis of FSM is not precisely known, genetic and environmental factors, as well as peripheral and central mechanisms are thought to have roles [4]. Leading hypotheses include central sensitization, central nervous system dysfunction, alterations in neuropeptide levels, neuroendocrinal dysfunction, and sleep disorders, while peripheral hypotheses include

Received: June 06, 2017 Accepted: August 18, 2017 Online: April 16, 2018 Correspondence: Dr. Handan ANKARALI. Department of Biostatistics and Medical Informatics, University of Istanbul Medeniyet, Medical Faculty, Istanbul, Turkey. Phone: +90 216 280 40 18 e-mail: handanankarali@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Ataoglu et al., Serum Leptin Level in Fibromyalgia Patients

autonomic dysfunction, and structural and functional disorders involving immunological and inflammatory processes, and muscle tissue [5]. The theory that chronic pain in FMS may be the result of inflammation or a response to inflammation has promoted investigation of inflammatory disorders associated with changes in the neuroimmunoendocrine system [6, 7]. Some of the studies performed thus far have demonstrated increases in the levels of inflammatory markers in FMS [8, 9]. Leptin is a multifactorial hormone produced by differentiated adipocytes. It suppresses food intake and increases energy expenditure [10]. Among its many functions in the body, leptin also plays a role in the pathogenesis of inflammation and pain [11]. In the literature, only 4 studies have investigated an association between leptin and FMS. The results of these studies are contradictory, reporting higher, normal, and lower leptin levels [12-14]. The aim of this study was to investigate the correlation between serum leptin level, disease activity, and markers of inflammation, and to compare the leptin level in patients diagnosed with FMS with that of healthy individuals. MATERIALS AND METHODS Sampling and data A total of 48 female patients aged between 18 and 60 years who presented at the Düzce University Faculty of Medicine Department of Physical Medicine and Rehabilitation and were diagnosed with FMS based on the 1990 American College of Rheumatology classification criteria, and 36 healthy women were enrolled in the study. All of the participants were informed about the research and provided informed consent forms. Approval was obtained from the ethics committee of Duzce University. In both groups, a baseline record was made of age, height, weight, body mass index (BMI), educational level, history of surgery, exercise habits, and smoking and alcohol use history. The patients with FMS were asked about the onset of complaints, duration, symptoms of disease, treatments received, and concurrent diseases present, and generalized pain was evaluated. The Visual Analogue Scale (VAS) was used to gauge pain severity, the Fibromyalgia Impact Questionnaire (FIQ) was used to assess disease severity, the 36-Item Short Form Health Survey (SF-36) was used to examine quality of life, and depression was measured with the Beck Depression Inventory (BDI).

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Patients with a history of antidepressant use; malignancy; acute or subacute chronic viral/bacterial infection; major psychiatric disease; chronic inflammatory disease; neurological disease; diabetes mellitus or other endocrinological or metabolic disease; age <18 or >60 years; or current pregnancy or nursing were not included in the study. Furthermore, in order to eliminate the obesity factor on leptin level, women with a BMI >30 kg/m2 were excluded. Following an overnight of fast of 12 hours, venous blood samples were drawn from the patients and healthy controls at between 8:00 and 9:00 am. Three gel vacuum tubes were used for each participant. The first sample was used for routine biochemical analyses (hemogram, erythrocyte sedimentation rate [ESR], rheumatoid factor, thyroid function tests, 25-hydroxy vitamin D, vitamin B12), C-reactive protein (CRP), and high-sensitivity CRP (hsCRP). The second tube was used to measure the serum leptin level, and the third tube was held in reserve as a backup, since hemolysis may affect measurement results. The blood samples were centrifuged at 3500 rpm for 4 minutes, and the serum was separated. The remainder of the sample was divided into 2 portions, placed in Eppendorf tubes, and kept frozen at -20°C until the day of analysis. The samples were left at room temperature to achieve lysis before the serum leptin level of all of the samples was measured in a single session using the enzyme-linked immunosorbent assay method and a commercial kit (DRG Leptin ELISA Kit; DRG International, Inc., Springfield, NJ, USA). The results were expressed in ng/mL. Statistical analysis Descriptive statistics of the data were calculated as mean±SD, numerical values, and percentages, as appropriate, according to the type of data. The fitness of quantitative data to normal distribution was assessed using the Shapiro-Wilk test, and based on the normality of distribution, the groups were compared using an independent samples t-test or the Mann-Whitney U test. Correlations between quantitative characteristics were analyzed using the appropriate correlation coefficient. Associations between groups and categorical variables were evaluated using the Pearson chi-square or FisherFreeman-Halton test. PASW Statistics for Windows, Version 18.0 (SPSS, Inc., Chicago, IL, USA) was used to perform the analysis, and the level of statistical significance was accepted as p<0.05.

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RESULTS The mean age of the FMS patients and the healthy participants was 38.58±7.62 years and 37.86±9.46 years, respectively. The mean BMI value of the FMS patients and the controls was 25.02±3.24 kg/m² and 24.44±2.86 kg/m², respectively. No significant intergroup difference was detected between the mean values for age or BMI (p=0.700 and p=0.395, respectively). Among the patients, the mean duration of the complaints was 46.93±61.69 months (range: 3-360 months), the mean VAS pain score was 6.12±1.57 (range: 4-10 points), and the mean number of tender points detected was 14.31±3.66 (range: 11-18). Using the cut-off score of 17 points, BDI analysis revealed that 29.2 % (n=14) of the patients were not depressed (<17 points), while 70.9% (n=34) exhibited depression (>17 points). The mean FIQ score of the FMS patients was 56.23±18.06 points. The educational, professional, and marital status of the patients and the control group is provided in Table 1. There was a larger percentage of housewives among the FSM patients, and statistically significantly fewer manual laborers (p=0.009). Furthermore, a statistically significantly larger number of FMS patients had at most

a secondary school education (p=0.038). The distribution of marital status and exercise habit was comparable between the 2 groups (p=0.432 and 0.896, respectively Table 1). Descriptive values and intergroup comparisons of the subdimensional scores of the SF-36 and the BDI scales are presented in Table 2. The mean values for all of the subdimensional scores of the SF-36 were higher in the control group. However, the mean BDI score and the mean serum leptin level was significantly higher in the FMS group (p=0.001 and p=0.045, respectively). There was not a statistically significant difference in the mean serum leptin level between FMS patients with and without depression. A statistically significant correlation was not found between scale scores, blood parameters, VAS and BMI values, and the serum leptin level in the FMS patients (for each correlation, the coefficient was <0.20 and p>0.05). Symptoms of FMS observed included fatigue (85.4%), headache (85.4%), restless sleep (70.8%), morning stiffness (72.9%), irritable bowel syndrome (85.4%), Raynaud syndrome-like symptoms (29.2%), paresthesia (83.3%), sicca syndrome-like symptoms (62.5%), depression (50%), anxiety (87.5%), irritable bladder (54.2%), concentration and memory difficulties (83.3%),

Table 1. Distribution of the professional, educational, and marital status in the patient and control groups Profession Education Marital status Habit of exercising FMS: Fibromyalgia syndrome

Housewife Manual laborer White-collar worker Retiree Illiterate Primary/secondary Middle school High school/university Never married Married Divorced Deceased spouse Living separated Yes No

FMS (n=48) Number % 30 15 3 0 0 35 8 5 2 42 2 1 1 30 18

62.5 31.3 6.3 0 0 72.9 16.7 10.4 4.2 87.5 4.2 2.1 2.1 62.5 37,5

Control (n=36) Number % 10 22 3 1 2 17 7 10 5 28 2 1 0 23 13

27.8 61.1 8.3 2.8 5.6 47.2 19.4 27.8 13.9 77.8 5.6 2.8 0 63.9 36.1

0.009

0.038

0.432

0.896

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Table 2. Scale scores and clinical characteristics of the FMS patients and controls Scale scores and clinical characteristics

FMS (n=48) Control (n=36) Mean SD Mean SD

Physical function Physical role difficulty Pain General health Vitality Social function Emotional role Mental health BDI FIQ ESR (mm/hr) CRP (mg/L) hsCRP (mg/L) NLR Leptin (ng/mL)

18.87 5.12 5.61 12.72 10.58 6.31 4.16 16.66 20.14 56.23 14.10 0.26 3.20 2.01 30.32

4.45 1.29 1.76 4.05 3.53 1.82 1.20 5.10 10.52 18.06 11.80 0.49 6.27 0.84 57.25

24.15 6.18 8.28 16.44 14.39 7.93 4.75 20.87 9.36 --- 15.33 0.14 6.06 1.81 11.15

3.82 1.68 1.83 3.70 2.80 1.88 1.27 3.25 4.52 --- 10.59 0.11 17.85 0.56 7.06

<0.001 0.004 <0.001 <0.001 <0.001 <0.001 0.046 <0.001 <0.001 --0.199 0.520 0.923 0.406 0.045

BDI: Beck Depression Inventory; ESR: Erythrocyte sedimentation rate; FIQ: Fibromyalgia Impact Scale; FMS: Fibromyalgia syndrome; hsCRP: High-sensitivity Creactive protein; NLR: Neutrophil-to-lymphocyte ratio

and dysmenorrhea (43.8%). The level of leptin did not change significantly in parallel with the presence of FMS symptoms (p>0.05). DISCUSSION The etiopathogenesis of FMS, which is a complex and multidimensional syndrome, is not yet completely known. Therefore, studies continue with the goal of further clarification. Many factors, particularly central sensitization, have been demonstrated to play a part. Although there is strong belief that FMS is not essentially an inflammatory disease, hypotheses that advocate that the chronic pain in FMS is the result of inflammation and/or a response to inflammation are still relevant.6 In this study, the inflammatory hypothesis was investigated by examining the correlation between FMS disease activity, inflammatory markers, and leptin, which is known to have an effect on pain and inflammation. The serum leptin level of FMS patients was compared with that of healthy individuals. As a multifunctional hormone, leptin plays a role in both immune system activity and inflammation.1 Studies investigating the relationship between leptin and inflammation have particularly concentrated on chronic inflammatory rheumatic diseases. A growing number of studies are investigating correlations between leptin

and rheumatic diseases, such as rheumatoid arthritis, ankylosing spondylitis, systemic sclerosis, and systemic lupus erythematosus, with controversial outcomes [1518]. The role of leptin in inflammation is still not fully understood. Four studies in the literature have investigated a correlation between leptin and FMS. In these studies, contradictory outcomes were reported, with higher, normal, and lower levels of leptin [12-14, 19]. Fietta and Fietta [19] studied 10 male and 20 postmenopausal women with FMS matched for age, gender, and BMI. They found a significantly higher leptin level in FMS patients when compared with healthy control subjects, and they observed an insignificant decrease in the serum cortisol level. They suggested a potential etiopathogenic role in the interaction between leptin and the hypothalamo pituitary axis (HPA). They also emphasized that leptin may exert negative feedback on the HPA as an adaptation to chronic stress, and psychopathology may become manifest when this mechanism is impaired. Homann et al. 14 investigated a correlation between markers of obesity and the levels of the 2 hormones leptin and ghrelin, which are responsible for energy homeostasis in FMS. They detected a lower ghrelin level, but a higher serum leptin level in FMS patients compared with controls, independent of body fat stores.

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They associated pain with an increase in leptin receptors and sensitivity to leptin, and suggested that there might be a correlation between the clinical state of FMS and an elevated leptin level. Olama et al. [13] found significantly lower leptin levels in 50 female patients with FMS when they were compared with age-, gender-, and BMImatched healthy individuals. They suggested that leptin may be dysregulated in FSM and might have a potential role in the pathogenesis of FMS. In contrast, Ablin et al. [12] did not find a difference in the leptin level between FMS patients and healthy controls. In the present study we found a higher serum leptin level in FSM patients compared with healthy control subjects. Our results were comparable to the results reported by Fietta and Fietta [19] and Homann et al. [14]. The most important disadvantage of the study performed by Homann et al. [14] was the smaller study population. When our results and the other studies are taken into consideration, the elevated leptin level in 3 of 5 studies suggests that a higher leptin level in FSM may suppress the HPA and impair the mechanism so as to adapt to chronic stress with a resultant development of psychopathological disorders. Furthermore, pain may be related to leptin sensitivity. Yet the available results are still insufficient to determine an association between the pathogenesis of FSM and leptin. The most important limitation of this study was its small sample size. Laposky et al. [20] induced leptin deficiency in rats and found that the deficiency impaired sleep quality and the normal diurnal rhythm of the subjects. In a study of 1024 volunteer participants, Taheri et al. [21] detected a correlation between the level of leptin and reduced duration of sleep. However, most of the studies performed on leptin and sleep disorders were investigating obesity and obesity-related sleep disorders [22]. Piche et al. [23] found that fatigue was associated with an increased leptin level in patients with chronic hepatitis C. Olama et al. [13] observed a lower mean leptin level in FSM patients complaining of post exercise pain, confusion, dizziness, anxiety, short-term memory impairment, mood disorders, temporomandibular joint disorders, palpitations, sleep disorder, and irritable bowel syndrome when compared with FMS patients without these complaints. In the present study, we did not find a correlation between leptin level and fatigue, restless sleep, headache, morning stiffness, or other symptoms. Olama et al. [13] found a negative correlation between leptin level, the severity of clinical symptoms, functional sufficiency, and quality of life. However, Ablin et al. [12] did not find a correlation between serum leptin level and

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clinical parameters reflecting the severity of FSM. In this study, too, no significant correlation was found between the serum leptin level of the patients and components of the FIQ and SF-36 scales. Rats exposed to chronic stress have demonstrated a decreased leptin level, and the administration of leptin reduced depressive behaviors [24]. Yet, in human beings, the meaning of the results of research about leptin is still a question. In various studies, an increased, decreased, or stable level of leptin has been reported in patients with depression [25-27]. It has been suggested that leptin exerts an anxiogenic effect by antigonizing some activities of neuropeptide Y, which has anxiolytic properties [28]. Its use has been recommended as a valid neuroendocrinological marker in states of hypervigilance [29]. In this study, no significant difference in leptin level was seen between depressed and nondepressed patients with FMS. Olama et al. [13] also investigated a relationship between depression and serum leptin level, and found a negative correlation between the serum leptin level and BDI score in FMS patients. They reported that leptin may cause negative feedback inhibition in the HPA in order to adapt to chronic stress, and that impairment of this mechanism may result in the development of psychopathological disorders. In this study, we found a statistically insignificantly higher serum leptin level in FMS patients who had received treatment when compared with untreated FMS patients. Bokarewa et al. [30] also detected a statistically insignificantly higher serum leptin level in treated FMS patients when compared with those who were untreated. Ablin et al. [12] reported a lack of any significant change in leptin level in FMS after treatment for 3 months. Eser et al. [31] evaluated the effects on leptin level to treatment response to various antidepressants. At least in the short term, they found a marked increase in leptin level with therapeutic response to drug treatment for depression. Various studies have indicated that mirtazapine slightly increased leptin levels, fluoxetine decreased leptin in the short term, and venlafaxine, paroxetine, and tricyclic antidepressants did not change leptin levels [32-34]. Shamsuzzaman et al. [35] investigated the relationship between leptin and CRP, and detected a positive correlation in both men and women. They remarked on the contribution of adipose tissue to the synthesis of both leptin and CRP, which is a source of inflammatory cytokines. However, this strong relationship between leptin and CRP is independent of adipose tissue parameters like BMI and waist-hip ratio, which suggests that

Ataoglu et al., Serum Leptin Level in Fibromyalgia Patients

leptin may increase the CRP level via direct or indirect effects on the immune system. As another possibility, since leptin receptors have similar signal characteristics to interleukin 6 (IL-6) cytokine receptors, it may increase the level of CRP secondary to the induction of cytokines, including IL-6. In this study, we did not observe a significant correlation between the leptin level and inflammatory markers. Leptin has many functional roles in the body, including an important place in the regulation of pain. Leptin appears to have an important role in the regulation of pain and has been shown to inhibit the response of the HPA axis to stress by inhibiting the secretion of cortisol. 12 Some authors have suggested that leptin-related modulation of pain is realized through a neuropeptide Y-dependent mechanism in the thalamus [36]. Studies performed with patients suffering from chronic pain have detected higher levels of leptin compared with healthy individuals [37]. Some authors have also reported a correlation between leptin and pain in patients with spinal injury, acute coronary syndrome, and osteoarthritis of the knee [38]. Bokarewa et al. [30] investigated the correlation between the levels of leptin and neuropeptide Y and smoking in patients with FMS. They evaluated the impact of smoking on parameters of pain and adipokines in the FMS patients. Smoking was associated with a reduced serum leptin level among FMS patients. Despite a lower leptin level, an expected increase in the neuropeptide Y level was not observed in the smokers. The authors reported that an imbalance between leptin and neuropeptide Y may be a possible mechanism of the chronic pain seen in FMS. In this study, we thought that a higher leptin level in patients with FMS might be related to the pathophysiology of chronic pain. Studies investigating the correlation between leptin and BMI have tended to demonstrate the presence of a positive correlation between them [39]. However, our results in this study did not indicate a significant correlation between leptin and BMI. Our study has some limitations. The most important is that both the patient group and the control group included postmenopausal women. Pamuk et al. [40] reported that postmenopausal FMS patients had described more severe pain, and that the symptoms of some of them started with the onset of menopause or that menopause had exacerbated their symptoms. The level of leptin may be increased by exogenous and endogenous sources that are hard to control, and this may have affected the outcomes of our study. Another limitation is that instead of

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using detailed anthropometric measurements, we only used BMI values. In addition, the complaints of some of our study participants had started recently, while some of the FMS patients had been experiencing complaints for a long time. Therefore, a more homogenous grouping might prove beneficial. According to the results of our study, we think that leptin may have a potential role in the etiopathogenesis of FMS. However, our inability to find a correlation between leptin and clinical scores demonstrated that leptin cannot be used as a parameter for the evaluation of disease activity in FMS. We think that larger-scale studies with homogenous patient groups should be conducted to further investigate the correlation between FMS and leptin. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – S.A., R.S., M.O.; Design – S.A., R.S., M.O., H.A.; Supervision – S.A., M.O.; Materials – S.A., M.O., R.S., O.A.; Data collection &/or processing – H.A., R.S.; Analysis and/or interpretation – H.A., S.A.; Writing – R.S., S.A., H.A.; Critical review – S.A., H.A., R.S., O.A.

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108 11. Fantuzzi G, Faggioni R. Leptin in the regulation of immunity, inflammation, and hematopoiesis. J Leukoc Biol 2000;68:437–46. 12. Ablin JN, Aronov N, Shimon I, Kanety H, Pariente C, Aloush V, et al. Evaluation of leptin levels among fibromyalgia patients before and after three months of treatment, in comparison with healthy controls. Pain Res Manag 2012;17:89–92. 13. Olama SM, Elsaid TO, El-Arman M. Serum leptin in Egyptian patients with fibromyalgia syndrome: relation to disease severity. Int J Rheum Dis 2013;16:583–9. 14. Homann D, Carvalho HM, Stefanello JM, Góes SM, Lopes AL, de Oliveira AR, et al. Hyperleptinemia independent of body adiposity in women with fibromyalgia. Rheumatol Int 2014;34:1593–8. 15. Popa C, Netea MG, Radstake TR, van Riel PL, Barrera P, van der Meer JW. Markers of inflammation are negatively correlated with serum leptin in rheumatoid arthritis. Ann Rheum Dis 2005;64:1195–8. 16. Toussirot E, Streit G, Nguyen NU, Dumoulin G, Le Huédé G, Saas P, et al. Adipose tissue, serum adipokines, and ghrelin in patients with ankylosing spondylitis. Metabolism 2007;56:1383–9. 17. Wisłowska M, Rok M, Stepień K, Kuklo-Kowalska A. Serum leptin in systemic lupus erythematosus. Rheumatol Int 2008;28:467–73. 18. Budulgan M, Dilek B, Dağ ŞB, Batmaz I, Yıldız İ, Sarıyıldız MA, et al. Relationship between serum leptin level and disease activity in patients with systemic sclerosis. Clin Rheumatol 2014;33:335–9. 19. Fietta P, Fietta P. Counterbalance between leptin and cortisol may be associated with fibromyalgia. Psychiatry Clin Neurosci 2006;60:529. 20. Laposky AD, Shelton J, Bass J, Dugovic C, Perrino N, Turek FW. Altered sleep regulation in leptin-deficient mice. Am J Physiol Regul Integr Comp Physiol 2006;290:R894–903. 21. Taheri S, Lin L, Austin D, Young T, Mignot E. Short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. PLoS Med 2004;1:e62. 22. Ulukavak Ciftci T, Kokturk O, Bukan N, Bilgihan A. Leptin and ghrelin levels in patients with obstructive sleep apnea syndrome. Respiration 2005;72:395–401. 23. Piche T, Gelsi E, Schneider SM, Hébuterne X, Giudicelli J, Ferrua B, et al. Fatigue is associated with high circulating leptin levels in chronic hepatitis C. Gut 2002;51:434–9. 24. Kim CS, Huang TY, Garza J, Ramos F, Frazer A, Liu F, et al. Leptin induces antidepressant-like behavioral effects and activates specific signal transduction pathways in the hippocampus and amygdala of mice. Neuropsychopharmacology 2006;31:S237–8. 25. Kraus T, Haack M, Schuld A, Hinze-Selch D, Pollmächer T. Low leptin levels but normal body mass indices in patients with depression or schizophrenia. Neuroendocrinology 2001;73:243–7. 26. Rubin RT, Rhodes ME, Czambel RK. Sexual diergism of baseline plasma leptin and leptin suppression by arginine vasopressin in major depressives and matched controls. Psychiatry Res 2002;113:255–68. 27. Jow GM, Yang TT, Chen CL. Leptin and cholesterol levels are low in

North Clin Istanb major depressive disorder, but high in schizophrenia. J Affect Disord 2006;90:21–7. 28. Suomalainen M, Männistö PT. Lack of effect of leptin on the behaviour of mice predicting the level of anxiety and depression. Pharmacol Toxicol 1998;83:139–42. 29. Liao SC, Lee MB, Lee YJ, Huang TS. Hyperleptinemia in subjects with persistent partial posttraumatic stress disorder after a major earthquake. Psychosom Med 2004;66:23–8. 30. Bokarewa MI, Erlandsson MC, Bjersing J, Dehlin M, Mannerkorpi K. Smoking is associated with reduced leptin and neuropeptide Y levels and higher pain experience in patients with fibromyalgia. Mediators Inflamm 2014;2014:627041. 31. Esel E, Ozsoy S, Tutus A, Sofuoglu S, Kartalci S, Bayram F, et al. Effects of antidepressant treatment and of gender on serum leptin levels in patients with major depression. Prog Neuropsychopharmacol Biol Psychiatry 2005;29:565–70. 32. Kraus T, Haack M, Schuld A, Hinze-Selch D, Koethe D, Pollmächer T. Body weight, the tumor necrosis factor system, and leptin production during treatment with mirtazapine or venlafaxine. Pharmacopsychiatry 2002;35:220–5. 33. Dryden S, Brown M, King P, Williams G. Decreased plasma leptin levels in lean and obese Zucker rats after treatment with the serotonin reuptake inhibitor fluoxetine. Horm Metab Res 1999;31:363–6. 34. Hinze-Selch D, Schuld A, Kraus T, Kühn M, Uhr M, Haack M, et al. Effects of antidepressants on weight and on the plasma levels of leptin, TNF-alpha and soluble TNF receptors: A longitudinal study in patients treated with amitriptyline or paroxetine. Neuropsychopharmacology 2000;23:13–9. 35. Shamsuzzaman AS, Winnicki M, Wolk R, Svatikova A, Phillips BG, Davison DE, et al. Independent association between plasma leptin and C-reactive protein in healthy humans. Circulation 2004;109:2181–5. 36. Elmquist JK, Coppari R, Balthasar N, Ichinose M, Lowell BB. Identifying hypothalamic pathways controlling food intake, body weight, and glucose homeostasis. J Comp Neurol 2005;493:63–71. 37. Bedaiwy MA, Falcone T, Goldberg JM, Sharma RK, Nelson DR, Agarwal A. Peritoneal fluid leptin is associated with chronic pelvic pain but not infertility in endometriosis patients. Hum Reprod 2006;21:788– 91. 38. Karvonen-Gutierrez CA, Harlow SD, Jacobson J, Mancuso P, Jiang Y. The relationship between longitudinal serum leptin measures and measures of magnetic resonance imaging-assessed knee joint damage in a population of mid-life women. Ann Rheum Dis 2014;73:883–9. 39. Tang KL, Wang BL, Yang L, Li LM, Zhou Y, Yang CH. Sexual function improvement in association with serum leptin level elevation in patients with premature ejaculation following sertraline treatment: a preliminary observation. Bosn J Basic Med Sci 2013;13:248–52. 40. Pamuk ON, Cakir N. The variation in chronic widespread pain and other symptoms in fibromyalgia patients. The effects of menses and menopause. Clin Exp Rheumatol 2005;23:778–82.

Orıgınal Article

GASTROENTEROLOGY

North Clin Istanb 2018;5(2):109–113 doi: 10.14744/nci.2018.50570

Evaluation of hepatitis A, B, and C serology in patients with cirrhosis and intensive alcohol consumption Sezgin Vatansever,1 Zehra Betul Pakoz,2 Belkis Unsal1 Department of Gastroenterology, Katip Celebi University, Ataturk Training and Research Hospital, İzmir, Turkey

Department of Gastroenterology, Tepecik Training and Research Hospital, İzmir, Turkey

ABSTRACT OBJECTIVE: The objective of this study was to evaluate the serology of hepatitis A, B, and C in patients with cirrhosis and intensive alcohol consumption. METHODS: We retrospectively reviewed the viral serology results of 817 patients with cirrhosis and intensive alcohol consumption who presented to the Gastroenterology Clinic of Atatürk Training and Research Hospital of Izmir Katip Çelebi University between April 2008 and December 2017. The diagnosis of cirrhosis was based on clinical and biochemical evaluations and imaging results. Patients consuming absolute alcohol 40 g/day for >10 years were included and those who quit drinking ≥15 years ago were excluded. RESULTS: Of all the patients, 806 (98.7%) were positive for anti-HAV IgG, 159 (19.5%) for HBsAg, and 32 (3.9%) for antiHCV. Genotyping was performed in 13 patients. Genotype 1 was detected in 10 patients (1a, one patient; 1b, nine patients) and genotype 3 in three patients. Of the patients with HBV, 10.0% had HBeAg and 7.6% had anti-delta. One-hundred and two (12.5%) patients had HCC, and of these, six (5.9%) were HCV-positive and 53 (52.0%) were HBsAg-positive. CONCLUSION: Patients with cirrhosis and intensive alcohol consumption have an increased hepatitis B and C prevalence. Patients with chronic viral hepatitis with alcohol habit are at a higher risk for HCC. Therefore, patients with cirrhosis and intensive alcohol consumption should be screened for hepatitis B and C. Keywords: Alcohol, cirrhosis, Hepatitis A, Hepatitis B, Hepatitis C.

Cite this article as: Vatansever S., Pakoz Z.B., Unsal B. Evaluation of hepatitis A, B, and C serology in patients with cirrhosis and intensive alcohol consumption. North Clin Istanb 2018;5(2):109–113.

lcohol-related mortality and morbidity is an important public health problem worldwide. In the USA half of the liver-related deaths are due to alcohol [1]. In Europe, the most common cause of advanced hepatic disease is alcohol [2]. In Germany, 18% of the population aged >18 years consumes >20–30 g of alcohol per day [3]. Alcohol is responsible for 5.9% of all deaths world-

wide [4]. Intensive alcohol consumption is prevalent in alcoholic chronic HCV infection, with high seroprevalence of HCV detected in alcoholic individuals [5-8]. Alcohol consumption combined with hepatitis B presence results in the progression of chronic liver disease [9, 10]. Alcohol combined with hepatitis B or C presence has a synergistic effect for developing HCC [11].

Received: February 06, 2018 Accepted: April 25, 2018 Online: May 22, 2018 Correspondence: Dr. Sezgin VATANSEVER. Department of Gastroenterology, Katip Celebi University, Ataturk Training and Research Hospital, İzmir, Turkey Phone: +90 232 244 44 44-28 07 e-mail: sezginvatansever19@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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The present study aimed to determine hepatitis A, B, and C seroprevalence in patients with cirrhosis and intensive alcohol consumption. MATERIALS AND METHODS Patients We retrospectively reviewed 817 patients with cirrhosis and intensive alcohol consumption who presented to our clinic between April 2008 and December 2017. Clinically, cirrhosis was defined as the presence of jaundice, ascites, and hepatic encephalopathy. Regarding the laboratory findings, PT prolongation and the presence of decreased albumin indicated cirrhosis. Radiologically, the presence of nodular liver, splenomegaly, and ascites indicated chronic liver disease. Patients consuming alcohol 40 g/day for >10 years were included in the study (>80 g/day in 800 patients). Individuals who quit drinking ≥15 years ago were excluded from the study. Patients were asked about the amount and type of alcohol they consumed and the duration (years) of their alcohol habit. The time and amount of smoking were expressed as daily number of packs multiplied by the duration. The height and weight of the patients were measured. For patients in whom HBV and HCV were detected, HCV-RNA or HBV-DNA was investigated using the real-time PCR method. The assessment was based on the serologic profile at the time of admission to the hepatology outpatient clinic. HBsAg was measured using the chemiluminescence method with the fully automated Johnson & Johnson macro ELISA instrument . HCC diagnosis was made using dynamic imaging methods (MRI and CT) for patients with early arterial staining and venous washout. Statistical analysis Statistical analyses were performed using the IBM SPSS Statistics 22 program. Statistics are reported as means, ranges, and percentages. The normal distribution suitability of the variables was studied using analytical methods. Patient distribution was done using Pearson’s chisquare test and Fisher’s exact test for categorical variables and Student’s t test for independent samples. Kruskal– Wallis and Mann–Whitney U tests were used for samples with non-normal distribution. One-way ANOVA was used to assess multiple groups for normal distributions in continuous variables. Bonferroni correction was used to determine p value in post-hoc tests. When the

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ANOVA results were evaluated post-hoc, the Scheffe test was used for homogenous distribution and Dunnett’s C test for nonhomogeneous data. Statistical significance was set at p<0.05. RESULTS We evaluated 817 patients with cirrhosis and intensive alcohol consumption. Table 1 summarizes the demographical and clinical data of the patients. Of the patients, 806 (98.7%) were positive for antiHAV IgG, 159 (19.5%) for HBsAg, and 32 (3.9%) for anti-HCV. One patient was negative for HCV-RNA. Genotyping was performed in 13 patients. Genotype 1 was detected in 10 patients (1a, one patient; 1b, nine patients) and genotype 3 in three patients. One patient was positive for both hepatitis B and C. Of the patients with HBV, delta antibody was detected in 7.2% and HBeAg was positive in 10.0%. Table 2 summarizes the characteristics of patients with hepatitis B and C infection.

Table 1. Demographic profiles and clinical characteristics of the study group

Patients characteristics n=817 Age Sex (F/M) Alcohol consumption time (year) Alcohol consumption (g/day) Recent 10 year alcohol consumption (g/day) Kind of alcohol Beer Raki Wine Whiskey Smoking rate (%) Smoking consumption time (year) Smoking (packs*year) BMI (kg/m2) Serology Anti HAV IgG HBsAg Anti HBc IgG Isolated Anti HBc IgG Anti HBs Anti HCV

55.8±9.9 13/804 27.6±9.4 149±62 165±83 22.4% 68.5% 7.6% 1.6% 90.0% 32 (5-62) 35 (3-110) 27.5±5.4 806 (98.7%) 159 (19.5%) 448 (54.8%) 91 (11.1%) 248 (30.4%) 32 (%3.9)

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Table 2. Comparison of HBV+alcohol, HCV+alcohol and alcohol groups Patients characteristics Age Age at the time of first drinking alcohol Sex (F/M) Alcohol consumption time (year) Alcohol consumption (g/day) Recent 10 year alcohol consumption (g/day) Smoking rate (%) Smoking consumption time (year)* Smoking (packs*year)* BMI (kg/m2) Presence of HCC at admission Anti HAV IgG Anti Delta HBeAg Log HBV-DNA Log HCV-RNA

Alcohol+HBV n=159

Alcohol+HCV n=31

Alcohol n=628

55±9 29.4±9.8 2/157 26.3±8.9 136±56 137±59 93.5% 35 (8-60) 32.5 (3-100) 25.8±5.9 53/159 (33.3%) 97.9% 7.2% 10.0% 4.3±2.3 -

60±10 32.5±13.5 0/31 29.1±10.7 154±57 156±58 92.9% 40 (20-60) 50 (10-110) 25.7±4.1 6/31 (19.4%) 100% - - - 5.5±1.6

56±10 28.1±9.0 11/616 27.8±9.4 152±63 172±87 89.2% 32 (5-62) 35 (3-100) 27.8±5.4 41/627 (6.5%) 98.7% - - - -

0.03 0.071 0.698 0.236 0.049 <0.0001 0.436 0.007 0.039 0.147 <0.0001 0.833

*Smokers only

One-hundred and two (12.5%) patients had HCC on admission. Of these patients, six (5.9%) were HCVpositive and 53 (52.0%) were HBsAg-positive. Among anti-HBs positive patients, 12 (4.83%) had HCC on admission. Multivariate regression analysis showed that age and HBV infection were independently related to HCC occurrence. DISCUSSION A population-based multicenter study performed in Turkey found HBsAg, anti-HAV total, and anti-HCV seroprevalences of 4.0%, 93.2%, and 1%, respectively [12]. According to this data, hepatitis B and C seroprevalence was higher in our patients with cirrhosis and intensive alcohol consumption than in the Turkish population. Figure 1 presents a comparison of data from the normal population and subjects in our study. The reason for admission among patients with cirrhosis is the symptoms emerging as a result of progressing cirrhosis. The HBV group, despite less alcohol use (p=0.0001), had earlier onset of symptoms (p=0.03) and higher probability of presenting with HCC (p=0.0001). There are many studies evaluating hepatitis B and C sero-

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

93.2%

98.7%

54.8% 32.0% 30.4%

32.6%

19.5% 4.0%

Anti HAV IgG

1.0%

3.9%

Anti HBs AntiHBc IgG Anti HCV TÜRKHEP Our Cases

HBsAg

Figure 1. Comparision of viral hepatitis seroprevalences between alcoholic cirrhotic patients and normal population.

prevalences in subjects with alcohol intake. The results of 25 studies publishing HCV prevalence in patients with HCV were pooled and resulted in a mean prevalence of 16.3% [13]. However, this study found a higher result as it involved European subjects. In a study by Tekin et al. in 2015, anti-HAV total, HBsAg, and anti-HCV positivity for patients with alcoholic cirrhosis were 91.5%, 16.3%, and 8.2%, respectively. Bruno et al. determined hepatitis C seroprevalence of 15% in alcoholic individuals [14]. In a further study, anti-HCV and HBsAg were found to be 55.6% and 15.7 %, respectively [15]. Although varying

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numbers have been reported across studies, all had higher hepatitis B and hepatitis C seroprevalences in subjects with alcohol intake than in the normal population. In our study, the results were high, similar to those reported in previous studies. In the HBV group, anti-delta and HBeAg frequency were comparable with that in the normal population in Turkey. Among HCV patients, genotype 3 was detected in 3/13 (23.1%) patients. Genotype 3 is more common in some geographical regions and is more frequent among IV drug abusers. In Turkey, genotype 1B (about 90%) is the dominant HCV genotype. The result may be incidental. A meta-analysis by Hutchinson et al. demonstrated in 15,000 patients with chronic HCV infection [16] that heavy alcohol intake (210–260 g/week) increased the risk of advanced fibrosis and cirrhosis. Another study found an increased cirrhosis risk in patients with hepatitis B and C and alcohol intake [17]. Alcohol intake increased hepatic necroinflammatory activity and fibrosis in HBsAg-positive patients. A study by Larkin et al. in transgenic mice in 2001 demonstrated that alcohol intake combined with hepatitis B increased the risk of developing cirrhosis and HCC [18]. HCV-related hepatic disease progression and HCC risk were evaluated in a study in Japanese moderate (<80 g/day) and heavy (>80 g/day) drinkers. Compared with nonalcohol drinkers, the risk of developing cirrhosis and HCC was 1.5–2.5 times higher [19]. There are other studies showing an increased HCC risk in patients with viral hepatitis and alcohol intake [18, 20, 21]. A study by Cortes et al. in 2013 found a high risk of developing HCC in patients with hepatitis B and heavy alcohol consumption [15]. A study in Turkey investigating the risk factors for HCC determined HBV and HCV infections with alcohol intake in 18 (8.6%) of 207 patients with HCC. The proportion of those taking alcohol only was 7.2% [22]. In our study, 102 (12.5%) patients had HCC at the time of admission. Of these patients, 52.0% were positive for HBsAg and 5.9% for HCV. In this study, the clinical, laboratory, and radiological findings indicated cirrhosis in all patients. The increased risk of HCC and cirrhosis associated with alcohol intake combined with hepatitis B or hepatitis C is also described in the literature. Therefore, viral hepatitis serology should be checked in all patients with cirrhosis and intensive alcohol consumption, and a closer monitoring of patients with positive results may be appropriate.

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The limitation of our study was its retrospective and cross-sectional design. Thus, it is not conclusively known whether the risk of developing HCC remains high following the cessation of drinking, particularly in patients with chronic viral hepatitis. It may be more appropriate to seek the answer to this question in cohort studies. The other limitation is that we were unable to distinguish alcoholic cirrhosis from alcoholic steatohepatitis. Although laboratory and clinical findings are similar in these situations, determining fibrosis with biopsy is helpful for discrimination. We were unable to obtain biopsies because of the laboratory findings of the patients . In conclusion, both the risk of encountering chronic viral hepatitis and the prevalence of chronic viral hepatitis is higher in patients with cirrhosis and alcohol intake. There is a higher risk of progressing to advanced liver disease and developing HCC in chronic viral hepatitis. CONCLUSION Hepatitis C and B seroprevalences in patients with cirrhosis and intensive alcoholic consumption were higher than that in the normal population. The proportion of our patients with HCC at the time of first admission was also high. Our data is consistent with other results in the literature. Therefore, serologic tests for hepatitis B and C should be performed in patients with cirrhosis and intensive alcohol consumption, and they should be vaccinated as necessary. Studies should be performed to determine whether the risk of HCC remains high even after quitting alcohol. Conflict of Interest: The authors declare no conflict of interest. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – S.V.; Design – S.V.; Supervision – B.U.; Materials – S.V.; Data collection &/or processing – S.V.; Analysis and/or interpretation – S.V., B.P.; Writing – B.P.; Critical review – S.V., B.P., B.U.

REFERENCES 1. Maher JJ. Alcoholic liver disease. In: Feldman M, Friedman LS, Sleisenger MH, editors. Gastrointestinal and Liver Disease Vol II. Philadelphia: Saunders; 2002. p. 1375–91. 2. European Association for the Study of Liver. EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol 2012;57:399–420. 3. Mueller S, Millonig G, Seitz HK. Alcoholic liver disease and hepatitis C: a frequently underestimated combination. World J Gastroenterol 2009;15:3462–71.

Vatansever et al., Viral hepatitis serology in heavy alcohol consumption

4. World Health Organization. Global status report on alcohol and health. Available at: http://www.who.int/substance_abuse/publications/ global_alcohol_report/en/. Accessed Apr 26, 2018. 5. Anand BS, Currie S, Dieperink E, Bini EJ, Shen H, Ho SB, et al; VAHCV-001 Study Group. Alcohol use and treatment of hepatitis C virus: results of a national multicenter study. Gastroenterology 2006;130:1607– 16. 6. Bhattacharya R, Shuhart MC. Hepatitis C and alcohol: interactions, outcomes, and implications. J Clin Gastroenterol 2003;36:242–52. 7. Costentin CE, Trabut JB, Mallet V, Darbeda S, Thépot V, Nalpas B, et al. Management of hepatitis C virus infection in heavy drinkers. Alcohol Alcohol 2013;48:337–42. 8. de Oliveira LC, Buso AG, de Oliveira AT, Arantes CA, Borges LV, Valente SR. Prevalence of hepatitis B and hepatitis C markers in alcoholics with and without clinically evident hepatic cirrhosis. Rev Inst Med Trop Sao Paulo 1999;41:69–73. 9. Hassan MM, Hwang LY, Hatten CJ, Swaim M, Li D, Abbruzzese JL, et al. Risk factors for hepatocellular carcinoma: synergism of alcohol with viral hepatitis and diabetes mellitus. Hepatology 2002;36:1206–13. 10. Stroffolini T, Cotticelli G, Medda E, Niosi M, Del Vecchio-Blanco C, Addolorato G, et al. Interaction of alcohol intake and cofactors on the risk of cirrhosis. Liver Int 2010;30:867–70. 11. Donato F, Tagger A, Chiesa R, Ribero ML, Tomasoni V, Fasola M, et al. Hepatitis B and C virus infection, alcohol drinking, and hepatocellular carcinoma: a case-control study in Italy. Brescia HCC Study. Hepatology 1997;26:579–84. 12. Tozun N, Ozdogan O, Cakaloglu Y, Idilman R, Karasu Z, Akarca US, et al. A nationwide prevalence study and risk factors for hepatitis A, B, C and D infections in Turkey. Hepatology 2010;52 Supp1:697. 13. Novo-Veleiro I, Calle Cde L, Domínguez-Quibén S, Pastor I, Marcos M, Laso FJ. Prevalence of hepatitis C virus infection in alcoholic patients:

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cohort study and systematic review. Alcohol Alcohol 2013;48:564–9. 14. Galperim B, Cheinquer H, Stein A, Fonseca A, Lunge V, Ikuta N. Prevalence of hepatitis C virus in alcoholic patients: role of parenteral risk factors. Arq Gastroenterol 2006;43:81–4. 15. Cortes VF, Taveira A, Cruz HM, Reis AA, Cezar JS, Silva BS, et al. Prevalence of Hepatitis B and C virus infection among alcoholic individuals: importance of screening and vaccination. Rev Inst Med Trop Sao Paulo 2017;59:e47. 16. Hutchinson SJ, Bird SM, Goldberg DJ. Influence of alcohol on the progression of hepatitis C virus infection: a meta-analysis. Clin Gastroenterol Hepatol 2005;3:1150–9. 17. Stroffolini T, Cotticelli G, Medda E, Niosi M, Del Vecchio-Blanco C, Addolorato G, et al. Interaction of alcohol intake and cofactors on the risk of cirrhosis. Liver Int 2010;30:867–70. 18. Larkin J, Clayton MM, Liu J, Feitelson MA. Chronic ethanol consumption stimulates hepatitis B virus gene expression and replication in transgenic mice. Hepatology 2001;34:792–7. 19. Khan KN, Yatsuhashi H. Effect of alcohol consumption on the progression of hepatitis C virus infection and risk of hepatocellular carcinoma in Japanese patients. Alcohol Alcohol 2000;35:286–95. 20. Fukushima W, Tanaka T, Ohfuji S, Habu D, Tamori A, Kawada N, et al. Does alcohol increase the risk of hepatocellular carcinoma among patients with hepatitis C virus infection? Hepatol Res 2006;34:141–9. 21. Uetake S, Yamauchi M, Itoh S, Kawashima O, Takeda K, Ohata M. Analysis of risk factors for hepatocellular carcinoma in patients with HBs antigen- and anti-HCV antibody-negative alcoholic cirrhosis: clinical significance of prior hepatitis B virus infection. Alcohol Clin Exp Res 2003;27:47S–51. 22. Uzunalimoğlu O, Yurdaydin C, Cetinkaya H, Bozkaya H, Sahin T, Colakoğlu S, et al. Risk factors for hepatocellular carcinoma in Turkey. Dig Dis Sci 2001;46:1022–8.

Orıgınal Article

DERMATOLOGY

North Clin Istanb 2018;5(2):114–119 doi: 10.14744/nci.2017.68553

Comparison of cutaneous manifestations in diabetic and nondiabetic obese patients: A prospective, controlled study Emin Ozlu,1 Tugba Kevser Uzuncakmak,2 Mumtaz Takır,3 Necmettin Akdeniz,4 Ayse Serap Karadag4 Department of Dermatology, Faculty of Medicine, Duzce University, Duzce, Turkey

Department of Dermatology, Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey

Department of Endocrinology and Metabolism, Istanbul Medeniyet University, Istanbul, Turkey

Department of Dermatology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey

ABSTRACT OBJECTIVE: Obesity is known to be a risk factor for many diseases including dermatological problems. Here, we aimed to determine the cutaneous manifestations in obese patients and the frequency of the accompanying dermatoses and to investigate the effect of diabetes mellitus in obese patients on cutaneous manifestations compared with the control group. METHODS: Our study included a total of 600 adults: 450 obese volunteers and 150 healthy volunteers. The number of diabetic obese patients was 138 (30%), whereas that of nondiabetic obese patients was 312 (70%). A detailed dermatological examination was performed for each case, and accompanying dermatoses were compared. RESULTS: The mean body mass index (BMI) in the obese patients and control group was 37.22 kg/m2 and 22.23 kg/m2, respectively. The most common dermatoses in the obese patients were, according to their frequency: striae distensae (291 patients, 64.7%), acrochordon (236 patients, 52.4%), acanthosis nigricans (213 patients, 47.3%), plantar hyperkeratosis (209 patients, 46.4%), and venous insufficiency (202 patients, 44.9%). Although hirsutism was more frequently observed in the nondiabetic obese group than in the diabetic obese group, stasis dermatitis was less frequently observed (p<0.05). CONCLUSION: We found that many dermatoses are more frequently observed in the obese patients than in the controls. We observed that the effect of obesity on skin is different from that of diabetes mellitus and that cutaneous manifestations of obesity occur more frequently. More extensive, comprehensive, and advanced studies on this subject are required. Keywords: Diabetes mellitus; obesity; skin findings.

Cite this article as: Ozlu E., Uzuncakmak T. K., Takır M., Akdeniz N., Karadag A. S. Comparison of Cutaneous Manifestations in Diabetic and Nondiabetic Obese Patients: A Prospective, Controlled Study. North Clin Istanb 2018;5(2):114–119.

besity is defined as having a body mass index (BMI) of ≥30 kg/m2, and it has become one of the major health problems in the world. The prevalence of obesity is increasing all over the world. In the United States of America (USA), its prevalence is estimated as 33.8% [1]. In a study by Gultekin et al. [2], the prevalence of obesity in Turkey was reported to be 20% in men and 34.19% in women.

Obesity leads to an increase in not only comorbidities such as cardiovascular diseases, cancer, diabetes mellitus (DM), and orthopedic problems but also the overall mortality rate by 20% [3]. Obesity is also known to affect the barrier function of the skin, sebum production, sweat glands, lymphatics, collagen structure and function, wound healing, and microcirculation and is closely associated with many skin lesions and skin diseases [1, 4].

Received: April 26, 2017 Accepted: December 21, 2017 Online: May 21, 2018 Correspondence: Dr. Emin OZLU. Dermatology, Faculty of Medicine, Duzce University, Duzce, Turkey Phone: +90 505 278 81 74 e-mail: dermatologg@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Ozlu et al., Cutaneous manifestations in obese patients

The incidence of DM has been rapidly increasing throughout the world, and in 2010, its incidence was reported to be 8.3% in the USA [5]. The complications of diabetes are known to affect all organs, including the skin, and skin lesions have been reported in about onethird of patients with DM [5]. Skin lesions may even be the first sign of DM in some cases and may be a guiding tool for physicians before the initiation of diagnostic tests for DM [5]. To date, many studies evaluating skin lesions in obese patients have been conducted; however, studies investigating the effect of DM on skin lesions in obese patients are limited. Therefore, we aimed to evaluate skin lesions and concomitant dermatoses in obese patients and to investigate the effect of DM on skin lesions in these patients . MATERIALS AND METHODS This prospective study was conducted in accordance with the principles of the Declaration of Helsinki, and it followed the protocol approved by the institutional ethical review board of Istanbul Medeniyet University. Patients were recruited in the study after they gave informed consent. This prospective-controlled study included 600 adults, including 450 obese patients who were admitted to the endocrinology outpatient clinic and 150 healthy volunteers. A BMI of ≥30 kg/m2 was considered as a diagnostic criterion for obesity [1]. The obese patients were divided into two groups: diabetic (n=138) and nondiabetic (n=312). A hemoglobin A1c (HbA1c) value of ≥6.5% or a fasting blood glucose level of ≥126 mg/dL, a 2-h postprandial glucose of ≥200 mg/dL, or a random glucose value of ≥200 mg/dL in patients with classical symptoms of DM was considered as the main diagnostic criterion of DM [6]. The sociodemographic characteristics and BMI values of all the participants were recorded. The blood count and detailed biochemical and hormonal analysis of all participants were obtained from the medical records. The waist circumference and blood pressure values were measured. Detailed dermatological examinations were performed by the same dermatologist, and concomitant dermatoses were separately compared between the obese and control groups and between the diabetic and nondiabetic obese patients. Patients aged <18 years, pregnant women, longterm corticosteroid users, patients with acromegaly and Cushing’s disease, cigarette smokers, and those who consumed alcohol were excluded.

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Statistical analyses were performed using the SPSS software version 16. The variables were investigated using Kolmogorov–Smirnov test to determine whether or not they were normally distributed. Non-normally distributed variables were expressed as median with interquartile range and normally distributed variables as mean±SD, as appropriate. Between-group comparisons were assessed for nominal variables with the Student’s t test and for non-normal variables with the Mann–Whitney U test. P<0.05 was considered as statistically significant. RESULTS Of the 450 obese patients, 370 were females and 80 were males. Of the 150 healthy controls, 114 were females and 36 were males. The mean ages of the obese patients and controls were 37.25±11.37 and 35.67±11.24 years, respectively. No statistically significant difference was found in the age and sex distribution between the patients and healthy controls (p>0.05). The mean waist circumferences of the obese patients and healthy controls were 119.72±12.98 and 82.37±9.21 cm, respectively. The BMI values of the obese patients and healthy controls were 37.22±6.07 and 22.23±2.19 kg/m2, respectively (p<0.05) (Table 1). The prevalence of acanthosis nigricans, acrochordon, keratosis pilaris, hirsutism, striae distensae, lymphedema, venous insufficiency, stasis dermatitis, plantar hyperkeratosis, hyperhidrosis, pretibial myxedema, cellulitis, varicose vein, atopic dermatitis, erythema intertrigo, tinea pedis, onychomycosis, tinea cruris, and candidal infections was higher in the obese patients than in the healthy controls (p<0.05), although there were no statistically significant difference in the other skin lesions between the groups (p>0.05) (Table 2).

Table 1. Demographics data and body measurements of obese patients and controls

Study group

Control Group P value

Participants (n) 450 150 Age (years±SD) 37.25±11.37 35.67±11.24 0.141 Gender (F/M) 370/80 114/36 0.085 Waist circumference 119.72±12.98 82.37±9.21 <0.001 BMI 37.22±6.07 22.23±2.19 <0.001 BMI: Body mass index, F: Female, M: Male, SD: Standard deviation

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Table 2. Evaluation of skin findings in obese patients and controls Acanthosis nigricans Acrochordon Keratosis pilaris Gouty tophi Hirsutismus Striae distensae Adiposis dolorosa Lymphedema Venous insufficiency Plantar hyperkeratosis Hyperhidrosis Intertrigo Pretibial myxedema Cellulitis Viral infections Varicous vein Hidradenitis suppurativa Psoriasis Atopic dermatitis Skin cancer Contact dermatitis Seborrheic dermatitis Stasis dermatitis Dishydrotic eczema Tinea pedis Onychomycosis Tinea cruris Tinea versicolor Candidal infections Folliculitis Furuncle Carbuncle Impetigo Acute paronychia

Study Group n (%)

Control Group n (%)

P value

213 (47.3) 236 (52.4) 78 (17.3) 1 (0.2) 131 (29.1) 291 (64.7) 2 (0.4) 26 (5.8) 202 (44.9) 209 (46.4) 81 (18.0) 62 (13.8) 12 (2.7) 135 (30) 11 (2.4) 185 (41.1) 4 (0.9) 11 (2.4) 65 (14.4) 1 (0.2) 18 (4) 44 (9.8) 14 (3.1) 5 (1.1) 90 (20) 66 (14.7) 13 (2.9) 4 (0.9) 43 (9.6) 24 (5.3) 12 (2.7) 2 (0.4) 1 (0.2) 0

5 (3.3) 5 (3.3) 2 (1.3) 0 2 (1.3) 5 (3.3) 0 0 5 (3.3) 5 (3.3) 1 (0.7) 0 0 0 1 (0.7) 6 (4) 0 3 (2.0) 3 (2.0) 0 10 (6.7) 7 (4.7) 0 4 (2.7) 12 (8.0) 7 (4.7) 0 4 (2.7) 1 (0.7) 5 (3.3) 2 (1.3) 0 0 1 (0.7)

<0.001 <0.001 <0.001 0.564 <0.001 <0.001 0.414 0.003 <0.001 <0.001 <0.001 <0.001 0.044 <0.001 0.054 <0.001 0.247 0.755 <0.001 0.564 0.180 0.052 0.029 0.175 0.001 0.001 0.035 0.100 <0.001 0.328 0.354 0.414 0.564 0.083

The most common dermatoses in obese patients were striae distensae in 291 (64.7%) patients, acrochordon in 236 (52.4%), acanthosis nigricans in 213 (47.3%), plantar hyperkeratosis in 209 (46.4%), and venous insufficiency in 202 (44.9%). Although the prevalence of hirsutism in the nondiabetic obese group was found to be higher, the prevalence of stasis dermatitis was found to be lower than that in the diabetic obese group (p<0.05). However, there were no statistically significant difference regarding other skin lesions and dermatoses between the diabetic and nondiabetic obese groups (p>0.05) (Table 3).

DISCUSSION In the present study, many skin lesions were found to be more common in obese patients than in healthy controls. However, there were no statistically significant differences in the frequency of skin lesions, except for hirsutism and stasis dermatitis, between the diabetic and nondiabetic obese groups. According to these results, the effect of obesity on the prevalence of skin lesions was more prominent than that of DM, and the occurrence of concomitant DM in obese patients did not significantly

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Table 3. Evaluation of skin findings in diabetic and nondiabetic obese patients Acanthosis nigricans Acrochordon Keratosis pilaris Gouty tophi Hirsutismus Striae distensae Adiposis dolorosa Lymphedema Venous insufficiency Plantar hyperkeratosis Hyperhidrosis Intertrigo Pretibial myxedema Cellulitis Viral infections Varicous vein Hidradenitis suppurativa Psoriasis Atopic dermatitis Skin cancer Contact dermatitis Seborrheic dermatitis Stasis dermatitis Dishydrotic eczema Tinea pedis Onychomycosis Tinea cruris Tinea versicolor Candidal infections Folliculitis Furuncle Carbuncle Impetigo

Diabetic Obese n=138 (%)

Non-Diabetic Obese n=312 (%)

P value

66 (47.8) 75 (54.3) 17 (12.3) 1 (0.7) 27 (19.6) 86 (62.3) 0 9 (6.5) 60(43.5) 63 (45.7) 23 (16.7) 19 (13.8) 1 (0.7) 37 (26.8) 3 (2.2) 57 (41.3) 1 (0.7) 1 (0.7) 15 (10.9) 0 5 (3.6) 14 (10.1) 8 (5.8) 1 (0.7) 29 (21.0) 19 (13.8) 3 (2.2) 0 9 (6.5) 8 (5.8) 5 (3.6) 0 0

146 (46.9) 160 (51.4) 61 (19.6) 0 103 (33.1) 204 (65.6) 2 (0.6) 16 (5.1) 141 (45.3) 145 (46.6) 58 (18.6) 42 (13.5) 11 (3.5) 98 (31.5) 8 (2.6) 127 (40.8) 3 (1.0) 10 (3.2) 49 (15.8) 1 (0.3) 13 (4.2) 30 (9.6) 6 (1.9) 4 (1.3) 61 (19.6) 47 (15.1) 10 (3.2) 4 (1.3) 34 (10.9) 16 (5.1) 7 (2.3) 2 (0.6) 1 (0.3)

0.937 0.639 0.060 0.133 0.004 0.438 0.346 0.558 0.715 0.849 0.615 0.940 0.089 0.317 0.801 0.926 0.803 0.116 0.172 0.505 0.782 0.870 0.030 0.601 0.733 0.711 0.544 0.181 0.143 0.783 0.406 0.346 0.505

affect the prevalence of skin disorders. Many adipokines secreted from adipose tissues are known to have autocrine, paracrine, and endocrine effects. Adipose tissues act as endocrine organs and play an important role in the regulation of insulin resistance and inflammation through the secretion of proinflammatory cytokines. Obesity, which is characterized by a massive increase in the body fat, is known to be associated with many dermatoses due to mechanical effects [7]. Also, it is a predisposing factor for many bacterial and fungal infections [1, 8]. Striae distensae are often characterized by linear atrophic plaques seen on the breast, hips, abdomen, and legs. In a

previous study by Nazik et al. [7], striae distensae (62%) were found to be the most common skin lesion in obese patients. Boza et al. [9] reported that the most common skin lesion in obese patients was striae distensae (68.4%) and that there was a positive correlation between BMI and the prevalence of striae distensae. In our study, striae distensae (64.7%) were also the most common dermatosis in obese patients, which was consistent with the studies conducted by Nazik et al. [7] and Boza et al. [9]. The frequent occurrence of striae distensae in obese patients may be due to excessive tension in the skin caused by overweight [10]. However, we found no significant dif-

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ference in the prevalence of striae distensae between the diabetic and nondiabetic patients in our study (p>0.05). Acrochordons are asymptomatic, pedunculated, polypoid structures commonly seen in the intertriginous areas [11]. They are known to be strongly associated with DM and insulin resistance [12]. Rasi et al. [12] demonstrated a positive correlation between the number of acrochordons and DM and impaired glucose tolerance. Erdogan et al. [4] reported that acrochordons (53.3%) were the most common skin lesions in adult obese patients. In addition, Garcia et al. [13] showed that there was a positive correlation between the prevalence of acrochordons and BMI. Conversely, the prevalence of acrochordons was found to be 52.4% in the obese group in our study and was significantly higher than that in the control group (p<0.05). In addition, the prevalence of acrochordons was reported to be higher in diabetic obese patients than in nondiabetic obese patients, although this difference did not reach statistical significance (p>0.05). Acanthosis nigricans is a dermatosis characterized by symmetrical, velvety, hyperpigmented plaques in the intertriginous areas. The most common etiological factors include hyperinsulinemia and obesity [14]. Hud et al. [15] reported that the prevalence of AN was 74% in obese patients. In a previous study by Dassanayake et al. [16], the prevalence of AN in the normal population aged 35–64 years was reported to be 17.4%. In our study, AN was reported to be the third most common dermatosis, with a prevalence of 47.3%. There was no significant difference in the prevalence of AN between diabetic and nondiabetic obese patients (p>0.05). Obesity is a risk factor for the development of chronic venous insufficiency. Increased intra-abdominal pressure in obese patients is known to counteract venous blood return from the lower extremities, leading to the development of varicose veins [1]. Nazik et al. [7] found that varicose veins were more common in obese patients than in controls. In our study, varicose veins and stasis dermatitis were found to be more common in obese patients than in controls (p<0.05). Furthermore, stasis dermatitis was found to be more common in diabetic obese patients than in nondiabetic obese patients (p<0.05), indicating an important role of the DM pathogenesis in the development of stasis dermatitis. Obesity is a risk factor for the development of hyperandrogenism and hirsutism [1]. Nazik et al. [7] demonstrated that hirsutism was more common in obese patients than in controls. Codner et al. [17] reported that

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DM increased the androgen level and that drugs used in the treatment of DM decreased the androgen levels. Consistent with the study of Nazik et al. [7], our study also demonstrated that the incidence of hirsutism was higher in obese patients than in controls (p<0.05). In our study, however, the fact that the incidence of hirsutism was found to be lower in the diabetic obese group than in the nondiabetic obese group may be associated with the lowering of androgen levels by the drugs used by diabetic obese patients for the treatment of DM. In conclusion, skin manifestations are known to occur in obese patients. These skin lesions can sometimes be indicative of another systemic disease and adversely affect the quality of life of patients. However, the coexistence of DM in obese patients seems to have no significant effect on the prevalence of skin lesions, although further largescale studies are required to establish a definite conclusion. Conflict of Interest: The authors declare no conflict of interest. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – E.O.; Design – E.O., T.K.U.; Supervision – N.A., A.S.K.; Materials – M.T., A.S.K.; Data collection &/ or processing – T.K.U., E.O.; Analysis and/or interpretation – A.S.K., E.O.; Writing – E.O., A.S.K.; Critical review – A.S.K., N.A.

REFERENCES 1. Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: skin physiology and skin manifestations of obesity. J Am Acad Dermatol 2007;56:901–16. 2. Gültekin T, Ozer BK, Akin G, Bektaş Y, Sağir M, Güleç E. Prevalence of overweight and obesity in Turkish adults. Anthropol Anz 2009;67:205–12. 3. Lenz M, Richter T, Mühlhauser I. The morbidity and mortality associated with overweight and obesity in adulthood: a systematic review. Dtsch Arztebl Int 2009;106:641–8. 4. Kaya Erdoğan H, Gökdemir G, Purisa S, Kıvanç Altunay İ. Evaluation of Skin Findings in Adult Obese Dermatology Outpatients. TURKDERM 2011;45:184–7. 5. Levy L, Zeichner JA. Dermatologic manifestation of diabetes. J Diabetes 2012;4:68–76. 6. American Diabetes Association. Standards of Medical Care in Diabetes—2015. Diabetes Care 2015;38:S1–90. 7. Nazik H, Kökçam İ, Demir B, Çoban Gül F. Skin findings in overweight and obese individuals. Turkderm - Arch Turk Dermatol Venerology 2016;50:59–64. 8. Scheinfeld NS. Obesity and dermatology. Clin Dermatol 2004;22:303– 9. 9. Boza JC, Trindade EN, Peruzzo J, Sachett L, Rech L, Cestari TF. Skin manifestations of obesity: a comparative study. J Eur Acad Dermatol Venereol 2012;26:1220–3. 10. Strumia R. Dermatologic signs in patients with eating disorders. Am J

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Clin Dermatol 2005;6:165–73. 11. Murphy-Chutorian B, Han G, Cohen SR. Dermatologic manifestations of diabetes mellitus: a review. Endocrinol Metab Clin North Am 2013;42:869–98. 12. Rasi A, Soltani-Arabshahi R, Shahbazi N. Skin tag as a cutaneous marker for impaired carbohydrate metabolism: a case-control study. Int J Dermatol 2007;46:1155–9. 13. García-Hidalgo L, Orozco-Topete R, Gonzalez-Barranco J, Villa AR, Dalman JJ, Ortiz-Pedroza G. Dermatoses in 156 obese adults. Obes Res 1999;7:299–302. 14. Sadeghian G, Ziaie H, Amini M, Ali Nilfroushzadeh M. Evaluation of

119 insulin resistance in obese women with and without acanthosis nigricans. J Dermatol 2009;36:209–12. 15. Hud JA Jr, Cohen JB, Wagner JM, Cruz PD Jr. Prevalence and significance of acanthosis nigricans in an adult obese population. Arch Dermatol 1992;128:941–4. 16. Dassanayake AS, Kasturiratne A, Niriella MA, Kalubovila U, Rajindrajith S, de Silva AP, et al. Prevalence of Acanthosis Nigricans in an urban population in Sri Lanka and its utility to detect metabolic syndrome. BMC Res Notes 2011;4:25. 17. Codner E, Iñíguez G, López P, Mujica V, Eyzaguirre FC, Asenjo S, et al. Metformin for the treatment of hyperandrogenism in adolescents with type 1 diabetes mellitus. Horm Res Paediatr 2013;80:343–9.

Orıgınal Article

ANESTHESIOLOGY & REANIMATION

North Clin Istanb 2018;5(2):120–124 doi: 10.14744/nci.2017.42243

Determination of colistin-related nephrotoxicity and risk factors in intensive care unit Ayse Inci,1 Melike Korkmaz Toker,2 Ilhan Guney Bicer,2 Abdurrrahim Derbent,2 Ziya Salihoglu2 Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Istanbul Kanuni Sultan Suleyman Training and

Research Hospital, Istanbul, Turkey Department of Anesthesiology and Reanimation, University of Health Sciences, Istanbul Kanuni Sultan Suleyman Training and Research

Hospital, Istanbul, Turkey

ABSTRACT OBJECTIVE: Colistin is a cationic polypeptide antibiotic with a cyclic structure that belongs to the polymyxin group. It was banned from clinical use because of its significant renal side effects, such as nephrotoxicity. However, the administration of colistin has recently been initiated again in the treatment of multi-drug resistant pathogens, such as Acinetobacter baumannii and Pseudomonas aeruginosa. Nephrotoxicity and neurotoxicity are the main problems encountered in the clinical use of polymyxins. The aim of this study was to determine the frequency and risk factors of colistin-related nephrotoxicity in the adult intensive care unit (ICU). METHODS: In this study, a retrospective review of patients who were followed up between January 1 and December 31, 2016 and who received colistin treatment in the adult ICU was performed. Retrospective computer records of age, sex, site of infection and microorganism breeding, daily creatinine values, and additional diseases were recorded and examined. Nephrotoxicity was assessed using the Risk, Injury, Failure, Loss, and End-stage kidney disease criteria. RESULTS: A total of 48 patients were included in the study. Of these, 50% were male. The mean age of the patients with nephrotoxicity was 59.73±22.38 years, and the mean age of those without nephrotoxicity was 58.00±22.39 years. A. baumanni was observed to be the causative microorganism in all patients, and the most frequent infection was pneumonia. Nephrotoxicity was investigated in 54.2% (n=26) of the patients. In this study, when risk factors for nephrotoxicity were evaluated, it was found that the presence of nephrotoxicity was greater in cases with chronic obstructive pulmonary disease, malignancy, or abdominal surgery in patients older than 65 years. In addition, mortality was greater in those who developed nephrotoxicity, although it was not statistically significant. CONCLUSION: In this study, the rate of nephrotoxicity was 54.2% in patients who received colistin in the ICU. Therefore, patients in the adult ICU receiving colistin therapy should be carefully monitored for the development of nephrotoxicity as a side effect. Keywords: Colistin; end-stage kidney disease criteria; failure; injury; loss; multi-drug resistant pathogens; nephrotoxicity; risk.

Cite this article as: Inci A., Korkmaz Toker M., Bicer I. G., Derbent A., Salihoglu Z. Determination of colistin-related nephrotoxicity and risk factors in intensive care unit. North Clin Istanb 2018;5(2):120–124.

ntensive care units (ICUs) are the units in which invasive procedures are performed, mechanical ventilation (MV) is applied, and patients who receive intensive drug therapy are followed up; in these units, the hospital-ac-

quired infections (HAIs) and mortality rates are also high [1]. Approximately 25% of HAIs occur in ICU. The frequency of hospital infection and antibiotic susceptibil-

Received: July 15, 2017 Accepted: October 02, 2017 Online: April 11, 2018 Correspondence: Dr. Melike KORKMAZ TOKER. Department of Anesthesiology and Reanimation, University of Health Sciences, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey. Phone: +90 505 474 70 98 e-mail: meltoker@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Inci et al., Colistin-related nephrotoxicity

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Table 1. RIFLE classification (serum creatinine and GFR criteria) Category Criteria Risk (R) Injury (I) Failure (F) Loss (L) ESKD (E)

Increased creatinine level x1.5 or GFR decrease >25% Increased creatinine level x2 or GFR decrease >50% Increased creatinine level x3, GFR decrease >74% or creatinine level >4mg/dl Persistent acute renal failure or complete loss of function for >4 weeks ESKD for >3 months

ESKD: End stage kidney disease. GFR: Glomerular filtration rate.

ity may vary from country to country, from hospital to hospital, and within different units of the same hospital. Reduction in resistance of patients followed up in ICU, long-term hospitalization, MV, and invasive procedures such as catheterization lead to an increase in the incidence of infections in these units. Multiple antimicrobial resistances occur with the widespread use of broad-spectrum antibiotics in these units [2-4]. Colistin is a cationic polypeptide antibiotic that was introduced in the 1960s. Its use had been banned due to its potential side effects, particularly owing to the nephrotoxicity rates approaching 50% and subsequent use of other antimicrobials. Recently, its administration has been reinitiated in the treatment of multi-drug resistant pathogens (MDRP) such as Acinetobacter baumannii, Pseudomonas aeruginosa, and carbapenem-resistant Enterobacteriaceae. Nephrotoxicity and neurotoxicity are the main problems encountered in the clinical use of polymyxins [5-8]. In this study, our aim was to determine the frequency and risk factors of colistin-related nephrotoxicity in the adult ICU. MATERIALS AND METHODS This was a retrospective cohort analysis to assess nephrotoxicity in critically ill patients receiving colistin at a university-affiliated tertiary research and training hospital. In this study, patients who received intravenous colistin during follow-up in the adult ICU of University of Health Sciences Istanbul Kanuni Sultan Suleyman Research and Training Hospital between January 01 and December 31, 2016 were retrospectively evaluated. Computer records of age, sex, site of infection and microorganism breeding, daily creatinine values, comorbidities such as diabetes mellitus (DM), cerebrovascular disease (CVD), chronic obstructive pulmonary disease (COPD), malig-

nancy, trauma, and presence of abdominal surgery were recorded and examined. Concurrent use of nephrotoxic antibiotics such as aminoglycoside, vancomycin, and carbapenem has been identified in patients who have received colistin. Patients were excluded if they received colistin therapy for less than 72 hours, had a diagnosis of chronic renal failure according to documented medical history, or were younger than 18 years of age. If a patient received recurrent colistin treatment, only the first treatment was evaluated. The primary outcome was the occurrence of nephrotoxicity according to the Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) criteria. The RIFLE criteria (Table 1) represent a valuable validated tool for evaluation of acute kidney injury (AKI) based on both change in glomerular filtration rate (GFR) and serum creatinine concentration [9]. These criteria have been validated and continue to be used in literature describing colistin-associated nephrotoxicity [10]. For statistical analysis, SPSS 15.0 package program, chi-square test, and T-test were used. In the analysis results, a p value less than 0.05 were considered to indicate a statistically significant difference. RESULTS A total of 48 patients met the inclusion criteria and were included in the study. Of these, 50% were male. A. baumanni was observed to be the causative microorganism in all patients and the most frequent infection was pneumonia. Patients were treated for pneumonia (73%), blood stream infection (23%), soft tissue infection (2%), and urinary system infection (2%) (Table 2). Nephrotoxicity was investigated in 54.2% (n=26) of the patients. Overall, the 26 patients with nephrotoxicity were classi-

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Table 2. Distribution of infections in patients

Pneumonia Blood stream infection Soft tissue infection Urinary system infection

35 11 1 1

73 23 2 2

Table 3. Distribution of patients according to RIFLE criteria Criteria (Patient)

(%)

No risk Risk (R) Injury (I) Failure (F)

22 7 10 9

(45.8) (14.5) (20.8) (18.7)

fied as risk (7 patients), injury (10 patients), and failure (9 patients) (Table 3). The mean age of the patients with nephrotoxicity was 59.73±22.38 years and of those without nephrotoxicity was 58.00±22.39 years.

Demographic features of the patients and clinical characteristics are listed in Table 4. The incidence of nephrotoxicity was not affected by other variables. DISCUSSION Hospital infections are one of the major causes of mortality and morbidity in hospitalized patients and cause serious problems particularly in patients in ICU. Inflammatory infections caused by resistant microorganisms are frequent in ICU due to invasive interventions, prolonged hospitalization, and frequent use of broad-spectrum antibiotics [11]. This retrospective cohort study was designed to evaluate the incidence of severe AKI and the associated risk factors in ICU patients, without pre-existing renal impairment, receiving colistin treatment for the MDRP infections. Colistin is a cyclic structured polypeptide. Nowadays, the increase of multi-drug resistant gram-negative pathogens has attracted interest with respect to colistin. The most important disadvantage of this drug is its nephrotoxic effect, which is the only option in patients with P. aeruginosa and A. baumannii infections, particularly in their last few years. A. baumannii has been iden-

Table 4. Demographic and clinical characteristics of patients who received colistin

Patients with nephrotoxicity (n=26)

Patients without nephrotoxicity (n=22)

Age (years) (mean±SD) Gender (M/F) >65 years, N. (%) Diabetes Mellitus, N. (%) COPD, N. (%) Malignancy, N. (%) Cerebrovascular disease, N.(%) Postoperative visceral surgery, N. (%) Creatinin level before therapy (mg/ dL) (mean±SD) Concomitant aminoglycoside use Concomitant vancomycin use Concomitant carbapenem use Concomitant tigecycline use Duration of treatment (day) (mean±SD) Mortality, N. (%)

59.73±22.38 15/11 (58/42) 13 (50) 9 (35) 11 (42) 3 (12) 5 (19) 12 (46) 0.66±0.24 1 (4) 12 (46) 26 (100) 0 (0) 13.38±7.17 19 (73)

58.00±22.39 9/13 (41/59) 9 (41) 9 (41) 4 (18) 1 (4) 2 (9) 7 (32) 0.70±0.18 3 (14) 10 (45) 20 (91) 3 (14) 15.18±7.12 14 (64)

0.39 0.24 0.52 0.65 0.72 0.38 0.32 0.31 0.51 0.22 0.56 0.11 0.52 0.39 0.48

COPD: Chronic Obstructive Pulmonary Disease.

Inci et al., Colistin-related nephrotoxicity

tified as the most frequent cause of hospital infections in elderly patients followed up in ICU [12-14]. Nephrotoxicity and neurotoxicity are the main problems encountered in the clinical use of polymyxins. Nephrotoxicity ratios differ in studies conducted on the subject, and it is thought that this difference may be due to different patient populations and the use of different criteria. In recent years, for obtaining more standardized data, varying criteria have been used, and the RIFLE criteria provide a useful framework for nephrotoxicity [8, 14]. Ricci et al [15] defined the RIFLE classification as a simple, readily available clinical tool to classify AKI in different populations. Authors concluded their review by stating that the RIFLE classification seems to be a good outcome predictor. Due to the high sensitivity of the RIFLE criteria with respect to determining acute renal failure, in our study, we decided to use RIFLE as a degree of measuring nephrotoxicity. In our study, the rate of nephrotoxicity was detected to be 54.2% in patients who received colistin in ICU. The rate of nephrotoxicity varies widely throughout the published literature. A total of 11 relevant study results [520] have been identified in Table 5. The incidence of AKI related to colistin varies widely, ranging from 16.2% to 77.5% in the literature [5-20]. This wide variety is likely due to differences in study populations. Bilgili et al. reported a rather high overall AKI incidence, and they explained this high occurrence by the severity of illness. Their median Apache score was 21. The lack of Apache scores of our patients in this study is insufficient to compare our outcome with this study. In the current study, among the 26 patients with nephrotoxicity, 14.6% were classified as risk, 20.8% as injury, and 18.7% as failure. Pogue et al. presented similar rates of nephrotoxicity in a cohort of 126 patients: 13% as risk, 17% as injury, and 17% as failure. A. baumanni was observed to be the causative microorganism in all patients, and the most frequent infection was pneumonia. Similar to our study, it was determined that A. baumannii is the most common agent in other studies [8, 18, 22], and the most frequent infection is pneumonia [8, 12, 18, 19]. When risk factors for nephrotoxicity were evaluated, it was found that nephrotoxicity was higher in the presence of COPD, malignancy, and abdominal surgery in those older than 65 years, and mortality was higher in those who developed nephrotoxicity, although the toxicity was not statistically significant.

123

Pogue et al. [5] reported that higher colistin doses led to a relatively high rate of nephrotoxicity. Tuon et al. [7] concluded their study stating that vancomycin co-administration likely increases the risk of AKI. In our country, Köksal et al. [8] showed that older age, presence of COPD, and DM increased the risk of nephrotoxicity. There are several studies that revealed the association between COPD and renal failure. Gadam et al. [23] reviewed prospective and retrospective observational studies that reported the prevalence of chronic kidney disease (CKD) in patients with COPD. They found that patients with COPD have increased odds of developing CKD. The mechanism by which COPD potentiates the development of CKD remains unclear. COPD has been associated with systemic inflammation. This inflammation is also potentially related to development of kidney disease. Mapel et al. [24] examined renal disease in a population-based cohort of persons with COPD. They found that COPD patients have a substantially increased prevalence of renal diseases as well as abnormal renal and hepatic laboratory values. Our results revealed that COPD patients have more nephrotoxicity as studies mentioned above. This result can be explained by stating that COPD patients are also more likely to be prescribed medications with potentially toxic renal side effects. Other studies on the subject have reported that the presence of malignancy, hypotension, simultaneous vancomycin use, high dose, advanced age, and septic shock are factors that increase nephrotoxicity [13, 14, 17, 18, 20-22]. In conclusion, nephrotoxicity seems to be an important adverse effect in our study because of the fact that the risk factors affecting nephrotoxicity were not statistically determined but the rate of development of nephrotoxicity was 54.2% in patients using colistin. Therefore, periodic assessment of serum creatinine levels, modification of the colistin dose according to renal function, avoidance of coadministration of other nephrotoxic agents (if possible), and shortening the duration of antimicrobial treatment will minimize the potential for nephrotoxic effects of this valuable old antibiotic. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – A.İ., M.K.T.; Design – A.İ., M.K.T.; Supervision – A.İ.; Materials – A.İ., İ.G.B.; Data collection &/or processing – A.İ., İ.G.B.; Analysis and/or interpretation – A.İ., M.K.T.; Critical review – A.D., Z.S.

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REFERENCES 1. Palabıyık O, Öğütlü A, Toptaş Y. Ventilator-associated pneumonia and causative microorganisms in intensive care unit: a 2-year retrospective analysis. J Turk Soc Intens Care 2016;14:80–5. 2. Biberoğlu K. Intensive Care Unit Infections - Risk Factors, Epidemiology and Prevention. Flora 1997;2:79–84. 3. Inan D, Saba R, Keskin S, Öğünç D, Çiftçi C, Günseren F, Mamikoğlu L, Gültekin M. Nosocomial Infections in Akdeniz University Intensive Care Units. Yoğun Bakım Dergisi 2002;2(2):129-135. 4. Camkıran A, Kundakçı A, Araz C, Pirat A, Zeyneloğlu P, Arslan H, et al. Predictors of Multidrug Resistant Acinetobacter Baumannii Infections in Surgical Intensive Care Patients: A Retrospective Analysis. Journal of the Turkish Society of Intensive Care 2011;9: 53–8 5. Pogue JM, Lee J, Marchaim D, Yee V, Zhao JJ, et al. Incidence of and risk factors for colistin-associated nephrotoxicity in a large academic health system. Clin Infect Dis 2011;53:879–84. 6. Justo JA, Bosso JA. Adverse reactions associated with systemic polymyxin therapy. Pharmacotherapy 2015;35:28–33. 7. Tuon FF, Rigatto MH, Lopes CK, Kamei LK, Rocha JL, Zavascki AP. Risk factors for acute kidney injury in patients treated with polymyxin B or colistin methanesulfonate sodium. Int J Antimicrob Agents 2014;43:349–52. 8. Koksal I, Kaya S, Gencalioglu E, Yilmaz G. Evaluation of Risk Factors for Intravenous Colistin Use-related Nephrotoxicity. Oman Med J 2016;31:318–21 9. Spapen H, Jacobs R, Van Gorp V, Troubleyn J, Honoré PM. Renal and neurological side effects of colistin in critically ill patients. Ann Intensive Care 2011;1:14. 10. Gaynes R, Edwards JR; National Nosocomial Infections Surveillance System. Overview of nosocomial infections caused by gram-negative bacilli. Clin Infect Dis 2005;41:848–54. 11. Yilmaz N, Kose S, AguS N, Ece G, Akkoclu G, Kirakli C. Microorganisms Isolated from Blood Cultures of Intensive Care Unit Patients, their Antimicrobial Susceptibility and Etiological Agents in Nosocomial Bacteremia. ANKEM J 2010;24:12–9. 12. Arslan Zİ, Özbudak E, Türkyılmaz N, Cesur S, Alparslan V, Mirhanoğulları AF, et al. Evaluation of the Use of Colistin on Nephrotoxicity and Mortality in the Intensive Care Unit, Turkiye Klinikleri J Anest Reanim 2015;13:21–4

North Clin Istanb 13. Kaya M, Tunçel YI, Kuru RN, Menteş S, Ünver S, Çeken S, et al. Retrospective Evaluation of Colistin Associated Nephrotoxicity at Oncology Hospital Intensive Care Unit, J Turk Soc Intens Care 2014;12: 51–6 14. Inci A, Karabay A, Erus S, Demiraran Y. Nosocomial Infections and Associated Risk Factors in Geriatric Patients in the Intensive Care Unit. Eurasian J Emerg Med 2016; 15: 177–80. 15. Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney Int 2008;73:538–46. 16. Bahlis LF, Diogo LP, Lemons D, Klaus D. Risk factors for acute kidney injury in patients treated with polymyxin B at a Tertiary Care Medical Center. J Bras Nefrol 2015;37:446–50. 17. Akajagbor DS, Wilson SL, Shere-Wolfe KD, Dakum P, Charurat ME, Gilliam BL. Higher incidence of acute kidney injury with intravenous colistimethate sodium compared with polymyxin B in critically ill patients at a tertiary care medical center. Clin Infect Dis 2013;57:1300–3. 18. Dewan A, Shoukat M. Evaluation of risk of nephrotoxicity with high dose, extended-interval colistin administration. Indian J Crit Care Med 2014;18:427–30. 19. Hür E, Çetintürk A, Eminoğlu V, Sungur M, Tavşan Ö, Pişkinpaşa SV, et al. Colistin and Acute Renal Failure: A Centre’s Experience. Turk Neph Dial Transpl 2014; 23: 196–201. 20. Demirtürk N, Demir S, Aşçı Z, Doğan N. Evaluation of renal functions in patients treated with colistin. Nobel Med 2016; 12: 74–8 21. Rocco M, Montini L, Alessandri E, Venditti M, Laderchi A, De Pascale G, et al. Risk factors for acute kidney injury in critically ill patients receiving high intravenous doses of colistin methanesulfonate and/or other nephrotoxic antibiotics: a retrospective cohort study. Crit Care 2013;17:R174. 22. Bilgili B, Haliloğlu M, Gül F, Cinel I. Septic shock is an independent risk factor for colistin-induced severe acute kidney injury: a retrospective cohort study. Int J Clin Exp Med 2016;9:14649–55. 23. Gaddam S, Gunukula SK, Lohr JW, Arora P. Prevalence of chronic kidney disease in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMC Pulm Med 2016;16:158. 24. Mapel DW, Marton JP. Prevalence of renal and hepatobiliary disease, laboratory abnormalities, and potentially toxic medication exposures among persons with COPD. Int J Chron Obstruct Pulmon Dis 2013;8:127–34

Orıgınal Article

PUBLIC HEALTH

North Clin Istanb 2018;5(2):125–131 doi: 10.14744/nci.2017.91259

Violence and related factors among high school students in semirural areas of Eskisehir Burcu Isiktekin Atalay,1 Egemen Unal,1 Muhammed Fatih Onsuz,1 Burhanettin Isikli,1 Cinar Yenilmez,2 Selma Metintas1 Department of Public Health, Osmangazi University, Faculty of Medicine, Eskisehir, Turkey

Department of Pyschiatry, Osmangazi University, Faculty of Medicine, Eskisehir, Turkey

ABSTRACT OBJECTIVE: The aim of the study was to determine the frequency of violence-related behaviors and related factors at school or school environment among high school students educated in the semirural areas of Eskisehir. METHODS: This was a cross-sectional study. The sample comprised 1465 high school students. Data were collected using a questionnaire that included questions regarding sociodemographic characteristics and the 2013 survey questions of the “Youth Risk Behavior Surveillance System” of the Centers for Disease Control and Prevention. RESULTS: It was found that 8.5% of students exhibited violent behaviors at school or school environment. According to multiple logistic regression analysis, sex, father’s employment status, smoking, alcohol use, and feeling unsafe were effective independent variables on violence. CONCLUSION: Students had a high rate of violence-related behaviors at school or school environment. Community-based public health interventions are required to solve this problem. Keywords: Violence; risk factor; adolescent; semirural; high school student.

Cite this article as: Isiktekin Atalay B., Unal E., Onsuz M. F., Isikli B., Yenilmez C., Metintas S. Violence and related factors among high school students in semirural areas of Eskisehir. North Clin Istanb 2018;5(2):125–131.

iolence is a critical public health problem that has been increasing. The World Health Organization (WHO) defines violence as the deliberate use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation. Every year, more than 1 million people die because of violence and several nonfatal injuries occur as well [1]. Moreover, violence adversely influences the quality of life apart from contributing to disease, death, and disability [2]. Because violence affects the lives of millions in the long term, it is a risk factor for lifelong health and social problems [3].

Adolescents as a whole are among the groups that are the most vulnerable to violence. In addition, violence caused by adolescents is one of the most overt forms of violence prevailing in the society [1, 2]. WHO defines the 10–19 age group, the period after childhood before adulthood, as adolescence. This period is a dynamic period wherein physical, psychological, and social maturity reach completion and adulthood-specific roles, responsibilities, and behaviors are acquired. This age group is generally considered healthy [4, 5]. Conversely, adolescents are both perpetrators and victims of violence, which does not only influence them but also affects their families, friends, and societies [1]. Physical fights, bullying, and gun possession are crucial risk behaviors. In addition, us-

Received: July 25, 2017 Accepted: October 04, 2017 Online: April 11, 2018 Correspondence: Dr. Muhammed Fatih ONSUZ. Department of Public Health, Osmangazi University, Faculty of Medicine, Eskisehir, Turkey Phone: +90 222 239 29 79 e-mail: fatihonsuz@yahoo.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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ing lethal weapons, such as guns or knives, is common [1, 3]. Every day, approximately 565 people aged 10–29 years die because of violence [1]. According to the 2010 data of the Center for Disease Control and Prevention (CDC), homicide is the second cause for the death of people aged 15–24 years in the United States. In addition, 82.8% of the death of the people aged 10–24 years occurred with a gunshot [6]. The School Crime and Safety Indicators report stated that 33 deaths related to school violence occurred in the 2009–2010 among children aged 5–18 years [7]. According to a WHO study that was conducted in 133 countries, violence was observed among 26.0% of adolescents [3]. A study in Turkey found 44.0% of high school students to be exposed to verbal violence, 30.0% to physical violence, 18.0% to emotional violence, and 9.0% to sexual violence [8]. Adolescents who are involved in an act of violence during high school usually continue this behavior during their adulthood [1]. Thus, there is a need to study the dimensions of violent adolescent behavior to improve the health of adolescents and reduce problematic behaviors associated with health. Interventions conducted in this period may prevent dangers arising from violent behavior [3]. The aim of the study was to determine the frequency of violent behaviors among high school students in and around school in the semirural areas of Eskisehir and to indicate factors related to these behaviors. MATERIALS AND METHODS Setting and participants This cross-sectional study was conducted in the 2014 academic year in high schools of four districts (Alpu, Mahmudiye, Beylikova, and Sivrihisar) forming the education and research area of the Eskisehir Osmangazi University School of Medicine. The frequency of students carrying weapons, such as guns, knives or sticks, which is a criterion for violent behavior, was used to determine the sample size. This frequency has been shown to range from 5.2% to 15.3 % in Turkey [9-11]. Given 15% frequency, 3% margin of error, and 95% confidence intervals, the sample size for this study was calculated as at least 1225. The sample comprised 1465 high school students who were present in the school during the study and whose verbal permissions were received. Measures A questionnaire was prepared comprising two sections by benefiting from the literature; the first section inves-

North Clin Istanb

tigated sociodemographic characteristics of students, and the second section comprised some questions from the 2013 questionnaire of CDC’s Youth Risk Behavior Surveillance [1, 2, 10, 12-14]. This questionnaire inquired about the risky behaviors that can lead to death and disability in adolescents and adults under six headings. Violence-related behaviors were captured by asking questions regarding weapon possession, the lack of a sense of security, armed threats, clothing or book theft, fights with injuries, and fights around school. Questions related to unwanted pregnancy, behaviors causing sexually transmitted diseases, and drug usage were removed from the questionnaire because of the social and cultural characteristics of the sample region. The dependent variable of this study was determined using questions such as “how many days have you carried a gun with you in the last 30 days” and “how many times have you been involved in a fight in or around school in the last 12 months.” The frequency of these behaviors was rated as “never,” “at least once,” or “more than once.” Students who were involved in both these situations at least once were considered to be involved in a violent behavior. The family income of students in the study was evaluated as good, medium, and bad as per their own perception. Parents who were actively working on any job that delivered income were considered as “working.” Necessary permissions were obtained from the district Directorate of Education and related school executives. Later, school visits were performed at designated appointment dates and hours and students were made to come together in their classes. After informing students about the subject and purpose of the study, their verbal consents were obtained. This study complied with the Declaration of Helsinki. The questionnaires were answered by students themselves under observation. Statistical analyses Data were evaluated using IBM SPSS (version 20.0) Statistics Package Program. For analyzing the differences between groups, univariate analysis was used, and odds ratio (OR) and 95% confidence intervals (CI) were obtained. In addition, multiple logistic regression analysis was used to identify variables that influence violent behavior. A model was constructed with eleven independent variables (class, sex, family income, education of mother, job situation of father, smoking status, alcohol consumption status, sense of safety status in school, physical activity participation status, TV watching sta-

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Table 1. Distribution according to sociodemographic charac-

Table 2. Distribution according to violence-related behaviors in the school and school environment of the study group

Violence-related behaviors (n:1465)

teristics of the study group

Sociodemographic characteristics

Class 9-10 grade 11-12 grade Gender Male Female Family type Nuclear family Extended family Socioeconomic status Higher income Middle income Lower income Mother’s education level Primary school and lower Middle school and higher Father’s education level Primary school and lower Middle school and higher Mother’s working status Employed Unemployed Father’s working status Employed Unemployed Smoking No Yes Alcohol consumption No Yes Making physical activity status No Yes Watching TV status No Yes Computer use status No Yes

n (%) n: 1465 854 (58.3) 611 (41.7) 759 (51.8) 706 (48.2) 1282 (87.5) 183 (12.5) 357 (24.4) 1022 (69.8) 86 (5.8) 938 (64.0) 527 (36.0) 633 (43.2) 832 (56.8) 263 (18.0) 1202 (82.0) 1189 (81.2) 276 (18.8) 1201 (82.0) 264 (18.0) 1170 (79.9) 295 (20.1) 659 (45.0) 806 (55.0) 351 (24.0) 1114 (76.0) 516 (35.2) 949 (64.8)

tus, and computer use status), which gave p≤0.01 in one variable analysis. P≤0.05 was considered statistically significant. RESULTS The average age of high school students was 16.03±1.19 years, and 51.8% (n=759) were males, 87.5% (n=1282) grew up in a nuclear family, and 69.8% (n=1022) were from middle income families. The distribution of students according to the socio demographic characteristics is given in Table 1.

Had a weapona Lack of sense of securitya Threatened of weaponb Clothes or books is stolenb Involved in an injury fightb Involved in a fight at school environmentb

To have at least once violent behavior n (%) 183 (12.5) 291 (19.9) 149 (10.2) 401 (27.4) 223 (15.2) 515 (35.2)

Last 30 days bLast 12 months.

Of all surveyed students, 12.5% (n=183) reported that they carried a weapon at least once in the last 30 days, 10.2% (n=149) reported that they had been threatened with a weapon in and around school, 15.2% (n=223) reported that they were involved in fights that caused injuries or required treatment, and 35.2% (n=515) reported that they were involved in a fight in or around the school at least once in the last 12 months. The distribution of students according to violent behavior in schools is shown in Table 2. It was observed that 8.5% (n=125) of students had been involved in a violent behavior. According to the univariate logistic regression analysis, students with 11–12 grades [OR (%95 GA), 1.94 (1.34–2.82)], males [10.11 (5.52–18.51)], students with lower family incomes [2.19 (1.10–4.37)], students whose mothers’ education level was middle school or higher [1.78 (1.23–2.58)], students with unemployed fathers [2.20 (1.47–3.28)], students who smoked [6.96 (4.74–10.21)], students consuming alcohol [8.93 (6.04–13.22)], students feeling unsafe [3.04 (2.07–4.46)], students who were physically active [1.89 (1.28–2.81)], students who watched TV [1.96 (1.17–3.28)], and students who used computer [2.90 (1.79–4.69)] were involved in violent behavior in and around school. According to the multiple logistic regression analysis, sex [4.66 (2.43–8.95)], employment status of father [2.27 (1.38–3.75)], smoking status [2.56 (1.61–4.07)], alcohol consumption status [3.85 (2.42–6.12)], and a sense of security status [2.88 (1.82–4.55)] were independent variables on violent behavior. The results of univariate and multivariate analyses of the factors influenc-

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Table 3. Results of univariate and multivariate analyses of factors influencing the behavior, including violence in school and school environment, of students who participated in the study Class 9-10 grade 11-12 grade Gender Female Male Socioeconomic status Good Moderate Poor Mother’s education level Primary school and lower Middle school and higher Father’s working status Employed Unemployed Smoking No Yes Alcohol consumption No Yes Feeling safe Yes No Making physical activity status No Yes Watching TV status No Yes Computer use status No Yes

Show behavior including violence in school and school enviroment n (%)

Univariate analysis OR (95%Cl)

54 (6.3) 71 (11.6)

1 1.94 (1.34-2.82)

12 (1.7) 113 (4.9)

1 10.11(5.52-18.51)

29 (8.1) 82 (8.0) 14 (16.3)

1 0.98 (0.63-1.53) 2.19 (1.10-4.37)

64 (6.8) 61 (11.6)

1 1.78 (1.23-2.58)

85 (7.1) 40 (14.5)

1 2.20 (1.47-3.28)

1 2.27 (1.38-3.75)

57 (4.7) 68 (25.8)

1 6.96 (4.74-10.21)

1 2.56 (1.61-4.07)

46 (3.9) 79 (26.8)

1 8.93 (6.04-13.22)

1 3.85 (2.42-6.12)

75 (6.4) 50 (17.2)

1 3.04 (2.07-4.46)

1 2.88 (1.82-4.55)

39 (5.9) 86 (10.7)

1 1.89 (1.28-2.81)

18 (5.1) 107 (9.6)

1 1.96 (1.17-3.28)

21 (4.1) 104 (11.0)

1 2.90 (1.79-4.69)

ing students’ violent behaviors in and around the school are given in Table 3. DISCUSSION Violence, which is an important cause of mortality and morbidity among adolescents, is a public health problem that is commonly seen worldwide. There is no single

Multivariate analysis OR (95%Cl)

1 4.66 (2.43-8.95)

factor that can explain violence. These behaviors emerge as a result of an interaction between various factors [1, 3]. Our results indicate that sex, employment of father, smoking, alcohol consumption, and a sense of security in the school are the predictors of violent behavior. Other variables that were considered statistically significant in the univariate analysis but not in the multivariable analysis are not taken in the context of the discussion.

Isiktekin Atalay et al., Violence and related factors among high school students

Among the study students, 12.5% reported that they had possessed a gun in the last month and 10.2% reported that they had been threatened with a gun in the last month. Studies conducted in Turkey have indicated that 5.2%–15.3% adolescents carry a gun [9-11]. In addition, studies conducted in various countries have reported that 3.6%–17.3% adolescents carry a gun [1, 15, 16]. It is worrying that the result of this study is close to the upper limits of the ratio indicated in the results of previous studies, which suggests that adolescents have an easy access to weapons. However, this consequence may have emerged because our study was conducted in a semirural district with lower socioeconomic status. It has been reported that there is an easy access to weapons in schools that are located in districts with lower socioeconomic conditions [17]. Gun possession is one of the most important risky violent behavior for adolescents. Adolescents who consider that resorting to violence is necessary to protect themselves and their families carry weapons and threaten their environment. Such adolescents may be involved in more fights and, as a result, to feel more secure in fights, they continue to carry guns [18, 19]. In our study, 35.2% students reported that they were involved in a fight in or around school and 15.2% of them reported that they were involved in a fight where they could get injured. Studies have demonstrated that 24.5%–50.2% students are involved a fight in or around the school [9–11, 20, 21], and studies conducted in the United States and Brazil have found this frequency to be between 6.5% and 33.0% [1, 13, 15, 16, 22]. The results of our study and those of other studies conducted in our country are much higher than those of international studies. Adolescents do not prefer staying alone in the school and desire to be accepted by their peers. Adolescents consider it important to have a good position, popularity, leadership, and power among their school friends. From time to time, this need for possessing power and popularity may cause violent behaviors in adolescents [23]. Furthermore, during adolescence, which is an interim period between childhood and adulthood, acquiring a new identity and expressing the desire to make society accept this new identity or psychology that is developed by encountering a hard time, which they had not previously experienced, may have caused these results. Our study found violent behavior to be more common among males, which is in line with the findings of previous studies [1, 9, 10, 13, 21, 24–28]. Sex is considered an important predictor of violent behavior, and the tendency of male students to exhibit violent behavior

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may be explained by sex roles. The construct of sex refers to the roles, behaviors, activities, and qualifications that are created by the society for females and males [29]. Regarding sex roles, males with more traditional jurisdiction, which is encouraged by the society and benefited by males themselves, may be considered to be a factor supporting this result. The violent behavior of adolescent males may be related to tolerance shown to their behavior in the framework of social and cultural rules [20, 30]. In line with the literature, students with unemployed fathers were more involved in violent behaviors in or around the school [28, 31]. Because of the role that a society ascribes on the father, an unemployed father may create a restless environment in the house, which may cause the child to be engaged in violent behavior. In addition, an employed father may resort to violence to cope with problems in stressful environments, and, thus, children may learn violent behaviors from their fathers and tend to exhibit more violent behaviors. Our study suggested that violent behaviors were more common among students who smoke. Smoking habit is an important public health problem in our country as well as worldwide. The age average of smokers has been reported to be declining day by day both in Turkey and worldwide [32]. Previous studies have suggested a relationship between violence and smoking [2, 21, 33, 34]. In contrast, Gofin et al. have reported no relationship between violence and smoking [35]. Smoking has been reported to cause several health problems in adolescents, and, thus, is an important factor for violent behaviors [2]. Smoking and violent behavior are crucial risky health behaviors [13]. Risky behaviors can trigger and be associated with each other. In our study, alcohol consumption was shown to influence violent behaviors in students in and around the school. According to the WHO, 34.1% of students aged 15–19 years consume alcohol worldwide. Alcohol is an important factor that can trigger violent behaviors and is an important cause of violence-related injuries [1, 12, 34, 36]. Studies conducted in our country and those conducted worldwide have also suggested that students who consume alcohol are more engaged in violent behaviors [12, 21, 33, 37, 38], which indicates that alcohol may be a cause for violent behaviors and that alcohol and violence may also trigger each other. People may be prone to apply violent behaviors in result of psychological effects caused by alcohol. In addition, conducting the study in rural areas may affect the results because providing alcohol as

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a weapon supply is easier in disadvantageous districts, and violent behaviors are more commonly observed in schools [17]. Approximately one-fifth of the students surveyed in this study stated that they did not go to school because they did not feel secure. In addition, students with a lack of a sense of security presented more violent behaviors. Studies conducted in Turkey have reported lower rates of students limiting their lives because they feel insecure than the rates reported in our study [9-11, 21, 25]. The desensitization of students about violence in the school or their different perceptions about the concept of feeling secure may reveal this consequence. Previous studies have revealed a relationship between feeling insecure and violence [22, 24]. It has been reported that students assuming school as insecure because of violence in the school cause their absence unless it is compulsory [39]. Violence in the school and a lack of a sense of security could be considered as interactive factors influencing each other. This cause an insecure environment in the school, and healthy education is not possible in such environments. Ensuring a safer school environment may make students and teachers feel physically, psychologically, and emotionally free and enable them to more comfortably express themselves. There are some limitations of our study. First, instead of a direct observation of violent behaviors, we relied on behavioral characteristics defined by the students. Second, this was a cross-sectional study. Third, this study was conducted in the rural area of Eskisehir and, therefore, cannot be generalized to entire Turkey. In conclusion, school violence is becoming an individual and social problem in Turkey as it is worldwide. In addition, our study determined that sex, father’s employment status, smoking status, alcohol consumption status, and a lack of a sense of security affected violent behavior in and around school. Moreover, violent behavior was related to changeable risky behaviors. Society-based public health interventions toward changeable risky behaviors associated with violent behaviors will be crucial for preventing violence. Further, school management should make arrangements to provide security both in the school and in the school environment. Students should also be encouraged to share this with their families and teachers when exposed to violence. Effectively implemented school health services are required to improve these interventions. Interventions executed in this framework will assist adolescents to pursue their ed-

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ucation in a healthy and secure school environment and structure their future. The media can also play a role in this subject. Violent broadcasts must be effectively controlled, and educational programs on the subject should be made by media. Healthier adolescents far from violence will contribute toward constructing a healthy society in the future. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – B.I.A., E.U., M.F.O., B.I., Ç.Y., S.M.; Design – B.I.A., E.U., M.F.O., B.I., Ç.Y., S.M.; Supervision – B.I.A., E.U., M.F.O., B.I., Ç.Y., S.M.; Materials – B.I.A., E.U., M.F.O., B.I., Ç.Y., S.M.; Data collection &/or processing – B.I.A., E.U., M.F.O.; Analysis and/or interpretation – B.I.A., E.U., S.M.; Writing – B.I.A., E.U., M.F.O., B.I., Ç.Y., S.M.; Critical review – B.I.A., M.F.O., B.I., Ç.Y., S.M.

REFERENCES 1. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. World Health Organization: Geneva; 2002. 2. Türkiye Büyük Millet Meclisi. Türkiye’de ortaöğretime devam eden öğrencilerde ve ceza ve infaz kurumlarında bulunan tutuklu ve hükümlü çocuklarda şiddet ve bunu etkileyen etkenlerin saptanması araştırma raporu. Ankara: Türkiye Büyük Millet Meclisi Arastırma Komisyonu; 2007. 3. World Health Organization. Global status report on violence prevention 2014. Available at: http://www.who.int/violence_injury_prevention/violence/status_report/2014/en/. Accessed Mar 29, 2018. 4. Turkish Statistical Institute. Statistics on Child 2014. Publication Number 4372. Ankara: Turkish Statistical Institute; 2015. 5. World Health Organization. Adolescent development. Available at: http://www.who.int/maternal_child_adolescent/topics/adolescence/ development/en/. Accessed Mar 29, 2018. 6. National Center for Injury Prevention and Control. Youth Violence – Facts at a glance 2012. Available at: https://www.cdc.gov/violenceprevention/pdf/yv-datasheet-a.pdf. Accessed Mar 29, 2018. 7. National Center for Injury Prevention and Control. Youth violence prevention. Atlanta, GA: Centers for Disease Control and Prevention, 2015. 8. Haskan O, Yildirim I. Development of Violence Tendency Scale. Education and Science 2012;37:166–77. 9. Aras S, Gunay T, Ozan S, Orcin E. Risky behaviors among high school students in İzmir. Anadolu Psikiyatri Derg 2007;8:186–96. 10. Celbiş O, Karaoğlu L, Eğri M, Özdemir B. Violence among high school students in Malatya: a prevalence study. Turk J Med Sci 2012;42:343–50. 11. Eker HH, Tasdemir M, Ulger Z, Ozder A. Violence Related Behaviours among Adolescent Students and Factors Affecting Thereto. J Psychiatry 2015;18:239. 12. Anderson P, Baumberg Geiberg B. Alcohol in Europe: A public health perspective London: Institute of Alcohol Studies. Available at: https:// kar.kent.ac.uk/36384/. Accessed 29 Mar, 2018. 13. Kann L, Kinchen S, Shanklin SL, Flint KH, Kawkins J, Harris WA, et

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al; Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance--United States, 2013. MMWR Suppl 2014;63:1– 168. 14. World Health Organization. Health for the World’s Adolescents: a second chance in the second decade. Available at: http://apps.who.int/ adolescent/second-decade/files/1612_MNCAH_HWA_Executive_ Summary.pdf. Accessed Mar 29, 2018. 15. Grunbaum JA, Kann L, Kinchen S, Ross J, Hawkins J, Lowry R, et al. Youth risk behavior surveillance-United States, 2003. MMWR Surveill Summ 2004;53:1–96. 16. Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings. Available at: http://www.dpft.org/resources/NSDUHresults2005.pdf. Accessed Mar 29, 2018. 17. Limbos MA, Casteel C. Schools and neighborhoods: organizational and environmental factors associated with crime in secondary schools. J Sch Health 2008;78:539–44. 18. Malek MK, Chang BH, Davis TC. Fighting and weapon-carrying among seventh-grade students in Massachusetts and Louisiana. J Adolesc Health 1998;23:94–102. 19. Quinn GP, Bell-Ellison BA, Loomis W, Tucci M. Adolescent perceptions of violence: formative research findings from a social marketing campaign to reduce violence among middle school youth. Public Health 2007;121:357–66. 20. Alikasifoglu M, Erginoz E, Ercan O, Uysal O, Kaymak DA, Iiter O. Violent behaviour among Turkish high school students and correlates of physical fighting. Eur J Public Health 2004;14:173–7. 21. Alikasifoglu M, Erginoz E, Ercan O, Uysal O, Albayrak-Kaymak D. Bullying behaviours and psychosocial health: results from a cross-sectional survey among high school students in Istanbul, Turkey. Eur J Pediatr 2007;166:1253–60. 22. Malta DC, do Prado RR, Caribe SS, da Silva MM, de Andreazzi MA, da Silva Júnior JB, et al. Factors associated with injuries in adolescents, from the National Adolescent School-based Health Survey (PeNSE 2012). Rev Bras Epidemiol 2014;17 Suppl 1:183–202. 23. Cowie H. Bystanding or standing by: Gender issues in coping with bullying in English schools. Aggr Behav 2000;26:85–97. 24. Earnest AA, Brady SS. Dating Violence Victimization Among High School Students in Minnesota: Associations With Family Violence, Unsafe Schools, and Resources for Support. J Interpers Violence 2016;31:383–406. 25. Evren H, Tokuç B, Ekuklu G. Associations Between Violence Related Behaviors and Self Perceived Health Among Trakya University Students. Balkan Med J 2011;28:380–4.

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Orıgınal Article

EAR, NOSE, THROAT DISEASES

North Clin Istanb 2018;5(2):132–138 doi: 10.14744/nci.2018.01328

Anti-HDV seroprevalance among patients with previous HBV infection Abdurrahman Sahin,1 Suzan Gurocak,1 Nurettin Tunc,1 Ulvi Demirel,1 Orhan Kursat Poyrazoglu,1 Handan Akbulut,2 Mehmet Yalniz,1 Zulal Asci Toraman,2 Ibrahim Halil Bahcecioglu1 Department of Internal Medicine, Faculty of Medicine, Firat University, Division of Gastroenterology, Elazig, Turkey

Department of Microbiology, Faculty of Medicine, Firat University, Elazig, Turkey

ABSTRACT OBJECTIVE: This prospective study aimed to determine the prevalence of anti-HDV seropositivity among subjects who had previous hepatitis B virus (HBV) infection. METHODS: Subjects who were admitted to the gastroenterology inpatient clinic of our hospital between August 2016 and July 2017 were screened for previous HBV infection. The subjects who had HBV serology compatible with resolved HBV infection were recruited in the study, and the seroprevalance of anti-HDV was studied. Participants answered a short questionnaire regarding their family history of chronic hepatitis B (CHB) and chronic hepatitis D (CHD) infection and risk factors for transmission. Subjects who were anti-HDV positive were recalled for a control visit, and HBV-DNA and HDV-RNA were assayed in the blood samples of the responders. RESULTS: Among 554 subjects who had previous HBV infection, 53 (9.6%) were anti-HDV positive. The mean age was 63.1±15.4 years in the anti-HDV-positive group and 65.9±15.6 years in the anti-HDV-negative group (p=0.19). The most common risk factor for both groups was dental procedures (89% vs 80%, p=0.33). Anti-Hbc IgG, anti-Hbs, and anti-HBeAg seropositivity did not differ between the anti-HDV-positive and -negative groups (for all, p>0.05). Although HDV-RNA was not detectable in all studied samples, only one subject had detectable HBV-DNA in the anti-HDV-positive group. CONCLUSION: This study highlighted the prevalence of anti-HDV among subjects who had resolved HBV infection. Longterm follow-up studies, including after the resolution of both infections, are needed to explore HBV–HDV interactions and the behavioral patterns of these viruses. Keywords: Anti-HDV, HBV-DNA, HDV-RNA, previous HBV, transmission route.

Cite this article as: Sahin A., Gurocak S., Tunc N., Demirel U., Poyrazoglu O. K., Akbulut H., Yalniz M., Asci Toraman Z., Bahcecioglu I. H. Anti-HDV Seroprevalance among Patients with Previous HBV Infection. North Clin Istanb 2018;5(2):132–138.

epatitis delta virus (HDV) is a single-stranded circular RNA satellite virus and is the smallest of the known mammalian viruses [1, 2]. HDV requires the hepatitis B virus (HBV) envelope proteins for the dissemination of virus particles [3]. Thus, hepatitis delta infection occurs only in hepatitis B surface antigen (HBsAg)-positive individuals. Chronic hepatitis D (CHD) is the most severe form of

viral hepatitis, with the clinical features of accelerated progression to cirrhosis, increased risk of hepatocellular carcinoma, and early decompensation in patients with cirrhosis. CHD affects approximately 15–20 million patients among the approximately 400 million people chronically infected with HBV worldwide. HDV is found throughout the world, but its prevalence, incidence, clinical features, and epidemiological characteris-

Received: January 23, 2018 Accepted: April 13, 2018 Online: May 21, 2018 Correspondence: Dr. Abdurrahman SAHIN. Department of Internal Medicine, Faculty of Medicine, Firat University, Division of Gastroenterology, Elazig, Turkey Phone: +90 424 233 35 55 e-mail: arahmansmd@yahoo.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Sahin et al., HDV seroprevalance in the setting of past HBV infection

tics vary according to the geography [4]. Turkey is one of the high prevalence countries, and there are geographical differences between the western and eastern regions of Turkey. Epidemiological studies from the eastern and southeastern Anatolia regions have reported a prevalence of 16%–33% for delta hepatitis superinfection among chronic hepatitis B (CHB) patients [5-7]. Similarly, lower rates of CHD (2% to 7%) were reported in the western regions of Turkey [7, 8]. Studies evaluating antibodies to HDV (anti-HDV seropositivity) among HBsAg positive subjects from Turkey, Italy, and Germany found a prevalence of 8%–12% [9-11]. Resolved or previous HBV infection is defined as the clearance of HBsAg, with or without the development of antibodies to HBsAg (anti-HBs) and with or without antibodies to hepatitis B core antigen (anti-HBc). Resolution of the infection occurs spontaneously in inactive HBV carriers, at an annual rate of 0.5%–2.3% for treated CHB patients [12-15]. The loss of HBsAg is the primary end point of CHB treatment according to the international guidelines [16, 17]. The loss of HBsAg is also the ultimate goal in CHD treatment. The seroprevalence of anti-HDV has been studied in different populations including inactive HBV carriers and patients with CHB and cirrhosis [5-7, 9, 10]. No reports on the HDV prevalence among those who have resolved HBV infection have been published to date in the peer-reviewed literature. The current study aimed to determine the anti-HDV prevalence among subjects with resolved HBV infection in an area that is highly endemic for HDV. MATERIALS AND METHODS Subjects and Study Design The current study was conducted on 2736 subjects (1396 females and 1340 males) who were admitted to the gastroenterology inpatient clinic of our hospital between August 2016 and July 2017 because of several complaints and underwent HBV and hepatitis C virus (HCV) serologic testing for the assessment of previous HBV infection. If the HBV serology was compatible with one of the following three scenarios and the HCV serology was negative, the patient was considered to have previous HBV infection and was recruited in the present study: [1] HBsAg-negative, anti-HBs antibody (ab)-positive and anti-hepatitis B core (anti-HBc) IgG ab-positive; [2] HBsAg-negative, anti-HBs ab-negative and anti-HBc

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IgG ab-positive; and [3] HBsAg-negative, anti-HBs abpositive and anti-HBc IgG ab-negative (patients in the last group were questioned to determine whether they had been vaccinated against HBV or refused the HBV vaccination). Previous HBV infection was detected in 554 subjects (268 females and 286 males); these subjects were asked about their family history of CHB and CHD and risk factors for transmission [such as prior surgery, dental procedures, blood transfusion history, intravenous (IV) drug use, high-risk sexual behaviors, tattoos, and piercings]. Complete blood count; liver function tests including alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, and bilirubin levels; international normalized ratio (INR); and anti-HDV were assessed. The presence and absence of anti-HDV are shown in Figure 1. Subjects positive for anti-HDV were recalled for a control visit, and HBV-DNA and HDV-RNA were studied in the blood samples of the responders (39 anti-HDV-positive subjects). Subjects who had liver cirrhosis, seroclearance of HBsAg after the treatment of CHB and/or CHD, previous or concurrent exposure to HCV, those taking immunosuppressive medications, and those with disorders causing immune system dysfunction such as hematological diseases, chronic renal failure, or rheumatologic diseases were excluded. Age <18 years and pregnancy were other exclusion criteria. The current study was approved by the institutional review board. Informed consent was obtained from all individual participants included in the study. HBV and HDV Serology All blood samples were analyzed in the central clinical microbiology laboratory at our hospital. Approximately 5 mL of venous blood was collected from 2736 subjects and then centrifuged at 4000 rpm for 5 min for the serologic testing of HBV and HCV. Serum samples were obtained and studied on the same day. Anti-HDV was also studied using the same method in the 554 subjects who had previous HBV infection. The 53 subjects who had anti-HDV seropositivity were recalled. The blood samples of the 39 responder subjects who were antiHDV positive were collected into tubes with EDTA and centrifuged at 4500 rpm. Plasma samples were separated and stored at −20°C until the study date. Plasma samples were kept at room temperature and dissolved before the beginning the study for HBV-DNA and HDV-RNA and then tested without delay. Serum samples were tested for HBsAg, hepatitis B

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Statistical analysis Statistical analyses were performed using SPSS (version 21; SPSS Inc., Chicago, Illinois, USA). Categorical variables are presented as frequencies and percentages. Variables with a normal distribution are represented as mean±SD, those with a non-normal distribution and ordinal variables are described as median (interquartile range). Categorical variables were compared using the χ2 test or Fischer’s exact test. Differences between continuous variables were analyzed using Student’s t-test and Mann–Whitney U test in a proper approach. P<0.05 was considered statistically significant. RESULTS Overall, 554 subjects with a mean age of 65.7±15.5 years were screened for the presence of anti-HDV. Of these subjects, 268 (48%) were women and 286 (52%) were men. Among the participants, anti-HDV positivity was found in 53 subjects (9.6%) (Fig. 1). The demographic, clinical features, and laboratory findings of the anti-HDV-positive and -negative groups are shown in Table 1. While 11 subjects (20.8%) had a family history

Anti-HDV (-) Anti-HDV (+)

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100 Count (n)

e-antigen (HBeAg), anti-HBs, anti-HBc IgG, antibody against HBeAg (anti-HBeAg), and anti-HCV with macro enzyme-linked immunosorbent assay (ELISA) using Abbott Architect kits in the Abbott Architect i2000 SR system (Abbott, Axsym, Ireland) according to the manufacturer’s instructions. The presence of anti-HDV was analyzed using micro-ELISA (HDV Ab, Enzyme Immunoassay Test Kit, Delta Biologicals, Italy) with the Triturus system (Triturus, Grifols, Spain) according to the manufacturer’s instructions. This assay has been reported to have a sensitivity over 98% and a specificity over 98%. The values over 1.1 were accepted as positive for anti-HDV. Isolation of HBV-DNA and HDV-RNA in the blood samples was performed with QIAsymphony® DSP Virus/Pathogen Midi Kit, Version 1 extraction kits (QIAGEN, Germany). The presence of HBV-DNA and HDV-RNA was assessed by the real-time polymerase chain reaction (PCR) method using Rotor Gene Q (QIAGEN, Germany). HBV-DNA was tested using Artus® HBVQS-RGQ kit- 24, V1 kits (IQAGEN, Germany); HDV-RNA was also tested using Fluorion HDV Real-Time PCR kit-HDV QNP1.0 (IONTEK, Turkey) according to the manufacturer’s instructions.

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75 133

101 92

50 24 11

10 8 5 6 0 0 4 ≤ 30 31-40 41-50 51-60 61-70 71-80 81-90 >90

Age groups

Figure 1. Distribution of the subjects according to the presence or absence of anti-HDV by age.

of CHB and one (1.9%) had a family history of CHD in the anti-HDV-positive group, the ratios of CHB and CHD family histories in the anti-HDV-negative group were 17% and 2.6%, respectively (for all, p>0.05). Laboratory parameters did not differ between the anti-HDVpositive and -negative subjects (for all, p>0.05). Serological analysis of participants is shown in Table 2. The presence of anti-HBs, anti-HBc IgG, and antiHBeAg was not different between the anti-HDV-positive group and -negative group. The participants were neither HbeAg-positive nor anti-HBc IgM-positive. Although HDV-RNA was undetectable, HBV-DNA was detectable in only one subject (2.6%) among the 39 responders in the anti-HDV-positive group. DISCUSSION In the present study, the anti-HDV seropositivity was 9.6% among subjects who had previous HBV infection. To our knowledge, this is the first study to investigate HDV infection among subjects who had previous HBV infection. Although anti-HDV seroprevalence has been commonly studied in different HBV patient groups, there is little information on the exposure of patients with resolved HBV to HDV. Approximately 25 years ago, anti-HDV

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Table 1. Clinical, demographic features, and laboratory data of the participants

Anti-HDV negative

Anti-HDV positive

Patient count, n(%) 501 (90,4) 53 (9.6) Age, years mean±SD 65.9±15.6 63.0±14.4 Sex, Female n (%) 248 (49) 24 (45) Risk factors and transmission route, n (%) HBV family history 85 (17) 11 (21) HDV family history 13 (2.6) 1 (1.9) Surgery 334 (67) 35 (66) Dental procedure 403 (80) 47 (89) Blood transfusion 148 (30) 15 (28) IV drug use 3 (0.6) 0 Sexual partner with HBV 20 (4.0) 3 (5.7) Tatoo or piercing 0 0 Laboratory findings White blood count 6945±1800 7170±2300 Hemoglobin 12.9±1.8 12.4±1.8 Hematocrit 39.4±5.6 37.9±4.8 Platelet, x103 250 (198-311) 237 (198-310) ALT 21 (15-31) 22 (15-36) AST 24 (18-31) 26 (20-31) Albumin 3.99±0.48 4.02±0.52 Bilirubin 0.6 (0.4-0.9) 0.7 (0.6-0.9) INR 1.06±0.11 1.09±0.15

0.19 0.64 0.49 1.00 0.92 0.33 0.85 1.00 0.48

0.39 0.92 0.87 0.65 0.67 0.17 0.54 0.46 0.11

Table 2. Serological analysis of the participants

Anti-HDV negative (n, %)

Anti-HDV positive (n, %)

Anti-HBs positivity 420 (84) 44 (83) Anti-HBs titer IU/mL 10-99 218 (44) 26 (49) 100-999 153 (30) 12 (23) ≥1000 49 (10) 6 (11) HBeAg positivity 0 0 Anti-HBeAg positivity 157 (31) 21 (40) Anti-HBc IgG positivity 407 (81) 39 (74) Anti-HBs+Anti-HBc IgG positivity 326 (65) 30 (57) Isolated Anti-HBs positivity 94 (19) 14 (26) Isolated Anti-HBc IgG positivity 81 (16) 9 (17) HBV DNA* (detectable) NA 1 (2.6) HDV RNA* (detectable) NA 0

p 0.88 0.48

0.22 0.18 0.37

* HBV DNA and HDV RNA were studied in 39 subjects who responded to recall. NA: Not available

positivity was first reported in HBsAg-negative IV drug users [18, 19]. Later, a study conducted on Mongolian subjects found anti-HDV positivity among subjects

with resolved HBV infection (HBsAg-negative and anti-HBc IgG-positive) [20]. In this study on Mongolian subjects, 20 of the 170 subjects (11.8%) who had pre-

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vious HBV infection were anti-HDV-positive and one of them (0.6%) was also HDV-RNA-positive. A survey in Switzerland also found a 13% prevalence of HBsAg negativity and a 10% prevalence of anti-HBs positivity among subjects who had proof of HDV infection consisting of at least anti-HDV positivity [21]. These studies are evidence of HDV exposure in HBsAg-negative subjects by anti-HDV. Several hypotheses can be discussed with respect to this issue. First, some cross-sectional studies demonstrated the disappearance of HBsAg in patients with CHD over time. Niro et al. demonstrated HBsAg loss in six patients (10%) among 60 patients with CHD (HBs Ag-positive and anti-HDV positive) who were not treated with interferon (IFN) or who were non-responders to IFN after a mean of 4 years of follow-up [22]. Another longterm follow-up study also demonstrated seroclearance of HBsAg in 22 of 299 patients (7%, a rate of 0.25 per year) [23]. Half of these patients were untreated, and seroconversion to anti-HBs developed in all patients. In another study from Spain, HBsAg seroclearance was found to be 7% among 158 CHD subjects, with a median follow-up of 75 months [24]. The previously mentioned studies reveal that HBsAg loss and even anti-HBs seroconversion have been seen in the long-term follow-up of patients with CHD. However, participants who had any cause of chronic hepatitis and cirrhosis were excluded in the current study. HDV is transmitted mainly via the parenteral route. Considering the older age of the study participants (mean age, 65.5 years) and data from earlier studies in Turkey demonstrating an increasing incidence of exposure to HBV with age, unsafe hospital-based medical procedures in earlier time periods and household contacts, these might be the cardinal sources of dual HBV/ HDV infection in this endemic area. HDV was discovered as an epidemic in the 1970s and 1980s [24]. This is related to a cumulative risk of HDV exposure over time. Thus, most of the study participants might have been infected with HDV 2â&#x20AC;&#x201C;4 decades ago. As shown Figure 1, it appears that HDV exposure continued for two decades. After the beginning of a universal vaccination program in Turkey in 1999, there was an accelerated reduction in HDV exposure related to HBV exposure. The clinical scenario of HDV infection is variable, and asymptomatic carriage or benign hepatitis is also described in the endemic areas [1]. Resolution of dual infection occurs in most co-infected cases. Based on the

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current knowledge, a loss of HBsAg with the presence of HDV is the characteristic finding of the resolution of HBV/HDV coinfection. However, the time required for anti-HDV to disappear is not well known. Acute HBV/ HDV coinfection usually appears first as IgM anti-HDV and then converts to IgG anti-HDV. In superinfection, HDV antibodies appear early as IgM, followed by IgG anti-HDV [4]. Generally, anti-HDV IgM antibodies become detectable approximately 4 weeks after the infection, but then disappear several weeks after the onset of acute coinfection [25, 26]. Conversely, IgM anti-HD may persist over time in patients whose infection progresses to chronicity. Anti-HDV IgG antibodies persist for a long time in the course of chronic superinfection [26]. Anti-HDV IgG remains positive for years after the successful treatment of CHD including HBsAg clearance. There are scarce data on the disappearance of anti-HDV IgG antibodies. The loss of anti-HDV was reported in untreated patients and in patients who undergo liver transplantation for CHD after the fifth year of seroclearance of HBsAg or liver transplantation [22, 27]. Thus, some of our subjects might be surviving cases of HBV/ HDV coinfection. Furthermore, the current study is a cross-sectional study on subjects who had resolved HBV infection. Thus, it was not possible to detect the duration of HBsAg seroclearance. The lower seroprevalence of anti-HDV in subjects aged >50 years might be because of the accelerated seroclearance of anti-HDV. The preferred screening method for the diagnosis of HDV infection is the measurement of anti-HDV. The diagnosis of HDV infection is based on the presence of HDV-RNA after the positive test results of anti-HDV. There are several commercial anti-HDV tests using the method of simultaneous competitive assays [28]. In a recent study, it was shown that commercially available assays can effectively detect antibodies to HDV [29]. Most of these tests are qualitative measurement of anti-HDV. Recently, quantitative microarray antibody capture (QMAC) assay was shown closely related with the presence of HDV-RNA (sensitivity, 100%; specificity, 94.3% for Q-MAC assay) [30]. Although anti-HDV IgG is the most commonly used tool to screen patients with CHB for concomitant HDV infection or previous infection, competitive assays measure all types of antibodies to HDV [1, 28]. In the current study, we used total antiHDV as a screening tool to determine the exposure to HDV. Although we could not test the participants for anti-HDV IgM separately, they were all negative for anti-HBc IgM. Thus, we considered that it was not possible

Sahin et al., HDV seroprevalance in the setting of past HBV infection

to have acute HBV/HDV coinfection in our study population. Several studies have found a higher prevalence of HDV exposure by HDV-RNA compared with antiHDV IgG [9, 31]. Further, the expense of HDV-RNA measurement compared with anti-HDV measurement restricts the common use of this assay as a screening modality. Another hypothesis is that occult HBV infection may result in undetectable HBsAg and undetectable or low levels of HBV-DNA in dual infection, as a consequence of the suppression of HBV by HDV. In the present study, HDV-RNA was negative in all subjects, and only one subject had detectable HBV-DNA. A study by Delfino et al. demonstrated the presence of HDV by HDV-RNA in three cases that had occult HBV infection (HBsAg-negative, anti-HBc IgG-positive, and HBV-DNA-positive in two of them) [32]. Interestingly, all three of these subjects were anti-HDV negative, and the authors concluded that large HD-Ag variants were responsible for covert HDV infection in these subjects. It can be concluded that unidentified occult HDV infection might be a part of the clinical spectrum of HDV. The clinical importance of resolved dual HBV/HDV infection arises in cases of patients taking immunosuppressive agents. Data on this topic is derived from patients undergoing liver transplantation for CHD. Before effective antiviral treatment using nucleoside analogs and hepatitis B immunoglobulin (HBIG), the reinfection rate after liver transplantation had reached up to 77% and reinfection was similar to the HBV/HDV coinfection pattern [33]. Helper-independent HDV infection was first described in patients undergoing liver transplantation with isolated HDV infection in the liver and HDV viremia [34, 35]. Although this form of HDV is considered not to have clinical importance and isolated HDV infection may become symptomatic only after HBV reactivation, one recent report from Japan drew attention to this issue [36]. A patient who underwent liver transplantation for CHD-related cirrhosis 4 years prior was being treated with entecavir, HBIG, corticosteroid, and mycophenolate mofetil. After the discontinuation of entecavir treatment, a hepatitic attack with reversion of HBsAg and HBeAg occurred. In the retrospective analysis of the patient’s serum and liver tissue, HDV-RNA was detected. The authors of this report attributed detectable HDV-RNA to the repackaging of HDV after the beginning of HBV replication and they concluded that long-term steroid treatment, which is clearly related with HBV reactivation, may also cause HDV reactiva-

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tion. As a result, HDV reactivation after HBV reactivation should be kept in mind in patients who have resolved HBV infection and are given immunosuppressive treatments, particularly corticosteroids. These subjects should also be checked for HDV exposure in the endemic areas. There are some limitations to the current study. First, we screened a study population for HDV exposure by antiHDV. The replication of HDV has been detected most efficiently using HDV-RNA measurement. Testing the entire study population for HDV-RNA would have been a more accurate approach for investigating HDV replication. Second, some of the anti-HDV-positive subjects did not respond to the request for HDV-RNA and HBV-DNA measurements. Another limitation is that our results cannot be generalized to the Turkish population because of epidemiological differences in the Eastern and Western parts of Turkey in terms of HDV prevalence. Finally, the current study is a cross-sectional study investigating anti-HDV seroprevalence in subjects with previous HBV infection. Additionally, long-term follow-up studies are needed to determine the clinical importance of anti-HDV seropositivity. In conclusion, the current study enables the evaluation of the prevalence of HDV exposure among subjects surviving HBV infection in an endemic area. A prevalence of 9.6% anti-HDV was found among subjects who had previous HBV infection. The clinical course of HDV infection is variable. Though HBV/HDV coinfection is the most severe form of viral hepatitis, milder forms of the dual infection or the resolution of both infections have been identified. Additional HDV testing for the detection of previous HDV exposure is required in endemic areas and in those taking immunosuppressive medications, particularly corticosteroids. Conflict of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – A.S., M.Y.; Design – A.S., Z.A.T.; Supervision – H.A., I.H.B.; Materials – S.G., N.T.; Data collection &/or processing – A.S., U.D., O.K.P.; Analysis and/or interpretation – H.A., Z.A.T.; Writing – A.S.; Critical review – H.A., M.Y.

REFERENCES 1. Alvarado-Mora MV, Locarnini S, Rizzetto M, Pinho JR. An update on HDV: virology, pathogenesis and treatment. Antivir Ther 2013;18:541–8.

138 2. Sureau C, Negro F. The hepatitis delta virus: Replication and pathogenesis. J Hepatol 2016;64:S102–16. 3. Rizzetto M. Current management of delta hepatitis. Liver Int 2013;33 Suppl 1:195–7. 4. Noureddin M, Gish R. Hepatitis delta: epidemiology, diagnosis and management 36 years after discovery. Curr Gastroenterol Rep 2014;16:365. 5. Türkdoğan MK, Bozkurt H, Uygan I, Tuncer I, Irmak H, Buzgan T, et al. Chronic hepatitis delta virus infection in Van region of eastern Turkey. Turk J Gastroenterol 2005;16:17–20. 6. Bahcecioglu IH, Aygun C, Gozel N, Poyrazoglu OK, Bulut Y, Yalniz M. Prevalence of hepatitis delta virus (HDV) infection in chronic hepatitis B patients in eastern Turkey: still a serious problem to consider. J Viral Hepat 2011;18:518–24. 7. Değertekin H, Yalçin K, Yakut M, Yurdaydin C. Seropositivity for delta hepatitis in patients with chronic hepatitis B and liver cirrhosis in Turkey: a meta-analysis. Liver Int 2008;28:494–8. 8. Kose S, Ece G, Gozaydin A, Turken M. Study on seroprevalence of hepatitis delta in a regional hospital in western Turkey. J Infect Dev Ctries 2012;6:782–5. 9. Reinheimer C, Doerr HW, Berger A. Hepatitis delta: on soft paws across Germany. Infection 2012;40:621–5. 10. Stroffolini T, Sagnelli E, Sagnelli C, Russello M, De Luca M, Rosina F, et al; behalf of EPACRON study group. Hepatitis delta infection in Italian patients: towards the end of the story? Infection 2017;45:277–81. 11. Celen MK, Ayaz C, Hosoglu S, Geyik MF, Ulug M. Anti-hepatitis delta virus seroprevalence and risk factors in patients with hepatitis B in Southeast Turkey. Saudi Med J 2006;27:617–20. 12. Liaw YF, Sheen IS, Chen TJ, Chu CM, Pao CC. Incidence, determinants and significance of delayed clearance of serum HBsAg in chronic hepatitis B virus infection: a prospective study. Hepatology 1991;13:627–31. 13. Fattovich G, Bortolotti F, Donato F. Natural history of chronic hepatitis B: special emphasis on disease progression and prognostic factors. J Hepatol 2008;48:335–52. 14. Yuan T, Jiang Y, Li M, Li W. Chronic hepatitis B surface antigen seroclearance-related immune factors. Hepatol Res 2017;47:49–59. 15. Simonetti J, Bulkow L, McMahon BJ, Homan C, Snowball M, Negus S, et al. Clearance of hepatitis B surface antigen and risk of hepatocellular carcinoma in a cohort chronically infected with hepatitis B virus. Hepatology 2010;51:1531–7. 16. Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH; American Association for the Study of Liver Diseases. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016;63:261–83. 17. European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2017;67:370–98. 18. Weller IV, Karayiannis P, Lok AS, Montano L, Bamber M, Thomas HC, et al. Significance of delta agent infection in chronic hepatitis B virus infection: a study in British carriers. Gut 1983;24:1061–3. 19. Novick DM, Farci P, Karayiannis P, Gelb AM, Stenger RJ, Kreek MJ, Thomas HC. Hepatitis D virus antibody in HBsAg-positive and HBsAg-negative substance abusers with chronic liver disease. J Med

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Orıgınal Article

EAR, NOSE, THROAT DISEASES

North Clin Istanb 2018;5(2):139–143 doi: 10.14744/nci.2017.57984

Single-sided sinonasal mass: A retrospective study Seyda Belli,1 Metin Yildirim,1 Sinan Eroglu,1 Funda Kaya Emre2 Department of Nose and Throat Diseases Clinic,Health Sciences University Bağcılar Education and Research Hospital Ear, Istanbul, Turkey

Department of Pathology Clinic, Health Sciences University Bağcılar Training and Research Hospital, Istanbul, Turkey

ABSTRACT OBJECTIVE: A unilateral sinonasal mass is a common pathology in ear, nose, and throat clinical practice. However, it may be confused with early stage inflammatory pathologies. The aim of this study was to examine the diagnostic histopathological, clinical, and radiological criteria for a unilateral nasal mass. METHODS: The present study examined the clinical and pathological profiles of unilateral sinonasal masses observed in patients at an ear, nose, and throat clinic in Istanbul between January 2008 and January 2016. During the period of this retrospective study, 195 patients presented with a single-sided sinonasal mass (males: 130, females: 65; age range: 9-93 years). The data analyzed were obtained from patient records. RESULTS: The single-sided sinonasal mass was benign in 187 (95.9%) cases and malignant in 8 (4.1%) cases. Inflammatory polyps (81.03%) were the most frequent benign finding. Squamous cell carcinoma (1.54%) was the most commonly diagnosed malignant lesion. CONCLUSION: A single-sided sinonasal mass is commonly detected by otorhinolaryngologists. Although most often the diagnosis is inflammatory nasal polyposis, the risk of malignancy should not be overlooked. For this reason, careful endoscopic examination should be performed, all lesions should undergo a pathological examination, and it should be kept in mind that neoplastic disease can occur at any age and may be associated with many symptoms. Keywords: Benign; malignant; nasal polyp; single-sided sinonasal mass

Cite this article as: Belli S., Yildirim M., Eroglu S., Kaya Emre F. Single-sided sinonasal mass: A retrospective study. North Clin Istanb 2018;5(2):139–143.

ingle-sided sinonasal mass is a frequently seen entity. Nasal congestion, unilateral nasal discharge, and bleeding, migraine, and dysosmia, and facial swelling are most frequent complaints. [1, 2, 3]. The patients presenting with these symptoms undergo rhinoscopic, and concurrent endoscopic examinations. Frequently inflammatory etiology is found. This entity can be treated conservatively, and very few patients require surgical treatment [1]. In a study by Lee et al. unilateral sinusitis was found in 23% of the patients who applied with complaints of single- sided nasal complaints [4, 5]. Presence

of unilateral symptoms, and nasal mass may imitate inflammatory pathology during early phase. Therefore clinician evaluates the patient together with radiological findings, and priorly plans pathological examination [1]. Early diagnosis plays an important role in the establishment of early diagnosis, and faster planning of the treatment. Though single-sided nasal mass is frequently face us in the clinical practice of ENT diseases, very few studies have investigated this entity in the literature [6]. We retrospectively investigated the files of the patients presented to our clinic with single-sided sinonasal symp-

Received: June 09, 2017 Accepted: September 21, 2017 Online: April 12, 2018 Correspondence: Dr. Seyda BELLI. Department of Nose and Throat Diseases Clinic, Health Sciences University Bağcılar Training and Research Hospital Ear, Istanbul, Turkey Phone: +90 212 440 40 00 e-mail: drseydabelli@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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toms, and diagnosed as single-sided nasal mass lesion, and evaluated their histopathological diagnosis in the light of the literature. MATERIALS AND METHODS Before proceeding with the study, ethics committee approval was obtained from the ethics committee of noninvasive investigations. The files of the patients diagnosed as single-sided sinonasal mass between January 2008, and January 2017 were retrospectively analyzed. Medical records, results of histopathological analyses, and computed tomographic images of a total of 195 patients could be obtained. The patients were divided into two groups, as those with diagnosis of benign, or malignant lesions. The frequency of lesions was investigated. Demographic characteristics of the groups as age, and gender, and also histopathological examination results were compared. In the study statistical analyses were performed using NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah, USA) package program. Data were evaluated using descriptive statistical methods (mean, standard deviation, distributions of frequencies, and proportions) and also independent t-test was used for intergroup comparisons. Results were evaluated at p<0.05 which was accepted as the level of significance. RESULTS Punch biopsy was performed for all patients with singlesided nasal mass. Based on the results of histopathological tests, and radiological examinations various treatment modalities as conservative treatment, chemoradiotherapy or singlesided functional/advanced endoscopic sinus surgery were performed. A total of 195 (male, n=130, and female, =65) patients were included in the study. Median age of biopsized patients was 42 (9-93) years. (Table 1). Histopathological examination of biopsy materials revealed the presence of 7 benign, and 6 malignant diseases. A 95.9 % of the lesions had benign, and 4.1 % of them malignant characteristics (Table 2). Benign lesions included nasal polyps, hemangiomas, chondromesenchymal hamartoma, schneiderian papilloma (oncocytic type, fungiform type, and inverted type), fungal rhinosinusitis (Table 3). A hundred and eighty-seven benign lesions were detected with a male/female ratio of 1:2. (Table 2).

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Table 1. Sociodemographic data

Age (years) Male Female

Mean (range)

195 42.43 (9-93) 130 65

66.67 % 33.3%

Table 2. Distribution of benign, and malignant entities

Benign 187 (95.90%) Malign 8 (4.10%)

Female

Male

Age (years)

62 (33.16%) 3 (37.50%)

125 (66.84%) 5 (62.50%)

41.50±17.99 64.25±17.04

Among all lesions, and also benign lesions most frequently nasal polyp was seen. Nasal polyps were seen more frequently in adults rather than children, and men rather than women. Nasal polyp was diagnosed in 158 patients (81.03%) (Table 3). Schnederian papilloma was the second most frequently seen tumor. Schnederian papilloma has inverted, fungiform, and oncocytic types. In this study we detected inverted (92.31%), fungiform (3.85%), and oncocytic (3.85%) types in respective percentages of patients with schnederian papillomas (Table 4). As malignant lesions we encountered high-grade dysplasia, squamous cell carcinoma developed on the background of inverted papilloma, squamous cell carcinoma, adenoid cystic carcinoma, malignant melanoma, β-cell non-Hodgkin lymphoma. We detected malignant lesions in 5 male, and 3 female patients (Table 2). Most frequently seen malignant lesion was squamous cell carcinoma (SCC). In 2 out of 3 patients with SCC, the disease developed in the presence of inverted papilloma. Among our patients malignant melanoma (n=2), adenoid cystic adenoma (n=1), β-cell non-Hodgkin lymphoma (n=1), and high grade dysplasia (n=1) were detected. (Table 3) Median ages of the patients with benign and malignant lesions were 41.50, and 64.25 years, respectively Mean age of the patients with malignant lesions was statistically significantly higher relative to that with benign lesions (p=0.001) (Table 2).

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Table 3. Histopathological diagnoses, and their distribution Nasal Polyp Schnederian papilloma, Inverted type Schneiderian papilloma, Fungiform type Schneiderian papilloma, Oncocytic type Malignant Melanoma Squamous cell carcinoma developed on the background of inverted papilloma Squamous cell carcinoma Chondromesenchymal hamartoma Adenoid cystic carcinoma B-cell non-Hodgkin lymphoma Fungal rhinosinusitis Hemangioma Tumoral proliferation with papillary demonstrating dysplastic changes Total

Mean

Minimum

Maximum

158 24 1 1 2 2

81.03 12.31 0.51 0.51 1.03 1.03

39.80 50.71 43.00 60.00 73.50 69.00

17.70 15.06 . . 7.78 7.07

10 13 43 60 68 64

93 92 43 60 79 74

1 1 1 1 1 1 1

0.51 0.51 0.51 0.51 0.51 0.51 0.51

67.00 9.00 43.00 84.00 61.00 81.00 35.00

. . . . . . .

67 9 43 84 61 81 35

195

100.00

42.43

18.48

Table 4. Types of Schnederian papillomas Diagnosis

Schnederian papilloma, Inverted type Schneiderian papilloma, Fungiform type Schneiderian papilloma, Oncocytic type

24 1 1

92.31 3.85 3.85

DISCUSSION Clinical diagnosis of a patient presented with singlesided sinonasal mass is an important clinically challenging issue because of multifactorial underlying etiologies [1, 3]. Comprehensive evaluation of the patient requires investigation of patient’s age, symptoms, nasal endoscopic examination, and computed tomographic findings [1]. In our study most frequently seen nasal mass lesion was nasal polyp (81.03%), followed by schnederian papilloma (13.33%). These results of our study were also in compliance with those of the studies performed by Nair et al., and Habeşoğlu et al. [1, 3]. However in a study realized by Erkul et al. contrary to our results most frequently antrochoanal polyp was detected [7]. Nasal polyps are abnormal protrusions of nasal or paranasal mucosa into nasal cavity. Nasal polyps develop as a result of chronic inflammation, allergy, infectious

agents, and cystic fibrosis, and they are seen in 1-4% of the overall population. They are more frequently seen in adults rather than children, and in men rather than women [2]. The results of our study were also in accordance with the literature findings (81.03%). Although bilateral sinonasal disease is more frequently diagnosed in clinical practice, in the presence of single— sided malignancy clinician should suspect malignancy, and examine the patient accordingly [2, 7]. Squamous cell carcinoma is the most frequently seen neoplastic lesion in sinonasal cavity. Frequently it gives symptoms as a unilateral nasal mass, and at early stages of the disease they appear like benign nasal polyps [6]. Neoplastic diseases of nose, and paranasal sinus frequently become manifest during 5.7. decades with a female/male ratio of 2:1. [5, 7, 8]. Also in our study, in compliance with the literature, malignant sinonasal disease is more frequently seen during 5. and 6. decades (median age 64.25 years), and in men, rather than women (men, 62.5% vs women, 37.50%). Typically inverted papilloma is seen on computed tomography as a mass starting from middle mea, and extending up to maxillary antrum, and nasal cavity [9, 10]. In our study most frequently, maxillary sinus, and then ethmoidal cells were affected. The characteristic features of inverted papillomas include their capability to cause bone erosion,

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Figure 1. Coronal section computed tomographic (CT) imaging of inverted papilloma.

postoperative recurrences, and malignant transformation [9, 10]. Malignant transformation is seen in 5-20% of the patients with inverted papillomas. [11, 12]. Also in our study, malignant transformation was seen in 7.69% of the patients, and we observed squamous cell carcinoma on the background of inverted papilloma in 2 cases. In a study performed by Lee, and Rudralingam, the authors asserted that CT is a helpful method in demonstrating bone erosion, and determination of the etiology of fungal diseases [3, 4, 13]. In patients with inverted papilloma bone erosion may be seen. In this study in a patient with inverted papilloma we observed defect on anterior wall of maxillary sinus in one, and also a defect on lamina papyracea of another patient (Fig. 1). In non- Hodgkin lymphomas, most frequent extranodal location is head and neck region, this malignancy is rarely seen in sinonasal cavity. The incidence of all malignant lesions in sinonasal cavity is reported as 0.3-2 percent [14]. In our study, we detected Î˛-cell non-Hodgkin lymphoma in an 84-year-old woman. In this patient lamina papyracea, and skull base defects striked our attention. (Fig. 2) In a systematic review performed by Mason et al. in 2015, the authors demonstrated that chondromesenchymal hamartoma is seen between 1, and 69 years of age with a median age of 9 years [15]. Chondromesenchymal hamartoma has mesenchymal, and cartilaginous components and it is a mixed tumor seen more frequently in infants, and small children which leads to nasal congestion, face, and tooth pain. In our study we saw this entity in a 9-year-old male child. Computed tomographic images of his lesion is shown in Figure 3. CONCLUSION

Figure 2. Coronal section computed tomographic (CT) imaging of B-cell non-Hodgkin lymphoma.

Establishment of diagnosis, and treatment planning are very challenging issues for clinicians. Indeed, it may be confused with benign lesions, and it may become symp-

Figure 3. Coronal section computed tomographic (CT) imaging of chondromesenchymal hamartoma.

Belli et al., Single-sided sinonasal mass

tomatic at a later stage of the disease. Nasal endoscopyguided biopsy, plays a very important role in the establishment of early diagnosis, and treatment planning. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – S.B.; Design – M.Y.; Supervision – S.B.; Materials – M.Y., S.E.; Data collection &/or processing – F.E.K.; Analysis and/or interpretation – S.B.; Writing – S.B.; Critical review – S.B., M.Y.

REFERENCES 1. Nair S, James E, Awasthi S, Nambiar S, Goyal S. A review of the clinicopathological and radiological features of unilateral nasal mass. Indian J Otolaryngol Head Neck Surg 2013;65:199–204. 2. Paz Silva M, Pinto JM, Corey JP, Mhoon EE, Baroody FM, Naclerio RM. Diagnostic algorithm for unilateral sinus disease: a 15-year retrospective review. Int Forum Allergy Rhinol 2015;5:590–6. 3. Habeşoğlu TE, Habeşoğlu M, Toros SZ, Naiboğlu B, Sürmeli M, Egeli E. Tek taraflı sinonazal polipoid kitlelerde histopatoloji ve neoplastik için risk faktörleri. Göztepe Tıp Dergisi 2010;25:78–81. 4. Lee JY. Unilateral paranasal sinus diseases: analysis of the clinical characteristics, diagnosis, pathology, and computed tomography findings. Acta Otolaryngol 2008;128:621–6. 5. Sökmen MF, Özer F, Özer C, Canbolat ET, Yılmazer C. Clinicopathological analysis in unilateral endoscopic sinus surgery. KBB Uygulamaları 2015;3:13–9.

143 6. Chung HK, Tai CJ, Wang PC, Lin CD, Tsai MH. Analysis of disease patterns in patients with unilateral sinonasal diseases. Mid-Taiwan Journal of Medicine 2008;13:82–8. 7. Erkul E, Çekin İE, Kurt O, Güngor A, Babayiğit MA. Evaluation of patients with unilateral endoscopic sinus surgery. Turk Arch Otolaryngol 2012;50:41–5. 8. Zbären P, Richard JM, Schwaab G, Mamelle G. Malignant neoplasms of the nasal cavity and paranasal sinuses. Analysis of 216 cases of malignant neoplasms of nasal cavity and paranasal sinuses. HNO 1987;35:246–9. 9. Ikeda K, Tanno N, Suzuki H, Oshima T, Kano S, Takasaka T. Unilateral sinonasal disease without bone destruction. Differential diagnosis using diagnostic imaging and endonasal endoscopic biopsy. Arch Otolaryngol Head Neck Surg 1997;123:198–200. 10. Savy L, Lloyd G, Lund VJ, Howard D. Optimum imaging for inverted papilloma. J Laryngol Otol 2000;114:891–3. 11. Mansell NJ, Bates GJ. The inverted Schneiderian papilloma: a review and literature report of 43 new cases. Rhinology 2000;38:97–101. 12. Al-Mujaini A, Wali U, Alkhabori M. Functional endoscopic sinus surgery: indications and complications in the ophthalmic field. Oman Med J 2009;24:70–80. 13. Rudralingam M, Jones K, Woolford TJ. The unilateral opaque maxillary sinus on computed tomography. Br J Oral Maxillofac Surg 2002;40:504–7. 14. Chalastras T, Elefteriadou A, Giotakis J, Soulandikas K, Korres S, Ferekidis E, et al. Non-Hodgkin’s lymphoma of nasal cavity and paranasal sinuses. A clinicopathological and immunohistochemical study. Acta Otorhinolaryngol Ital 2007;27:6–9. 15. Mason KA, Navaratnam A, Theodorakopoulou E, Chokkalingam PG. Nasal Chondromesenchymal Hamartoma (NCMH): a systematic review of the literature with a new case report. J Otolaryngol Head Neck Surg 2015;44:28.

Original Images

PHYSICAL THERAPY AND REHABILITATION

North Clin Istanb 2018;5(2):144 doi: 10.14744/nci.2017.16878

Ultrasound diagnosis of a pathological fracture of the phalanx in a patient with chronic kidney disease: After a 2-month diagnostic delay Selcuk Sayilir Department of Physical Medicine & Rehabilitation, Mugla Sıtkı Kocman University Faculty of Medicine, Mugla, Turkey

Cite this article as: Sayilir S. Ultrasound diagnosis of a pathological fracture of the phalanx in a patient with chronic kidney disease: After a 2-month diagnostic delay. North Clin Istanb 2018;5(2):144.

56-year-old man was admitted to our clinic with pain, swelling, and tenderness in the third finger of his right hand for 2 months. He did not report a physical injury. He was admitted to other clinics for these symptoms, where he was misdiagnosed inflammatory arthritis and treated with deflazacort (3 mg/day). He has a history of chronic kidney disease (CKD) and has been undergoing hemodialysis for 4 years. On physical examination, he had pain and edema on the proximal interphalangeal joint of the right hand (Fig. 1), and no warmth or change in color was noted. In addition, there were no findings of active peripheral arthritis. Blood culture was positive for Staphylococcus epidermidis, and he was administered an intravenous antibiotic. An ultrasound examination performed for the finger due to these clinical findings showed a fracture line in the proximal phalanx of the third finger. Peripheral and axial skeletal fractures are frequent complications of CKD as a result of altered mineral and bone metabolism and enhanced bone fragility. Several authors have reported that fractures can be considered dramatic events in CKD patients. The effectiveness of ultrasound examination in fracture diagnosis has also been reported in the literature. It was remarkable that the patient was admitted to different clinics for his complaints, but he was mistreated with corticosteroids and analgesics because of misdiagnosis with inflammatory arthritis. X-ray examination after the ultrasound examination also showed a fracture line, but it was not

a clear view and may overlook (Fig. 1). If patients with immunodeficiency are inappropriately treated with corticosteroids, they can become susceptible to severe infections. The reported patient had a history of using corticosteroids for 2 months. He had a serious blood infection and was treated with intravenous antibiotics. A

Figure 1.

(A) X-ray showing a nebulous fracture line at the third proximal phalanx (arrow). (B) Edema in the third finger. (C) Ultrasound examination showed a fracture line at the proximal phalanx (black arrow)

Received: February 14, 2017 Accepted: July 27, 2017 Online: March 26, 2018 Correspondence: Dr. Selcuk SAYILIR. Department of Physical Medicine & Rehabilitation, Mugla Sıtkı Kocman University Faculty of Medicine, Mugla, Turkey. Phone: +90 252 214 13 26 e-mail: selcukssay@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Case Report

CARDIOLOGY

North Clin Istanb 2018;5(2):145–147 doi: 10.14744/nci.2017.53254

Peripartum cardiomyopathy and ventricular thrombus: A case report and review of literature Ugur Aksu,1 Selim Topcu,2 Oktay Gulcu,2 Ibrahim Halil Tanboga2 Department of Cardiology, Bursa State Hospital, Bursa, Turkey

Department of Cardiology, Atatürk University Faculty of Medicine, Erzurum, Turkey

ABSTRACT Peripartum cardiomyopathy (PPCMP) is a rare and life-threatening condition. Intracardiac thrombus is characteristically associated with increased adverse events, mortality, and a high risk of thromboembolic events, and has been associated with PPCMP. Early diagnosis and treatment play a critical role. Although echocardiography is the first-line diagnostic method, other imaging modalities may provide useful information in appropriate patients. Presently described is a case in which an apical intracardiac thrombus coexisting with PPCMP was identified and managed using multimodality imaging studies. Keywords: Congestive heart failure; dilated cardiomyopathy; thrombus.

Cite this article as: Aksu U., Topcu S., Gulcu O., Tanboga I. H. TPeripartum cardiomyopathy and ventricular thrombus: A case report and review of literature. North Clin Istanb 2018;5(2):145–147.

eripartum cardiomyopathy (PPCMP) is a rare disease, which can present between the final months of pregnancy and the 6th postpartum week and can lead to heart failure. Intracardiac thrombus is characteristically associated with a high risk of thromboembolic events and reported as an additional finding together with PPCMP. Transthoracic echocardiography (TTE) is a very important diagnostic modality for both of these entities [1-4]. Although most of the literature relies exclusively on TTE findings for diagnosis, we report a case, in which an apical intracardiac thrombus coexisting with PPCMP was identified and managed using multimodality imaging studies. CASE REPORT A 25-year-old female patient presented to the emergency room with dyspnea and markedly reduced effort capacity. Medical history was notable for an uneventful pregnancy and normal delivery of a healthy baby 1 week

prior to presentation. Dyspnea on exertion started on the 2nd postpartum day, progressed, and the patient reported paroxysmal nocturnal dyspnea for 3 nights. Her admission vitals were normal except tachypnea and a relatively low oxygen saturation (93%). Physical examination revealed general pallor, bibasilar rales, and S3. Electrocardiography showed sinus tachycardia. Ventricular dilatation, increased ventricular filling pressure, moderate systolic dysfunction, and moderate mitral regurgitation were found on TTE, together with an sPAB of 40 mmHg. A hypoechoic mass with irregular borders concurrent with a thrombus was apparent in the left ventricle (Fig. 1). Liver and kidney function tests were within normal limits; brain natriuretic peptide and Ddimer levels were high. Autoimmune panel and thyroid function tests were normal. Patient was admitted to the coronary care unit with presumed diagnoses of peripartum cardiomyopathy and an apical thrombus. Diuresis and heparinization were initiated. Cardiac tomography scan (CTC) was planned

Received: January 19, 2017 Accepted: July 24, 2017 Online: March 30, 2018 Correspondence: Dr. Ugur AKSU. Department of Cardiology, Bursa State Hospital, Bursa, Turkey. Phone: +90 541 787 57 25 e-mail: aksuuu001@msn.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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DISCUSSION

Figure 1. A hypoechoic mass with irregular borders concurrent with a thrombus based on the apical two-chamber view

to investigate the accompanied cardiac anomaly causing ventricular thrombus development, and apical cardiac thrombus was confirmed (Fig. 2a, b). On the 3rd day of admission, a control TTE showed that the embolus had diminished in size. To exclude coronary heart disease, invasive coronary angiography (ICA) was scheduled, and ICA performed on the 5th day revealed a normal coronary artery (Fig. 3) concurrent with peripartum cardiomyopathy. Patient was maintained on diuretics and coumadin and was discharged on the 10th day of admission. Control TTE in the 1st month showed improvement of ventricular diameters, absence of embolus, and an EF of 50%. Patient was maintained on anticoagulation and 1st year TTE was within normal limits. Patient was counseled for further pregnancies and increased risk of cardiac and thromboembolic events. A

Exact incidence of peripartum cardiomyopathy is not known, and reported incidence varies between 1/15000 and 1/3000 due to population heterogeneity. TTE is the most common modality used for diagnosis of PPCMP. Dilated ventricles and reduced ejection fractures are commonly seen. Most established risk factors are age older than 30 years, multiple gestations, hypertension during pregnancy, and conduction defects. Late presentation after delivery is a sign of bad prognosis [5, 6]. Blood volume increases progressively and peaks at a high of 150% of normal at the last trimester during pregnancy. In the absence of cardiac failure, this situation is well tolerated, but during delivery, stress, pain, uterine contractions, and relief of pressure from IVC post-delivery, all serve to increase preload, further burdening the myocardium. In nearly 50% of cases, PPCMP coexists with ventricular thrombus. Ventricular thrombus causes thromboembolic events in majority of cases. In our case, shortness of breath and decreased effort capacity were not present before or immediately after the delivery. This fact is concurrent with established literature regarding PPCMP [7, 8]. Pregnancy is a hypercoagulable state due to increased levels of factor 7, 8, 10-fibrinogen as well as platelet activity. This state can last until 6 weeks postpartum and is the main reason underlying the development of thrombi. Also, the volume stasis due to cardiac failure further predisposes patients to cardiac emboli, as shown by various case reports describing peripheral and central thromboemboli, during pregnancy [5, 6, 9]. Because the patient described here had a negative autoimmune/viral panel and no history of medication or alcohol use and the properties of the ventricular thrombus itself (hypoechoic, irregular

Figure 2. Two-dimensional (A) and three-dimensional (B) tomography scan with volume rendering showed large ventricular thrombus

Figure 3. ICA showed no evidence of obstructive coronary artery disease concurrent with peripartum cardiomyopathy

Aksu et al., Peripartum cardiomyopathy and ventricular thrombus

borders, and pedunculated) most likely pointed to a de novo thrombus, we consider that it was precipitated by PPCMP and not as a result of a pre-existing process. There is no consensus on the duration of anticoagulation treatment in a patient with PPCMP and ventricular thrombus. Our patient had complete resolution of the ventricular thrombus on TTE in the 1st month, with mostly normalized cardiac function. We ultimately decided to provide lifelong anticoagulation based on the patient’s perfect compliance to the medical therapy and absence of side effects. CONCLUSION PPCMP is the most frequently encountered reason for cardiac failure in the medium term postpartum period. The stasis induced by cardiac failure and the hypercoagulable state of pregnancy may easily lead to cardiac thrombus. Cardiac thrombus is a source of serious morbidity and mortality in this patient population. Early diagnosis, confirmation, and follow-up with appropriate modalities and prompt start of treatment are the main targets when confronted with such situations. Informed Consent: Written informed consent was obtained from the patient who participated in this study. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.

147 Authorship contributions: Concept – U.A.; Design – I.H.T.; Supervision – S.T.; Materials – O.G.; Data collection &/or processing – U.A.; Analysis and/or interpretation – I.H.T.; Writing – U.A.; Critical review – U.A.

REFERENCES 1. Abboud J, Murad Y, Chen-Scarabelli C, Saravolatz L, Scarabelli TM. Peripartum cardiomyopathy: a comprehensive review. Int J Cardiol 2007;118:295–303. 2. Shimamoto T, Marui A, Oda M, Tomita S, Nakajima H, Takeuchi T, Komeda M. A case of peripartum cardiomyopathy with recurrent left ventricularapical thrombus. Circ J 2008;72:853–4. 3. Altuwaijri WA, Kirkpatrick ID, Jassal DS, Soni A. Vanishing left ventricular thrombus in a woman with peripartum cardiomyopathy: a case report. BMC Res Notes 2012;5:544. 4. Kharwar RB, Chandra S, Dwivedi SK, Saran RK. A pedunculated left ventricular thrombus in a women with peripartum cardiomyopathy: evaluation by three dimensional echocardiography. J Cardiovasc Ultrasound;22:139–43. 5. Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation 2016;133:1397–409. 6. Hilfiker-Kleiner D, Haghikia A, Nonhoff J, Bauersachs J. Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J 2015;36:1090–7. 7. Gutterman DD, Ayres RW. Use of echocardiography in detecting cardiac sources of embolus. Echocardiography 1993;10:311–20. 8. Bauersachs J, Arrigo M, Hilfiker-Kleiner D, Veltmann C, Coats AJ, Crespo-Leiro MG, et al. Current management of patients with severe acute peripartum cardiomyopathy: practical guidance from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail 2016;18:1096–105. 9. Koç M, Sahin DY, Tekin K, Caylı M. Development of biventricular large apical thrombi and cerebral embolism in a young woman with peripartum cardiomyopathy. Turk Kardiyol Dern Ars 2011;39:591–4.

Case Report

GENERAL SURGERY

North Clin Istanb 2018;5(2):148–152 doi: 10.14744/nci.2017.60565

Solitary cecal diverticulitis, a rare cause of right lower quadrant pain: Four cases Adem Yuksel,1 Osman Civil,2 Muhammed Kadri Colakoglu,3 Fatih Sumer,4 Ahmet Tugrul Eruyar5 Department of Gastrointestinal Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey

Department of General Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey

Department of Gastrointestinal Surgery, Recep Tayyip Erdogan University, Rize, Turkey

Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey

Department of Pathology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey

ABSTRACT Solitary cecal diverticulitis is a rare clinical condition. Like diverticulitis in other segments of the colon, it requires immediate surgical intervention if it is causing complications. Solitary cecal diverticulitis may be misdiagnosed as acute appendicitis, since it causes right lower quadrant pain, or as a cecal tumor or inflammatory bowel disease, due to an intraoperative appearance resembling an inflammatory mass. Four patients with solitary cecum diverticulitis presenting with acute right lower quadrant pain are discussed in this report. Three patients underwent surgery with a preliminary diagnosis of acute appendicitis or cecal tumor, and 1 patient was diagnosed with cecal diverticulitis and treated medically. The treatment approach may change depending on a preoperative or intraoperative diagnosis of cecal diverticulitis. Therefore, in areas where this disease is uncommon, cecum diverticulitis should not be forgotten in the differential diagnosis of acute right lower quadrant pain or inflammatory bowel mass. Keywords: Acute abdominal pain; acute appendicitis; cecal diverticulitis.

Cite this article as: Yuksel A., Civil O., Colakoglu M. K., Sumer F., Eruyar A. T. Solitary cecal diverticulitis, a rare cause of right lower quadrant pain: Four cases. North Clin Istanb 2018;5(2):148–152.

cute abdominal pain is one of the most frequent causes of emergency service applications in adults, It constitutes 4-6.5% of all emergency service applications [1]. Acute diverticulitis is also one of the most frequent causes of acute abdominal pain. Eighty-85 % of the patients with colonic diverticular disease lead an asymptomatic course, while in nearly 4-15 % of the patients episodes of acute diverticulitis are seen [2]. In Western countries, cecal diverticulas are rarely seen clinical entities among patients with colonic diverticula. It has been reported that cecal diverticula comprise 3.6 % of all colonic diverticula [3]. Therefore in Western societies cecal diverticulitis are rarely encountered clinical entities. Ninety-nine percent of the patients with cecal diverticulitis present with right lower quadrant pain.

Clinically, they often imitate acute appendicitis which requires emergency surgery [3]. In this study we aimed to present, and discuss three cases with solitary cecal diverticulitis who were treated with the initial diagnosis of acute appendicitis, and a patient who was diagnosed as cecal diverticulitis based on examinations performed to find out the etiology of the right lower quadrant pain, and treated medically in the light of the literature information. CASE REPORT Case 1- A 18-year-old male patient applied to the emergency service with right lower quadrant pain persisting for three days. The patient had not complaints of

Received: March 03, 2017 Accepted: July 31, 2017 Online: March 15, 2018 Correspondence: Dr. Adem YUKSEL. Department of Gastrointestinal Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey. Phone: +90 262 317 80 00 e-mail: drademyuksel@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Yuksel et al., Solitary cecal diverticulitis

nausea, vomiting, diarrhea, and loss of appetite. Physical examination revealed tenderness on the right lower abdominal quadrant, rebound tenderness, and abdominal guarding. White blood cell count (WBC) (10.2 x106/ mm3), and C-reactive protein (CRP) (40.7 mg/dl) were measured as indicated. The diameter of the appendix was 6 mm. The patient was urgently operated in consideration of his clinical findings. Through Mc Burney incision, abdominal cavity was entered. Abdominal exploration revealed minimal free fluid in the intraabdominal cavity, and an inflammatory mass covered with fibrinous material nearly 1 cm distal to the ileocecal region, and occupying nearly an area of a diameter of 3 cm on the anterior surface of the cecum (Fig. 1). Appendix had a normal appearance. Inflammatory intestinal disease was presumed, and through the same incision ileocecal resection was performed. Histopathological examination of the specimen was reported as cecal diverticulitis next to ileocecal valve whose opening occluded with a fecal plug. Patientâ&#x20AC;&#x2122;s health state was stable during postoperative follow-up period. The patient was discharged on postoperative 5. day. Any pathology was not observed during colonoscopic examination performed at 3. postoperative month. Case 2- A 34-year-old female patient applied to emergency service with complaints of right lower quadrant, and suprapubic pain persisting for 4 days. Physical examination revealed the presence of right lower quadrant tenderness, rebound and abdominal guarding. White blood cell counts (WBC) (11.2x106/mm3), and CRP (20.3 mg/dl) were measured as indicated. As for differential diagnosis the patient was evaluated using intravenous, and oral contrast-enhanced abdominal to-

Figure 1. Diverticulitis on the anterior aspect of cecum (Ileocecal Resection).

149

mography (CT). On CT free fluid in pelvis, right lower quadrant, Morrison pouch, contamination of the right lower quadrant mesentery, and heterogenous contrast uptake on the wall of the cecum were detected (Fig. 2). The patient was evaluated as case with perforated appendicitis based on radiological examination, and clinical findings. Through Mc Burney incision the abdominal cavity was entered. Free serous fluid in the intraabdominal cavity, and mass lesion on the anterior surface of the cecum were detected. Then midline laparotomy was performed. Since maligancy could not be discarded, lymphadenectomy together with right hemicolectomy was performed. The health state of the patient led a stable course, and she discharged at 6. postoperative day. Histopathological examination revealed the presence of pericolic abscess formation, inflammatory granulation tissue, and cecal diverticulitis (Fig. 3). On colonoscopy performed at 4. postoperative month any pathology was not observed. Case 3- A 21-year-old female patient consulted emergency room with complaint of right lower quadrant pain persisting for 3 days. Physical examination revealed a generalized abdominal tenderness, rebound, and guarding especially prominent on the right lower abdominal quadrant. WBC (11.2x106/mm3) and C-reactive protein (CRP) (44.2 mg/dl) levels were as indicated. As for differential diagnosis the patient was evaluated using intravenous contrast-enhanced abdominal tomography (CT). On CT, cecal wall consolidation along a 7-cm-segment on the pericecal area which extended up to ileocecal valve, and ascending colon, and paracecal free fluid was observed. The patient was operated with the diagnosis of perforated appendicitis. Through Mc Burney inci-

Figure 2. Appearance of cecal diverticulitis on CT.

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sion intraabdominal cavity was entered. Intraabdominal purulent fluid, and an inflammatory mass nearly 4 cm in diameter on the anterior surface of the cecum, and in the close vicinity of ileocecal valve were seen. Since malignancy could not be ruled out, we performed lymphadenectomy together with right hemicolectomy (Fig. 4). The patient was discharged on postoperative 5. day. On histopathological examination pericolic abscess formation, inflammatory granulation tissue, and cecal diverticulitis were detected. Case 4- A 22-year-old male patient applied to emergency polyclinic with complaint of right lower abdominal quadrant pain persisting for 2 days. Physical examination of the patient revealed right lower abdominal quadrant tenderness, rebound, and guarding. WBC (11.0x106/ mm3), and C-reactive (CRP: 41.0 mg/dl) values were measured as indicated. On contrast-enhanced abdominal CT, signs consistent with diverticulitis on the anterior surface of the cecum were detected (Fig. 4). The patient received antibiotherapy (2nd generation cephalosporin). The patientâ&#x20AC;&#x2122;s complaint of abdominal pain regressed after treatment. His laboratory values dropped within normal ranges. The patient was discharged with recommendations. During first postoperative follow-up of the patient any medical problem was not detected. DISCUSSION Diverticulitis is an important clinical condition which effects 4-15 % of the patients with colonic diverticular disease [2]. In Western countries, diverticula mostly settle on the left colon. Therefore, right colonic diverticula

Figure 3. Appearance of cecal diverticulitis on CT.

North Clin Istanb

consist only 1.5 % of the cases. Right colonic diverticula may be single or multiple, and settle on appendix, cecum or ascending colon Solitary cecal diverticulum is a real congenital diverticulum generally involving all layers of the bowels. Nearly 80% of cecal diverticula generally settle on the anterior surface of the cecum on an area between 1 cm proximal, and 2 cm distal to ileocecal valve [5]. Also in our cases, solitary diverticula on the anterior surface of the cecum nearly 1-2 cm distal to the ileocecal valve was found. Cecal diverticulitis cause right lower quadrant pain in 99% of the patients, and in the differential diagnosis it may be confused with diseases which cause right lower quadrant pain including especially acute appendicitis, inflammatory bowel disease, and cancer of cecum. As an important issue, cecal diverticulitis should be differentiated from diseases which require surgical intervention as acute appendicitis, and cancer of cecum. Indeed, acute diverticulitis which did not lead to complications as abscess, fistula, obstruction or perforation may be treated using medical methods [6]. In some studies, it has been reported that different from acute appendicitis, relatively more prolonged right lower abdominal quadrant pain, but less frequent complaints of nausea, and vomiting, presence of diarrhea, WBC counts just over upper limit of normal with lower percentage of polymorphonuclear leukocytes, but higher percentage of lymphocytes in differential counts may aid in the establishment of differential diagnosis of di-

Figure 4. Diverticulitis on the anterior aspect of cecum (Right Hemicolectomy).

Yuksel et al., Solitary cecal diverticulitis

verticulitis [7-9]. However some investigators reported that this clinical discrimination could not be made easily based only on clinical, and laboratory findings, and 75 % of the patients received the preoperative diagnosis of acute appendicitis, while only 6% of the patients received the preoperative diagnosis of cecal diverticulitis [4]. Conventional radiological examination methods do not geerally aid in the establishment of diagnosis of cecal diverticulitis. Ultrasound is a widely used diagnostic radiological examination in patients presented with acute abdominal pain. On ultrasonograms detection of hypo or anechoic formations protruding from colonic wall may aid in making diagnosis of diverticulitis. In a study, Chou et al. reported sensitivity, and specificity as 91.3, and 99.8%, respectively [10]. However, in contrast with this study, much lower rates of accurate diagnosis as low as 22.6% were also reported [11]. Rates of accurate ultrasonographic diagnosis may be adversely affected by some factors including small size of the diverticulum, obesity, tenderness on the right lower abdominal quadrant, and presence of intestinal gasses which lead to suboptimal US examination. Besides, US is an operator- dependent examination, and lack of experience in the assessment, and interpretation of the regions where cecal diverticulum is rarely seen may decrease diagnostic value of the ultrasonographic examination. Signs of diverticulitis noted during computed tomography include thickening of the cecal wall, focal pericecal inflammation extending to the adjacent fascia, diverticulitis-related abscess, extraluminal air, and mass. The sensitivity, and specificity of computed tomography in the differential diagnosis between acute appendicitis, and cecal diverticulum has been reported as 98% in various studies [3, 10]. However, in the presence of inflammation, CT could not reportedly differentiate between cecal diverticulitis, and cecal cancer in 10% of the cases [16]. In our case that was evaluated preoperatively using US, small diameter of the diverticulum, and its rarety might decrease diagnostic accuracy of US. In 2 out of 3 patients that were evaluated using computed tomography, we thought of perforated acute appendicitis because of diffuse inflammation found in the right lower abdominal quadrant. In consideration of clinical findings of the patient, surgical treatment was decided. The most important point in the treatment of cecal diverticulitis is establishment of accurate preoperative diagnosis. Some literature studies have demonstrated that the patients diagnosed as cecal diverticulitis during preoperative period may be treated using conservative

151

approaches (IV antibiotherapy) [7, 12]. However it has been reported that during preoperative period, only 6% of the patients could receive the diagnosis of cecal diverticulitis, and 75% of the patients had been operated with the diagnosis of acute appendicitis, while 65-84% of the surgically treated patients could receive intraoperative diagnosis of cecal diverticulitis [4, 12]. Therefore, a standardized surgical approach to cecal diverticulitis does not exist. In some studies, conservative surgical approaches (appendectomy, drainage, diverticulectomy etc.) have been recommended, and disease recurrence of 15% has been reported. On the contrary, some studies have indicated that since the presence of malignancy could not be ruled out, and disease recurrence rate of 40% is seen in the treatment of cecal diverticulitis mostly diagnosed intraoperatively, resection of all visible diseased areas are advisable (ie. right hemicolectomy) [4, 12, 15]. In conclusion, based on the extent of inflammation, experience of the surgeon, and intraoperative diagnosis, different procedures as appendectomy combined with drainage, diverticulectomy, ileocecal resection or right hemicolectomy may be applied using conventional or laparoscopic techniques [4, 12-15]. In one of our cases, limited resection (ileocecal resection) was performed with suggestive intraoperative diagnosis of inflammatory bowel disease, and in other two cases intraoperative malignancy could not be discarded so lymphadenectomy together with right hemicolectomy was performed. In the management of cecal diverticulitis accurate pre, and postoperative diagnosis should be made. Especially in regions where this disease is rarely seen, cecal diverticulitis should not be overlooked in the differential diagnosis of acute right lower quadrant pain or inflammatory cecal mass. Informed Consent: Written informed consent was obtained from the patient who participated in this study. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – A.Y., O.C.; Design – A.Y., F.S.; Supervision – M.K.C.; Materials – A.Y., O.C.; Data collection &/or processing – A.Y., A.T.E.; Analysis and/or interpretation – A.Y., O.C., A.T.E.; Writing – A.Y.; Critical review – F.S.

REFERENCES 1. Hastings RS, Powers RD. Abdominal pain in the ED: a 35 year retrospective. Am J Emerg Med 2011;29:711–6.

152 2. Shahedi K, Fuller G, Bolus R, Cohen E, Vu M, Shah R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol 2013;11:1609–13. 3. Sardi A, Gokli A, Singer JA. Diverticular disease of the cecum and ascending colon. A review of 881 cases. Am Surg 1987;53:41–5. 4. Graham SM, Ballantyne GH. Cecal diverticulitis. A review of the American experience. Dis Colon Rectum 1987;30:821–6. 5. Lauridsen J, Ross FP. Acute diverticulitis of the cecum; a report of four cases and review of one hundred fifty-three surgical cases. AMA Arch Surg 1952;64:320–30. 6. Wada M, Kikuchi Y, Doy M. Uncomplicated acute diverticulitis of the cecum and ascending colon: sonographic findings in 18 patients. AJR Am J Roentgenol 1990;155:283–7. 7. Cristaudo A, Pillay P, Naidu S. Caecal diverticulitis: Presentation and management. Ann Med Surg (Lond) 2015;4:72–5. 8. Cho HJ, Cho SY, Oh JH. Clinical Analysis of Right Colonic Diverticulitis That was Operated under the Impression of Acute Appendicitis. J Korean Soc Coloproctol 2000;16:18–24. 9. Shin JH, Son BH, Kim H. Clinically distinguishing between appendicitis and right-sided colonic diverticulitis at initial presentation. Yonsei Med J 2007;48:511–6.

North Clin Istanb 10. Chou YH, Chiou HJ, Tiu CM, Chen JD, Hsu CC, Lee CH, et al. Sonography of acute right side colonic diverticulitis. Am J Surg 2001;181:122–7. 11. Lee IK, Kim SH, Lee YS, Kim HJ, Lee SK, Kang WK, et al. Diverticulitis of the right colon: tips for preoperative diagnosis and treatment strategy. J Korean Soc Coloproctol 2007;23:223–31. 12. Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson JE Jr. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999;188:629–34. 13. Altun H, Mantoglu B, Okuducu M, Onur E, Baskent A, Karip AB, et al. Therapy of solitary cecal diverticulitis in a young patient with laparoscopic right hemicolectomy. Surg Laparosc Endosc Percutan Tech 2011;21:e176–8. 14. Hot S, Eğin S, Gökçek B, Yeşiltaş M, Alemdar A, Akan A, et al. Solitary caecum diverticulitis mimicking acute appendicitis. Ulus Travma Acil Cerrahi Derg 2015;21:520–3. 15. Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Aggressive resection is indicated for cecal diverticulitis. Am J Surg 2003;185:135–40. 16. Jang HJ, Lim HK, Lee SJ, Lee WJ, Kim EY, Kim SH. Acute diverticulitis of the cecum and ascending colon: the value of thin-section helical CT findings in excluding colonic carcinoma. AJR Am J Roentgenol 2000;174:1397–402.

Case Report

OPHTHALMOLOGY

North Clin Istanb 2018;5(2):153–156 doi: 10.14744/nci.2017.49344

Neuro-Behcet’s disease in a case with papilledema and intracranial hypertension as the initial presentation Sevda Aydin Kurna,1 Ahmet Altun,1 Necati Cakir,2 Aysu Karatay Arsan3 Department of Ophthalmology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey

Department of Rheumatology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey

Department of Ophthalmology, Kartal Lütfü Kırdar Training and Research Hospital, Istanbul, Turkey

ABSTRACT A 27-year-old female presented to the Clinic of Ophthalmology with the complaints of photophobia, headache, and diplopia. An ophthalmological examination indicated that her best-corrected visual acuity was 20/20 in both eyes with decreased contrast sensitivity. Fundoscopic examination revealed bilateral papilledema. The cerebrospinal fluid opening pressure was above normal at 38.5 cm H2O. Cranial magnetic resonance imagining venography revealed left lateral sinus thrombosis and right lateral sinus retardation of filling. Based on her history, laboratory tests, and neuro-imaging findings, she was diagnosed with vascular neuro-Behcet’s disease (NBD). It is important to consider NBD in the differential diagnosis of patients with bilateral papilledema and intracranial hypertension. Keywords: Intracranial hypertension; neuro-Behcet’s disease; papilledema.

Cite this article as: Aydin Kurna S., Altun A., Cakir N., Karatay Arsan A. Neuro-Behcet’s disease in a case with papilledema and intracranial hypertension as the initial presentation. North Clin Istanb 2018;5(2):153–156.

ehcet’s disease (BD) is an inflammatory multisystem disease described by Hulusi Behcet in 1937 [1]. According to the International Study Group’s classification, a definitive diagnosis of BD requires recurrent oral ulcerations plus two of the following: recurrent genital ulcerations, skin lesions, eye lesions, and a positive pathergy test [2]. The diagnostic criteria for neuro-Behcet’s disease (NBD) is a current diagnosis of BD plus the presence of neurological symptoms not otherwise explained by known systemic or neurological diseases [3, 4]. NBD has variable prevalence depending on the series but can represent around 5%-10% of the affected patients in a large series [5, 6]. In this report, we would like to present a case of NBD with an unusual initial presentation of papilledema and

intracranial hypertension and emphasize on NBD as a rare but important cause of bilateral papilledema due to intracranial hypertension. CASE REPORT A 27-year-old female presented to the Fatih Sultan Mehmet Education and Research Hospital Ophthalmology Clinic with the complaints of photophobia, headache, and diplopia since 10 days. On ophthalmological examination, her best-corrected visual acuity (BCVA) was 20/20, with decreased contrast sensitivity in both eyes. Anterior segment examination, extraocular movements, and intraocular pressures were within normal limits. Fundoscopic examination revealed bilateral

Received: March 18, 2017 Accepted: September 30, 2017 Online: April 17, 2018 Correspondence: Dr. Sevda AYDIN KURNA. Department of Ophthalmology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey. Tel: +90 216 578 30 00/3715 e-mail: sevdaydin@yahoo.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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Figure 3. Normal optic disc appearence after treatment in the

Figure 1. Papilledema and peripapillary small hemorrhages in

right eye (A) and the left eye (B).

the right eye (A) and left eye at presentation (B).

Figure 2. Enlarged blind spots in the visual fields in the right eye (A) and the left eye (B) at presentation.

papilledema and peripapillary small hemorrhages with normal retinal and macular appearance (Fig. 1 A, B). There were enlarged blind points in the visual field of both eyes measured with automated perimetry (Swedish Interactive Threshold Algorithm standard 30-2 strategy, Humphrey Visual Field Analyzer; Carl Zeiss Meditec, Dublin, CA) (Fig. 2 A, B). Laboratory test revealed elevated erythrocyte sedimentation rate and C-reactive protein level. Laboratory work-up regarding infectious diseases was negative. Cranial magnetic resonance imagining (MRI, 3 tesla) venography revealed dominancy in the internal jugular vein and transverse and sigmoid sinuses with left lateral sinus thrombosis and right lateral sinus retardation of filling. The opening pressure of the cerebrospinal fluid was 38.5 cm H2O (Normal value: 10-18 cm H2O) when she was lying on side, with no microscopic findings. The patient had no systemic risk factors such as diabetes mellitus, hypertension, or hyperlipidemia. She

Figure 4. Visual field showed a normal pattern on the right side (A) with a minimal enlargement of the blind spot on the left side (B). had smoked for 8 years but not consumed alcohol before. According to the history obtained from the patient, she had recurrent oral and genital ulcerations of an unknown etiology for 9 years. She had a positive family history of Behcetâ&#x20AC;&#x2122;s disease. Physical examination revealed multiple genital scar lesions due to previous ulcers and was otherwise unremarkable. Pathergy test was negative. She was positive for HLA-B51. According to her history, laboratory tests, and neuro-imaging findings, she was diagnosed with vascular NBD. The patient was hospitalized in the Rheumatology Clinic and administered a medical treatment comprising systemic pulse intravenous methylprednisolone (1000 mg/day) for 5 days and oral acetazolamide 250 mg tablet 2Ă&#x2014;2/day. Subsequently, the patient started using oral 30 mg/day prednisolone for 1 month, with a tapering scheme of 2.5 mg every week afterward, and azathioprine 50 mg 3Ă&#x2014;1 for 2 years.

Aydin Kurna et al., Neuro-Behcet’s disease in a case with papilledema

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DISCUSSION RNFLT Map (ILM-NFL/GCL) 250 200 150 100 50 [um]

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Figure 5. Optical coherence tomography of the optic nerve was normal on the right side (A), whereas there was a membrane over the optic disc on the left side after 1 year (B). Patient’s symptoms and fundoscopic findings were regressed on the second day of the treatment. At the firstmonth control examination, optic discs appeared normal without edema and hemorrhage (Fig. 3 A, B), BCVA was 20/20 in both eyes, contrast sensitivity improved to normal levels, and opening pressure of cerebrospinal fluid was 14.5 cm H2O. At the 8th month visit of the patient, visual field showed a normal pattern on the right side with a minimal enlargement of the blind spot on the left side (Fig. 4 A, B). Optical coherence tomography (OCT) of the optic nerve was normal on the right side, whereas there was a membrane over the optic disc on the left side (Fig. 5 A, B).

BD is a systemic inflammatory disorder for which the underlying histopathology is an occlusive vasculitis. Ocular participation occurs in about 70% of patients, typically in the form of a relapsing-remitting uveitis [7]. The mean age of onset for BD and NBD was found to be 26.7±8.0 and 32.0±8.7 years, respectively [6, 8]. Neurological involvement in BD occurs more commonly in men, with a male to female ratio of up to 4:1 [3]. Our case was a 27-yearold female who reported a history of recurrent oral and genital ulcerations. NBD can be diagnosed if there is central nervous system involvement and the BD diagnostic criteria are satisfied. It is quite common in adult patients and occurs rarely during childhood and adolescence. Young patients may share symptoms and signs of NBD with other neuro-ophthalmological disorders (e.g., idiopathic intracranial hypertension), thus making the differential diagnosis difficult. Neuro-imaging is mandatory and necessary for a correct NBD diagnosis [9]. The radiological pattern of NBD has been divided into two major forms: parenchymal and non-parenchymal (vascular) forms. Neurological involvement in BD is usually presented as brainstem disturbance, meningomyelitis, and palsy involving cranial nerves VI and VII, although cerebral venous sinus thrombosis is seen in 10%-20% of the cases of NBD [5, 6]. Our case had nonparenchymal (vascular) NBD because there was vascular evidence on MRI venography. In nonparenchymal NBD, cerebral venous thrombosis (CVT) may cause increased intracranial pressure with severe headache, mental changes, and motor ocular cranial nerve palsies. Among a cohort of 820 patients with BD, CVT was present in 64 (7.8%). BD patients with CVT had lower parenchymal central nervous system involvement and higher extraneurologic vascular lesions. Severe visual loss due to optic atrophy was the main complication of CVT that was observed in 15% of the patients. In multivariate analysis, papilledema and concurrent prothrombotic risk factors were independently associated with the occurrence of sequelae [10]. Our case had elevated intracranial pressure and papilledema, but she had only severe headache and diplopia without any mental change, cranial nerve palsy, or visual loss. The cerebrospinal fluid in NBD is normal in 40% of cases. In cases where changes are noticed in the cerebrospinal fluid, mild pleocytosis, mildly elevated protein levels, and oligoclonal bands may be observed [11]. Our

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case had elevated cerebrospinal fluid pressure with no microscopic findings. Akman-Demir et al. reported a large NBD study in 1999 [5]. According to their study, only a minority of patients exhibited neurological features without evident systemic disease: 15 cases (8%) exhibited a neurological onset concomitant with BD onset and 6 cases (3%) exhibited neurological disease prior to the occurrence of other BD features. There are a few cases in the literature documenting cerebral vein thrombosis and papilledema or cranial hypertension as the first manifestation in BD patients [12-14]. The most common visual field defects in the patients with idiopathic intracranial hypertension, also known as pseudotumor cerebri, are enlargement of the blind spot and diffuse visual field loss at presentation [15]. Our case showed bilateral enlargement of the blind spot in the presentation, which improved at 1 month. Visual field showed a normal pattern with a minimal enlargement of the blind spot on the left side after 1 year; OCT of the optic nerve was normal on the right side, whereas there was a membrane over the optic disc on the left side possibly explaining the minimal enlargement of the blind spot on the left side observed at the last visit. In conclusion, in this report, we want to emphasize the importance of considering NBD in the differential diagnosis when patients present with bilateral papilledema and intracranial hypertension. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – S.A.K., A.A., N.C., A.K.A.; Design – S.A.K., A.A., N.C., A.K.A.; Supervision – N.C., A.K.A.; Materials – S.A.K.; Data collection &/or processing – S.A.K., N.C.; Analysis and/or interpretation – S.A.K., N.C., A.A.; Writing – S.A.K., A.A., N.C.; Critical review – S.A.K., A.A., N.C., A.K.A.

North Clin Istanb

REFERENCES 1. Behçet, H. Uber rezidivierende Aphthose, durch ein Virus verursachte Geschwure am Mund, am Auge und an den Genitalien. Derm Wochenschrift 1937;105:1152–7. 2. Criteria for diagnosis of Behçet’s disease. International Study Group for Behçet’s Disease. Lancet 1990;335:1078–80. 3. Siva A, Altintas A, Saip S. Behçet’s syndrome and the nervous system. Curr Opin Neurol 2004;17:347–57. 4. Kalra S, Silman A, Akman-Demir G, Bohlega S, Borhani-Haghighi A, Constantinescu CS, et al. Diagnosis and management of NeuroBehçet’s disease: international consensus recommendations. J Neurol 2014;261:1662–76. 5. Akman-Demir G, Serdaroglu P, Tasçi B. Clinical patterns of neurological involvement in Behçet’s disease: evaluation of 200 patients. The Neuro-Behçet Study Group. Brain 1999;122:2171–82. 6. Siva A, Kantarci OH, Saip S, Altintas A, Hamuryudan V, Islak C, et al. Behçet’s disease: diagnostic and prognostic aspects of neurological involvement. J Neurol 2001;248:95–103. 7. Deuter CM, Kötter I, Wallace GR, Murray PI, Stübiger N, Zierhut M. Behçet’s disease: ocular effects and treatment. Prog Retin Eye Res 2008;27:111–36. 8. Saip S, Akman-Demir G, Siva A. Neuro-Behçet syndrome. Handb Clin Neurol 2014;121:1703–23. 9. Mora P, Menozzi C, Orsoni JG, Rubino P, Ruffini L, Carta A. NeuroBehçet’s disease in childhood: a focus on the neuro-ophthalmological features. Orphanet J Rare Dis 2013;8:18. 10. Saadoun D, Wechsler B, Resche-Rigon M, Trad S, Le Thi Huong D, Sbai A, et al. Cerebral venous thrombosis in Behçet’s disease. Arthritis Rheum 2009;61:518–26. 11. Hirohata S, Kikuchi H, Sawada T, Nagafuchi H, Kuwana M, Takeno M, et al. Clinical characteristics of neuro-Behcet’s disease in Japan: a multicenter retrospective analysis. Mod Rheumatol 2012;22:405–13. 12. Lizarazo-Barrera JC, Jacobelli S, Mellado P, González S, Massardo L. Extensive cerebral vein thrombosis as first manifestation of Behçet’s disease. Report of one case. Rev Med Chil 2010;138:746–51. 13. Ascaso FJ, Rodriguez A, Cristóbal JA. Cranial hypertension as first manifestation of Behçet’s disease: a case report. Doc Ophthalmol 2002;105:291–9. 14. Ginés MA, Jaber I, Pérez J, Estrada RV. Papilledema as the first manifestation of Behçet’s disease. An Med Interna 1996;13:255–6. 15. Rebolleda G, Muñoz-Negrete FJ. Follow-up of mild papilledema in idiopathic intracranial hypertension with optical coherence tomography. Invest Ophthalmol Vis Sci 2009;50:5197–200.

Case Report

EMERGENCY MEDICINE

North Clin Istanb 2018;5(2):157–159 doi: 10.14744/nci.2017.75547

An unusual complication of posterior packing in epistaxis Mehmet Ozgur Erdogan,1 Engin Ozturk,2 Baris Erdogan,3 Mustafa Ahmet Afacan,1 Ismail Tayfur,1 Kaan Yusufoglu,4 Sahin Colak,1 Abdullah Algin5 Department of Emergency Medicine, University of Health Sciences Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

Department of Emergency Medicine, Aydin Ataturk State Hospital, Aydin, Turkey

Department of Otolaryngology, Medipol University Esenler Training and Research Hospital, Istanbul, Turkey

Department of Emergency Medicine, University of Health Sciences Sisli Etfal Training and Research Hospital, Istanbul, Turkey

Department of Emergency Medicine, Adıyaman University Training and Research Hospital, Adıyaman, Turkey

ABSTRACT Endonasal or transnasal procedures are sometimes necessary in patients with head trauma. Before these procedures, the integrity of the skull base must be considered to avoid penetration of the cranial vault. A 54-year-old man was taken to a district hospital following a car accident. After the initial assessment and emergency treatment, he was transferred to our emergency clinic for further examination. The patient had massive nasal bleeding, though a Foley catheter had been inserted to control posterior bleeding. Computed tomography (CT) revealed that the catheter was not positioned correctly and was in the cranial vault. Several fractures of the maxillofacial and cranial bones and cervical vertebrae were detected on CT. He also had right hemothorax and bilateral brain contusions. Endonasal insertion of catheters or tubes in trauma patients without a complete assessment of the skull base can cause serious complications. Keywords: Cathater; complication; epistaxis; trauma.

Cite this article as: Erdogan M. O., Ozturk E., Erdogan B., Afacan M. A., Tayfur I., Yusufoglu K., Colak S., Algin A. An unusual complication of posterior packing in epistaxis. North Clin Istanb 2018;5(2):157–159.

n patients with head trauma, nasal bleeding can sometimes be massive and can lead to increased morbidity and mortality [1]. Endonasal or transnasal procedures might be necessary to stop bleeding [2, 3]. However, before performing these procedures, the integrity of the skull base must be assessed to avoid penetration of the cranial vault. The application of a nasogastric tube, nasal intubation, or posterior packing for severe nasal bleeding can cause penetration of the skull base and severe or even deadly injuries [1]. After the resuscitative measures are undertaken, stopping a major bleeding becomes the first aspect to look into in a trauma patient. Yet, before making an in-

tervention, the physician must be sure of the condition of the skull base [1]. In this case report, we present a complication that occurred as a result of inadequate assessment of the skull base before intervention. A detailed discussion of the complication and treatment options is provided with it. CASE REPORT A 54-year-old man with multiple maxillofacial, cervical, and thoracic injuries and deterioration of mental status due to a car/pedestrian accident was transferred to our

Received: December 12, 2016 Accepted: September 14, 2017 Online: April 12, 2018 Correspondence: Dr. Mehmet Ozgur ERDOGAN. Department of Emergency Medicine, University of Health Sciences Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey. Phone: +90 216 542 32 32 e-mail: ozgurtheerdogan@mynet.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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emergency department (ED) from a district hospital. The patientâ&#x20AC;&#x2122;s Glasgow score was 10 at referral from the district hospital. He had massive nasal bleeding. In the first hospital, it could not be stopped with anterior nasal packing; thus, a 14-French Foley catheter was used to pack the posterior nose. This did not stop the bleeding either; thus, the patient was transferred to our ED for further evaluation. When initially examined in our ED, the patientâ&#x20AC;&#x2122;s Glasgow score was 10. He was confused and had multiple lacerations of different depths in the face. He also had massive epistaxis and tachypnea. After the initial assessment, routine laboratory tests and maxillofacial, cranial, cervical, and thoracic computed tomographies (CTs) of the patient were obtained. He had frontal bone, anterior cranial base, and bilateral orbital roof fractures along with nasal bone and C4 and C7 vertebrae fractures. He had bilateral frontal contusions and right hemothorax. A massive air bubble was detected inside the brain parenchyma, which was the Foley catheter balloon that was meant to stop the nasal bleeding (Figs. 1, 2). The balloon was deflated slowly, and the Foley catheter was removed by a neurosurgeon. The posterior nasopharynx was packed with gauze via the mouth and supported with anterior nasal packing, which successfully stopped the bleeding. Chest-tube drainage was initiated. Three units of erythrocytes and fresh frozen plasma were

Figure 1. Foley catheter in the cranial vault.

North Clin Istanb

transfused. After completing emergency interventions, the patient was transferred to the intensive care unit for a close follow-up. DISCUSSION In multiple trauma patients, epistaxis can be a major problem, which might be underestimated or overlooked but can be life threatening. Several arteries from both the internal and external carotid systems supply blood to the nose. The arteries that are usually involved in epistaxis are the internal maxillary, facial, and ophthalmic arteries [1], but any artery could be involved in a patient with maxillofacial trauma. Rupture of any of these arteries can cause life-threatening, massive hemorrhages. Stopping the bleeding can be challenging, as observed in our case, and anterior packing is not always sufficient. Methods to treat epistaxis vary [2] and range from slight pressure on the nasal ala to arterial embolization or surgical ligation [3]. Posterior nasal packing is another technique, which is less invasive than angiographic or surgical methods but should be applied with great caution, particularly in patients with maxillofacial fractures. Our patient had massive nasal bleeding that could not be stopped by anterior packing, and the otolaryngologistâ&#x20AC;&#x2122;s attempt to stop the bleeding with posterior packing failed because of the defect in the anterior

Figure 2. Foley catheter in the cranial vault.

Erdogan et al., Epistaxis

skull base. We recommend using nasal endoscopy to place the Foley catheter. A method in which a nasogastric tube is sutured to a flexible bronchoscope and passed into the nasal cavity under direct visualization has been described [4]. The bronchoscope is pulled out of the mouth, the suture is cut, and then the tube is pulled back. This method could be applied to posterior packing with a Foley catheter. Nasal intubation or nasogastric tube insertion should be avoided in patients with a suspected anterior skull base fracture [1]. Endonasal procedures confer a risk of violating the cranial vault [5]. Despite the fact that Foley catheters are not designed for stopping nasal bleeding, they have been use for this purpose for a long time [6]. Their applicability due to their flexibility is a reason to choose them for posterior packing of the nasal cavity. Although they have been widely used for a long time, only a few cases of intracranial penetration have been reported. In a literature review about traumatic epistaxis, only 5 of the 33 cases reported to have intracranial penetration of applied instruments were found to be Foley catheters [7]. The rest were nasogastric tubes. The major site for penetration was found to be the cribriform plate. In our case, cribriform plate was also the site of intracranial penetration. This site is more vulnerable to fractures than the other parts of the cranial base because the bony structure of the ethmoid bone is made up of thin lamellar bones. The tiny bony septae can be easily penetrated by application of minor forces. We report a case in which transnasal posterior packing caused a serious complication due to incomplete evaluation of the trauma patient. Physicians should

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select and use methods to treat epistaxis very carefully and be alert of unexpected complications at all times. They should not rush into nasal interventions without complete assessment of the stability of the cranial base, no matter how safe the procedure seems or how experienced they are. Informed Consent: Written informed consent was obtained from the patient who participated in this study. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – M.O.E., E.O.; Design – M.A.A., S.C., I.T.; Supervision – B.E., A.A.; Materials – B.E.; Data collection &/or processing – M.O.E., E.O.; Analysis and/or interpretation – M.O.E., B.E.; Writing – M.O.E., B.E.; Critical review – M.A.A., I.T., A.A., E.O.

REFERENCES 1. Krajina A, Chrobok V. Radiological diagnosis and management of epistaxis. Cardiovasc Intervent Radiol 2014;37:26–36. 2. Villwock JA, Jones K. Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngol Head Neck Surg 2013;139:1279–84. 3. Dubel GJ, Ahn SH, Soares GM. Transcatheter embolization in the management of epistaxis. Semin Intervent Radiol 2013;30:249–62. 4. Jones AP, Diddee R, Bonner S. Insertion of a nasogastric tube under direct vision. Anaesthesia 2006;61:305. 5. Spurrier EJ, Johnston AM. Use of nasogastric tubes in trauma patients-a review. J R Army Med Corps 2008;154:10–3. 6. Pawar SJ, Sharma RR, Lad SD. Intracranial migration of Foley catheteran unusual complication. J Clin Neurosci 2003;10:248–9. 7. Veeravagu A, Joseph R, Jiang B, Lober RM, Ludwig C, Torres R, et al. Traumatic epistaxis: Skull base defects, intracranial complications and neurosurgical considerations. Int J Surg Case Rep 2013;4:656–61.

Case Report

CARDIOLOGY

North Clin Istanb 2018;5(2):160–162 doi: 10.14744/nci.2017.20092

Successful percutaneous coronary intervention for chronic total occlusion via the radial artery Mustafa Adem Tatlisu Department of Cardiology, Sivas Numune State Hospital, Sivas, Turkey

ABSTRACT Over the past decade, percutaneous coronary interventions (PCIs) performed via radial artery (RA) access have become popular among interventional cardiologists. Since the radial approach may limit the options in complex cases, most interventional cardiologists prefer femoral access to RA access for complex procedures, such as chronic total occlusions (CTOs) and bifurcation lesions. Presently described is a case of CTO of the right coronary artery that was successfully treated with PCI via the left RA. This study demonstrates that if there is an indication for revascularization and the CTO lesions are short and without poor prognostic factors, an intervention for CTO should still be considered, even if there is no femoral access. Keywords: Chronic total occlusion; percutaneous coronary intervention; transradial approach.

Cite this article as: Tatlisu M. A. Successful percutaneous coronary intervention for chronic total occlusion via the radial artery. North Clin Istanb 2018;5(2):160–162.

ver the past decades, percutaneous coronary interventions (PCIs) performed via the radial access (RA) have become popular among interventional cardiologists. In a meta-analysis of PCI studies performed via both RA and femoral access (FA) incorporating many of these studies, better outcomes were obtained with RA than with FA with respect to access site complications, bleeding, and death [1]. Because the radial approach may limit our options in complex cases, most interventional cardiologists prefer the transfemoral approach over the transradial approach for complex procedures such as those for chronic total occlusions (CTOs) and bifurcation lesions. Here we present a case of CTO of the right coronary artery (RCA) that was successfully treated with PCI via the left radial artery. CASE REPORT A 52-year-old man presented with shortness of breath and stable class III angina for 7 months despite treatment

with acetylsalicylic acid (100 mg/day), clopidogrel (75 mg/day), metoprolol extended-release succinate (200 mg/day), extended-release isosorbide mononitrate (60 mg/day), modified-release trimetazidine (70 mg/day), telmisartan (80 mg/day), and rosuvastatin (40 mg/day). Six year ago, he underwent elective coronary stent placement for symptomatic 80% stenosis in mid-RCA. His second coronary angiogram was performed at 6 months previously because of an unstable angina. Angiogram revealed that the coronary stent in mid-RCA was completely occluded (Fig. 1A) with Rentrop grade II collaterals from the left anterior descending artery (Fig. 1B). PCI failed, and the patient was prescribed optimal antiischemic therapy that included isosorbide mononitrate and trimetazidine. The patient had a 10-year history of hypertension and a 2-year history of Leriche’s syndrome that was treated with aorta–iliac artery bypass. He had been smoking two packs of cigarettes daily for 32 years. Electrocardiogram of the patient did not reveal any recent ST-segment elevation myocardial infarction. The patient previously underwent myocardial perfusion single

Received: April 04, 2017 Accepted: August 05, 2017 Online: March 27, 2018 Correspondence: Dr. Mustafa Adem TATLISU. Department of Cardiology, Sivas Numune State Hospital, Sivas, Turkey. Phone: +90 536 443 99 06 e-mail: ademtatlisu@gmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

Tatlisu, Percutaneous coronary intervention

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Figure 1. (A) Coronary angiogram of the completely occluded

Figure 2. (A)

Coronary angiogram of the right coronary artery flow before cutting balloon dilatation. (B) Coronary angiogram of the right coronary artery flow after cutting balloon dilatation.

right coronary artery. (B) Coronary angiogram showing Rentrop grade II collateral flow to the right coronary artery from the left ascending coronary artery

photon emission computed tomography, which revealed significant viability in the inferior, inferoseptal, and inferolateral walls. Left ventricular function was moderately diminished, with significant wall motion abnormality in the inferior, inferoseptal, and inferolateral walls and a calculated ejection fraction of 40%. Therefore, it was decided that the patient would benefit after undergoing PCI for CTO of RCA. Because he previously underwent aorta–iliac artery bypass and impalpable right radial pulse, the only option for the procedure was antegrade wire escalation technique via the left radial artery using a 6-Fr right Judkins guiding catheter. The success rate with antegrade wiring and intimal tracking technique is high for short CTOs without proximal cap ambiguity. The Fielder XT®-tapered tip 0.009″ (Asahi Intecc Co. Ltd., Nagoya-shi, Aichi, Japan) failed to penetrate the hard and calcified proximal cap. However, the proximal CTO cap was eventually penetrated using the Asahi Confianza PROTM 12-tapered tip 0.009″ wire (Asahi Intecc Co. Ltd., Nagoya-shi, Aichi, Japan). After predilation using a 1.2-×15-mm balloon, the buddy wire technique with Fielder XT® was used to advance a wider and longer balloon through the lesion. Despite several predilations with 1.5-×20-mm, 2.5-×20-mm, and 3.0-×20-mm balloons, a satisfactory angiographic result was not observed (Fig. 2A). To achieve better results, the 3.0-×15-mm cutting balloon, which resulted in TIMI II flow (Fig. 2B). After an intracoronary injection of nitroglycerin (100 µg), two 3.0-×38-mm everolimus-eluting coronary stents (Promus ElementTM, Boston Scientific, Marlborough, MA, USA) were used in a telescopic manner to cover the previous stent. After dilation at 20 atm of pressure via a 3-×20-mm NC balloon, the result was satisfactory (Fig. 3). During follow-up, the symptoms and exercise capac-

Figure 3. Coronary angiogram of the right coronary artery after two overriding coronary stents.

ity of the patients rapidly improved. During follow-up, isosorbide mononitrate and trimetazidine therapies were discontinued. He was advised to quit smoking; however, he continues to smoke. He is currently symptom free for 2.5 years (from July 2014 to March 2017). DISCUSSION Identification of anatomical features of procedural complexity may predict procedural success such as the presence of significant coronary calcium and vessel tortuosity [2]. Several factors are associated with poor procedural success, including the morphology of the proximal cap, presence of bridging collaterals, and length of occlusion [3]. Antegrade wire escalation with intimal tracking should be the preferred initial strategy for short CTOs without poor prognostic factors [4]. Retrograde or antegrade dissection re-entry approach should be reserved for more complex anatomies. Patients with CTO who remain symptomatic despite optimal medical therapy can be considered for revascularization [5]. In a meta-analysis of long-term clinical outcomes of patients who underwent PCI for CTO, successful PCIs for CTOs were associated with a lower

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risk for death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris [6]. Most recent data showed that PCI may reduce the risk for cardiac mortality in patients without diabetes but not in patients with diabetes [7]. In light of current evidence, the initial decision regarding the mode of revascularization should be based on the symptoms and complexity of lesions. In this case report, left RA was used to treating CTO owing to the lack of FA, which resulted in successful PCI. If there is an indication for revascularization and CTO lesions are short without poor prognostic factors, an intervention for CTO should be considered even if there is no FA. Informed Consent: Written informed consent was obtained from the patient who participated in this study. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.

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REFERENCES 1. Bertrand OF, Bélisle P, Joyal D, Costerousse O, Rao SV, Jolly SS, et al. Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis. Am Heart J 2012;163:632–48. 2. Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu T, et al. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 2011;4:213–21. 3. Muramatsu T, Tsuchikane E, Oikawa Y, Otsuji S, Fujita T, Ochiai M, et al. Incidence and impact on midterm outcome of controlled subintimal tracking in patients with successful recanalisation of chronic total occlusions: J-PROCTOR registry. EuroIntervention 2014;10:681–8. 4. Wilson W, Spratt JC. Advances in procedural techniques--antegrade. Curr Cardiol Rev 2014;10:127–44. 5. Shah PB. Management of coronary chronic total occlusion. Circulation 2011;123:1780–4. 6. Christakopoulos GE, Christopoulos G, Carlino M, Jeroudi OM, Roesle M, Rangan BV, et al. Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions. Am J Cardiol 2015;115:1367–75 7. Choi KH, Yang JH, Song YB, Hahn JY, Choi JH, Gwon HC, et al. Long-term clinical outcomes of patients with coronary chronic totalocclusion treated with percutaneous coronary intervention versusmedical therapy according to presence of diabetes mellitus. EuroIntervention 2017;13:970–7.

Invited Review

CHILD HEALTH&DISEASES

North Clin Istanb 2018;5(2):163-168 doi: 10.14744/nci.2017.69379

Underlying factors of recurrent infections in patients with down syndrome Turkan Patiroglu, Murat Cansever, Fulya Bektas Department of Pediatrics and Immunology, Erciyes University Faculty of Medicine, Kayseri, Turkey

ABSTRACT Down syndrome is the most common chromosomal aberration. Patientswith Down syndrome suffer more infections than those without the disease. Underlying immunological disorders are consideredto be the reason for the increasing frequency of infections in patients with Down syndrome. In addition, some anatomical abnormalities in the respiratory tractaccompanying Down syndrome can disturb the innate immunity and contribute to the increase in infection rate. Respiratory tract infections are one of the most common causes of mortality in patients with Down syndrome. Awareness of the underlying reason for frequent respiratory tract infections should result in a decrease in mortality among these patients and contribute to an improvementin their quality of life. Keywords: Down syndrome; infections; innate immunity; immune deficiency.

Cite this article as: Patiroglu T., Cansever M., Bektas F. Underlying factors of recurrent infections in Down syndrome. North Clin Istanb 2018;5(2):163-168.

own syndrome (DS) is the most common chromosomal aberration. Its frequency varies between 1/6000 and 1/8000 in the Turkish population [1]. It is also the most common genetic reason of mental retardation. DS is also associated with various congenital anomalies such as congenital heart disease (CHD), gastrointestinal anomalies, orthopedic problems alongwith characteristic dysmorphic features. Endocrine and neurologic disorders besides visual and hearing problems can be seen in patients with DS. In addition,hematologic disorders, particularly leukemia; autoimmune diseases such as celiac disease; and type 1 diabetes mellitusis seen in patients with DS. The rise inthe prevalence of both infections and autoimmune disorders are thought to be related to immune disorders [2]. Respiratory tract infectionsare the most commonly observed infection in patients with DS. Furthermore, CHD and respiratory tract infections are important reasons of mortality. Even though many immunologic

disorders have been defined in patients with DS, there are still undefined topics in underlying immune deficiency in patients with DS [3]. Immune deficiency may be the reason for frequent respiratory tract infection. In this study, we aimed to review the underlyıng factors of recurrentinfections inpatients with DS. The frequency of upper and lower respiratory tract infections is higherin patients with DS than in those without the disease. Pharyngitis and otitis media with effusion are the most commonly diagnosed upper respiratory tract infections and pneumonia as the most commonly diagnosed lower respiratory tract infection. Moreover, pneumonia is the most important cause of hospitalization and mortality inpatients with DS [3]. Secondary respiratory distress syndromedue to pneumonia is higher and severe in children with DS [4]. Respiratory syncytial virus (RSV) is the most commonly observed cause of lower respiratory tract infections and bronchiolitis in infancy and early childhood

Received: January 15, 2017 Accepted: July 30, 2017 Online: January 29, 2018 Correspondence: Dr. Murat CANSEVER. Erciyes Universitesi, Tip Fakultesi, Cocuk Sagligi ve Hastaliklari Anabilim Dalı, Kayseri, Turkey. Tel: +90 530 561 78 37 e-mail: mcansever66@hotmail.com © Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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[5]. Some studies have shownthat the rate of hospitalization because of RSV infection is higher in patients with D Seven if they do nothavea Congenital Heart Diesase (CHD) [6]. However, there is no explanation about the increased risk of RSVinfection in patients with DS. Staglianao et al. [5] found that length of hospital stay is longer and requirement of respiratory support is much higherin patients with DS during RSV infection. RSV has no specific treatment, but in infants at a risk of RSV (e.g., prematurity, bronchopulmonary dysplasia, CHD, etc.) palivizumab (monoclonal antibody against RSV) is used prophylactically for reducing hospitalization and/or its duration and need for respiratory support. Recently, prophylactic use of palivizumab has been recommended for patients with DS [7]. Hao Yi et al. [7] used palivizumab prophylaxis to prevent RSV infections in patients with DS and demonstrated that palivizumab prophylaxis shortens hospitalization duration in patients with DS. The risk of serious infections occurring in patients with DShas been found to beincreased compared with the normal population [8]. Studies show that the risk of mortalitydue to sepsis is higher in children with DS [8]. 1) Non-Immunologic Causes of Increased Infections in Patients with DS: It is assumed that some dysmorphic features in affected individuals andanatomicalabnormalities contribute to the frequency of infections in patients with DS (Table 1) [2]. Anatomical Abnormalities in Children with DS Laryngomalacia, narrowed trachea, tracheomalacia, tracheal stenosis, and subglottic stenosis are the most frequently encountered congenital anomalies in patients with DS. Airway narrowingis caused by various reasons

Table 1.

Abnormalities (nonimmunological) known to increase the incidence of infections in patients with Down syndrome Anatomical abnormalities of the airways Obstructive sleep apnea Congenital anomalies of the lower respiratory tract Congenital heart disease Congenital ear anomalies Gastroesophageal refluxand deglutition disorders

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in patients with DS. Bertrand et al. [9] foundanatomical abnormalities in the airways in 75% of patients with DSwho underwent bronchoscopy because of lowerrespiratory tract infections. The mostly common seen abnormality among these is laryngomalacia [10]. Subglottic stenosis is another frequently seen abnormality, which occurs post-intubation [11]. Another important cause of airway narrowing seen in patients with DS is phenotypic findings specific to the syndrome. When the nasopharynx is narrowerthan usual, sinusitis formation and nasal congestion occurs. Hypoplasia of the nose and sinus contributes to nasal obstruction, and repetitive nasal congestion occurs. Adenotonsillar hypertrophy, macroglossia, and choanal stenosis also contribute to narrowing of the airways [2]. Tracheal bronchus, which originates from the trachea, is described as an accessory bronchus. It has been shown that tracheal bronchus is associated with repetitive right lower lobe pneumonia [12]. The frequency of tracheal bronchus abnormality with repetitive right lower lobe pneumonia caused by it is high in patients with DS. Congenital anomalies of the airways cause both repetitive wheezing and coughing, increased risk of respiratory tract infection, and pulmonary hypertension [13]. Creating awareness in patients with congenital airway malformations will contribute to the treatment of patients. Sleep-related respiratory disorders are one of the most commonly seen respiratory disorders in patients with DS. The rate of obstructive sleep apnea is 30%â&#x20AC;&#x201C;80% [14]. Hypoplasia of the nose and sinus, narrowness of the upper respiratory tract, macroglossia, mandibular hypoplasia, adenotonsillar hypertrophy, and obesity are factors that contribute to the development of obstructive sleep apnea in patients with DS. Although adenotonsillectomy provides improvement in symptoms, obstructive sleep apnea may continue in patients with structural airway abnormalities [14]. Even though these patients are asymptomatic, they should be assessed using polysomnography for obstructive sleep apnea. Above all, obstructive sleep apnea may lead to pulmonary hypertension and cor pulmonale by causing intermittent hypoxia and respiratory acidosis. An autopsy study performed in patients with DS showed that there was a smaller number of alveoli with largened alveoli in the lungs [15]. Because subpleural cyst is another finding, which is a lung parenchymal abnormality, its frequency is highin patients with DS [15]. CHD is one of the main problems causing morbidity in patients with DS (approximately 40% of patients)

Patiroglu et al., Underlying factors of recurrent infections

[16]. The most frequently observed types of CHD are atrioventricular septal defect, atrial septal defect,and ventricular septal defect. Faria et al. [17] found that the risk of serious infections such as pneumonia and sepsis in patients with DS with CHD is considerably higher than in those without CHD. Chronic otitis and hearing loss are more frequently seen in patients with DS [18]. These may be caused by a variety of anatomical defects. A study showeda stenosis of the external auditory canal in approximately 50% of patients with DS [19]. Small width of the Eustachian tube and its increased cylindricity leads to collection of more fluid in the middle ear . This contributes to chronic otitis formation [18, 20]. Barr et al. [21] showed that the frequency of middle ear infections in patients with DS aged >1 year rises up to 93%. Moreover, repetitive middle ear infections lead to hearing loss [20]. Gastroesophageal reflux may lead to chronic lung inflammation and bronchospasm. It has also been known that recurrent silent aspiration of gastric fluid causes recurrent respiratory tract infections [22]. It is thought that hypotony, which is seen in patients with DS,reduces pharyngeal muscle tonus and increases the risk of aspiration [22]. The frequency of gastroesophageal reflux disease in patients with DS is higher than that in those with out the disease [22]. There is an increased frequency of esophageal atresia in patients with DS, and disturbed physiological mechanisms after surgery lead to respiratory complications, such as pneumonia, asthma, and high rates of hospitalization due to respiratory tract infections [23]. 2) Immune Disorders in Children with DS: Immunity is defined as the bodyâ&#x20AC;&#x2122;s defense against infectious

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diseases. It consistsof natural/innate immunity (first protectivebarrier against infectious diseases) and acquired immunity (provides specific and more effective defenses against infections) [24]. Innate immunity provides the first defense when a foreign microorganism appears in the body. It exists in every person from birth and is fast. Becauseit cannot form memory cells, it gives the same response in each case and is not specific to any microorganism [24]. Normal anatomical development and normalphysiological process of organs arean essential part of innate immunity. Several innate and acquired immune disordershave been reported in children with DS (Table 2) [24]. To date, a reduction in neutrophil chemotaxis in patients with DS has been shown in many studies [25]. In addition, the cause of chemotaxis reduction has not yet been fully clarified. On the other hand, studies on neutrophil functions (especially in patients with DS who have recurrent periodontitis) indicate that there are no significant problems in neutrophil oxidative burst reaction or in phagocytosis capacity [25]. Another problem in natural immunity is the decrease in absolute number of monocytes [26]. A study by Bloemers et al. showed that even though the number of absolute monocyte is low, the number of CD14+CD16+ monocytes (a subset of monocytes) is higher in patients with DS. It is well known that monocytes belonging to this subgroup are very effective in the event of proinflammation. This situation may be responsible for the chronic inflammatory events observed in patients with DS [26]. NK anddendritic cells are another important part of innate immunity, and dendritic cells are also responsible for the delivery of antigens to T helper cells. It has been

Table 2. Major immune system disorders in patients with Down syndrome Natural/innate immunity

Acquired immunity

Decreased neutrophil chemotaxis Decreased number of NK cells Decrease in the absolute number of monocytes Decrease in the number of dendritic cells Reduction in mannose-binding lectin level

Decrease in the number of T cells (particularly naive T cells) Low number of B cells Lack of memory cell formation Lack of T cell proliferation Size of the thymus is smaller than normal Inadequate antibody response to vaccination Decrease in the levelof humoral IgA Low levelof IgM, IgG2, and IgG4-type antibody

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shown that the numbers of these two cells are significantly lower in patients with DS than in those without the disease [26]. Another disorder in innate immunity in patients with DS is the lackof mannose-bindinglectin (MBL). MBL starts the lectin-dependent pathway of the complement system and acts as opsonin for phagocytosis. MBL deficiency is one of the most common immune deficiencies. There is an increased frequency of infections especially with extracellular pathogensdue to MBL deficiency. Nisiharaet al. [27] showed that the MBL level was lower in children with DS. In particular, regarding repetitive respiratory tract infections in patients with DS, MBL deficiency is much more common than in those who do not have recurrent infections [27]. Acquired immunity isalso known as acquired and specific immunity. Response is specifically formed against unique microorganisms. Its effect is slower but more powerful. It can create a stronger response when faced with the same microorganism again by its ability to create memory cells. Although all types of lymphocytes are produced in the bone marrow, T-lymphocytes mature in the thymus and B cells mature in the bone marrow [24]. Various studies have shown that total lymphocyte and T-lymphocyte counts arelow in patients with DS. A low level of T-lymphocytes is also reflected in the T-lymphocyte subsets.The levels of both CD4+ T-lymphocytes and CD8+ T-lymphocytes are low in patients with DScompared with those without the disease. Thissituation wasespeciallyseen in the naive T cells and becomes apparent in the first 2 years of life. The number of T-lymphocytes increases with age and eventually reaches normal levels [28]. The primary expansion of T- and B-lymphocytes was severely defectivein children with DS [29]. In addition, it has been reportedthat the T-cell receptorexcision circle, which reflects the number of naive T cells secreted from the thymus was low in patients with DS [28, 29]. Early aging, decreased thymic production, intrinsic defects, and one or more mechanisms of apoptosis are responsible for the reduction in the number of T-lymphocytes. Kusters et al. [30] stated that naive T-lymphocytes have a low rate and memory T cells have a normal rate of reduction. Therefore, they claimed that the reason for the reduction in the number of T-lymphocytes isan intrinsic defect in patients with DS. Bloemers et al. [28] conducted a study to determine the reason for the decrease inthe number of naive T cells. They concluded that reduced thymic production is responsible for the decrease in the number of naive T cells [28, 29]. In severalstudies,

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it has also been shown that areduction in the number of naive T cells is not associated with frequent infection [28, 29]. Regulatory T cells are responsible for both the elimination of autoreactive T cells, which get rid of negative selection from the thymus, and suppression of inflammatory response. The effect of regulatory T cells on the increased frequency of autoimmune diseases in patients with DSwas studied; Pellegrini et al. [31] showed that the number of regulatory T cellswas higher but their functions weredefective. A reduction in the number of T-lymphocytes (especially naive T-lymphocytes) was associated with pathology in the thymus where T-lymphocytesmature. Therefore, some studies focused on the development of the thymus. Studies have revealed that the thymus gland is very small inpatients with DS even in newborns [32]. Levin et al. [33] reported cortical atrophy in the thymus, corticomedullary border loss, defect of thymocyte development, and expansion of Hassall’s corpuscles in patients with DS. Although there was a defect in thymocyte maturation, mature CD3+ and TCRαβ+ cells were present in the blood [28]. The number of B-lymphocytes in patients with DS is lower than that in those without DS. In contrast to T-lymphocytes, thissituationdoes not improve with age. Furthermore, the proliferation and maturation of lymphocytes are not observed in these patients, which were normally seen in the first years of life. Studies related to B-lymphocyte subsets showed that there is a decrease in CD27+ IgM+ memory B cells, natural effector B cells, CD27+ IgA+, and CD27+ IgG+ memory cells [34]. Despite the problems of memory B cells,plasma cells are present in normal numbers and lymph nodes are not defective in the germinal centers [35]. It is thought that one of the reasons for frequent infections is the reduction in class-switching and thedecreasing number of memory B cells, which are responsible for effective response to vaccination. Carsetti et al. [34] described an imperfection in B-lymphocytes based on a defect in the maturation of B-lymphocytes. Valentini et al. [36] evaluated antibody production and memory B cellsthat perform classswitching after polysaccharide vaccine. They stated that there is no problem in terms of antibody production after vaccination, but they showed that there was no success in terms of the production and maintenance ofclassswiched B cells. The immunoglobulin (Ig) levels and IgG subclasses of patients with DS were evaluated several times. Stud-

Patiroglu et al., Underlying factors of recurrent infections

ies have revealed that the IgA and IgG levels were normal,butthe IgM level was decreased [35, 36]. Subgroups IgG1- and IgG3-type antibodies, which are effective in the fight against viruses, were at normal or high levels. IgG2 and IgG4, which are effective in response to bacterial polysaccharide antigen,were at low levels [37].

Summary It is known that frequent infections, particularly respiratory tract infections, areincreasedin patients with DS. Both anatomical and immunological problems associated with DS are thought to be the reason for this. These anatomical problems can be classified as anatomical abnormalities of the airways, obstructive sleep apnea, congenital anomalies of the lower respiratory tract, CHD, congenital ear anomalies, gastroesophageal reflux, and deglutition disorders. The best known immunological problems aredecrease in T- and B-lymphocytes; small size of the thymus;reduction in the number of memory B cells;inadequate response to vaccine; decrease in the number of IgG2, IgG4, and IgM levels; and defects in neutrophil chemotaxis.

Conclusion Even though many immunological problems have been defined in patients with DS, the underlying mechanism is not fully understood. Studies about memory cells, T- and B-lymphocytesubsets, and dendritic cells are promising. Nevertheless, further research is needed on this topic. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – M.C., F.B., T.P.; Design – M.C., F.B., T.P.; Supervision – M.C., F.B., T.P.; Materials – M.C., F.B., T.P.; Data collection &/or processing – M.C., F.B., T.P.; Analysis and/ or interpretation – M.C., F.B., T.P.; Writing – M.C., F.B., T.P.; Critical review – M.C., F.B., T.P.

REFERENCES 1. Acar M, Zorlu P, Tos T, Koca SB, Senel S. Evaluation of demographic and clinical features of patients with down syndrome: Single center experience. Turkish Journal of Pediatric Disease 2014;8:71–4. 2. Watts R, Vyas H. An overview of respiratory problems in children with Down’s syndrome. Arch Dis Child 2013;98:812–7. 3. Ram G, Chinen J. Infections and immunodeficiency in Down syndrome. Clin Exp Immunol 2011;164:9–16. 4. Bloemers BL, Broers CJ, Bont L, Weijerman ME, Gemke RJ, van Furth AM. Increased risk of respiratory tract infections in children with

167 Down syndrome: the consequence of an altered immune system. Microbes Infect 2010;12:799–808. 5. Stagliano DR, Nylund CM, Eide MB, Eberly MD. Children with Down syndrome are high-risk for severe respiratory syncytial virus disease. J Pediatr 2015;166:703–9.e2. 6. Mori M, Morio T, Ito S, Morimoto A, Ota S, Mizuta K, et al. Risks and prevention of severe RS virus infection among children with immunodeficiency and Down’s syndrome. J Infect Chemother 2014;20:455–9. 7. Yi H, Lanctôt KL, Bont L, Bloemers BL, Weijerman M, Broers C, et al. Respiratory syncytial virus prophylaxis in Down syndrome: a prospective cohort study. Pediatrics 2014;133:1031–7. 8. Garrison MM, Jeffries H, Christakis DA. Risk of death for children with down syndrome and sepsis. J Pediatr 2005;147:748–52. 9. Bertrand P, Navarro H, Caussade S, Holmgren N, Sánchez I. Airway anomalies in children with Down syndrome: endoscopic findings. Pediatr Pulmonol 2003;36:137–41. 10. Mitchell RB, Call E, Kelly J. Diagnosis and therapy for airway obstruction in children with Down syndrome. Arch Otolaryngol Head Neck Surg 2003;129:642–5. 11. de Jong AL, Sulek M, Nihill M, Duncan NO, Friedman EM. Tenuous airway in children with trisomy 21. Laryngoscope 1997;107:345–50. 12. McLaughlin FJ, Strieder DJ, Harris GB, Vawter GP, Eraklis AJ. Tracheal bronchus: association with respiratory morbidity in childhood. J Pediatr 1985;106:751–5. 13. Unal E, Oran B, Baysal T, Baspinar O, Keser M, Karaarslan S, et al. Pulmonary arterial pressure in infants with laryngomalacia. Int J Pediatr Otorhinolaryngol 2006;70:2067–71. 14. McDowell KM, Craven DI. Pulmonary complications of Down syndrome during childhood. J Pediatr 2011;158:319–25. 15. Biko DM, Schwartz M, Anupindi SA, Altes TA. Subpleural lung cysts in Down syndrome: prevalence and association with coexisting diagnoses. Pediatr Radiol 2008;38:280–4. 16. Irving CA, Chaudhari MP. Cardiovascular abnormalities in Down’s syndrome: spectrum, management and survival over 22 years. Arch Dis Child 2012;97:326–30. 17. Faria PF, Nicolau JA, Melek MZ, de Oliveira Nde S, Bermudez BE, Nisihara RM. Association between congenital heart defects and severe infections in children with Down syndrome. Rev Port Cardiol 2014;33:15–8. 18. Chin CJ, Khami MM, Husein M. A general review of the otolaryngologic manifestations of Down Syndrome. Int J Pediatr Otorhinolaryngol 2014;78:899–904. 19. Strome M. Down’s syndrome: a modern otorhinolaryngological perspective. Laryngoscope 1981;91:1581–94. 20. Shott SR. Down syndrome: common otolaryngologic manifestations. Am J Med Genet C Semin Med Genet 2006;142C:131–40. 21. Barr E, Dungworth J, Hunter K, McFarlane M, Kubba H. The prevalence of ear, nose and throat disorders in preschool children with Down’s syndrome in Glasgow. Scott Med J 2011;56:98–103. 22. Macchini F, Leva E, Torricelli M, Valadè A. Treating acid reflux disease in patients with Down syndrome: pharmacological and physiological approaches. Clin Exp Gastroenterol 2011;4:19–22. 23. Delacourt C, Hadchouel A, Toelen J, Rayyan M, de Blic J, Deprest J. Long term respiratory outcomes of congenital diaphragmatic hernia, esophageal atresia, and cardiovascular anomalies. Semin Fetal Neonatal Med 2012;17:105–11. 24. Abbas AK, Lichtman AHH, Pillai S. Basic Immunology: Functions and Disorders of the Immune System, 4rd ed. Philadelphia: Saunders Elsevier; 2014.

168 25. Khocht A, Russell B, Cannon JG, Turner B, Janal M. Phagocytic cell activity and periodontitis in Down syndrome. Oral Dis 2012;18:346–52. 26. Bloemers BL, van Bleek GM, Kimpen JL, Bont L. Distinct abnormalities in the innate immune system of children with Down syndrome. J Pediatr 2010;156:804–9. 27. Nisihara RM, Utiyama SR, Oliveira NP, Messias-Reason IJ. Mannanbinding lectin deficiency increases the risk of recurrent infections in children with Down’s syndrome. Hum Immunol 2010;71:63–6. 28. Bloemers BL, Bont L, de Weger RA, Otto SA, Borghans JA, Tesselaar K. Decreased thymic output accounts for decreased naive T cell numbers in children with Down syndrome. J Immunol 2011;186:4500–7. 29. de Hingh YC, van der Vossen PW, Gemen EF, Mulder AB, Hop WC, Brus F, et al. Intrinsic abnormalities of lymphocyte counts in children with down syndrome. J Pediatr 2005;147:744–7. 30. Kusters MA, Gemen EF, Verstegen RH, Wever PC, DE Vries E. Both normal memory counts and decreased naive cells favor intrinsic defect over early senescence of Down syndrome T lymphocytes. Pediatr Res 2010;67:557–62. 31. Pellegrini FP, Marinoni M, Frangione V, Tedeschi A, Gandini V, Ciglia F, et al. Down syndrome, autoimmunity and T regulatory cells. Clin Exp Immunol 2012;169:238–43.

North Clin Istanb 32. Kusters MA, Verstegen RH, Gemen EF, de Vries E. Intrinsic defect of the immune system in children with Down syndrome: a review. Clin Exp Immunol 2009;156:189–93. 33. Levin S, Schlesinger M, Handzel Z, Hahn T, Altman Y, Czernobilsky B, et al. Thymic deficiency in Down’s syndrome. Pediatrics 1979;63:80– 7. 34. Carsetti R, Valentini D, Marcellini V, Scarsella M, Marasco E, Giustini F, et al. Reduced numbers of switched memory B cells with high terminal differentiation potential in Down syndrome. Eur J Immunol 2015;45:903–14. 35. Joshi AY, Abraham RS, Snyder MR, Boyce TG. Immune evaluation and vaccine responses in Down syndrome: evidence of immunodeficiency? Vaccine 2011;29:5040–6. 36. Valentini D, Marcellini V, Bianchi S, Villani A, Facchini M, Donatelli I, et al. Generation of switched memory B cells in response to vaccination in Down syndrome children and their siblings. Vaccine 2015;33:6689– 96. 37. Barradas C, Charlton J, MendoCa P, Lopes AI, Palha M, Trindade JC. IgG subclasses serum concentrations in a population of children with Down syndrome: comparative study with siblings and general population. Allergol Immunopathol (Madr) 2002;30:57–61.

Letter to the Editor

ANESTHESIOLOGY & REANIMATION

North Clin Istanb 2018;5(2):169-170 doi: 10.14744/nci.2018.92679

Endoscopic retrograde cholangiopancreaticography in elderly patients: A reliable alternative in sepsis Ebru Tarikci Kilic,1 Levent Doganay,2 Kamil Ozdil2 Department of Anaesthesiology, Health Sciences University, Umraniye Training and Research Hospital, Istanbul,Turkey

Department of Gastroenterology, Health Sciences University, Umraniye Training and Research Hospital,Istanbul,Turkey

Cite this article as: Tarikci Kilic E, Doganay L, Ozdil K. Endoscopic retrograde cholangiopancreaticography in elderly patients: A reliable alternative in sepsis. North Clin Istanb 2018;5(2):169-170.

To the Editor, With the increase in the average life span, endoscopic examinations and endoscopic retrograde cholangiopancreaticography (ERCP) are now more frequently performed in the elderly. Since the incidence of biliary tract and pancreatic cancers increases with age, and because surgical interventions demonstrate a very high morbidity and mortality in this age group, ERCP is an important, effective, and reliable method of diagnosis and treatment [1]. Complications related to the procedure and to anesthesia increase in direct proportion to age. This is a description of our experience with an 85-year-old patient who underwent ERCP as a result of sepsis developing secondary to cholangitis. An 85-year-old male patient who presented at the emergency service with abdominal and epigastric pain, nausea, and a high fever was admitted with the diagnosis of cholangitis. The most important laboratory test results were as follows: aspartate aminotransferase: 219 U/L, alkaline phosphatase: 560U/L, gamma-glutamyl transpeptidase: 1200 U/L, white blood cell count: 30000 K/mm3, C-reactive protein level: 100.8 mg/L, and total bilirubin value: 2.5 mg/dL. Hepatobiliary sonography

revealed a 25-mm dilation of the proximal part of the choledochus. Given the appearance of sepsis, ERCP was planned for the patient. The preoperative evaluation revealed the presence of comorbidities: type II diabetes, hypertension, peripheral vascular disease, and dilated cardiomyopathy, and an echocardiographic examination demonstrated advanced mitral insufficiency and moderate tricuspid insufficiency. The cardiac ejection fraction recorded was 30%. Based on the available findings, the patient was classified as American Society of Anesthesiologists physical status class IV. A beta-blocker (metoprolol, 5 mg intravenously [IV]) was administered preoperatively. His vital signs, peripheral oxygen saturation and end-tidal carbon dioxide pressure were monitored, and a 5-lead electrocardiogram was obtained. Before the procedure, his blood pressure was 100/70 mmHg and his pulse rate was 120 bpm. The patient, who weighed 78 kg, was given sedoanalgesia with midazolam (1mg IV) and ketamine (30 mg IV). Oxygen was delivered through the nasal route at a rate of 6 L per minute. Sedoanalgesia was maintained with a mixture of ketamine and propofol (0.75 mg/kg/hr, 1/1), which was titrated and infused throughout the procedure. The choledochus was cannulated using a sphincterotome, and

Received: November 11, 2017 Accepted: February 20, 2018 Online: May 17, 2018 Correspondence: Dr. Ebru TARIKCI KILIC. Umraniye Egitim ve Arastirma Hastanesi, Saglik Bilimleri Universitesi, Anesteziyoloji Anabilim Dali, Istanbul, Turkey. Tel: +90 216 632 18 18 e-mail: ebru.tarkc@yahoo.com ÂŠ Copyright 2018 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com

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following lithotripsy, the calculi were extracted. The procedure was completed within 40 minutes without the occurrence of apnea, hemodynamic instability, or any other complication. Although preoperative blood cultures did not reveal any bacterial growth, IV antibiotherapy and fluid therapy were administered for 5 days in the hospital, after which the patient was discharged. ERCP has been used with increasing frequency in the geriatric population in the diagnosis of pancreatobiliary diseases and in the treatment of common biliary duct obstruction secondary to malignancy or a stone. In one study, the success rate of ERCP was 88% in patients aged >80 years, and 86% in patients aged <80 years, and the corresponding complication rates were 6.8% and 5.1%, respectively [2]. The mortality and complication rates of biliary surgery have been reported to be 9.5% and 62%, respectively [2]. Complications have been observed during the early postoperative period in 1.6% of patients older than 90 years [2, 3]. In a retrospective single-center study conducted by Sobani et al. [4] performed with 1389 patients, 74 patients were ≥90 years of age, and the success rate of ERCP was 89.2%. The authors empha-

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sized the safety of this procedure, even in this age group, provided that the necessary preparation is performed. Sepsis secondary to cholangitis is an important cause of morbidity and mortality in older patients. ERCP performed with the appropriate indications, the proper preparation, and with good postprocedural follow-up has become a life-saving treatment alternative in this age group. REFERENCES 1. Day LW, Lin L, Somsouk M. Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis. Endosc Int Open 2014;2:E28–36. 2. Fritz E, Kirchgatterer A, Hubner D, Aschl G, Hinterreiter M, Stadler B, et al. ERCP is safe and effective in patients 80 years of age and older compared with younger patients. Gastrointest Endosc 2006;64:899– 905. 3. Katsinelos P, Paroutoglou G, Kountouras J, Zavos C, Beltsis A, Tzovaras G. Efficacy and safety of therapeutic ERCP in patients 90 years of age and older. Gastrointest Endosc 2006;63:417–23. 4. Sobani ZA, Yunina D, Abbasi A, Tin K, Simkin D, Rojas M, et al. Endoscopic Retrograde Cholangiopancreatography in Nonagenarian Patients: Is It Really Safe? Clin Endosc 2017 Sep 18 [Epub ahead of print] doi: 10.5946/ce.2017.123.