hyposplenism as a risk factor of infection, …doc/a-di-sabatino.pdf · igd memory 8.1% mature...

First Department of Medicine, University of Pavia, Fondazione IRCCS Policlinico S. Matteo, Pavia

Antonio Di Sabatino

HYPOSPLENISM AS A RISK FACTOR OF INFECTION, AUTOIMMUNITY AND

COMPLICATIONS IN COELIAC DISEASE

In 1955, Dameshek coined the term “hyposplenism” to describe a

patient with coeliac disease in whom Howell-Jolly bodies were

detected on peripheral blood smear and an atrophic spleen was

confirmed at post-mortem examination

Since then, hyposplenism has been regarded as an acquired disorder,

potentially associated with several diseases, sometimes

accompanied by a reduction in spleen size, and burdened by the

same complications occurring in surgical asplenia

Definition of hyposplenism

••••

••••

COMPARTMENT

White pulp

Marginal zone

Red pulp

PALS PALS

MZ MZ

STRUCTURE

Cords

Sinus

Follicle

Sinus

A

GCMn

HISTOLOGY

A

PALS

Follicle

MZ

Sinus

Cords

GC

Mn

FUNCTION

Adaptive response (antigen-specific) consequent to interaction between antigen presenting cells (dendritic cells or marginal zone B lymphocytes) and B or T lymphocytes

Innate response (first line defence, non-antigen specific) characterised by IgM-memory B lymphocyte production of natural antibodies

Innate response characterised by activation of macrophages in cords

Adaptive response characterised by plasma cell migration from the white pulp after antigen-specific differentiation in follicles

Blood filter (pitting, culling)

CELL

PALS (T-dependent)Small CD4+ T lymphocytesDendritic cellsB lymphocytesMacrophagesPlasma cells

Follicle (B-dependent)B lymphocytes/plasma cellsDendritic cells

ResidentB lymphocytesMacrophages

In transitCD4+ T lymphocytesCD27+ memory B lymphocytesDendritic cells

Cords of BillrothCD8+ T lymphocytesFibroblastsMacrophagesNatural killer cells

SinusoidsCD8+ endothelial cells

Structure, function, and cell populations of thethree functional compartments of the spleen

Di Sabatino & Corazza. Lancet 2011

Function of CD27+ memory B cells in steady-state conditions

T

APC

Switched-memory B cells (IgM neg IgDneg)

Bonemarrow B

spleen

Lymph node B

T-dependent reaction

Carsetti et al. Immunol Rev 2004

IgM-memory B cells (IgM bright IgDdull )

Fetalliver B

spleen

T-independent reaction

?

IgM memory B cells controlling Streptococcus pneumoniaeinfections are generated in the spleen

Kruetzmann et al. J Exp Med 2003

100

102

103

101

104

100

102

103

101

104

010

210

310

110

4

memory4.8%

CD27

IgD

CD22

IgM10

010

210

310

110

4

Splenectomizedpatient (SP)

Controlsubject (CS)

memory54.3%

IgM mem3.6%

IgM mem21.5%

Switched Switched

mature mature10

0

104

103

102

100

104

103

102

1010

0

104

103

102

100

104

103

102

0

10

20

% o

f tot

al ly

mph

ocyt

es

SP CS

30

B cells

•••••

•

•

% o

f tot

al B

cel

ls

SP CS

B Memory

10

20%

of t

otal

B c

ells 30

IgM-mem Switched-mem

0

10

20

50

30

40

••••••••••••••••••

••

••••••••••••••••••••••••••••••••

60

••••••••••••••••••••••

•••••

••• •

•••••••••••••••••••••••••••••

p<0.001

0SP CS

••••••••• • •••••••• •• •••• ••• ••••••••

•••••••••••••••••••••••••

0

10

20

% o

f tot

al B

cel

ls

SP CS

30

40

p<0.0001

•••••••••••••••••••••••••••

•••••••••

••••••••••••••••••••••••

Clinical consequences of defective spleen function

Immune

Filtering

↓↓↓↓ IgM-memory B cells↓↓↓↓ Tuftsin/properdin activity

↓↓↓↓ Marginal zone B cells

↓↓↓↓ Sequestration of platelets(Culling)

FUNCTION RESULT OF DEFECTIVE FUNCTION CLINICAL CONSEQUENCES

Serious infections byencapsulated bacteria(Streptococcus pneumoniae,Neisseria meningitidis,Haemophylus influenzae)

Autoimmunity

Thromboembolism

↓↓↓↓ Treg

↓↓↓↓ removal of pits from erythrocytes(Pitting)

↑↑↑↑ circulating pittederythrocytes and Howell-Jolly bodies

Diagnostic techniques for spleen dysfunction

Di Sabatino & Corazza. Lancet 2011

99Tc Spleen scan Howell-Jolly bodies Pitted red cells

Flow cytometric analysis of IgM-memory B cellsas a diagnostic tool for spleen dysfunction

•• • •••• •

••••••

•••••••••

••••

•••••••

•••••••••

••••

IgM-memory B cells (% total B cells)

0 5 10 15 20 25 30 350

p=0.01

30

0

10

20

p<0.01

Pitt

ed re

d ce

lls (%

)

0 5 10 15 20 25 30 35

10

20 •

30


Pitt

ed re

d ce

lls (%

)

SPLENECTOMIZED PATIENTS HYPOSPLENIC PATIENTS

Di Sabatino et al. Am J Gastro 2005

4 4

•

•

•

•••

•

•

••

•

• •

•

••

••

• •

Natural history of splenic hypofunction

0

4

8

Pitt

ed r

ed c

ells

(%

)

12

10

6

2

14

Pre-ifx Post-ifx

•

p<0.01

••

•

• •

•

••

•

•

•

•

••

•

•

•

•

•

0

4

8P

itted

red

cel

ls (

%)

12

10

6

2

14

Pre-ifx Post-ifx

REVERSIBLEHYPOSPLENISM

IRREVERSIBLEHYPOSPLENISM

SPLENICATROPHY

••

•

•

• •

•

••••

•

Responder Crohn’s disease pts Non-responder Crohn’s disease pts

Di Sabatino et al. IBD 2008Di Sabatino et al. IBD 2008

DISEASES ASSOCIATED WITH FUNCTIONAL HYPOSPLENISM/SPLENIC ATROPHY

Coeliac disease as the commonest cause of nonsurgical asplenia

Di Sabatino A & Corazza GR. Lancet 2011

Functional hyposplenism in untreated coeliac disease (CD)

• • •• • ••• •• • • ••• ••• •• • •• • ••• •• • • ••• ••• •• • •• • ••• •• • • ••• ••• •• • •• •• •• • •• ••• •• ••• •• •• ••••• •••• •••

0

10

20

30

40

50

• •••• •••••• •••• ••• ••••••

•••

•

••

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• •• •• •• •• ••• ••

•••

••

••••••

•••

••••••

Pitt

ed r

ed c

ells

(%

)Untreated CD

(Hypo=33%)Control subjects

(Hypo=0%)Asplenic subjects

(Hypo=100%)

4

Corazza et al. Am J Gastroenterol 1999

Pitted red cell counting correlates with IgM-memory B cellsand serum tuftsin activity in untreated coeliac disease

•• ••••• • • •• •

••••

••••••

•••

•••• ••

••••••••••••••••

•••••

••••••• ••••

••••••••

••••••

0 5 10 15 20 25 30 350

• •

••

•

••

•

• ••••

•• • • ••••

• ••

• • •••

•••••••••••••••• ••••0 10 20 30 40

0

10

20

30

10

20 •

30p=0.001rs=-0.34

p<0.01rs=-0.36

Pitt

ed re

d ce

lls (%

)

Pitt

ed re

d ce

lls (%

)

Serum tuftsinactivity (%)

IgM memory B cells(% total B cells)

Corazza et al. Am J Gastro 1999; Di Sabatino et al. Clin Gastroenterol Hepatol 2006

Untreated coeliac patients

30

20

10

0

Controlsubjects

Pitt

ed re

d ce

lls (%

)

••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

••••

••••

••••••••••••••••••••••••••••••••••••

••••••••

EFFECT OF AGE AT ONSET

Corazza et al. Gut 1982

30

20

10

0

40

60

50

70

Hyp

ospl

enic

coe

liacs

(%)

Age (years)

15/19 20/29 30/39 40/49 50/59 60/69 >69

Age at study

Age at diagnosis

EFFECT OF AGE AT DIAGNOSIS

Effect of age at onset, age at diagnosisand gluten-free diet in patients with coeliac disease

EFFECT OF GLUTEN-FREE DIET

••••

••••

•••• ••••••••••••

••••••••••••

••••••••

••••••••••••••••

••••••••

••••

•••••••••••• ••••••••

••••••••••••

•••• •••• ••••••••

Pitt

ed re

d ce

lls (%

)

3

2

10

5

4

30

25

2015

40

35

0 2 4 6 8 10 12

Months of gluten-free diet

p<0.005

Coeliacchildren

Asplenicsubjects

4

Corazza et al. Am J Gastro 1999 Corazza et al. Gut 1983

0

10

20

Pitt

ed r

ed c

ells

(%

)

30

25

15

5

35

Splenectomizedpatients

(Hypo=100%)

CD patientswithout AID(Hypo=19%)

CD patientswith AID

(Hypo=59%)

••• •••

••

•

••••••

•

••

•••

••••

•

•

HealthyVolunteers(Hypo=0%)

••• •• ••••••••••• •• •••

•••••••

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•

•

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•

••

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•

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•

Di Sabatino et al. Clin Gastroenterol Hepatol 2006

Splenic hypofunction and coeliac disease (CD)-associated autoimmune disorders (AID)

4


10010

210

310

110

4

100

102

103

101

104 10

010

210

310

110

4

10010

210

310

110

4 10010

210

310

110

4

100

102

103

101

104

CD

27Ig

D

memory8.1%

mature

memory22.6%

mature mature

memory46.3%

IgM mem2.1%

Switched

IgM mem3.8%

IgM mem15.4%

Switched Switched

IgM

CD22

Asplenicsubject

Hypospleniccoeliac

Controlsubject

5

10

% o

f tot

al B

cel

ls 15

MEMORY B CELLS

0SP CD

+ AIDCD

w/o AIDHC

20

Circulating IgM-memory and switched-memory B cells incoeliac disease (CD)-associated autoimmune disorders (AID)

IgM

Switchedp<0.05


Splenic hypofunction and the spectrum of malignantcomplications in adult coeliac disease

0

10

20

Pitt

ed r

ed c

ells

(%

)

Uncompl.CD

(Hypo=19%)30

25

15

5

35

•••

•

••

••••••••••• ••••••• ••••

••

•

••••

••

Compl.CD

(Hypo=80%)

4


Splenic atrophy and mesenteric lymph node cavitationin a patient with refractory coeliac disease

Abdominal Bowel Sonography99mTc Splenic Scan

Posteroanterior Laterolateral

CD

45R

OC

D20

Controlsubject

Coeliacpatient

Control-PBL CD-PBL

Control-SPL CD-SPL

CD19+

CD19+

CD21bright

CD19+

CD27+

CD

27C

D27

IgD

0

2

4

6

8

10

12

Imm

unog

lobu

lins

(µµ µµg

/ml)

IgMIgA

IgG

Controlsubject

Coeliacpatient

Response to CpG-ODN

IgM

Splenic atrophy and coeliac disease.Morphological and functional aspects

Di Sabatino et al. J Allergy Clin Immunol 2007

Case reports of hyposplenism-related infectionsin patients with coeliac disease

AUTHOR

Corazza GR

Matuchansky C

O’Donogue DJ

Logan RFA

Stevens FM

Howat AJ

Harmon GS

YEAR

1984

1984

1986

1989

1990

1995

2010

JOURNAL

Ital J Gastroenterol

Gastroenterology

Postgrad Med J

Gastroenterology

Digestion

Histopathology

Clin Gastro Hep

CASES

1

2

1

2

3

2

1

TYPE OF INFECTION

Pneumoccoccal pneumonia

Pneumococcal pneumonia,infectious pericarditis

Pneumococcal septicemia

Pneumococcal meningitis,septicemia by Salmonella

Lung abscesses by Staphyl,Klebsiella, MycoTBC

Fatal chest infection,septicemia

Septicemia by Klebsiella

OTHER DETAILS

Splenic atrophy

Splenic atrophy (2)MLNC (2)

Splenic atrophy

Splenic atrophy (1)

Splenic atrophy (2)Hyposplenism (1)

Splenic atrophy (1)MLNC (2)

Splenic atrophy

Ludvigsson et al. Gut 2008

vs general population

vs hospitalized patients Sepsis Hip

fracture Lymphoma

0

20

40

60

80

100

Abs

olut

e R

isk

Walters et al. Gut 2008

Risk for pneumococcal sepsis in coeliac disease

Thomas et al. EJGH 2008

0

1

2

3

4

5Coeliacpatients

Asplenicpatients

Rel

ativ

e R

isk

0

1

2

3

4

5

Rel

ativ

e R

isk

p<0.001p<0.01

15,325 coeliac patients14,494 hospitalized patients

2,044 coeliac patients

2,956 asplenic patients

Peters et al. Arch Intern Med 2003

0

5

10

Sta

ndar

dize

d M

orta

lity

Rat

io

Allinfections

15

2.9

Septicemia

7.1

Allmalignancies

1.7

Respiratorydiseases

2.8

Pneumonia

2.9

Septicemia and pneumonia as frequent causes of deathin coeliac patients: the Swedish cohort (10,032 pts)

80

0

60

40

20

% v

acci

nate

d pa

tient

s

2001 2002 2003 2004 2005 2001 2002 2003 2004 2005

Splenectomy(n. 2,001)

Coeliac disease / sickle cell anemia(n. 3,584)

Pebody et al. Epidemiol Infect 2008

Use of anti-pneumococcal vaccines in at risk populationsin UK (Q-research database 2001-2005)

Traditional polysaccharide and new conjugate anti-pneumococcal vaccines

used in the prophylactic management of asplenic/hyposplenic patients

VACCINE

PPV23

PCV13

BRAND NAME

Pneumovax®

Prevnar®

MECHANISM

T-cell independent

T-cell dependent

SEROTYPES

1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B,17F, 18C, 19A, 19F,20, 22F, 23F, 33F

1, 3, 4, 5, 6A, 6B,7F, 9V, 14, 18C,19A, 19F, 23F

STRUCTURE

Polysaccharide

Protein-conjugate(CRM197 protein)

INDICATIONS

- Asplenic or hyposplenicadults

- Asplenic or hyposplenicchildren > 5 yrs

- Asplenic or hyposplenicchildren < 5 yrs

Traditional polysaccharide and new conjugate anti-pneumococcal vaccines

used in the prophylactic management of asplenic/hyposplenic patients

VACCINE

PPV23

PCV13

BRAND NAME

Pneumovax®

Prevnar®

MECHANISM

T-cell independent

T-cell dependent

SEROTYPES

1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B,17F, 18C, 19A, 19F,20, 22F, 23F, 33F

1, 3, 4, 5, 6A, 6B,7F, 9V, 14, 18C,19A, 19F, 23F

STRUCTURE

Polysaccharide

Protein-conjugate(CRM197 protein)

INDICATIONS

- Asplenic or hyposplenicadults

- Asplenic or hyposplenicchildren > 5 yrs

- Asplenic or hyposplenicchildren < 5 yrs

- Adult patients with majorhyposplenism

Asplenia/hyposplenism-related thromboembolism

� Splenectomy

� Coeliac disease

� Inflammatory bowel disease

� Whipple’s disease p=0.007rs=0.66

Platelet count (x10 3/µµµµl)

Pitt

ed r

ed c

ells

(%

)

Di Sabatino et al. Am J Gastro 2009

Risk of thromboembolism in 14,207 patients withcoeliac disease versus 69,048 matched reference individuals

Ludvigsson et al. Br J Haematol 2007

0

1

2H

azar

d ra

tios

Referenceindividuals

Coeliacpatients

1.86

p<0.001

0-15 yrs ≥16 yrs

1.97

p<0.001

Age at diagnosis

Critical issues in coeliac disease-associated hyposplenism

1. When to evaluate splenic function

2. How to measure splenic function

3. When to recommend prophylactic vaccination

4. What is the cause of hyposplenism


1. When to evaluate splenic function in CD

� Patients with complications (RCD, UJI, EATL, collagenous sprue)

� Patients with concomitant autoimmune disorders

� Patients with old age at diagnosis

� Patients with previous history of major infections/sepsis

� Patients with mesenteric lymph node cavitation and/orsmall sized spleen ( φφφφF<7.5cm; φφφφM<8.0cm) at abdominal US or CT

Two-thirds of individuals with small sized spleen (φφφφF<7.5cm; φφφφM<8.0cm)incidentally detected at abdominal US are hyposplenic

0

12

16

20

24

28

Splenectomized patients(n=52)

Patients with small sized spleen(n=128)

4

8

Pitt

ed r

ed c

ells

(%

)85 hyposplenic patients

Di Sabatino et al. Intern Emerg Med 2011


2. How to measure splenic function

� Pitted red cell counting by phase-interference microscopy

� Flow cytometric analysis of circulating memory B cells

� Flow cytometric detection of circulating Howell-Jolly bodies

•

•

•

•• •

••

•

•

•20 25 30

1.0

0.5

1.5

% PITTED RED CELLS

% H

JB (

CD

71- /T

OP

RO

+ ) p=0.0128rs=0.73

Splenectomized

10 15

0.2

0.1

0.3

% PITTED RED CELLS

p=0.002rs=0.83

Hyposplenic••• •

• •• •

•

• •

Critical issues in coeliac disease-associated hyposplenism3. When to recommend prophylactic vaccination


0 10 20 300

30

0

10

20 •

Pitt

ed re

d ce

lls (%

)

•

0 10

•

•••

•

•

••

•

• •

•

••

••

20 30

20

30


Pitt

ed re

d ce

lls (%

)

• •

SPLENECTOMIZED PATIENTS HYPOSPLENIC COELIAC PATIENTS

4 4

10

••

••

••• •

•

••

•

•• ••

•

••

••

••••

•• •

•

•• •

To clarify mutual connections between spleen and gut

4. What is the cause of hyposplenism

Spleen

Gut

The spleen plays a major function in the protection of gut mucosa

Rosado et al. Mucosal Immunol 2009

Di Sabatino et al. FISMAD, Naples, March 2012

Con

trol

Asp

leni

cA

sple

nic

Oral tolerance to deamidated gliadin in HLA-DQ2 transgenic miceis predominantly mounted in the spleen

Du Pré et al. Gastroenterology 2011

Deamidated gliadin Ovalbumine

Response to pneumococcal vaccine in 10 patients with coeliac disease

Num

ber

of s

erot

ypes

in w

hich

pts

achi

eved

a 2

-fol

d ris

e in

ant

ibod

y le

vels

1

2

3

4

5

6

7

8

9

10

11

12

0Pt.#1 Pt.#2 Pt.#3 Pt.#4 Pt.#5 Pt.#6 Pt.#7 Pt.#8 Pt.#9 Pt.#10

Eusplenic coeliac patients Hyposplenic coeliac patients

McKinley et al. J Clin Gastroenterol 1995

hyposplenism as a risk factor of infection, …doc/a-di-sabatino.pdf · igd memory 8.1% mature...

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