Biological and other studies which are relevant to the notion that MMR may be related to autism (particularly as it may relate to gastrointestinal disorders)
Biological and other studies which are relevant to the
notion that MMR may be related to autism (particularly as it may relate to
gastrointestinal disorders)
Note: I left some citations
in for which there was no text to refer to and for which I couldn't be sure
what the conclusion was, in case it might be relevant. Please do not
assume the position taken based on the title. When I am able to add
text, I will do so. - SM
In a series of 43 autistic children,
mostly regressive, with chronic gastrointestinal symptoms, the majority were
found to have pathologic inflammation of the colon and terminal ileum. 90% had
pathologic lymphonodular
hyperplasia of the terminal ileum. Moreover, the findings were similar and
consistent from patient to patient within the affected group.
Abnormal measles-mumps-rubella antibodies and CNS
autoimmunity in children with autism.
Singh VK, Lin SX, Newell E, Nelson C.
Department of Biology and Biotechnology Center, Utah State University,
Logan, Utah, USA.
Autoimmunity to the central nervous system (CNS), especially to myelin basic
protein (MBP), may play a causal role in autism, a neurodevelopmental
disorder. Because many autistic children harbor elevated levels of measles
antibodies, we conducted a serological study of measles-mumps-rubella (MMR)
and MBP autoantibodies. Using serum samples of 125 autistic children and 92
control children, antibodies were assayed by ELISA or immunoblotting
methods. ELISA analysis showed a significant increase in the level of MMR
antibodies in autistic children. Immunoblotting analysis revealed the
presence of an unusual MMR antibody in 75 of 125 (60%) autistic sera but not
in control sera. This antibody specifically detected a protein of 73-75 kD
of MMR. This protein band, as analyzed with monoclonal antibodies, was
immunopositive for measles hemagglutinin (HA) protein but not for measles
nucleoprotein and rubella or mumps viral proteins. Thus the MMR antibody in
autistic sera detected measles HA protein, which is unique to the measles
subunit of the vaccine. Furthermore, over 90% of MMR antibody-positive
autistic sera were also positive for MBP autoantibodies, suggesting a strong
association between MMR and CNS autoimmunity in autism.
Stemming from this evidence, we
suggest that an inappropriate antibody response to MMR, specifically the
measles component thereof, might be related to pathogenesis of autism.
Copyright 2002 National Science Council, ROC and S. Karger AG, Basel
The gut-brain axis in childhood developmental disorders.
Wakefield AJ.
Experimental Gastroenterology, Centre for Gastroenterology, Royal Free and
University College Medical School, London, United Kingdom. awakefield@rfc.ucl.ac.uk
Small intestinal enteropathy with epithelial IgG and
complement deposition in children with regressive autism.
Torrente F, Ashwood P, Day R, Machado N, Furlano RI, Anthony A, Davies
SE, Wakefield AJ, Thomson MA, Walker-Smith JA, Murch SH.
Centre for Paediatric Gastroenterology, Royal Free & University College
Medical School, London, UK.
We have reported lymphocytic colitis in children with regressive autism,
with epithelial damage prominent. We now compare duodenal biopsies in 25
children with regressive autism to 11 with coeliac disease, five with
cerebral palsy and mental retardation and 18 histologically normal controls.
Immunohistochemistry was performed for lymphocyte and epithelial lineage and
functional markers. We determined the density of intraepithelial and lamina
propria lymphocyte populations, and studied mucosal immunoglobulin and
complement C1q localisation. Standard histopathology showed increased
enterocyte and Paneth cell numbers in the autistic children.
Immunohistochemistry demonstrated increased lymphocyte infiltration in both
epithelium and lamina propria with upregulated crypt cell proliferation,
compared to normal and cerebral palsy controls. Intraepithelial lymphocytes
and lamina propria plasma cells were lower than in coeliac disease, but
lamina propria T cell populations were higher and crypt proliferation
similar. Most strikingly, IgG deposition was seen on the basolateral
epithelial surface in 23/25 autistic children, co-localising with complement
C1q. This was not seen in the other conditions.
These findings demonstrate a novel
form of enteropathy
in autistic children, in which increases in mucosal lymphocyte density and
crypt cell proliferation occur with epithelial IgG
deposition. The features are suggestive of an autoimmune lesion.
Potential viral pathogenic mechanism for new variant
inflammatory bowel disease.
Uhlmann V, Martin CM, Sheils O, Pilkington L, Silva I, Killalea A, Murch
SB, Walker-Smith J, Thomson M, Wakefield AJ, O'Leary JJ.
Department of Pathology, Coombe Women's Hospital, Dublin 8, Ireland.
AIMS: A new form of inflammatory bowel disease (ileocolonic lymphonodular
hyperplasia) has been described in a cohort of children with developmental
disorder. This study investigates the presence of persistent measles virus
in the intestinal tissue of these patients (new variant inflammatory bowel
disease) and a series of controls by molecular analysis. METHODS: Formalin
fixed, paraffin wax embedded and fresh frozen biopsies from the terminal
ileum were examined from affected children and histological normal controls.
The measles virus Fusion (F) and Haemagglutinin (H) genes were detected by
TaqMan reverse transcription polymerase chain reaction (RT-PCR) and the
Nucleocapsid (N) gene by RT in situ PCR. Localisation of the mRNA signal was
performed using a specific follicular dendritic cell antibody. RESULTS:
Seventy five of 91 patients with a histologically confirmed diagnosis of
ileal lymphonodular hyperplasia and enterocolitis were positive for measles
virus in their intestinal tissue compared with five of 70 control patients.
Measles virus was identified within the follicular dendritic cells and some
lymphocytes in foci of reactive follicular hyperplasia. The copy number of
measles virus ranged from one to 300,00 copies/ng total RNA. CONCLUSIONS:
The data confirm an association
between the presence of measles virus and gut pathology in children with
developmental disorder.
Review article: the concept of entero-colonic
encephalopathy, autism and opioid receptor ligands.
Wakefield AJ, Puleston JM, Montgomery SM, Anthony A, O'Leary JJ, Murch SH.
Inflammatory Bowel Disease Study Group, Centre for Gastroenterology,
Department of Medicine, Royal Free and University College Medical School,
London, UK. wakers@aol.com
There is growing awareness that
primary gastrointestinal pathology may play an important role in the
inception and clinical expression of some childhood developmental disorders,
including autism. In addition to frequent gastrointestinal symptoms,
children with autism often manifest complex biochemical and immunological
abnormalities. The gut-brain axis is central to certain encephalopathies
of extra-cranial origin, hepatic encephalopathy being the best
characterized.Commonalities
in the clinical characteristics of hepatic encephalopathy and a form of
autism associated with developmental regression in an apparently previously
normal child, accompanied by immune-mediated gastrointestinal pathology,
have led to the proposal that there may be analogous mechanisms of toxic
encephalopathy in patients with liver failure and some children with autism.
Aberrations in opioid biochemistry are common to these two
conditions, and there is evidence that opioid peptides may mediate certain
aspects of the respective syndromes. The generation of plausible and
testable hypotheses in this area may help to identify new treatment options
in encephalopathies of extra-cranial origin. Therapeutic targets for this
autistic phenotype may include: modification of diet and entero-colonic
microbial milieu in order to reduce toxin substrates, improve nutritional
status and modify mucosal immunity; anti-inflammatory/immunomodulatory
therapy; and specific treatment of dysmotility, focusing, for example, on
the pharmacology of local opioid activity in the gut.
Inflammatory bowel disease and laterality: is left
handedness a risk?
Morris DL, Montgomery SM, Galloway ML, Pounder RE, Wakefield AJ.
Inflamatory Bowel Disease Study Group, Royal Free and University College
Hospital Medical School, London, UK. Wisemail@compuserve.com
BACKGROUND: Left handedness has been associated with inflammatory bowel
disease (IBD) and autoimmune diseases. AIMS: To determine whether left
handedness is associated with IBD in two prospective national birth cohorts.
METHODS: Subjects with Crohn's disease (CD) and ulcerative colitis (UC) were
identified from two national longitudinal birth cohorts at age 26 years
(1970 British Cohort Study (BCS70), born in 1970) and age 33 years (National
Child Development Study (NCDS), born in 1958). Laterality was determined at
age 10 (BCS70) or seven (NCDS) years, based on hand preference for writing
and foot preference for kicking a ball (BCS70 only). Multiple logistic
regression was used to assess the relationship of handedness with CD, UC,
and IBD in the cohorts combined and adjusted for sex. RESULTS: Both cohorts
combined showed increased adjusted relative odds of 2.13 (95% confidence
interval (CI) 0.97--4.65; p=0.059), 2.13 (95% CI 0.92--4.91; p=0. 077), and
2.13 (95% CI 1.20--3.78; p=0.010) for CD, UC, and IBD, respectively in left
handers. CONCLUSIONS: The study
suggests a link between IBD
and left handedness which may be genetic and/or environmental in origin.
Activation of the inflammatory response
system in autism.
Croonenberghs J, Bosmans E, Deboutte D, Kenis G, Maes M.
University Center of Child and Adolescent Psychiatry, Antwerp, Belgium.
Background/Aim: There is now some evidence
that autism may be accompanied by abnormalities in the inflammatory response
system (IRS). Products of the IRS, such as proinflammatory cytokines,
may induce some of the behavioral symptoms of autism, such as social
withdrawal, resistance to novelty and sleep disturbances. The main aim of the
present study was to examine whether autism is accompanied by an activation of
the IRS. Methods: We measured the production of interleukin (IL)-6, IL-10, the
IL-1 receptor antagonist (IL-1RA), interferon (IFN)-gamma and tumor necrosis
factor (TNF)-alpha by whole blood and the serum concentrations of IL-6, the
IL-2 receptor (IL-2R) and IL-1RA. Results: This study showed a significantly
increased production of IFN-gamma and IL-1RA and a trend toward a
significantly increased production of IL-6 and TNF-alpha by whole blood of
autistic children. There were no significant differences in the serum
concentrations of IL-6, IL-2R and IL-1RA between autistic and normal children.
Conclusions: These results suggest that
autism may be accompanied by an activation of the monocytic (increased IL-1RA)
and Th-1-like (increased IFN-gamma) arm of the IRS. It is hypothesized that
increased production of proinflammatory cytokines could play a role in the
pathophysiology of autism. Copyright 2002 S. Karger AG, Basel
Use of secretin in the treatment of
childhood autism.
Kaminska B, Czaja M, Kozielska E, Mazur E, Korzon M.
Department and Clinic of Pediatrics, Gastroenterology and Pediatric Oncology,
Medical University, Gdansk, Poland.
The paper presents current views concerning childhood autism. The authors
present the concepts of etiology of this disorder, emphasizing the role of
negative psychical stimuli in early childhood and the role of mother's contact
with the child. Organic factors, including genetic background, developmental
abnormalities of the nervous system, teratogenic factors and perinatal traumas
are also taken into consideration. The role of metabolic factors and
enterohormones, particularly those belonging to the secretin group and their
effect on the function of the gastrointestinal tract and central nervous
system is emphasized. We discuss signs which may be indicative of first
symptoms of autism in different age groups. A typical symptom of autism is no
development of speech, observed from infancy, taking the form of complete
mutism at later stages. It has been emphasized that most pathologic symptoms
result from altered perception of external stimuli, which arouse fear and
anxiety. Autistic patients may suffer from
gastrointestinal tract disturbances such as abdominal pains and diarrhea.
Methods used hitherto in the therapy of childhood autism, mainly by
psychologists and psychiatrists, as well as some attempts of pharmacological
treatment, are presented. The structure and function of secretin, as well as
its effects on the motor and secretory function of the stomach and the
exocrine function of the pancreas are discussed. The role of secretin in
diagnostic tests, among others in the diagnosis of gastrinoma, is emphasized.
We also present the history of the application of secretin in the therapy of
childhood autism.
A study of novel polymorphisms in the
upstream region of vasoactive intestinal peptide receptor type 2 gene in
autism.
Asano E, Kuivaniemi H, Huq AH, Tromp G, Behen M, Rothermel R, Herron J,
Chugani DC.
Department of Pediatrics, Children's Hospital of Michigan and Wayne State
University School of Medicine, Detroit 48201, USA.
We investigated the vasoactive intestinal peptide receptor type 2 (VIPR2) gene
as a candidate gene for autism. We searched for mutations in the VIPR2 gene in
autistic individuals, and 10 novel polymorphisms were identified. Three
polymorphisms in the upstream region were studied in detail, and there was no
significant difference in the frequencies between the autistic group (n = 14)
and unrelated controls (n = 52). The
distribution of the genotypes in two of the three polymorphisms differed
somewhat between autistic subjects with gastrointestinal problems and those
without.Moreover, there was a trend
showing a correlation between the genotypes for the third polymorphism and the
severity of stereotypical behavior as ranked by the Gilliam Autism Rating
Scale. These preliminary results suggest that VIPR2 may have a role in
gastrointestinal symptoms and stereotypical behaviors in autism, although a
larger collection of samples suitable for transmission disequilibrium tests is
necessary to validate the results.
Colonic CD8 and gamma delta T-cell infiltration with
epithelial damage in children with autism.
Furlano RI, Anthony A, Day R, Brown A, McGarvey L, Thomson MA, Davies SE,
Berelowitz M, Forbes A, Wakefield AJ, Walker-Smith JA, Murch SH.
University Department of Paediatric Gastroenterology, the Inflammatory Bowel
Diseases Study Group, Royal Free and University College School of Medicine,
London, United Kingdom.
OBJECTIVES: We have reported colitis with ileal lymphoid nodular hyperplasia
(LNH) in children with regressive autism. The aims of this study were to
characterize this lesion and determine whether LNH is specific for autism.
METHODS: Ileo-colonoscopy was performed in 21 consecutively evaluated
children with autistic spectrum disorders and bowel symptoms. Blinded
comparison was made with 8 children with histologically normal ileum and
colon, 10 developmentally normal children with ileal LNH, 15 with Crohn's
disease, and 14 with ulcerative colitis. Immunohistochemistry was performed
for cell lineage and functional markers, and histochemistry was performed
for glycosaminoglycans and basement membrane thickness. RESULTS: Histology
demonstrated lymphocytic colitis in the autistic children, less severe than
classical inflammatory bowel disease. However, basement membrane thickness
and mucosal gamma delta cell density were significantly increased above
those of all other groups including patients with inflammatory bowel
disease. CD8(+) density and intraepithelial lymphocyte numbers were higher
than those in the Crohn's disease, LNH, and normal control groups; and CD3
and plasma cell density and crypt proliferation were higher than those in
normal and LNH control groups. Epithelial, but not lamina propria,
glycosaminoglycans were disrupted. However, the epithelium was HLA-DR(-),
suggesting a predominantly T(H)2 response. INTERPRETATION:
Immunohistochemistry
confirms a distinct
lymphocytic colitis in
autistic spectrum disorders in which the epithelium appears particularly
affected. This is consistent with increasing evidence for gut epithelial
dysfunction in autism.
Application of genomeceuticals to the
molecular and immunological aspects of autism.
Brudnak MA.
MAK Wood Inc., Thiensville, Wisconsin 53024, USA. makwood@earthlink.net
Autism is a developmental disease affecting as many as 1 in 300 children and
is often characterized as a mental disorder originating in infancy that is
associated with self-absorption, inability to interact socially, behavior, and
language dysfunction (e.g. echolalia). Current theories indicate an important
role of diet in the development of disease. It is thought that, as a result of
maldigestion of casein and gluten, opioid-type peptides, or exorphins, are
produced. Additionally, because of the time-frame of development of the
disease, there has been an association with childhood vaccination.
Consequently, prevailing therapies attempt to address these causes in one, or
a combination, of three ways: diet restriction (removing casein and gluten);
supplementation with exogenous enzymes; and probiotic bacteria. Until
recently, none of the therapies addressed the molecular mechanisms that may be
at work in the development and progression of autism. This paper presents
potential molecular and cellular mechanism related to autism as well as
discusses their application to the treatment of the disease through the
application of genomeceuticals. Additionally,
a link between developmentally associated aberrant immune and inflammatory
responses, and autism is suggested and explored. Copyright 2001
Harcourt Publishers Ltd.
Measles vaccination and inflammatory bowel disease: a
national British Cohort Study.
Morris DL, Montgomery SM, Thompson NP, Ebrahim S, Pounder RE, Wakefield
AJ.
Department of Medicine, Royal Free and University College Medical School,
London, UK.
OBJECTIVE: Measles vaccination has been suggested as a risk for inflammatory
bowel disease. Atypical age of measles infection has also been associated
with Crohn's disease. This study was designed to examine the relationship of
measles vaccination and age of measles vaccination with later inflammatory
bowel disease. METHODS: A prospective population-based national birth cohort
was used, of those born in 1 wk in April 1970 in Great Britain. The data are
from 7616 responding members of the 1970 British Cohort Study with complete
vaccination data, who were traced at age 26 yr. A diagnosis of Crohn's
disease, ulcerative colitis, and diabetes mellitus (a control disease) was
obtained by survey at age 26 yr, and confirmed by physicians. Vaccination
data were from survey at age 5 yr. Measles and mumps infection data were
obtained from the survey at age 10 yr. Adjustment was made for sex,
household crowding in childhood, and father's social class at birth.
RESULTS: No statistically significant association was found between measles
vaccination status at 5 yr and Crohn's disease (adjusted odds ratio [OR]
0.67, 95% confidence interval [CI] 0.27-1.63), ulcerative colitis (adjusted
OR 0.57, 95% CI 0.20-1.61), or diabetes (adjusted OR 0.75, 95% CI
0.33-1.74). There was a statistically significant trend (p = 0.040) with
increasing age of measles vaccination for risk of Crohn' s disease, although
this was based on very few cases vaccinated after age 2 yr. CONCLUSIONS:
In this cohort, monovalent
measles vaccination status is not associated with inflammatory bowel disease
by age 26 yr. Older age at measles vaccination needs to be examined in other
studies to confirm whether it is a genuine risk for Crohn's
disease.
From the article: "In summary, analysis of pre-licensure
trials of MMR reveals that gastrointestinal, and other possible adverse
events were evident in children from developed countries. Although
evidence of gastrointestinal adverse events was a recurring feature of
post-licensure studies, they were not considered to be of clinical
significance. Follow up for detection of adverse events was reduced
from 4 weeks in the initial controlled trial, to 3 weeks in subsequent
studies. This was despite the fact that, in the original controlled
trial, possible adverse events were still evident in American children at 4
weeks. There was evidence beyond 1968, that the component viruses of
MMR could exert both dose- and strain-dependent interference upon the
clinical and immunological response of the host to the individual
constituent viruses. This effect, for which the influence of mumps
virus upon the measles virus component was particularly evident, merits
thorough investigation. Clearly, one plus one, plus one never did
equal three. There is more than a theoretical risk, supported by more
more recent studies, that interference with clearance of measles virus might
increase the risk of persistent infection and/or delayed disease. The
official argument that the mumps vaccine is less effect alone, but
potentiated by combination in MMR, is tacit admission of "interference".
Finally, two-dose MMR vaccine schedules appear to be unsatisfactorily tested
for safety."
Publication Types:
Sir--Contrary to supposition by
Masahiro Iizuka and colleagues (July 8, p 160),1
our data from molecular virological studies examining the role of
measles virus infection in children with autism and enterocolitis
have been peer-reviewed, presented, and published at four
international scientific meetings.2-4 We would have
been happy to share this information with Iizuka and colleagues if
asked. The antibody used in our studies is not that used by Iizuka
and colleagues. For the purpose of clarification, our studies
involved the use of in-situ hybridisation, in-cell reverse
transcriptase, real-time quantitative Taq Man PCR using
complementary RNA standards for quantitation and sequencing of
complementary DNA measles virus amplicon. In addition, three genes
N, F, and H of measles virus were examined. We have also provided
data in relation to sub-cellular localisation of measles virus,
concordant with the molecular biological findings.
*J J O'Leary, V Uhlmann, A J Wakefield
*Coombe Women's Hospital and Trinity College Dublin, Dublin
8, Ireland; and Royal Free and University College Medical School,
London, UK
1 Iizuka M, Itou H, Chiba M, et al. The MMR question. Lancet
2000; 356: 160.
Enterocolitis in children with developmental disorders.
Wakefield AJ, Anthony A, Murch SH, Thomson M, Montgomery SM, Davies S,
O'Leary JJ, Berelowitz M, Walker-Smith JA.
University Department of Medicine, Royal Free and University College Medical
School, London, United Kingdom.
OBJECTIVE: Intestinal pathology, i.e., ileocolonic lymphoid nodular
hyperplasia (LNH) and mucosal inflammation, has been described in children
with developmental disorders. This study describes some of the endoscopic
and pathological characteristics in a group of children with developmental
disorders (affected children) that are associated with behavioral regression
and bowel symptoms, and compares them with pediatric controls. METHODS:
Ileocolonoscopy and biopsy were performed on 60 affected children (median
age 6 yr, range 3-16; 53 male). Developmental diagnoses were autism (50
patients), Asperger's syndrome (five), disintegrative disorder (two),
attention deficit hyperactivity disorder (ADHD) (one), schizophrenia (one),
and dyslexia (one). Severity of ileal LNH was graded (0-3) in both affected
children and 37 developmentally normal controls (median age 11 yr, range
2-13 yr) who were investigated for possible inflammatory bowel disease (IBD).
Tissue sections were reviewed by three pathologists and scored on a standard
proforma. Data were compared with ileocolonic biopsies from 22
histologically normal children (controls) and 20 children with ulcerative
colitis (UC), scored in an identical manner. Gut pathogens were sought
routinely. RESULTS: Ileal LNH was present in 54 of 58 (93%) affected
children and in five of 35 (14.3%) controls (p < 0.001). Colonic LNH was
present in 18 of 60 (30%) affected children and in two of 37 (5.4%) controls
(p < 0.01). Histologically, reactive follicular hyperplasia was present in
46 of 52 (88.5%) ileal biopsies from affected children and in four of 14
(29%) with UC, but not in non-IBD controls (p < 0.01). Active ileitis was
present in four of 51 (8%) affected children but not in controls. Chronic
colitis was identified in 53 of 60 (88%) affected children compared with one
of 22 (4.5%) controls and in 20 of 20 (100%) with UC. Scores of frequency
and severity of inflammation were significantly greater in both affected
children and those with UC, compared with controls (p < 0.001). CONCLUSIONS:
A new variant of inflammatory bowel disease is present in this group of
children with developmental disorders.
Early determinants of inflammatory bowel disease: use of
two national longitudinal birth cohorts.
Thompson NP, Montgomery SM, Wadsworth ME, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London, UK.
OBJECTIVE: To examine previously cited early risk factors for inflammatory
bowel disease. DESIGN: The 1946 National Survey of Health & Development (NSHD)
and the 1958 National Child Development Study (NCDS) are on-going,
longitudinal birth cohort studies. A nested case-control design was used
combining data from both cohorts; eight controls per case, matched for
gender and social class, were selected randomly. METHODS: Data concerning
maternal infection in pregnancy (NCDS only), childhood infection (measles,
mumps and whooping cough), birth order, appendicectomy, breast-feeding and
measures of poor housing conditions in childhood were analysed. In both
cohorts, the member's hospital physician or medical records were used to
confirm the diagnosis. RESULTS: Twenty-six cases of Crohn's disease and 29
cases of ulcerative colitis were identified. No significant association was
found between the development of Crohn's disease or ulcerative colitis and
any of the studied factors. There was a trend that those with Crohn's
disease were more likely not to have been breast-fed (OR 0.4, 95% CI
0.15-1.03) and not to have had an appendicectomy (OR < 1.00). The opposite
was true of those with ulcerative colitis (OR 2.76, 95% CI 0.86-9.81 and OR
2.34, 95% CI 0.69-7.46, respectively). The prevalence of inflammatory bowel
disease was 5.12/1000 by the age of 43 years in NSHD and 2.02-2.54/1000 by
the age of 33 years in NCDS. CONCLUSIONS:
The prevalence of inflammatory bowel
disease in these cohorts is among the highest recorded in Europe. Childhood
factors may be different for those with Crohn's
disease and ulcerative colitis. These cohorts will be increasingly valuable
data sources.
Detection and sequencing of measles virus
from peripheral mononuclear cells from patients with inflammatory bowel
disease and autism.
Kawashima H, Mori T, Kashiwagi Y, Takekuma K, Hoshika A, Wakefield A.
Department of Paediatrics, Tokyo Medical University, Japan.
It has been reported that measles virus may be present in the intestine of
patients with Crohn's disease. Additionally, a new syndrome has been reported
in children with autism who exhibited developmental regression and
gastrointestinal symptoms (autistic enterocolitis), in some cases soon after
MMR vaccine. It is not known whether the virus, if confirmed to be present in
these patients, derives from either wild strains or vaccine strains. In order
to characterize the strains that may be present, we have carried out the
detection of measles genomic RNA in peripheral mononuclear cells (PBMC) in
eight patients with Crohn's disease, three patients with ulcerative colitis,
and nine children with autistic enterocolitis. As controls, we examined
healthy children and patients with SSPE, SLE, HIV-1 (a total of eight cases).
RNA was purified from PBMC by Ficoll-paque, followed by reverse transcription
using AMV; cDNAs were subjected to nested PCR for detection of specific
regions of the hemagglutinin (H) and fusion (F) gene regions. Positive samples
were sequenced directly, in nucleotides 8393-8676 (H region) or 5325-5465
(from noncoding F to coding F region). One of eight patients with Crohn
disease, one of three patients with ulcerative colitis, and three of nine
children with autism, were positive. Controls were all negative. The sequences
obtained from the patients with Crohn's disease shared the characteristics
with wild-strain virus. The sequences
obtained from the patients with ulcerative colitis and children with autism
were consistent with being vaccine strains. The results were concordant
with the exposure history of the patients. Persistence of measles virus was
confirmed in PBMC in some patients with chronic intestinal inflammation.
Autism, viral infection and measles-mumps-rubella
vaccination.
Wakefield AJ, Montgomery SM.
Department of Medicine, Royal Free and University College Medical School,
London, UK. awakefield@rfc.ucl.ac.uk
From the article: "Does any
of this evidence implicate MMR vaccination as a potential risk for either
inflammatory bowel disease, autism, or other immune-mediated diseases?
We believe that it is both biologically plausible and consistent with
temporal trends. The virological and immunological evidence is
supportive. It is therefore legitimate to hypothesize that the
combination of three viruses that have been associated both independently
and in combination with autism, may represent - through mechanisms that are
not yet fully understood - a compound risk for the disorder. Clearly,
although the case is not proven, MMR vaccination is a candidate worthy of
investigation."
From the letter: "Taylor
et al tested the hypothesis that there should be no temporal clustering of
first parenteral concerns with measles, mumps, and rubella (MMR)
vaccination. They identified a statistically significant excess risk
by 6 months after MMR, which they dismiss, post hoc, as indicating parental
recall bias. Had this been the case it should have been seen in both
of their vaccine groups - those receiving MMR and those receiving any
measles-containing vaccine. The excess risk was seen only in the MMR
group; this is a fundamental flaw.
However, it pales into
insignificance compared with their failure to declare the fact of an MMR
catch-up campaign that was initiated in 1988 with the introduction of this
vaccine. This campaign was targeted at children, whatever their age,
who presumably had not received either monovalent
mumps or rubella vaccine whatever their exposure status. As such it
was a a novel and, in terms of safety, untested policy. On the basis
of Taylor and colleagues'' inclusion criteria, and taking account of the
catch-up campaign, then those first birth cohorts who actually received MMR
(circa 1986) were precisely those in whom a doubling of the seen numbers of
cases of autism were seen. Thereafter these numbers continue to
increase strikingly. Omission of this essential fact - the catch-up campaign
- requires explanation lest it be misconstrued."
Asian ethnic origin and the risk of inflammatory bowel
disease.
Montgomery SM, Morris DL, Pounder RE, Wakefield AJ.
Department of Medicine, Royal Free & University College Medical School,
London, UK.
OBJECTIVE: To assess whether inflammatory bowel disease (IBD) is more
prevalent in young Asians than Europeans living in Great Britain. DESIGN:
Longitudinal birth cohort study of all those born 5-11 April 1970 in Great
Britain--the 1970 British Cohort Study (BCS70). METHODS: The relationship of
a diagnosis of ulcerative colitis or Crohn's disease by age 26 years with
ethnic origin was investigated among 8,432 cohort members with complete data
using multiple logistic regression. We adjusted for potential confounding
factors, household crowding and sex, as well as for a family history of IBD.
RESULTS: Young Asians born in Britain were significantly more likely than
indigenous Europeans to have a diagnosis of IBD by age 26 years, with
relative odds of 6.10 (95% CI 2.14-17.33). This group of cohort members had
ethnic origins in India, Pakistan or Bangladesh (although none of those from
Bangladesh had IBD). This relationship remained statistically significant
after adjustment for the potential confounding factors and family history of
IBD. CONCLUSION: Young Asians who were born in Britain are at a
significantly higher risk of developing IBD than the indigenous European
population. This may reflect a
greater genetic predisposition to IBD
that is uncovered by exposure to environmental factors.
Department of Medicine, Royal Free Hospital, Hampstead, London, UK. Wakersa@aol.com
Crohn's
disease has the epidemiological and pathological hallmarks of an infection
with a long natural history. Its emergence in developed countries in the
middle of the 20th Century represents an instant in the continuum of human
evolution, indicating either a new infection or, as with poliomyelitis, a
changing pattern of exposure to a common childhood pathogen. Both short- and
long-term outcomes from viral infection are largely dependent upon age and
dose of exposure. We and others have suggested that measles virus may be
causally related to Crohn's
disease, and that the associated risk is an atypical pattern of exposure.
Early, intensive, and concurrent infections have been identified as risks
for subacutesclerosingpanencephalitis,
a delayed sequelae
to measles virus infection, possibly through a process of high zone
immunological tolerance and persistent infection. The data for Crohn's
disease suggest that persistent infection may follow early low dose exposure
and low zone immunological tolerance. The changing pattern of measles virus
exposure this century would be consistent with a shift towards lower dose of
infection. Such an exposure would also be consistent with persistence of the
virus at very low copy number within discrete foci of granulomatous
inflammation. The ability of measles virus to profoundly disrupt mucosal
immune responses may provide the human counterpart of the cytokine-gene
knockout.
Paramyxovirus infections in childhood and subsequent
inflammatory bowel disease.
Montgomery SM, Morris DL, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, Department of Medicine, Royal Free
and University College Medical School, London, England. smm@rfhsm.ac.uk
BACKGROUND & AIMS: Measles virus has
been implicated in the etiology of both inflammatory bowel diseases (IBDs),
Crohn's
disease and ulcerative colitis. Subacutesclerosingpanencephalitis
(SSPE)
is caused by atypical measles infection. This study investigated the
patterns of infection that are risks for SSPE,
early infection and a close temporal relationship between measles and
another infection, as potential risks for IBD.
METHODS: The data are from 7019 members of a nationally representative 1970
British Cohort Study. The ages of five childhood infections were recorded
before onset of IBD symptoms. Diagnoses of IBD and insulin-dependent
diabetes mellitus (IDDM), as a control disease, were identified by age 26
years. RESULTS: Mumps infection before age 2 years was a risk for ulcerative
colitis (odds ratio, 25.12; 95% confidence interval, 6. 35-99.36). Measles
and mumps infections in the same year of life were significantly associated
with ulcerative colitis and Crohn's disease, with odds ratios of 7.47
(2.42-23.06) and 4.27 (1.24-14.46), but not with IDDM. These relationships
are independent of each other as well as sex, social class at birth,
household crowding in childhood, and family history of IBD. CONCLUSIONS:
Atypical paramyxovirus
infections in childhood may be risk factors for later IBD.
Gastrointestinal abnormalities in children
with autistic disorder.
Horvath K, Papadimitriou JC, Rabsztyn A, Drachenberg C, Tildon JT.
Department of Pediatrics, University of Maryland School of Medicine,
Baltimore, USA.
OBJECTIVES: Our aim was to evaluate the structure and function of the upper
gastrointestinal tract in a group of patients with autism who had
gastrointestinal symptoms. STUDY DESIGN: Thirty-six children (age: 5.7 +/- 2
years, mean +/- SD) with autistic disorder underwent upper gastrointestinal
endoscopy with biopsies, intestinal and pancreatic enzyme analyses, and
bacterial and fungal cultures. The most frequent gastrointestinal complaints
were chronic diarrhea, gaseousness, and abdominal discomfort and distension.
RESULTS: Histologic examination in these 36 children revealed grade I or II
reflux esophagitis in 25 (69.4%), chronic gastritis in 15, and chronic
duodenitis in 24. The number of Paneth's cells in the duodenal crypts was
significantly elevated in autistic children compared with non-autistic control
subjects. Low intestinal carbohydrate digestive enzyme activity was reported
in 21 children (58.3%), although there was no abnormality found in pancreatic
function. Seventy-five percent of the autistic children (27/36) had an
increased pancreatico-biliary fluid output after intravenous secretin
administration. Nineteen of the 21 patients with diarrhea had significantly
higher fluid output than those without diarrhea. CONCLUSIONS:
Unrecognized gastrointestinal disorders,
especially reflux esophagitis and disaccharide malabsorption, may contribute
to the behavioral problems of the non-verbal autistic patients. The
observed increase in pancreatico-biliary secretion after secretin infusion
suggests an upregulation of secretin receptors in the pancreas and liver.
Further studies are required to determine the possible association between the
brain and gastrointestinal dysfunctions in children with autistic disorder.
Serological association of measles virus and human
herpesvirus-6 with brain autoantibodies in autism.
Singh VK, Lin SX, Yang VC.
College of Pharmacy, University of Michigan, Ann Arbor, Michigan,
48109-1065, USA.
Considering an autoimmunity and autism connection, brain autoantibodies to
myelin basic protein (anti-MBP) and neuron-axon filament protein (anti-NAFP)
have been found in autistic children. In this current study, we examined
associations between virus serology and autoantibody by simultaneous
analysis of measles virus antibody (measles-IgG), human herpesvirus-6
antibody (HHV-6-IgG), anti-MBP, and anti-NAFP. We found that measles-IgG and
HHV-6-IgG titers were moderately higher in autistic children but they did
not significantly differ from normal controls. Moreover, we found that a
vast majority of virus serology-positive autistic sera was also positive for
brain autoantibody: (i) 90% of measles-IgG-positive autistic sera was also
positive for anti-MBP; (ii) 73% of measles-IgG-positive autistic sera was
also positive for anti-NAFP; (iii) 84% of HHV-6-IgG-positive autistic sera
was also positive for anti-MBP; and (iv) 72% of HHV-6-IgG-positive autistic
sera was also positive for anti-NAFP. This study is the first to report an
association between virus serology and brain autoantibody in autism; it
supports the hypothesis that a virus-induced autoimmune response may play a
causal role in autism. Copyright 1998 Academic Press.
Absence of Escherichia coli, Listeria monocytogenes, and
Klebsiella pneumoniae antigens within inflammatory bowel disease tissues.
Walmsley RS, Anthony A, Sim R, Pounder RE, Wakefield AJ.
Department of Medicine, Royal Free Hospital School of Medicine, London, UK.
BACKGROUND: Escherichia coli, listeria, and streptococcal antigens have been
found in Crohn's disease tissues. Antibodies to Klebsiella pneumoniae have
been found in patients with inflammatory bowel disease and ankylosing
spondylitis. The presence of these bacterial antigens in Crohn's granulomas
would be of aetiological interest, while their presence in ulcers alone
would be more likely to indicate secondary infection. AIM: To investigate
inflammatory bowel disease tissues for the presence of these bacteria.
METHODS: Formalin fixed, paraffin processed sections from 53 patients (19
ulcerative colitis, 23 Crohn's disease; 11 normal tissues from cancer
resections) were studied by immunohistochemistry. Control tissue consisted
of normal human small bowel injected submucosally with either E coli,
Listeria monocytogenes, Proteus mirabilis, or Klebsiella pneumoniae
serotypes K2, 3, 17, 21, 26, 36, and 50, and colonic biopsies from a child
with E coli 0114 infection. Tissues were stained by Gram-Twort, and with
specific antibodies for E coli (Dako B357), L monocytogenes (Difco 2302-50),
and K pneumoniae (Biogenesis 5580-5208) using an immunoperoxidase technique.
RESULTS: Positive staining for E coli was observed on the luminal surface
epithelium and in ulcers in 35% of Crohn's disease patients, 26% of
ulcerative colitis patients, and no normal controls. Superficial staining
for L monocytogenes was observed in one case of ulcerative colitis only.
Staining for K pneumoniae was observed in one case of ulcerative colitis and
one of Crohn's disease. No granulomas, giant cells, or germinal centres
stained positively for any of the three bacterial antigens. CONCLUSIONS:
These data do not support a primary role for E coli, L monocytogenes, and K
pneumoniae in inflammatory bowel disease. The presence of E coli antigens in
ulcers suggests secondary infection in these lesions.
Measles IgM immunoreactivity in patients with
inflammatory bowel disease.
Balzola FA, Khan K, Pera A, Bonino F, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London, United Kingdom.
AIM: The purpose of our study was to examine measles IgM immunoreactivity in
patients with inflammatory bowel disease. PATIENTS AND METHODS: In an
International collaborative study, serum measles IgM immunoreactivity was
assayed in consecutive outpatients with Crohn's disease (n = 95), ulcerative
colitis (n = 79), viral hepatitis (n = 63) and blood donors (n = 30). Two
commercial measles assays--enzyme linked immunosorbent assay and indirect
fluorescence assay--and a Public Health Laboratory Service (PHLS) "in house"
antibody capture radioimmunoassay were used. Results were compared with
serum rubella and Epstein-Barr virus-specific IgM immunoreactivity, total
serum IgM, and measles IgG immunoreactivity. Twenty patients with
inflammatory bowel disease were studied serially over a 4-month period.
RESULTS: By enzyme linked immunosorbent assay, the prevalence of raised
serum measles IgM immunoreactivity was significantly greater in patients
with Crohn's disease 23/95 (24%) and ulcerative colitis 20/79 (27%) compared
with hepatitis patients 2/63 (3%) and normal controls 0/30 (0%) (p < 0.001).
Indirect fluorescence assay produced significantly more positive results
than enzyme linked immunosorbent assay in both Crohn's disease (50/87; 57%)
and ulcerative colitis (35/68; 51%) but not in controls (0%) (p < 0.001). In
contrast, no sera were positive using MCRIA. In the enzyme linked
immunosorbent assay, measles IgM immunoreactivity did not correlate with
either total IgM, rubella or Epstein-Barr virus IgM immunoreactivities-which
were not raised-measles IgM immunoreactivity, or disease activity. Patients
not receiving steroids were more likely to have raised measles IgM
immunoreactivity (p < 0.5). All sera tested for Rheumatoid factor were
negative. Of 20 patients with inflammatory bowel disease studied by ELISA
over a 4-month period, 50% showed raised measles IgM immunoreactivity at
some stage. CONCLUSION: The data
suggest a specific and fluctuating immune response to measles virus in
patients with Crohn's
disease and ulcerative colitis, that may be modified by
corticosteroid therapy.
Measles virus RNA is not detected in inflammatory bowel
disease using hybrid capture and reverse transcription followed by the
polymerase chain reaction.
Chadwick N, Bruce IJ, Schepelmann S, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, Royal Free Hospital, London,
England, United Kingdom.
Recent epidemiological and immunohistochemical studies have indicated a
possible link between measles virus and inflammatory bowel disease (IBD).
The aim of this study was to use a sensitive and robust method for the
detection of measles virus RNA in IBD and control clinical samples.
Peripheral blood mononuclear cells and intestinal resection tissue from IBD
and control patients were studied. Two methods were used to determine the
presence of measles virus RNA: hybrid capture, using measles virus-specific
oligonucleotides linked to paramagnetic solid-phase supports, was carried
out on total cellular RNA to enrich for measles virus RNA sequences. Reverse
transcription followed by the polymerase chain reaction (RT-PCR) using rTth
DNA polymerase was employed for amplification of measles virus N-gene
sequences amongst the enriched species. Total RNA was also used for RT-PCR
of a housekeeping mRNA species to assess RNA quality. RT-PCR for another
region of the measles genome (the haemagglutinin (H) gene) was also
undertaken in order to confirm the results obtained using N-gene primers for
analysis of these samples. None of the samples were positive for measles N-
or H-gene RNA using RT-PCR. Positive control samples confirmed the
sensitivity of the methods employed.
These results show that either measles virus RNA was not present in the
samples, or was present below the sensitivity limits known to have been
achieved.
Ileal-lymphoid-nodular hyperplasia, non-specific colitis,
and pervasive developmental disorder in children.
Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M,
Berelowitz M, Dhillon AP, Thomson MA, Harvey P, Valentine A, Davies SE,
Walker-Smith JA.
Inflammatory Bowel Disease Study Group, University Department of Medicine,
Royal Free Hospital and School of Medicine, London, UK.
BACKGROUND: We investigated a consecutive series of children with chronic
enterocolitis and regressive developmental disorder. METHODS: 12 children
(mean age 6 years [range 3-10], 11 boys) were referred to a paediatric
gastroenterology unit with a history of normal development followed by loss
of acquired skills, including language, together with diarrhoea and
abdominal pain. Children underwent gastroenterological, neurological, and
developmental assessment and review of developmental records.
Ileocolonoscopy and biopsy sampling, magnetic-resonance imaging (MRI),
electroencephalography (EEG), and lumbar puncture were done under sedation.
Barium follow-through radiography was done where possible. Biochemical,
haematological, and immunological profiles were examined. FINDINGS: Onset of
behavioural symptoms was associated, by the parents, with measles, mumps,
and rubella vaccination in eight of the 12 children, with measles infection
in one child, and otitis media in another. All 12 children had intestinal
abnormalities, ranging from lymphoid nodular hyperplasia to aphthoid
ulceration. Histology showed patchy chronic inflammation in the colon in 11
children and reactive ileal lymphoid hyperplasia in seven, but no granulomas.
Behavioural disorders included autism (nine), disintegrative psychosis
(one), and possible postviral or vaccinal encephalitis (two). There were no
focal neurological abnormalities and MRI and EEG tests were normal. Abnormal
laboratory results were significantly raised urinary methylmalonic acid
compared with age-matched controls (p=0.003), low haemoglobin in four
children, and a low serum IgA in four children. INTERPRETATION:
We identified associated
gastrointestinal disease and developmental regression in a group of
previously normal children, which was generally associated in time with
possible environmental triggers.
Department of Pediatrics, University of Maryland School of Medicine, Maryland,
USA.
We report three children with autistic
spectrum disorders who underwent upper gastrointestinal endoscopy and
intravenous administration of secretin to stimulate pancreaticobiliary
secretion. All three had an increased pancreaticobiliary secretory response
when compared with nonautistic patients (7.5 to 10 mL/min versus 1 to 2 mL/min).
Within 5 weeks of the secretin infusion, a
significant amelioration of the children's gastrointestinal symptoms was
observed, as was a dramatic improvement in their behavior, manifested
by improved eye contact, alertness, and expansion of expressive language.
These clinical observations suggest an
association between gastrointestinal and brain function in patients with
autistic behavior.
Measles vaccination and inflammatory bowel disease.
Montgomery SM, Morris DL, Pounder RE, Wakefield AJ.
Sir--Mark
Feeney and colleagues (Sept 13, p 764)1 are to be commended
on their efforts to investigate a possible link between measles vaccine
and inflammatory bowel disease (IBD). However, as they themselves
acknowledge, the potential difficulty of poor ascertainment of vaccination
status could blur any relation between vaccination and the risk of IBD.
Thompson and co-workers,2 who used the Royal College of General
Practitioners (RCGP) database covering a nationally representative 1% of
the UK population, found that, at a time when national vaccine uptake
rates exceeded 55%, general practitioners recorded having given measles
vaccine in only 8% of patients in the appropriate age-group. According to
the RCGP, recording was only improved when general practitioners were
remunerated for achieving vaccination targets. On the basis of Thompson's
study,2 ascertainment of vaccination status from
general-practitioner records covering the relevant period1
could have underestimated measles vaccination rates by as much as 47%
among either cases or controls. Absence of a record of measles vaccination
cannot be taken as absence of vaccination.
Poor ascertainment of measles vaccination status is likely to reduce
the statistical significance of any relation between vaccination and
subsequent disease, so that a small systematic bias is more likely to
obliterate any such relation. There is a risk that by replacing controls,
but not patients with IBD who had inadequate vaccination records,
systematic bias may have been introduced into this study. Feeney and
colleagues have attempted to address the issue of unobserved heterogeneity
by looking at the uptake rates for vaccination against pertussis and
diphtheria/tetanus. Although examination of vaccinations other than
against measles provides more evidence about reliability of these data, it
cannot provide conclusive evidence of homogeneity among cases and
controls. The significantly higher uptake rates for pertussis and
diphtheria/tetanus indicate that there could be a less significant
relation between socioeconomic circumstances and vaccine uptake when
compared with vaccination against measles. When this is coupled with the
uncertainty of vaccination records, it renders them inadequate as
indicators of childhood circumstances and characteristics. It is important
that trials such as this are conducted and reported, but they cannot be a
substitute for adequate safety trials of procedure that might cause severe
iatrogenic damage, even if only in a few cases.
*Scott M Montgomery, D L Morris, R E Pounder, A J Wakefield
University Department of Medicine, Royal Free Hospital School of
Medicine, University of London, London NW3 2PF, UK
1
Feeney M, Clegg A, Winwood P, Snook J. A case control study of measles
vaccination and inflammatory bowel disease. Lancet 1997; 350: 76466. [Text]
2 Thompson NP, Flemming DM,Pounder RE, Wakefield AJ. Crohn's disease,
measles, and measles vaccination: a case control failure. Lancet
1996; 347: 263.
Detection and comparative analysis of persistent measles
virus infection in Crohn's disease by immunogold electron microscopy.
Daszak P, Purcell M, Lewin J, Dhillon AP, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, School of Life Sciences, Kingston
University, Kingston-on-Thames, Surrey, United Kingdom.
AIMS: To determine the specificity of persistent measles virus infection in
intestinal samples from Crohn's disease patients using quantitative
immunogold electron microscopy. To compare the results with samples from
ulcerative colitis, a granulomatous inflammatory control (tuberculous
lymphadenitis), and a positive control. METHODS: Formalin fixed, paraffin
embedded intestinal tissue from patients with Crohn's disease was
reprocessed and stained with antimeasles nucleocaspid protein primary
antibody followed by 10 nm gold conjugated secondary antibody. Tissue
samples were taken from granulomatous and non-granulomatous areas of the
intestine. Intestinal samples from patients with ulcerative colitis,
tuberculous lymphadenitis, or acute mesenteric ischaemia were similarly
processed. Brain tissue from a patient with subacute sclerosing
panencephalitis (SSPE) was used as the positive control. Duplicate sections
of all tissues were processed without the primary antibody. Stained
specimens were examined by electron microscopy. RESULTS: In Crohn's disease
patients, 8/9 foci of granulomatous inflammation and 0/4 foci of
non-specific inflammation were positive for measles virus. Of controls, 0/5
non-inflamed intestinal tissues, 1/8 tuberculous tissues, 1/5 ulcerative
colitis tissues, and 1/1 SSPE tissues were positive. Gold grain counts per
nuclear field-of-view in both Crohn's disease granulomas (43.29) and SSPE
(36.94) were significantly higher than in tissues from patients with
ulcerative colitis (13.52) or tuberculous lymphadenitis (15.875), and
nongranulomatous areas of Crohn's disease (4.89) (p < 0.001, p < 0.001, p =
0.0006, respectively), with no significant difference between Crohn's
disease and SSPE (p > 0.1). In both SSPE and Crohn's disease staining was
confined to a small population of cells exhibiting characteristic
cytopathology. CONCLUSION: These
data support a role for measles virus in the aetiology
of Crohn's
disease.
In situ immune responses in Crohn's disease: a comparison
with acute and persistent measles virus infection.
Wakefield AJ, Sim R, Akbar AN, Pounder RE, Dhillon AP.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London, United Kingdom.
The implied aetiological association of measles virus with Crohn's disease
would be supported by detection of an immune response to infected cells in
affected tissues. This study sought to detect and characterise in situ
immune responses to measles virus in both acutely and persistently infected
tissues, and in particular, Crohn's granulomata. Tissue sections from
patients with Crohn's disease (n = 17), tuberculosis (n = 9), acute
intestinal ischaemia (n = 5), acute measles pneumonitis (n = 2), acute
measles appendicitis (n = 1), subacute sclerosing panencephalitis (SSPE; n =
1), and measles inclusion body encephalitis (MIBE; n = 1), were examined.
Single and double immunohistochemical labelling was performed to identify
both cytotoxic lymphocytes (CD8, TIA, perforin, Leu 7, CD45RO, CD45RA) and
macrophages (KP1). The relationship of these cells to measles infected cells
was examined by double immunolabelling with antimeasles virus nucleoprotein
antibody. In both acute measles appendicitis and SSPE, CD8+/TIA cytotoxic
lymphocytes (CTL) targeted infected cells. In the cases of Crohn's disease
(13/17), MIBE, fatal pneumonitis, and one tuberculous granuloma, that were
positive for measles virus, infected cells appeared to be targeted by
macrophages rather than CTL. CTL in both tuberculous and Crohn's granulomata
were similar in their peripheral distribution, number, and phenotype. The
data suggest that measles-specific CTL responses may be attenuated in
Crohn's disease compared with acute measles appendicitis and SSPE, and
secondly, that an abnormal macrophage response to persistent measles virus
infection of the intestine may result in granulomatous inflammation.
Antibody responses to gut bacteria in ankylosing
spondylitis, rheumatoid arthritis, Crohn's disease and ulcerative colitis.
Tiwana H, Wilson C, Walmsley RS, Wakefield AJ, Smith MS, Cox NL, Hudson
MJ, Ebringer A.
Division of Life Sciences, King's College, London, UK.
Specific immunoreactive anti-Klebsiella antibodies are found in patients
with ankylosing spondylitis (AS), a significant proportion of whom have
occult inflammatory bowel disease. Molecular mimicry between Klebsiella or
other bacterial antigens and HLA-B27 has been suggested in the pathogenesis
of AS. The specificity of increased immunoreactivity against Klebsiella
remains to be assessed against the abundant anaerobic bacterial flora,
present either in healthy controls or in patients with ulcerative colitis (UC)
and Crohn's disease (CD). Total immunoglobulin (Ig; IgG, IgA, IgM)
immunoreactivity was measured by ELISA against Klebsiella pneumoniae,
Proteus mirabilis, Escherichia coli and ten anaerobic isolates of the
predominant normal bowel flora in 35 patients with active AS, 60 patients
with inflammatory bowel disease (30 CD, 30 UC), 60 patients with active
rheumatoid arthritis (RA) and 60 healthy controls. Ig immunoreactivity to K.
pneumoniae was significantly elevated in AS (P < 0.001), CD (P < 0.001) and
UC (P < 0.001) patients compared with RA patients and healthy controls.
Furthermore, Ig immunoreactivity to P. mirabilis was significantly elevated
only in RA patients, compared with the other inflammatory groups (P < 0.001)
and controls (P < 0.001). There was no significant antibody response against
E. coli or the ten obligate anaerobes in any of the test groups. The data
suggested an increased immune response to Klebsiella in patients with AS, UC,
CD and to Proteus in patients with RA. The specificity of these responses in
some patients supported a possible role for enteric Klebsiella in the
pathogenesis of AS and Proteus in RA. The role of Klebsiella in inflammatory
bowel disease requires further study.
Crohn's disease after in-utero measles virus exposure.
Ekbom A, Daszak P, Kraaz W, Wakefield AJ.
Department of Cancer Epidemiology, University Hospital, Uppsala, Sweden.
BACKGROUND: An epidemiological association between Crohn's disease and
measles virus exposure in early life has been suggested in case-control
studies. METHODS: To determine absolute risk estimates for in-utero measles
virus exposure and Crohn's disease, maternity charts for all 25000
deliveries at University Hospital, Uppsala, between 1940-49 were reviewed:
four cases of measles infection in the mother during pregnancy were
identified. The children and two of their mothers were interviewed and case
records reviewed. Three offspring had undergone multiple intestinal
resections; tissue from these cases were examined by routine histology, and
for measles-virus nucleoprotein antigen by immunohistochemistry and
immunogold electronmicroscopy. FINDINGS: Three of the four children had
Crohn's disease. In each the disease was preceded by recurrent,
antibiotic-resistant pneumonia. They had extensive ileal and colonic
disease; two patients required intravenous feeding. The only offspring to
have had measles as a child did not develop Crohn's disease. Measles virus
antigen was detected in foci of granulomatous and lymphocytic inflammation
in all children with Crohn's disease. INTERPRETATION:
The data indicate that exposure of mothers to measles virus in utero
is a risk factor for Crohn's
disease in their children. Exposure at this time may lead to persistent
infection, or modify the response to infection in later life, leading to
persistence of measles virus.
Direct in situ reverse transcriptase polymerase chain
reaction for detection of measles virus.
Ray R, Cooper PJ, Sim R, Chadwick N, Earle P, Dhillon AP, Pounder RE,
Wakefield AJ.
Department of Medicine, Royal Free Hospital School of Medicine, Hampstead,
London, UK.
New methods are described for combined intracellular reverse transcription (RT)
and polymerase chain reaction (PCR) using single primer pairs, with direct
incorporation of digoxigenin-11-dUTP into amplificants (direct in situ RT/PCR).
Routinely used fixatives and minimal pre-treatments were employed. Target
sequences of measles virus nucleocapsid (N) and phosphoprotein genes were
detected within measles virus infected Vero cells, both in suspension and in
formalin-fixed sections, that had been treated by in situ reverse
transcription and 30 cycles of direct in situ PCR. Uninfected cells,
omission of Taq polymerase, and irrelevant primers were used as controls.
Distribution of measles virus within infected cells was determined by in
situ hybridisation and immunocytochemistry for measles virus N gene and
protein, respectively. Confirmation of amplification within sections was by
gel electrophoresis, Southern blotting and sequencing of extracted amplicons.
In the majority of cases, measles-infected cells exhibited intense
cytoplasmic signal after direct in situ PCR; this was not seen in uninfected
cells or infected cells reacted either with irrelevant primers or without
Taq polymerase. Unfixed cells in suspension required nested reaction.
Measles-specific in situ hybridisation and immunocytochemistry gave an
identical signal distribution in sections. Nuclear artifact occurred in some
sections and was unpredictable, although it was greatest either in areas of
cellular damage, following DNase predigestion, or with vigorous protease
pre-treatment. In situ RT-PCR is feasible for measles virus in acutely
infected cells both in sections and in suspension. Further work is required
to improve the procedure and to eliminate artefactual nuclear signal.
Genetics versus environment in inflammatory bowel
disease: results of a British twin study.
Thompson NP, Driscoll R, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London.
From the article: " In summary,
identical twins are significantly more likely to be concordant for
inflammatory bowel disease than non-identical twins. Nevertheless,
even in identical twins the concordance was only 17%, which suggests that
non-genetic -- that is, environmental -- causes are more important in the
development of Crohn's
disease and ulcerative colitis."
Abnormal intestinal permeability in
children with autism.
D'Eufemia P, Celli M, Finocchiaro R, Pacifico L, Viozzi L, Zaccagnini M,
Cardi E, Giardini O.
Institute of Pediatrics, La Sapienza University of Rome, Italy.
We determined the occurrence of gut mucosal damage using the intestinal
permeability test in 21 autistic children who had no clinical and laboratory
findings consistent with known intestinal disorders. An altered intestinal
permeability was found in 9 of the 21 (43%) autistic patients, but in none of
the 40 controls. Compared to the controls, these nine patients showed a
similar mean mannitol recovery, but a significantly higher mean lactulose
recovery (1.64% +/- 1.43 vs 0.38% +/- 0.14; P < 0.001).
We speculate that an altered intestinal
permeability could represent a possible mechanism for the increased passage
through the gut mucosa of peptides derived from foods with subsequent
behavioural abnormalities.
Perinatal and childhood risk factors for inflammatory
bowel disease: a case-control study.
Thompson NP, Pounder RE, Wakefield AJ.
Department of Medicine, Royal Free Hospital School of Medicine, London, UK.
OBJECTIVE: To determine whether exposure to a measles epidemic in utero or
in infancy is a risk factor for the development of Crohn's disease, and to
determine whether such an association can be found in individuals with
subacute sclerosing panencephalitis (SSPE), a condition in which early
infection with measles is known to be of aetiological importance. METHODS: A
postal questionnaire was sent to 16,875 members of two national inflammatory
bowel disease patient support groups. A control group was composed of
friends or neighbours. Birth data were compared with the dates of measles
epidemics and six possible periods of susceptibility were examined. Birth
data from a national register of patients with SSPE were analysed similarly.
Previously identified risk factors were also examined. RESULTS: The answers
from 2522 members and 2379 controls were analysed. We found no evidence of
an association between the development of Crohn's disease and exposure to a
measles epidemic. The birth dates of both groups were distributed normally
throughout the year. No other early risk factor for the development of
inflammatory bowel disease was detected. Exposure to a measles epidemic
before the age of 1 year did not emerge as a risk factor for SSPE.
CONCLUSION: These data contradict
reports from a recent study in central Sweden, but relatively early exposure
to measles in childhood may still be a risk factor for the development of
Crohn's
disease.
Is measles vaccination a risk factor for inflammatory
bowel disease?
Thompson NP, Montgomery SM, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London, UK.
Measles virus may persist in intestinal tissue, particularly that affected
by Crohn's disease, and early exposure to measles may be a risk factor for
the development of Crohn's disease. Crohn's disease and ulcerative colitis
occur in the same families and may share a common aetiology. In view of the
rising incidence of inflammatory bowel disease (Crohn's disease and
ulcerative colitis), we examined the impact of measles vaccination upon
these conditions. Prevalences of Crohn's disease, ulcerative colitis,
coeliac disease, and peptic ulceration were determined in 3545 people who
had received live measles vaccine in 1964 as part of a measles vaccine
trial. A longitudinal birth cohort of 11,407 subjects was one unvaccinated
comparison cohort, and 2541 partners of those vaccinated was another.
Compared with the birth cohort, the relative risk of developing Crohn's
disease in the vaccinated group was 3.01 (95% CI 1.45-6.23) and of
developing ulcerative colitis was 2.53 (1.15-5.58). There was no significant
difference between these two groups in coeliac disease prevalence. Increased
prevalence of inflammatory bowel disease, but not coeliac disease or peptic
ulceration, was found in the vaccinated cohort compared with their partners.
These findings suggest that measles
virus may play a part in the development not only of Crohn's
disease but also of ulcerative colitis.
Persistent measles virus infection of the intestine:
confirmation by immunogold electron microscopy.
Lewin J, Dhillon AP, Sim R, Mazure G, Pounder RE, Wakefield AJ.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London.
This study sought to investigate persistent measles virus infection of the
intestine: a novel protocol for immunogold electron microscopy was developed
using a polyclonal anti-measles nucleoprotein antibody on reprocessed,
formalin fixed paraffin wax embedded tissue sections. Antibody binding was
detected using both immunoperoxidase and light microscopy on tissue
sections, and 10 nm gold conjugated secondary antibody and electron
microscopy on ultrathin sections. The techniques were validated using both
measles infected vero cells and human tissues with established measles
infection: these included brain affected by subacute sclerosing
panencephalitis and acute measles appendicitis. The technique was applied
subsequently to six untreated cases of granulomatous Crohn's disease, and
two cases of ileocaecal tuberculosis, a granulomatous control. Mumps primary
antibody--applied to both mumps infected vero cells, and measles infected
vero cells and tissues studied by immunoperoxidase, and measles antibody on
mumps infected cells studied by immunoperoxidase and immunogold--were used
as specificity controls: the primary antibodies identified their respective
target antigen and there was no antibody cross reactivity. Measles virus
nucleocapsids labelled with gold conjugated antibody in both infected cells
and tissues, including foci of granulomatous inflammation in five of six
cases of Crohn's disease: in the fifth case, the granuloma could not be
identified in ultrathin section. In one of the tuberculosis cases, a low
level of signal was noted while the second case was negative. Labelling
adopted a characteristic pattern in all infected tissues, strengthening the
specificity of these findings. This
study provides the first direct confirmation of persistent measles virus
infection of the intestine.
Crohn's disease: pathogenesis and persistent measles
virus infection.
Wakefield AJ, Ekbom A, Dhillon AP, Pittilo RM, Pounder RE.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London, England.
The Inflammatory Bowel Disease Study Group at the Royal Free Hospital School
of Medicine has tested the hypothesis that the primary pathological
abnormality in Crohn's disease is in the mesenteric blood supply. Early
morphological studies involved arterial perfusion-fixation and either resin
casting and scanning electron microscopy or vascular immunostaining of
resected intestine affected by Crohn's disease. Granulomatous and
lymphocytic damage to intramural blood vessels, even in macroscopically
normal areas, was observed. We put forward possible mechanisms by which a
chronic ischemic process might account for many of the idiosyncracies of
Crohn's disease. It was proposed that persistent viral infection of the
mesenteric microvascular endothelium might underly this vasculitic process;
based on certain behavioral characteristics of measles virus, including its
tropism for the submucosal endothelium of the intestine, this agent was
investigated further. This report reviews the preliminary evidence from both
epidemiological and basic scientific data for persistent measles virus in
the intestine of patients with Crohn's disease. Possible mechanisms for
virus persistence and subsequent reactivation are discussed. In conclusion,
we believe that Crohn's disease may be a chronic granulomatous vasculitis in
reaction to a persistent infection with measles virus within the vascular
endothelium. This granulomatous inflammation, perhaps aggravated by either a
hypercoagulable state or mechanical stress, results in the clinical features
of Crohn's disease.
Perinatal measles infection and subsequent Crohn's
disease.
Ekbom A, Wakefield AJ, Zack M, Adami HO.
Cancer Epidemiology Unit, University Hospital, Uppsala, Sweden.
Although the aetiology of Crohn's disease is unknown, morphological and
epidemiological studies have implicated measles virus as a potential
component cause, particularly when exposure occurs in utero or early in
life. An increased incidence of Crohn's disease among people born during
measles epidemics would support this hypothesis. We identified all
individuals born in four counties in central Sweden in 1945-54 who had had
Crohn's disease diagnosed before the age of 30 years. Yearly reports
compiled in these counties revealed that five measles epidemics had affected
all four counties during the trial period. After adjusting for monthly
differences in the number of livebirths in the four counties, we calculated
the expected number of patients with Crohn's disease and ulcerative colitis
born during the 3-month period after the peaks of the epidemics. The number
of people with Crohn's disease significantly exceeded that expected: 57
versus 39.0 (standardised incidence ratio 1.46, 95% CI 1.11-1.89). For
patients with ulcerative colitis, the observed number (42) was close to that
expected (46.8). Our results
strengthen the hypothesis that measles is related to Crohn's
disease and that the
perinatal period is a time of
vulnerability.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London, UK.
Crohn's disease is an inflammatory disorder of the gastrointestinal tract,
the cause of which remains unknown. Since the first description by Dalziel
in 1913 (1), similarities between Crohn's disease and intestinal
mycobacterial infection, particularly Johne's disease in ruminants, have
been widely recognized (2, 3). After Mitchell and Rees demonstrated the
transmission of granulomata from Crohn's disease by injecting intestinal
homogenates into the footpads of mice (4), there followed many studies
attempting to identify infective agents within the bowel of patients with
Crohn's disease. Although Mycobacterium paratuberculosis has been identified
in intestinal tissue from a proportion of patients with Crohn's disease, a
convincing role for this agent in the aetiology of Crohn's disease has not
been established (5). Likewise, extensive studies into bacterial (6-9) and
viral (10) agents potentially associated with Crohn's disease have been
inconclusive, although recent ultrastructural observations of viral
particles within submucosal granulomata have added a new impetus to the
search (11, 12). This review examines the evidence for an association
between Crohn's disease and viral infection from epidemiological studies,
transmission and cell culture, specific immunological responses,
ultrastructure and from molecular biological techniques.
Inflammatory Bowel Disease Study Group, Royal Free Hospital School of
Medicine, London, United Kingdom.
Transmission electron microscopy was used to examine the microvasculature of
perfusion-fixed tissues from Crohn's disease and control patients.
Paramyxovirus-like particles, and inclusions consisting of condensations of
nucleocapsid, in giant cells and endothelium at foci of vascular injury were
identified in all 9 Crohn's disease patients. Tissues from patients with
Crohn's disease were also examined by either in situ hybridisation (n = 10)
or immunohistochemistry (n = 15), and compared to inflammatory and
noninflammatory controls (n = 22). Hybridisation for measles virus N-protein
genomic RNA was positive in all cases of Crohn's disease localising to foci
of granulomatous vasculitis and lymphoid follicles. Positive
immunohistochemical staining for measles virus nucleocapsid protein was
positive in 13 of 15 patients with Crohn's disease, localising to foci of
granulomatous inflammation. Hybridisation for measles virus RNA was positive
in a minority of control intestinal tissues; viral inclusions were not seen
ultrastructurally. Immunostaining was negative in control cases of
intestinal tuberculosis. These
observations suggest that measles virus is capable of causing persistent
infection of the intestine and that Crohn's
disease may be caused by a
granulomatousvasculitis
in response to this virus.
Antibodies to myelin basic protein in children with
autistic behavior.
Singh VK, Warren RP, Odell JD, Warren WL, Cole P.
Biomedical Division, Center for Persons with Disabilities, Logan, Utah.
Based on a possible pathological relationship of autoimmunity to autism,
antibodies reactive with myelin basic protein (anti-MBP) were investigated
in the sera of autistic children. Using a screening serum dilution of 1:400
in the protein-immunoblotting technique, approximately 58% (19 of 33) sera
of autistic children (< or = 10 years of age) were found to be positive for
anti-MBP. This result in autistics was significantly (p < or = .0001)
different from the controls (8 of 88 or only 9% positive), which included
age-matched children with normal health, idiopathic mental retardation (MR)
and Down syndrome (DS), and normal adults of 20 to 40 years of age.
Since autism is a syndrome of
unknown etiology, it is possible that anti-MBP
antibodies are associated with the development of autistic behavior.
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MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
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COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.
"A foolish faith in authority is the worst enemy of truth."
-- Albert Einstein, letter to a friend, 1901
"I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education."
-- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820
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