Serum Neopterin Concentration in Children with Ulcerative Colitis

Plata-Nazar K. et al.: Neopterin in Children with Ulcerative Colitis 23

Pteridines Vol. 19, 2008, pp. 23 - 27

Katarzyna Plata-Nazar, Grazyna Luczak, Barbara Kaminska, Marta Bogotko-Szarszewska, Joanna Renke, Malgorzata Szumera

Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition Medical University of Gdansk, Poland

Abstract

To further evaluate the clinical usefulness of serum neopterin measurement as a parameter monitoring disease activity in children with ulcerative colitis, serum neopterin concentrations were evaluated using immunoenzyme assay (ELISA) in 48 patients suffering from ulcerative colitis with different disease activity. Statistically significant differences in serum neopterin concentration depending on disease activity (according to Truelove-Witts score) as well as statistically significant positive correlation between these variables were observed. We conclude that serum neopterin measurement can be clinically valuable as the parameter monitoring disease activity in children with ulcerative colitis.

Key words: neopterin, cellular immunity, ulcerative colitis, children Introduction ing alterations of neopterin concentrations contributed to better knowledge concerning etiopathogenesis of At the beginning of the eighties of the 20th century, this disease and immune system participation. pteridine derivative neopterin was described as bio- Similarly, usefulness of neopterin concentrations was chemical indicator of cell-mediated immune response assessed in monitoring disease activity in patients with (1). It was proved that activated T lymphocytes secrete diagnosed ulcerative colitis (11). γ-interferon stimulating monocytes/macrophages to The aim of the study is to evaluate clinical useful- release neopterin (2). Defining autoimmunization phe- ness of serum neopterin measurement as a parameter nomenon, we consider reactivity of cells that belong to monitoring disease activity in children with ulcerative adaptive immunity system (immunocompetent lym- colitis. phocytes T and B), directed against specific antigens of the organism. Participation of cell-mediated immunity Materials and Methods in autoimmune diseases permits to expect increased neopterin concentration in patient's systemic fluids. Forty eight patients suffering from ulcerative colitis Neopterin concentration was assessed in patients with with different disease severity entered the study. These rheumatoid arthritis (3, 4), systemic lupus erythemato- children were diagnosed and treated in the Chair and sus (5, 6), Wegener granuloma (7), polymyositis, and Department of Pediatrics, Pediatric Gastroenterology dermatomyositis (8). Considering above mentioned and Oncology, Medical University of Gdansk, during diseases, neopterin concentration increased in accor- the period from September 2004 to June 2005. In all dance with degree of disease progression. On the base the children the detailed history concerning the fre- of these observations, assessment of neopterin concen- quency of loose stools, blood in stools, and body tem- tration is described as sensitive parameter in disease perature was taken. Careful clinical examinations with clinical course monitoring, but authors greatly empha- Cole's index evaluation based on actual and normal for size shortage of test specificity. Analysis of neopterin age weight and height were conducted. Performed lab- concentration in systemic fluids also permits to moni- oratory tests included: tor activity of inflammatory bowel diseases (IBD), ·Whole blood count with white blood count - ana- including Crohn's disease (9, 10). Observations regard- lyzed by standard method

Correspondence to: Katarzyna Plata-Nazar MD, PhD, Chair and Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Medical University of Gdansk, Poland. Ul. Nowe Ogrody 1-6, 80-803 Gda sk, Poland, phone/fax ++48 58 302 25 91, [email protected] Pteridines/Vol. 19/No. 1 24 Plata-Nazar K. et al.: Neopterin in Children with Ulcerative Colitis

·Erythrocytes sedimentation rate (ESR) - analyzed Scientific Research of the Medical University of by standard method Gdansk was obtained to perform these studies ·Serum C-reactive protein concentration (CRP), (NKEBN/942/2004). established by immunoturbidimetric method with latex test ·Serum procalcitonin concentration (PCT), estab- Results lished by quantitative immunoluminometric method using commercial LIA PCT kit by BRAHMS Forty-eight patients suffering from ulcerative colitis Corporation, Hennigsdorf/Berlin, Germany formed a group including 16 (33%) girls and 32 (67%) ± ·Serum urea (by urease method with GLDH) and boys, at the age from 3.9 to 17.8 years (mean 13.5 4.0 creatinine concentration (by Jaffe's method) - estab- years, median 15.4 years). Urea and creatinine concen- lished to confirm the normal kidneys function trations were within the normal for age values in all the In the study group an extra 50 µl of blood was taken children. for determination of serum neopterin concentration. Serum neopterin concentration in the study group The blood samplings were carefully protected from was within the limits from 3.44 to 26.1 nmol/L (mean ± sunlight, then in less than 20 minutes after collection 8.76 5.57 nmol/L, median 6.89 nmol/L). In children they were centrifuged at 3,000 rpm for 10 minutes. The with ulcerative colitis statistically significant positive obtained serum was frozen at -20°C. Measurement of correlation was observed between serum neopterin = = serum neopterin concentration was performed using concentration and: body temperature (rs 0.33, p = immunoenzyme assay (ELISA) commercial kit by 0.02), erythrocyte sedimentation rate (rs 0.65, p BRAHMS Corporation, Hennigsdorf/Berlin, Germa- <0.001) (Figure 1), serum C-reactive proteine concen- = < ny, for quantitative measurement of serum neopterin tration (rs 0.59, p 0.001) (Figure 2), and leukocytes = = concentrations. This test uses technique of covered count (rs 0.44, p 0.002). There were no statistical- plates. ly significant correlation between serum neopterin In all the patients the diagnosis of the active stage of concentration and serum procalcitonin concentration = = ulcerative colitis was confirmed by endoscopic and (rs 0.24, p 0.10). histological changes. None of the children was treated Disease activity in children with ulcerative colitis with steroids, immunosuppressive or immunomodula- was assessed on the basis of commonly used Truelove- tory therapy during the 3 months before the study. Witts score modified by Polish authors (12). In 30 chil- The results of the study were analyzed statistically dren low activity, in 12 moderate, and in 6 severe using Statistica 7.0 (StatSoft, Inc., Tulsa, OK., USA). activity of the disease was evaluated. Serum neopterin The correlation of parameters was analyzed by concentration was statistically significantly higher in Spearmann test and differences among groups of children with severe than with moderate activity of the = unpaired data by distribution-free Mann-Whitney test. disease (p 0.01) and the concentration in patients A p-value of <0.05 was regarded as statistically signif- with moderate activity was also significantly higher icant. than in patients with mild activity of ulcerative colitis All tests were performed in children with written (p = 0.04) (Table 1). Statistically significant positive consent of their parents/legal tutors who were correlation between serum neopterin concentration and = informed about the aim and assumptions of the study. the activity of the disease were observed (rs 0.64; p < The consent of Independent Bioethical Committee for 0.001).

Table 1. Serum neopterin concentration in different disease activity (according to Truelove-Witts score) in children with ulcerative colitis

Disease Number Serum neopterin concentration (nmol/L) activity of children Mean Median Minimum Maximum S.D.

Mild 30 6.17 5.28 3.44 13.3 2.37 Moderate 12 9.83 9.07 6.34 15.4 3.13 Severe 6 19.63 20.7 6.12 26.1 7.25

Pteridines/Vol. 19/No. 1 Plata-Nazar K. et al.: Neopterin in Children with Ulcerative Colitis 25

14 NPT nmol/L NP T (nmol/L) T NP 12

2 0 102030405060708090100 E SR (mm /h) 95% confidence interval

Figure 1. Correlation between serum neopterin concentration and erythrocyte sedimentation rate (ESR)

14 PT( ol/L) l mo (n T NP NPT nmol/L 12

2 0 20 40 60 80 100 120 140 CRP (mg/L) 95% confidence interval

Figure 2. Correlation between serum neopterin and CRP concentrations

Studies included for example children suffering from Discussion celiac disease, in whom significantly higher neopterin concentrations were observed during active disease, Literature data indicate that multiple attempts were but gluten-free diet administration caused systematic undertaken to explore clinical usefulness of neopterin decrease of urine neopterin concentration (13). concentration measurement in autoimmune diseases Studies performed among children with juvenile (13-15). It is generally known that cell-mediated form of dermatomyositis (at the age of 4-17 years) immune response participates in etiopathogenesis of revealed that their urine neopterin concentration con- this group of diseases (16). It was noted that neopterin siderably correlates with disease activity, muscles concentration reflects activity and progression of function and allows to predict further course of the dis- autoimmune diseases (17). Above mentioned reports ease. Correlation between neopterin concentration and assessed neopterin concentration mainly in adults, but concentrations of the enzymes lactate dehydrogenase only in few cases they concern childhood diseases. (LDH) and aspartate aminotransferase (AST) was not

Pteridines/Vol. 19/No. 1 26 Plata-Nazar K. et al.: Neopterin in Children with Ulcerative Colitis found. LDH and AST are usually increased in patients such as: blood hemoglobin level, frequency of stools with juvenile form of dermatomyositis (18). per day, body temperature, erythrocyte sedimentation There are relatively few reports in world literature rate, the region of inflamed bowel. Correlation concerning clinical usefulness of neopterin concentra- between each of these parameters and clinical activity tion measurement in inflammatory bowel diseases. of the disease classified according to Truelove-Witts Studies were predominantly performed in adults (9, 10, score was assessed. The strongest correlation was 19) and only one case concerns children with Crohn's observed with the extent of inflamed bowel and only disease (20). Urine neopterin concentration was meas- little less strong correlation was noted for urine ured in majority of studies (9, 10, 21). There are only neopterin concentration. Erythrocyte sedimentation single reports about serum neopterin concentration in rate and frequency of stools per day correlated poorer IBD patients (7, 22, 23). No publication concerning with disease activity, but the weakest correlation was this subject was found in local literature. According to found for body temperature and blood hemoglobin known reports, increased neopterin concentration is level (11). observed in majority of patients with active form of In our study statistically significant positive correla- IBD (Crohn's disease, ulcerative colitis). Almost all tion between serum neopterin concentration and dis- authors greatly emphasize lack of specificity of this ease activity assessed according to Truelove-Witts marker besides noted positive correlations between score in children with ulcerative colitis was observed. neopterin concentration in systemic fluids and activity In conclusion, serum neopterin concentrations can of Crohn's disease or ulcerative colitis. Authors con- be clinically valuable as the parameter monitoring dis- sider that neopterin concentration monitoring is rec- ease activity in children with ulcerative colitis. ommended parallel to observations concerning number of other laboratory and clinical parameters (24). No significant difference in serum neopterin con- References centration between patients with inflammatory bowel diseases and the control group was found by Forrest et 1 Hausen A, Bichler A, Fuchs D, Hetzel H, al. It should be emphasized that groups analyzed in Reibnegger G, Wachter H. 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