Sabin-Feldman Dye Test in Ulcerative Colitis and Crohn's Disease J. RATTAN, M.D, A. HALLAK, M.D., H. SHVARTZMAN,M.D., S. FELNER, M.D., T. GILAT, M.D.

Rattan J, Hallak A, Shvartzman H, Felner S, Gilat T. Sabin-Feldman dye test in ulcerative colitis and Crohn's disease. Dis Colon Rectum 1986;29:402-404. The prevalence of Toxoplasma infection among patients with inflammatory bowel disease was studied. The Sabin-Feldman dye test was performed on 35 patients with Crohn's disease, 44 patients with ulcerative colitis, and 140 control patients. A higher incidence of positive reactions was found in Crohn's disease patients over the age of 40 (P < 0.05). All other factors showed no significant differences among the three groups of patients. These factors include age younger than 40 years, sex, duration of disease, extent of disease, and type of treatment. It is concluded that there is no correlation between inflammatory bowel diseases and toxoplasmosis. Toxoplasma infection, however, should be considered in patients with Crohn's disease who are over 40 years old, and who present with nonspecific signs of intercurrent infection. [Key words: Toxoplasmosis; Sabin-Feldman test; Crohn's disease; Ulcerative colitis]

THE ETIOLOGY OF CROHN'S DISEASEAND ULCERATIVE

COLITIS is unknown. T h e two diseases may or m a y not have a c o m m o n etiology. There are m a n y hypotheses as to their cause. Genetic, environmental, immunologic, ~ and infectious factors 2 have been suggested. Infectious agents, such as specific viruses, 3 Chlamydia, Yersinia, cytomegalovirus, 4 and mycobacteri# have been suspected. These agents and others, including parasites such as Toxoplasma, 6 were found to be relatively c o m m o n in immunosuppressed or chronic disease states. Serologic evidence of toxoplasmosis has been reported a m o n g patients with polymyositis 7 and other collagen diseases. Our study determined the prevalence of toxoplasmic infection a m o n g padents with inflammatory bowel diseases, attempted to establish a relationship between Toxoplasma and these diseases. Methods

From the Department of Gastroenterolog% Ichilov Hospital, and the Sackler Facult~ o] Medicine, Tel/lviv University, Tel Aviv, Israel method of revealing the presence of antibodies against

Toxoplasma. In this test, viable Toxoplasma organisms are mixed with a series of serum dilutions. After an incubation period of 1 hour at 37~ alkaline methylene blue is added and the organisms are studied under the microscope. Avoidance of blue color by the Toxoplasma organisms indicates the presence of antibodies in the serum in question. T h e highest dilution at which at least 50 percent of the organisms are uncolored is considered to be the antibody titer. Positive titer is above 1/16. T h e test lacks false-positive reactions, particularly in patients with immunodeficiency states and therefore is preferred in such patients, s T o minimize the possibility of technical error, all tests were performed in the same laboratory by the same technician. Three groups of patients were studied. T h e first group consisted of 35 patients, 21 men and 14 women, who were suffering from Crohn's disease. T h e second g r o u p consisted of 44 patients, 28 men and 16 women, w h o were suffering from ulcerative colitis. T h e duration of disease in both groups was from one to 23 years for ulcerative colitis (mean, 8.8 years) and one to 21 years for Crohn's disease (mean, 5.6 years). A third g r o u p of 140 patients, 68 men and 72 women, served as a control group and were selected randomly at the opthalmologic and orthopedic outpatient clinics. None of these had any gastrointestinal diseases. T h e chi-square test was used for statistical analysis.

T h e Sabin-Feldman dye test was chosen as a screening test because of its simplicity. It is considered a c o m m o n

Results

Received for publication December31, 1985. Address reprint requests to Dr. Rattan: Department o[ Gastroenterology, Ichilov Hospital, 6 Weizman Street, Tel Aviv 64239, Israel.

Overall, there were no significant differences a m o n g the three groups. In the patient groups, the test was positive more frequently in men (Crohn's disease, 58

402

Volume29 Number6

403

SABIN-FELDMAN TEST

TABLE 1. Results o] the Sabin-Feldman Test in Controls and Patients Controls

Crohn's Disease

TABLE 3. EI[ect o[ Extent o[ Disease

Ulcerative Colitis

% Sabin% Sabin% SabinFeldman Feldman Feldman N u m b e r Positive N u m b e r Positive N u m b e r Positive Men Women

68 72

23.4 49.2

21 14

58 29

28 16

50 38

TOTAl,

140

38.5

35

45.8

44

45,4

percent; ulcerative colitis, 50 percent); in the controls it was positive more often in women (49 percent) (Table 1). These differences were not statistically significant. When the groups were subdivided according to age (below and above the age of 40 years), there was a higher incidence of positive reaction in the older groups, with a statistical significance for the Crohn's disease g r o u p only (Table 2). Neither in Crohn's disease nor in ulcerative colitis was there a correlation between the affected area and the results of the Sabin-Feldman test (Table 3). No correlation existed between the type of treatment (Table 4) or duration of disease and the result of the Sabin-Feldman test.

Discussion Many factors have been suspected to be involved in the etiology of Crohn's disease and ulcerative colitis. T h e role of most of those factors remains speculative, and a direct cause has not been identified. Since the report of Mitchell and Rees 9 in 1970, the "transmissible agent" and its identification have been the target of m a n y investigators. Three principal agents are still under study: viruses, cellwall deficient bacteria (L-forms), and mycobacteria. Agents such as clostridia have been suspected of playing an aggravating role. ~~ Other agents, e.g., Chlarnydia, were found to lack any relation to inflammatory bowel disease. ~1 In parallel to the infectious etiology, the i m m u n e system has been widely investigated in inflammatory bowel disease. Abnormalities of peripheral B a n d / o r t-cells were found by some but not other investigators, and no clear-

Affected Area

Age < 40 _> 40

30 40

Group Ulcerative Colitis Crohn's Disease Percent P Percent N.S. 33.8 56

N.S. N.S.

21.1 75

N.S. < 0.05

* T h e test was more often positive in patients w h o were older than age 40, but the difference was statistically significant only for patients with Crohn's disease.

Sabin-Feldman Negative

N u m b e r Percent

N u m b e r Percent

Crohn's disease Colon Small intestine Colon and small intestine Ulcerative colitis Rectum-sigmoid Left and transverse Pancolitis

3 7

18.7 43.8

7 4

6

37.5

42.1

17 1 2

85 5 10

36.8 21.1

13 5 6

54.2 20.8 25

cut abnormality has emerged. Several abnormalities of the i m m u n e system at the level of the affected area were found.12-~4 Patients with inflammatory bowel disease are not considered as " i m m u n e compromised" patients, unless treated with steroids or immunosuppressors. Nevertheless, Crohn's disease and ulcerative colitis are chronic and debilitating diseases, and patients are more susceptible to various infectious agents. One of those agents, Toxoplasrna gondii has been reported with increased frequency in collagen diseases.7,15 In our study, a potential relationship between T. gondii and inflammatory bowel disease was investigated. O u r results failed to demonstrate such a relationship, except in Crohn's disease patients older than 40 years of age. In this subgroup, the Sabin-Feldman test was more frequently positive (P ~ 0.05). No relationship was found between either the affected area or the duration of the disease and toxoplasma infection. T h e treatment did not seem to affect the results of the Sabin-Feldman test, even in the steroid-treated group. Our results suggest no correlation between inflammatory bowel disease and toxoplasma infection. T h e rate of contagion of Toxoplasma, however, is higher in patients with Crohn's disease w h o are older than the age of 40 in comparison with controls. T h e reason for this is unknown. We suggest that toxoplasma infection should be

TABLE 4. Effect of Treatment Crohn's Disease

Ulcerative Colitis

SabinFeldman Positive

SabinFeldman Positive

TABIJ," 2. The Effect o] Age* (Percent) Control

Sabin-Feldman Positive

Treatment

Number

Number

N u m b e r Percent No treatment Steroids Sulfasalazine Steroids and sulfasalazine Total

N u m b e r Percent

4 6 12

2 l 4

12.5 6.3 25

4 -33

1 -14

5 -70

13 35

9 16

56.3 100

7 44

5 20

25 100

404

RATTAN, ET AL.

c o n s i d e r e d i n a n y p a t i e n t w i t h C r o h n ' s disease o v e r 40 years o l d w h o p r e s e n t s w i t h n o n s p e c i f i c s i g n s of i n t e r c u r r e n t i n f e c t i o n . F u r t h e r i n v e s t i g a t i o n is n e e d e d to c l a r i f y t h e m e a n i n g of t h e r e l a t i v e l y h i g h i n c i d e n c e of t o x o p l a s m a i n f e c t i o n i n this p a r t i c u l a r g r o u p of p a t i e n t s .

References 1. Auer IO, Ziemer E, Sommer H. Immune status in Crohn's disease: V. Decreased in vitro natural killer cell activity in peripheral blood. Clin Exp Immunol 1980;42:41-9. 2. Smith PD, Infectious agents and inflammatory bowel disease (editorial). Gastroenterology 1983;85:475-6. 3. Gimick GL, Rosen VJ, Arthur MH, Hertweck SA. Evidence for the isolation of a new virus from ulcerative colitis patients: comparison with virus derived from Crohn's disease. Dig Dis Sci

1979;24:609-19. 4. Swarbrick ET, Kingham JG, Price HL, Blackshaw AJ, Griffiths PD. Chlamydia, cytomegalovirus, and Yersinia in inflammatory bowel disease. Lancet 1979;2:11-2. 5. Burnham WR, Lennard-Jones JE, Stanford JL, Bird RG. Mycobacteria as a possible cause of inflammatory bowel disease. Lancet 1978;2:693-6.

Dis. Col. & Rec

June 19~

6. Ruskin J, Remington JS. Toxoplasmosis in the compromisec host. Ann Intern Med 1976;84:193-9. 7. Samuels BS, Rietschel RL. Polymyositis and toxoplasmosis JAMA 1976;235:60-1. 8. Krick JA, Remington JS. Toxoplasmosis in the adult: an overview N Engl J Med 1978;298:550-3. 9. Mitchell DN, Rees RJ. Agent transmissible from Crohn's diseasq tissue. Lancet 1970;2:168-71. 10. Bohon RP, Sherriff R J, Read AE. Clostridium difficile associate~ with diarrhea: a role in inflammatory bowel disease? Lance 1980; 1:383-4. 11. Taylor-Robinson D, O'Morain CA, Thomas BJ, Levi AJ. Lov frequency of chlamydial antibodies in patients with Crohn' disease and ulcerative colitis. Lancet 1979;1:1162-3. 12. Fiocchi C, Youngman KR, Farmer RG. Immunoregulatory func tion of human intestinal mucosa lymphoid cells: evidence fo enhanced suppressor cell activity in inflammatory bowel dis ease. Gut 1983;24:692-701. 13. Yuan SZ, Hanauer SB, Kluskens LF, Kraft SC. Circulating lyrn phocyte subpopulations in Crohn's disease. Gastroenterolog 1983;85:1313-8. 14. Kirsner JB, Shorter RG. Recent developments in 'non-specific inflammatory bowel disease. N Engl J Med 1982;306:775-85. 15. Kagen LJ, Kimball AC, Christian CL. Serologic evidence of toxc plasmosis among patients with polymyositis. Am J Med 1974 56:186-91.

Announcement 48TH ANNUAL POSTGRADUATE COURSE "Principles of Colon and Rectal Surgery" will be the topic of the 48th a n n u a l postgraduate course sponsored by the University of Minnesota. It will be held at the University of Minnesota, Minneapolis, on October 8-11, 1986. Contact: C o n t i n u i n g Medical Education, University of Minnesota Medical School, Box 293 Mayo, 420 Delaware Street Southeast, Minneapolis, Minnesota 55455. Telephone: (612) 373-8012.