Mitochondrial neurogastrointestinal encephalopathy: a clinicopathological mimic of Crohn's disease

• Published in: BMC gastroenterology Vol. 19; no. 1; p. 11
• Main Authors: Patel, Ravi, Coulter, Lucia Lee, Rimmer, Joanna, Parkes, Miles, Chinnery, Patrick Francis, Swift, Oscar
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 15.01.2019; BioMed Central; BMC
• Subjects: Abdomen; Azathioprine; Biopsy; Case Report; Complications and side effects; Crohn’s disease; Deoxyribonucleic acid; Diagnosis; Diagnostic imaging; Diarrhea; DNA; Dosage and administration; Edema; Encephalopathy; Fever; Gastroenterology; Gastrointestinal diseases; Gastrointestinal system; Genetic screening; Genetic testing; Genomes; Headache; Health aspects; Inflammatory bowel disease; Inherited mitochondrial disorders; Leukoencephalopathy; Liver; Magnetic resonance imaging; Medical research; Mesentery; Mitochondrial DNA; Mitochondrial neurogastrointestinal encephalopathy; Mutation; Myalgia; Neuroimaging; NMR; Nuclear magnetic resonance; Nucleic acids; Nucleosides; Pain; Pharyngitis; Pharynx; Phenotypes; Phosphorylase; Sore throat; Substantia alba; Supplements; Thymidine; Thymidine phosphorylase; Transplants & implants; Urine; Vomiting; United Kingdom > UK; Inflammatory bowel disease; Inherited mitochondrial disorders; Mitochondrial neurogastrointestinal encephalopathy; Azathioprine; Leukoencephalopathy; Thymidine phosphorylase; Crohn’s disease
• ISSN: 1471-230X; 1471-230X
• DOI: 10.1186/s12876-018-0925-5

Mitochondrial neurogastrointestinal encephalopathy (MNGIE), due to mutations in TYMP, often presents with gastrointestinal symptoms. Two sisters, initially managed for Crohn's disease based upon clinical, imaging and pathological findings, were later found to have MNGIE. The cases provide novel clinicopathological insight, for two further reasons: both sisters remain ambulant and in employment in their late 20s and 30s; diagnosis in one sister was made after a suspected azathioprine-precipitated acute illness. A 25-year-old female presented with diarrhoea, vomiting, abdominal pain, and bloating. Faecal calprotectin, colonic biopsies and magnetic resonance enterography were consistent with a diagnosis of Crohn's disease. Azathioprine initiation preceded admission with a sore throat, headache, myalgia, and pyrexia. Withdrawal led to rapid clinical improvement. MRI brain revealed persistent, extensive white matter changes. Elevated plasma and urine thymidine and deoxyuridine, and genetic testing for TYMP variants, confirmed MNGIE. Testing of the patient's sister, also diagnosed with Crohn's disease, revealed identical variants. In this context, retrospective review of colonic biopsies identified histological findings suggestive of MNGIE. Azathioprine interference in nucleic acid metabolism may interact with the mitochondrial DNA depletion of MNGIE. Nucleotide supplementation, proposed for treatment by manipulating mitochondrial nucleoside pools, may require caution. The late onset and mild phenotype observed confirms presentation can occur later in life, and may reflect residual thymidine phosphorylase activity. Clinicians should consider measuring plasma thymidine levels in suspected Crohn's disease to rule out MNGIE, particularly if white matter abnormalities are identified on neuroimaging.