Alimentary Pharmacology and Therapeutics Letters to the Editors often overlooked that the risk of developing familial CRC is dependent not only on the age of the index cancer case but also on the relative’s age. Prior studies have generally been underpowered to reliably characterise this dual dependence on age of the index case and relative. We hope to further elucidate this dual dependence on age in subsequent analyses and future publications.
REFERENCES 1. Matuchansky C. Letter: colorectal cancer in relatives of patients with common colorectal cancer. Aliment Pharmacol Ther 2015; 41: 1026. 2. Samadder NJ, Smith KR, Mineau GP, et al. Familial colorectal cancer risk by subsite of primary cancer: a population-based study in Utah. Aliment Pharmacol Ther 2015; 41: 573–80.
ACKNOWLEDGEMENT The author’s declarations of personal and financial interests are unchanged from those in the original article.2
Letter: monoclonal gammopathy of HEV infection. When is it significant? E. Ozturk* & B. Baran† *Department of Haematology, Kocß University Hospital, Istanbul, Turkey. † Department of Gastroenterology, Kocß University Hospital, Istanbul, Turkey. E-mail: [email protected] doi:10.1111/apt.13161
SIRS, We read with interest the recent article by Woolson et al.1 which reported extrahepatic manifestations of autochthonous hepatitis E virus (HEV) infection in 106 patients who attended four hospitals in Southwest England between 1999 and 2013. All patients were demonstrated to be infected with HEV genotype 3. The authors reported that neurological and haematological manifestations were prevalent in this large cohort. To us, the most striking feature of the study, among other important findings, was the high prevalence of haematological abnormalities, especially monoclonal gammopathy of undetermined significance (MGUS) in patients with HEV infection. The results of protein electrophoresis were available in 65 of 106 patients, and they found monoclonal gammopathy in 17 patients (26.2%). They stated that none of the patients with monoclonal gammopathy demonstrated any clinical or laboratory findings suggestive of myeloma or lymphoma. However, they did not perform a bone marrow biopsy, which is recommended to differentiate MGUS from smouldering or multiple myeloma. MGUS is a subclinical clonal plasma cell expansion and is defined as Aliment Pharmacol Ther 2015; 41: 1026–1028 ª 2015 John Wiley & Sons Ltd
the presence of a serum monoclonal protein at a concentration less than 3 g/dL, a bone marrow biopsy demonstrating less than 10% monoclonal plasma cells, and absence of end-organ damage.2 According to the latest definition of the International Myeloma Working Group, even a monoclonal protein concentration less than 3 g/ dL can be associated with smouldering or multiple myeloma, which necessitates a bone marrow biopsy for a definitive diagnosis. Furthermore, nine patients had a monoclonal protein concentration ≥3 g/dL, which is certainly outside the definition of MGUS. The authors stated that none of the patients with monoclonal gammopathy demonstrated any findings suggestive of myeloma or lymphoma, which indicates smouldering myeloma instead of MGUS in those patients with ≥3 g/dL paraproteinaemia. We believe that there is some confusion in the literature regarding the terminology of MGUS. It is frequent to misinterpret secondary causes of monoclonal gammopathy, which can be transient, especially in viral infections.3 A diagnosis of MGUS requires a persistent clonal expansion of plasma cells which is manifested by a paraprotein concentration
REFERENCES 1. Matuchansky C. Letter: colorectal cancer in relatives of patients with common colorectal cancer. Aliment Pharmacol Ther 2015; 41: 1026. 2. Samadder NJ, Smith KR, Mineau GP, et al. Familial colorectal cancer risk by subsite of primary cancer: a population-based study in Utah. Aliment Pharmacol Ther 2015; 41: 573–80.
ACKNOWLEDGEMENT The author’s declarations of personal and financial interests are unchanged from those in the original article.2
Letter: monoclonal gammopathy of HEV infection. When is it significant? E. Ozturk* & B. Baran† *Department of Haematology, Kocß University Hospital, Istanbul, Turkey. † Department of Gastroenterology, Kocß University Hospital, Istanbul, Turkey. E-mail: [email protected] doi:10.1111/apt.13161
SIRS, We read with interest the recent article by Woolson et al.1 which reported extrahepatic manifestations of autochthonous hepatitis E virus (HEV) infection in 106 patients who attended four hospitals in Southwest England between 1999 and 2013. All patients were demonstrated to be infected with HEV genotype 3. The authors reported that neurological and haematological manifestations were prevalent in this large cohort. To us, the most striking feature of the study, among other important findings, was the high prevalence of haematological abnormalities, especially monoclonal gammopathy of undetermined significance (MGUS) in patients with HEV infection. The results of protein electrophoresis were available in 65 of 106 patients, and they found monoclonal gammopathy in 17 patients (26.2%). They stated that none of the patients with monoclonal gammopathy demonstrated any clinical or laboratory findings suggestive of myeloma or lymphoma. However, they did not perform a bone marrow biopsy, which is recommended to differentiate MGUS from smouldering or multiple myeloma. MGUS is a subclinical clonal plasma cell expansion and is defined as Aliment Pharmacol Ther 2015; 41: 1026–1028 ª 2015 John Wiley & Sons Ltd
the presence of a serum monoclonal protein at a concentration less than 3 g/dL, a bone marrow biopsy demonstrating less than 10% monoclonal plasma cells, and absence of end-organ damage.2 According to the latest definition of the International Myeloma Working Group, even a monoclonal protein concentration less than 3 g/ dL can be associated with smouldering or multiple myeloma, which necessitates a bone marrow biopsy for a definitive diagnosis. Furthermore, nine patients had a monoclonal protein concentration ≥3 g/dL, which is certainly outside the definition of MGUS. The authors stated that none of the patients with monoclonal gammopathy demonstrated any findings suggestive of myeloma or lymphoma, which indicates smouldering myeloma instead of MGUS in those patients with ≥3 g/dL paraproteinaemia. We believe that there is some confusion in the literature regarding the terminology of MGUS. It is frequent to misinterpret secondary causes of monoclonal gammopathy, which can be transient, especially in viral infections.3 A diagnosis of MGUS requires a persistent clonal expansion of plasma cells which is manifested by a paraprotein concentration
