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Infectious Disease Pathology
Wednesday, March 2, 2011, 7:30 PM
CC 102 A/B
Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Gastrointestinal Infections
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Moderator:
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JEANNETTE GUARNER
Emory University
Decatur, GA
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Disclosure:
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In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose.
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Panelists:
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Laura W. Lamps, University of Arkansas/Medical Sciences, Little Rock, AR
Alton Brad Farris, Emory University, Atlanta, GA
Jose Jessurun, University of Minnesota, Minneapolis, MN
Brian West, Yale University, New Haven, CT
Jeannette Guarner, Emory University, Atlanta, GA
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Clinical Histories and Still Images are displayed below.
Click on slide thumbnail images for an enlarged view.
If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137.
for Text and References
Submitted by: Laura W. Lamps -
A 60 year old woman from Arkansas presented with a one month history of worsening nausea, vomiting, and abdominal pain. She had a past medical history of Crohn’s disease and had been taking 20mg of prednisone daily for more than ten years. Upon physical examination she had diffuse abdominal pain and distension, with tenderness to palpation in the right upper quadrant. The remainder of her physical exam was unremarkable except for diffuse expiratory wheezes that were heard on pulmonary examination. Initial laboratory results included a white blood cell count of 8500/µl (86 % neutrophils, 12 % lymphocytes, 1 % monocytes and 1 % eosinophils). Blood cultures were obtained and were negative. The patient was started on antibiotics including levofloxacin and metronidazole. A CT scan of her abdomen on hospital day 2 revealed edema of the right colonic wall as well as air in the wall of the cecum. CT scan of the chest revealed infiltrates in the right middle and right lower lobes. The patient then underwent exploratory laparotomy with right hemicolectomy on hospital day 3.
Case 1 - Figure 1
A low power view of the colon resection shows chronic, active colitis. |
Case 1 - Figure 2
Higher power view shows architectural distortion and basal plasmacytosis. |
Case 1 - Figure 3
Epithelioid granulomas with associated eosinophils are found within the bowel wall. |
Case 1 - Figure 4
Some sections of the colectomy show larvae within the glandular epithelium. |
Case 1 - Figure 5
Numerous larvae with pointed tails are present within the crypts, consistent with strongyloides. |
Case 1 - Figure 6
Larvae were also present within numerous lymph nodes in the pericolonic fat. |
for Text and References
Submitted by: Alton B. (Brad) Farris -
A 48 year old male presented with fever, weight loss, and malaise. Surgery was performed for the clinical impression of an intestinal obstruction, and exploration of the abdomen showed an 8 cm pericecal abscess and localized cecal ulceration.
Case 2 - Figure 1
Localized eosinophilic collections were identified within the tissue. Within the collections of tissue eosinophlia, fungal forms could be identified. (H & E, Original magnification: 10x) |
Case 2 - Figure 2
Fungal forms were broad, pleomorphic, and pauciseptate. (H & E, Original magnification: 20x) |
Case 2 - Figure 3
Fungal forms were associated with numerous inflammatory cells with a predominance of eosinophils. (H & E, Original magnification: 40x) |
Case 2 - Figure 4
The fungal forms stained with a Periodic acid-Schiff (PAS) stain. (PAS, Original magnifications: 10x) |
Case 2 - Figure 5
The fungal forms stained with a Periodic acid-Schiff (PAS) stain. (PAS, Original magnifications: 20x) |
Case 2 - Figure 6
The fungal forms stained with a Periodic acid-Schiff (PAS) stain. (PAS, Original magnifications: 40x) |
for Text and References
Submitted by: Jose Jessurun -
An 8-year-old previously healthy white girl presented with abdominal pain and vomiting of a month's duration with recent weight loss and jaundice. She was the product of first-degree consanguinity. Family history was non-contributory. Physical examination revealed a thin, jaundiced child. A firm, non-tender liver edge was noted two centimeters below the right costal margin. Laboratory tests showed normal leukocyte count and hemoglobin, total bilirubin of 9 mg/dL (0.2 – 1), direct 6.5 mg/dL, ALT 155 IU/L (8-20), AST 116 IU/L (8-20), alkaline phosphatase 931 IU/L (30-115), lipase 5094 IU/L (2.3-50) and amylase 612 IU/L (35-118). Computerized abdominal tomography demonstrated multiple gallstones. Endoscopic retrograde cholangiopancreatography (ERCP) revealed multiple stenotic lesions in the distal biliary tree without evidence of ductal stones. Colonoscopy to the ileum was normal. A cholecystectomy was performed, during which a 1.5 cm stone and exudate were found in the cystic duct. Further evaluation included an immunologic profile. The patient was deficient in suppressor/cytotoxic T (CD8) cells and natural killer (NK) cells (CD16+CD56). Cytotoxic testing of NK cell lytic activity showed complete absence of NK cell function. A quantitative immunoglobulin (Ig) panel showed elevation of IgE. Lymphocyte and neutrophil function, leukocyte adhesion, and complement studies were all normal. Autoimmune antibody titer for anti-saccaromyces cerevisiae antibody, anti-neutrophilic cytoplasmic antibody, and anti-nuclear antibody were negative. Smooth-muscle antibody was minimally elevated with a titer of 40 (normal titer <20). Genetic testing was negative for chromosomal deletions, duplications, or translocations. Evaluations for human immunodeficiency virus, histoplasmosis, blastomycosis, leptospirosis, Epstein-Barr Virus, Hepatitis Virus A, B, and C, and tuberculosis were negative.
Case 3 - Slide 1
Gallbladder showing granulomatous inflammation.
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Case 3 - Slide 2
A GMS stain highlights organisms within granulomas.
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for Text and References
Submitted by: A. Brian West -
A 53 year old gay man presented to his gastroenterologist complaining of rectal bleeding that he had noticed intermittently over a period of months and that he had attributed to hemorrhoids. He was HIV-positive, and on treatment with highly active anti-retroviral therapy. On questioning the bleeding proved to be low-volume spotting evident at defecation, and the patient admitted to increasingly severe proctalgia over several weeks. He denied recent anal intercourse. On colonoscopy he had a tubular adenoma at 50 cm and patchy moderately severe proctitis with focal ulceration. The large intestinal mucosa was otherwise normal. Multiple endoscopic biopsies of the rectum were taken.
Case 4 - Slide 1
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Case 4 - Figure 1
Rectal mucosa with mild architectural distortion and lymphoid infiltrate |
Case 4 - Figure 2
Distorted rectal mucosa with branched gland, and marked chronic inflammation extending into muscularis propria |
Case 4 - Figure 3
Prominent plasma cell component in lamina propria infiltrate. Plump endothelial cells are present in some capillaries |
Case 4 - Figure 4
Neutrophils are present in area of erosion. Plump endothelial cells are present also. |
Case 4 - Figure 5
Mild cryptitis. Note prominent plasma cells in lamina propria |
Case 4 - Figure 6
Tightly coiled spirochetes in lamina propria (Warthin-Starry, 100x) |
Case 4 - Figure 7
Immunostaining with polyclonal anti- T.pallidum antibody (40X; Stain by Dr R Cartun) |
Case 4 - Figure 8
Immunostaining with polyclonal anti- T.pallidum antibody (100x; Stain by Dr R Cartun) |
for Text and References
Submitted by: Jeannette Guarner -
57 year old man being treated for acute lymphocytic leukemia with persistent diarrhea.
Stool cultures negative; ova and parasites negative; 4 stoool specimens obtained on different days 1 week prior to the biopsy were negative for Clostridium difficile toxin by ELISA.
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