Bone marrow examination in patients with immune thrombocytopenia: is there anything different in older patients?

Immune thrombocytopenia (ITP) is a disorder characterised by immune-mediated accelerated platelet destruction and suppressed platelet production. In the bone marrow examinations of patients with ITP, some investigators found megakaryocyte numbers to be increased while others have found them to be normal. Although recent guidelines recommend against bone marrow examinations in typical ITP patients, the recent introduction of thrombopoietin receptor agonists as an effective treatment for ITP has refocused attention on abnormalities of bone marrow megakaryocytes. In this study, we retrospectively analysed the bone marrow aspiration, flow cytometry-CD45 side scatter (SSC) and biopsy results of our patients with ITP by dividing them into two groups according to age (<60 yr and ≥60 yr). Ninety eight newly diagnosed ITP patients were included in the study. CD45 SSC results were recorded as percentages of normoblasts, granulocytes, lymphocytes, monocytes and myeloid/erythroid ratio. Length of the biopsy specimen, cellularity, presence of dysplasia or fibrosis with number, morphology and distribution of megakaryocytes were recorded. In group 1, there were 49 patients. Mean age was 41.31 ± 12.77 yr. In group 2, there were 49 patients. Mean age was 70.78 ± 7.88 yr. Megakaryocyte numbers on bone marrow aspirates were not recorded in most patients, so we could not comment on this point. Flow cytometry results and bone marrow findings were similar between two groups. In conclusion, there is no difference between bone marrow examinations of young and older patients with ITP, and biopsy should not be recommended in typical ITP patients as already mentioned in guidelines.

The effects of bupivacaine injection and oral nitric oxide on extraocular muscle in the rabbit.

AIM: Nitric oxide (NO) plays a key role in muscle regeneration, which is the primary response, observed during bupivacaine-induced extraocular muscle (EOM) hypertrophy. Our aims were to investigate the effects of bupivacaine injection into the rabbit EOM and the interaction with NO. MATERIALS AND METHODS: Superior rectus (SR) muscles of 24 New Zealand albino rabbits were studied. Single muscle twitch tension (SMTT) and tetanic muscle tensions at 50, 75, and 100 Hz were recorded using a 15 V stimuli. The rabbits were equally allocated into three groups. Measurements were performed without any drug treatments in group 1. In groups 2 and 3, bupivacaine, 0.5 ml of a 0.50 % solution, was injected into the EOM, and after 21 days, measurements were performed. Oral isosorbide dinitrate (NO donor) at 20 mg/day was given each day prior to measurements in group 3. RESULTS: SMTTs were 69.9 (66.7-77.6), 187.7 (114.9-252.1) and 204.2 (135.3-311.6) mg in groups 1, 2, and 3 respectively. SMTTs for both groups 2 and 3 were significantly higher than that for group 1 (p < 0.05). Compared with group 1, group 2 exhibited a 3.8-11.7 % increase in the tetanic tensions at 50, 75, and 100 Hz, but none of these differences were statistically significant. The increase was 47.5-137.5 % in group 3 relative to group 2, and the differences were statistically significant except at 100 Hz. The enlargement of the muscle fibers after bupivacaine injection was shown histopathologically. CONCLUSION: Bupivacaine injection increased the EOM tension in rabbits to some extent. NO augmented the effect of bupivacaine.

Necrotic ulcer: a manifestation of leukemia cutis.

A 71-year-old man presented to our dermatological clinic with a 3-month history of a wound on his leg. He complained of weakness for the past few months. On his dermatological examination he had a 3x3-cm necrotic ulcer on his left tibia (Figure 1). On physical examination, there was 1 x 1-cm axillary lymphadenopathy. There was no other lymph node enlargement, hepatosplenomegaly, or gingival hypertrophy. Peripheral blood results showed 2.4x103/mm3 leukocytes (normal range 4-11 x 103/mm3) with 66% neutrophils. The hemoglobin value was 10.1 g/dL (13-18 g/dL), and the platelet count was 63x103/mm3 (150-440 x 103/mm3). No blasts were detected in a peripheral blood smear. His lactate dehydrogenase level was 567 U/L (240-480 U/L). All other results of blood chemistry were within normal limits. Punch biopsy of the skin lesion showed ulceration and dense dermal acute and chronic inflammation. There was a superficial and deep perivascular and periadnexal infiltrate of neoplastic cells composed of relatively abundant eosinophilic cytoplasm and large nuclei with blastic chromatin and occasional small nucleoli (Figure 2). Mitotic figures were prominent. Immunohistochemical stains were performed, and the neoplastic cells were CD3, CD20, CD138, and S100 protein negative. Myeloperoxidase and CD68 were positive. The histopathological findings were consistent with leukemic infiltration. Examination of bone marrow biopsy revealed that the blastic cells constituted more than 20% of the bone marrow cellularity. Cytogenetic analysis of bone marrow aspiration with fluorescence in situ hybridization was negative for inversion 16, t(8;21) and t(15;7). Histochemical stains for myeloperoxidase, sudan black, periodic acid-Schiff, and alpha naphthyl acetate were also negative. Blastic cells were DR, CD13, CD117, and CD34 positive and CD5, CD7, CD10, CD14, CD19, CD20, CD33, CD41, CD56, CD64, and CD79 negative according to flow cytometry immunophenotyping. Blastic cells were 35% in the bone marrow. Based on the findings of bone marrow examination, the patient was diagnosed as having acute myeloblastic leukeamia (AML) with minimal differentiation (subtype MO) according to French-American-British and World Health Organization classification. The examination of abdominal ultrasonography and thorocic and abominal computed tomography revealed no metastases. The patient was treated with chemotherapy that consisted of cytarabin and daunorubicin. After chemotherapy, the lesion regressed. One month after chemotherapy, the patient presented to the hospital with a complaint of fever. He was diagnosed with febrile neutropenia. He died of cardiac failure 12 months after appearance of skin infiltration.

Autoimmune hypothyroidism and lupus-like syndrome.

The frequency of thyroid disorders, particularly Hashimoto's thyroiditis, may be increased in patients with connective tissue diseases. Both hypothyroidism and connective tissue diseases often cause muscle and joint aches, pains and stiffness. Skin, renal and cardiovascular involvement seen in the course of autoimmune hypothyroidism (AIH) may simulate connective tissue diseases such as systemic lupus erythematosus (SLE). We herein report a case of AIH who presented with massive proteinuria, haematuria, pleural fluid and arthritis simulating SLE.

De novo isolated gastrointestinal tract vasculitis without associated systemic disease in renal transplant recipients successfully treated with rituximab.

Systemic vasculitic diseases can show recurrence after kidney transplantation, but de novo systemic vasculitis is rarely seen after kidney transplantation, and in literature, there are only a few cases. In general population, the incidence of isolated organ vasculitis is unknown, and according to the best of our knowledge, there is no information about de novo isolated organ vasculitis after renal transplantation. We report, most probably, the first case of a 40-year-old woman who was restarted on dialysis treatment after renal transplantation and developed isolated gastrointestinal vasculitis and intestinal hemorrhage under immunosuppressive treatment. She was treated successfully with rituximab.

Which of the fluorine-18 fluorodeoxyglucose positron emission tomography/computerized tomography parameters are better associated with prognostic factors in breast cancer?

The aim of the present study is to evaluate the relationship between the immunohistochemical and histopathological prognostic factors and the metabolic fluorine-18 fluorodeoxyglucose positron emission tomography/computerized tomography (PET/CT) parameters in breast cancer.A total of 94 female patients diagnosed with primary breast cancer (median age: 54.5 years, 94 lesions with size >15 mm) who underwent PET/CT imaging before any treatment were enrolled to this retrospective study. Maximum and average standardized uptake values (SUVmax and SUVavg), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and tumor/liver uptake ratio (TLR) of the primary tumors were calculated and compared between various histopathological and immunohistochemical prognostic factor groups.All metabolic parameters were associated with clinical T stage, metabolic M stage, and nuclear grade. The MTV, TLG, and TLR were significantly higher in patients with suspected lymph node metastasis. There were significant differences according to estrogen receptor and human epidermal growth factor-2 status in the metabolic values other than MTV. In case of progesterone receptor, there were significant differences in the metabolic characteristics except for the MTV and TLG values. The Ki-67 labeling index was moderately correlated with SUVmax, SUVavg, and TLR. All metabolic characteristics except MTV were significantly higher in triple negative breast cancer compared with the other molecular subtypes.The results of the present study suggest that the TLG and TLR values have stronger associations with several prognostic factors in breast cancer (BC) compared with other metabolic parameters.

Rapid molecular cytogenetic diagnosis of transfusion associated graft-versus-host disease by fluorescent in situ hybridization (FISH).

Transfusion associated graft-versus-host disease (TA-GVHD) is a rare, dreadful complication of transfusion in immunocompromized and immunologically competent individuals. The diagnosis is often delayed, because of lack of awareness and the non-specific clinical features. We describe a rapid molecular cytogenetic analysis of FISH for the diagnosis of two cases of TA-GVHD with sex-mismatched donors. The use of FISH is a rapid and sensitive technique for the early diagnosis of TA-GVHD when the recipient and donor are of different gender.

The effects of intra-rectal and intra-peritoneal application of Origanum onites L. essential oil on 2,4,6-trinitrobenzenesulfonic acid-induced colitis in the rat.

The aim of the present study is to investigate the treatment efficiency of intra-rectal (IR) and intra-peritoneal (IP) application of Origanum onites essential oil (OOEO), which is a well-known antioxidant, in the colitis model induced by 2,4,6-trinitrobenzenesulfonic acid (TNBS) and ethanol (E) in comparison with dexamethasone therapy through the morphologic damage score. Monoclonal antibodies against intercellular adhesion molecule-1 (ICAM-1, CD54), anti-rat granulocytes, and myeloperoxidase (MPO), were also investigated immunohistochemically. There was a significant difference in terms of ulceration, mucus cell depletion, inflammatory cell infiltration, vascular dilatation (p<0.001), crypt abscesses (p<0.01), and edema (p<0.05) between OOEO-1mg/kg-IR and control colitis groups. A significant difference was encountered in terms of mucus cell depletion, crypt abscesses, inflammatory cell infiltration, vascular dilatation (p<0.01), and ulceration (p<0.05) between the OOEO-0.1mg/kg-IR and control colitis groups. A significant difference was noticed in terms of ulceration, inflammatory cell infiltration, mucus cell depletion (p<0.001), vascular dilatation (p<0.01), and mucosal atrophy (p<0.05) between the OOEO-1mg/kg-IP and control colitis groups. There was a significant difference in terms of ulceration, mucus cell depletion, inflammatory cell infiltration (p<0.001), crypt abscesses, vascular dilatation (p<0.01), and mucosal atrophy (p<0.05) between the OOEO-0.1mg/kg-IP and control colitis groups. No significant difference was determined in terms of ulceration, inflammatory cyst, mucosal atrophy, edema, and vascular dilatation between the dexamethazone and control colitis groups (p>0.05). Under the present conditions, we concluded that IR and IP OOEO treatment, applied at the dosage of 0.1 or 1mg/kg/day, have a significant protective effect on the colonic injury.

Bone marrow as a target organ of systemic lupus erythematosus: analysis of cases with myelofibrosis.

AIM: Cytopenia in the course of systemic lupus erythematosus (SLE) may be due to multiple factors. In this study, we aimed primarily to evaluate the detailed results of bone marrow (BM) biopsies of SLE patients, secondly to determine the myelofibrosis (MF) frequency and thirdly to compare BM morphologic findings as well as the clinical and laboratory parameters between groups (with MF and without MF) in cytopenic SLE patients. METHODS: We retrospectively analyzed 224 SLE patients' files. Patients were divided into two groups according to whether they had MF or not. Concurrent SLE organ involvements, medical therapy and detailed BM findings were recorded. RESULTS: Forty-five (20%) of 224 SLE patients were found to have undergone BM biopsy due to cytopenia. Four patients were excluded (two drug-induced cytopenia, one lymphoma, one insufficient BM biopsy samples). While MF was detected in 29 (70.7%) of the 41 patients, 12 patients did not have MF. Between the two groups, no differences were identified in terms Systemic Lupus Erythematosus Disease Activity Index, BM cellularity, or BM dysplastic changes (P = 0.788, P = 0.672 and P = 0.494, respectively). In the SLE-associated MF group, 27 patients responded to immunosuppressive therapy and corticosteroids, but two patients were unresponsive. The response time was longer for the SLE-associated MF group compared to the without MF group (3.3 ± 3.1 months vs. 1.7 ± 1.2 months, P = 0.091). Correlation analysis revealed that increased degree of BM fibrosis delayed the response time (r = 0.471, P = 0.002). CONCLUSIONS: MF is common in SLE patients. SLE-associated MF as an additional factor for cytopenia in SLE patients may lead to delayed response to appropriate therapy, which may be dependent on the increased grade of BM fibrosis.

A missense mutation in the M1S1 gene found in a turkish patient with gelatinous droplike corneal dystrophy.

PURPOSE: To report a missense mutation in the M1S1 gene found in a Turkish patient with gelatinous droplike corneal dystrophy (GDLD). METHODS: A Turkish patient with GDLD was examined. Keratoplasty was performed and a diagnosis of GDLD was made by histopathologic and electron microscopic studies. Genomic DNA was extracted from peripheral blood and the paraffin-embedded tissue of the corneal button. A 248-bp DNA fragment of the M1S1 gene was amplified, and sequencing reactions were analyzed. The results were compared with those of 30 healthy, nonrelated individuals. RESULTS: On light microscopic examination, sheets of amorphous amyloid deposits were observed in subepithelial regions and in the anterior and midcorneal stroma. Electron microscopy revealed dense collagen fibrils and entrapped filamentous amyloid fibrils in the corneal stroma. A substitution of T-->C at nucleotide 557 was found in the peripheral blood DNA sequence analysis, which resulted in an amino acid substitution of L-->P (L186P). Results were confirmed by direct DNA sequencing analysis of the paraffin-embedded corneal button. The patient with GDLD was homozygous for the mutation, resulting in amino acid substitution L186P. CONCLUSIONS: This is the first report, to our knowledge, of a homozygous mutation (L186P) in the M1S1 gene found in a Turkish patient. The clinical examination may be insufficient in sporadic cases, and histopathologic examination and molecular genetic analysis can accelerate and improve the accuracy of diagnosis in patients with GDLD.

Mazabraud's syndrome coexisting with a uterine tumor resembling an ovarian sex cord tumor (UTROSCT): a case report.

The association of intramuscular myxoma and fibrous dysplasia is a rare disease known as Mazabraud's syndrome. We present a case of Mazabraud's syndrome coexisting with a uterine tumor and resembling an ovarian sex cord tumor (UTROSCT). This uterine tumor showed a high mitotic index and cytological atypia. To the best of our knowledge, the coexistence of the two different entities has not been reported in the literature.

Retro-orbital, Breast, Cardiac, Skin, and Subcutaneous Metastases of Neuroendocrine Tumor From a Tail Gut Cyst on 68Ga-DOTATATE PET/CT Imaging.

Tail gut cysts are rare congenital lesions developing from postanal primitive gut remnants. They are mostly benign but carry a potential of malignant transformation, such as adenocarcinoma, neuroendocrine tumor, adenosquamous carcinoma, and pseudomyxoma peritonei. We present a 39-year-old woman with a neuroendocrine tumor arising within a tail gut cyst. She underwent complete resection in 2011. After 4 years, she was admitted with breast nodules, left proptosis, and gaze difficulties. Ga-DOTATATE PET/CT demonstrated extensive metastases including pelvic, lymph node, adrenal gland, bone, retro-orbital, cardiac, breast, skin, and subcutaneous metastases.

Fatal isoflurane hepatotoxicity without re-exposure.

Isoflurane is less hepatotoxic than its predecessors, halothane and enflurane. We present a 68-year-old man who developed fulminant and fatal hepatic necrosis two days after open cholecystectomy done under isoflurane anesthesia. Laboratory findings included grossly elevated transaminases and bilirubin and prolonged prothrombin time. Serological studies were negative for viral hepatitis. Postmortem examination demonstrated centrilobular necrosis of liver.

Small cell carcinoma of rectum: a case report.

We present a case of a 40-year-old woman with small-cell carcinoma (SCC) of the rectum. She had profuse bleeding in rectum for 5 d. By colonoscopy, polyps were determined in the rectum and biopsies were carried out. Histopathologically, the polyps were adenomatous. Because of the profuse bleeding in rectum, she underwent low anterior resection. After the diagnosis of SCC, she received intravenous chemotherapy with standard doses of siklofosfamid, adriamycin, and vepesid. Nevertheless, intracranial metastases were revealed and she died 6 mo after the operation.

Effect of H. pylori infection on gastrin, ghrelin, motilin, and gastroesophageal reflux.

BACKGROUND/AIMS: To evaluate the occurrence of gastroesophageal reflux and possible mechanisms in Helicobacter pylori infection. MATERIALS AND METHODS: Symptoms of H. pylori-infected children, their total gastroesophageal reflux episodes, acid exposure percentage, gastrin, ghrelin, and motilin levels were evaluated before and after H. pylori eradication. RESULTS: Forty-two H. pylori-infected children were eligible for this study. Acid exposure % and total reflux episodes before and after H. pylori eradication were 10.2%±14.8% vs. 7.71%±5.0% and 94.7%±102.1% vs. 64.6%±55.0%, respectively (p=0.28, p=0.082). There was an insignificant change in the serum gastrin (93.4±153.8 pmol/L vs. 1.28±149.4 pmol/L, p=0.67), ghrelin (7.69±197.5 pg/mL vs. 8.36±299.5 pg/mL, p=0.274), and motilin (75.1±81.2 pg/mL vs. 97.2±80.5 pg/mL, p=0.206) levels after eradication. Gastrin and ghrelin levels were negatively correlated after H. pylori eradication (r=-0.38, p=0.031). There was no association between gastroesophageal reflux episodes and gastrin, ghrelin, and motilin levels (r=0.25 and p=0.11; r= 0.24 and p=0.13; r=-0.23 and p=0.14, respectively). CONCLUSION: H. pylori infection is neither protective nor harmful in the gastroesophageal reflux. Neither ghrelin nor motilin levels was associated with gastroesophageal reflux. None of gastrin, ghrelin, and motilin levels was affected by H. pylori infection. There is an inverse association between gastrin and ghrelin levels after H. pylori eradication.

Chromosomal abnormalities, p53 and Bcl-2 expression and clinical outcome in choroidal melanoma.

OBJECTIVE: To determine whether alterations of p53, Bcl-2 and chromosomes were present in choroidal melanoma and to further characterize the prognosis of these changes. METHODS: The expression of p53 and Bcl-2 protein was assessed by immunohistochemistry from paraffin blocks. Tumours were analysed by comparative genomic hybridization (CGH) to identify chromosomal aberrations. Fifteen tumours were studied, and the survival results were compared by Spearman correlation analysis with a mean follow-up of 36.5+/-8 months. The majority of tumours were mixed (eight cases), and the others were spindle cell (four cases) and epithelioid cell (three cases) types. Four patients have already died due to metastatic disease. RESULTS: p53 was expressed at a low percentage in only two tumours. There were no differences in Bcl-2 expression in our cases. Bcl-2 was expressed by the majority of cells in all cases. Chromosomal copy number aberrations were detected in 10 of the 15 patients by CGH analyses. A gain at chromosome 8 and a loss at chromosome 3 were the most frequently seen abnormalities. The other aberrations observed were losses at 6q, 7q14 and 17p13-15, and gains at 6p and 18q. Two of the three cases with a loss at 17p13 showed a low percentage expression of p53. No relationship was determined between the chromosomal abnormalities, cell type, expression of p53 and survey. The presence of a chromosome 6q deletion in two of the four patients who died of metastatic disease may indicate that chromosome 6q deletion may be correlated with a poor prognosis. CONCLUSIONS: Our results suggest that choroidal melanomas show high levels of chromosomal alterations. Further studies are necessary to determine the correlation between chromosomal abnormalities and prognosis.

Lazaroid attenuates edema by stabilizing ATPase in the traumatized rat brain.

OBJECTIVE: The aim of the present study was to determine the potential therapeutic value of the lazaroid U-83836E on blood brain barrier (BBB) breakdown and edema with respect to the changes in the synaptosomal Na+/K+ and Mg(2+)/Ca(2+)-adenosinetriphosphatase (ATPase) activities, tissue malondialdehyde levels and the neuronal viability in the rat brain subjected to cerebral trauma. METHODS: Traumatic brain injury (TBI) was introduced by applying a 75 gm. cm force to the right parietal cortex using the weight-drop method. The first set of animals was used for determining time course changes of the synaptosomal Na+/K+ and Mg(2+)/Ca(2+)-ATPase and the malondialdehyde levels and were sacrificed 2, 6 and 24h after lesion production. A group of the animals was treated with U-83836E proir to TBI and sacrificed 24h after cerebral injury. A second set of animals was used for evaluating the alterations in BBB disruption and tissue water content and were sacrificed 2, 6 and 24h after lesion production. Two groups of animals were treated with U-83836E and sacrificed after 2 and 24h following TBI. U-83836E was given intraperitoneally thirty minutes before trauma at a dose of 10 mg/kg. Neuronal necrosis was also evaluated in the groups of U-83836E and physiological saline-treated animals. RESULTS: Extravasation of Evans blue into the traumatized hemisphere was maximum at 2h (p<0.001) and returned close to the control levels at 24h after TBI (p>0.05). Edema had developed progressively over time and reached the maximum degree of 2.1% (p<0.001) at 24h. U-83836E showed no effect on the BBB breakdown and the tissue water content at 2h and still had no effect on the BBB breakdown after 24h following the trauma (p>0.05), although it reduced edema after 24h (p<0.01). The losses of Na+/K+ and Mg(2+)/Ca(2+)-ATPase activities were found as 39.5% (p<0.001) and 29.4% (p<0.01) of the control value, respectively, and remained at the decreased levels throughout the experiment. Malondialdehyde level continued to increase over time reaching up to 209% (p<0.001) of the control value 24h after TBI. Both ATPase activities were improved to near control values (p>.05) by the effect of U-83836E. U-83836E inhibited the increase of lipid peroxidation (p<0.001) and also salvaged neuronal necrosis (p<0.05). CONCLUSION: U-83836E given prophylactically after cerebral trauma appears to reduce edema, possibly by inhibiting increases in lipid peroxidation and by stabilizing ATPase. Further studies are recommended to verify the similar effects of the brain penetrating lazaroids when they are given after trauma.

The effects of sodium phosphate and polyethylene glycol-electrolyte bowel preparation solutions on 2,4,6-trinitrobenzenesulfonic acid-induced colitis in the rat.

The aim of the present study is to evaluate the effects of sodium phosphate (NaP) and polyethylene glycol-electrolyte (PEG-EL) colon cleansing solutions on histopathology of 2,4,6-trinitrobenzene sulfonic acid (TNBS) and ethanol (E)-induced colitis in the rat and normal rat colon. The presence of hyperemia, inflammation and ulcer was evaluated to score of macroscopic morphologic damage. The microscopic criteria including ulceration, mucus cell depletion, crypt abscesses, inflammatory cysts, mucosal atrophy, edema, inflammatory cell infiltration, and vascular dilatation were evaluated to determine the extent of inflammatory reaction. Colitis findings were determined on the rats which were administered TNBS-E. Aphthoid lesions were seen 30% and 20 % of rats, respectively, by NaP and PEG-EL solutions in healthy group. Microscopic examination of aphthoid lesions revealed edema within the lamina propria and lymphoid hyperplasia in the mucosa and submucosa without erosion, ulceration and inflammatory cell infiltration. No significant difference was statistically found either macroscopically or microscopically in terms of the effects of saline, NaP and PEG-EL solutions in healthy rats and rats with colitis (p > .05). Under the present conditions, we concluded administration of NaP and PEG-EL solutions did not cause evident morphological changes on the rectal mucosa macroscopically and microscopically, although in a proportion of rats aphthoid lesions seem as a marker of mucosal damage macroscopically.

Type 1 gastric carcinoid tumor: another extrahepatic manifestation of hepatitis C virus infection?

A 67 year-old female with a 10-year history of cirrhosis due to hepatitis C virus who developed a gastric carcinoid tumor of the corpus is described. Carcinoid tumor was identified during her last routine gastroscopic evaluation for portal hypertension. In the case, serum parietal cell antibodies, hypergastrinemia and atrophic gastritis were also found. Chronic hepatitis C virus infection is known to induce clinical and laboratory signs of autoimmunity. But the question of whether hepatitis C virus plays a pathogenic role in the development of gastric carcinoid tumor is unknown. As far as we know, this is the first report describing gastric carcinoid tumor in hepatitis C virus induced chronic liver disease. We suggest that the possibility of the development of autoimmune atrophic gastritis and carcinoid tumors should be considered in patients with chronic hepatitis C that coexists with autoimmune diseases and has positive parietal cell antibodies.