Tryptase staining of mast cells may differentiate eosinophilic esophagitis from gastroesophageal reflux disease.

OBJECTIVES: Mast cells may contribute to the pathogenesis of eosinophilic esophagitis (EoE), but their role in diagnosis is unknown. Our aim was to determine whether tryptase staining of esophageal mast cells differentiates EoE from gastroesophageal reflux disease (GERD) and has utility for diagnosis of EoE. METHODS: We performed a case-control study comparing patients with EoE, defined by consensus guidelines, to GERD patients with eosinophils on esophageal biopsy. Immunohistochemistry was performed with mast cell tryptase. The density (mast cells/mm2) and intensity (0-4 scale) of mast cell staining was compared between groups after masking the diagnosis. Receiver operating characteristic (ROC) curves were constructed, and the area under the curve (AUC) was calculated to assess mast cell staining as both a stand-alone diagnostic test and an adjunctive assay with eosinophil counts. RESULTS: Fifty-four EoE (mean age 24 years; 69% male; mean 146 eosinophils per high-power field (eos/hpf)) and 55 GERD (mean age 34 years; 60% male; mean 20 eos/hpf) patients were analyzed. The maximum epithelial tryptase density was higher in EoE than in GERD (162±87 mast cells/mm2 vs. 67±54; P<0.001). Mast cells were diffusely distributed throughout the biopsy in more EoE than GERD patients (41 vs. 7%; P<0.001). Tryptase density and eosinophil count were only weakly correlated (R2=0.09; P=0.002). The AUC was 0.84 for tryptase staining alone, and 0.96 for the combination of mast cells and eosinophils. CONCLUSIONS: Patients with EoE have higher levels of tryptase-positive mast cells compared with GERD patients, improving the diagnostic value of biopsies beyond eosinophil counts alone. Mast cell tryptase may have utility as a diagnostic assay for EoE.

Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications.

BACKGROUND: Esophageal strictures resulting from eosinophilic esophagitis present management challenges, and high rates of rents and perforation have been reported. OBJECTIVE: To assess the safety of esophageal dilation in eosinophilic esophagitis and to characterize predictors of both clinical response and complications of the procedure. DESIGN: Retrospective study of the University of North Carolina eosinophilic esophagitis database. SETTING: Tertiary care referral center. PATIENTS: Cases of eosinophilic esophagitis were defined as per consensus guidelines. INTERVENTION: Dilation with either Savary or through-the-scope balloon techniques. MAIN OUTCOME MEASUREMENTS: Complications (deep mucosal rents, contained or free perforation, and chest pain requiring medical attention or hospitalization) and the global clinical symptom response. RESULTS: Of 130 eosinophilic esophagitis cases identified, 70 dilations (12 Savary, 58 balloon) were performed in 36 patients. Esophageal size improved from 12 to 16 mm (P < .001), with an overall symptom response rate of 83%. The only predictor of clinical response was final dilation diameter. There were 5 complications (7%): 2 deep mucosal rents and 3 episodes of chest pain. There were no perforations. There was one hospitalization for chest pain. All complications occurred in patients being treated with topical steroids, who underwent balloon dilation. Complications were associated with younger age (23 vs 42; P = .02) and more dilations (4 vs 1.7; P = .009). LIMITATIONS: Single center, retrospective study. CONCLUSIONS: Esophageal dilation can be performed in eosinophilic esophagitis with low rates of tears, chest pain, and hospitalization. No perforations were found in our database. The effectiveness of dilation was best when a larger esophageal caliber was achieved, but patients undergoing more procedures was associated with complications.

Evaluation of a non-invasive method to detect cytomegalovirus (CMV)-DNA in stool samples of patients with inflammatory bowel disease (IBD): a pilot study.

BACKGROUND: A severe flare of colitis in patients with IBD treated with immunosuppressive therapy may be complicated by an underlying CMV infection. The aim of this pilot study was to investigate the diagnostic efficacy of quantitative polymerase chain reaction (PCR) to detect CMV DNA in stool samples of IBD patients. METHODS: Twenty-one patients with a severe flare of IBD, incompletely responding or refractory to either steroids or immunosuppressive agents, were included in the study. Nineteen patients completed the study according to the protocol undergoing an endoscopy with biopsies and collection of stool samples. Biopsy and stool samples were qualitatively and quantitatively analyzed for CMV DNA using real-time PCR. RESULTS: Thirty-two percent (6/19) of the patients had detectable CMV DNA in colonic biopsies and in five (83%) of those patients CMV DNA was detected in the stool. Thirteen patients had negative findings for CMV DNA in biopsy and stool samples. The sensitivity, specificity, and accuracy of the PCR-based stool test for detection of CMV DNA compared to PCR-based detection of CMV in mucosal biopsies were 83, 93, and 90%, respectively. CONCLUSIONS: The pilot study suggests a high accuracy of this non-invasive testing method to detect CMV DNA in stool samples as compared to mucosal biopsies. This approach may offer a non-endoscopic testing modality for underlying CMV infection in patients with a severe flare of IBD, which could also be applied more broadly to determine the prevalence of CMV infections in patients with IBD.

Inter- and intraobserver reliability and validation of a new method for determination of eosinophil counts in patients with esophageal eosinophilia.

BACKGROUND: Diagnosis of eosinophilic esophagitis (EoE) requires quantification of esophageal eosinophilia. AIMS: The aims of this study were to assess inter- and intraobserver reliability for measuring esophageal eosinophil counts and to validate a novel method of determining tissue eosinophil density using digitized histopathology slides. METHODS: Patients were selected from the University of North Carolina EoE clinicopathologic database. Glass slides were de-identified and scanned to create digitized slides. Using a set protocol, 40 slides were read by each of three pathologists for interobserver measures, and were also reread by one pathologist as traditional glass slides. Different sets of 20 unique slides were read twice by each pathologist for intraobserver measures. Correlation and agreement were calculated with Pearson's rho and the kappa statistic. RESULTS: There was excellent correction between digitized images and glass slides (r = 0.91-0.95, P < 0.001). For maximum eosinophil densities, interobserver correlations were 0.91, 0.76, and 0.79. For mean densities, interobserver correlations were 0.90, 0.89, and 0.85. Intraobserver correlations for maximum densities were 0.99, 0.94, and 0.96, and for mean densities were 0.97, 0.87, and 0.89 (P < 0.001 for all correlations). Agreement was in the "substantial" to "near-perfect" range for pathologists using several diagnostic cut-points for EoE. CONCLUSIONS: Both inter- and intraobserver correlations were excellent for determining eosinophil densities and counts. A method of using digitized slides was valid when compared with traditional glass slides. This protocol could be adopted for research and clinical purposes to further standardize the diagnostic process for EoE.

Clinical, endoscopic, and histologic findings distinguish eosinophilic esophagitis from gastroesophageal reflux disease.

BACKGROUND & AIMS: Features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap; because they cannot be differentiated on the basis of eosinophil counts alone, it can be a challenge to distinguish these disorders. We aimed to characterize the clinical, endoscopic, and histologic features of EoE and GERD and to identify factors that might be used to differentiate them. METHODS: We performed a retrospective case-control study on data collected from 2000 to 2007. Cases were patients of any age with EoE, as defined by recent consensus guidelines; controls were patients of any age with GERD. Clinical and endoscopic data were collected, and all esophageal biopsy specimens were reassessed by gastrointestinal pathologists. Cases and controls were compared, unconditional logistic regression was performed to develop a model to predict EoE, and receiver operator characteristic curves were constructed. RESULTS: Data from 151 patients with EoE and 226 with GERD were analyzed. Compared with GERD, features that independently predicted EoE included younger age; symptoms of dysphagia; documented food allergies; observations of esophageal rings, linear furrows, white plaques, or exudates by upper endoscopy; an absence of a hiatal hernia, observed by upper endoscopy; a higher maximum eosinophil count; and the presence of eosinophil degranulation observed in biopsy specimens. The area under the curve for this model was 0.934. CONCLUSIONS: We identified a set of readily available and routinely measured variables that differentiate EoE from GERD. Use of this type of analysis with patients suspected to have EoE might lead to more accurate diagnoses.

Renal angiomyolipoma, fat-poor variant--a clinicopathologic mimicker of malignancy.

Angiomyolipomas, composed of thick-walled blood vessels, smooth muscle, and adipose tissue, belong to the perivascular epithelioid cell neoplasms (PEComas), a family of tumors believed to be derived from perivascular epithelioid cells which co-express smooth muscle and melanocytic markers. Although most angiomyolipomas are benign, a subset of PEComas has metastatic potential. The pathologic and clinical spectrum of these tumors continues to evolve. We sought to evaluate a subset of renal angiomyolipomas with a minimal amount of fat. We studied 48 renal angiomyolipomas in 41 patients (33 females and 8 males). Based on the amount of adipose tissue, the lesions were categorized as fat-poor, fat-average, and fat-rich lesions (<25, 25-75, and >75 % of fat, respectively). Stains for smooth muscle actin, calponin, HMB-45, melanocyte-associated antigen PNL2, estrogen, and progesterone receptor were examined. Four patients (all females) had more than one lesion, four had coexistent uterine leiomyomata, two had coexistent renomedullary interstitial tumor, and males had only single lesions. Except for one woman, all lesions were sporadic. Twenty-nine were fat-poor (60 %) lesions; 8, fat-average (17 %) lesions; and 11, fat-rich (23 %) lesions. The fat content did not correlate with tumor size: the largest fat-poor and smallest fat-rich lesions were >6 and <2 cm, respectively. All lesions stained with smooth muscle actin and HMB-45; 41 % of tumors were positive for estrogen receptor (11 females and 1 male). No patient had metastases (follow-up 2-11 years). In our series, fat content in angiomyolipoma was not associated with tumor size. Fat-poor angiomyolipomas affected predominantly women and were morphologically and radiologically distinct as mimickers of malignancy. Whether they are biologically different from conventional tumors requires further studies.

Modulation of the intestinal microbiota alters colitis-associated colorectal cancer susceptibility.

It is well established that the intestinal microbiota plays a key role in the pathogenesis of Crohn's disease (CD) and ulcerative colitis (UC) collectively referred to as inflammatory bowel disease (IBD). Epidemiological studies have provided strong evidence that IBD patients bear increased risk for the development of colorectal cancer (CRC). However, the impact of the microbiota on the development of colitis-associated cancer (CAC) remains largely unknown. In this study, we established a new model of CAC using azoxymethane (AOM)-exposed, conventionalized-Il10(-/-) mice and have explored the contribution of the host intestinal microbiota and MyD88 signaling to the development of CAC. We show that 8/13 (62%) of AOM-Il10(-/-) mice developed colon tumors compared to only 3/15 (20%) of AOM- wild-type (WT) mice. Conventionalized AOM-Il10(-/-) mice developed spontaneous colitis and colorectal carcinomas while AOM-WT mice were colitis-free and developed only rare adenomas. Importantly, tumor multiplicity directly correlated with the presence of colitis. Il10(-/-) mice mono-associated with the mildly colitogenic bacterium Bacteroides vulgatus displayed significantly reduced colitis and colorectal tumor multiplicity compared to Il10(-/-) mice. Germ-free AOM-treated Il10(-/-) mice showed normal colon histology and were devoid of tumors. Il10(-/-); Myd88(-/-) mice treated with AOM displayed reduced expression of Il12p40 and Tnfalpha mRNA and showed no signs of tumor development. We present the first direct demonstration that manipulation of the intestinal microbiota alters the development of CAC. The TLR/MyD88 pathway is essential for microbiota-induced development of CAC. Unlike findings obtained using the AOM/DSS model, we demonstrate that the severity of chronic colitis directly correlates to colorectal tumor development and that bacterial-induced inflammation drives progression from adenoma to invasive carcinoma.

Oral budesonide for the therapy of post-liver transplant de novo inflammatory bowel disease: a case series and systematic review of the literature.

BACKGROUND: The therapy for posttransplant IBD is clinically challenging. Patients receiving liver transplants are immunosuppressed to prevent rejection, but via an unknown mechanism develop de novo IBD in spite of receiving some of the same medications used for therapy in traditional IBD. In the published literature most of the patients who developed de novo IBD were treated with traditional corticosteroids. Exposure to systemic corticosteroids increases risks of infection, diabetes mellitus, and osteoporosis among other complications. Budesonide, a luminally active steroid with low systemic absorption, is an established therapeutic agent for IBD that should receive special considerations as first-line therapy in this patient population. METHODS: We describe 3 cases of de novo IBD after liver transplantation. None of these patients had a history of IBD prior to their transplant. All 3 were treated with oral budesonide in lieu of systemic corticosteroids. Additionally, a Medline MeSH search was performed using the terms "inflammatory bowel disease" and "liver transplant" as part of a systematic review of the literature. RESULTS: All 3 cases of de novo post transplant IBD went into clinical remission with oral budesonide. The Medline search ultimately revealed 19 case reports, case series or retrospective reviews on de novo post liver transplant IBD. Most reports focused on the diagnosis and risk factors and did not have an emphasis on therapy. CONCLUSIONS: Given the track record for budesonide in traditional IBD, and its documented efficacy and systemic steroid-sparing benefit, in our opinion this drug should be considered first-line therapy for de novo posttransplant IBD.

Flat colorectal cancers are genetically determined and progress to invasion without going through a polypoid stage.

Growing evidence suggests that flat colorectal cancers (CRC) account for 10% to 20% of all CRCs and that these are frequently associated with more advanced pathologies. However, controversy exists as to the origin and progression of flat CRCs compared with the more common polypoid-type morphology. We report using the azoxymethane mouse model for human CRC that KK/HIJ and I/LNJ mice develop different frequencies of flat and polypoid tumors; 83% of colon tumors in I/LNJ mice are flat compared with only 19% in KK/HIJ mice, indicating a strong genetic predisposition to the development of specific CRC morphologies. Like polypoid tumors, all flat tumors show a significant increase in the level of nuclear beta-catenin (CATNNB1), supported by similar frequencies of mutations in the phosphorylation domain-coding region (codons 32-41) of Catnnb1. However, in contrast to previous reports, tumors bearing higher "oncogenic potential" do not cluster in codon 41 of Catnnb1. There are no differences between flat and polypoid tumors in the frequency of mutations in codons 12 and 13 of Kras or codon 624 of Braf. Similarly, there are no differences between tumor morphologies in their location along the proximal-to-distal colonic axis or in the relative quantity of intratumor stromal myofibroblasts as marked by the expression of alpha-smooth muscle actin. Using a combination of serial colonoscopic and histologic analyses, we definitively show that flat CRCs do not develop de novo but progress through a flat adenomatous stage to invasive carcinoma without transit through an intermediary polypoid stage.

Determination of ultrafilterable prolactin: elimination of macroprolactin interference with a monomeric prolactin-selective sample pretreatment.

CONTEXT: Macroprolactin (macroPRL), present in as many as 25% of serum specimens with elevated serum prolactin concentrations, can cause apparent hyperprolactinemia in the absence of clinical features and lead to unnecessary clinical, laboratory, and neuroradiological workups. OBJECTIVE: To develop an ultrafiltration method that eliminates macroPRL interference from PRL immunoassays. DESIGN: The method involves centrifugation of undiluted serum in a Centricon-100 filter device followed by a PRL assay of the serum ultrafiltrate. RESULTS: Ultrafiltrates prepared by this technique are devoid of gamma globulins and contain (mean +/- SE) 19% +/- 7% of the albumin concentration of the original serum. These ultrafiltrates contain 85% +/- 7% of the total PRL immunoreactivity of serum spiked with 23 kd recombinant human prolactin (rHuPRL) and less than 2% of the 50 kd big PRL (bPRL) of whole serum. The fractional recovery of ultrafilterable PRL (uPRL) from serum samples of 54 female patients was 0.78 (confidence interval 0.73-0.83) of the total. The run-to-run coefficient of variation of the uPRL assay was 4.3%. The uPRL concentration (mean +/- SD) in a group of healthy female controls was 8.0 +/- 3.1 ng/mL. CONCLUSIONS: Ultrafiltration is a rapid and simple method for eliminating analytical interference by macroPRL. Ultrafiltrates can be analyzed by most, if not all, currently available PRL immunoassays and represent a practical and precise alternative to gel filtration chromatography for the estimation of the monomeric prolactin concentration of serum.

Multifocal gastrointestinal stromal tumor (GIST) of the stomach in an 11-year-old girl.

A previously healthy 11-year-old girl presented with an 8-month history of anemia and left upper quadrant abdominal pain. US examination demonstrated a 9-cm cystic mass with a fluid-fluid level in the left upper quadrant with unclear organ of origin. Abdominal MR imaging demonstrated a complex cystic mass, likely arising from the stomach. Additional T2 hyperintense submucosal lesions were identified in the gastric wall. Surgical excision confirmed the diagnosis of multifocal gastric gastrointestinal stromal tumor (GIST). MR imaging was helpful in suggesting a gastric origin of the primary mass and in demonstrating multifocal disease within the stomach.

Fatal hemorrhagic pneumonia concomitant with Chlamydia pneumoniae and parainfluenza virus 4 infection.

CONTEXT: Cases of fatal hemorrhagic pneumonia need to be investigated for highly contagious viral causes. While not all hemorrhagic pneumonias are caused by very contagious agents, the etiology must be correctly determined in order to administer appropriate patient care. OBJECTIVE: To determine whether chlamydia, paramyxovirus, or mycoplasma was the causative agent in a case of fatal hemorrhagic pneumonia, and to evaluate the possibility that this was the first case of hantavirus pulmonary syndrome in Illinois. DESIGN: Nonroutine virological and molecular analyses were performed on lung tissue taken during an unrestricted autopsy of a patient who died in 2002. SETTING AND PATIENT: An elderly, male, Chicago-area resident with a 3-week history of nonspecific, mild upper respiratory tract infection was admitted for hospital treatment of the respiratory infection and viral myositis without cardiac involvement. The patient became febrile, hypoxic, developed hemorrhagic pneumonia, and died. Because he had proven exposure to mice and had developed hemorrhagic pneumonia, hantavirus pulmonary syndrome was suspected as the cause of death. Mice known to carry hantaviruses live in Illinois, including the Chicago area. INTERVENTIONS: Gatifloxacin and heparin anticoagulation were initiated because community-acquired pneumonia and pulmonary embolism were considered likely etiologies for an acute exacerbation of hypoxemia. RESULTS: Two respiratory pathogens were isolated and identified: Chlamydia pneumoniae and human parainfluenza virus 4a. CONCLUSIONS: A mixed (polymicrobial) infection contributed to the patient's death. Hemorrhage was likely a result of anticoagulation therapy superimposed on lung tissues damaged by pneumonia. The uncommon nature of this case and the pathogens involved underscore the challenges in infection control and clinical evaluation that hospitals will face when confronted with possibly new and potentially deadly communicable diseases.

A case of acute hemolysis after ceftriaxone: immune complex mechanism demonstrated by flow cytometry.

An immune complex mechanism for ceftriaxone sodium- induced severe autoimmune hemolytic anemia has previously been demonstrated using routine blood bank techniques. We describe herein a patient with severe hemolysis that subsided once the drug was discontinued. Serologic techniques demonstrated immune complex-mediated ceftriaxone-dependent red cell antibodies. These findings were further supported by the results of flow cytometry, in which a change in basal red cell autofluorescence was seen in the presence of the antibody and the drug. Our case illustrates the adjunctive value of flow cytometry in the diagnosis of ceftriaxone-dependent red cell antibody.