Successful Food-Elimination Diet in an Adult with Eosinophilic Gastroenteritis.

We successfully treated a 22-year-old woman with eosinophilic gastroenteritis (EGE) using a multiple food-elimination diet. The patient was diagnosed with EGE based on histopathological findings and initially treated with oral prednisolone. The symptoms immediately improved, although they recurred when prednisolone was tapered to a low dose. We then treated her with a multiple food-elimination diet, including milk, soy, eggs, wheat, nuts, seafood, and rice. During dietary treatment, we identified dairy products and eggs as causative foods of the symptoms, and we ceased prednisolone. Similar to eosinophilic esophagitis, an elimination diet may be effective for adult patients with EGE.

Ankylosaurus back sign: novel endoscopic finding in esophageal eosinophilia patients indicating proton pump inhibitor response.

BACKGROUND AND STUDY AIMS: Characteristic endoscopic findings, such as linear furrows, rings, and whitish exudates, indicate the presence of esophageal eosinophilia (EE), though no specific findings are known to distinguish eosinophilic esophagitis (EoE) from proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE). Here, we present a novel endoscopic finding in some EE patients possessing a linear longitudinal arrangement of whitish nodules with the appearance of the back of an Ankylosaurus dinosaur, termed Ankylosaurus back sign (ABS), and evaluations of its significance in affected patients. PATIENTS AND METHODS: Fifty-five patients diagnosed with EE (≥ 15 eosinophils/high power field) who were treated at our hospital and shown to evaluate a PPI response were enrolled. Endoscopic findings at baseline and clinical parameters were retrospectively reviewed. Furthermore, the clinicopathological features of patients with ABS, as well as the relationship between its presence and PPI response were evaluated. RESULTS: Fifty-five patients (47 males, 8 females) with EE (17 with EoE, 38 with PPI-REE) were evaluated, of whom 50 (90.9 %) had linear furrows, the most frequently found feature, while ABS was found in 9 (16.4 %). Inter-observer agreement was substantial for ABS (κ 0.77). Interestingly, all patients with ABS had PPI-REE. Our findings revealed that the presence of ABS was closely associated with reflux esophagitis (RE) in patients with PPI-REE. CONCLUSIONS: Although ABS was less frequent than typical endoscopic findings such as linear furrows in EE, this novel finding was closely associated with PPI-REE accompanied with RE. The clinical implications of ABS in patients with EE should be investigated further.

Celiac disease in non-clinical populations of Japan.

BACKGROUND: Celiac disease is a chronic autoimmune enteropathy caused by gluten ingestion. While its prevalence in Western countries is reported to be as high as 1%, the prevalence has not been evaluated in a large-scale study of a Japanese population. The aim of our study was to clarify the possible presence of celiac disease in a Japanese non-clinical population as well as in patients showing symptoms suggestive of the disease. METHODS: Serum samples were collected from 2008 non-clinical adults and 47 patients with chronic unexplained abdominal symptoms between April 2014 and June 2016. The anti-tissue transglutaminase (TTG) immunoglobulin A antibody titer was determined as a screening test for celiac disease in all subjects, and individuals with a value of >2 U/mL subsequently underwent testing for the presence of serum endomysial IgA antibody (EMA) as confirmation. Those testing positive for EMA or with a high concentration (>10 U/mL) of TTG were further investigated by histopathological examinations of duodenal mucosal biopsy specimens and HLA typing tests. RESULTS: Of the 2008 non-clinical adults from whom serum samples were collected, 161 tested positive for TTG, and all tested negative for EMA. Four subjects who had a high TTG titer were invited to undergo confirmatory testing, and the histopathological results confirmed the presence of celiac disease in only a single case (0.05%). Of the 47 symptomatic patients, one (2.1%) was found to have a high TTG titer and was diagnosed with celiac disease based on duodenal histopathological findings. CONCLUSION: The presence of celiac disease in a non-clinical Japanese population was low at 0.05% and was rarely found in patients with unexplained chronic abdominal symptoms.

A Combined Deposition of Lanthanum and ß2-Microglobulin-Related Amyloid in the Gastroduodenal Mucosa of Hemodialysis-Dependent Patients: An Immunohistochemical, Electron Microscopic, and Energy Dispersive X-Ray Spectrometric Analysis.

Lanthanum carbonate (LC) is a new type of phosphate adsorbent used to treat patients with hyperphosphatemia caused by chronic kidney diseases. Recent studies have pointed out that lanthanum deposition can be found in the cytoplasm of histiocytes in the gastroduodenal mucosa of these patients. On the other hand, it is well known that patients on long-term hemodialysis can develop deposition of ß2-microglobulin-related amyloid (Aß2M) mainly around joints. However, involvement of the gastrointestinal tract by hemodialysis-associated amyloidosis has been thought to be rare, and therefore only Aß2M, if any, has been reported to accumulate in the vascular walls of the submucosa and muscularis propria. Thus, in contrast to AA amyloid, biopsy from gastrointestinal mucosa has long been considered to have little significance in detecting amyloid. We present unusual histologic findings on biopsy specimens taken from the gastroduodenal mucosa of 7 hemodialysis-dependent patients taking LC for more than a year. These findings were due to a combined deposition of lanthanum and ß2-microglobulin-related amyloid in the cytoplasm of histiocytes. The deposition of amyloid was confirmed by conventional histochemistry, immunohistochemistry, and transmission electron microscopy, and that of lanthanum by transmission electron microscopy and scanning electron microscopy/energy dispersive X-ray spectrometry. This is the first report of such a peculiar combined deposition of lanthanum and amyloid in the gastroduodenal mucosa of hemodialysis patients. Although the exact mechanism of combination and pathogenesis is unclear, we believe that histologic examination of the gastrointestinal mucosa should be considered in the careful follow-up and observation of hemodialysis patients taking LC.

Interpretation of postmortem head computed tomography for non-traumatic in-hospital deaths by non-radiologists: a preliminary study.

PURPOSE: Postmortem computed tomography (PMCT) has recently become important to clarify the cause of death in forensic medicine. It has also been proven to be useful for in-hospital deaths to a certain extent when interpreted by radiologists. However, accuracy of the interpretations of PMCT by non-radiologists remains to be elucidated. Nevertheless, they are often required to write death certificates based on the findings of PMCT in the absence of radiologists in Japan. We compared the interpretations of postmortem head CT (PMCT-H) by non-radiologists with the autopsy findings. METHODS: This study included 13 patients who underwent both brain dissection at autopsy and PMCT between June 2011 and December 2014. All cases were non-traumatic in-hospital deaths. Interpretation of PMCT was performed by the clinicians in charge of the patients, not by radiology experts. RESULTS: The patients were first examined with PMCT and then autopsies were performed. Ten out of 13 cases were confirmed to have no lesions in the cranial cavity by both PMCT-H and autopsy. Two cases were diagnosed with intracranial hemorrhage (intracerebral and/or subarachnoid hemorrhage) and one with recurrent malignant lymphoma by both the clinicians and the pathologists. Intracranial hemorrhages were thought to be the direct causes of mortality of the two patients, and recurrent malignant lymphoma was considered to be one of the cardinal findings of the cancer death. There were no discrepancies between PMCT-H and autopsy findings. CONCLUSIONS: The interpretations of PMCT-H by non-radiologists were completely the same as the autopsy findings regarding the non-traumatic in-hospital deaths in this study. It is premature to draw a definitive conclusion at present, but PMCT-H might be as effective as autopsy not only for those lesions described above but also for no remarkable changes in the brain. There has been no report on such a comparison. We believe further verification of the validity of interpretation of PMCT by non-radiologists is worthwhile in terms of death certificates made out in the absence of radiology experts and pathologists.

A Case Report of Bilateral Sarcomatoid Carcinoma of Adrenal Glands With Adrenal Insufficiency.

Adrenocortical carcinomas are relatively rare, but they are considered to be highly aggressive malignant tumors. Sarcomatoid carcinomas represent an even more aggressive type. Bilateral malignant adrenal tumors are extraordinary rare, except for those that represent metastatic spread from a primary neoplasm. Here we report a case of a 69-year-old woman who presented symptoms that raised strong suspicions of adrenal insufficiency. Bilateral adrenal masses, identified in the imaging study, were responsible for the clinical manifestation and surgically resected. Surgical specimens of the bilateral adrenal tumors shared histological features compatible with sarcomatoid carcinoma. It was very difficult to confirm that the sarcomatoid carcinomas were derived from the cortex of the adrenal glands, but careful morphological observation and the panel of antibodies used for immunohistochemistry made the diagnosis possible. This is the first report of sarcomatoid carcinomas involving both adrenal glands. It should be emphasized that sarcomatoid carcinoma can arise bilaterally from even functionally impaired adrenal glands.

The number and distribution of eosinophils in the adult human gastrointestinal tract: a study and comparison of racial and environmental factors.

There are surprisingly limited data regarding normal counts or distribution of eosinophils in the gastrointestinal tract, despite the increasing incidence of eosinophilic gastrointestinal tract diseases. Moreover, there are no published reports on the eosinophil number throughout the gastrointestinal tract of adults or Asian populations, or those investigating the effect of race on eosinophil count. First, in our study, the number of eosinophils from each portion of the gastrointestinal mucosa was quantified on biopsy slides from a Japanese adult population (132 samples). Next, the surgical resections from Japanese (110 samples), Japanese Americans (64), and Caucasians (57) were used to investigate the racial and environmental effects. Our results with the Japanese biopsy samples showed a significant increase in the number of eosinophils from the esophagus to the right colon (mean±SD/mm: 0.07±0.43 for the esophagus, 12.18±11.39 for the stomach, and 36.59±15.50 for the right colon), compared with a decrease in the left colon (8.53±7.83). Investigation using surgical samples showed that the distribution patterns in the gastrointestinal tract were very similar among the 3 ethnic groups, and there were no significant differences in the number of eosinophils among these groups, except in the esophageal epithelium. This study is the first report on the normal numbers and distribution of eosinophils throughout the gastrointestinal tract not only of an Asian population but also of adults. Our data suggest that a cutoff value for eosinophil counts, when rendering a diagnosis of eosinophilic gastrointestinal tract disease, should be individualized to the different biopsy sites. Interestingly, race and environmental factors did not seem to have a significant effect on eosinophil densities and distributions.