Coexistencia de colitis linfocítica y enteritis microscópica en pacientes con diarrea crónica / Concurrent lymphocytic colitis and microscopic enteritis in patients with chronic diarrhea

Introducción: Colitis linfocítica y enteritis microscópica son causas relativamente comunes de diarrea crónica y ambas se caracterizan por un infiltrado linfocitico intraepitelial. No existen reportes previos de la coexistencia de ambas entidades. Objetivo: Describir las características clínicas e histológicas de los pacientes que presentan este diagnóstico simultáneamente. Material y métodos: Se seleccionaron pacientes adultos con diarrea crónica que tuvieran biopsia simultánea de colon y duodeno tomados el mismo día, durante los años 2010-2016, en el Servicio de Gastroenterología del Hospital Nacional Daniel Alcides Carrión. Se recopiló información clínica del archivo de historias. Las láminas fueron reevaluadas histológicamente por 3 patólogos. Se realizó estudio inmunohistoquímico de linfocitos intraepiteliales para CD8 y CD3 en 6 casos. Resultados: De 63 pacientes con diarrea crónica y biopsia simultánea de duodeno y colon, se identificó un total de 35 pacientes (55,5%) con diagnóstico simultáneo de enteritis microscópica y colitis linfocítica, 80% fueron mujeres. Se identificó anemia en 28,5% de los pacientes e infestación por Blastocystis hominis en el 31,8.%. En enteritis microscópica, el promedio de linfocitos intraepiteliales con CD8 y CD3 fue 40%, mientras que, en colitis linfocítica, el promedio fue de 37,2% para CD3 y 29,2% para CD8. En 11 de los 35 casos, se pudo obtener biopsias de íleon que fueron diagnosticadas como ileitis linfocítica. En 9 casos se diagnosticó colitis eosinofílica asociada a colitis linfocítica. Conclusión: Se encontró coexistencia de colitis linfocítica, enteritis microscópica y en algunos de ileitis linfocítica en un 55,5% pacientes con diarrea crónica con biopsia duodenal y colónica. Estos resultados abren la interrogante sobre si colitis linfocítica y enteritis microscópica son entidades diferentes o constituyen una sola patología que en algunos pacientes afecta varios segmentos del tubo digestivo.

Introduction: Lymphocytic colitis and microscopic enteritis are relatively common causes of chronic diarrhea and it is characterized by an intraepithelial lymphocytic infiltrate. There have been no previous reports of coexistence between these 2 pathologies. Objective: To describe histological and clinical characteristic in patients with coexistence of lymphocytic colitis and microscopic enteritis. Material and methods: All cases with simultaneous diagnosis of lymphocytic duodenosis and lymphocytic colitis were reevaluated during lapse time 2010-2016 in hospital Daniel Carrion. The slides were reviewed by 3 pathologists and clinical information was obtained from clinical records. Expression of CD3 and CD8 was detected in 6 cases by immunohistochemical assays. Results: A total of 35 patients with coexistence of lymphocytic duodenitis and lymphocytic colitis were selected of the pathology archives, 80% were females, Anemia was identified in 28.5% of patients. Blastocysitis hominis infestation was identified in 31.8%. The mean intraepithelial lymphocyte CD8 and CD3 positive was 40% in microscopic enteritis, while the mean intraepithelial lymphocyte CD3 positive was 37.2% and CD8 positive was 29.2% Additionally, lymphocytic ileitis was diagnosed in 11 of our cases. Eosinophilic colitis was diagnosed in 9 cases of lymphocytic colitis Conclusion: We found that lymphocytic colitis, microscopic enteritis and even lymphocytic ileitis can coexist in a group of patients with chronic diarrhea. These findings bring the question if this concurrence of both pathologies constituted a more generalized gastrointestinal disorder, involving both the large and the small intestines.

[Concurrent lymphocytic colitis and microscopic enteritis in patients with chronic diarrhea]. / Coexistencia de colitis linfocítica y enteritis microscópica en pacientes con diarrea crónica.

INTRODUCTION: Lymphocytic colitis and microscopic enteritis are relatively common causes of chronic diarrhea and it is characterized by an intraepithelial lymphocytic infiltrate. There have been no previous reports of coexistence between these 2 pathologies. OBJECTIVE: To describe histological and clinical characteristic in patients with coexistence of lymphocytic colitis and microscopic enteritis. MATERIAL AND METHODS: All cases with simultaneous diagnosis of lymphocytic duodenosis and lymphocytic colitis were reevaluated during lapse time 2010-2016 in hospital Daniel Carrion. The slides were reviewed by 3 pathologists and clinical information was obtained from clinical records. Expression of CD3 and CD8 was detected in 6 cases by immunohistochemical assays. RESULTS: A total of 35 patients with coexistence of lymphocytic duodenitis and lymphocytic colitis were selected of the pathology archives, 80% were females, Anemia was identified in 28.5% of patients. Blastocysitis hominis infestation was identified in 31.8%. The mean intraepithelial lymphocyte CD8 and CD3 positive was 40% in microscopic enteritis, while the mean intraepithelial lymphocyte CD3 positive was 37.2% and CD8 positive was 29.2% Additionally, lymphocytic ileitis was diagnosed in 11 of our cases. Eosinophilic colitis was diagnosed in 9 cases of lymphocytic colitis Conclusion: We found that lymphocytic colitis, microscopic enteritis and even lymphocytic ileitis can coexist in a group of patients with chronic diarrhea. These findings bring the question if this concurrence of both pathologies constituted a more generalized gastrointestinal disorder, involving both the large and the small intestines.

Blastocystis sp. in splenic cysts: causative agent or accidental association? A unique case report.

BACKGROUND: Blastocystis sp. is one of the most prevalent parasites found in human stool and has been recently considered an opportunistic emerging pathogen in immunocompromised individuals. However, cases of invasive intestinal infections and skin rashes have been attributed to infection by Blastocystis sp in immunocompetent individuals, suggesting that it is an emerging parasite with pathogenic potential. FINDINGS: We present a case of a 22 year old female patient who complained of pain in the left hypochondrium. Ultrasonography and abdominal computed tomography scans showed two splenic cysts. The cyst fluid analysis demonstrated numerous Blastocystis sp.; PCR and DNA sequencing analyses confirmed the presence of Blastocystis subtype 3. CONCLUSIONS: This is, to our knowledge, the first case report of the presence of Blastocystis subtype 3 in extra-intestinal organs and is strong evidence that Blastocystis sp. is potentially pathogenic and invasive. However, further studies are required to determine the pathogenicity of the parasite.

[Blastocystis hominis in symptomatic celiac patients]. / Blastocystis hominis en pacientes celíacos sintomáticos.

INTRODUCTION: Celiac disease (EC) not diagnosed or treated affect histological, immunological and nutritional status of patients who suffer it. These changes allow infection by parasites that cause no symptoms in immunocompetent patients, such as Blastocystis hominis (Bh). OBJETIVE. To analyze the presence of Bh in symptomatic celiac patients and describe the clinical, histological, immune and nutritional status in these patients. MATERIAL AND METHOD An observational descriptive cross sectional study was performed. Thirty symptomatic celiac patients (18 women, mean age 41 years old, range 19-68 years), assisted at the Institute of Gastroenterology of Cuba from January to December 2009, entered the study. RESULTS: Diarrhea and chronic anemia were the most commonly reported clinical manifestations (22 and 4 patients, respectively). The analysis of more than five Bh per field was more frequent in the group ofpatients studied (63.3%), with statistically significant difference in patients with vilous atrophy and low weight (P < 0.03) compared to cases with less than five Bh per feld. No significant differences were found when the immune status of patients was analyzed. CONCLUSIONS. In symptomatic celiac patients with subtotal-total villous atrophy and low weight the finding of more than five Bh perfield should be considered as opportunistic.

Infección experimental de aislados humanos de Blastocystis sp. en ratones inmunosuprimidos con dexamentasona / Experimental infection using human isolates of Blastocystis sp. in dexamethasone immunosurpressed mice

Blastocystis sp. es un protozoario controversial en cuanto a su papel patogénico, asociado a enfermedad gastrointestinal, con alta prevalencia. A fin de evaluar signos, síntomas y hallazgos de laboratorio producidos por Blastocystis sp., ratones inmunosuprimidos con dexametasona fueron infectados con morfologías del parásito obtenidos de pacientes sintomáticos y asintomáticos. Los parásitos se aislaron empleando gradiente de densidad con lymphoprep™, se realizó semicuantificación de las morfologías presentes en las muestra de heces, y se inocularon 1,6 × 105 parásitos en ratones Balb/c, vía intragástrica. En heces de pacientes sintomáticos se encontraron seis veces más vacuolares que granulares, mientras que en asintomáticos la relación fue apenas dos veces mayor. Los síntomas más frecuentes en los pacientes fueron: flatulencia (85%), dolor de cabeza(62%), dolor abdominal (55%), fiebre (30%) y estreñimiento (8%). La semicuantificación de parásitos por campo en humanos no encontró relación directa entre carga parasitaria y sintomatología gastrointestinal, mientras que en la cuantificación de parásitos por gramo de heces si existió. Los ratones presentaron signos variables luego de la infección, todos aquellos infectados con muestras de pacientes sintomáticos presentaron signos, mientras que solo algunos de los infectados con muestras de pacientes asintomáticos los desarrollaron. Se demostró que no existe relación estadísticamente significativa (p= 0,8) entre la morfología del parásito y los signos manifestados por el ratón; sin embargo hubo una relación estadísticamente significativa (p=0,02) entre las formas vacuolares del parásito y la aparición de síntomas en los pacientes. Se concluye que Blastocystis sp. tiene capacidad de producir signos sugestivos de patología en ratones.

Blastocystis sp. is a controversial protozoan in terms of its pathogenic role associated with high-prevalence gastrointestinal disease. To evaluate signs, symptoms and laboratory findings produced by Blastocystis sp., dexamethasone immunosuppressed mice were infected with parasite morphologies obtained from symptomatic and asymptomatic patients. The parasites were isolated using density gradient with lymphoprep™, semi-quantification of the morphologies present in the stool sample was performed and 1.6 × 105 parasites were inoculated into Balb/c mice, intragastrically. In the faeces of symptomatic patients, vacuolar morphology was six times greater than granular morphology, whereas the ratio in asymptomatic patients was only two times greater. The most common symptoms in patients were flatulence (85%), headache (62%), abdominal pain (55%), fever (30%) and constipation (8%). The semi-quantification of parasites per field in humans evidenced no direct relationship between parasite burden and gastrointestinal symptoms, while in parasite quantification per gram of feces, a direct relationship was found. The mice showed variable signs after infection; all those infected with samples from symptomatic patients showed signs, while only some of those infected with samples from asymptomatic patients developed them. It was demonstrated that no statistically significant (p = 0.8) relationship exists between the morphology of the parasite and the signs manifested by the mouse; nevertheless, there was a statistically significant (p = 0.02) relationship between the vacuolar forms of the parasite and onset of symptoms in patients. Conclusions are that Blastocystis sp. is capable of producing signs suggestive of pathology in mice.