Cowdry Type Research Articles

Two Sides of the Same Coin: Eosinophilic and Herpetic Esophagitis in an Immunocompetent Young Adult.

Dear Editor, We report a case of a 30-year-old woman with an 8-year diagnosis of eosinophilic esophagitis (EoE) treated with swallowed fluticasone propionate throughout this period. She presented to the emergency room with a two-day history of severe odynophagia, aphagia, retrosternal pain, and fever. The patient was febrile and hemodynamically stable, with no visible oropharyngeal lesions. She presented with elevated C-reactive protein (37 mg/L). An esophagogastroduodenoscopy was performed, which revealed white plaque-like lesions with "volcano-like" shallow ulcerations with raised edges on the distal esophagus (Figure 1aandb). Multiple biopsies were taken from both the center and edges of the lesions. The patient was empirically started on intravenous fluconazole due to the suspicion of candida esophagitis. However, the patient's symptoms worsened over the next two days, and acyclovir at a dose of 5 mg/kg was started. The initial work-up showed a positive titer for Herpes Simplex Virus (HSV)-2 IgM (1.6 U/L) and a negative titer for IgG (2.24 U/L), as well as a negative serological study for HSV-1, cytomegalovirus, and human immunodeficiency virus (HIV). Histological examination revealed multinucleated giant cells with nuclear molding and chromatin margination and cells with "ground glass" nuclei, along with typical Cowdry type A intranuclear inclusion bodies and immunohistochemical staining for HSV type 2, confirmed the diagnosis of herpetic esophagitis (Figure 1candd). The patient experienced rapid improvement and was discharged on oral acyclovir therapy at 400 mg/day, completing a total of 14 days of treatment with a total resolution of symptoms.

Detection and diagnosis of Panulirus argus virus 1 in captive spiny lobsters using qPCR in conjunction with histopathology and transmission electron microscopy.

Panulirus argus virus 1 (PaV1) is the first and only naturally occurring pathogenic virus described in the Caribbean spiny lobster, Panulirus argus. PaV1 infection in decapod species that commonly co-occur with P. argus, including the spotted spiny lobster Panulirus guttatus, has not been previously described. In 2016, 14 Caribbean and 5 spotted spiny lobsters were collected near Summerland Key, Florida, to supplement the resident population of the Audubon Aquarium of the Americas in New Orleans, Louisiana. After 5 months in quarantine, Caribbean and spotted spiny lobsters began to exhibit clinical signs of lethargy and dying in the molt. Initial histologic evaluation revealed intranuclear inclusion bodies in circulating hemocytes in the spongy connective tissue of the epidermis, suggesting a viral infection. Samples of hepatopancreas and hemolymph from deceased Caribbean and spotted spiny lobsters tested negative for white spot syndrome virus and positive for PaV1 using real-time quantitative polymerase chain reaction (qPCR). Intranuclear, eosinophilic to amphophilic, Cowdry type A inclusion bodies observed primarily within fixed phagocytes and circulating hemocytes in the hepatopancreas of freshly euthanized Caribbean spiny lobsters were consistent with PaV1 infection. Transmission electron microscopy revealed that hemocytes associated with hepatopancreatic tubules contained viral inclusions with location, size, and morphology consistent with previously described PaV1 infection. These findings highlight the significance of using molecular diagnostics in conjunction with histopathology and electron microscopy in the investigation and diagnosis of PaV1 in spiny lobsters. Further study is required to investigate the relationship of PaV1-associated mortality events and microscopic lesions in the spotted spiny lobster.

S2350 Mind the Steroids: Herpes Esophagitis in an Immunocompetent Patient After Steroid Therapy

Introduction: Infective esophagitis (IE) is rare, but well known to complicate the immunosuppressed state; particularly the HIV infected, transplant recipient, cancer patient and those treated with chronic corticosteroids or immunomodulators. Common infections include candida, cytomegalovirus, and herpes simplex virus (HSV). Steroids have been used for symptomatic relief of an acute sore throat. Short courses are considered benign with low risk of infectious complications. We report an immunocompetent patient found to have herpes esophagitis after a short course of corticosteroids. Case Description/Methods: A 41-year-old African American male with history of hypertension presented with worsening sore throat and odynophagia restricting oral intake. Prior to presentation, he had a 10-day history of sore throat. He was diagnosed with streptococcal pharyngitis and was on antibiotics and steroids 7 days ago. Given persistent symptoms he underwent laryngoscopy which demonstrated bilateral tonsillar exudates and normal pharyngeal mucosa, prompting admission and initiation of IV antibiotics and dexamethasone. He had modest improvement of pain, however 8 days later expressed worsening burning retrosternal chest pain and progressed oral intolerance. He underwent upper endoscopy revealing multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus (Figure A). Biopsies demonstrated viral intranuclear inclusions that stained positive for HSV1/HSV2 (Figure B, C). His symptoms abated while on IV acyclovir allowing transition to oral valacyclovir. Discussion: Corticosteroids are well known for their anti-inflammatory effect but immunosuppression with short courses may be underestimated. Infectious sequalae such as herpetic esophagitis may complicate steroid use even when therapy duration is short. This patient was found to have progressive odynophagia while on corticosteroids administered for analgesia and had significant improvement after antiviral therapy. It is easy to overlook IE as a cause of odynophagia in the immunocompetent, however, with history of steroid use, a diagnosis of IE, especially HSV esophagitis, should be considered in the differential. Therefore, one should have a low threshold for early endoscopy when evaluating these patients.Figure 1.: A: Endoscopic photograph displaying multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus. B: (x200): Photomicrograph of hematoxylin and eosin-stained section of the esophageal biopsy, showing multiple multinucleated epithelial cells. Cowdry type A is observed. C: (x200): IHC study using antibodies against HSV-1. Numerous intranuclear viral inclusions are positive with HSV-1 within the infected cells.

Current status of infection with infectious hypodermal and hematopoietic necrosis virus (IHHNV) in the Peruvian and Ecuadorian shrimp industry.

Infection with infectious hypodermal and hematopoietic necrosis virus (IHHNV) is a crustacean disease that caused large-scale mortality in Penaeus stylirostris, deformity and growth retardation in Penaeus vannamei and Penaeus monodon. We surveyed the presence of IHHNV in three major shrimp-producing regions in Ecuador, namely Guayas, El Oro, and Esmeralda. The data show that IHHNV is endemic (3.3–100% prevalence) to shrimp farms in these regions. The whole genome sequences of representative circulating IHHNV genotypes in Ecuador and Peru showed that these genotypes formed a separate cluster within the Type II genotypes and were divergent from other geographical isolates of IHHNV originating in Asia, Africa, Australia, and Brazil. In experimental bioassays using specific pathogen-free (SPF) P. vannamei, P. monodon, and P. stylirostris and representative IHHNV isolates from Ecuador and Peru, the virus did not cause any mortality or induce clinical signs in any of the three penaeid species. Although IHHNV-specific Cowdry type A inclusion bodies were histologically detected in experimentally challenged P. vannamei and P. monodon and confirmed by in situ hybridization, no such inclusions were observed in P. stylirostris. Moreover, P. vannamei had the highest viral load, followed by P. monodon and P. stylirostris. Based on IHHNV surveillance data, we conclude that the currently farmed P. vannamei lines in Ecuador are tolerant to circulating IHHNV genotypes. The genome sequence and experimental bioassay data showed that, although the currently circulating genotypes are infectious, they do not induce clinical lesions in the three commercially important penaeid species. These findings suggest a potentially evolving virus-host relationship where circulating genotypes of IHHNV co-exist in equilibrium with P. vannamei raised in Peru and Ecuador.

Usefulness of the pancreas as a prime target for histopathological diagnosis of Tilapia parvovirus (TiPV) infection in Nile tilapia, Oreochromis niloticus.

Tilapia parvovirus (TiPV) is an emerging virus reportedly associated with disease and mortality in farmed tilapia. Although previous descriptions of histopathological changes are available, the lesions reported in these are not pathognomonic. Here, we report Cowdry type A inclusion bodies (CAIB) in the pancreas as a diagnostic histopathological feature found in adult Nile tilapia naturally infected with TiPV. This type of inclusion body has been well-known as a histopathological landmark for the diagnosis of other parvoviral infections in shrimp and terrestrial species. Interestingly, this lesion could be exclusively observed in pancreatic acinar cells, both in the hepatopancreas and pancreatic tissue along the intestine. In situ hybridization (ISH) using a TiPV-specific probe revealed the intranuclear presence of TiPV DNA in multiple tissues, including the liver, pancreas, kidney, spleen, gills and the membrane of oocytes in the ovary. These findings suggest that although TiPV can replicate in several tissue types, CAIB manifest exclusively in pancreatic tissues. In addition to TiPV, most diseased fish were co-infected with Streptococcus agalactiae, and presented with multifocal granulomas secondary to this bacterial infection. Partial genome amplification of TiPV was successful and revealed high nucleotide identity (>99%) to previously reported isolates. In summary, this study highlights the usefulness of pancreatic tissue as a prime target for histopathological diagnosis of TiPV in diseased Nile tilapia. This pattern may be critical when determining the presence of TiPV infection in new geographic areas, where ancillary testing may not be available. TiPV pathogenesis in this landmark organ warrants further investigation.

EMYDID HERPESVIRUS 1 INFECTIONS IN WESTERN POND TURTLES (ACTINEMYS MARMORATA) AND A RED-EARED SLIDER (TRACHEMYS SCRIPTA ELEGANS) WITH FATAL AND NONFATAL OUTCOMES.

Herpesviruses are important pathogens in zoologic chelonian collections and have been associated with fatal disease in turtles of the family Emydidae. In this report, three western pond turtles (Actinemys marmorata), living in a mixed-species freshwater turtle exhibit, presented with varying degrees of lethargy, pallor, generalized edema, and cloacal hemorrhage before death within a 2-wk period. Postmortem findings included necrohemorrhagic enterocolitis, necrotizing splenitis, hepatic necrosis, esophagitis, thymic necrosis, and pneumonia with epithelial necrosis and degeneration of the trachea and kidneys. Intraepithelial, intranuclear, amphophilic to eosinophilic, Cowdry type A viral inclusion bodies were identified in the intestinal tract, liver, spleen, kidney, trachea, lung, and thymus. PCR amplification and sequencing of liver tissue produced amplicons that were 100% homologous with emydid herpesvirus 1 (EmyHV-1). Molecular screening of cohoused emydid turtles revealed that a red-eared slider (Trachemys scripta elegans) and a western pond turtle, both asymptomatic, were PCR-positive for EmyHV-1 on combined oral-cloacal swabs. This report describes, for the first time, EmyHV-1-associated disease in western pond turtles and molecularly identifies EmyHV-1 in an asymptomatic red-eared slider.

Co-Infection of Infectious Hypodermal and Hematopoietic Necrosis Virus (IHHNV) and White Spot Syndrome Virus (WSSV) in the Wild Crustaceans of Andaman and Nicobar Archipelago, India.

The present study was intended to screen the wild crustaceans for co-infection with Infectious Hypodermal and Hematopoietic Necrosis Virus (IHHNV) and White Spot Syndrome Virus (WSSV) in Andaman and Nicobar Archipelago, India. We screened a total of 607 shrimp and 110 crab samples using a specific polymerase chain reaction, and out of them, 82 shrimps (13.5%) and 5 (4.5%) crabs were found positive for co-infection of IHHNV and WSSV. A higher rate of co-infection was observed in Penaeus monodon and Scylla serrata than other shrimp and crab species. The nucleotide sequences of IHHNV and WSSV obtained from crab in this present study exhibited very high sequence identity with their counterparts retrieved from various countries. Histopathological analysis of the infected shrimp gill sections further confirmed the eosinophilic intra-nuclear cowdry type A inclusion bodies and basophilic intra-nuclear inclusion bodies characteristics of IHHNV and WSSV infections, respectively. The present study serves as the first report on co-infection of WSSV and IHHNV in Andaman and Nicobar Archipelago, India and accentuates the critical need for continuous monitoring of wild crustaceans and appropriate biosecurity measures for brackishwater aquaculture.

Studies on infectious myonecrosis virus (IMNV) and infectious hypodermal and hematopoietic necrosis virus (IHHNV) in cultured penaeid shrimp in Egypt.

The present study aimed to diagnose infectious myonecrosis virus (IMNV) and infectious hypodermal and hematopoietic necrosis virus (IHHNV) among cultured penaeid shrimp (Penaeus semisulcatus, n = 120) collected from private farms in 2 Egyptian provinces (Damietta and North Sinai) along the Mediterranean coast. The collected shrimp were subjected to clinical examination, histopathology, molecular characterization, and phylogenetic analysis. Most of the shrimp infected with IMNV showed a distinctive appearance resembling cooked shrimp and white necrosis on distal abdominal segments and tail fans. Simultaneously, IHHNV-infected cases displayed opaque abdominal muscles, white milky to buff mottling on the shell, and a pathognomonic runt-deformity syndrome. Histopathological examination of infected specimens revealed muscular edema, hemocyte infiltration, deformities, Zenker's necrosis, and eosinophilic intra-nuclear inclusion bodies (Cowdry type A). PCR results gave predictable amplicon sizes of 139 and 81 bp and confirmed the presence of IMNV and IHHNV with a total prevalence of 37.5 and 25%, respectively. A homology search by BLAST analysis showed that the retrieved isolates putatively belonged to IMNV and IHHNV based on 96.3 to 97% nucleotide identity to the corresponding open reading frame gene of each virus. The phylogenetic analysis clearly showed genetic similarity and cross-lineage between our isolates and other isolates from Egypt, the USA, Brazil, Indonesia, China, Korea, Taiwan, and Ecuador. In conclusion, gross inspection and histopathology may aid in the diagnosis of viral diseases; however, molecular tools are indispensable for confirming a possible infection. The current study recommends strict regulations during live shrimp transportation and implementing health control certificates over all imports and exports, especially in developing countries, including Egypt.

2517 Isn't Herpes Esophagitis Enough?

INTRODUCTION: Herpes simplex (HSV) esophagitis, typically found in immunocompromised hosts, is increasingly being seen in immunocompetent hosts. A PubMed search covering the last 10 years yielded 8 publications of HSV esophagitis in the immunocompetent pediatric population, 3 of which were associated with eosinophilic esophagitis. No literature was found regarding HSV esophagitis associated with H. pylori infection. This is not surprising as the incidence of H. pylori is <10% in developed countries. To our knowledge, this is the first case report of co-infection of HSV esophagitis and H. pylori gastritis. CASE DESCRIPTION/METHODS: A healthy 16 year old male presented with 7 days of fever, severe odynophagia, and epigastric pain with no oral ulcers. He had a one year history of heartburn and dysphagia. Family history positive for H. pylori in paternal grandmother. He was seen at multiple facilities prior to transfer with prior diagnosis of costochondritis, pericarditis, pneumonia, and cholecystitis. Work up showed a normal KUB, abdominal ultrasound and upper GI series. WBC was 12.7 × 103/µL with left shift and elevated CRP at 86 mg/L. He was unresponsive to 24 hours of IV acid suppression therapy. Urgent endoscopy revealed extensive shallow ulcerations with exudate of the mid and distal esophagus and mild nodularity of the antrum. Empiric IV acyclovir was started with rapid symptom improvement within 24 hours. Biopsies showed ulcerated squamous esophageal mucosa with acute inflammation and exudate without eosinophilia. Adjacent reactive epithelium included binucleated to multinucleated cells with eosinophil nuclear structures suggestive of Cowdry type A inclusion bodies. A single cell showed a Cowdry type B inclusion but without the presence of classic multinucleated cells with molded nuclei. Immunohistochemistry confirmed the presence of HSV and was negative for CMV. Gastric biopsy showed mild, diffuse chronic gastritis with scant acute inflammation. CLO test was negative, but Diff-Quik and immunohistochemistry stains confirmed H. pylori. Triple therapy for H. pylori and a 10 day acyclovir course were completed. Currently his immune work-up is still pending. DISCUSSION: Since herpes esophagitis is a rare diagnosis in pediatrics, it is easy to ignore the possibility of co-infection. The importance of considering a co-infection in acute herpes esophagitis important to consider as the acute symptoms did not explain the patient's chronic peptic symptoms.

AN UNUSUAL CASE OF HERPES SIMPLEX VIRUS PNEUMONIA WITH NECROTIC AND CAVITARY CHANGES

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Herpes simplex virus (HSV) pneumonia can occur in both immunocompromised and immunocompetent patients. Ground glass opacities, consolidation, and pleural effusions are observed in HSV pneumonia. Neither necrosis nor cavitation has been reported in areas of parenchymal disease. We describe a case of HSV pneumonia with unusual multiple cavitary and necrotic changes. CASE PRESENTATION: A 63-year-old woman was referred to us on January 15, 2019. She had been managed as a case of community-acquired pneumonia for 15 days at another hospital but had been progressed to respiratory failure. On January 2, chest CT scan showed peribronchial and subpleural patchy consolidation, and multiple small nodules in both lungs. She was intubated on January 4. She had a medical history of hypertension. She was newly diagnosed with diabetes at admission. Upon admission, broad spectrum antibiotics were administered but she did not improve. On January 23, chest CT showed progressive necrotic and cavitary changes in areas of consolidation and small nodules in both lungs. Bilateral pleural effusion was also increased with multiple necrotic lymph nodes. Bronchoscopy on the same day showed scattered whitish plaque-like lesions, especially on both lower lobe bronchi. Biopsy showed ulceration, necrotic inflammatory exudate, extensive squamous metaplasia and several multinucleated epithelial cells containing intranuclear inclusions, consistent with HSV or varicella-zoster virus infection. Immunohistochemical staining showed a positive reaction to HSV. Viral serology, PCR, and viral, bacterial, and fungal cultures with bronchial aspirate showed negative results. Acyclovir therapy was started on January 24. Percutaneous catheter drainage was performed for left exudative pleural effusion. The patient improved slowly; a CT scan on February 12 showed overall improvement. She was moved to the general ward after being weaned off mechanical ventilation on February 14. DISCUSSION: HSV pneumonitis cannot be diagnosed based on imaging alone; evidence of viral cytopathic effect on cytologic and/or histopathologic specimens with confirmation of HSV infection via culture, PCR, or immunohistochemical staining is required. Detection of histological hallmarks of HSV infection, such as multinucleated cells with ground glass intranuclear changes and Cowdry type A intranuclear inclusion bodies, is specific for true lower respiratory tract infections rather than a carrier state, especially in critically ill patients. In this case, we could confirm HSV pneumonia by typical endobronchial lesions, histopathologic findings, immunohistochemical staining, and overall improvement on follow-up chest CT with acyclovir therapy. CONCLUSIONS: To our knowledge, this is the first reported case of HSV pneumonia with multiple cavitary and necrotic changes in areas of consolidation and nodules. Reference #1: Chong S, Kim TS, Cho EY. Herpes simplex virus pneumonia: high-resolution CT findings. Br J Radiol 2010; 83:585–589. Reference #2: Aquino SL, Dunagan DP, Chiles C, Haponik EF. Herpes simplex virus 1 pneumonia: patterns on CT scans and conventional chest radiographs. J Comput Assist Tomogr 1998; 22(5):795-800. Reference #3: Simoons-Smit AM, Kraan EM, Beishuizen A, Strack van Schijndel AJ, Vandenbroucke-Grauls CM. Herpes simplex virus type 1 and respiratory disease in critically-ill patients: real pathogen or innocent bystander? Clin Microbiol Infect 2006; 12:1050–1059 DISCLOSURES: No relevant relationships by Cheol-Woo Kim, source=Web Response No relevant relationships by Hong Lyeol Lee, source=Web Response

IHHNV Infection from the Wild Shrimps of Andaman and Nicobar Islands, India

The present study was intended to screen the wild shrimps of Andaman and Nicobar Islands (ANI) against infectious diseases. A total of 175 shrimp samples (35 pools) consisting of Fenneropenaeus indicus, Penaeus monodon, Penaeus merguiensis and Metapenaeus monoceros were collected from different landing centres across ANI. Out of 35 pools of samples analysed by polymerase chain reaction (PCR), a total of 10 pools of Penaeus monodon collected from Betapur (1 pool), Lohabarrack (4 pools) and Campbell Bay (5 pools) were found positive for Infectious Hypodermal and Hematopoietic Necrosis Virus (IHHNV). Nucleotide sequence of IHHNV isolated from ANI showed 100% identity to the sequences of IHHNV reported from Vietnam, Taiwan, Australia, China, Egypt, USA, Ecuador, 99% identity to IHHNV reported from Brazil, Venezuela, Korea, 96% identity to IHHNV reported from Thailand and 95% identity to IHHNV reported from India. Based on phylogenetic tree analysis, IHHNV of ANI is closely related to IHHNV of Vietnam. Histopathological analysis revealed typical eosinophilic intranuclear cowdry type A inclusion bodies in gill lamellae which further confirmed the IHHNV infection. The present study provides a definitive evidence for the first report of infectious IHHNV in wild P. monodon from ANI.

Spontaneous white spot syndrome virus (WSSV) infection in mud crab (Scylla serrata Forskal 1775) fattening pens farm of south east coast of India

The white spot syndrome virus (WSSV) is one of the most serious diseases in the shrimp and crab farm. This virus disseminates very quickly and causes high mortality in culture pond, accompanied by great economic losses. Recently, high mortality of WSSV-infected mud crabs collected from M.G.R. Thittu, Cuddalore district, Tamil Nadu, south east coast of India during 2015 and 2016. A total of 283 samples collected from pens fattening ponds were tested for the presence of WSSV. Of these, a prevalence of 32.5% WSSV-infected mud crabs showed. Hence, the present study was carried to understand the reason for the mortality. Our examinations of crab mortality confirmed the possible infestation of white spot syndrome virus. The classical symptoms of white spot virus infections like white spots in the inner carapace and histopathological changes on gills like eosinophilic inclusion bodies and basophilic Cowdry type “A” inclusion bodies have been observed. Also, our examinations confirmed the infestation through molecular diagnosis and TEM visualization of hypertrophied cells with massive viral particles in the nucleus and cytoplasm of infected gills. In the experimental work, the fastest mortality was observed in the ingestion then in the waterborne mode of infection. The waterborne mode caused the 40% mortality on 90th days. The ingestion mode caused the 100% mortality on 90th days.

Polyomavirus Infection in Gouldian Finches (Erythrura gouldiae) and Other Pet Birds of the Family Estrildidae

A syndrome characterized by apathy, diarrhoea and high mortality of nestlings was observed in a flock of pet birds of the family Estrildidae. Enlargement of the liver, pulmonary congestion and urate accretions in the kidney were observed. Microscopically, there was glomerular atrophy, oedema and congestion of the lungs and necrosis and fibrosis of the liver. Cowdry type B intranuclear inclusion bodies were detected in the tissues. Polyomavirus was detected by polymerase chain reaction. The entire genome of the virus was amplified and sequenced, revealing 99 % identity to the sequence of finch polyomavirus isolated from the Eurasian bullfinch (family Fringillidae).

Acute Liver Failure Due to Suspected Herpes Simplex Virus Hepatitis: A Call to Consider Empirical Acyclovir in High-risk Cases

Background: Although rare, Herpes simplex virus (HSV-2) is a fatal cause of acute liver failure (ALF) if unrecognized or with delayed treatment. The accepted protocol for empirical management of ALF has a well-defined role for N-acetylcysteine (NAC), but none for antivirals. We have encountered three HSV ALF cases recently, with varying clinical courses, compelling us to highlight this unresolved issue. Case: A 25-year-old man with sickle trait presented with 1-week of fever, headache and myalgia. He claimed sexual monogamy and no medication/drug use. On admission, he was tachycardic, hypotensive, oriented mentally, with tender hepatomegaly and abdomen and lymphadenopathy in axilla/groin. Labwork suggested mild renal insufficiency, low platelets, leukopenia, coagulopathy (INR 2.4) with marked transaminasemia (AST/ALT 4009/3504), mild hyperbilirubinemia (1.8mg/dL) and LDH 4400, but negative Tylenol, salicylate and viral hepatitis panel and imaging unrevealing of cause. Patient was initiated on NAC protocol, but worsened hemodynamically, clinically and biochemically, required intubation, DIC management but eventually died due to multi-organ failure. While all serologies were negative, HSV-2 came positive (titer >1x108). Histopathology on autopsy showed HSV-2 (Fig 1).Figure 1Another woman, aged 30 years was admitted with right upper quadrant pain, headache, fever, increased transaminases in hepatocellular pattern (AST/ALT 1721/975), Hyperbilirubinemia (2.3) and LDH 3930, leukopenia, low platelets, high INR (2). The patient was initiated on NAC protocol, additionally started on empirical Acyclovir given her high-risk sexual behavior, while awaiting serologies. On day 4 of admission transaminases started to improve (AST/ALT 303/567) and so did the coagulopathy. Her HSV-2 titers resulted positive on day 3 (titer >1x10 8). Liver biopsy confirmed HSV-2 hepatitis with Cowdry type A bodies. The patient had uneventful recovery after completion of antivirals. Discussion: Mortality with HSV hepatitis progressing to ALF is high (˜90%). Diagnosis is often delayed (HSV PCR), or false negative (serology) or based on Tzank smear (only if rash is present) or liver biopsy (risky because of coagulopathy). Patients can have maculopapular rash, leukopenia, thrombocytopenia, but fever and anicteric hepatitis are the hallmark features of HSV hepatitis, which if seen should serve as red flags. Based on our experiences, we urge clinicians to remain cognizant in young ALF patients to consider Acyclovir, which may be life-saving. This further raises a debate if Acylovir dose should be included as a part of ALF management protocol, while awaiting serologies, especially in high-risk patients with above mentioned suggestive clinical features.

Herpes simplex esophagitis: Report of 4 pediatric cases in immunocompetent patients

Although herpetic infection is considered in the differential diagnosis of a patient who is immunocompromised with esophagitis, it is less thought of in the immunocompetent patient. There are few reports of esophagitis caused by herpes simplex virus in immunocompetent children and adolescents. We are reporting four cases in this age group who have been identified to have herpes simplex esophagitis. The first patient was nine-year-old boy who presented with chest pain, fever, and diarrhea. The second patient was a six-year-old boy who presented severe chest pain and had a negative endoscopy four months prior. The third was an 18-year-old young man with history of vomiting, odynophagia, and recent weight loss of 25 lbs. The fourth patient was a six-year-old girl admitted for dehydration and febrile illness three days after tonsillectomy, complaining of chest pain and epigastric abdominal.Their endoscopic findings varied from punched-out ulceration only to erosive esophagitis or both. They were all diagnosed by PCR analysis and not by pathology. All had biopsies suggestive of esophagitis. They all responded well to acyclovir. Based on testing and available follow up, all patients appeared to be immunocompetent, although one case refused HIV testing. Herpes simplex esophagitis in children can have variable presentations. High level of suspicion is warranted even in the immunocompetent patient. This is especially important when the history of acute gastrointestinal symptoms includes a triad of fever, chest pain, and odynophagia, but also even if these symptoms are recurrent. Viral cultures and PCR of the esophageal biopsies should be performed in addition to pathology looking for Cowdry Type A bodies.

Herpes simplex lymphadenitis in association with chronic lymphocytic leukaemia

Herpes simplex lymphadenitis is a rare condition that is most commonly seen in immunocompromised patients. To date, less than 30 cases have been reported in the literature. It is most commonly seen in patients with haematological malignancy, especially with chronic lymphocytic leukaemia. However, it can be associated with other neoplasms such as Hodgkin lymphoma, mantle and marginal zone B-cell lymphoma, acute and chronic myeloid leukaemia. Presentation can be varied from localised lymphadenopathy, generalised lymphadenopathy with or without a rash, and disseminated HSV infection with multiple organ involvement. Histologically, it shows areas of coalescing necrosis and inflammatory cell infiltrates including histiocytes and neutrophils. Multinucleate cells with ground glass nuclei and Cowdry type A intranuclear inclusions are diagnostic; the diagnosis can be confirmed with herpes simplex virus in-situ hybridisation or immunohistochemistry. Differential diagnoses to consider include cat scratch lymphadenitis, mycobacterial tuberculosis lymphadenitis, Kikuchi-Fujimoto lymphadenitis, systemic lupus erythematosus, Hodgkin lymphoma and large cell non-Hodgkin lymphoma. Herpes simplex lymphadenitis is an important diagnosis which can mimic transformation of an underlying haematological malignancy. We present a case of a 68-year-old male with localised lymphadenopathy and history of chronic lymphocytic leukaemia.

Herpes Simplex Virus (HSV) in the Differential for Fulminant Hepatic Failure

Following an elective transphenoidal resection of a pituitary tumor, a 66-year-old Hispanic male acutely developed fulminant hepatic failure and severe coagulopathy. He received parenteral corticosteroids the day prior to surgery, and was first noted to have significant coagulopathy intraoperatively. Despite aggressive workup and treatment for fulminant hepatic failure, the patient developed multiorgan failure by post-operative day 2, and expired on post-operative day 3. On post-mortem examination, hemorrhagic necrosis of the liver was noted and microscopic examination revealed Cowdry type A inclusions, consistent with Herpes Simplex Virus (HSV) infection. This diagnosis was subsequently confirmed by immunehistochemistry. Fulminant hepatic failure due to HSV is a rare but highly fatal disease if untreated. Most case reports include only immunocompromised or pregnant patients. However, the lack of clinical suspicion in this previously healthy patient may have delayed prompt treatment with antiviral agents. It is important to raise the awareness of this rare and life-threatening, but potentially treatable, etiology when clinicians are faced with acute idiopathic fulminant hepatic failure.

Intussusception Associated With Adenovirus

A 7-month-old girl presented with irritability, bilious vomiting, and hematochezia. A week before presentation she had an upper respiratory tract infection. Initial evaluation showed distended bowel loops on abdominal film and intussusception of the ascending colon on ultrasound. While attempting a reduction with an air contrast enema, an air leak occurred, necessitating an ileocecal resection and reanastomosis. Gross examination of the specimen showed a partially necrotic segment of terminal ileum invaginated into the cecum. Mucosal thickening and lymphonodular hyperplasia in the ileocecal valve was consistent with a lead point (Fig. 1). Histological examination showed active epithelial injury with ulcerations, granulation, and necrosis. Surface epithelium contained transformed cells with smudgy, enlarged nuclei consistent with Cowdry type B viral inclusions (Fig. 2). The presence of adenovirus was confirmed by immunohistochemistry (Fig. 3).FIGURE 1: Ileocecum showing mural edema (arrows) and focal hemorrhagic necrosis.FIGURE 2: High-power view showing homogeneous eosinophilic intranuclear inclusions (arrows) (H&E, original magnification ×40).FIGURE 3: Immunohistochemistry utilizing an Adenovirus antibody confirms the presence of the virus (IHC, DAB chromogen, hematoxilin counterstain, original magnification ×10).Intussusception is the most common cause of intestinal obstruction in children younger than 2 years. Ninety percent of the cases are associated with hyperplastic lymphoid tissue, suggesting an infectious cause. Studies conducted in the United States have identified species C adenoviruses in fewer than 15% of intussusception cases (1). In a small Mexican series species C was also demonstrated in all patients with adenovirus infection (2).

Multiple infections in shrimp Litopenaeus vannamei broodstock in commercial hatcheries in Khouzestan Province

The present study was carried out to investigate the status of health and disease, and their impact on shrimp broodstock (Litopenaeus vannamei) in Khouzestan Province (Choeibde Area) in the south of Iran. From March 2012 until April 2013, about 140 broodstock and 5000 postlarvae (PLs) were collected from hatcheries and grow out farms. Clinical signs of samples were documented in take history forms and then the samples were transported to Iranian South Aquaculture Institute (Ahvaz). Bacterial and fungal studies were carried out on hemolymph, hepatopancreas and gill tissue and then the shrimps were preserved in Davidson Fixative for histopathology. A part of uropods was also preserved in ethyl alcohol for PCR study and detecting three viruses, WSSV, TSV and IMNV. A part of PLs was also preserved in ethyl alcohol for PCR and the remaining was preserved in Davidson Fixative for histopathology. The results showed that 5 bacteria consisting of Vibrio alginolyticus, V. proteolyticus, V. mimicus, A. hydrophila and Plesiomonas shigelloides and one fungi Aspergillus fumigatus were identified. The results of PCR exhibited that the broodstock was free of the three viruses and the PL was infected with WSSV. In histopathology some tissues showed the effects of Vibrio infection in different organs such as gill and midgut, and the infection of PL tissues showed the Cowdry type A inclusion bodies in WSSV. Two specific signs of abnormality were also exhibited in histopathology that we call them Pseudo inclusion and Reolike particles and we need to conduct a new study to clarify detailed information about these finding. This finding can be used for assessing the health of shrimp culture and prevention of disease in broodstock in Iran.

Investigation of an Idiopathic Lesion in Redclaw Crayfish Cherax Quadricarinatus Using Suppression Subtractive Hybridization

Lesions indicative of putative parvovirus infection were detected in a population of freshwater redclaw crayfish ( Cherax quadricarinatus ) displaying hypertrophied nuclei, while these changes were undetected in another population. These changes were characterised by hypertrophic nuclei with marginated chromatin but without Cowdry type A (CA) intranuclear inclusion bodies. Suppression subtractive hybridization (SSH) was performed to generate a cDNA forward library between the two populations of crayfish. A total of 323 sequences were analysed from SSH libraries. These sequences were grouped into 76 consensus sequences and clustered into 8 categories based on sequence homology from the NCBI GenBank database. Even though histopathological observations consistently revealed lesions presumptive of putative parvovirus in C. quadricarinatus as previously reported, the molecular method failed to confirm a viral aetiology. Despite the absence of viral gene detection and therefore a conclusion of an idiopathic aetiology, the health status of these two populations of redclaw crayfish was different, resulting in differentially expressed immune-related genes in the two populations, with some genes being up-regulated in the hypertrophied nuclei population. Furthermore, the absence of parvovirus from the SSH libraries indicates that perhaps the viral messenger RNA was in too low a concentration to be detected or does not have any poly(A) tail which the SSH methodology needs to function correctly.