Diffuse Nodular Lymphoid Hyperplasia Research Articles

Endoscopic and histopathological hints on infections in patients of common variable immunodeficiency disorder with gastrointestinal symptoms

Background and aimsCommon variable immunodeficiency disorder (CVID) patients may have gastrointestinal (GI) involvement and suffer from infections, which are poorly understood. This study aimed to evaluate the clinical, endoscopic, and histopathological features of CVID patients with GI symptoms and determine their correlation with infections.MethodsWe performed a retrospective study on 21 CVID patients with GI symptoms who underwent endoscopic examination in Peking Union Medical College Hospital from 2000 to 2020. The clinical, infectious, endoscopic, and histopathological features were reassessed.ResultsChronic diarrhea was the most prevalent GI symptom, observed in 95.2% of our CVID cohort. Over 85% of patients had low body weight and malabsorption. Small bowel villous atrophy was found in 90.5% of patients under endoscopy and mostly confirmed by histopathology. GI infections were identified in 9 (42.9%) patients. Of these, 7 patients with diffuse and obvious nodular lymphoid hyperplasia (NLH) of small bowel under endoscopy had significantly higher infection rate (85.7% vs 21.4%, p < 0.05), predominantly with Giardia and bacteria. Small bowel biopsies showed 95% of patients lacked plasma cells and 60% had increased intraepithelial lymphocytes (IELs), but not significantly different between GI infection and non-infection group. Most patients improved after intravenous immunoglobulin and anti-infection therapy.ConclusionsCVID could involve GI tract, particularly small bowel. Obvious NLH under endoscopy could be a hint for GI infection in CVID patients. Comprehensive endoscopic and histopathological evaluation may be helpful in CVID diagnosis and identification of potential co-infection, leading to proper treatment.

Evaluation of Morphological and Histological Changes of Aggregated Lymph Nodes in the Small Intestine after Imofan Treatment in Immunosuppressed Rats.

Diffuse nodular lymphoid hyperplasia is a rare gastrointestinal disease that can be diagnosed by multiple nodules in the small intestine, large intestine, or both. Immunodeficiency and infections are the common situations that lead to the diffusion of nodular lymphoid hyperplasia. For instance, Giardia lamblia and Helicobacter pylori are the major pathogens leading to this disorder. Diffuse nodular lymphoid hyperplasia leads to allergic reactions, immunodeficiency, and autoimmune diseases. Imunofan-RDKVYR Peptide-is a potential agent in regenerative medicine. The present study aimed to investigate morphological features of the aggregated lymphoid nodules of the small intestine after the Imunofan (IM) administration following Cyclophosphamide-induced immunosuppression. In total, 72 Wistar male rats were randomly divided into two groups (n=36). Group I was considered the control group, and group II was subjected to intramuscular injections (needle 21 G) of0.2 ml of normal saline following the Cyclophosphamide-induced immunosuppression on the 2nd, 4th, 6th, 8th, and 10th days of the experiment. The animals in group II were injected with Cyclophosphamide at a dose of 200 mg/kg bodyweight to induce immunosuppression. The animals in the experimental group (n=36) were subjected to intramuscular injections (needle 21 G) of the 0.2 ml IM at a dose of 0.7μg/kg body weight on the 2nd, 4th, 6th, 8th, 10th days of the experiment. The results of the study indicated that on the 7th day in group II, the length and width of the aggregated lymphoid nodules increased, as well as the height and width of the lymphoid nodules and internodular zones as structural components of the lymphoid formations in the small intestine. In group I, by the 30th day of the experiment, the linear dimensions of the aggregated lymphoid nodules exceeded, but to a lesser extent than on the 7th day of the experiment which explains the ability of IM to neutralize the effects of Cyclophosphamide. It should also be noted that the IM was performed to regenerate damaged cells which helped maintain the population of lymphocytes in the limb and led to an increase in linear dimensions (length and width) not only between the joint but also in the lymph nodes.

S0917 Robotic-Assisted Endoscopic Submucosal Dissection of Distal Colon and Rectal Lesions

INTRODUCTION: Endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) are therapeutic alternatives to surgery for resection of colon and rectal lesions. In regards to large colon and rectal polyps and tumors, both ESD and EFTR have high en bloc resection rates and low recurrence rates, but are limited by training, procedure length, stability, and instrumentation. The Robotic System (RS) is a new robot-assisted endoscopic platform with multiple degrees of freedom allowing improved visualization, dexterity, and tissue manipulation with traction. This is the first U.S. experience assessing the feasibility and safety of robot-assisted ESD and EFTR in resection of distal colon and rectal lesions and its implication for polyps and tumors. METHODS: This is a multicenter retrospective study from five institutions. Patients with distal colon or rectal lesions who underwent either ESD or EFTR with the RS were included. Each patient’s clinical history, endoscopic findings, procedural records, and pathology records were reviewed. RESULTS: Forty-one patients underwent either ESD or EFTR with the RS for distal colon or rectal lesions, with an average total resection time of 135.0 minutes (σ 62.8, n = 24). On average, lesions were 9.3 cm from the anal verge (range: 2 cm to 17 cm, n = 35) and were 30.0 mm in max diameter (range: 9 to 77 mm, n = 28). There were 13 (31.7%) neoplasms and 23 (56.1%) adenomatous polyps; other lesions included inflammatory polyps, diffuse nodular lymphoid hyperplasia, and granulation tissue—all were suspicious for malignancy. Neoplasms included 11 adenocarcinomas and 2 GISTs. Adenomatous polyps included 11 tubular adenomas and 11 tubulovillous adenomas. Twenty-nine out of 34 patients (85.3%) with either adenomatous polyps or adenocarcinoma were successfully removed with the RS alone. Of these, 23 (79.3%) demonstrated clean margins on pathology. Post-endoscopic complications included rectal pain and bleeding. CONCLUSION: This report demonstrates a role of robotic endoscopy for the safe and effective treatment of natural orifice endoscopic surgical resection, with its benefits including traction and triangulation. As endoscopic surgery in the form of ESD evolves, refinement of the tools and techniques of the robotic platform will allow endoscopists to have shorter learning curves and resection of distal colon and rectal polyps and tumors to have higher negative margin rates, potentially allowing more endoscopists the ability to perform ESD.Figure 1.: The robot-assisted endoscopic platform.Table 1Table 2

Diffuse Nodular Lymphoid Hyperplasia of Colon in a Child- A Case Report with Review of Literature

Diffuse Nodular Lymphoid Hyperplasia of Colon in a Child- A Case Report with Review of Literature

A Case of Diffuse Nodular Lymphoid Hyperplasia (NLH) of Duodenum in a Patient with Selective IgA Deficiency and Helicobacter Pylori Infection

Introduction: Nodular lymphoid hyperplasia (NLH) is characterized by the presence of multiple small nodules, between 2-10 mm in diameter, distributed more commonly in the small intestine, sometimes in the stomach and large intestine. It affects individuals with or without immunodeficiency and is associated with diseases such as common variable immunodeficiency, selective IgA deficiency (sIgAD), giardia, celiac disease and helicobacter pylori (H pylori) infections. We present a case of diffuse duodenal NLH in a patient with sIgAD and H Pylori infection. Case: A 59 year old female with history of sIgAD presents with generalized weakness for 2 months. Hemoglobin at presentation was 9.1 g/dL (12-16 g/dL), IgA levels were 6.1 mg/dL (68-423 mg/dL). She denied melena, hematemesis or GI bleed. She underwent colonoscopy and endoscopy for normochromic normocytic anemia. Colonoscopy was unremarkable. Upper endoscopy showed nodular mucosa in the entire duodenum (figure 1), erythema in gastric antrum, and a single 7 mm sessile polyp in gastric body (figure 2). Pathology was consistent with NLH in duodenum (figure 3), gastric adenomatous polyp with low grade dysplasia and positive H pylori. She was started on treatment with clarithromycin, amoxicillin and pantoprazole. She underwent upper endoscopy with endoscopic ultrasound for resection of gastric adenoma which again showed nodular mucosa in duodenum consistent with NLH.Figure 1Figure 2Figure 3Discussion: The incidence of NLH is unknown but rare condition in adults. Histologically it is defined as hyperplastic, mitotically active germinal centers with well-defined lymphocyte mantles in lamina propria. In immunodeficiency states NLH may result from an accumulation of plasma-cell precursors due to a maturational defect in the development of B-lymphocytes. In H pylori infection, pathogenesis involves immune stimulation by H pylori. It is usually asymptomatic but can present with abdominal pain, chronic diarrhea, bleeding, intussusception or intestinal obstruction. The diagnosis is established by endoscopy or contrast barium studies and confirmed histologically. Treatment involves treating the associated conditions. NLH is a risk factor for both intestinal and extra-intestinal lymphomas. Some authors recommend surveillance, however, the duration and intervals are undefined. Conclusion: The case illustrates the rare impressive endoscopic findings of NLH in a patient with sIgAD and H. pylori infection.

Diffuse Nodular Lymphoidhyperplasia with Selective IgA Deficiency Syndrome Presenting with Intestinal Lymphoma

Diffuse Nodular Lymphoidhyperplasia with Selective IgA Deficiency Syndrome Presenting with Intestinal Lymphoma

Diffuse Nodular Lymphoid Hyperplasia Associated With Giardia Infection

30 y.o M presented with nausea, vomiting, weight loss and diarrhea for three weeks. The patient had no other systemic symptoms. His medical history was notable for occasional upper respiratory infections and prior episodes of spontaneously resolved diarrhea over the last several years. Family history was unremarkable. Labs were notable for microcytic anemia. Initial stool studies and fecal WBC were negative. CT imaging was notable for mesenteric lymphadenopathy and inflammation of the small bowel concerning for enteritis. Endoscopic evaluation revealed mucosal abnormalities (fig 1-2) which were biopsied. Pathology revealed lymphoid hyperplasia with villous blunting. Subsequent stool studies were positive for Giardia. Immunoglobulin testing was notable for low IgG and IgA levels consistent with CVID. The patient was placed on Flagyl and had resolution of symptoms after completion of therapy.Figure 1Figure 2Discussion: Diffuse nodular lymphoid hyperplasia of the gastrointestinal tract is a rare, benign, usually asymptomatic, disorder of unclear pathogenesis. A common hypothesis is that an intestinal antigenic trigger leads to repetitive stimulation and hyperplasia of lymphoid follicles. DNLH is most commonly characterized by multiple small nodules in the small intestine, although it can be found anywhere along the GI tract. DNLH has been most strongly associated with common variable immunodeficiency and Giardia, although there have been reported links with HIV, IgA deficiency, celiac disease, H. pylori, EBV, and CMV. Common clinical presentations are nausea, vomiting, diarrhea, abdominal pain, obstruction, with or without malabsorption and weight loss. DNLH is diagnosed by endoscopy and confirmed by histology showing hyperplastic lymphoid follicles. It is important to perform immunologic screening after the diagnosis of DNLH. DNLH is found in 20% of CVID patients. Despite appropriate antibiotic therapy, lymphoid hyperplasia and symptoms may persist. Although DNLH is often a benign course, patients with this disease may have an increased risk of intestinal lymphoma. For this reason, more investigation is warranted in regard to possible surveillance modalities and intervals.

Diffuse nodular lymphoid hyperplasia of the small bowel associated with common variable immunodeficiency and giardiasis: a rare case report

Diffuse nodular lymphoid hyperplasia (DNLH) of the intestine is an extremely rare lymphoproliferative disorder of uncertain etiology. Typically, numerous polypoid nodules composed of hyperplastic benign lymphoid tissue are present in the small and/or large intestinal mucosa. DNLH has been observed in association with common variable immunodeficiency (CVID). A 38-years-old man was admitted to our clinic due to dyspeptic complaints. An upper gastrointestinal system endoscopic examination revealed DNLH in the duodenum. A biopsy specimen showed the presence of nodular lymphoid hyperplasia and a Giardia lamblia infection in the duodenum. CVID was suspected, and the diagnosis was established by demonstrating a significant reduction in the serum gamma-globulin levels. DNLH is a rare benign condition with regards to diagnosis and treatment of unknown etiology. In patients with DNLH, screening for the immune deficiencies is being important in addition to histopathological examinations.

Diffuse Nodular Lymphoid Hyperplasia of Intestine in Selective IgG 2 Subclass Deficiency, Autoimunne Thyroiditis, and Autoimmune Hemolytic Anemia in 60 Year Old Male

Purpose: Diffuse Nodular Lymphoid Hyperplasia (DNLH) of the intestine is a rare lymphoproliferative disorder of uncertain etiology. We present a rare case of DNLH associated with IgG2 subclass deficiency, autoimmune thyroiditis and autoimmune hemolytic anemia. A 60 year old Turkish male presented to GI clinic with watery diarrhea and crampy abdominal pain for 1 month. He had a history of treated prostate cancer. He denied any family history, alcohol, tobacco, or illicit drugs. He denied any sick contacts, or recent travel. One week prior, he was seen in the ER for similar complaints where he was anemic (hemoglobin 7.4 g/dl, mean corpuscular volume 103). CT abdomen revealed extensive lymphadenopathy. He was discharged with a one week course of ciprofloxacin and metronidazole, and scheduled for follow up in the GI clinic. At follow up iron deficiency anemia was found. Assays for vitamin B12, folate, methylmalonic acid and homocysteine were within normal range. Lactate dehydrogenase and reticulocyte count was high, haptoglobin low, and direct coomb's test positive with warm antibody. Gastrointestinal bacterial and parasitic infections were ruled out. Tissue transglumatinase antibody IgA and anti-parietal cell antibody were negative. Thyroid stimulating hormone was 12.6, with elevated thyroglobulin and thyroid peroxidase antibody. EGD and colonoscopy showed nodular mucosa in duodenal bulb and rectosigmoid respectively. Small bowel series followed by capsule endoscopy was performed. Bone marrow and abdominal lymph node biopsy was negative for malignancy. Gallium scan was negative for any metastatic disease. An increased risk (2-10%) of malignancy, mainly gastrointestinal lymphoma has been reported in patients with DNLH and hypogammaglobulinemia. These lymphoid aggregates could be an independent response to antigenic stimuli in presence of deranged immunoglobulin function. However, the relationship is unclear. Because of the risk of malignant transformation prophylactic examinations and small bowel studies are recommended by some authors. Diffuse nodular lymphoid hyperplasia in itself is a rare benign condition of unknown etiology. In symptomatic patients, workup should be directed towards underlying hypogammaglulinemia, infections and possible malignancy. Eradication of infection could lead to resolution of symptoms. Patients should undergo prophylactic surveillance endoscopy to rule out complications and to establish extent of disease. However, there are no clear cut guidelines for surveillance.

Diffuse duodenal nodular lymphoid hyperplasia: a large cohort of patients etiologically related to Helicobacter pyloriinfection

BackgroundNodular lymphoid hyperplasia of gastrointestinal tract is a rare disorder, often associated with immunodeficiency syndromes. There are no published reports of its association with Helicobacter pylori infection.MethodsFrom March 2005 till February 2010, we prospectively followed all patients with diffuse duodenal nodular lymphoid hyperplasia (DDNLH). Patients underwent esophagogastroduodenoscopy with targeted biopsies, colonoscopy, and small bowel video capsule endoscopy. Duodenal nodular lesions were graded from 0 to 4 based on their size and density. Patients were screened for celiac sprue (IgA endomysial antibody), immunoglobulin abnormalities (immunoglobulin levels & serum protein electrophoresis), small intestine bacterial overgrowth (lactulose hydrogen breath test), and Helicobacter pylori infection (rapid urease test, and histological examination of gastric biopsies). Patients infected with Helicobacter pylori received sequential antibiotic therapy and eradication of infection was evaluated by 14C urea breath test. Follow up duodenoscopies with biopsies were performed to ascertain resolution of nodular lesions.ResultsForty patients (Males 23, females 17; mean age ± 1SD 35.6 ± 14.6 years) with DDNLH were studied. Patients presented with epigastric pain, vomiting, and weight loss. Esophagogastroduodenoscopy showed diffuse nodular lesions (size varying from 2 to 5 mm or more) of varying grades (mean score ± 1SD 2.70 ± 0.84) involving postbulbar duodenum. Video capsule endoscopies revealed nodular disease exclusively limited to duodenum. None of the patients had immunoglobulin deficiency or small intestine bacterial overgrowth or positive IgA endomysial antibodies. All patients were infected with Helicobacter pylori infection. Sequential antibiotic therapy eradicated Helicobacter pylori infection in 26 patients. Follow up duodenoscopies in these patients showed significant reduction of duodenal nodular lesions score (2.69 ± 0.79 to 1.50 ± 1.10; p < 0.001). Nodular lesions showed complete resolution in 5 patients and significant resolution in remaining 21 patients. Patients with resistant Helicobacter pylori infection showed no significant reduction of nodular lesions score (2.71 ± 0.96 to 2.64 ± 1.15; p = 0.58). Nodules partially regressed in score in 2 patients, showed no interval change in 10 patients and progressed in 2 patients.ConclusionsWe report on a large cohort of patients with DDNLH, etiologically related to Helicobacter pylori infection.

An unusual cause of diarrhea: diffuse intestinal nodular lymphoid hyperplasia in association with selective immunoglobulin A deficiency (with video)

A 33-year-old man was referred to our institution with a 5-year history of abdominal pain and diarrhea and recent weight loss. There was no history of recurrent sinopulmonary infection. A maternal history of celiac disease was reported Laboratory test results were normal except for a deficiency of serum immunoglobulin (Ig) A (<0.36 g/L; normal range, 0.7-4.0 g/L). Levels of both total serum IgG (7.9 g/L; normal range, 7.0-16.0 g/L) and IgG 1-4 subclasses (5.9 g/L, 2.2 g/L, 0.5 g/L, and 0.2 g/L, respectively) were within normal ranges.

Diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia in an infant with obscure massive lower gastrointestinal bleeding: a diagnostic challenge

The authors report a rare case of diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia involving the distal ileum and total colon in a 13-month-old girl who had recurrent episodes of massive lower gastrointestinal bleeding of obscure origin. Colonoscopy showed multiple nodular hyperplasia and mucosal erosions, and all other diagnostic studies were negative. At laparotomy, intraoperative transluminal endoscopic transillumination was of benefit in identifying the bleeding foci but could not detect every angiodysplastic lesion.

Nodular lymphoid hyperplasia and histologic changes mimicking celiac disease, collagenous sprue, and lymphocytic colitis in a patient with selective IgA deficiency

Selective IgA deficiency is the most common primary immunoglobulin deficiency. The clinical manifestations of selective IgA deficiency, including gastrointestinal (GI) complications, are rare and typically milder than those seen with common variable immunodeficiency or X-linked agammaglobulinemia. We present a rare case of selective IgA deficiency that shows a number of interesting histological features in the GI tract, including diffuse nodular lymphoid hyperplasia involving the entire small and large intestine, celiac disease-like and collagenous sprue-like changes in the small intestine, as well as lymphocytic colitis pattern. However, this patient had no particular GI symptoms suggestive of celiac sprue or microscopic colitis. These findings suggest that the GI tract in patients with selective IgA deficiency can show peculiar histologic changes that mimic celiac disease, collagenous sprue, or lymphocytic colitis, which may be a pattern of injury related to infection or immunoglobulin immunodeficiency-associated autoimmune phenomena.

Diffuse nodular lymphoid hyperplasia of small bowel, colon and esophagus complicating primary immunodeficiency

Diffuse nodular lymphoid hyperplasia of small bowel, colon and esophagus complicating primary immunodeficiency

Nodular lymphoid hyperplasia of the small bowel associated with two primary colonic adenocarcinomas

A patient presented with rectal bleeding and weight loss. On barium enema two space-occupying lesions, one in the cecum and the other in the right transverse colon, were demonstrated. He underwent right hemicolectomy. The surgical specimen demostrated diffuse nodular lymphoid hyperplasia (NLH) of the small intestine and two primary carcinomas of the colon, an association that to the best of our knowledge has not been previously described.

Nodular lymphoid hyperplasia of the small intestine with Burkitt's lymphoma and dysgammaglobulinemia

An unusual case of American Burkitt's lymphoma of the jejunum complicating diffuse nodular lymphoid hyperplasia of the small bowel is reported. The radiological and pathological findings are correlated and the pertinent literature is reviewed.

Nodular Lymphoid Hyperplasia of the Small Bowel Associated with Primary jejunal Malignant Lymphoma: Evidence Favoring a Cytogenetic Relationship

A nonimmunodeficient patient with diffuse nodular lymphoid hyperplasia of the small bowel and a jejunal malignant lymphoma of mixed lymphocytic-histiocytic type is reported. Surface marker and immunohistologic studies of the malignant lymphoma and of histologically benign lymphoid nodules proximal to the tumor showed a similar pattern of monoclonality (IgM-kappa) and gave suggestive evidence of a cytogenetic relation of the lymphoma to nodular lymphoid hyperplasia. It is suggested that intestinal nodular lymphoid hyperplasia may be a condition leading to lymphoid malignancy; its exact incidence in patients with both malignant lymphoma of the gut and a primary immunodeficiency syndrome should warrant further consideration.

Ileal blind loop in childhood.

A child had two stagnant loops of the terminal part of the ileum, resulting from a bypass operation in infancy for ileal atresia. The patient had an iron deficiency anemia that was shown at operation to be due to mucosal ulceration within the terminal part of the ileum. Diffuse nodular lymphoid hyperplasia was also demonstrated within the blind loop, and the mucosal ulceration and nodular lymphoid hyperplasia may be a response of the ileal mucosa to the increased counts of aerobic and anaerobic bacteria and to deconjugated intraluminal bile salts. Deconjugated bile salts and bacteria with deconjugating properties were also found in the upper part of the small intestine, showing that lesions of the terminal part of the ileum may be associated with metabolic abnormalities within the upper part of the small intestine.