Eosinophilic Inflammatory Infiltrate Research Articles

Kimura Disease: An Atypical Presentation

Abstract Introduction/Objective Kimura disease is a benign, chronic inflammatory process which presents with enlarged, painless lymphadenopathy. The etiology is currently unknown. It is most commonly seen in young males of Asian descent and is rare in other populations. It typically affects the subcutaneous tissue and regional lymph nodes, as well as the orbit and adnexal tissues. Clinically, peripheral eosinophilia and increased levels of immunoglobulin are commonly seen. Histologically, the disease presents with follicular hyperplasia with germinal center formation, hyperplastic vasculature, increased eosinophilic inflammatory infiltrate, and characteristic Warthin-Finkedly cells. Methods/Case Report A 70-year-old white male with no significant past medical history presented to an outpatient clinic with a painless right eyebrow mass. The mass had grown in size which prompted the patient to seek evaluation. The decision to excise the mass was made. Upon pathologic review, hematological workup was performed, and the case was subsequently diagnosed as Kimura disease. Results (if a Case Study enter NA) The specimen was excised and H&E showed background benign fibroadipose tissue with prominent, lymphoid follicles. Within the follicles, there was a significant increase in eosinophils. Warthin- Finkeldey cells were commonly identified within germinal centers as well. Immunohistochemical staining was performed with appropriate controls which ruled out other common lymphoid malignancies and to the diagnosis of Kimura Disease. Conclusion Kimura disease is a rare, benign inflammatory disorder that most commonly affects the lymph nodes. It may be overlooked histologically when the patient does not fit the typical clinical picture. It can closely resemble neoplastic, hematologic conditions, and it should be distinguished from a more aggressive entity due to its benign, indolent behavior. From a pathologist’s point of view, because it occurs almost exclusively in young, Asian males, it is important to consider when presented with an atypical demographic to avoid unnecessary additional workup.

Hydatid Cyst at Unusual Location (Spleen) - A Case Report

Echinococcosis or Hydatid disease is a zoonosis endemic in agricultural areas of the world. It is caused by tapeworm of genus Echinococcus excreted in the faeces of infected dogs. Most common site of involvement is liver (50-77%) followed by lungs (18-35%), abdominal cavity and brain. Splenic hydatid cyst is a rare entity constituting 0.5 - 4% of abdominal hydatid disease. We report a case of 62 yrs old female who presented with vague abdominal pain and vomiting. Her abdominal CECT revealed a cystic lesion with peripheral calcified foci at lower pole of spleen. All other investigations were normal except for raised serum echinococcus IgG levels. Splenectomy specimen was received and histopathological examination confirmed it as hydatid cyst. Microscopy showed outer acellular laminated membrane, inner germinal layer with scolices along with eosinophilic inflammatory infiltrate. Patients presenting with hydatid disease are usually asymptomatic or can have vague abdominal pain. The disease is associated with recurrences, fatal anaphylaxis if neglected and high morbidity and mortality, therefore it should be considered as a differential for any cystic mass found in any part of the body.

Angiolymphoid Hyperplasia with Eosinophilia of the External Auditory Canal.

Angiolymphoid hyperplasia with eosinophilia is a rare, benign, vaso-proliferative disease with a dense eosinophilic inflammatory infiltrate seen in the intradermal or subcutaneous region. It is also termed an epitheloid hemangioma, and it mostly affects females rather than males. It is seen as reddish to brown, fleshy, proliferative, papular, or nodular lesion affecting the head and neck region, most commonly the auricular and periauricular regions. The aetiology is unknown, but the most likely causes are trauma, infection, and hyperestrogenic condition like pregnancy or the use of oral contraceptive agents. It usually measures about 2-3cm in size. It should be differentiated from Kimura disease, which is characterized by chronic inflammation and large subcutaneous nodules in the head and neck region. Here is a rare case report of angiolymphoid hyperplasia in a middle-aged male patient involving the external auditory canal of the left ear.

DP12 Painful oral keratosis and skin lesions: a paraneoplastic diagnostic conundrum

Abstract A 70-year-old man was referred to oral medicine with extensive, painful oral hyperkeratosis affecting the tongue, buccal mucosa and palate. Medical history included a previous diagnosis of prostate cancer. Histology from multiple oral biopsy specimens showed only hyperparakeratosis and acanthosis, with no fungi or dysplasia. Owing to the absence of oral inflammation, the pain was treated as neuropathic. The patient then developed skin lesions and dermatology review was requested. Skin examination revealed marked hyperkeratotic, verrucous plaques affecting the extensor surfaces of the limbs and dorsal hands, as well as the plantar feet bilaterally. The nails were unaffected. There was violaceous discolouration of the pinnae. Given the history of prostate cancer, a paraneoplastic process was suspected. Two incisional biopsies were taken, which showed epidermal acanthosis with necrotic and dyskeratotic keratinocytes throughout the epidermis. There was a dense eosinophilic inflammatory infiltrate. Direct and indirect immunofluorescence was negative. The appearances were suggestive of a paraneoplastic phenomenon, including acrokeratosis paraneoplastica. Haematological investigations identified an IgG monoclonal paraproteinaemia with raised kappa:lambda ratio. Following further investigation, including bone marrow biopsy and positron emission tomography computed tomography, a diagnosis of monoclonal gammopathy of undetermined significance was made by haematology. A repeat bone marrow biopsy 7 months later confirmed evolution to myeloma. As CRAB criteria (hypercalcaemia, renal insufficiency, anaemia and bone lesions) were absent, a period of observation followed. A trial of oral steroids improved the cutaneous eruption, but he developed significant side-effects. Oral mycophenolate, methotrexate and acitretin were used as steroid-sparing agents, with a poor clinical response. The skin lesions progressed to a widespread psoriasiform eruption on the trunk and lower limbs with the formation of bullae. Further biopsies showed an eosinophil-rich infiltrate with negative immunofluorescence, raising the possibility of an eosinophilic dermatosis of haematological malignancy. After 2 years, given the worsening skin symptoms, it was decided to commence bortezomib, cyclophosphamide and dexamethasone (VCD) chemotherapy. Despite four cycles of VCD treatment, the skin lesions worsened and as the paraprotein levels did not reduce, treatment was stopped. Subsequently, further elevations in serum free light chains prompted treatment with lenalidomide. This resulted in a marked improvement in the skin and reduced pain from the oral lesions, as well as a reduction in serum free light chains. Acrokeratosis paraneoplastica (Bazex syndrome) is characterized by digital hyperkeratosis and paronychia, which may progress to involve the limbs and trunk. Eosinophilic dermatosis of haematological malignancy is characterized by a pruritic, papular skin eruption with a vesiculobullous component. This case presents a diagnostic conundrum, with evolving features of two different paraneoplastic conditions.

Gurltia paralysans infection in a domestic cat in the São Paulo state, southeastern Brazil

Gurltia paralysans is a nematode first described in 1933 in Chile, causing a syndrome called feline crural parasitic paraplegia. Insects, mollusks, frogs, lizards, and rodents are paratenic hosts of this nematode, and cats probably become infected by ingesting them. This report aims to discuss the main anatomopathological findings of gurltiosis in a cat submitted to necropsy in a laboratory in Ribeirão Preto city, São Paulo state, southeastern Brazil, being the first case reported in this state. The main necroscopic findings were extramedullary reddened areas below the leptomeninges in the cervical and lumbar segments of the spinal cord. The histopathological examination showed marked thickening of the leptomeninges in the lumbar segment of the spinal cord, with marked neovascularization and fibrosis associated with eosinophilic and mononuclear inflammatory infiltration, as well as the presence of intravascular nematodes. The diagnosis of this lesion was chronic segmental meningomyelitis associated with intralesional parasites. Although uncommon, feline gurltiosis is a neglected parasitic disease that should be included as a differential diagnosis of paraparesis in domestic cats.

Submucosal infiltrate of anisakis larvae. Rare cause of intestinal obstruction.

Patient aged 71 with a history of type 2 diabetes mellitus. He came to the emergency department for abdominal pain and vomiting. Laboratory tests showed an increase in acute phase reactants. Abdominal CT scan showed dilated jejunal loops, compatible with intestinal occlusion. Urgent intervention was performed, resecting the affected segment. The pathology report showed a prominent transmural inflammatory infiltrate and interstitial oedema, with moderate villous atrophy, identifying parasitic structures compatible with anisakis larvae (family Anisakidae). Given the mechanism of tissue invasion, the larvae are surrounded by a predominantly eosinophilic inflammatory infiltrate, organised as granulomas or abscesses.

Examining the Role of Type 2 Inflammation in Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic type 2 inflammatory disease characterized by an eosinophilic inflammatory infiltrate in the esophagus, leading to remodeling, stricture formation, and fibrosis. Triggered by food and aeroallergens, type 2 cytokines interleukin (IL)-4, IL-13, IL-5 produced by CD4+ T helper 2 cells (Th2), eosinophils, mast cells, basophils, and type 2 innate lymphoid cells alter the esophageal epithelial barrier and increase inflammatory cell tissue infiltration. Clustering analysis based on the expression of type 2 inflammatory genes demonstrated the diversity of EoE endotypes. Despite the availability of treatment options for patients with EoE, which include dietary restriction, proton pump inhibitors, swallowed topical steroids, and esophageal dilation, there are still no Food and Drug Administration-approved medications for this disease; as such, there are clear unmet medical needs for these patients. A number of novel biologic therapies currently in clinical trials represent a promising avenue for targeted therapeutic approaches in EoE. This review summarizes our current knowledge on the role of type 2 inflammatory cells and mediators in EoE disease pathogenesis, as well as the future treatment landscape targeting underlying inflammation in EoE.

Hepatitis in Idiopathic Hypereosinophilic Syndrome: Report of an Unusual Case

World Health Organization defines a rare diagnosis Idiopathic hypereosinophilic syndrome (HES) as a persistent eosinophilia for 6 months and resulting in end-organ dysfunction. Most of the patients present with nonspecific symptoms, while others will present with symptoms of the affected organs, commonly those involving the heart, skin, or nervous system. Gastrointestinal or liver involvement is estimated to affect up to one-third of patients with HES, although patients with clinically significant disease are limited to case reports. This is the first report of a patient presenting with idiopathic HES related hepatitis and achalasia. Hypereosinophilic syndrome has been reported to be associated with hepatic dysfunction; liver histology is mainly characterized by a diffuse eosinophilic inflammatory infiltrate. A 49-yr-old woman, diagnosed as a case of idiopathic hypereosinophilic syndrome with bone marrow and pulmonary eosinophilic infiltrates associated with peripheral eosinophilia,high IgE level developed features of chronic gatrornteritis, hepatitis, with a significant eosinophil component. She responded well to systemic glucocorticoid and Imatinib therapy with normalization of liver function tests within a few weeks.

Parasitism with Acanthocephalus Ranae in Frogs (Pelophylax Ridibundus Pallas 1771), from North-east Romania.

SummaryThe present study was carried out on 10 frogs, Pelophylax ridibundus (Pallas, 1771), captured near the river Bahlui, Iasi, between April and May, 2019, for the study of digestive helminths and their effect on the digestive tract. Macroscopic examination of the general cavity revealed distension of the small intestine. The sectioning of the intestinal wall revealed a variable number of parasites (1 – 12) with a whitish cylindrical body, anchored in the duodenal mucosa. The morphological study of the parasites confirmed the species as Acantocephalus ranae. The prevalence of the infection was 60 % and the average intensity was 4.83 ± 4.15. Lesions of the small intestine were characterized by catarrhal enteritis, hemorrhagic spots and ulcers on the mucosa, occlusion and obstruction of the intestinal lumen. Histologically, eosinophilic inflammatory infiltrate in the glandular crypts, mucosal and submucosal edema, fibrosis and conjunctival hyperplasia, total mucosal atrophy, were found. The infection with Acanthocephalus ranae in Pelophylax ridibundus caused severe pathological changes, conditioned by the intensity of the infection, aspects revealed for the first time in Romania.

Dermatitis Associated with the Intake of Defatted Rice Bran by Cattle in the Southern Region of the State of Rio Grande do Sul

Background: Dermatitis associated with defatted rice bran (DRB) seems to be an underdiagnosed disease in Brazilian confined herds, characterized by localized skin lesions that develop mainly on hind limbs, and can affect any animal category. In this context, the goal of the present study was to describe an outbreak of dermatitis associated with the consumption of defatted rice bran on a property in the State of Rio Grande do Sul, demonstrating the clinical, hematological and epidemiological characteristics of the animals, as well as alternatives for the definitive diagnosis.Cases: Clinical and epidemiological data were obtained by anamnesis with the technician responsible for the property. Aberdeen Angus and crossbred males, with 24 to 36 months of age, with an average of 413 kg, from a property in the interior of the state of Rio Grande do Sul were analyzed. From a batch of 45 cattle, from 24 to 36 months of age, 20 presented lesions on hind limbs 8-17 days after supplementation of a commercial feed containing defatted rice bran. To assist in the diagnosis, blood samples were drawn into vacuum tubes with 10% EDTA, for a complete blood count with the investigation of hemoparasites, and without anticoagulant, for liver function tests. In addition, lesion tissue samples were also collected for bacteriological, mycological and histopathological examination and the ration offered to the animals, for intradermal tests. There were no significant hematological and biochemical changes in animals that developed DRB dermatitis, except when they have an associated secondary infection. The fungal research was negative. The bacterial culture revealed a growth of Staphylococcus aureus, possibly due to secondary infection resulting from the lesions. In histopathological examination, lesions were characterized by areas of alopecia, thickening of the epidermis, forming dry, thick crusts, and some ulcerative and serosanguineous lesions. Histologically, lesions were characterized by marked hyperkeratosis, ulceration, and in the superficial dermis, intense inflammatory infiltrate of eosinophils and lymphocytes.Histologic changes, although not pathognomonic, are typically described in this disease. The intradermal test was performed to contribute to the diagnosis of the disease, where a significant increase in volume was found between measurements on animals that developed the disease. It is believed that the disease is produced due to a food hypersensitivity as a consequence of the high protein level in DRB. The results of the intradermal test indicate that the animals developed hypersensitivity and reaction to proteins, and further research is required to determine the protein fraction leading to hypersensitivity reactions.Discussion: In the present study, acute lesions in hind limbs in a significant number of animals of the same batch in a short period of time after supplementation with a diet containing defatted rice bran, enabled a clinical diagnosis suggestive of dermatitis associated with DRB consumption. Through epidemiological data, reactive intradermal test, associated with the findings of the histopathological exam, which showed characteristic lesions of the disease (alopecia, erythema, epidermis thickening, with the formation of thick crusts, usually on hind limbs in the region of the hoof coronary band, progressing to pastern and fetlock), it was possible to establish the clinical-pathological diagnosis of dermatitis associated with the consumption of defatted rice bran. Keywords: dermatitis, cattle, supplementation, defatted rice bran.Descritores: dermatite, bovinos, suplementação, farelo de arroz desengordurado.Título: Dermatite associada ao consumo de farelo de arroz desengorduradoem bovinos na região sul do Estado do Rio Grande do Sul.

Rare case of gastric inflammatory fibroid polyp located at the fornix of the stomach and mimicking gastric cancer: a case report

BackgroundGastric inflammatory fibroid polyp (IFP) is a rare polypoid lesion of the stomach that is characterized pathologically by the presence of spindle cells, a prominent network of blood vessels, and inflammatory infiltration of eosinophils. IFP is mainly located in the gastric antrum and is usually semi-pedunculated and covered with normal mucosa. There have been several reports of large IFPs with ulceration on the surface, at the apex, but no report of the IFP with ulceration at the fornix of the stomach. We report a case of IFP with ulceration that was suggested to be gastric cancer and was resected for diagnostic treatment.Case presentationA 79-year-old woman presented to our hospital. During mass screening for cancer, stomach fluoroscopy revealed an abnormal shadow. Endoscopy showed an ulcerated tumor at the fornix of stomach; hence, gastric cancer was suggested because of the polypoid lesion with irregular ridges and ulceration. Pathological diagnosis of gastric biopsy specimens revealed an inflammation of the gastric mucosa, and specific findings for gastric cancer were not obtained. Because we could not exclude gastric malignancies such as cancer or gastrointestinal stromal tumor, we performed a partial resection of the stomach with a 2-cm margin using the laparoscopic-assisted method. Pathological examination of the resected specimen revealed that the tumor was present in the submucosal layer and consisted of collagen fiber containing inflammatory cell infiltration of mainly eosinophils. A prominent network of blood vessels was also found in the specimens. Immunohistochemical staining revealed mild positivity for CD34, and α-SMA and was negative for c-kit, DOG-1, s-100, desmin, ALK, and IgG4. The lesion was thus diagnosed as an IFP. The postoperative course was uneventful. The patient is currently asymptomatic and has shown no recurrence.ConclusionIFPs have variable locational, morphological, histological, pathological, and immunohistochemical features. We reported that the gastric IFP was located at the fornix of the stomach and was similar in morphology to gastric cancer. This case is clinically significant to avoid over-surgery.

Eosinophilic Gastrointestinal Diseases in Children: A Practical Review.

Primary eosinophilic gastrointestinal diseases (EGIDs) represent a heterogeneous group of disorders characterized by eosinophilic inflammation in the absence of known causes for eosinophilia, selectively affecting different segments of the gastrointestinal tract. While pediatric eosinophilic esophagitis (EoE) is a well-defined disease with established guidelines, Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC) remain a clinical enigma with evidence based on limited anecdotal case reports. Large cross-sectional studies in the US defined a prevalence of EoG and EoGE ranging from 1,5 to 6,4/100.000 and from 2,7 to 8,3/100.000 subjects respectively, while the prevalence of EoC ranges from 1,7 to 3,5/100.000 subjects. Regarding the pathogenesis, it is hypothesized that EGIDs result from the interplay between genetic predisposition, intestinal dysbiosis and environmental triggers. Clinically, EGIDs might present with different and nonspecific gastrointestinal symptoms depending on the involved intestinal tract and the extension of eosinophilic inflammatory infiltrate. The diagnosis of EGIDs requires: 1. recurrent gastrointestinal symptoms, 2. increased eosinophils for high power field in biopsy specimens, 3. absence of secondary causes of gastrointestinal eosinophilia. No validated guidelines are available on the clinical management of patients with EGIDs. Evidence from case reports and small uncontrolled case series suggests the use of dietary and corticosteroids as the first-line treatments. Considering the clinical follow-up of EGIDs, three different patterns of disease course are identified: single flare, recurring course-disease and chronic course-disease. This review will focus on pediatric EGIDs distal to esophagus, including Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC).

Eosinophilic Gastrointestinal Diseases in Children: A Practical Review

Primary eosinophilic gastrointestinal diseases (EGIDs) represent a heterogeneous group of disorders characterized by eosinophilic inflammation in the absence of known causes for eosinophilia, selectively affecting different segments of the gastrointestinal tract. While pediatric eosinophilic esophagitis (EoE) is a well-defined disease with established guidelines, Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC) remain a clinical enigma with evidence based on limited anecdotal case reports. Large cross-sectional studies in the US defined a prevalence of EoG and EoGE ranging from 1,5 to 6,4/100.000 and from 2,7 to 8,3/100.000 subjects respectively, while the prevalence of EoC ranges from 1,7 to 3,5/100.000 subjects. Regarding the pathogenesis, it is hypothesized that EGIDs result from the interplay between genetic predisposition, intestinal dysbiosis and environmental triggers. Clinically, EGIDs might present with different and nonspecific gastrointestinal symptoms depending on the involved intestinal tract and the extension of eosinophilic inflammatory infiltrate. The diagnosis of EGIDs requires: 1. recurrent gastrointestinal symptoms, 2. increased eosinophils for high power field in biopsy specimens, 3. absence of secondary causes of gastrointestinal eosinophilia. No validated guidelines are available on the clinical management of patients with EGIDs. Evidence from case reports and small uncontrolled case series suggests the use of dietary and corticosteroids as the first-line treatments. Considering the clinical follow-up of EGIDs, three different patterns of disease course are identified: single flare, recurring course-disease and chronic course-disease. This review will focus on pediatric EGIDs distal to esophagus, including Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC).

SAT-LB101 Sclerosing Mucoepidermoid Carcinoma with Eosinophilia (SMECE) of the Thyroid: Benign Long Term Course with Conservative Treatment in a High Risk Thyroid Cancer

SMECE is a rare thyroid carcinoma (<1%), on the background of Hashimoto's thyroiditis, with a female predominance. SMECE is characterized by inflammatory infiltrate of eosinophils, extensive sclerosis and squamous and glandular differentiation. It is mostly regarded as an aggressive tumor. Most SMECE stain negative with thyroglobulin and positive with p63, but to date lack a pathgnomonic molecular/genetic/epigenetic diagnostic marker. SMECE should be differentiated from salivary mucoepidermoid carcinoma, papillary carcinoma with squamous metaplasia and Hodgkin lymphoma. Here we describe a 42-year-old female that presented with a right-sided thyroid swelling. A total-thyroidectomy was preformed and the pathological report described a tumor of 2.2cm which reached the inked surgical margins at several foci. Staining showed typical features of SMECE. Calcitonin, thyroglobulin stains were negative but cytokeratin staining was positive. No extra-thyroidal extension was seen. Post-operative PET scan and US showed no evidence of residual/recurrence disease during the next 9 years of follow -up. There are about 55 cases of SMECE described in the literature. SMECE was categorized as low-grade tumor but recent reports suggested a more aggressive behavior both locally and occasionally by distant metastasis. In the largest published series nearly half of the cases presented with an extrathyroidal extension and over 1/3 had lymph node metastases. After an average of 4 years follow up, 24% were deceased and 15% were alive with disease. In the present case, despite some involvement of the surgical margins no other aggressive feature was noted. This case then may indicate that a localized tumor, at diagnosis, without extrathyroidal and lymph node involvement may be regarded as a low-grade tumor with a favorable prognosis. Shah A et al - Modern Pathology 2017; 30: 329-339 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Evaluation of acute toxicity of plants' mixture used in traditional treatment of kidney diseases in Morocco

Background: The use of plants' mixture in the traditional treatment of kidney diseases in Morocco is widespread. Objective: To evaluate the toxic effects of plants' mixture used in the traditional treatment of kidney diseases in Morocco. Materials and Methods: The phytochemical screening was performed. For acute toxicity, single doses of low dose (300 mg/kg), medium dose (500 mg/kg), high dose (2000 mg/kg), lethal dose (6000 mg/kg), and traditional dose (10 ml/kg) body weight of aqueous extracts of plants' mixture were administered orally in Wistar rats. Animals were monitored daily for at least 15 days after an oral administration of aqueous extract of the mixture to detect any changes in body weight, behavior, autonomic profiles, or mortality. Calculation of relative organ weight (ROW), hematological, biochemical analysis, and histopathology evaluation were carried out. Results: The acute oral toxicity study showed diarrhea, somnolence, and agitation of different groups of rats, while no mortality and no statistically significant decrease in body weight was observed. Statistically, the kidneys, liver, and spleen showed significant decrease in the ROW of the treated groups of rats when compared to the control group. In biochemical analysis, there was a significant increase in aspartate aminotransferase, creatinine, urea, and uric acid. Hematological parameters showed a significant decrease in leukocytes, eosinophil, basophil, lymphocytes, monocytes, and hematocrit. Histopathological evaluation which revealed major histology changes of liver sections of rats treated with low and medium doses had lymphocyte and plasma cell inflammatory infiltrates; whereas, the liver sections of rats treated with high, lethal, and traditional doses exhibited lymphocyte, plasma cell, and eosinophilic inflammatory infiltrates. Conclusion: The study finds that the plants' mixture marketed by herbalists for the treatment of kidney diseases is toxic to body organs such as the liver and the hematopoietic system.

Antrochoanal Polyp: A Literature Update

The antrochoanal polyp (ACP) is a unilateral, solitary, pear shaped mass with a cystic stalk, differing from the inflammatory polyps in the formation of a constricted sac, half in the maxillary antrum and the other half in the nose, extruding in a variable extent to the nasopharynx. The ACP has a clinic diagnosis, with image studies as the CT scan and the MRI for the differential diagnosis. By microscopy ACP lacks minor mucoserous glands and a well-developed eosinophilic inflammatory infiltrate, the surface epithelium goblet cells are less frequent than in sinunasal polyps. Surgery is the only known treatment, complete removal by functional endoscopic sinus surgery with treatment of the obstructed ostium complex as the current standard.

Eosinophilic effusions: A clinicocytologic study of 12 cases

Our aim is to study the prevalence of eosinophilic effusions (EEs) in our institution, to highlight their cytologic patterns, potential interpretation pitfalls, diagnostic importance, and to investigate their possible causes and clinical associations. We conducted a retrospective review study for over 13 years. We retrieved all of the cytology reports of pleural, pericardial, and peritoneal effusions with eosinophils. We reviewed and screened the cytology slides looking for eosinophils that constitute >10% of the cells. We extracted the clinical, radiologic, and laboratory findings and follow-up data for each patient. We found 12 patients (0.7%) with EEs. They included five pleural, five peritoneal, and two pericardial fluids. The age range was between 16 and 75 with a mean age of 36.5 years. The male to female ratio was 3:1. We have recognized three cytomorphologic patterns; purely eosinophilic, dominantly eosinophilic, and mixed inflammatory infiltrate that correlated with peripheral blood eosinophilia. Two cases demonstrated extracellular and intracellular Charcot-Leyden crystals. Certain cellular and crystal features are potential cytologic pitfalls. EEs were associated with miscellaneous specific and non-specific medical conditions. None was associated with tuberculosis, malignancy, drugs, or parasites. EEs are uncommon. They mostly occur in young adult males. There are three cytomorphologic patterns that correlate with peripheral eosinophilia. Etiologies are diverse or obscure. EEs with a very high eosinophilia are less likely malignant, tuberculous, parasitic, and seldom associated with drugs. Cytopathologists should be aware of certain potential diagnostic pitfalls. Correct cytologic recognition is clinically important since some causes are treatable.

Donʼt Judge a Polyp by Its Cover: A Case of an Inflammatory Fibroid Polyp in the Duodenum

This is a case presentation of an Inflammatory Fibroid Polyp, a rare submucosal lesion with eosinophilic inflammatory infiltrates that can be found throughout the gastrointestinal tract. Proper diagnosis of these lesions is important for surgical planning, with a diagnosis based on histologic and immunohistochemical examination, highlighting the need for thorough investigation of duodenal lesions. A 64 year-old man presented to clinic with complaints of occasional diarrhea after ingesting milk products, as well as a five-pound unintentional weight loss in the past three weeks. He denied other GI symptoms, including nausea, vomiting, constipation, rectal bleeding, fevers, or chills. He underwent an EGD for further investigation into these symptoms, and was found to have gastritis and an 8-9 mm submucosal fundic lesion; he was then referred for endoscopic ultrasound. About one year later, he underwent a second EGD, and was found to have multiple subcentimeter polpys in the body of the stomach. During this intervening one year, he also developed a single polyp measuring 6-7 mm in his duodenal bulb, from which a biopsy was taken. The specimen was sent for analysis and pathology showed duodenal mucosa with eosinophilia (more than 50 eosinophils per high power field), and reactive lymphoid aggregate. No dysplasia or malignancy was noted. Inflammatory fibroid polyps (IFP) are exceedingly rare submucosal lesions with eosinophilic inflammatory infiltrates. Of the approximately 1,000 cases identified, only about 1% have occurred in the duodenum, with roughly 70% in the stomach. The presentations of IFPs are variable; our patient did not have worsening symptoms over the one year prior to diagnosis. Thus, histopathologic examination remains the cornerstone for diagnosis of IFP. Immunohistochemically, actin and CD34 are positive, while CD117 and S100 are negative. CD117 is a useful cell surface marker to differentiate IFP from GIST. The etiology of these polyps is still unknown, and although it is believed to be a benign process, these polyps can resemble malignant lesions and should be resected, either endoscopically or surgically, depending on the size of the lesion. Proper diagnosis of this benign lesion is essential to avoid unnecessarily wide resections, and endoscopic ultrasound can help guide pre-surgical planning.2567_A Figure 1. EGD from patient showing single polyp (6-7 mm in size) in the duodenal bulb2567_B Figure 2. Duodenal mucosa with eosinophilia (>50 eosinophils per high powered field 400x)”2567_C Figure 3. Duodenal mucosa with eosinophilia (>50 eosinophils per high powered field, 200x)

Acne Treatment Gone Erratic: A Rare Case of Minocycline-induced Eosinophilic Cholecystitis, Myopericarditis, and CNS Vasculitis

Eosinophilic cholecystitis (EC) is a rare entity that has a clinical presentation indistinguishable from acute cholecystitis and is diagnosed based on classical symptoms of cholecystitis with the presence of > 90% eosinophilic infiltration within the gallbladder wall. EC has never been reported before in combination with eosinophilic myopericarditis and an isolated central nervous system (CNS) vasculitis. Minocycline is commonly used to treat dermatologic conditions. One of the rare drug-reaction is eosinophilia with systemic symptoms. We present an extremely rare case of minocycline-induced hypereosinophilia, which resulted in simultaneous onset of acute cholecystitis, myopericarditis, and non-granulomatous eosinophilic CNS vasculitis. A 36-year female who was started on minocycline for back acne a month ago presented with an acute onset of right-upper-quadrant abdominal pain and tenderness associated with nausea. Ultrasound demonstrated thickened gallbladder wall with pericholecystic fluid in the absence of gallstones. Hepatobiliary scan (HIDA) documented conclusions consistent with biliary dyskinesia. She underwent cholecystectomy for acalculous cholecystitis. A week later, she presented with chest pain and weakness. A marked increase in peripheral eosinophilia was observed. Electrocardiogram revealed low-voltage in frontal leads without ST or T wave changes. Cardiac enzymes were elevated. Imaging modalities showed findings consistent with eosinophilic myopericarditis. During hospitalization, the patient also developed focal weakness. Magnetic resonance imaging revealed at least 40 diffuse scattered brain infarcts. She was started on steroids after ruling out infectious causes and had a rapid resolution of symptoms. To our knowledge, this is the first case of minocycline-induced hypereosinophilia presenting as a combination of eosinophilic cholecystitis, myopericarditis, and CNS vasculitis. Our patient had a remarkable and speedy recovery with steroid treatment. Our case illustrates that acalculous cholecystitis in the presence of peripheral eosinophilia should raise suspicion of EC and ensuing end-organ damage from eosinophilic infiltration. Peripheral eosinophilia indicates that EC is likely to be a manifestation of a systemic hypereosinophilic disorder. A high eosinophil count can provide an essential diagnostic clue to initiate early aggressive management.2469_A Figure 1. Diffusion-weighted magnetic resonance imaging showing multiple brain infarcts predominantly concentrated at the margin of the vascular territories representing watershed infarcts.2469_B Figure 2. Gallbladder submucosa with predominantly eosinophilic inflammatory infiltration2469_C Figure 3. Gallbladder submucosa with predominantly eosinophilic inflammatory infiltration.

Neotropical echinococcosis caused by Echinococcus vogeli in rural Huila, Colombia: report of two last cases in the last 35 years

Background: Human polycystic echinococcosis is a parasitic infection caused by the larval stage of Echinococcus vogeli which occurs in rural areas of Latin America. Echinococcosis, and even more, human polycystic echinococcosis due to E. vogeli is neglected, particularly in Colombia. Methods & Materials: Cases report diagnosed by histological, morphometric and molecular techniques. Results: Case 1: A 9-year-old female from rural Huila, was brought to our hospital, due to an umbilical hernia (5 mm), confirmed by an abdominal ultrasound. This, and a subsequent computed tomography, revealed a lesion with solid and liquid components in the umbilical region, 40 mL, consistent with an echinococcal cyst. An uncomplicated resection of the tumor was performed (sized 6x4x3.5 cms), wall of 1 mm, multilocular cysts of 1 mm. The lesion was surrounded by fibrosis with eosinophilic and lymphoplasmacytic inflammatory infiltrate and a rim of histiocytes and multinucleated giant cells. Microscopic examination of resected tissue found vesicles containing protoscolices surrounded by PAS–positive membranes. The mean lengths of the rostellar hooks was 40 μm, then suggesting the diagnosis of E. vogeli echinococcosis. Case 2: 47-year-old woman patient from rural area Curillo, Caqueta, Colombia, with right upper quadrant and epigastric abdominal pain of 4-months of evolution with subsequent severe itching, dark urine and progressive jaundice, afebrile, with occasional emesis food content. Abdominal ultrasound found liver cystic lesion that compromises segments VI, VII and VIII. Resection of hydatid cyst was performed. PCR and sequencing Ev3-ev5 was performed. Samples submitted present Alignment: 188/188 with complete mitochondrial genome of E. vogeli. Nucleotide identity: 100% nucleotide to the original sequence described in Genbank E. vogeli identity. Conclusion: More undiagnosed cases of polycystic neotropical echinococcoses in Colombia should exist. A recent historical review of echinococcosis in Colombia showed that no previous cases have been reported from Huila, and even more, before the current cases (first reported in 35 years), only 3 previous reports were made. The review described 303 cases during 2009-2013, all of them due to E. granulosus and E. multilocularis (no cases of E. vogeli nor E. oligarthrus were reported). These recent cases highlights the possible emergence of this pathogen in certain areas of Colombia.