Grocott's Methenamine Silver Stain Research Articles

A Case Report of Pulmonary Alveolar Proteinosis with Associated Opportunistic Infection of Pneumocystis jirovecii and Molluscum Contagiosum

Abstract Pulmonary alveolar proteinosis (PAP) is an idiopathic rare diffuse pulmonary disease, first described in 1958 by Rosen et al. Its estimated prevalence is about 1 in 3.7–6.9 × 106 with a male: female ratio of 1:1–2:1. Majority of the patient’s age ranges between 20 and 50 years. PAP on microscopy is characterized by the presence of massive insoluble, amorphous, phospholipid-rich protein deposits in the bronchial and alveolar cavities. Most patients with acquired PAP present with cough and exertional dyspnea. It has been studied that there is increased risk of superinfection in PAP with opportunistic organisms like pneumocystis and vice versa. Definitive diagnosis of Pneumocystis jirovecii pneumonia rests on the demonstration of the organism within the alveoli by special stains like Grocott Methenamine Silver stain. Molluscum contagiosum (MC) is a common superficial skin infection caused by the poxvirus. MC is characterized by painless papules commonly seen in children and immunocompromised individuals. Here, we present a 34-year-old female who had complaints of severe difficulty in breathing and was brought dead to our hospital. On external examination, she had multiple warts over chest, abdomen, and over genitalia. Internal examination was unremarkable. Specimens of kidney, lung, and skin biopsy of genital warts sent for histopathological examination revealed acute tubular necrosis, P. jirovecii with PAP, and MC respectively.

Novel B-DNA dermatophyte assay for demonstration of canonical DNA in dermatophytes: Histopathologic characterization by artificial intelligence

We describe a novel assay and artificial intelligence–driven histopathologic approach identifying dermatophytes in human skin tissue sections (ie, B-DNA dermatophyte assay) and demonstrate, for the first time, the presence of dermatophytes in tissue using immunohistochemistry to detect canonical right-handed double-stranded (ds) B-DNA. Immunohistochemistry was performed using anti-ds-B-DNA monoclonal antibodies with formalin-fixed paraffin-embedded tissues to determine the presence of dermatophytes. The B-DNA assay resulted in a more accurate identification of dermatophytes, nuclear morphology, dimensions, and gene expression of dermatophytes (ie, optical density values) than periodic acid–Schiff (PAS), Grocott methenamine silver (GMS), or hematoxylin and eosin (H&E) stains. The novel assay guided by artificial intelligence allowed for efficient identification of different types of dermatophytes (eg, hyphae, microconidia, macroconidia, and arthroconidia). Using the B-DNA dermatophyte assay as a clinical tool for diagnosing dermatophytes is an alternative to PAS, GMS, and H&E as a fast and inexpensive way to accurately detect dermatophytosis and reduce the number of false negatives. Our assay resulted in superior identification, sensitivity, life cycle stages, and morphology compared to H&E, PAS, and GMS stains. This method detects a specific structural marker (ie, ds-B-DNA), which can assist with diagnosis of dermatophytes. It represents a significant advantage over methods currently in use.

An Unusual Etiology of Fluorodeoxyglucose Avid Intrathoracic Lymph Nodes.

A middle-aged man in his 50s, active smoker, presented to the pulmonary office for lung cancer evaluation. On a low-dose computed tomography for lung cancer screening, he was found to have an 8 mm endobronchial lesion in the right main stem bronchus. A PET-CT revealed no endobronchial lesion, but incidentally, fluorodeoxyglucose (FDG) avidity was present in the right hilar (SUV 13.2) and paratracheal lymph nodes (LNs). He underwent bronchoscopy and EBUS-TBNA of station 7 and 10 R LNs. The fine needle aspiration (FNA) revealed necrotizing epithelioid granuloma. The acid-fast bacilli (AFB) and Grocott methenamine silver (GMS) stains were negative. He had suffered from pneumonic tularemia 13 months ago and immunohistochemical staining for Francisella tularensis on FNA samples at Center for Disease Control and Prevention was negative. The intense positron emission tomography (PET) avidity was attributed to prior tularemic intrathoracic lymphadenitis without active tularemia, a rare occurrence. To the best of our knowledge, PET-positive intrathoracic lymph node beyond one year without evidence of active tularemia has not been previously reported.

FRI345 A Rare Case Of Pituitary Histoplasmosis Presenting With Hypopituitarism

Abstract Disclosure: A. Jung: None. J. Tan: None. S. Charatz: None. S. Azim: None. A 58-year-old female presented to the endocrine clinic with a history of headache of one year duration. Prior to the visit, she had undergone a right middle lobe lung resection. Histopathology revealed necrotizing granulomas with yeast resembling histoplasmosis on fungal stains. She had no past history to suggest that she was immunocompromised. The patient had completed a three months course of itraconazole. Shortly after, she experienced daily headaches. Pituitary MRI demonstrated an enlarged 1.5cm pituitary gland without compression of the optic chiasm. Laboratory tests showed hypogonadotropic hypogonadism with LH 2.4 mIU/mL (15.9- 54.0), FSH 9.6mIU/mL (23 -116.3), and estradiol 14 pg/mL (<32.2). Free T4 was low 0.7 ng/dL (0.9-1.8) without elevated TSH 1.81 uIU/mL (0.55-4.78). Prolactin was 29.7 ng/mL (2.8-29.2). GH, ACTH, and morning cortisol were normal. Due to the constant headache with hypopituitarism, the decision was made to proceed with transsphenoidal surgery. Pituitary biopsy reported histoplasmosis on Grocott methenamine silver and Periodic acid-Schiff stains. The patient was started on amphotericin B. Repeat MRI confirmed the decrease in size of the pituitary gland after the procedure. Pituitary fungal infections are extremely rare. To our knowledge, this is the first reported case of pituitary histoplasmosis presenting with hypopituitarism. Clinicians should be mindful of the rare etiologies of hypopituitarism when evaluating patients with pituitary enlargement and hypopituitarism. Presentation: Friday, June 16, 2023

Rosai-Dorfman disease of the breast: a clinicoradiologic and pathologic study

Rosai-Dorfman disease (RDD) is an uncommon histiocytic disorder typically involving lymph nodes and less frequently extranodal tissues. RDD involving the breast is rare and may clinically and radiologically mimic neoplastic and non-neoplastic disorders. We report seven patients with breast RDD, describe their clinicoradiologic and pathologic features, and discuss the differential diagnosis. Patients, ranging from 15 to 74 years of age, presented with unilateral and unifocal (5/7) or bilateral and multifocal (2/7) masses. RDD was either confined to the breast (6/7) or concurrently involved a lymph node (1/7). Masses ranged from 8 to 31mm, categorized as Breast Imaging-Reporting and Data System (BI-RADS) 4 (6/7) or 5 (1/7). All cases showed similar morphology with many large histiocytes displaying emperipolesis with associated fibrosis and dense lymphoplasmacytic infiltrate. The abnormal histiocytes co-expressed CD68/CD163, S100, OCT2, and Cyclin D1 (7/7), and were negative for CK AE1/AE3 (7/7), CD1a (7/7), and BRAF V600E (6/6). Flow cytometry (n=3), kappa/lambda in situ hybridization (n=5), and IgG4/IgG immunohistochemistry (n=1) did not reveal lymphoma or IgG4-related disease. No mycobacterial or fungal organisms were identified on acid-fast bacillus (AFB) and Grocott methenamine silver (GMS) stains (n=5). Three patients underwent complete excision and none recurred or progressed to systemic disease during follow-up (88-151 months). In summary, breast RDD should be included in the differential diagnosis of a mass-forming breast lesion. Histopathology with ancillary studies and clinicoradiologic correlation is essential for accurate diagnosis and optimal clinical management. Patients with RDD of the breast have an excellent prognosis after complete excision.

Identification of a Unique Morphological Pattern for the Diagnosis of Fungal Rhinosinusitis.

Fungal rhinosinusitis (FRS) is a relatively common, but often misdiagnosed disease of paranasal sinuses. The FRS is classified into invasive and non-invasive forms. The non-invasive form includes fungal ball and allergic FRS, and invasive form includes acute invasive FRS, chronic invasive FRS, and granulomatous FRS. Invasive fungal infections are associated with high morbidity and mortality, hence requiring urgent medical and surgical intervention. The histomorphology can help identify certain fungal organisms that cannot be cultured or are rarely visible in exudates. The morphologic diagnosis of tissue invasive and non-invasive fungal infection is essential for appropriate treatment. We analyzed cases of rhinosinusitis from 2017 to 2019 in Pathology Department at a tertiary care cancer hospital, Lahore, Pakistan. All clinical information was retrieved from patient records. Paraffin-embedded tissue blocks were stained with hematoxylin and eosin (H&E), special Grocott methenamine silver stain (GMS), and periodic acid Schiff stain (PAS) according to standard protocol. They were reviewed by two pathologists blinded by fungus status. A total of 169 cases of rhinosinusitis were reviewed. FRS comprised 146 (86.4%) of them. The mean age of patients with FRS was 32.8±14 years. The male:female ratio was 1.4:1. Maxillary sinus was the main site of involvement in 39 (27%) FRS cases. Aspergillus was identified in 117 (80.1%) cases of FRS. The culture reports were available in 44/146 (30.14%) FRS cases. They were negative in 22/44 (50.0%), and Aspergillus species were isolated in 18/44 (40.9%) cases of FRS. There were 84 (57.5%) cases of non-invasive FRS and 59 (40.4%) cases of invasive FRS. Among invasive FRS, there were 56 (38.4%) chronic granulomatous FRS cases including mixed patterns. Majority cases, 54 (96.4%), of chronic granulomatous FRS showed a unique crowded giant cell pattern comprising of foreign body and Langhans type giant cells. These giant cells were arranged closely forming irregular non-caseating granulomas surrounded by lymphocytes and fibrosis. Interestingly, the giant cells were scattered haphazardly without forming a granuloma as well. Fungal organisms were identified in all 56 cases of chronic granulomatous FRS. Histologically, predominant organism was Aspergillus in 48 (85.7%) on GMS and PAS stain. Our study observed a unique crowded giant cell pattern, which is a hallmark of invasive fungal infection. If pathologists are familiar with this unique pattern, they can make a quick and accurate diagnosis on histology. The physician can start antifungal treatment timely for better prognosis.

Clinicopathological profile of post-COVID-19 mucormycosis cases: A report from a tertiary care center.

Mucormycosis is a fatal fungal infection, which is rare but commonly affects immunocompromised patients. Coronavirus disease 2019 (COVID-19) patients who were immunocompromised, due to comorbid conditions, such as hematological malignancy and diabetes mellitus (DM), and patients on immunosuppressive therapy such as steroid therapy were the important host for mucormycosis infection. This study aimed to study the clinicopathological correlation of mucormycosis in post-COVID-19 patients. The study was a retrospective study conducted in the Department of Pathology, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, over four months from April 2021 to July 2021, and clinically diagnosed mucormycosis cases were included in this study. Clinical details, histology slides, and blocks were reviewed, and the data were analyzed. Three- to four-micrometer sections were taken from the blocks and stained with hematoxylin and eosin, and two more slides were made for each case for periodic acid-Schiff (PAS) and Grocott methenamine silver (GMS) staining. In this study, the maximum cases were above the fifth decade of life. Males were more commonly affected than females with a male-to-female ratio of 2.09:1. Of the total of 65 cases, 46 (70.77%) cases were positive for mucormycosis and 19 (29.23%) cases were negative on histopathological examination and special stain PAS and GMS. A significant correlation was found between mucormycosis-positive cases on steroid therapy and oxygen supply during the treatment for COVID-19 with P- values of 0.001 and 0.027, respectively. For COVID-19 patients with altered glycemic control, receiving steroid therapy and oxygen supply poses a significant threat to the development of mucormycosis.

Rinite granulomatosa por Neoconidiobolus lamprauges em uma mula

ABSTRACT: Conidiobolomycosis has a wide distribution, predominantly in humid tropical regions, affecting several species with significant mortality rates. The genus Conidiobolus is now divided into four genera: Capillidium, Conidiobolus, Microconidiobolus, and Neoconidiobolus. There are no confirmed reports of infection by these fungi in Equidae in Brazil. We present a rhinofacial rhinitis caused by Neoconidiobolus lamprauges in a mule from Rio de Janeiro, Brazil. The mule presented bilateral semi-occlusion of the nostrils, difficulty breathing, and weight loss. The histological examination of the nostril biopsied mass revealed multifocal necrotizing areas with nonstained images of fungal hyphae in the Splendore-Hoeppli reaction and surrounded by macrophages, eosinophils, neutrophils, and multinucleated giant cells. The Grocott methenamine silver staining revealed thin-walled, rarely septated, irregular branching hyphae, with a varying diameter of 12 μm (± 3.63 μm), and terminal ballooning dilations. The determining etiology of this rhinitis was based on the hyphae staining by immunohistochemistry and by amplifying the DNA fragment of N. lamprauges by polymerase chain reaction. Conidiobolomycosis should be included in the differential diagnosis of the causes of rhinitis in equids, mainly in tropical regions.

CRYPTIC CRYPTO: PULMONARY CRYPTOCOCCOSIS IN AN IMMUNOCOMPETENT HOST

CRYPTIC CRYPTO: PULMONARY CRYPTOCOCCOSIS IN AN IMMUNOCOMPETENT HOST

S3328 An Atypical Etiology of Chronic Abdominal Pain: Peritoneal Tuberculosis

Introduction: Peritoneal tuberculosis (TB) is a rare presentation of extra-pulmonary TB, comprising only 5% of extra-pulmonary TB cases. Patients oftentimes present with non-specific complaints and without typical Mycobacterium tuberculosis risk factors. Additionally, diagnostic testing lacks high sensitivity and specificity with further invasive methods frequently necessitated. We present an unusual case of peritoneal TB presenting as non-localized abdominal pain, facilitating insight into this uncommon disease. Case Description/Methods: A 53-year-old female with a past medical history of hypothyroidism presented with joint pain diagnosed as seronegative rheumatoid arthritis and subsequently began treatment with methotrexate and adalimumab for one year. Within the following year, she experienced chronic right lower quadrant (RLQ) abdominal pain, fevers, night sweats, fatigue, and ascites. Extensive work-up revealed a positive QuantiFERON gold TB test. A diagnostic laparoscopy with peritoneal biopsy successively demonstrated elevated CA-125 and large-volume ascites. Mycobacterium tuberculosis PCR and Grocott methenamine silver staining were negative. One of two acid-fast bacillus (AFB) smear and cultures yielded a positive result. Our patient was treated for peritoneal TB. She continued to have several years of chronic RLQ abdominal pain several months after RIPE treatment completion, undergoing a cholecystectomy and three adhesion lysis procedures with mild symptomatic improvement and subsequent worsening thereafter. An operative note highlighted the large amount of adhesions from the patient’s liver to her diaphragm and anterior abdominal wall, appearing similar to Fitz-Hugh-Curtis syndrome. She continues to have chronic abdominal pain and is followed closely by her treatment team. Discussion: Our patient was on immunosuppressive medications and had a history of travel to Mexico, a high TB burden country. Notably, AFB smear and culture has a poor sensitivity for peritoneal TB, oftentimes necessitating laparoscopic peritoneal biopsy for further diagnosis. Our patient was empirically treated for peritoneal TB before AFB culture yielded positive results, given her B symptoms and positive QuantiFERON test. She also had an elevated CA-125 value, which is associated with peritoneal TB and may be used in patients with a negative AFB stain. Our patient experienced recurrent adhesions, an unfortunate and persistent consequence of the inflammatory nature of peritoneal TB.

S2011 Disseminated Histoplasmosis Involving the Whole Colon: It's Ulcers All the Way Down

Introduction: Histoplasma capsulatum is a dimorphic fungus endemic to river valleys of Eastern and Central U.S. that is spread via inhalation of spores from soil contaminated by bird or bat droppings. Disseminated Histoplasmosis (DH) spreads through the reticuloendothelial system via parasitized macrophages and can cause severe infection in immunocompromised patients with AIDS, hematologic malignancies, transplant recipients, and those receiving tumor necrosis factor (TNF)-alpha inhibitors or chronic corticosteroids. Gastrointestinal involvement in DH is frequently seen, but it is not uncommon for patients to be asymptomatic. We present a case of DH with pan-colonic ulcerations in a renal transplant patient. Case Description/Methods: A 83-year-old male with deceased donor renal transplantation on immunosuppression therapies presented with profound weakness. He was restarted on hemodialysis one month prior for declining renal allograft function which had been stable for the past 2 decades. Initial workup showed pneumonia on imaging, elevated procalcitonin, alkaline phosphatase, and pancytopenia. He developed hematochezia with worsening anemia which prompted colonoscopy that revealed deep and innumerable ulcers measuring greater than one cm in the whole colon. One large ulcer with a visible vessel near the hepatic flexure was treated with epinephrine, electrocautery, and endoclip for hemostasis. Ulcer biopsy revealed granulomatous inflammation with fungal yeast forms morphologically compatible with Histoplasma by Grocott's Methenamine Silver (GMS) staining. Bone marrow pathology was suggestive of fungal infiltration, but marrow and blood cultures were negative. Family revealed he lives in an old mold infested home and has history of visiting caves. Treatment was initiated with liposomal Amphotericin B then transitioned to oral Itraconazole. He has continued to make a strong recovery and remains on dialysis (Figure). Discussion: For healthy individuals, exposures to Histoplasma generally occur as asymptomatic to self-limited pulmonary infection. Disseminated Histoplasmosis is often undiagnosed and carries high mortality if untreated. These patients usually had past exposures with dormant inoculation that is reactivated after immunosuppression. GI involvement is common but can be non-symptomatic or with only vague abdominal complaints from colonic fungal invasion. Suspicion of DH should be met with a low threshold for endoscopic evaluation and requires tissue biopsy for diagnosis.Figure 1.: (A) Large ulcer in the cecum which was biopsied. (B) Numerous ulcers seen diffusely throughout the colon. (C, D) H&E and Grocott’s Methenamine Silver (GMS) stain of colonic mucosa with patchy ulceration and granulomatous inflammation including fungal yeast forms, morphologically compatible with Histoplasma.

P506 First case of cutaneous mycosis caused by Nannizziopsis sp. in Chelonia

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMThe present report characterized a case of severe superficial and deep mycoses in a yellow-bellied slider (Trachemys scripta scripta) caused by Nannizziopsis sp. detected by histopathology and fungal culture. A female, 4-year-old, yellow-bellied slider (Trachemys scripta scripta) was presented for ulcerative and proliferative, chronic, skin lesions. White to pink, slightly round, with fuzzy borders, 0.5-2.5 cm in diameter, multifocal, proliferative, and ulcerative lesions were evident mainly on the left forelimb, right forelimb, pericloacal, chin, and oral cavity. The left forelimb was severely affected by a nodular subcutaneous mass.Several courses of disinfectant therapy, antibiotic, and antifungal treatments were given with no clinical improvements.Cytological smears of the ulcerative skin lesion revealed macrophages, heterophils, and fragments of septate hyphae. To investigate the cause of the lesions, the left forelimb was excised, fixed in 10% neutral buffered formalin, and submitted for histopathological examination. Biopsies and swabs from left forelimb, right forelimb, chin, and oral lesions were submitted for microbiological analysis.Samples were cultured on Sabouraud Dextrose Agar (SDA) and incubated at 30°C for 10 days. Histopathological examination showed severe pyogranulomatous dermatitis and myositis. Numerous septate, irregularly branched hyphae were evident within the pyogranulomas. Grocott methenamine silver stain (GMS) and Periodic acid-Schiff (PAS) confirmed the presence of filamentous fungi in the examined sections.Pure cultures of the same fungal strain were obtained from all the samples. Mature colonies on SDA showed a powdery aspect and a white felted surface. Microscopically, the hyphae were straight and branched, and conidia were clavate, sessile, or on short stalks.Based on both macroscopic and microscopic features the fungal strain was identified as Nannizziopsis sp.Susceptibility profile of the fungal isolate was tested for griseofulvin, miconazole, fluconazole, voriconazole, itraconazole, clotrimazole, and ketoconazole. Amplification and sequencing of ITS, 18S, and SSU gene regions have been performed to identify the fungal isolate. The sequences were aligned with the most similar sequences of established species deposited in GenBank in order to define levels of relatedness. Sequences showed that the isolate clustered with Nannizziopsiaceae. The sequence similarities of the isolate were 99% to N. arthrosporioides in ITS (535/543 bps), 99% to N. vriesii in 18S, and SSU (1648/1649 and 970/973 bps, respectively).Based on the histopathological, microbiological, and molecular analysis, Nannizziopsis sp. was the primary cause of severe deep mycoses in the present turtle. Mycoses caused by Chrysosporium-related fungi are an emerging infectious disease affecting reptiles. The fungi of this group were collectively identified as Chrysosporium anamorph of Nannizziopsis vriesii (CAVN) complex by their morphological characteristics. Recent molecular taxonomy studies have now re-classified Chrysosporium-related fungi into three genera: Nannizziopsis, Paranannizziopsis, and Ophidiomyces.Until now, nine species have been isolated and identified from reptiles. Dermatomycosis associated with Nannizziopsis spp. is frequently reported in lizards, terrestrial, and aquatic snakes, and crocodiles, with classical cutaneous ulcerative lesions. Cutaneous mycosis is common in turtles, however, to our knowledge this is the first case of Nannizziopsis cutaneous mycosis in Chelonia.

Host factors and characteristics of hospitalized patients with pneumocystis jirovecii pneumonia

Objectives: To describe the underlying diseases, microbiologic examination and severity of hospitalized patients with Pneumocystis jirovecii pneumonia (PJP) in a tertiary Chinese hospital. Methods: We conducted a retrospective analysis of 485 identified PJP patients who were admitted to our hospital between January 2013 and December 2021. Results: Among the 485 enrolled PJP cases, there were 237 males and 248 females, aging (53.3±16.2) years (range from 14 y to 88 y). They were divided into 8 subgroups with variable underlying diseases. There were 209 cases with connective tissue diseases(CTD), 27 cases with non-hematologic malignancies, 38 cases with hematologic malignancies, 81 cases with kidney diseases, 33 cases with idiopathic interstitial pneumonia(IIP), 30 cases infected with human immunodeficiency virus (HIV), and 42 cases with miscellaneous underlying diseases. In the CTD group, there was more females than males, while male patients were predominant in both the malignant and the HIV groups. The Pneumocystis was identified in 44.95%(218/485) sputum samples and 92.01%(265/288) bronchoscopic samples. Pneumocystis asci were observed at direct microscopic examination with Grocott's methenamine silver stain in 4.95%(24/485)sputum samples and 9.72%(28/288)bronchoscopic samples. Pneumocystis DNA fragments were identified by PCR analysis in 43.09%(209/485)sputum samples and 90.63%(261/288)bronchoscopic samples. Among the 8 groups, cytomegaviremia and respiratory failure were most common in the HIV-infected PJP group, but the rates of mechanic ventilation, intensive care unit (ICU) admission and death were the lowest. There were less PJP patients in the IIP group (IIP-PJP) who received mechanic ventilation and admitted to ICU than the other groups except HIV-infected PJP group. However, the mortality rate was highest for the IIP-PJP group. Conclusions: CTD was the most common predisposed underlying disease for our enrolled PJP cases. Cytomegaviremia and respiratory failure were common in HIV-infected PJP patients, but the prognosis of HIV-PJP was slightly better than the others. The disease was more severe, rapidly progressive and fatal in the IIP-PJP group.

Sinonasal Bacteroma/Bacteria-related Concretions: A Distinct Pathologic Entity of the Sinonasal Tract.

Patients can be seen where "fungal debris," "mycetoma," or "mass-like obstruction" of the sinonasal tract is suspected clinically but lack fungus and instead have granular, eosinophilic debris and bacterial colonies. We report and characterize 15 such cases, tentatively termed "bacteromas," compared with randomly selected cases of mycetoma and allergic fungal sinusitis (AFS). Pathology reports from 2016 to 2021 were searched. All candidate cases were examined microscopically and included if they had granular, amorphous debris with negative Grocott methenamine silver staining and lacked diagnostic features of other entities. The 7 males and 8 females ranged from 21 to 78 years old. Imaging frequently revealed opacification of the paranasal sinuses. Operative reports showed all to have paranasal sinus involvement. Most were unilateral (13/15, 87%). The maxillary sinus was involved in 11/15 (73%) cases, sphenoid sinus in 2/15 (13%), and frontal and ethmoid sinuses in 1/15 (7%), each. Bacteroma patients frequently had a history of allergic rhinitis (8/15, 53%), more than mycetomas (1/15, 7%) and AFS (5/15, 33%) ( P =0.0142). Facial pain was a common presenting symptom (13/15, 87%) in bacteromas compared with mycetomas (5/15, 33%) or AFS (1/15, 7%). Morphologically, cases consisted of large aggregates of paucicellular to acellular debris with a characteristic densely eosinophilic granular appearance, commonly associated with bacteria. Four of the 10 cultured patients grew Pseudomonas aeruginosa . Course posttreatment ranged from symptom resolution 1 week postoperatively to recurrent infections and symptoms 23 months from the initial operation. In summary, "bacteroma" is a heretofore undescribed pathologic entity of the sinuses that appears to be related to chronic bacterial infection and is distinct from mycetoma, AFS, and rhinolithiasis.

Macrophage Lysosomal Alkalinization Drives Invasive Aspergillosis in a Mouse Cystic Fibrosis Model of Airway Transplantation.

Cystic fibrosis (CF) lung transplant recipients (LTRs) exhibit a disproportionately high rate of life-threatening invasive aspergillosis (IA). Loss of the cystic fibrosis transmembrane conductance regulator (CFTR-/-) in macrophages (mφs) has been associated with lyosomal alkalinization. We hypothesize that this alkalinization would persist in the iron-laden post-transplant microenvironment increasing the risk of IA. To investigate our hypothesis, we developed a murine CF orthotopic tracheal transplant (OTT) model. Iron levels were detected by immunofluorescence staining and colorimetric assays. Aspergillus fumigatus (Af) invasion was evaluated by Grocott methenamine silver staining. Phagocytosis and killing of Af conidia were examined by flow cytometry and confocal microscopy. pH and lysosomal acidification were measured by LysoSensorTM and LysotrackerTM, respectively. Af was more invasive in the CF airway transplant recipient compared to the WT recipient (p < 0.05). CFTR-/- mφs were alkaline at baseline, a characteristic that was increased with iron-overload. These CFTR-/- mφs were unable to phagocytose and kill Af conidia (p < 0.001). Poly(lactic-co-glycolic acid) (PLGA) nanoparticles acidified lysosomes, restoring the CFTR-/- mφs’ ability to clear conidia. Our results suggest that CFTR-/- mφs’ alkalinization interacts with the iron-loaded transplant microenvironment, decreasing the CF-mφs’ ability to kill Af conidia, which may explain the increased risk of IA. Therapeutic pH modulation after transplantation could decrease the risk of IA.

Biliary candidiasis mimicking IgG4‐related disease in a patient with normal immunity

AbstractPurposeTo report a rare case of biliary candidiasis in a host with normal immunity.MethodsLaboratory tests indicated an elevated G level of 1000 pg/ml. Microscopic examination of pathological sections demonstrated multiple, narrow base, budding yeast cells following Grocott's methenamine silver staining and periodic acid‐Schiff staining. Subsequent sequence analysis supported the diagnosis of biliary candidiasis.ResultsA 31‐year‐old previously healthy man developed obstructive jaundice under no obvious inducement. He experienced cholecystectomy and biliary drainage. Surgical specimens revealed granulomatous chronic inflammation in the gallbladder, liver, bile ducts and mesenteric lymph nodes. He was misdiagnosed with tuberculosis and received antituberculosis treatment. However, his condition did not improve. He was finally diagnosed with biliary candidiasis and administered the antifungal treatment with fluconazole. His symptoms improved after such treatment.ConclusionsWe reported a case of biliary candidiasis that mimicked IgG4‐RD in a host with normal immunity. Our findings highlighted the need for pathological diagnosis in patients with symptoms resembling IgG4‐RD.

Acute Abdominal Distention in a Premature Low-birthweight Infant.

Acute Abdominal Distention in a Premature Low-birthweight Infant.

Grocott Methenamine Silver Staining Is the Optimal Approach to Histological Diagnosis of Pulmonary Cryptococcosis.

BackgroundHistological staining methods for Cryptococcus identification vary in accuracy. This study aimed to investigate the clinical value of Grocott methenamine silver (GMS), periodic acid-Schiff (PAS), and Alcian blue (AB) staining in the diagnosis of pulmonary cryptococcosis (PC).MethodsFrom April 2004 to June 2021, the clinical and pathological data of 152 patients with PC were collected from the Department of Pathology, Sun Yat-sen University Cancer Center. The sensitivity and identifiability of GMS, PAS, and AB staining for histological diagnosis were systematically evaluated using statistical methods combined with the microscopic characteristics of PC cases.ResultsStatistical analysis showed that the detection rates of GMS, PAS, and AB staining were 100.0% (152/152), 94.7% (144/152), and 81.6% (124/152), respectively. McNemar’s test showed that the sensitivity of GMS was significantly higher than those of PAS (P = 0.008) and AB stains (P < 0.001). Both PAS and AB stains had obvious non-specific staining, which interfered with the detection of Cryptococcus, and increased diagnostic difficulties. In contrast, in GMS staining, Cryptococcus spores were prominent with a clean background and were clearly observed at low or medium power magnification, with the identifiability significantly better than those of PAS or AB staining.ConclusionGMS staining had sensitivity up to 100%, and identifiability that was better than those of PAS and AB staining. GMS is the best method for histological diagnosis of PC.

Invasive Pulmonary Aspergillosis Diagnosis via Peripheral Blood Metagenomic Next-Generation Sequencing.

Invasive pulmonary aspergillosis (IPA) is one of the major causes of morbidity and mortality in immunocompromised patients such as hematological malignancies, hematopoietic stem cell transplantation, and solid organ transplantation. The diagnosis of IPA in these patients is still difficult because it has no obvious specificity in clinical symptoms, signs and imaging, and test sensitivity of blood 1,3-β-d-glucan test, galactomannan are low. Therefore, we still need to explore more diagnostic methods. In our study, via peripheral blood metagenomic next-generation sequencing (mNGS), five patients were tested positive for Aspergillus DNA and then quickly diagnosed as IPA. Out of the 5 cases, 1 was proven and 4 were probable IPA. The underlying diseases of the 5 patients were myelodysplastic syndrome (2 cases), acute myeloid leukemia (2 cases), and renal transplantation (1 case). Then they were diagnosed as IPA using other methods such as lung histopathology, bronchoalveolar lavage fluid (BALF) mNGS, and sputum culture or sputum mNGS. In case 1, sputum culture suggested Aspergillus flavus. In case 2, both Grocott methenamine silver (GMS) stain of lung histopathology and lung tissue mNGS suggested Aspergillus infection. In cases 3 and 4, BALF-mNGS suggested Aspergillus infection. In case 5, sputum mNGS suggested Aspergillus infection. In conclusion, detecting the cfDNA of Aspergillus via peripheral blood mNGS can be used to diagnose IPA and is a rapid and non-invasive diagnosis method.

Aerossacolitis and Pneumonia in an Indian Peafowl Caused by Lactobacillus agilis

Background: The peafowl is an ornamental bird that has the habit of eating directly from the earthy soil, which makes this bird more susceptible to endoparasites. One important endoparasite is Eucoleus contortus, which leads to inflammatory processes that alter the local microbiota, potentializing disease. By the other way, a member of the bird’s microbiota there is the genus Lactobacillus, but when occurs some imbalance, these bacteria can overgrowth and even cause some infection. This report describes the pathological and microbiological findings of chronic necrotizing pneumonia and aerossacolitis caused by Lactobacillus agilis in a peafowl, associated with parasitism by E. contortus. Case: A peafowl (Pavo cristatus), adult, male, who lived on a farm with contact with other species of animal, was submitted to post-mortem examination due to sudden death. This animal lived in an extensive system on the property and was the only one of its species. During the gross evaluation, the air sacs were filled with solid yellowish crumbly material. The same material was observed forming well-defined nodules that occupied &gt; 50% of the lung parenchyma. Histological analysis showed multiple parabronchi dilated and filled with caseous necrosis, characterized by abundant cellular debris and fibrin deposition. These areas were surrounded by the proliferation of fibrous connective tissue and inflammatory infiltrate of macrophages, giant cells, lymphocytes, and plasma cells. The air sacs parenchyma showed fibrin deposition and mixed inflammatory infiltrate. Multiple gram-positive bacilli were observed within the caseous foci in Gram-stained slides. In the crop and esophageal mucosa, cross-sections of filiform nematodes morphologically compatible with E. contortus were associated with chronic inflammatory infiltrate and epidermal hyperkeratosis. A lung section was submitted to Gram-Brown-Hopps and Ziehl-Neelsen (ZN) stains for bacterial investigation, and Grocott's methenamine silver (GMS) stain for fungal investigation. Short gram-positive bacilli bacteria are observed within the caseous foci in Gram-stained slides. By the other way, no agents were identified on the ZN and GMS stains. Following the analysis, lung fragments were cultivated at aerobic and microaerophilic conditions on sheep blood agar and McConkey agar. All the microbial cultures were incubated at 37°C to 48 h. Pure culture, in microaerophilic condition, of Gram-positive bacilli, was observed. The isolated bacterium was identified by MALDI-TOF MS as L. agilis.Discussion: Although uncommon, L. agilis was the single bacterium identified and therefore, associated as a primary cause of necrotic pneumonia and aerossacolitis in the studied peafowl. The presence of E. contortus could induce the aspiration of regurgitated of little amount of material from the gastrointestinal tract with sufficient bacterial load to initiate an infection, but not enough to smother the animal. The gradual aspiration can induce a chronic inflammatory condition. Infections by bacteria from the host microbiota have been observed in animals and humans with immunodeficiency. In summary, both the parasitosis and the inflammation could be resulted by the parasite and the aspiration of gastric product, which probably interfered in the immune response and allowed the overgrowth of L. agilis. In the current case report, based on macroscopic, microscopic and bacteriological results, we have provided insights to understand how the parasitosis made possible a pneumonia from a bacterium from the host's microbiota. Finally, to the best of our knowledge, this is the first report of L. agilis as causal agent of fatal necrotic pneumonia and aerossacolitis in peafowl.Keywords: respiratory infection, ornamental birds, secondary infection, parasitosis.