Grocott Methenamine Research Articles

A Case of the Hiccups in the Setting of Colonic Ulcers

Question: A 51-year-old seasonal farm worker with the human immunodeficiency virus (HIV; CD4 count, 122 cells/mm3) presented with persistent unexplained diarrhea, fevers, and hiccups. Although he had no pulmonary symptoms, the admission chest radiograph revealed bilateral miliary nodular opacities that were concerning for granulomatous processes including tuberculosis and fungal disease (Figure A). Sputum analysis and subsequently bronchoscopy with extensive brushing revealed no evidence of acid-fast bacilli. He was anemic with a hemoglobin of 8.4 g/dL and his albumin level was decreased at 2.8 g/dL. Blood, stool, and urine cultures to evaluate his recurrent fevers were also noncontributory; thus, more extensive imaging was obtained. Abdominal CT demonstrated bowel thickening of the right hemicolon and proximal transverse colon as well as adjacent inflammatory changes (Figure B). Subsequent colonoscopy revealed multiple, small ulcers (Figure C). Biopsy of the ulcer edges was performed and histology is presented in Figure D–G. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. On pathologic examination (Figure D–G) spherules were seen on Grocott's methenamine silver stain consistent with the fungus Coccidioides immitis. Serum coccidioides titer via complement fixation was significantly elevated at 1:64. He was started on fluconazole and his symptoms promptly abated. Disseminated coccidioidomycosis rarely presents with gastrointestinal symptoms.1Adam R.D. Elliott S.P. Taljanovic M.S. The spectrum and presentation of disseminated coccidioidomycosis.Am J Med. 2009; 122: 770-777Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Diarrhea illness is even more unusual; those with gastrointestinal manifestations almost always present with peritonitis.2Smith G. Hoover S. Sobonya R. et al.Abdominal and pelvic coccidioidomycosis.Am J Med Sci. 2011; 341: 308-311Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar It is postulated that an immune response mediated by intrinsic CD-8 T cells, natural killer T cells, and pre-mast cells in the lamina propria protects the hollow luminal organs of the gastrointestinal tract from fungal pathogens. Given the nonspecific presentation, a high index of suspicion is critical to obtain the appropriate histologic stains and serologic tests. Given its rarity the sensitivity of stool studies for coccidioidomycosis is unknown, but is likely poor based on its performance in other fungal gastrointestinal infections in HIV-positive patients.3Cello J.P. Day L.W. Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens.Gastroenterology. 2009; 136: 1952-1965Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar The patient’s history of HIV and vocation as a seasonal farm labor in California’s San Joaquin Valley prompted the appropriate evaluation.

Nausea, Vomiting, and Weight Loss: Common Symptoms of an Uncommon Disease

Question: A 36-year-old black woman with no significant past medical history presented with progressive nausea, vomiting, and weight loss for several months. She had no lymphadenopathy or hepatomegaly on physical examination. Laboratory tests showed hemoglobin of 11 g/dL and normal liver functions tests. An esophagogastroduodenoscopy revealed diffuse erythematous, nodular, friable mucosa in the stomach and the antrum was not easily distended on insufflations (Figure A). The pylorus was narrowed but was easily traversed by the endoscope (Figure B). Computed tomography of the abdomen and pelvis showed thickening of the antral wall of the stomach but was otherwise unremarkable (Figure C, arrow). An upper gastrointestinal series confirmed a conical configuration and lack of distension throughout the gastric antrum with patulous pyloric channel (Figure D). Small bowel follow-through showed no evidence of active or chronic inflammatory disease in the small intestine. What is your diagnosis? Look on page 574 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Pathology findings from the gastric biopsy demonstrated chronic severely active gastritis with noncaseating granuloma formation (Figure E). Additional stains for Helicobacter pylori, acid-fast bacilli, and Grocott's methenamine silver were negative. Further workup showed CRP <3 mg/L, antinuclear antibody <40 titer, antineutrophil cytoplasmic antibody nonelevation, rapid plasma reagin nonreactive and, Quantiferon Tb-gold test negative. Tuberculosis was unlikely. Clinicopathologic findings were consistent with gastric sarcoidosis. Chest and abdominopelvic computed tomography showed no evidence of adenopathy or other organ involvements. Patient responded to oral prednisone and had subsequent resolution of symptoms. She successfully tapered off prednisone over the several weeks. Although the stomach is the most commonly involved organ in the gastrointestinal sarcoidosis, isolated gastric sarcoidosis occurs in <1% of patients with sarcoidosis.1Afshar K. BoydKing A. Sharma O.P. Shigemitsu H. Gastric sarcoidosis and review of the literature.J Natl Med Assoc. 2010; 102: 419-422Crossref PubMed Scopus (28) Google Scholar Clinical manifestations are usually related to the anatomical alterations caused by disease involvement. The common imaging findings are mucosal nodularity, thickened irregular folds and deformity of the antrum.2Warshauer D.M. Lee J.K. Imaging Manifestations of Abdominal Sarcoidosis.AJR Am J Roentgenol. 2004; 182: 15-28Crossref PubMed Scopus (137) Google Scholar Diagnosis is based on histologic evidence of noncaseating granuloma in the context of clinically relevant features. Other diseases that may yield similar pathology, including Crohn’s disease, tuberculosis, Whipple’s disease, and fungal or parasite infections, should be ruled out. Glucocorticoid is the treatment of choice. Disease activity should be monitored clinically and immunosuppressants should gradually be tapered while monitoring clinical course. The role of serum ACE level for disease monitoring is limited. Surveillance endoscopy is indicated if disease recurrence is clinically suspected. This case highlights that gastric sarcoidosis should be considered when there is mucosal change suspicious of infiltrative process in gastrointestinal tract.

Mucormycosis with diabetic and lupus nephropathy.

A 67-year-old woman with Stage 3 chronic kidney disease (CKD) due to systemic lupus erythematous (SLE). She was admitted to our hospital with a diagnosis of acute kidney injury. She had a past medical history of hypertension, acanthosis nigricans, obesity, obstructive sleep apnoea and type 2 diabetes mellitus with diabetic retinopathy. Two months prior to admission she had presented with a deterioration in renal function with proteinuria, which was interpreted as a flare of her SLE and she had received treatment with cyclophosphamide and i.v. 6-methylprednisolone. Five days after admission she presented with dyspnoea with bilateral pulmonary infiltrates. A diagnosis of heart failure was made and she underwent ultrafiltration with slight improvement. On the 10th day after admission she developed a right third cranial nerve palsy. A brain CT scan and lumbar puncture were normal except for the findings suggestive of chronic maxillary sinusitis. Fibrobronchoscopy showed necrosis of the nasal septum and infection due to Mucor genera was suspected. She underwent surgical debridement and initiated treatment with amphotericin B and caspofungin and was admitted to the ICU for respiratory support. The patient deteriorated despite treatment and died on her fourth day in the ICU. Rhizopus spp was identified in the oral cavity biopsies (Figure 1). Fig. 1. Necrosis of the oral cavity due to Rhizopus (green arrows). As the number of immunocompromised patients increase, the frequency of mucormycosis [1] is increasing. Mucormycosis, also known as zygomycosis, is an opportunistic fungal infection caused by organisms of the mucorales order. The most frequent species are Rhizopus, Mucor and Rhizomucor (Figure 2). Fig. 2. Rhizopus in oral cavity biopsy (green arrows). Haematoxylin and eosin stain. Risk factors [2] for these infections include diabetes mellitus (especially in patients with ketoacidosis), haematologic malignancies, haematopoietic stem cell transplantation, solid organ transplantation, deferoxamine treatment and iron overload (Figure 3). Fig. 3. Rhizopus in oral cavity biopsy (green arrow). Grocott's Methenamine Silver stain. Mucormycosis may present with rhino-orbital-cerebral (which is the most common), pulmonary, gastrointestinal, cutaneous, renal and disseminated involvement [3]. The diagnosis is based on identification of organisms in the tissue by histopathology with confirmation by culture. Treatment is based on a combination of surgical debridement with long-term amphotericin B therapy. Owing to the aggressive course of mucormycosis, even with treatment, many other treatments [4] have been considered such caspofungin (for rhino-orbital-cerebral disease), long-term posaconazol (as a step-down therapy) and deferasirox. The prognosis is poor in all the presentations with mortality rates as high as 87% with pulmonary involvement.

Histopathology of Pneumocystis carinii pneumonia in immunocompetent laboratory rats.

The occurrence of idiopathic pulmonary lesions in laboratory rats, characterized by lymphohistiocytic interstitial pneumonia with dense perivascular lymphoid cuffs, has been reported over the past decade. Although the term rat respiratory virus (RRV) was adopted to confer a putative viral etiology to the idiopathic pulmonary lesions, the etiology of this disease remains to be elucidated. Recently, inflammatory lesions have been observed in the lungs of immunocompetent laboratory rats similar to those previously described. Based on the latest evidence indicating that Pneumocystis carinii (P. carinii), and not putative RRV, causes infectious interstitial pneumonia in laboratory rats, the present study investigated whether the pulmonary lesions observed were caused by P. carinii infection. Male Sprague-Dawley rats, free of known pathogens, were introduced into a rat colony positive for RRV-type lesions. Routine histopathological examinations were performed on the rat lung tissues following exposure. The presence of Pneumocystis organisms was confirmed using Grocott’s methenamine silver (GMS) staining. At week 3 following introduction, a few small lymphoid aggregates were located adjacent to the edematous vascular sheath. By week 5, foci of dense perivascular lymphoid cuffing were observed. Multifocal lymphohistiocytic interstitial pneumonia and prominent lymphoid perivascular cuffs were observed between week 7 and 10. GMS staining confirmed the presence of Pneumocystis cysts. Thus, the results of the present study demonstrated that P. carinii caused lymphohistiocytic interstitial pneumonia in a group of laboratory rats. The observations strongly support the conclusion that P. carinii infection in immunocompetent laboratory rats causes the lung lesions that were previously attributed to RRV.

Utilização da técnica de imuno-histoquímica para confirmar casos de pitiose cutânea equina diagnosticados por meio de caracterização clínica e avaliação histopatológica

Avaliaram-se 12 feridas granulomatosas em membros torácicos e pélvicos de equinos da raça Pantaneira. Foi realizado diagnóstico sugestivo para pitiose cutânea de acordo com as características clínicas das feridas e avaliação histopatológica, com as colorações de hematoxilina-eosina (HE) e Prata Metenamina de Grocott (GMS). A confirmação do diagnóstico foi realizada por exame imuno-histoquímico, método streptavidina-biotina marcada (LSAB). O diagnóstico histopatológico foi de dermatite piogranulomatosa, focal extensa, acentuada, associada a "pseudo-hifas" características de Pythium insidiosum (pitiose cutânea), nos 12 animais desta pesquisa. O diagnóstico de pitiose foi confirmado em 100% dos casos pela imunomarcação positiva (LSAB) para Pythium insidiosum, caracterizada pela visualização de estruturas ramificadas e septadas, sendo observados 100% de paridade entre as técnicas. É possível concluir que a caracterização clínica das feridas granulomatosas com aspecto de pitiose em equinos associada ao resultado histopatológico sugestivo para pitiose equina constituem métodos de diagnóstico confiáveis, os quais podem ser confirmados pela técnica de imuno-histoquímica.

Mucormycosis of the hard palate: a rare case report

Mucormycosis is a rare but aggressive opportunistic fungal infection. Mucormycosis refers to several different diseases; the causative agents of mucormycosis are the filamentous fungi of the Mucoraceae family, of the order Mucorales. Here, we report a case of mucormycosis in the hard palate of a 46-year-old woman without any predisposing factors. For early diagnosis of mucormycosis, histopathological examination is essential. In the present case, the fungus was identified by hematoxylin and eosin staining and confirmed by PAS and Grocott's silver methenamine special staining. As mucormycosis occurs infrequently, it may pose a diagnostic and therapeutic dilemma to those who are not familiar with its clinical presentation. The patient was successfully treated with a combination of surgical debridement and amphotericin-B. Through this case report, we would like to emphasize that mucormycosis of the hard palate occurs even in immunocompetent patients.

Laryngeal histoplasmosis: an occupational hazard

Isolated laryngeal histoplasmosis is a very rare entity. It has variable clinical presentations that might mimic both benign and malignant lesions, and is usually associated with pulmonary and other disseminated forms of histoplasmosis. Herein, we report a case of primary laryngeal histoplasmosis without the involvement of other systems in a 70-year-old Chinese man, who previously worked as a miner. He presented with a history of hoarseness for two months, with no other associated symptoms. Direct laryngoscopy revealed irregularity of the posterior one-third of both vocal folds. Histopathological examination revealed the presence of Histoplasma capsulatumon periodic acidSchiff and Grocott's methenamine silver staining. The lesion resolved after one month of oral itraconazole treatment. However, the patient had to complete six months of antifungal treatment to prevent recurrence.

Detection ofPneumocystisinfections by in situ hybridization in lung samples of Austrian pigs with interstitial pneumonia

Pneumocystis carinii f. sp. suis is a fungus multiplying in the respiratory tract of pigs which occasionally is associated with interstitial pneumonia. Identification of Pneumocystis in tissue samples is considered difficult and there are only scarce data on its occurrence in European pigs. This investigation presents an in situ hybridization (ISH) procedure for identification of Pneumocystis spp. in paraffin wax embedded tissue samples and its application for labeling the agent in lung samples of pigs with interstitial pneumonia. Thirty-two out of 100 lung samples from pigs on Austrian farms were identified as positive, five of them with multiple, 12 with moderate and 15 with few organisms but Grocott’s methenamine silver staining demonstrated that only 20 cases were unequivocally positive for Pneumocystis carinii. In addition to interstitial pneumonia Pneumocystis-positive pigs were more frequently affected with granulomatous pneumonia than Pneumocystis-negative pigs. Frequently concurrent infections with different viral or bacterial lung pathogens were noted but there was no positive correlation between Pneumocystis- and PCV-2-infections. With other infections, no clear-cut differences between Pneumocystis-positive and Pneumocystis-negative animals were found. This study shows that Pneumocystis infections occur frequently in Austrian pigs with interstitial pneumonia. It remains to be shown which are the factors triggering severe multiplication and whether infection with Pneumocystis alone is able to induce lung disease in pigs.

Successful treatment of tattoo-induced pseudolymphoma with sequential ablative fractional resurfacing followed by Q-switched Nd: Yag 532 nm laser

Decorative tattooing has been linked with a range of complications, with pseudolymphoma being unusual and challenging to manage. We report a case of tattoo-induced pseudolymphoma, who failed treatment with potent topical and intralesional steroids. She responded well to sequential treatment with ablative fractional resurfacing (AFR) followed by Q-Switched (QS) Nd:YAG 532 nm laser. Interestingly, we managed to document the clearance of her tattoo pigments after laser treatments on histology and would like to highlight the use of special stains such as the Grocott's Methenamine Silver (GMS) stain as a useful method to assess the presence of tattoo pigment in cases where dense inflammatory infiltrates are present.

Role of tumor necrosis factor inhibitor in granulomatous interstitial nephritis secondary to Crohn’s disease

A 17-year-old male with attention deficit hyperactivity disorder was admitted to the hospital with generalized weakness. Vital signs and physical examination were normal. Laboratory data were notable for a creatinine of 4.5 mg/dL (baseline 0.6 mg/dL), estimated glomerular filtration rate of 18 ml/min/1.73 m² and hemoglobin 10 g/dL. Urinalysis revealed only 30 mg/dL protein. Serology for autoimmune workup was negative. Renal ultrasound was normal. Kidney biopsy showed noncaseating granulomas and acute on chronic tubulointerstitial nephritis (TIN) with lymphocytes, macrophages, plasma cells and no eosinophils. Acid fast bacilli and Grocott's methenamine silver stains were negative. Granulomatous interstitial nephritis (GIN) was diagnosed. Prednisone at 60 mg/day was started and tapered. He was then noted to have diarrhea. Colonoscopy showed active enteritis with granulomatous inflammation consistent with Crohn's disease (CD). Azathioprine was started but due to worsening renal function and diarrhea, it was discontinued. He did not tolerate continued higher doses of prednisone because of mood swings and cushingoid features. Infliximab was initiated with improvement in renal function. There was rapid worsening of renal function when infliximab therapy was interrupted but improved when both prednisone and inflixamb were reinitiated.

A young woman with systemic lupus erythematosus and extensive mesenteric vasculitis involving small and medium vessels

History of the present illness The patient had 2 recent hospital admissions. Two months prior to her current presentation, she presented to the emergency department with a tooth abscess for which she underwent incision and drainage, and received a 1-week course of penicillin. One week later, she was admitted with a fever of 40.8°C and was noted to have tooth decay on panoramic radiographs without evidence of an abscess. She was treated with intravenous vancomycin and piperacillin tazobactam for 48 hours and then switched to oral clindamycin. Because of her elevated international normalized ratio (INR), she was unable to undergo tooth extraction prior to discharge. Two weeks later, she was readmitted with 4 days of recurrent fevers, malaise, diffuse arthralgias, and increased dyspnea with minimal exertion. Previous lupus exacerbations were characterized by arthralgias, rash, and hemolytic anemia. On this admission, laboratory evaluation revealed leukocytosis, worsening anemia and thrombocytopenia, creatinine of 0.7 mg/dl, alkaline phosphatase of 127 units/liter (normal value 111), spot urine proteinto-creatinine ratio of 1.47 (prior 1.1), low C3 and C4, and an increase in her double-stranded DNA by enzyme immunoassay from 120 to 768 IU/ml (normal value 30). She was empirically treated with vancomycin and piperacillin tazobactam given her recent tooth infection. The elevated alkaline phosphatase level prompted an abdominal ultrasound that showed multiple small hypoechoic areas in the spleen. An extensive infectious evaluation, including blood cultures, fungal serologies, knee arthrocentesis, magnetic resonance imaging of the lumbar spine, transthoracic and transesophageal echocardiograms, and computed tomography of the chest, abdomen, and pelvis, was negative. Her viral serologies were also unremarkable, other than evidence of IgG seropositivity for cytomegalovirus (CMV) with a negative viral load, consistent with prior exposure. Despite broad-spectrum antibiotics, she remained febrile. Her baseline prednisone dose of 12.5 mg was increased to 60 mg daily for possible lupus flare, after which she defervesced within 48 hours. Her thrombocytopenia was thought to be secondary to SLE-related idiopathic thrombocytopenic purpura because it resolved with high-dose steroids and intravenous immunoglobulin. She was discharged home 11 days after admission. The patient remained afebrile for 1 week at home. During this period she developed new-onset progressive upper abdominal pain with meals lasting 20–30 minutes. She denied associated constitutional symptoms, diarrhea, hematochezia, or melena.

Detection and characterization ofHistoplasma capsulatumin a German badger (Meles meles) by ITS sequencing and multilocus sequencing analysis

A wild badger (Meles meles) with a severe nodular dermatitis was presented for post mortem examination. Numerous cutaneous granulomas with superficial ulceration were present especially on head, dorsum, and forearms were found at necropsy. Histopathological examination of the skin revealed a severe granulomatous dermatitis with abundant intralesional round to spherical yeast-like cells, 2-5 μm in diameter, altogether consistent with the clinical appearance of histoplasmosis farciminosi. The structures stained positively with Grocott's methenamine silver and Periodic acid-Schiff stains, but attempts to isolate the etiologic agent at 25 and 37°C failed. DNA was directly extracted from tissue samples and the ribosomal genes ITS1-5.8S-ITS2 were partially sequenced. This revealed 99% identity to sequences from Ajellomyces capsulatus, the teleomorph of Histoplasma capsulatum, which was derived from a human case in Japan, as well as from horses from Egypt and Poland. Phylogenetic multi-locus sequence analysis demonstrated that the fungus in our case belonged to the Eurasian clade which contains members of former varieties H. capsulatum var. capsulatum, H. capsulatum var. farciminosum. This is the first study of molecular and phylogenetic aspects of H. capsulatum, as well as evidence for histoplasmosis farciminosi in a badger, further illuminating the role of this rare pathogen in Central Europe.

Intraabdominal abscess caused by actinomycosis in a patient with mesenteric fibromatosis of the small intestine: report of a case

A 38-year-old man presented to our Emergency Department with acute severe abdominal pain; 3 days after, a mesenteric mass had been detected by abdomino-pelvic computed tomography. Emergency laparotomy revealed a mesenteric mass with focal surface rupture. Microscopically, the mesenteric mass was composed of fibroblast-like spindle cells with intervening marked collagen deposits. These spindle cells were positive for nuclear β-catenin and negative for CD34, c-kit, smooth muscle actin, and S-100 protein. We diagnosed the mesenteric lesion as deep fibromatosis, consistent with mesenteric fibromatosis (MF). Serial sections of the ruptured portion showed abscess formation with a peripheral radiating pattern of microcolonies, proven to be actinomycosis by Grocott's methenamine silver stain and gram staining. One glandular fragment was found in the adhered muscle layers and a foreign body reaction was seen within the abscess cavity. We speculate that MF involved the serosal adhesions between the adjacent bowel walls and the subsequent fibrous pulling might have created the connection between the bowel lumen and the bowel wall. This disrupted barrier led to the Actinomyces infection. To our knowledge, this is the first report of sporadic MF leading to the formation of an abscess cavity with rupture and actinomycosis.

Bacterial and Mucopeptide Concretions of the Lacrimal Drainage System

To demonstrate the histopathologic characteristics of different types of lacrimal drainage system concretions with clinical correlations. Thirty lacrimal drainage system concretions submitted to the Cogan Eye Pathology Laboratory at the Massachusetts Eye and Ear Infirmary over a 2-year period were reviewed. Concretions were studied in detail using their histopathologic staining features as revealed with hematoxylin and eosin, Gomori methenamine silver, periodic acid-Schiff, iron stain, and Brown-Hopps tissue gram stain. A separate retrospective chart review was conducted for each patient to identify any clinical correlations. Two major forms of concretions were identified histopathologically: mucopeptide (7) and bacterial (20). Mucopeptide concretions were found exclusively within the lacrimal sac, while bacterial concretions were found chiefly in the canaliculus. A third category of "mixed" concretions with substantial mucopeptide and bacterial characteristics comprised 3 specimens. Bacterial concretions consisted of large matted masses of filamentous, presumed Actinomyces organisms that were easily identified with the Grocott's methenamine silver stain; they were frequently cocolonized at their edges with coccal bacterial forms. Mucopeptide concretions were generally devoid of cellular elements and were composed of broad bland whorls of diffusely eosinophilic, acellular, periodic acid-Schiff-positive material punctuated by lacunae. They were often cocolonized by small numbers of bacterial cocci and occasional fungi. Culture results disclosed low virulence species. All 3 types of concretions predominated in women. Patients with bacterial concretions frequently had dry eye symptoms. The 2 major types of lacrimal system concretions differ in their primary location and histopathologic composition. Further characterization may lead to an understanding of the mechanisms for their formation. Mucopeptide concretion is more appropriate than terms such as "dacryolith" and "mucolith," and bacterial concretion is a more appropriate term than "canaliculith," because of the absence of significant calcium or stone-like density in these masses.

Cutaneous manifestations of deep mycosis: An experience in a tropical pathology laboratory

Background:Cutaneous manifestations of deep mycotic infection are fraught with delayed or misdiagnosis from mainly cutaneous neoplastic lesions.Aim:This study is designed to present our experience of these mycoses in a pathology laboratory in the tropics.Materials and Methods:A clinicopathologic analysis of deep mycotic infections was conducted over a 15 years period Formalin fixed and paraffin wax processed biopsies were stained with hematoxylin and eosin, periodic acid Schiff (PAS), and Grocott's methenamine silver (GMS) for the identification of fungus specie. Patients’ bio-data and clinical information were obtained from records.Results:Twenty males and seven females presented with 6 months to 6 years histories of varying symptoms of slow growing facial swellings, nodules, subcutaneous frontal skull swelling, proptosis, nasal blockage, epistaxis, discharging leg sinuses, flank mass, convulsion and pain. Of the 27 patients, four gave antecedent history of trauma, two had recurrent lesions which necessitated maxilectomy, two presented with convulsion without motor dysfunction while one had associated erosion of the small bones of the foot. None of the patients had debilitating illnesses such as diabetes mellitus, tuberculosis, and HIV infection. Tissue histology revealed histoplasmosis (10), mycetoma (9), subcutaneous phycomycosis (6), and phaeohyphomycosis (2).Conclusion:Deep mycoses may present primarily as cutaneous lesions in immunocompetent persons and often elicit distinct histologic inflammatory response characterized by granuloma formation. Diagnosis in resource constraint setting can be achieved with tissue stained with PAS and GMS which identifies implicated fungus. Clinical recognition and adequate knowledge of the pathology of these mycoses may reduce attendant patient morbidity.

Infección múltiple fúngica en un paciente diabético

Background Mixed fungal infections although undervalued, are more common than mentioned in the scientific literature. These infections have a poor prognosis for the patient. Objectives We present an unusual case of a 61-year-old diabetic male who had a rhino-orbito-sinusal zygomycosis in 2001. After surgical debridement of the infected parts, along with antifungal therapy with liposomal amphotericin B, the patient started improving. Several years later the patient was hospitalized due to a similar problem and was diagnosed of rhino-orbito-cerebral zygomycosis. Methods In both episodes, a histopathological examination and cultures were performed on the sinus lesions. Tissue sections were stained with haematoxylin and eosin, Giemsa, periodic acid-Schiff (PAS) and Grocott's methenamine silver, and cultures specific for fungi were performed. Results The histopathology studies revealed the presence of bacteria, actinomyces and a mixed infection by at least four different fungi, all of them well differentiated by their morphology. Despite the rapid diagnosis the patient died due to spreading to the central nervous system. Conclusions Mixed infections by fungi are rare, but due to the high incidence of immunodeficiencies they could occur more often than reported. We would like to alert on the possibility of acquired mixed infection by fungi which have shown to be high aggressive and have a worse prognostic in patients with underlying diseases.

Screening Pneumocystis carinii pneumonia in non–HIV-infected immunocompromised patients using polymerase chain reaction

We evaluated the clinical value of polymerase chain reaction (PCR) for screening Pneumocystis carinii pneumonia (PCP) in non–HIV-infected immunocompromised patients. We retrospectively analyzed PCR and Grocott's methenamine silver (GMS) staining on 1044 clinical specimens obtained from 756 patients. Positive rates of PCR and GMS staining in sputum specimens were 21.1% and 9.5%, respectively ( P < 0.01), and in bronchoalveolar lavage (BAL), specimens were 31.9% and 25.5%, respectively. Among 5 patient groups, the highest GMS staining and PCR positive rates were observed in immunosuppressed patients. In 28 GMS staining-positive patients, positive rates of PCR and GMS staining after a short anti-PCP treatment were 39.3% and 17.9%, respectively. In 5 patients with positive PCR but negative GMS staining results in initial sputum examination, GMS staining result turned positive in subsequent BAL specimens. In conclusion, PCR is sensitive for detection of Pneumocystis in sputum specimens and is useful for screening PCP in non–HIV-infected high-risk patients.

Comparative Pathology of Nocardiosis in Marine Mammals

Nocardia spp. infections in mammals cause pyogranulomatous lesions in a variety of organs, most typically the lung. Members of the Nocardia asteroides complex are the most frequently recognized pathogens. Nine cases of nocardiosis in free-ranging pinnipeds and 10 cases of nocardiosis in cetaceans were evaluated. Host species included the hooded seal (Cystophora cristata, n = 8), leopard seal (Hydrurga leptonyx, n = 1), Atlantic bottlenose dolphin (Tursiops truncatus, n = 4), beluga whale (Delphinapterus leucas, n = 4), and killer whale (Orcinus orca, n = 2). The most common presentation of nocardiosis in both pinnipeds and cetaceans was the systemic form, involving 2 or more organs. Organs most frequently affected were lung and thoracic lymph nodes in 7 of 9 cases in pinnipeds and 8 of 10 cases in cetaceans. Molecular identification and bacterial isolation demonstrated a variety of pathogenic species. N. asteroides, N. farcinica, N. brasiliensis, and N. otitisdiscaviarum are pathogenic for pinnipeds. In cetaceans N. asteroides, N. farcinica, N. brasiliensis, N. cyriacigeorgica, and N. levis are pathogenic. Hematoxylin and eosin and acid fast staining failed to reveal bacteria in every case, whereas modified acid fast and Grocott's methenamine silver consistently demonstrated the characteristic organisms. In both pinnipeds and cetaceans, juvenile animals were affected more often than adults. Hooded seals demonstrated more cases of nocardiosis than other pinnipeds.

Granulomatous prostatitis due to Cryptococcus neoformans: diagnostic usefulness of special stains and molecular analysis of 18S rDNA

A 57-year-old Japanese man complained of pain on micturition. The prostate was of normal size but hard. Transrectal needle biopsy demonstrated granulomatous prostatitis with small focal abscesses. Staining with periodic acid-Schiff, Grocott's methenamine silver and Fontana-Masson revealed yeast-form fungus in the granulomas. The mucoid capsule of the fungus stained with mucicarmine. PCR specific for cryptococcal 18S rDNA using DNA extracted from the pathological specimen was positive, and the sequence was homologous to Cryptococcus neoformans. A diagnosis of cryptococcal granulomatous prostatitis was made. The patient was then found to suffer from meningitis and lung abscess, and was treated with amphotericin B and flucytosine. Careful histological and molecular studies are beneficial to reach the correct diagnosis and to prevent an unfavorable outcome of disseminated cryptococcosis.

The pro-apoptotic human BH3-only peptide harakiri is expressed in cryptococcus-infected perivascular macrophages in HIV-1 encephalitis patients

In the central nervous system (CNS), HIV-1 targets mainly microglia/macrophages. Like the CD4+ T cell depletion and neuronal loss in AIDS, apoptosis is thought to be involved in eliminating infected macrophages. In this study, we examined the expression of the pro-apoptotic BH3-peptide harakiri (Hrk) in brain tissues of AIDS patients. Immunoreactivity against Hrk was positive in perivascular macrophages infiltrated into some restricted lesions. Most of these immunopositive cells contained small inclusions positive for Grocott's methenamine silver staining. Confocal laser microscopy demonstrated that Hrk expression coincided with immunoreactivities against HIV-1 and Cryptococcus neoformans. Expression of Hrk mRNA was demonstrated in these cells by in situ hybridization, which indicated that Hrk is not phagocytosed material. Some pro-apoptotic bcl-family members, including Hrk, may contribute to the delayed hypersensitive reaction in AIDS, in macrophages eliminating opportunistic infection.