Nonspecific Inflammatory Changes Research Articles

Tobacco Consumption in Some Traveling Agencies in Bafoussam in West Region Of Cameroon, Associated To Mouth Cytology and Malondialdehyde (MDA) Profile

Tobacco is mostly regarded as one of the primary etiologic factor in causing oral cancer. Its use affects the pattern of maturation in oral mucosal cells and results in changes in the appearance of the tissues. Lipid peroxidation (LPO) has been implicated in the pathogenesis of several pathologic disorders, including oral premalignant and malignant lesions. The aim of this study was to determine the prevalence of tobacco use and assess its effects on oral epithelial cells and oxidant/antioxidant balance in the oral cavities of tobacco consumers in some travelling agencies in Bafoussam West Region Cameroon.
 A cross sectional study with a total of 120 individuals (divided into two groups; group A (n=55) including non-consumers of tobacco above 21 years old and group B (n=65) including tobacco consumers above 21 years old), voluntarily enrolled in the study. After giving their consents and answering a series of questions from questionnaires, saliva samples and buccal smears were collected from their oral cavities. Buccal smears were stained using Papanicolaou staining technique and the presence of hyperkeratosis, tobacco hyperkeratosis, non-specific inflammatory changes and oral microflora were assessed. [MDA] was determined using the Thiobarbituric acid method. The results showed that male tobacco consumers made 48.3% and most of them were aged between 21-31 years old, while female tobacco consumers made 5.7% of the total sample population. Smoking was the method most used by consumers (41.7%) and 66% of them smoked for more than 10 years while 50% smoked more than 10 sticks of cigarette per day. A statistical significant relationship was found between tobacco consumption and oral epithelial changes (p<0.001). Only tobacco consumers presented with tobacco hyperkeratotic buccal smears (20%) when compared with the control group. A good number of hyperkeratotic buccal smears (39.2%) was found in both the case (17.5) and control (21.7%) groups. 24.1% of the total sample population had normal buccal smears, where 8.3% were consumers and 15.8% were non-consumers. Microorganisms were found on buccal smears of 5.9% of individuals and 9.2% had non-specific inflammatory changes. Between tobacco consumption and salivary [MDA] in saliva of tobacco consumers was significantly higher compared to non-consumers (p<0.001). A strongly positive correlation was found between salivary [MDA] and oral epithelial changes (r=0.204, p=0.026 at 0.05CI). In conclusion, tobacco consumption severely increases the risk for developing oral mucosal proliferative lesions, and the level of oxidative stress in the saliva of individuals in the study population.

Efficacy of Gastrointestinal Endoscopy in 398 Patients With Iron Deficiency Anemia Who Lack Gastrointestinal Symptoms: Basrah Experience.

IntroductionThe diagnosis of iron deficiency anemia (IDA) relies heavily on symptom presentation, and patients lacking typical gastrointestinal (GI) symptoms represent a diagnostic challenge. IDA may be the initial manifestation of underlying pathology. This study sought to evaluate the effectiveness of different GI endoscopic studies in patients with IDA who lack GI symptoms.MethodsWe conducted an observational, multicenter retrospective analysis of 398 asymptomatic IDA patients admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We analyzed demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings.ResultsThe mean age of the study population was 52±9 years (range, 23 to 85 years), and 53% were men. Most patients were older than 45 years (n=353, 89%) with mild to moderate IDA. Patients underwent esophagogastroduodenoscopy (EGD, n=102), colonoscopy (n=271), or bidirectional endoscopy (n=25). The mean hospital stay was 2.72±1.66 days. The most common EGD results were atrophic gastritis (n=31), peptic ulcer (n=25), and negative findings (n=25). The most common colonoscopic results were negative findings (n=118), nonspecific colonic inflammatory changes (n=117), and non-bleeding hemorrhoids (n=29). We found no significant association between any endoscopic findings and age, gender, the severity of anemia, and length of hospitalization.ConclusionsThe presence of symptoms is of limited value in guiding diagnostic procedures concerning GI etiologies. Asymptomatic patients with IDA patients should receive an endoscopic examination irrespective of iron parameters, age, or gender for potentially treatable pathologies, especially for patients with suspected malignancies.

Peculiarities of the Expression of Immunohistochemical Marker HCV nS3 in the Autopsy Brain of the Patients Died in the Outcome of Chronic Infection, Caused by Hepatitis C Virus

Background . Brain lesion is one of the most common extrahepatic manifestations of chronic HCV infection. To date, its main clinical and neurometabolic features have been established. However, the morphological picture of HCV-associated cerebral changes and peculiarities of viral molecular markers expression in brain matter remain poorly understood. This significantly limits the possibilities of pathological diagnosis of this disease. Aims . To study the morphological picture of brain lesion during chronic HCV infection and to determine the peculiarities of immunohistochemical (IHC) expression of the HCV NS3 antigen in brain matter. Materials and methods . The study was performed on autopsy brain of 40 patients who died in the outcome of HCV infection and 15 patients died without signs of mental pathology. Complex of pathomorphological and ICH methods was used. Results . It was demonstrated that morphological picture of brain lesion in chronic HCV infection is represented by nonspecific dystrophic, inflammatory and proliferative changes, the severity of which varies significantly depending on the brain departments (p < 0.001). Expression of the NS3 marker is found in all studied brain regions and shows the highest intensity in white matter of cerebral hemispheres and in brain stem (p < 0.05). The ICH reaction of NS3 is manifested in microglia cells, vascular endothelium, inflammatory infiltrate cells and in periventricular ependyma cells. Using correlation analysis method it was found that NS3 expression formed the strongest correlations with such categories as CD68 expression, microgliosis, and axonal degeneration. This allows considering they are the main factors by which HCV realizes its deleterious effect on the brain. Conclusion . Characteristic morphological changes of the brain in chronic HCV infection were studied. The features of ICH expression of the NS3 in various parts of the brain are established. The results can be used to improve pathological diagnosis of brain lesion in chronic HCV infection.

Pathologic Manifestations of Gastrointestinal and Hepatobiliary Injury in Immune Checkpoint Inhibitor Therapy.

Immune checkpoint inhibitors (CPIs), including cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors and the programmed death receptor-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors, are being increasingly used for treating many advanced malignancies. However, CPI therapy is also associated with gastrointestinal and hepatobiliary adverse effects. To review the adverse effects of CPI therapy on the gastrointestinal tract and hepatobiliary system. To describe histopathologic patterns and discuss differential diagnostic considerations in the diagnosis of CPI injuries. Published peer-reviewed literature in the English language and personal experience in the diagnosis of CPI injuries. The pathologic manifestations of CPI therapy-induced gastrointestinal and hepatobiliary injury are broad. The patterns of esophageal CPI injury include lymphocytic inflammation and ulcerative esophagitis, while those of gastric injury include chronic active gastritis, lymphocytic gastritis, focal enhancing gastritis, and periglandular inflammation. The duodenal injury may present as duodenitis with villous blunting and granulomas. We also noticed active colitis, microscopic colitis, chronic active colitis, increased apoptosis, ischemic colitis, and nonspecific inflammatory reactive changes in colonic injuries. The reported histologic features of hepatobiliary injuries are panlobular hepatitis, centrilobular necrosis, portal inflammation with bile duct injury, steatosis, nodular regenerative hyperplasia, and secondary sclerosing cholangitis. In summary, we discuss the pathologic features and differential diagnosis of CPI therapy-induced gastrointestinal and hepatobiliary injury. Recognition of CPI injury is important to determine the proper management that often includes cessation of CPI therapy, and administration of steroids or other immunosuppressive agents, based on severity of injury.

P014 Case Series of Small Bowel Crohn's Disease Diagnosed in 10 Pediatric Patients by Video Capsule Endoscopy

BACKGROUND: Crohn's disease (CD) can affect the entire gastrointestinal tract. Up to 70–90% of patients who have CD have small bowel (SB) involvement. Of these patients up to one third may have disease limited to the small bowel which can make both diagnoses and surveillance of inflammatory lesions challenging. Video capsule endoscopy (CE) provides a noninvasive way to evaluate the entire small bowel for Crohn's disease. METHODS: 155 total children (18.0 years old or younger) who underwent video capsule endoscopy at Alfred I duPont Hospital for Children and Nemours Children Hospital between April 2008 to April 2019 were identified via a retrospective electronic medical record chart review. 71 of these children were either previously or ultimately diagnosed with inflammatory bowel disease (69% with Crohn's disease). Data was collected from these 71 patients including age, chief complaint, endoscopy and colonoscopy results, small bowel imaging, fecal calprotectin and blood work including albumin, hemoglobin, ESR, CRP, pANCA, and ASCA. Video capsule endoscopy was read by one primary gastroenterologist to evaluate for small bowel disease. This ongoing study was approved by Nemours IRB. RESULTS: We present ten cases of pediatric patients ages ranging from 10 to 18 years old diagnosed with Crohn's disease utilizing video capsule endoscopy. Indications for CE in these patients included 3 (30%) with diarrhea, 4 (40%) with abdominal pain, 2 (20%) with weight loss or poor growth, 3 (30%) with hematochezia, 1 (10%) with oral ulcers, and 1 (10%) with perianal disease initially felt to be a pilonidal cyst and later diagnosed as a perianal fistula. Only 1 (10%) presented with hypoalbuminemia, 1 (10%) with mildly elevated CRP, and 0 presented with either anemia or elevated ESR. Seven of the patients had fecal calprotectin collected with 1 (14.3 %), 50 mcg/g, 5 (71.4%) between 100–150 mcg/g, and 1 (14.3%) 250 mcg/g. 9 patients (90%) swallowed the capsule while 1 (10%) was placed during endoscopy. All 10 cases had previously completed endoscopy and colonoscopies with 7 of the 10 successfully intubating the ICV. Histology results were inconclusive for IBD in all 10 cases. Histology for 9 of the cases showed only acute inflammation and 1 case showed patchy subacute to chronic active colitis. All 10 cases also completed MR Enterography (MRE) as part of their workup. Of the 10 cases 5 had normal MREs and 5 had nonspecific inflammatory changes seen on imaging. All 10 cases were ultimately diagnosed with Crohn's disease, despite inconclusive histology and imaging, following capsule endoscopy findings consistent with small bowel inflammation. CONCLUSION: Small bowel Crohn's disease is common and unfortunately these lesions can often be missed without adequate assessment of the small bowel. The introduction of capsule endoscopy has provided a pivotal tool for the diagnosis and monitoring of small bowel Crohn's disease. These 10 pediatric cases show the value of utilizing capsule endoscopy to better diagnose patients with small bowel Crohn's disease.

A CASE OF EXOGENOUS LIPOID PNEUMONIA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Exogenous lipoid pneumonia (ELP) is a rare form of pneumonia caused by inhalation or aspiration of a fatty substance. In adults, most cases result from the use of oil-based laxatives for the treatment of constipation, followed by the nasal instillation of oily products for chronic rhino pharyngeal diseases. We present a patient who presented with persistent infiltrates and was diagnosed with lipoid pneumonia on lung biopsy. CASE PRESENTATION: A 48 year old female with past medical history of severe gastroesophageal reflux disease and Barrett’s esophagus was referred to the pulmonary clinic for recurrent pneumonia. She had been having gradual exertional dyspnea over two years. She denied chronic cough, wheezing, hemoptysis or overt aspiration. Social history was unremarkable with exception for tobacco abuse. Physical examination revealed oxygen saturation of 93% on room air; symmetrical breath sounds without crackles or wheezing and had normal heart sounds. Investigations including blood chemistries and serologies were unremarkable. Her pulmonary function test revealed normal spirometry with moderate diffusion impairment. Computed tomography revealed ground glass opacities with consolidative changes, with primarily left lung involvement. She was managed as pneumonia with multiple courses of antibiotics but her symptoms persisted. On serial imaging, the ground glass changes remain unchanged. Diagnostic bronchoscopy with biopsy revealed nonspecific chronic inflammatory changes which were assumed to be due to subclinical aspiration. She was treated with anti-acid medications but she continued to have exertional dyspnea. Eventually, she underwent left video assisted thoracoscopic surgery for tissue biopsy and diagnosis was consistent with lipoid pneumonia. She later revealed that she had been using mineral oil laxatives daily over the prior years. She has since stopped the usage of mineral oils. She continues to be mildly symptomatic and has persistent imaging findings. DISCUSSION: ELP is a rare cause of dyspnea and recurrent pneumonia. The typical clinical presentation of this condition includes a chronic cough with or without dyspnea and the presence of diffuse interstitial infiltrates on imaging studies of the chest. However, patients with ELP can present with symptoms ranging from asymptomatic state to severe life threatening respiratory failure. The imaging findings present with varying patterns and distribution and are not diagnostic. As seen in our case, the diagnosis can be delayed because of rather nonspecific clinical features of the disease and lack of a careful history taking for potential chemical irritants. Often, the exposure is identified only retrospectively after the diagnosis is made. CONCLUSIONS: Physicians need to have a high index of suspicion for ELP when managing patients with chronic cough or dyspnea and should elicit a history of mineral oil ingestion. Reference #1: Simmons, A., Rouf, E., & Whittle, J. (2007). Not Your Typical Pneumonia: A Case of Exogenous Lipoid Pneumonia. Journal of General Internal Medicine, 22(11), 1613-1616. https://doi.org/10.1007/s11606-007-0280-7 Reference #2: Marchiori, E., Zanetti, G., Mano, C. M., & Hochhegger, B. (2011). Exogenous lipoid pneumonia. Clinical and radiological manifestations. Respiratory Medicine, 105(5), 659-666. https://doi.org/10.1016/j.rmed.2010.12.001 DISCLOSURES: No relevant relationships by Amirahwaty Abdullah, source=Web Response no disclosure on file for Conrad Schuerch

THE FEATURES OF THE RADIOLOGICAL IMAGE OF COMMUNITY-ACQUIRED PNEUMONIA AT INTERSTITIAL LUNG DISEASES

Community-acquired pneumonia (CAP) in patients with interstitial lung diseases is a terrible complication and has an atypical course. Diagnosis of CAP is difficult, since the clinical symptoms of inflammation are similar to those of ILD. The results of radiation studies are not pathognomonic, they are not always correctly interpreted, which leads to errors in diagnosis, delay in the examination and treatment of the patient.Aims: to evaluate the possibilities of CT in the detection and differential diagnosis of pneumonia in patients with ILD.Material and methods. The results of a complex clinical and radiological studies of 336 patients with IZL, 48 patients showed infiltrative changes in the lungs that were not characteristic of the main process.Results. Nonspecific inflammatory changes in the lung tissue were manifested by the following CT symptoms: alveolar type with local infiltration of the lung tissue corresponding to the segmental structure of the lungs (segment, lobe), the appearance of peribronchial alveolar type lung tissue that is not characteristic of radiation semiotics of the underlying disease.Conclusions: рerforming CT and VRKT reveals the appearance of infiltrative and focal changes that are atypical for IL, characteristic of specific and non-specific inflammatory processes, which affects the treatment tactics of patients.

Idiopathic chronic productive cough and response to open-label macrolide therapy: An observational study.

Adult patients with chronic productive cough of unknown cause are commonly seen in respiratory clinics. We have previously described a subgroup of these patients who have a short-lived response to standard antibiotic treatment but a prolonged response to 3 months of low-dose azithromycin therapy. This observational study describes the physiological, radiological and pathological features of this patient cohort along with their response to a 12-week open-label trial of 250 mg azithromycin thrice weekly. A total of 30 subjects with a mean age of 57 were recruited. The majority demonstrated airway dilatation on high-resolution computed tomography (HRCT) scan without evidence of established bronchiectasis (n = 21) and non-specific chronic inflammatory changes on bronchial biopsy (n = 15/17). Twenty-nine subjects completed 3 months of azithromycin with a significant improvement in median Leicester Cough Questionnaire (LCQ) score (-6.3 points, P < 0.00001), reduction in median 24-h sputum volume (-5.8 mL, P = 0.0003) and improvement in sputum colour (P = 0.003). Patients responsive to azithromycin (n = 22) demonstrated neutrophilic or paucigranulocytic airway inflammation, whereas five subjects with eosinophilic airways inflammation did not respond symptomatically to azithromycin. We describe a cohort of patients with chronic productive cough not adequately described by existing disease labels whose symptoms responded well to low-dose azithromycin. Many of the features are similar to the paediatric condition protracted bacterial bronchitis.

DIFFICULTIES IN DIFFERENTIATED DIAGNOSIS OF LUNG CANCER AND INFLAMMATORY CHANGES IN LUNG TISSUE

The differential diagnosis of pulmonary diseases is extremely difficult and requires high qualifications of the radiologist and clinician. The differential diagnosis is used to distinguish different lung diseases: nonspecific inflammatory lung diseases (empyema, abscess, pneumonia), tuberculosis, sarcoidosis, benign tumors, lung cancer, lymphogranulomatosis, metastatic changes, and inflammatory changes in lung tissue. We present a clinical case, in which the differential diagnosis between tumor and inflammatory changes in lung tissue allowed the choice of optimal treatment tactics.

The low protein diet affects the nonspecific inflammatory response of middle-aged and old mice through mTOR.

To explore the effect of low protein diet on nonspecific inflammatory changes in mice during aging and related mechanisms. Thirty-two 14-month-old female KM mice were randomly divided into 4 groups: control group, low protein group, high protein group, high protein + rapamycin group. Hematoxylin-eosin (HE) staining was performed to observe the pathological changes of the liver. Immunohistochemistry of liver sections was performed to detect the expression of CD68 protein. HE staining of colon sections was performed to observe intestinal lymphocyte infiltration. The percentage of spleen CD4+ T and CD8+ T cells was detected by flow cytometry. The mTOR expression in the liver was detected by Western blot and immunohistochemistry. Compared with the control group, HE staining of liver tissue sections in high-protein group showed the cytoplasm of hepatocytes was loose and disordered, and the hepatic sinus was significantly expanded. Immunohistochemistry of the liver showed a significant increase in CD68 protein expression. Colorectal HE staining showed extensive lymphocyte infiltration. The number of CD4+ T and CD8+ T cells in spleen flow cytometry was significantly decreased (*p < 0.05). Western blot and immunohistochemistry detected a significant increase in mTOR expression in the liver (*p < 0.05, *p < 0.05). In the High Protein+Rapamycin group and Low-protein group, the time-dependent changes were reduced, the numbers of CD4+ T cell and CD8+ T cell in the spleen were significantly increased (*p < 0.05) and the expression of mTOR was significantly reduced (*p < 0.05). Low-protein diet is beneficial for delaying the non-specific inflammatory changes of liver and intestines in middle-aged and aged mice, and this effect may be achieved through down-regulation of mTOR.

Insidious Colonic Histoplasmosis in an Immunocompetent Patient: A Case Report

Histoplasmosis is caused by a dimorphic fungus, Histoplasma capsulatum. It most commonly affects the lungs, but disseminated infection involving the central nervous system, liver, spleen and gastrointestinal (GI) tract can occur. GI histoplasmosis most commonly occurs in immunocompromised patients, who present with abdominal signs and symptoms. Our case is unique in that the patient was immunocompetent and asymptomatic. A 71-year-old male anticoagulated for a prior DVT and protein C deficiency was seen for surveillance colonoscopy. Multiple polyps were seen throughout the colon, resected, and sent for pathology. Histopathology showed benign colonic mucosa and submucosal granulomatous reaction with abundant intracytoplasmic fungal organisms consistent with disseminated histoplasmosis [Figure 1]. Special staining with GMS stain also demonstrated yeast forms typical of Histoplasma [Figure 2]. Oral Itraconazole was initiated. CT showed no evidence of lung involvement. Lab testing revealed positive urine and serum Histoplasma antigens and negative antibody. Hepatitis and HIV testing were negative. One month later, the patient remained asymptomatic and Histoplasma urine antigen trended down. He will complete 12 months of Itraconazole with repeat colonoscopy at the end of treatment.1553_A Figure 1. Biopsy demonstrating aggregates of macrophages containing intracytoplasmic fungal organisms, consistent with Histoplasma. (H&E stain, orig. mag. x40)1553_B Figure 2. Biopsy with abundant loose groups of black-staining Histoplasma yeast forms. (GMS stain, orig. mag. x40)Histoplasmosis is endemic in the upper Mississippi and Ohio River valleys, with an incidence of 3.4/100000. GI involvement occurs in 0.05% of cases, commonly the colon or terminal ileum. Nonspecific abdominal pain or diarrhea is common. Intestinal obstruction and perforation can rarely occur. Interestingly, our patient presented for screening colonoscopy, without GI or systemic symptoms. GI histoplasmosis primarily occurs in immunocompromised patients above age 50. Limited cases in immunocompetent patients have been reported, attributed to defects in cellular immunity. Our patient had mild protein C deficiency, which may have non-specific immune defects. Endoscopic findings include normal mucosa, plaques, pseudopolyps, or a severe form with ulcers and strictures. Histopathology is the cornerstone of diagnosis, showing nonspecific inflammatory changes, giant macrophages and a diffuse lymphoplasmacytoid infiltrate. Intracytoplasmic organisms are confirmed with GMS stain. This case reflects the importance of screening colonoscopy. It emphasizes the need for high suspicion in patients in endemic areas with abnormal mucosal findings, as well as the importance of histopathology for diagnosis.

Starving Colon: A Rare Cause of Colitis in a Patient With a Diversion Ileostomy

Introduction An uncommon complication of bowel diversions presents as inflammation of the non-functioning, bypassed segment known as diversion colitis and is difficult to distinguish from other causes of colitis. Because diversion results in a deficiency of short-chain fatty acids (SCFAs) and other nutrients, the suspected pathogenesis likely results from alteration of mucosal cytokines and changes in the gut flora and metabolism. Case Description A 61 year old female with a prior history of perforated diverticulitis complicated by recurrent abscesses status-post Hartmann's procedure presented with worsening nausea, vomiting, and episodes of bloody diarrhea. Previously, she underwent a colostomy takedown, but a diversion ileostomy was required due to concern for a peri-rectal leak. Abdominalexam demonstrated diffuse tenderness with normoactive bowel sounds. Ileostomy had brown stool with some blood present. Laboratory analysis revealed a HGB of 7.7 g/dl, MCV of 75.1 fl, and negative stool studies. Abdominal computed tomography showed new diffuse colonic wall thickening suggesting colitis. Further work up revealed a high ANCA titer and positive ASCA IgG antibodies. A colonoscopy showed active enteritis in the terminal ileum and evidence of pancolitis, endoscopically, concerning for IBD. Biopsies were nonspecific, but displayed acute inflammation without evidence of viral infection. Prior colonoscopies were negative for findings of IBD. It was clinically determined that the etiology was likely diverting colitis based on clinical history with improvement after surgical reanastomosis. Discussion The incidence of diversion colitis is unclear and only documented in small studies. Endoscopy often shows non-specific inflammatory changes including erythema and friability of the mucosa with histology often non-diagnostic. Interestingly, previous studies suggest that diversion colitis arise more often in patients with a history of IBD. There has been no reported case to our knowledge of diversion colitis in a patient with diverting ileostomy, which ultimately recovered after integrity of the bowel was restored. Definitive treatment requires reanastomosis in symptomatic patients. If repair cannot be performed, then SCFAs enemas or 5-aminosalicyclic acid can be utilized. Early recognition and considering the diagnosis of diversion colitis in patients with segment diversions can allow appropriate management when evaluating colitis.

Granulomatous Esophagitis: Crohnʼs Disease in Rare Form

Introduction: Esophageal Crohn's disease (CD) is rare but must be recognized and distinguished from other esophageal diseases and treated accordingly. Case Report: A 35-year-old Caucasian man with CD presented with solid food dysphagia with associated odynophagia, heartburn and weight loss. He had a 20-year history of severe ileocolonic and perianal CD requiring subtotal colectomy and end ileostomy, subsequent ileal resection and ileostomy revision and multiple perianal drainage procedures. There was no history of upper gastrointestinal involvement. He previously lost response to infliximab and certolizumab and was then maintained successfully on adalimumab. An upper endoscopy revealed multiple deep, longitudinal ulcers coursing the length of the esophagus (Figure 1) with biopsies showing severe, non-specific inflammation and ulceration. A 12-week trial of twice daily proton pump inhibitor (PPI) resulted in partial relief of symptoms. A subsequent endoscopy showed no mucosal healing, and biopsies revealed dense inflammation and multiple small, non-caseating granulomas (Figure 2). Adalimumab and twice daily PPI were continued, and a prednisone taper followed by twice daily swallowed viscous budesonide resulted in significant improvement in symptoms as well as in endoscopic and histologic healing on follow-up endoscopy (Figure 3). Discussion: CD of the esophagus was first described in 1950 and is the least common location of disease in the GI tract. The prevalence among those with CD is estimated to be between 0.2-6.8% in adults with slightly higher prevalence reported in children, possibly because routine upper endoscopy is recommended in pediatric but not adult CD guidelines. Approximately 80% of patients have localizing symptoms including dysphagia and odynophagia. Non-specific inflammatory changes and ulcers are common on endoscopy and histology, but approximately 20% have detectable non-caseating granulomas. Care must be taken to rule out acid reflux, herpetic or tuberculous infection, pill esophagitis and infiltrative disease. PPI's, systemic and topical steroids and biologic therapies are the mainstays of management, while stricturing or fistulizing disease may require endoscopic dilation or surgery.1747_A Figure 1 No Caption available.1747_B Figure 2 No Caption available.1747_C Figure 3 No Caption available.

Pathology and terminology of interstitial cystitis/bladder pain syndrome: A review.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is an umbrella term of chronic debilitating conditions of unknown etiology characterized by symptoms of lower urinary tract hypersensitivity such as bladder pain/discomfort, urgency, and urinary frequency. The pathological features of IC/BPS have been generally reported as non-specific chronic inflammatory changes, with mast cell infiltration as a potential key finding. However, growing evidence reveals a histological distinction between IC/BPS with Hunner lesions and IC/BPS without Hunner lesions, and also sheds doubt on the diagnostic value of the mast cell count. Specifically, IC/BPS with Hunner lesions is an inflammatory disorder characterized by pancystitis with B cell abnormalities and epithelial denudation, while IC/BPS without Hunner lesions shows minimal histological changes. The umbrella term "IC/BPS" connects totally distinct clinical entities. Pathological evaluation thus plays an important role in the precise subtyping and clinical management of IC/BPS. In addition, terminology should be developed to refer separately to IC/BPS with Hunner lesions and IC/BPS without Hunner lesions.

Delayed Allergic Cutaneous Hypersensitivity to Icodextrin

Rashes pose a unique challenge to general internists. Here we present a case of a 51-year-old female with end-stage renal disease (ESRD) on peritoneal dialysis who presented to a General Internal Medicine clinic with a vesiculobullous rash on palms and soles 6 months after using icodextrin dialysate, a widely used osmotic agent in peritoneal dialysis. The investigations were positive for an elevated eosinophil count, elevated IgE level and a skin biopsy consistent with an allergic reaction. Her symptoms and labs normalized after stopping icodextrin. There are some reports of allergic reactions to icodextrin which usually occur within a month of initiation of the agent and are self-limiting. Here we hope to report a case of a reaction that occurred 6 months after using icodextrin.&#x0D; Resume&#x0D; Les éruptions cutanées posent un défi particulier aux internistes généraux. Nous rapportons ici le cas d’une femme de 51 ans atteinte d’insuffisance rénale terminale (IRT), sous dialyse péritonéale, qui se présente à une clinique de médecine interne générale avec une éruption cutanée vésiculo-bulleuse sur les paumes et la plante des pieds. Depuis six mois, la patiente utilise un dialysat d’icodextrine, un agent osmotique largement utilisé en dialyse péritonéale. Les analyses ont révélé une numération élevée des éosinophiles, un taux élevé d’IgE et une biopsie cutanée a indiqué la présence d’une réaction allergique. Les symptômes et les résultats d’analyses se sont normalisés après l’arrêt de l’icodextrine. Des réactions d’allergie à l’icodextrine ont déjà été rapportées, mais celles-ci surgissent habituellement dans le mois suivant le début de l’usage de l’agent et se résorbent d’elles-mêmes. Nous désirons signaler un cas de réaction survenue six mois après le début de l’utilisation de l’icodextrine.&#x0D; &#x0D; &#x0D;

Cervical Cytology: A Review of 597 Cases in a Tertiary Health Centre in Nigeria

Background: Cervical cancer is the most common gynaecological cancer among women in the developing countries. It is preventable by early detection and treatment of the precursor lesions. Cervical cytology became the standard screening test for cervical cancer and premalignant lesions with the introduction of the Papanicolau (Pap) smear. Aim: to determine the uptake, indications and results of cervical cytology in a tertiary health center in Nigeria. Materials and Methods: a 5-year descriptive study of the results of cervical cytology among women who attended the gynaecological outpatient clinic of the Hospital. Results: a total of 597 cases of cervical Pap smears were received at the histopathology department during the study period out of which 20 (3.4%) were inadequate for cytological evaluation. The patients age ranged from 15 to 80 (mean 38.8 SD = 11.4) years. The average annual uptake of the Cervical smear was 9.3% of the total number of patients seen in the gynaecological clinic during the study period and the main indications were routine medical check-up, 256 (42.9%) and cervicitis 76 (12.7%). About 398 (66.7%) were normal smears while 152 (26.3%) were abnormal. Non-specific inflammatory changes were present in 113 (74.3%) cases. Cytology was positive for intraepithelial lesions in 6.8% (39/577) cases. Eighteen percent (7/39) of them were high-grade lesions while squamous cell carcinoma was detected in 12.8% (5/39) cases. Conclusion: the uptake of cervical cytology of 8.7% is low and the main indication was routine check up. Premalignant lesions were detected in 6.8% of cases.

THE ROLE OF MORPHOLOGICAL STUDIES OF PLACENTA IN DIAGNOSIS OF INTRAUTERINE INFECTIONSOF NEWBORNS

Introduction. Infectious disorders of the afterbirth (or placenta) are now of frequent occurrence, and have specific morphologic manifestations, which significantly affects the course of pregnancy, childbirth, intrauterine growth and development and postnatal health of the infant.The purpose of the study was to optimize the diagnosis and prognosis of the severity of intrauterine infection in neonates based on an assessment of risk factors, perinatal history and the results of morphological studies of afterbirth of those mothers, who had children with intrauterine infection.Materials and methods. Clinical and laboratory examination of 834 mothers and their diseased newborns suspected to have intrauterine infection the first 3 days of life was performed. The subject of in-depth study was a group of 224 patients with newborns with congenital infections. The control group consisted of 30 apparently healthy newborns. Confirmation of intrauterine infection was conducted based on history, physical exam data, and standard tests and using morphological studies of the born placenta.Results of the study. Among the total number of examined newborns, intrauterine infection was verified in 708 (84.9%) patients. The subject of the in-depth study was a group of 224 (31.6%) diseased newborns with congenital viral infections. Among them were term infants - 132 (58.9%) and premature babies - 92 (41.1%). Among 224 children, 77 (34.4%) mixed viral infections, 62 (27.7%) viral and bacterial infections, 53 (23.6%) mixed viral TORCH infections with monoviral infections - in 32 (14.3%). Among the risk factors, acute respiratory viral infections predominate in pregnant women (45.5%), threatening miscarriage (43.7%), anemia of pregnancy (25.0%), preterm delivery (41.1%), placental dysfunction 23.2%), preeclampsia (17.4%), asphyxia of newborns (40.6%). Analyzing the results of a histological study of 224 placentas in women who gave birth to children with congenital viral infections we revealed that in addition to specific morphologic changes caused by respiratory viruses, 54 (24%) also manifested non-specific inflammation(deciduitis, villusitis) and diverse variants of altered placental circulation. It confirms that in addition to the direct harmful effect of the virus, the secondary hypoxia and fetal supply disturbance can occur. The absence of specific signs and symptoms of viral infections in pregnant women does not exclude the need to investigate the afterbirth of children at risk to have intrauterine infection.Conclusions. The results of the histological examination of the placentas substantiate both the etiology of congenital viral infections based on specific morphological features, as well as the effect of nonspecific inflammatory changes (basal deciduitis, vylusitis) and variations of transplacental circulation disturbances on prediction the severity of congenital viral infections in newborns.

Intestinal Spirochetosis: An Obscure Cause of Lower Gastrointestinal Bleeding

Intestinal Spirochetosis is a condition marked by anaerobic spirochetes adherence and colonization of the luminal surface of colonic epithelium with occasional penetration into the epithelium. Most cases are found incidentally on pathological evaluation of colonic biopsies taken during diagnostic or therapeutic colonoscopies. However, whether the colonization of the intestinal mucosa can be attributed to clinical symptoms is a matter of debate. Here we present a case of intermittent hematochezia due to invasion of the colonic mucosa by intestinal spirochetes. A 27 year old male with no medical history presented with four days of atypical chest pain and syncope the day prior to presentation. He also reported watery diarrhea and intermittent hematochezia for the past two weeks. A complete cardiovascular and neurologic workup was unremarkable. After a spontaneous episode of painless hematochezia he was found to have a decrease in Hgb from 14 g/dl to 10 g/dl. CRP was 6.5 and ESR was 60. All stool studies, including Clostridium difficile toxin were negative. Coagulation studies were within normal limits. Physical exam was unremarkable except for guaiac positive stool. Colonoscopy was performed, revealing mild erythematous mucosa of the terminal ileum, and a localized area of severely congested, erythematous and inflamed mucosa in the rectum. Random biopsies were taken. Intestinal spirochetes were found in biopsies of the ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and cecum. Terminal ileum and rectum biopsies showed nonspecific inflammatory changes. The overwhelming spirochete invasion suggested these changes were secondary to the infectious process. Screening for all sexually transmitted diseases was negative. He was treated with metronidazole and improvement in symptoms was reported. This case demonstrates that invasive IS may develop in healthy individuals. Although many cases of asymptomatic IS have been described, cases leading to severe gastrointestinal symptoms are rare. No current methods exist to prove a direct relationship between histologic findings of IS and active disease thus leaving IS as the diagnosis of exclusion. Diagnosis requires random colonic biopsies followed by direct visualization via histologic staining, and may be confirmed by fluorescence in situ hybridization. Treatment of IS is controversial and ultimately should be dictated by the presence of symptoms, after all other etiologies have been ruled out.Figure: Erythematous Colonic Mucosa.Figure: False Brush Border Intestinal Colonization of Spirochetes along the colonic epithelium.

Interval laparoscopic ileocecectomy in a child with cecal diverticulitis

Abstract Cecal diverticulitis is a rare condition in children that can present diagnostic and surgical challenges. Cecal diverticulitis has a similar presentation to appendicitis, but the surgical management is much different. We present a case of cecal diverticulitis in a 13-year-old Hispanic male who was initially treated nonoperatively, but ultimately underwent laparoscopic assisted ileocecectomy as definitive treatment. This is the only case report to describe a delayed surgical approach to this rare medical condition. We feel this approach has particular merit with respect to cecal diverticulitis as the possibility of diagnostic uncertainty is high. Cecal diverticulitis is a rare disease process, particularly in children. Patients predictably present with right lower quadrant abdominal pain in a manner similar to appendicitis. Imaging may reveal a phlegmon, perforation, bowel wall thickening, or nonspecific inflammatory changes. These imaging findings may not always indicate a clear diagnosis, especially if the appendix cannot be well visualized. Urgent operation may be ill advisable in this situation as the surgeon may encounter a hostile operative field with dense inflammatory changes resulting in an increased risk of ileostomy creation. We present a case of cecal diverticulitis managed safely with a delayed surgical approach. We feel a delayed surgical approach may provide an alternative option for patients with an uncertain diagnosis or surgeons who wish to avoid a potentially hazardous dissection. A delayed approach may also help to facilitate a minimally invasive approach.

Targeted fascicular biopsy of the brachial plexus- rationale and operative technique

Objectif Nerve biopsy is useful in the diagnosis and the management of neuromuscular disorders and is commonly performed in distal, noncritical sensory nerves without using imaging to target the most involved regions. In general, these procedures are diagnozed in 20–50%. In selected cases where preoperative evaluation points towards a more localized (usually a more proximal) process, targeted biopsy would likely capture the disease. Synthesis of data obtained from clinical examination, electrophysiological testing and MRI allows a targeted fascicular biopsy of a major nerves to be performed safely and efficiently. Herein, our experiences with the brachial plexus are reported and a description of the operative technique is provided. Methods All cases of brachial plexus biopsy performed between 2003 and 2015 were reviewed. Only cases of targeted nerve biopsy approached from supraclavicular, deltopectoral and proximal medial arm were included. Demographic data, clinical presentation and the presence of percussion tenderness for each patient were recorded. Reviewed studies included electrodiagnostic tests and high resolution MR imaging. Previous nerve and muscle biopsies were noted. All details of the procedure, final pathology and its treatment implications were recorded. The complication rate was carefully assessed for temporary as well as permanent complications. Results Seventy-seven cases (29 men and 48 women) of brachial plexus biopsy were performed. Mean patient age was 57.25 years. Sixty-eight (87.1%) patients presented with symptoms in one upper extremity, 8 (10.4%), in both upper limbs, and 1 (17%), with all limb. All 74 patients (100%) patients had abnormal physical examinations, electrodiagnostic studies and MRIs. The overall diagnostic yield of biopsy was 74.4% ( n = 55). The most common diagnoses included breast carcinoma (17), neurolymphomatosis (9), inflammatory demyelination (13), perineurinoma (7) and nonspecific inflammatory changes (4). The series included 4 cases of (5.4%) increased numbness and 3 (4.0%) with additional weakness. Conclusion Targeted fascicular biopsy of the brachial plexus is an efficient diagnostic procedure and in highly selected cases can be offered as the initial procedure over distal cutaneous nerve biopsy. Diagnoses were very diverse and included entities considered very rare. Even for the most prevalent diagnoses, this biopsy technique allowed a more targeted approach resulting in a higher diagnostic yield and justification for more aggressive treatment.