Positive Periodic acid-Schiff Staining Research Articles

Effect of glycyrrhizic acid and 18β-glycyrrhetinic acid on the differentiation of human umbilical cord-mesenchymal stem cells into hepatocytes.

BACKGROUNDEnd-stage liver disease is a global health complication with high prevalence and limited treatment options. Cell-based therapies using mesenchymal stem cells (MSCs) emerged as an alternative approach to support hepatic regeneration. In vitro preconditioning strategies have been employed to strengthen the regenerative and differentiation potential of MSCs towards hepatic lineage. Chemical compounds of the triterpene class; glycyrrhizic acid (GA) and 18β-glycyrrhetinic acid (GT) possess diverse therapeutic properties including hepato-protection and anti-fibrosis characteristics. They are capable of modulating several signaling pathways that are crucial in hepatic regeneration. Preconditioning with hepato-protective triterpenes may stimulate MSC fate transition towards hepatocytes.AIMTo explore the effect of GA and GT on hepatic differentiation of human umbilical cord-MSCs (hUC-MSCs).METHODShUC-MSCs were isolated and characterized phenotypically by flow cytometry and immunocytochemistry for the expression of MSC-associated surface molecules. Isolated cells were treated with GA, GT, and their combination for 24 h and then analyzed at three time points; day 7, 14, and 21. qRT-PCR was performed for the expression of hepatic genes. Expression of hepatic proteins was analyzed by immunocytochemistry at day 21. Periodic acid Schiff staining was performed to determine the functional ability of treated cells.RESULTSThe fusiform-shaped morphology of MSCs in the treatment groups in comparison with the untreated control, eventually progressed towards the polygonal morphology of hepatocytes with the passage of time. The temporal transcriptional profile of preconditioned MSCs displayed significant expression of hepatic genes with increasing time of differentiation. Preconditioned cells showed positive expression of hepatocyte-specific proteins. The results were further corroborated by positive periodic acid Schiff staining, indicating the presence of glycogen in their cytoplasm. Moreover, bi-nucleated cells, which is the typical feature of hepatocytes, were also seen in the preconditioned cells.CONCLUSIONPreconditioning with glycyrrhizic acid, 18β-glycyrrhetinic acid and their combination, successfully differentiates hUC-MSCs into hepatic-like cells. These MSCs may serve as a better therapeutic option for degenerative liver diseases in future.

Histological alterations in Rabbit liver after treatment with dexamethasone

Background One of the most potent glucocorticoids is known as Dexamethasone. Many metabolic side effect shave been reported on almost every organ after dexamethasone treatment specially its effect on liver. Aim: To investigate harmful side effects of dexamethasone sodium phosphate on rabbit’s liver that serve as human liver model via using light microscope, by administration of two doses (extreme) and two durations in order to depict the duration as well as dosage dependency. Methods: Liver samples were taken via rabbits who were administered dexamethasone sodium phosphate. Then two Stratas were made namely, 1 and 2. The fixations of liver samples were carried out and underwent into evaluation in order to observe any histochemical and histological alterations. Study duration is from February to May 2021 Rabbits were brought from Veterinary Research Institute, Lahore. These Rabbits were kept in cages in the animal house of PGMI, Bird wood road Lahore. Results: The ballooning and vacuolation of hepatic cells were seen in the liver in case of Stratas that were treated along with the degenerative alterations of these cells, congestion and dilatation of central hepatic vein with sinusoidal capillaries, positive periodic acid schiff's stain (PAS) reactions. The severity of all these alterations was dependent upon duration and dosage. Conclusion: Morphological variations induced in the liver by dexamethasone sodium phosphate could be accepted as side effects of these drugs. Keywords: Liver, dexamethasone, histology, glycogen.

Rheumatological features of Whipple disease

Whipple disease (WD) is a rare infectious systemic disease. Rheumatologists are at the frontline of WD diagnosis due to the early rheumatological manifestations. An early diagnosis is crucial, as usual anti-rheumatic drugs, especially TNF inhibitors, may worsen the disease course. We conducted a retrospective multicentre national study from January 2010 to April 2020 to better characterize the rheumatological features of WD. Classic WD (CWD) was defined by positive periodic acid-Schiff (PAS) staining of a small-bowel biopsy sample, and non-CWD (NCWD) was defined by negative PAS staining of a small-bowel biopsy sample but at least one positive Tropheryma whipplei (TW) polymerase chain reaction (PCR) for a digestive or extradigestive specimen. Sixty-eight patients were enrolled, including 11 CWD patients. Twenty patients (30%) received TNF inhibitors during the WD course, with inefficacy or symptom worsening. More digestive symptoms and systemic biological features were observed in CWD patients than in NCWD patients, but both patient groups had similar outcomes, especially concerning the response to antibiotics and relapse rate. Stool and saliva TW PCR sensitivity were both 100% for CWD and 75% for NCWD and 89% and 60% for small-bowel biopsy sample PCR, respectively. WD encountered in rheumatology units has many presentations, which might result from different pathophysiologies that are dependent on host immunity. Given the heterogeneous presentations and the presence of chronic carriage, multiple TW PCR tests on samples from specific rheumatological sites when possible should be performed, but samples from nonspecific digestive and extradigestive sites also have great value.

Structural and Ultrastructural Morphological Evaluation of Giant Anteater (Myrmecophaga tridactyla) Prostate Gland.

Simple SummaryThe giant anteater (Myrmecophaga tridactyla) is a vulnerable species that lives in South America, extinct in several countries. In the past year, different governmental and non-governmental programs were created for the giant anteater’s conservation. However, little is known regarding the reproductive aspects of this species. Thus, to the best of our knowledge, this is the first description of a morphological and ultrastructural analysis of the prostate gland.The giant anteater (Myrmecophaga tridactyla) is a vulnerable species from Central and South America, and is considered possibly extinct in Belize, Guatemala, El Salvador, and Uruguay. Due to the species’ conservation and reproductive importance, this research aimed to characterize the morphology, histochemical, immunohistochemical, and ultrastructural feature of the giant anteater prostate gland. For this, we collected 11 giant anteater prostate glands and performed macroscopic, morphological, histochemical, immunohistochemical, and ultrastructural analysis. Nine prostate glands from an adult subject and two from young subjects were studied. Grossly, the adult giant anteater prostate gland is divided in two distinct zones; the central zones (composed mainly of ducts) and the peripheral zones (of acini formed by secretory cells). The secretory cells showed positive periodic acid–Schiff staining. Furthermore, the immunohistochemical characterization revealed a similar human prostate pattern, with p63 staining basal cells, uroplakin III (UPIII) superficial cells of prostatic urethra, androgen receptor (AR) expressing nucleus of secretory and stromal cells, and prostatic specific antigen (PSA) staining prostatic epithelial cells. Overall, our research provided an in-depth morphological description of the giant anteater’s prostate gland, providing valuable information for futures studies focused on giant anteater conservation.

Indocyanine Green Uptake and Periodic Acid-Schiff Staining Method for Function Detection of Liver Cells are Affected by Different Cell Confluence.

The online version contains supplementary material available at 10.1007/s10616-021-00453-8.

Mechanism of nano-indium-tin oxide inducing pulmonary alveolar proteinosis in Sprague-Dawley rats

Objective: To investigate the pathogenesis of pulmonary alveolar proteinosis in rats induced by nano-indium-tin oxide exposure, and to provide a basis for further determining the limit of occupational exposure to indium and developing related protection measures. Methods: In August 2018, a total of 40 specific pathogen-free Sprague-Dawley rats, with an age of 6-8 weeks and a body weight of (200±10) g, were randomly divided into control group, low-dose group (1.2 mg/kg) , middle-dose group (3 mg/kg) , and high-dose group (6 mg/kg) , with 10 rats in each group. After 1 week of routine feeding, the rats were given non-exposed intratracheal instillation twice every week, with an interval of 3 days, for 12 consecutive weeks. Body weight was measured every week during exposure to observe the change in body weight; The rats were anesthetized and sacrificed by chloral hydrate after the exposure ended, and lung tissue and serum were collected; Hematoxylin-eosin staining and periodic acid-Schiff (PAS) staining were performed for lung tissue to observe pathological results; Inductively coupled plasma mass spectrometry was used to measure the serum level of indium; ELISA was used to measure the levels of surfactant protein A (SP-A) , surfactant protein D (SP-D) , and the type II alveolar cell surface antigen Krebs von den Lungen-6 (KL-6) in lung tissue and the serum level of granulocyte-macrophage colony-stimulating factor (GM-CSF) . Results: The pathological results showed that the rats in the control group had basically complete alveolar structure, and after intratracheal instillation of nano indium-tin oxide, uniform, eosinophilic, and unstructured granular substances were observed in the alveolar space of the low-, middle-, and high-dose exposure groups, with macrophage proliferation and an increase in macrophages, especially in the high-dose group. Negative PAS staining was observed in the control group, while substances with positive PAS staining were observed in lung tissue in each exposure group. The three exposure groups had a significantly higher serum level of indium than the control group (P<0.05) . Compared with the control group, the three exposure groups had significant increases in SP-A, SP-D, and KL-6 in lung tissue and a significant reduction in GM-CSF in serum (P<0.05) . Conclusion: Pulmonary alveolar proteinosis in rats may be associated with the destruction of alveolar macrophages caused by nano-indium-tin oxide and the aggregation of pulmonary surfactants due to disorders in the metabolism and clearance of pulmonary surfactants by macrophages.

A CASE OF AUTOIMMUNE PULMONARY ALVEOLAR PROTEINOSIS WITH UNDERLYING MONOCLONAL B-CELL LYMPHOCYTOSIS

SESSION TITLE: Fellows Diffuse Lung Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: We describe a rare case of autoimmune pulmonary alveolar proteinosis (PAP) with a concurrent low-grade lymphoproliferative disorder. CASE PRESENTATION: A 47-year-old male nonsmoker with obesity, hypertension and type 2 diabetes with nephropathy was admitted to the ICU with fever, cough and dyspnea leading to acute hypoxemic respiratory failure requiring intubation. He had been hospitalized for “heart failure” 6 months prior to presentation, and his dyspnea had slowly progressed since then. He worked as a butcher. Three of his 1st-degree relatives had died from presumed heart failure between ages 44-54. Additional features of his presentation included Raynaud’s phenomenon, high CRP of 254 mg/L and no clinical signs of heart failure. Chest x-ray (CXR) demonstrated nonspecific patchy bilateral opacities. The CXR from 6 months ago showed similarly distributed, albeit less prominent, opacities (Fig 1). Chest CT revealed diffuse, bilateral ground-glass opacities (GGOs) with interlobular septal thickening (crazy-paving pattern), consolidation and mediastinal lymphadenopathy (Fig 2). TTE showed normal biventricular function. Rheumatologic workup was negative. BAL microbiology showed S. pneumoniae, which was treated. Periodic acid-Schiff (PAS) staining from BAL showed bright globular material consistent with PAP (Fig 3). Serum anti-GM-CSF antibody was positive. Bone marrow biopsy revealed monoclonal B-cell lymphocytosis involving 20% of the marrow with positive peripheral blood flow cytometry, mutated IGH-V, and negative TP53 mutation. The patient required bilateral whole lung lavage (WLL) on two occasions, one month apart. He was started on inhaled GM-CSF after the first WLL and rituximab was added subsequently. His course was complicated by massive pulmonary embolism requiring VA-ECMO support, acute kidney injury requiring dialysis, and critical illness myoneuropathy. He was discharged home after 84 days. DISCUSSION: PAP is classified into 3 groups: primary (autoimmune and hereditary), secondary, and congenital (1). PAP is diagnosed with positive PAS stain on BAL fluid or lung biopsy in combination with typical features on CT, including bilateral GGOs with interlobular septal thickening. The hallmark of primary, or autoimmune, PAP includes presence of autoantibodies to GM-CSF, which are not present in secondary PAP (2). Common etiologies of secondary PAP are hematologic malignancies, most commonly myeloid (3). Ascertaining the etiology of PAP is important, and guides the choice of therapy. For autoimmune PAP, treatment includes WLL and inhaled GM-CSF. For secondary PAP, treatment is directed at the underlying cause. CONCLUSIONS: This is one of the first reported cases of autoimmune PAP with a concurrent low-grade lymphoproliferative disorder. The patient improved with WLL, inhaled GM-CSF and rituximab. Reference #1: Trapnell BC, Nakata K, Bonella F, et al. Pulmonary alveolar proteinosis. Nat Rev Dis Primers. 2019 March 7;5(1):16. Reference #2: Kumar A, Abdelmalak B, Inoue Y, Culver DA. Pulmonary alveolar proteinosis in adults: pathophysiology and clinical approach. Lance Respir Med. 2018 Jul;6(7):554-565. Reference #3: Chaulagain CP, Pilichowska M, Brinckerhoff L, Tabba M, Erban JK. Secondary pulmonary alveolar proteinosis in hematologic malignancies. Hematol Oncol Stem Cell Ther. 2014 Dec; 7(4):127-35. DISCLOSURES: No relevant relationships by Simone Barreto Siqueira Parrilha T, source=Admin input No relevant relationships by Brittany Blass, source=Web Response No relevant relationships by Melanie Bois, source=Web Response No relevant relationships by Sumedh Hoskote, source=Web Response no disclosure on file for Mark Norton

Whipple disease diagnosed by enteroscopy: first case report in Colombia of an underdiagnosed disease and literature review

BackgroundWhipple’s disease is a rare systemic disease caused by a gram-positive bacillus called Tropheryma whipplei. First described in 1907 as an intestinal lipodystrophy with histological finding of vacuoles in the macrophages of the intestinal mucous. Usually the symptoms are localized according to the compromised organ. The differential diagnosis is wide. It can be fatal without proper treatment. Recurrence can occur in up to 33% of the cases and usually compromises the neurological system.Case presentationThis article reports the case of a 46-year-old female patient with a history of a 6-month hypochromic microcytic anemia of unknown cause. She consulted for a 6-months oppressive abdominal pain located in the mesogastrium as well as abdominal distention associated with nausea and liquid stools; in addition, she had an 8-month small and medium joint pain, without edema or erythema. Physical examination without relevant findings. Multiple esophagogastroduodenoscopies with normal gastric and duodenal biopsies findings and a normal colonoscopy were performed. Endoscope capsule showed red spots in the duodenum and ulcerations in the jejunum and proximal ileum covered by fibrin; histological report showed macrophages with positive periodic acid-schiff reaction staining (PAS staining), disgnosing Whipple’s disease. Antibiotics were initiated. The patient is currently in the second phase of treatment without gastrointestinal and joint symptoms.ConclusionThis is the first case reported in Colombia. It is a rare entity and difficult to diagnose reason why it is important to continue with clinical investigations to give more clarity about the onset and appropriate diagnose to avoid the delay in treatment of this entity.

Establishment of an induced pluripotent cell line from Taiwan black silkie chick embryonic fibroblasts for replication-incompetent virus production

The objective of this study was to establish a versatile cell line for replication-incompetent virus production and inactivation with formaldehyde to generate a model of cell-based vaccine manufacturing process. To achieve this goal, we took advantage of the easily accessed chick embryonic fibroblasts. Nine-day old chick embryonic fibroblasts were obtained and subjected to be transduced with a set of lentivirus to develop a chick induced pluripotent stem (ciPS) cell line. Morphological features, positive periodic acid-Schiff staining as well as strong immunocytofluorescence of alkaline phosphatase, intestinal (ALPI) and POU class 5 homeobox 1 (POU5F1) proteins suggested that these chick embryonic fibroblasts have been transformed into ciPS cells. Further differentiation and immunocytofluorescence assays confirmed that this ciPS cell line possesses capacities and potentials to form embryoid bodies, differentiate into all three embryonic layers: ectoderm, mesoderm and endoderm with evidence of strongly positive and specific molecular markers. Immunoblot analysis next demonstrated that through recombinant DNA technology and the 2nd generation lentiviral transfer system, the goose hemagglutinin gene (H5) gene was packaged into the replication-incompetent virus and highly expressed in a bladder cancer-derived cell line, T24, after transduction. The titer of ciPS-generated replication-incompetent virus is comparable to that from the Phoenix-AMPHO cell line, which is a commercial and high productive retrovirus producer. Our study successfully established a ciPS cell line which is able to produce replication-incompetent virus, providing a new strategy for cell-based vaccine production after virus inactivation.

2563 When Considering a Broad Differential to Diarrhea and Joint Pain: Don't Forget About Whipple's Disease

INTRODUCTION: Whipple's disease (WD) is a rare systemic disease caused by bacteria Tropheryma whipplei and commonly overlooked as a diagnosis. CASE DESCRIPTION/METHODS: A 42-year-old man presented to the ED for intolerance chronic of diarrhea, lower extremity swelling, paresthesia, migratory monoarticular arthralgia, and weakness. Over 2 years he lost 60-pounds and had early satiety, intermittent dysphagia, and decreased concentration. Physical exam was remarkable for a scaphoid abdomen with mild diffuse tenderness, knee joint tenderness, lower extremity strength 4/5. Labs abnormalities: hemoglobin 6.5 g/dL, albumin 1.9, 25-OH vitamin D 5 ng/mL (nml &gt; 30 ng/mL), CRP 25.4 mg/L. Bilateral lower extremity ultrasound showed a blood clot in the right deep femoral vein and bilateral baker's cysts. Colonoscopy and EGD examinations were unrevealing. Histologic exam of duodenum biopsies showed dilated fat vacuoles and a positive periodic acid-Schiff (PAS) stain confirming Whipple's Disease. Cerebrospinal fluid was negative and cognitive changes improved with electrolyte replacement. He was treated with a 14-day course of intravenous ceftriaxone followed by Bactrim doubled-strength twice a day. After intravenous antibiotics, the diarrhea resolved and he regained weight. DISCUSSION: WD most commonly affects men (86%), farmers (35%), and those with occupational exposure to soil or animals (66%). Transmission is thought to be fecal-oral since sewage workers are more prevalent carriers. Common symptoms are weight loss, arthralgia, diarrhea, and abdominal pain. Arthralgia is the sentinel symptom preceding others by ∼6 years. Less common include skin hyperpigmentation, endocarditis, and CNS symptoms (severe disease). Three diagnostic tests exist: PAS-staining, PCR of the 16S ribosomal RNA of T. whipplei, and immunohistochemistry (IHC) via rabbit anti-T. whippleiantibodies. Diagnostic criteria include: 1) small intestine biopsies positive on PAS stain for bacillus material in the lamina or 2 positive tests from other origins. Initial testing is done with EGD and duodenal biopsies submitted for PAS staining and PCR testing ± IHC. If extraintestinal symptoms, PAS staining and PCR testing ± IHC on tissue or fluid samples. CSF should be tested by PCR in all cases. After diagnosis, treatment starts with a 2-week course of IV of antibiotics (4 weeks if CNS infection or endocarditis) followed by one year of Bactrim. Relapse occurs in 17-35%, years later.

Tropheryma whipplei Infection (Whipple Disease) in the USA.

Whipple disease (WD) is an infection caused by the bacterium Tropheryma whipplei (TW). Few cases have been reported in the USA. To report on the demographics, clinical manifestations, diagnostic findings, treatment, and outcomes of TW infection. Cases of TW infection diagnosed from 1995 to 2010 were identified in three US referral centers and from 1995 to 2015 in one. Definite classic WD was defined by positive periodic acid-Schiff (PAS) staining and probable WD by specific positive TW polymerase chain reaction (PCR) of intestinal specimens. Localized infections were defined by a positive TW PCR result from samples of other tissues/body fluids. Among the 33 cases of TW infections, 27 (82%) were male. Median age at diagnosis was 53years (range 11-75). Diagnosis was supported by a positive TW PCR in 29 (88%) and/or a positive PAS in 16 (48%) patients. Classic WD was the most frequent presentation (n = 18, 55%), with 14 definite and 4 probable cases. Localized infections (n = 15, 45%) affected the central nervous system (n = 7), joints (n = 4), heart (n = 2), eye (n = 1), and skeletal muscle (n = 1). Blood PCR was negative in 9 of 17 (53%) cases at diagnosis. Ceftriaxone intravenously followed by trimethoprim and sulfamethoxazole orally was the most common regimen (n = 23, 70%). Antibiotic therapy resulted in clinical response in 24 (73%). TW infection can present as intestinal or localized disease. Negative small bowel PAS and PCR do not exclude the diagnosis of TW infection, and blood PCR is insensitive for active infection.

Pulmonary interstitial glycogenosis associated with a spectrum of neonatal pulmonary disorders

Primary or isolated pulmonary interstitial glycogenosis (PIG) is a rare disease presenting as tachypnea and hypoxemia during the perinatal period. A diffuse interstitial infiltrate with focal hyperinflation is visible on chest imaging. The biopsy findings include diffuse expansion of the interstitium by spindle-shaped cells with pale cytoplasm that, on electron microscopy (EM), are poorly differentiated mesenchymal cells containing abundant monoparticulate glycogen. This glycogenosis appears to be a transient abnormality, usually with a favorable prognosis. Recently, cases of PIG, some associated with other pulmonary or systemic abnormalities, have been described. The clinical significance and potential role of PIG changes remain unknown. We report 28 cases of PIG associated with a spectrum of pediatric pulmonary and cardiovascular disorders, including arterial hypertensive changes with and without abnormal alveolar development (n=9), congenital heart disease (CHD; n=4), hyperplasia of pulmonary neuroendocrine cells resembling neuroendocrine hyperplasia of infancy (NEHI, n=5), congenital pulmonary airway malformation (n=5), congenital lobar emphysema (n=4), and Noonan syndrome (n=1). In all cases, PIG was confirmed by positive periodic acid-Schiff (PAS) staining, immunopositivity for vimentin, and EM. Although some patients improved with age, 7 died of respiratory failure or complications of CHD, suggesting that PIG may be clinically significant when associated with other severe disorders. The association of PIG with a spectrum of mostly congenital lung disorders supports its origin as a developmental abnormality of interstitial fibroblast differentiation rather than a nonspecific reactive process.

Granular Cell Tumor of Rectum: A Very Rare Entity

Granular cell tumor (GCT), also called as Abrikossoff tumor is a rare neoplastic process which is mostly benign. Granular cell tumors can develop in any part of the body, though oral cavity and subcutaneous tissue are the most common sites. Only about 10% of the tumors develop in the gastrointestinal tract with esophagus being the most common site and rectum being the rarest. We here present one such rare case of rectal granular cell tumor. A 61-year-old man with medical comorbidities of coronary artery disease, congestive heart failure, hypertension, dyslipidemia presented to the GI clinic for screening colonoscopy. The patient denied any gastrointestinal related complaints. Screening colonoscopy revealed good bowel preparation with a score of 8 on Boston Bowel Preparation Scale, a 1cm serrated adenomatous polyp in the transverse colon that was removed with hot snare polypectomy and a firm 4mm nodule in the rectum that was removed with biopsy forceps (Figure - 1). Biopsy of the rectal nodule revealed a granular cell tumor with positive periodic acid-Schiff (PAS) staining (Figure - 2). Immunohistochemical staining for S100 protein was positive as well (Figure - 3). A subsequent rectal endoscopic ultrasound (EUS) confirmed complete removal of the tumor. Granular cell tumors (GCTs) are mostly benign and very rarely malignant with tumors >4cm in size having metastatic potential. Patients with GCTs are mostly asymptomatic and GCTs are usually incidental findings. However, large tumors are known to present with hematochezia and/or pain. GCTs are more common in women than in men. Patients with GCTs are usually between the 4th and the 6th decades of life. The tumor can present as a painless, non-ulcerated nodule or a yellowish-gray sessile polyp with firm consistency. Endoscopic ultrasound can be used to evaluate the tumor invasion into the wall of the gastrointestinal tract. Diagnosis is made with histology. Fanburg-Smith et al. proposed six histological criteria to differentiate benign tumors from malignant ones. The six criteria include- cellular necrosis, pleomorphism, increased nuclear-cytoplasmic ratio, enlarged nucleoli, increased mitotic activity and cell elongation. A tumor is considered malignant if 3 or more criteria are fulfilled. Benign tumor can be removed with endoscopic resection as was the case with our patient. Surgical resection should be reserved for large and multifocal tumors.Figure 1Figure 2Figure 3

Maladie de Whipple et infections à Tropheryma whipplei. Quand l’interniste doit y penser ? Comment les traiter ?

Tropheryma whipplei culture and genome sequencing have, thanks to new tools, rationalized both diagnosis and treatment of Whipple's disease. Whipple's disease involves mainly Caucasian male, approximately 50-years-old, suffering from arthralgia, weight loss and diarrhea. A worsening of clinical manifestations after immunosuppressive therapy is frequently observed while antibiotics prescribed for another infection improves the clinical status. Clinical manifestations may more rarely suggest lymphoma or sarcoidosis. Positive T. whipplei performed on both saliva and stool samples are strongly suggestive of Whipple's disease. The diagnosis is confirmed by positive periodic acid Schiff staining or immunohistochemistry performed on small-bowel biopsies. Localized chronic infections are defined by the absence of histological duodenal involvement. Endocarditis mainly occurs in 60-years-old men with arthralgia, cardiac failure or embolic events. Encephalitis causes mainly cognitive and psychiatric involvement, and sometimes dementia, ataxia and weight gain. Uveitis and arthritis evolve chronically, and are frequently resistant to immunosuppressive treatment. PCR and culture (particularly for cerebrospinal fluid) performed on various tissues and fluids allow the localized infections diagnosis. In classic Whipple's disease, the treatment with doxycycline (200mg/day) and hydroxychloroquine (600mg/day) for a length of 12months followed by a lifetime treatment by doxycycline (200mg/day) should be recommended to avoid reinfection. In localized infections, a treatment with doxycycline (200mg/day) and hydroxychloroquine (600mg/day) is proposed for 12 to 18months followed by a lifetime follow-up.

Recognition of riboflavin and the capsular polysaccharide of Haemophilus influenzae type b by antibodies generated to the haptenic epitope D-ribitol

D-Ribitol, a five-carbon sugar alcohol, is an important metabolite in the pentose phosphate pathway; it is an integral part of riboflavin (vitamin B2) and cell wall polysaccharides in most Gram-positive and a few Gram-negative bacteria. Antibodies specific to D-ribitol were generated in New Zealand white rabbits by using reductively aminated D-ribose-BSA conjugate as the immunogen. MALDI-TOF and amino group analyses of ribitol-BSA conjugate following 120 h reaction showed ~27-30 mol of ribitol conjugated per mole BSA. The presence of sugar alcohol in the conjugates was also confirmed by an increase in molecular mass and a positive periodic acid-Schiff staining in SDS-PAGE. Caprylic acid precipitation of rabbit serum followed by hapten affinity chromatography on ribitol-KLH-Sepharose CL-6B resulted in pure ribitol-specific antibodies (~45-50 μg/mL). The affinity constant of ribitol antibodies was found to be 2.9 × 10(7) M(-1) by non-competitive ELISA. Ribitol antibodies showed 100% specificity towards ribitol, ~800% cross-reactivity towards riboflavin, 10-15% cross-reactivity with sorbitol, xylitol and mannitol, and 5-7% cross-reactivity with L-arabinitol and meso-erythritol. The specificity of antibody to ribitol was further confirmed by its low cross-reactivity (0.4%) with lumichrome. Antibodies to D-ribitol recognized the purified capsular polysaccharide of Haemophilus influenzae type b, which could be specifically inhibited by ribitol. In conclusion, antibodies specific to D-ribitol have been generated and characterized, which have potential applications in the detection of free riboflavin and ribitol in biological samples, as well as identification of cell-surface macromolecules containing ribitol.

Misdiagnosis of Alpha-1 Antitrypsin Phenotype in an Infant with CMV Infection and Liver Failure

A 4-month-old female with a history of neonatal cholestasis was initially evaluated with jaundice, ascites, coagulopathy, and worsening aminotransferase levels. At 5 weeks of age, her parents had noticed ‘‘yellowing’’ of her eyes and skin accompanied by a slightly more pale appearance of her regularly yellow-colored stools. Initially, she was noted to have conjugated hyperbilirubinemia, with total bilirubin 6.5 and conjugated 4.5, aspartate aminotransferase (AST) 163, alanine aminotransferase (ALT) 103, and elevated alkaline phosphatase. Liver ultrasound was normal. A percutaneous liver biopsy, obtained due to her continued unexplained cholestasis, was reported as showing possible large duct obstruction and bile duct proliferation, suggestive of extrahepatic biliary atresia. A subsequent endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiogram showed no anatomic abnormalities in the intrahepatic and extra hepatic biliary system, inconsistent with the diagnosis of biliary atresia (Fig. 1). During her hospital admission, a serum alpha-1 antitrypsin (A1AT) concentration was 34 mg/dl (normal 100–250 mg/dl), with A1AT MZ phenotype reported. Her conjugated hyperbilirubinemia improved slightly, and her liver numbers stabilized. She was discharged home with a close follow-up outpatient appointment in the pediatric gastroenterology clinic. The remainder of her evaluation for neonatal cholestasis, including an echocardiogram and ophthalmology examination for Alagille’s syndrome, was negative. Infectious studies were negative as well. Hepatosplenomegaly or ascites were not detected by physical examination, with reassuring and age-appropriate biometrics noted. Ongoing outpatient medical care revealed elevated cytomegalovirus (CMV) IgM titers (0.97). Due to persistent cholestasis, a repeat A1AT serum concentration was low level at 32 mg/dl, although a repeat ELISA was now reported as the Z phenotype consistent with the ZZ genotype. Due to conflicting tests of mutant serum A1AT proteins, her liver biopsy was re-analyzed with intrahepatic positive periodic acid–schiff stain (PAS) granules now reported, consistent with the diagnosis of A1AT deficiency (Fig. 2). Concomitantly, CMV viremia was confirmed with an elevated CMV polymerase chain reaction (PCR) assay of 12,800. In the clinic, she exhibited significantly increased abdominal distension and marked ascites. Her bilirubin (total 8.8 mg/dl; conjugated 5.3 mg/dl) and aminotransferases (AST/ALT 500/309 units/l) were elevated. Additionally, a significant coagulopathy was noted with an international normalized ratio (INR) of 2.2 and low fibrinogen of 88. Hyponatremia (119 mg/dl) and metabolic acidosis were also present. She did not have any changes in her mental status, and her venous ammonia concentration was mildly elevated to 68 lmol/l. She was admitted to Lucile Packard Children’s Hospital at Stanford for correction of her electrolyte abnormalities and coagulopathy. She was treated with ganciclovir for CMV viremia. During her first 48 h in the hospital, despite the use of IV phytonadione, her hepatic synthetic liver function deteriorated rapidly, with daily doses of fresh-frozen plasma required to treat her coagulopathy. Due to her P. Arias (&) J. Kerner M. Christofferson W. Berquist K. T. Park Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children’s Hospital, Stanford University Medical Center, 750 Welch Road, Suite 116, Palo Alto, CA 94304, USA e-mail: parias@stanford.edu

Whipple's in the valleys: a case of Whipple's with thrombocytopenia and endocarditis

IntroductionThis case report details the second described case of Whipple's disease-related thrombocytopenia in the medical literature. Whipple's disease is a rare multisystem infection caused by the actinomycete Tropheryma whipplei, first...

Rare occurrence of Whipple Disease in a young female patient with a fatal outcome

Abstract Whipple Disease is a rare chronic multi-systemic disease caused by the ubiquitous environmental Gram-positive bacterium Tropheryma whipplei . It can be fatal if untreated. Here we describe the fatal outcome in a 27-year-old Caucasian female patient with a three-month history of persistent fever, anemia, weight loss and diarrhea. The final resolution of the diagnostic process was only reached after the patient’s death thanks to autopsy. The case depicted is a classic Whipple Disease histologically characterized by digestive involvement based on positive periodic acid-Schiff (PAS) staining and immunohistochemical analysis for T. whipplei and systemic involvement (pericarditis, brain lipid storage, renal fat embolism). The case reported here is of interest because the patient was a woman and also young, characteristics which do not meet the classical epidemiological features of this elusive and troubling disease.

Glycogenic acanthosis of the bilateral buccal mucosa: Report of a case

We report a very rare case of glycogenic acanthosis of the bilateral buccal mucosa. The patient was a 46-year-old man who presented with white lesions of the bilateral buccal mucosa. These white lesions showed plaque-like thickening of the mucosa, whiter than the surrounding mucosa. Biopsy specimen revealed enlarged squamous cells with abundant clear cytoplasm and positive periodic acid-Schiff staining. Histopathological diagnosis was glycogenic acanthosis. Endoscopy examination also revealed multiple areas of glycogenic acanthosis of the esophagus.

Tropheryma whipplei aortic valve endocarditis, cured without surgical treatment

BackgroundCulture-negative endocarditis due to Tropheryma whipplei is a rare disease. Mostly the diagnosis is made by histologic examination of resected heart valve tissue.Case presentationIn this case report, we described a patient with a classical Whipple’s disease. Transesophageal echocardiography (TEE) showed a vegetation on noncoronary cusp of the aortic valve. Whipple’s disease was confirmed by positive Tropheryma whipplei polymerase chain reaction (PCR) in EDTA blood and a duodenal biopsy with positive periodic acid-Schiff stain (PAS) macrophages.ConclusionDue to timely diagnosis, our patient was treated with antibiotics without valve replacement.