Steiner Stain Research Articles

Tyzzer disease in 19 preweaned orphaned kittens.

Clostridium piliforme, the agent of Tyzzer disease, has traditionally not been considered a major pathogen of cats. We queried the database of the Pathology Service of the Veterinary Medical Teaching Hospital, University of California-Davis, for kittens <6-mo-old autopsied between 2000-2021 that had colitis, hepatitis, and/or myocarditis; 37 cases met the search criteria. Sections of colon, liver, and heart from these 37 cats were stained with modified Steiner; 19 of 37 (51%) cases had intraepithelial, Steiner-positive rods compatible with C. piliforme in at least one organ, confirming Tyzzer disease. The affected age range was 7-42 d (median: 17.5 d). Eighteen were orphaned kittens. Colitis was the major lesion (18 of 19) followed by random hepatitis (11 of 19). Perianal dermatitis with intraepithelial stacked rods was seen in 2 of 19. Myocarditis was not evident in any of the cases. A PCR assay for C. piliforme on 10 selected cases using formalin-fixed, paraffin-embedded (FFPE) blocks was positive or suspected in colon (5 of 10), liver (5 of 10), and heart (1 of 10). The modified Steiner stain was more sensitive in the detection of bacteria than PCR on FFPE samples. Fifteen kittens had comorbidities. A weakened immune state caused by maternal, environmental, infectious, and/or nutritional causes is speculated to have contributed to disease onset. We found that Tyzzer disease is more common than previously believed in orphaned kittens and should be considered in kittens with colitis and/or hepatitis.

Pseudomonas species may appear strikingly filamentous in tissue sections: an important consideration for surgical pathologists and a reminder of the utility of modified silver impregnation methods.

Although tissue culture is the gold standard for diagnosing infection, histologic examination of surgically resected tissue can be a critical component in the diagnosis of tissue infection. The goal of this brief report is to alert surgical pathologists that Pseudomonas species can appear strikingly filamentous histologically and may somewhat mimic the appearance of filamentous bacteria, such Actinomyces or Nocardia, or thin fungal hyphae. A secondary aim is to raise awareness that Pseudomonas can sometimes only be identified histologically through the use of a modified silver impregnation method (Steiner stain). Five cases of filamentous Pseudomonas were encountered in three different surgical pathology subspecialities (ophthalmic pathology, cardiovascular pathology, and dermatopathology) over a 1-year period. All cases were of formalin-fixed, paraffin-embedded tissue, stained using hematoxylin & eosin (H&E) and multiple histochemical stains. Four cases grew Pseudomonas aeruginosa in culture and, in the fifth case, a nonaeruginosa species was detected using polymerase chain reaction-based methods. The markedly filamentous-appearing Pseudomonas organisms were identified in five different tissue sites: vascular graft, enucleation (whole eye) specimen, scleral biopsy, soft-tissue excision, and skin punch biopsy. In one of the five cases the organisms were seen on H&E, and in only two of the five were the organisms seen on Brown-Hopps stain. In all five cases, the organisms were identified on Steiner stain. It is therefore important to recognize that Pseudomonas can appear markedly filamentous, Pseudomonas or other bacterial infection is suspected, the surgical pathologist would be advised to employ the Steiner stain to most consistently detect the organisms.

S2079 Granulomatous Esophageal Disease Mimicking Esophageal Malignancy

Introduction: We present a case of a young female patient with chronic dysphagia found to have an ulcerative esophageal mass. Pathology surprisingly demonstrated granulomatous inflammation. This case highlights the diagnostic challenges of gastrointestinal granulomatous disease mimicking esophageal malignancy. Case Description/Methods: A 22-year-old female presented with five years of progressive dysphagia to solid foods. Past medical history was significant for papillary thyroid carcinoma status post thyroidectomy two years prior (T1bN0M0) and psoriasis treated with topical corticosteroids. Upper endoscopy revealed a 2 cm ulcerated, partially obstructive mass in the lower third of the esophagus, Figure. Biopsy demonstrated granulomatous inflammation without neoplastic changes. Grocott’s methenamine silver stain (GMS) and Steiner stain showed small irregular structures in the granulomas. Acid-fast bacilli (AFB) stain was negative. A repeat upper endoscopy with endoscopic ultrasound (EUS) revealed an additional hypoechoic lesion in the proximal esophagus. EUS-guided fine needle aspiration of this lesion and repeat biopsy of the ulcerative mass both showed non-necrotizing granulomas without eosinophilia. GMS and AFB stains resulted negative. Colonoscopy with ileal and random biopsies was unremarkable. Interferon-gamma release assay, Treponema pallidum antibody, Legionella urine antigen, H. pylori stool antigen, and Histoplasma urine and serum antigens resulted negative. Computed tomography (CT) scan of the chest showed 1.1 cm and 0.6 cm right lower lobe pulmonary nodules and an enlarged right hilar node at 1.9 x 1.2 cm. The patient is awaiting pulmonary nodule biopsy given high suspicion for sarcoidosis. Discussion: Granulomatous disease of the gastrointestinal tract can be seen in infections, Crohn’s disease, sarcoidosis, malignancy, and immunodeficiency syndromes. The clinical context, morphology of the granuloma, and specialized stains for organisms can support a suspected diagnosis. Necrotizing granulomas are most frequently implicated in M. tuberculosis infection, while non-necrotizing granulomas have a wider differential diagnosis which includes infection, autoimmune disease, toxins, and medications. Sarcoidosis is suspected in our patient given the clinical history, negative diagnostic workup for infections and Crohn’s disease, and CT chest findings. In patients found to have gastrointestinal granulomas, a broad differential should be considered with thorough evaluation to obtain definitive diagnosis.Figure 1.: Lower third of the esophagus showing multiple yellowish plaque lesions.

Positive association between Helicobacter pylori infection and pancreatic cancer: A case-control study.

e16243 Background: Pancreatic adenocarcinoma is a malignancy with a very poor prognosis. The 5-year overall survival is about 9%. Helicobacter pylori ( H. pylori) is a known risk factor for gastric adenocarcinoma and gastric mucosa-associated lymphoid tissue (MALT) lymphoma. Whether H.pylori is a risk factor for pancreatic adenocarcinoma is still unclear. Previous observational retrospective studies trying to see if there is an association between H.pylori and pancreatic adenocarcinoma have used serology as a marker for H.pylori infection, but these have yielded mixed results. We seek to probe the association of H.pylori infection and pancreatic adenocarcinoma in a case-control study using histology for H.pylori bacteria from esophagogastroduodenoscopy (EGD) biopsies. Methods: A database for patients diagnosed with pancreatic adenocarcinoma at the Veterans Affairs Medical Center in Memphis, TN, from 1988 to 2018 was analyzed to obtain suitable cases. Pathology was reviewed to confirm the diagnosis and then the charts were reviewed to determine if the patient had undergone an EGD and if biopsies done obtained were tested for H.pylori. H.pylori positivity was determined using Steiner staining of the biopsy samples. 402 charts were reviewed and 51 cases meeting the above criteria were obtained. Controls were obtained by reviewing charts for all EGDs that were tested for H.pylori. Care was taken to make sure patients did not have any history of pancreatobiliary malignancy. 130 matched controls fit the screening criteria. Univariate and multivariate logistic regression analysis was done to analyze the risk factors. Results: Significantly more subjects in the case group (53%) were found to have H.Pylori infection compared to the control group (18%). Risk factors associated with pancreatic cancer in the literature, including age, race, smoking history, obesity, alcohol consumption, chronic pancreatitis, and diabetes, were analyzed using multivariate logistic regression. The results revealed that pancreatic cancer was significantly associated with a positive family history of pancreatic cancer (OR = 11.2, 95%CI 2.8-44.4, p = 0.001) and H.Pylori infection (OR = 5.5), 95%CI 2.4-12.7,p &lt; 0.001). Conclusions: A positive association was found between H.pylori infection and pancreatic adenocarcinoma.

Contrasting serum biomarker profiles in two Colombian populations with different risks for progression of premalignant gastric lesions during chronic Helicobacter pylori infection

BackgroundColombians in coastal Tumaco have a lower incidence of Helicobacter pylori-associated gastric cancer compared to individuals from Tuquerres in the high Andes. This is despite nearly universal prevalence of H. pylori infection and chronic gastritis. MethodsH. pylori infection was confirmed by Steiner stain and serology using African and European-origin strains. Gastric histology and serum inflammatory biomarkers in dyspeptic Tumaco or Tuquerres patients were evaluated to predict progression of gastric lesions. ResultsH. pylori infection was nearly universal by Steiner stain and serology. IgG response to European-origin H. pylori strains were greater than African-origin. High gastric cancer-risk Tuquerres patients, compared to low-risk Tumaco, had significant odds ratios for lesion progression associated with serum IL-5, trefoil factor 3 (TFF3), and low pepsinogen I/II ratio. Sensitivity and specificity for these parameters was 63.8% and 67.9%, respectively, with correctly classifying patients at 66.7%. Most odds ratios for 26 other biomarkers were significant for the town of residency, indicating an environmental impact on Tumaco patients associated with decreased lesion progression. ConclusionAn IL-5 association with progression of gastric lesions is novel and could be evaluated in addition to TFF3 and pepsinogen I/II ratio as a non-invasive prognostic screen. Results suggest Tumaco patients were exposed to infectious diseases beyond H. pylori such as the documented high incidence of helminthiasis and toxoplasmosis. ImpactResults support a prior recommendation to evaluate TFF3 and pepsinogen I/II together to predict aggressive gastric histology. Our data indicate IL-5 should be further evaluated as prognostic parameter.

Diagnostic immunohistochimique de la spirochétose colique avec l’anticorps anti-tréponème chez les patients consultant pour une diarrhée chronique. Résultats d’une étude prospective menée chez 137 patients

To assess the incidence of colonic spirochetosis, diagnosed by immunohistochemical stain with anti-Treponema pallidum antibody, in a prospective study of colonic biopsies of patients presenting with chronic diarrhea. From March 2017 to March 2018 the colonic biopsies of patients presenting with chronic diarrhea were stained with Hematoxylin Eosin and anti-Treponema pallidum antibody. The positive cases were also stained with Steiner stain. A total of 137 colonic biopsies were assessed and 3 cases were positive for immunohistochemical stain with anti-Treponema pallidum antibody (2% of the patients). One case was easy to diagnose with HE stain but the 2 other cases were not. The bacteria were stained with Steiner stain, but less easily seen than with the immunohistochemical stain. No patient was treated with antibiotics. The colonic spirochetosis can be easily diagnosed by pathologists with immunohistochemical stain with anti-Treponema pallidum antibody. The bacteria are more easily diagnosed with immunohistochemical stain than with HE stain or Steiner stain. However, colonic spirochetosis is rarely diagnosed on colonic biopsies of patients presenting with chronic diarrhea (2% of the patients in our study). Due to the rarity of the entity, and the cost of immunohistochemical stain and the weak benefit for the patient (no patient in our study was treated with antibiotics for colonic spirochetosis) we cannot advise to perform systematic immunohistochemical stain with anti-Treponema pallidum antibody in all the colonic biopsies of patients presenting with chronic diarrhea.

Helicobacter pylori stains and association between H. pylori and inflammation in gastric specimens

Gastric cancer has been strongly associated with presence of the bacterium Helicobacter pylori. To improve techniques in identifying H. pylori so that gastric cancer may be predicted early, this project was formulated to determine whether one particular stain is more effective in displaying H. pylori microscopically. In addition, this study attempted to determine whether the degree of inflammatory elements present in tissue could be used to predict the likelihood of H. pylori presence. Protocols for the staining techniques, Steiner and alcian yellow/toluidine blue (AY/TB), were employed on specimens to semi-quantitate H. pylori presence. Serial sections from the same specimens were stained with hematoxylin and eosin to determine the amount of inflammation. Spearman rho correlation was used to evaluate the association between amount of H. pylori and inflammation in each case. It was determined that AY/TB was more easily performed, more effective in demonstrating H. pylori, and more cost effective than the Steiner stain. Additionally, it was determined that a moderate positive association was indicated between high levels of inflammation and marked presence of H. pylori.

Gastic Mucosal Calcinosis Associated With Gastrointestinal Bleeding

Purpose: Gastric mucosal calcinosis (GMC) is a rare cause of gastrointestinal bleeding, and usually an incidental finding on endoscopy. Histopathology characteristically reveals deposits of irregular, amorphous microcalcifications in the gastric mucosa. GMC is classified as metastatic, dystrophic or idiopathic. Metastatic calcinosis is the most common, occurring in the setting of abnormal calciumphosphate metabolism, and resulting in deposition of calcium salts. We report a case of gastric mucosal calcinosis associated with overt gastrointestinal bleed. Case: A 59 year old Hispanic man presented with 1 week of black stools. Past medical history included end stage renal disease on hemodialysis for 8 years, atrial fibrillation on anticoagulation, diabetes, and coronary artery disease. He denied nausea, vomiting, hematemesis, or abdominal pain. No NSAID use other than daily aspirin was reported. Vital signs on presentation were unremarkable. Physical exam was notable for pale conjunctiva, soft, non-tender abdomen, and melena on rectal exam. Laboratory tests revealed hemoglobin of 5.9 g/dL (baseline 10 g/dL), creatinine 5.87 mg/dL, corrected calcium 9.3 mg/dL, phosphorus 3.4 mg/dL, calcium-phosphate product 31, and INR 2.8. The patient received 2 units of packed red blood cells and 4 units of fresh frozen plasma with appropriate response. EGD showed thickened antral folds (Figure 1), which were further evaluated with endoscopic ultrasound showing hyperechoic foci and shadowing with intact gastric layers (Figure 2). Histopathology of thickened folds showed foveolar hyperplasia and histiocytes in the lamina propria containing calcium deposits. Von Kossa stain confirmed calcium deposition (Figure 3). Steiner stain was negative for Helicobacter pylori. No other source of bleeding was identified on repeat EGD, colonoscopy, and capsule endoscopy. At 4 months follow up, patient has had no further bleeding.Figure 1Figure 2Figure 3Conclusions: The presentation above is suggestive of upper GI bleed secondary to gastric mucosal calcinosis in the setting of end stage renal disease. GMC has been rarely reported as a cause of GI bleeding. This case emphasizes that gastric mucosal calcinosis should be considered as a possible GI bleeding source especially in the clinical setting of chronic kidney disease.

Secondary syphilis and suspected child abuse

A 38-year-old Hispanic woman presented with a widespread papulosquamous eruption with accentuation on the palms and soles (Fig 1, A). Travel history was remarkable for a recent trip to her native country (Dominican Republic). Her 13-year-old son, who accompanied her on the trip, developed a similar rash after their return (Fig 1, B). In addition, the patient noted that her boyfriend, whom she was visiting in the Dominican Republic, had a rash when she arrived. The rapid plasma reagin (RPR) test produced negative findings whereas the skin biopsy specimen from the patient’s foot showed a psoriasiform lichenoid dermatitis teeming with spirochetes highlighted by a Steiner stain. After discussion with the laboratory about the RPR results, serial dilutions proved positive (prozone effect). At follow-up 4 days later, the son was evaluated for his rash. As expected, the patient’s fluorescent treponemal antibody absorption (FTA-ABS) test result was positive, but the son’s test finding was only minimally reactive.

An Unusual Cause of Abdominal Pain

A 14-year-old girl patient presented with intermittent generalized abdominal pain. There was no history of diarrhea, constipation, gastrointestinal bleeding, weight loss, nausea, or vomiting. Routine laboratory tests, imaging studies, and stool studies were unremarkable. Upper and lower endoscopy was grossly normal. Random biopsies of the colon revealed a 2- to 3-μm-thick basophilic band along the surface epithelium of the colon (Fig. 1).FIGURE 1: Hematoxylin and eosin stain.The patient was diagnosed as having intestinal spirochetosis and treated with metronidazole. Intestinal spirochetosis is rare in children with an increased prevalence in immunosuppressed patients and homosexual males (1,2). Spirochetes can cause abdominal pain, chronic diarrhea, hematochezia, and appendicitis in some cases (3,4). The majority of patients are asymptomatic with incidental findings of spirochetes on colonic biopsies (3–5). Histology is characterized by a densely packed brush border of spirochetes Brachyspira aalborgi and Brachyspira pilosicoli attached to the epithelial surface of the colon that can be stained with H and E or silver stains (Fig. 2) (6). Clinical significance remains elusive with treatment of incidental findings debatable. Antimicrobial agents such as metronidazole and macrolides have been associated with resolution of symptoms and eradication of the intestinal spirochetes in adults (1,3). There are no standard therapies in pediatric patients (1). Thus, large population-based studies are required to analyze the demographics, clinical significance, and therapeutic outcomes of intestinal spirochetosis in children.FIGURE 2: Steiner stain.

Bartonella henselae Infections in Solid Organ Transplant Recipients

Bartonella henselae is the causative agent of cat scratch disease and bacillary angiomatosis-peliosis. The spectrum of disease, diagnosis, and management of B. henselae infection in solid organ transplant recipients has not been well characterized. We identified 29 cases of solid organ transplant recipients who had Bartonella infection, 24 by a review of the English-language literature and 5 from our institution. Localized cat scratch disease was found in 8 patients (28%), and disseminated infection was found in 21 patients (72%). The mean time after transplantation to development of Bartonella infection among those with cat scratch disease was 5.6 ± 5.3 years, and among those with disseminated infection was 2.7 ± 2.4 years. Prominent clinical features included cat exposure in 26 patients (90%), fever in 27 patients (93%), lymphadenopathy in 12 patients (41%), and skin lesions in 7 patients (24%). Methods used in establishing the diagnosis of Bartonella infection included culture, polymerase chain reaction (PCR) assay, serologic assays, and histopathologic examination. Culture was positive in 2 of only 4 patients in whom this was performed, and PCR was positive in 12 of 14 patients (86%) in whom this test was performed. Serologic assays were positive in all 23 patients who were tested. Histopathologic examination of tissues in all 8 patients who had cat scratch disease revealed granulomatous inflammation in 4 (50%) and bacillary angiomatosis-peliosis in 2 (25%). Among the 15 patients who had disseminated infection and who had tissue examined, 8 (53%) had only granulomatous inflammation, 4 had only bacillary angiomatosis-peliosis (27%), and 2 had both granulomas and bacillary angiomatosis-peliosis (13%). A positive Warthin-Starry or Steiner stain was noted in 12 of 19 patients (63%) who had 1 of these stains performed. All 8 patients with cat scratch disease and 19 of 21 patients with disseminated bartonellosis were cured with antimicrobial therapy. Two patients, both of whom had endocarditis, died. Among solid organ transplant recipients, infection with B. henselae is uncommon and has diverse disease manifestations including disseminated disease. Persistent fevers or lymphadenopathy in a transplant recipient who has been exposed to cats should prompt clinicians to maintain a high index of suspicion for B. henselae infection. Identifying B. henselae as the causative organism often requires multiple diagnostic studies. Once the diagnosis is established, most solid organ transplant recipients respond appropriately to antimicrobial treatment.

Eosinophils and mast cells in chronic gastritis: possible implications in carcinogenesis

Eosinophils and mast cells participate in the immune response against Helicobacter pylori, but their involvement in the gastric precancerous process is unclear. This study aimed to estimate eosinophil and mast cell density in antral mucosa in subjects from 2 Colombian populations with contrasting gastric cancer risks. Gastric mucosa biopsies were collected from 117 adult males (72 from a high-risk area and 45 from a low-risk area). A histopathology score was used to quantify severity of the lesions. Quantitation of eosinophils in hematoxylin-eosin-stained sections and mast cells in immunostained sections for CD117/c-Kit was performed. Helicobacter pylori infection and genotyping were assessed in Steiner stain and polymerase chain reaction, respectively. Logistic regression models and semiparametric cubic smoothing splines were used for analysis of the results. Eosinophil density was significantly higher in subjects from the low-risk area as compared with subjects from the high-risk area. In both populations, eosinophil density increased with the histopathology score in the progression of lesions from normal morphology to multifocal atrophic gastritis. Intestinal metaplasia and dysplasia specimens showed further increase in eosinophil density in the high-risk area but an abrupt decrease in the low-risk area. Mast cell density increased in parallel to the histopathology score in both populations. Our results suggest that eosinophils play a dual role in chronic gastritis. In the low-risk area, elevated eosinophil density represents a T helper 2-biased response that may down-regulate the effects of proinflammatory cytokines preventing cancer development. In contrast, in the high-risk area, eosinophils might promote a T helper 1-type response leading to progression of precancerous lesions.

Association ofHelicobacterwith Cholangiohepatitis in Cats

Infection withHelicobacterspp. is increasingly linked with hepatobiliary inflammation and neoplasia in people and in a variety of animals. We sought to determine ifHelicobacterspecies infection is associated with Cholangiohepatitis in cats. Deoxyribonucleic acid was extracted from tissue blocks from cats with Cholangiohepatitis (32), noninflammatory liver disease (13), and cats with normal liver histology (4). Deoxyribonucleic acid was polymerase chain reaction‐amplified with 2 sets ofHelicobactergenus‐specific primers, gel purified, and sequenced. Polymerase chain reaction‐positive hepatic tissue was further examined with Steiner's stain, immunocytochemistry forHelicobacterspecies, and eubacterial fluorescent in situ hybridization. Gastric tissues of cats with knownHelicobacterinfection status served as controls for deoxyribonucleic acid extraction and sequence comparison.Helicobacterspecies were detected in 2/32 cats with Cholangiohepatitis, and 1/17 controls. Sequences had 100% identity withHelicobacterspecies liver,Helicobacter pylori, andHelicobacter fenelliaelcinaediiin a cat with suppurative cholangitis,Helicobacterspecies liver,Helicobacter pylori, andHelicobacter nemistrineaein a cat with mild lymphocytic portal hepatitis, andHelicobacter billsin a cat with portosystemic vascular anomaly. In contrast, sequences from gastric biopsies showed highest homology (99–100%) to“Helicobacter heilmannii,” Helicobacter bizzozeronii, Helicobacter felis, andHelicobacter salomonis.Fluorescent in situ hybridization revealed a semicurved bacterium, withHelicobacter‐like morphology, in an intrahepatic bile duct of the cat with suppurative cholangitis. This study has identifiedHelicobacterdeoxyribonucleic acid in 2/32 cats with Cholangiohepatitis and 1/13 cats with noninflammatory liver disease. Deoxyribonucleic acid sequences of hepaticHelicobacterspecies were distinct from those found in the stomach and are broadly consistent with those identified in cat intestine and bile, and hepatobiliary disease in people and rodents.

Association of Helicobacter with Cholangiohepatitis in Cats

Infection with Helicobacter spp. is increasingly linked with hepatobiliary inflammation and neoplasia in people and in a variety of animals. We sought to determine if Helicobacter species infection is associated with cholangiohepatitis in cats. Deoxyribonucleic acid was extracted from tissue blocks from cats with cholangiohepatitis (32), noninflammatory liver disease (13), and cats with normal liver histology (4). Deoxyribonucleic acid was polymerase chain reaction-amplified with 2 sets of Helicobacter genus-specific primers, gel purified, and sequenced. Polymerase chain reaction-positive hepatic tissue was further examined with Steiner's stain, immunocytochemistry for Helicobacter species, and eubacterial fluorescent in situ hybridization. Gastric tissues of cats with known Helicobacter infection status served as controls for deoxyribonucleic acid extraction and sequence comparison. Helicobacter species were detected in 2/32 cats with cholangiohepatitis, and 1/17 controls. Sequences had 100% identity with Helicobacter species liver, Helicobacter pylori, and Helicobacter fenelliae/cinaedii in a cat with suppurative cholangitis, Helicobacter species liver, Helicobacter pylori, and Helicobacter nemistrineae in a cat with mild lymphocytic portal hepatitis, and Helicobacter bilis in a cat with portosystemic vascular anomaly. In contrast, sequences from gastric biopsies showed highest homology (99-100%) to "Helicobacter heilmannii," Helicobacter bizzozeronii, Helicobacter felis, and Helicobacter salomonis. Fluorescent in situ hybridization revealed a semicurved bacterium, with Helicobacter-like morphology, in an intrahepatic bile duct of the cat with suppurative cholangitis. This study has identified Helicobacter deoxyribonucleic acid in 2/32 cats with cholangiohepatitis and 1/13 cats with noninflammatory liver disease. Deoxyribonucleic acid sequences of hepatic Helicobacter species were distinct from those found in the stomach and are broadly consistent with those identified in cat intestine and bile, and hepatobiliary disease in people and rodents.

Histochemical and Immunohistochemical Evidence of a Bacterium Associated with Lesions of Epizootic Bovine Abortion

Epizootic bovine abortion (EBA), a tick-transmitted disease of pregnant cattle grazing foothill pastures, is a major cause of reproductive failure in California and adjacent states. Affected fetuses develop a chronic disease, resulting in late-term abortion or premature calving. Despite investigations spanning 50 years, to the authors' knowledge, the etiologic agent of EBA has not yet been isolated from affected fetuses or the tick vector. The diagnosis of EBA is based on gross and microscopic lesions. Recently, documentation that the etiologic agent is susceptible to antibiotics and identification of a unique 16S deltaproteobacterial rDNA gene sequence in 90% of thymus tissues from aborted fetuses have supported the role of a bacterial infection as the cause of EBA. To determine whether bacteria could be detected in the tissues, histochemical staining and immunohistochemical procedures were used on formalin-fixed, paraffin-embedded tissues. Use of a modified Steiner silver stain revealed small numbers of intracytoplasmic bacterial rods in 37 of 42 thymic samples from EBA-affected fetuses. Improved detection was achieved by use of immunohistochemical staining with serum from EBA-affected fetuses that resulted in detection of numerous bacterial rods in the cytoplasm of histiocytic cells in the thymus from all 42 EBA-affected fetuses. Immunohistochemical examination of additional tissues from 21 field and experimental EBA cases revealed positively stained intracytoplasmic bacterial rods in many organs with inflammatory lesions. Use of the modified Steiner stain and immunohistochemical staining of tissues from negative-control fetuses failed to reveal organisms. To the authors' knowledge, this is the first report to document morphologic evidence of a bacterium associated with the lesions of EBA.

Colorectal Spirochetosis in a Child with Rectal Bleeding: Case Report and Literature Review

Colorectal Spirochetosis in a Child with Rectal Bleeding: Case Report and Literature Review

Secondary Syphilis Presenting as Cutaneous T‐Cell Lymphoma in an HIV‐Positive Patient

We present the case of an HIV‐positive 38‐year‐old Caucasian male with a history of fevers, chills, and disseminated nonpruritic erythematous papules that began on his abdomen. An initial skin biopsy revealed a lymphohistiocytic infiltrate at the dermoepidermal junction, exocytosis of atypical lymphocytes, and minimal spongiosis. Immunohistochemistry showed increased CD8‐positive cells but only scattered CD30‐positive cells. PCR analysis demonstrated T‐cell receptor gamma gene rearrangement. RPR, blood and tissue cultures were all negative. The patient was thought to have a cytotoxic cutaneous T‐cell lymphoma. Over time, the lesions progressed to the palms and soles and the patient remained febrile. Repeat biopsy demonstrated a lichenoid interface dermatitis with a superficial and deep perivascular, interstitial, and periadnexal lymphohistiocytic infiltrate and the formation of epithelioid granulomas throughout the dermis. The epidermis showed blurring of the dermoepidermal junction, spongiosis, and exocytosis of lymphocytes and neutrophils. Few spirochetes were demonstrated by Steiner stain. Repeat RPR and FTA‐Abs serologies were positive. The patient was diagnosed with late secondary syphilis and was successfully treated with benzathine penicillin. This case demonstrates that atypical lymphoid infiltrates can simulate mycosis fungoides in an HIV‐positive patient with secondary syphilis and also reiterates that syphilis is a great mimicker of other entities.

A 48-Year-Old HIV-Positive Man with Chronic Intermittent Diarrhea

Diagnosis: Intestinal spirochetosis. Results of histopathologic studies were pathognomonic for intestinal spirochetosis, a disorder that was first described in 1967 [1]. There are no distinct symptoms associated with intestinal spirochetosis other than diarrhea. The rate of colonization in humans is variable, but men who have sex with men and HIV-infected individuals appear to be at higher risk of being colonized [2, 3]. Endoscopic and gross examinations of the intestine reveal no distinctive findings. Histopathologic studies are characterized by a fuzzy, bluecolored, band-like fringe along the colonic brush border visible by hematoxylin-eosin staining [2, 4, 5]. Spirochetes are well stained using silver stains, such as Warthin-Starry [3] or Steiner stains, and are seen attached along the surface of the colonic epithelium (figures 1 and 2). The most commonly identified species are Brachyspira aalborgi and Serpulina pilosicoli [2, 3, 5]. PCR assays have been described for some species of intestinal spirochetes but are not clinically available and have not been validated for diagnostic purposes [6]. Although controversy exists regarding the clinical significance of this colonization [7], numerous case reports have described spirochetes in the intestines of patients with diarrhea and the elimination of spirochetes, with clinical improvement, after receipt of treatment with various antimicrobial agents, such as metronidazole [2–5]. The patient in this report was treated with oral metronidazole (500 mg t.i.d. for 10 days) and had clinical improvement, as manifested by decreased frequency of diarrhea and loose stools, although there was not complete resolution. Two weeks after completion of antibiotic therapy, colonoscopy was repeated, and no gross abnormalities were noted. The previously noted rectosigmoid mucosal erythema had resolved. Examination of colonic mucosa biopsy specimens revealed almost complete disappearance of spirochetes that had previously lined the mucosal border, with only a few organisms visualized by Steiner staining. The patient continues to be observed, and, to date, the improvement in symptoms has been maintained for 3 months.

Inlet patch: prevalence, histologic type, and association with esophagitis, Barrett esophagus, and antritis.

Inlet patch is a congenital anomaly of the cervical esophagus consisting of gastric mucosa. Case reports have documented the histologic type and its associated complications. To report the prevalence and histologic types of inlet patch as well as its association with Barrett esophagus and Helicobacter pylori-associated gastritis. We reviewed 1821 consecutive pathology reports from endoscopies of the upper gastrointestinal tract between 1995 and 2002 and identified 20 patients with inlet patch. The patients' ages ranged from 16 to 75 years (mean, 55 years). We examined biopsies from these patients of the cervical esophagus, distal esophagus, and antrum that had been stained with hematoxylin-eosin and the Steiner stain. Biopsies from the cervical esophagus composed of nonoxyntic gastric mucosa were also stained for gastrin-producing cells. In our patient population, inlet patch occurred in 1.1% of all patients in whom an inlet patch had been searched for endoscopically and a biopsy performed. In the inlet patch, oxyntic mucosa was the most common histologic type (11/20), followed by cardiac mucosa (5/20). Four specimens of the inlet patch contained only foveolar epithelium and were therefore considered too superficial to be classified. Twelve of 20 biopsies of the inlet patch were inflamed, and 1 of them was associated with H pylori. Pancreatic acinar tissue was noted in 2 patients; no intestinal metaplasia was found. In the distal esophagus, 4 patients with inlet patch had distal esophagitis, 4 had Barrett esophagus, 5 had oxyntic mucosa, 3 had pancreatic acinar tissue (1 coexisting with oxyntic mucosa), and 5 presented with only unremarkable esophageal squamous mucosa. Antral gastritis was seen in 2 patients, 1 of them with H pylori. The same patient also had H pylori in the inlet patch. Inlet patch occurred in about 1% of our study population. Oxyntic mucosa constituted the most common histologic type; inflammation was common. The H pylori infection of the inlet patch correlated with that of the antrum. None of the inlet patch biopsies showed intestinal metaplasia. Pancreatic acinar tissue occurred with similar frequency in the inlet patch and distal esophagus. Esophagitis was noted in 25% of the patients with inlet patch, and Barrett esophagus was noted in 20%.

Intestinal spirochetosis: clinicopathological features with review of the literature.

OBJECTIVE: The purpose of this study is to evaluate the clinical presentation of patients with intestinal spirochetosis, as it is has not been well described in the literature. METHODS: We studied 15 patients with colonic biopsies that showed spirochetosis. The study group consisted of 11 males and 4 females, 10 of the males were heterosexual and one was homosexual. None of these patients were clinically immunocompromized. A colonoscopy was performed for evaluation of different symptoms. The histological diagnosis of spirochetosis was made on H&E examination and confirmed by Giemsa and/or Steiner stain. There was no evidence of associated active or any specific colitis in any of the cases. The control group consisted of 30 patients, 16 males and 14 females that were matched for age and clinical indications for obtaining a colonic biopsy. RESULTS: Colonic mucosa with prominent brush border-like surface colonized with large amounts of spirochetes was noted in all 15 cases in the study group and in none of 30 cases in the control group. The clinical presentation in patients with spirochetosis was compared to the control group. Of the spirochetosis patients 86% presented with some form of clinical symptoms compared with 13% of controls. These symptoms included chronic watery diarrhoea in 40% spirochetosis patients vs 5% in controls; a change in bowel habit was present in 33% of spirochetosis patients vs 3.3% in controls. The endoscopic appearance in spirochetosis patients was reported as normal in six patients, 'polyoid' in seven patients, erythematous in one patient and 'lesion' in one patient. CONCLUSION: These findings suggest that colonic spirochetosis affects a heterogenous group of patients, the majority of whom presented with gastrointestinal symptoms. The variable clinical findings may be related to the infecting organism and the condition may not be harmless in all patients.