case 3 - cpo-media.netcpo-media.net/ecp/2019/congress-presentations/1267/-unlicensed-s… · no....
TRANSCRIPT
![Page 1: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/1.jpg)
Iva Brčić
Diagnostic and Research Institute of Pathology, Medical University Graz
Joint Session Digestive Diseases Pathology / Infectious Diseases Pathology
September 10th, 2019, Nice, ECP
Infectious lesions of the GI tract: new entities and pitfalls
Case 3
![Page 2: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/2.jpg)
Case
• 67-year old woman• recurrent symptoms of gastroesophageal reflux
Treatment:• hiatoplasty with gastropexy• PPI and physical rest
https://eref.thieme.de/cockpits/clRadio0001/0/coRadOGW00190/4-13722
![Page 3: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/3.jpg)
Case
after 3 months:
• readmitted for a routine gastroscopy
• symptoms of gastroesophageal reflux
![Page 4: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/4.jpg)
Gastroscopy:
• gastroesophageal junction: two erosions
• oxyntic and duodenal mucosa: normal• inversion vision showed a recurrence of the hiatus hernia
Bx
• gastric antrum: signs of biliary reflux and small hematin-covered erosions
![Page 5: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/5.jpg)
Case – after 3 months
1
2
3
4
5
![Page 6: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/6.jpg)
![Page 7: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/7.jpg)
![Page 8: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/8.jpg)
![Page 9: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/9.jpg)
![Page 10: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/10.jpg)
![Page 11: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/11.jpg)
PAS
![Page 12: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/12.jpg)
3 months post OP
Barium swallow study: atonic stomach with delayed gastric emptying
DIAGNOSIS???
![Page 13: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/13.jpg)
Diagnosis
Clostridium (Sarcina) ventriculi associated erosive esophagitis
Reactive gastropathy
16S ribosomal RNA gene amplicon sequencing (Bx esophagus):
➢ 31% of reads to Clostridium ventriculi (best match to C. ventriculi, GenBank acc. no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like Streptococcus, Lactobacillus, etc., typically found in the upper GI tract
Treatment: PPI and domperidone
![Page 14: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/14.jpg)
15 months post OP
Control gastroscopy: • stomach with food rests • small erosion at the ora serrata
Bx
![Page 15: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/15.jpg)
Microorganisms only in oxyntic mucosa biopsies without erosions or ulcerations
![Page 16: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/16.jpg)
16S ribosomal RNA gene amplicon sequencing (Bx esophagus):
➢ Clostridium ventriculi not found
Treatment: PPI and domperidone
![Page 17: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/17.jpg)
• first described by Goodsir (1842) in the stomach
• the appearance of a wool-pack or of a soft bundle bound with cord
➢ Sarcina ventriculi (Latin- package, bundle)
• Suringar (1866) – cubical form
C. (S.) ventriculi
Goodsir J. Edinb Med Surg J. 1842.Suringar WFR. Arch Néeri Sci Exact Natur 1866 Canale-Parola E. Bacteriol Rev 1970
![Page 18: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/18.jpg)
Sarcina
Holt SC, Canale-Parola E. J Bacteriol 1967
S. ventriculi
S. maxima
![Page 19: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/19.jpg)
• a gram-positive, obligate anaerobe, acidophilic coccoid bacterium
• recently reclassified to the genus Clostridium (Clostridium ventriculi)
• uses carbohydrate fermentation as its main energy source
C. (S.) ventriculi
Lawson PA, Rainey FA. Int J Syst Evol Microbiol. 2016Smit J. J Pathol Bacteriol. 1933
![Page 20: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/20.jpg)
• predominantly women• 3 - 73 years
• esophageal strictures, delayed gastric emptying, gastroparesis or gastric outlet obstruction
Clinical symptoms: • nausea• vomiting• weight loss• Anorexia• abdominal pain
C. (S.) ventriculi
Al Rasheed MRH, Senseng CG. Arch Pathol Lab Med. 2016
![Page 21: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/21.jpg)
• Endoscopy: often food residues with gastritis, gastric ulcers and esophagitis
C. (S.) ventriculi
![Page 22: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/22.jpg)
• Histology: H&E, PAS
• characteristic morphologic presentation as tetrads or packets of eight measuring 10μm in diameter
• result of cell division in at least two planes
• usually found on the mucosal surface, embedded in an ulcer bed or floating in luminal debris
C. (S.) ventriculi
PAS
![Page 23: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/23.jpg)
• CAVE! ➢ can be quite sparse and therefore not visible
on all re-cuts
C. (S.) ventriculi
![Page 24: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/24.jpg)
• severe and even fatal cases• in the veterinary literature• in humans (emphysematous gastritis)
➢ need for antibiotic treatment ?
C. (S.) ventriculi
Al Rasheed et al. Arch Pathol Lab Med. 2016 Marshall TS. Vet Clin North Am Food Anim Pract. 2009 Laass et al. Gastrointest Endosc. 2010Gaspar BL. APMIS. 2016
![Page 25: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/25.jpg)
Differential diagnosis
➢ Micrococcus spp.➢ Candida albicans
• Diagnostic confirmation to rule out the morphological differential diagnosis by 16S rRNA sequence analysis
![Page 26: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/26.jpg)
Micrococcus spp.
➢ M. Luteus – most common➢ M. Lylae➢ M. Antarcticus➢ M. Endophyticus➢ M. Flavus➢ M. Terreus➢ M. Yunnanensis
![Page 27: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/27.jpg)
Micrococcus spp.
• gram-positive, oxidase-positive, strictly aerobic coccus
• genus Micrococcaceae
• 1 to 1.8 mm
• usually occur in irregular
clusters, tetrads, and pairs
https://microbewiki.kenyon.edu/index.php/Micrococcus
![Page 28: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/28.jpg)
Micrococcus spp.
• harmless saprophytes
• can be opportunistic pathogens for the immunocompromised
patients
EPIDEMIOLOGY:
➢Worldwide, ubiquitous
➢Humans - exposed skin of face, arms, hands, and legs
➢Animals – skin
➢ In soil, marine and fresh water, plants, fomites, dust, and air
![Page 29: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/29.jpg)
Candida albicans
Candidiasis, Thrush, MoniliasisFungi - oval, budding yeast, pseudohyphae, occasional true hyphae
Genus: Saccharomycetaceae
part of normal human flora• endogenous spread • by contact with excretions of mouth, skin, and faeces• from mother to infant during childbirth
https://www.immunology.org/public-information/bitesized-immunology/pathogens-and-disease/candida-albicans
![Page 30: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/30.jpg)
Candida albicans
Kondo et al. N Engl J Med. 2017
Risk factors➢ Immunosuppression➢ Chemotherapy➢ Steroids➢ Major abdominal surgery
Clinics: • dry mouth• difficulty swallowing (pain, discomfort)• nausea• vomiting• weight loss• chest pain
![Page 31: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/31.jpg)
Candida albicans
Gastroscopy: ulcers or pseudomembranes/whitish plaques in esophagus, gastrointestinal tract
Kondo et al. N Engl J Med. 2017
![Page 32: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/32.jpg)
![Page 33: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/33.jpg)
![Page 34: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/34.jpg)
![Page 35: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/35.jpg)
![Page 36: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/36.jpg)
Summary
• Sarcina ventriculi – Clostridium ventriculi• esophageal strictures, delayed gastric emptying, gastroparesis
or gastric outlet obstruction
• H&E- characteristic morphology as tetrads or octets
DDx:
➢Micrococcus spp.➢Candida albicans
CUT DEEPER LEVELS!!!
![Page 37: Case 3 - cpo-media.netcpo-media.net/ECP/2019/Congress-Presentations/1267/-Unlicensed-S… · no. LC101492.1, identities: 253 bp from 253 bp (100%)) in addition to other taxa, like](https://reader036.vdocuments.mx/reader036/viewer/2022062414/5f0757377e708231d41c806d/html5/thumbnails/37.jpg)
THANK YOU FOR YOUR ATTENTION