Cytomegalovirus duodenitis associated with life-threatening duodenal hemorrhage in an immunocompetent patient: A case report.

INTRODUCTION: Cytomegalovirus (CMV) is known to be opportunistic in immunocompromised patients. However, there have been emerging cases of severe CMV infections found in immunocompetent patients. Gastrointestinal (GI) CMV disease is the most common manifestation affecting immunocompetent patients, with duodenal involvement being exceedingly rare. Presented is a case of an immunocompetent patient with life-threatening bleeding caused by CMV duodenitis, requiring surgical intervention. PRESENTATION OF CASE: A 60-year-old male with history of disseminated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and aortic valve infective endocarditis, presented with life-threatening upper GI hemorrhage. Endoscopy revealed ulcerations, with associated generalized mucosal bleeding in the duodenum. After repeated endoscopic therapies and failed interventional-radiology arterial embolization, the patient required a duodenectomy and associated total pancreatectomy, to control the duodenal hemorrhage. Pathologic review of the surgical specimen demonstrated CMV duodenitis. Systemic ganciclovir was utilized postoperatively. DISCUSSION: GI CMV infections should be on the differential diagnosis of immunocompetent patients presenting with uncontrollable GI bleeding, especially in critically ill patients due to transiently suppressed immunity. Endoscopic and histopathological examinations are often required for diagnosis. Ganciclovir is first-line treatment. Surgical intervention may be considered if there is recurrent bleeding and CMV duodenitis is suspected because of high potential for bleeding-associated mortality. CONCLUSION: Presented is a rare case of life-threatening GI hemorrhage caused by CMV duodenitis in an immunocompetent patient. The patient failed endoscopic and interventional-radiology treatment options, and ultimately stabilized after surgical intervention.

KIT gene mutations and patterns of protein expression in mucosal and acral melanoma.

BACKGROUND: Recently characterized KIT (CD117) gene mutations have revealed new pathways involved in melanoma pathogenesis. In particular, certain subtypes harbor mutations similar to those observed in gastrointestinal stromal tumors, which are sensitive to treatment with tyrosine kinase inhibitors. OBJECTIVE: The purpose of this study was to characterize KIT gene mutations and patterns of protein expression in mucosal and acral melanoma. METHODS: Formalin-fixed, paraffin-embedded tissues were retrieved from our archives. Histologic assessment included routine hematoxylin-eosin stains and immunohistochemical staining for KIT. Genomic DNA was used for polymerase chain reaction-based amplification of exons 11 and 13. RESULTS: We identified 59 acral and mucosal melanoma cases, of which 78% showed variable levels of KIT expression. Sequencing of exons 11 and 13 was completed on all cases, and 4 (6.8%) mutant cases were isolated. CONCLUSION: We successfully optimized conditions for the detection of KIT mutations and showed that 8.6% of mucosal and 4.2% of acral melanoma cases at our institution harbor KIT mutations; all mutant cases showed strong, diffuse KIT protein expression. Our case series represents the first Canadian study to characterize KIT gene mutations and patterns of protein expression in acral and mucosal melanoma.

The role of CYP26 enzymes in defining appropriate retinoic acid exposure during embryogenesis.

Retinoic acid (RA) is a pleiotropic derivative of vitamin A, or retinol, which is responsible for all of the bioactivity associated with this vitamin. The teratogenic influences of vitamin A deficiency and excess RA in rodents were first observed more than 50 years ago. Efforts over the last 15-20 years have refined these observations by defining the molecular mechanisms that control RA availability and signaling during murine embryonic development. This review will discuss our current understanding of the role of RA in teratogenesis, with specific emphasis on the essential function of the RA catabolic CYP26 enzymes in preventing teratogenic consequences caused by uncontrolled distribution of RA. Particular focus will be paid to the RA-sensitive tissues of the caudal and cranial regions, the limb, and the testis, and how genetic mutation of factors controlling RA distribution have revealed important roles for RA during embryogenesis.

Complementary expression patterns of retinoid acid-synthesizing and -metabolizing enzymes in pre-natal mouse inner ear structures.

Retinoic acid (RA) plays a pivotal role in patterning and differentiation of the embryonic inner ear. Despite its documented effects during embryonic development, the cellular sites that synthesize or metabolize RA in the inner ear have yet to be determined. Here we describe the distribution of three synthesizing enzymes, retinaldehyde dehydrogenases 1, 2 and 3 (RALDH1, RALDH2 and RALDH3) and two catabolizing enzymes (CYP26A1 and CYP26B1) in the mouse inner ear at embryonic day 18.5 when active cell differentiation is underway. Two detection methods, radioactive and non-radioactive in situ hybridization, were employed to elucidate the tissue distribution and cellular localization of these enzymes, respectively. All of the five enzymes examined, with the exception of CYP26A1, were expressed in both vestibular and cochlear end organs. While expression of the three RALDHs was observed in various cell types, CYP26B1 expression was found only in supporting cells of the vestibular and cochlear end organs. In the cochlea, expression domains of RALDH1-3 and CYP26B1 were complementary to one another. These results reveal specific tissue- and cellular expression patterns of RA synthesizing and catabolizing enzymes in the pre-natal inner ear, and suggest that a precise control of RA concentrations in various cell types of the inner ear is achieved by the balance between RALDHs and CYP26B1 activities.

Developing with lethal RA levels: genetic ablation of Rarg can restore the viability of mice lacking Cyp26a1.

We have previously reported that the retinoic acid (RA) catabolizing enzyme CYP26A1 plays an important role in protecting tail bud tissues from inappropriate exposure to RA generated in the adjacent trunk tissues by RALDH2, and that Cyp26a1-null animals exhibit spina bifida and caudal agenesis. We now show that, in the absence of Cyp26a1, retinoic acid receptor gamma (RARgamma) mediates ectopic RA-signaling in the tail bud. We also show that activated RARgamma results in downregulation of Wnt3a and Fgf8, which integrate highly conserved signaling pathways known for their role in specifying caudal morphogenesis. Ablation of the gene for RARgamma (Rarg) rescues Cyp26a1-null mutant animals from caudal regression and embryonic lethality, thus demonstrating that CYP26A1 suppresses the RA-mediated downregulation of WNT3A and FGF8 signaling pathways by eliminating ectopic RA in gastrulating tail bud mesoderm.

Genetic evidence that oxidative derivatives of retinoic acid are not involved in retinoid signaling during mouse development.

Retinoic acid, the active derivative of vitamin A (retinol), is a hormonal signaling molecule that acts in developing and adult tissues. The Cyp26a1 (cytochrome p450, 26) protein metabolizes retinoic acid into more polar hydroxylated and oxidized derivatives. Whether some of these derivatives are biologically active metabolites has been debated. Cyp26a1(-/-) mouse fetuses have lethal morphogenetic phenotypes mimicking those generated by excess retinoic acid administration, indicating that human CYP26A1 may be essential in controlling retinoic acid levels during development. This hypothesis suggests that the Cyp26a1(-/-) phenotype could be rescued under conditions in which embryonic retinoic acid levels are decreased. We show that Cyp26a1(-/-) mice are phenotypically rescued by heterozygous disruption of Aldh1a2 (also known as Raldh2), which encodes a retinaldehyde dehydrogenase responsible for the synthesis of retinoic acid during early embryonic development. Aldh1a2 haploinsufficiency prevents the appearance of spina bifida and rescues the development of posterior structures (sacral/caudal vertebrae, hindgut, urogenital tract), while partly preventing cervical vertebral transformations and hindbrain pattern alterations in Cyp26a1(-/-) mice. Thus, some of these double-mutant mice can reach adulthood. This study is the first report of a mutation acting as a dominant suppressor of a lethal morphogenetic mutation in mammals. We provide genetic evidence that ALDH1A2 and CYP26A1 activities concurrently establish local embryonic retinoic acid levels that must be finely tuned to allow posterior organ development and to prevent spina bifida.

Differential expression of the retinoic acid-metabolizing enzymes CYP26A1 and CYP26B1 during murine organogenesis.

We recently cloned the murine homologue of Cyp26B1, a novel retinoic acid (RA)-metabolizing enzyme and showed that its gene expression pattern is unique from that of Cyp26A1 during early embryogenesis. Here, we complete this comparative expression analysis from embryonic day (E) 12 to postnatal stages. Cyp26B1 expression was found in developing tendons and precartilaginous elements and in perichondrium by E14.5, while Cyp26A1 expression was restricted to extremities of rib and vertebral cartilage. Cyp26A1 and Cyp26B1 were expressed, in the distal epithelium and mesenchyme of the limbs and genital tubercle, respectively. High Cyp26B1 expression was found in craniofacial areas undergoing morphogenetic growth, whereas Cyp26A1 message was restricted to the mouth and dental epithelium. Cyp26A1 alone was expressed in the developing neural retina, while both genes were co-expressed in the retinal pigment epithelium. Cyp26B1 was specifically expressed in the developing hindbrain (pons, cerebellum) and forebrain (striatum, hippocampus), with forebrain expression persisting postnatally. In addition, Cyp26B1 was expressed at specific levels of the differentiating upper and lower thoracic spinal cord, adjacent to the cervical and lumbar regions that express the RA-synthesizing enzyme RALDH-2. In viscera, Cyp26B1 transcripts were detected in the developing lung, kidney, spleen, thymus and testis, whereas Cyp26A1 transcripts were found in the diaphragm and outer stomach mesenchyme. Cyp26B1 was also specifically expressed in dermis surrounding the developing hair follicles. Regulated RA metabolism may therefore be required in many developing systems.