Disseminated Histoplasmosis Causing Temporally and Spatially Discrete Gastrointestinal Perforations in an HIV-Negative Patient.

Histoplasma capsulatum is a dimorphic fungi endemic to the Ohio and Mississippi River valleys. Immunocompetent persons who become infected are generally asymptomatic or present with mild symptoms. Symptomatic disease is seen primarily in immunocompromised patients with pulmonary manifestations being the most common presentation. We present a case of a young HIV-negative male who required 4 exploratory laparotomies over the course of 4 months during 2 hospitalizations due to discrete perforations of the ileum and jejunum caused by biopsy-proven gastrointestinal histoplasmosis despite maximal medical therapy as well as a gastric perforation.

Jejunal stricture due to mucormycosis.

Mucormycosis is generally considered to be an acute, rapidly progressing, opportunistic fungal infection. Chronic manifestations are extremely rare. Mucormycosis affecting the jejunum is very rare and few cases have been reported. We report a case of mucormycosis causing jejunal stricture in an infant aged six months.

Equine duodenitis-proximal jejunitis: A review.

Duodenitis-proximal jejunitis (DPJ) is an inflammatory process of the proximal part of the small intestine and occurs sporadically in horses. It is clinically characterized by an acute onset of ileus and nasogastric reflux leading to systemic signs of toxemia. This review discusses the definition of the disease, potential etiologic agents, clinical findings, epidemiological features, histopathologic and clinico-pathological findings, and medical management of this condition. Salmonella spp., mycotoxins, Clostridium perfringens, and Clostridium difficile have all been associated with the disease but there is limited supporting evidence for any agent other than C. difficile. Particular attention, however, was given to etiological investigations and the data available to support the proposed etiological agents. The potential role of C. difficile as the etiological agent of DPJ, possible pathogenesis, and recent efforts to support this hypothesis are highlighted, but it is recognized that there could be more than one agent that causes the disease.

L'entérite proximale chez le cheval: revision. L'entérite proximale est un processus inflammatoire de la portion proximale du petit intestin qui se présente sporadiquement chez le cheval. Cliniquement, elle est caractérisée par un début soudain d'iléus et de reflux nasogastrique menant à des signes systémiques d'endotoxémie. Cet article discute de la définition de la maladie, des agents étiologiques potentiels, des signes cliniques, des caractéristiques épidémiologiques, des trouvailles histopathologique et clinique et du traitement médical de cette condition. Salmonella spp., les mycotoxines, Clostridium perfringens et Clostridium difficile ont tous été associés avec la maladie, mais les preuves sont limitées pour tout autre agent que C. difficile. Une attention particulière a été mise sur l'étude étiologique et sur les données disponibles pour supporter les agents étiologiques proposés. Le rôle potentiel de C. difficile comme étant l'agent étiologique de l'entérite proximale, la possible pathogénèse et les efforts récents pour supporter cette hypothèse sont soulignés, mais il est reconnu qu'il pourrait y avoir plus d'un agent causatif de la maladie.(Traduit par Dr Marie-Soleil Dubois).

Duodenitis-Proximal Jejunitis in Horses After Experimental Administration of Clostridium difficile Toxins.

BACKGROUND: Duodenitis-proximal jejunitis (DPJ) is an acute sporadic gastrointestinal disorder of horses of unknown cause. HYPOTHESIS/OBJECTIVES: We hypothesize that Clostridium difficile toxins are involved in the pathogenesis of DPJ in horses. The objective of this study was to determine whether experimentally delivered C. difficile toxins cause clinical signs and histologic lesions similar to those of naturally occurring DPJ. ANIMALS: Six healthy mature mixed breed horses. METHODS: Experimental study: animal model of animal disease. Fasted horses were administered crude C. difficile toxins via gastroscopy and monitored for up to 48 hour. Blood was collected for complete blood cell count, biochemistry profile, and plasma fibrinogen assay, and abdominal fluid was collected for cytologic analysis and total solids before and after toxin administration. Physical examination and abdominal ultrasonography were performed throughout the study period. Tissues were collected from the gastrointestinal tract and processed for routine histologic analysis, and lesions were scored. RESULTS: Clinical signs were observed in 2 of 6 horses that are typical although not specific for horses with naturally occurring DPJ. Histopathologic lesions were observed in 6 of 6 horses and were similar to those reported in horses with naturally occurring DPJ. Two horses were severely affected. CONCLUSIONS AND CLINICAL IMPORTANCE: Duodenitis-proximal jejunitis is likely a syndrome with multiple causes that result in the same clinical and pathologic findings, and our data suggest that the toxins of C. difficile represent one cause of this syndrome. Toxin dose and variation in individual animal susceptibility might affect the clinical signs and lesions after administration of C. difficile toxins.

New insights into environmental enteric dysfunction.

Environmental enteric dysfunction (EED) has been recognised as an important contributing factor to physical and cognitive stunting, poor response to oral vaccines, limited resilience to acute infections and ultimately global childhood mortality. The aetiology of EED remains poorly defined but the epidemiology suggests a multifactorial combination of prenatal and early-life undernutrition and repeated infectious and/or toxic environmental insults due to unsanitary and unhygienic environments. Previous attempts at medical interventions to ameliorate EED have been unsatisfying. However, a new generation of imaging and '-omics' technologies hold promise for developing a new understanding of the pathophysiology of EED. A series of trials designed to decrease EED and stunting are taking novel approaches, including improvements in sanitation, hygiene and nutritional interventions. Although many challenges remain in defeating EED, the global child health community must redouble their efforts to reduce EED in order to make substantive improvements in morbidity and mortality worldwide.

Jejunal hematoma in cattle: a retrospective case analysis.

Sixteen years of adult cattle submissions to the California Animal Health and Food Safety Laboratory System were examined and data captured from cases with anaerobic cultures of intestinal content. Analysis was performed to determine if there were statistical differences between case submission types (nonbloody intestinal content [129 cases], bloody intestinal content [134 cases], and jejunal hematoma [JH; 51 cases]) for the presence of Clostridium perfringens (314 cases), C. perfringens toxinotypes (35 cases), and C. perfringens toxins (51 cases) in the content. Across submission types, significant differences were found in the isolation of C. perfringens between different specimen types (live cow, dead cow, or tissue from a field necropsy) with field samples being the most likely to have C. perfringens detected and live animals the least likely (P = 0.001). In cases of JH, detection of C. perfringens by enzyme-linked immunosorbent assay was more likely when a live or dead animal was submitted (P = 0.023) or when a live animal was submitted (P = 0.019) compared with submission of field necropsy tissues. These differences were not observed when cultures were performed to detect C. perfringens in cases of JH. There were no statistical differences between submission types with regard to any other variables evaluated. Detailed histologic examination of 21 cases of JH suggested disturbance of normal vascular or lymphatic function as the underlying problem in this entity.

Utility of an immune cell function assay to differentiate rejection from infectious enteritis in pediatric intestinal transplant recipients.

The Cylex Immune Cell Function Assay measures cell-mediated immunity based on ATP production by stimulated CD4 + cells. We hypothesized that this test would discriminate acute cellular rejection (ACR) from infectious enteritis (IE) in pediatric intestinal transplant (ITx) recipients with allograft dysfunction. We retrospectively analyzed 224 Cylex assays drawn in 47 children who received 53 ITx. Samples were classified as stable, ACR, or IE based on clinical status. ATP values were analyzed using Kruskal-Wallis and t-tests. Overall, there was a statistically significant difference in ATP values based on clinical status (p = 0.03); however, overlap was observed between groups. The median ATP value during ACR was significantly greater than during stable periods (p = 0.02). No difference was seen in IE vs. stability (p = 0.8). The difference in median ATP value in ACR vs. IE approached significance (p = 0.1). Relative to previous levels, ACR episodes were associated with a median ATP increase of 101 ng/mL and IE episodes with a decrease of 3 ng/mL (p = 0.3). These data indicate that the Cylex assay has limited utility in differentiating ACR from IE, largely due to interpatient variability. Following longitudinal intrapatient trends may be an adjunctive tool in discriminating IE from ACR and guiding immunosuppression adjustments in select patients.

The rabbit as an infection model for equine proliferative enteropathy.

The objective of this study was to demonstrate the susceptibility of rabbits to Lawsonia intracellularis obtained from a case of clinical equine proliferative enteropathy (EPE). This is a preliminary step toward developing a rabbit infection model for studying pathogenesis and therapy of EPE in horses. Nine does were equally assigned to 3 groups. Animals in 2 groups (Group 1 and Group 2) were orally inoculated with different doses of cell-cultured L. intracellularis. Controls (Group 3) were sham-inoculated. Feces and blood were collected before the rabbits were infected and at 7, 14, and 21 days post-infection (DPI). Serum immunoglobulin G (IgG) titers were measured using an immunoperoxidase monolayer assay (IPMA) and fecal samples were analyzed with quantitative polymerase chain reaction (qPCR). A doe from each group was euthanized at 7, 14, and 21 DPI for collection and evaluation of intestinal samples. Tissues were stained by routine hematoxylin and eosin (H&E) method and immunohistochemistry (IHC) with L. intracellularis-specific mouse monoclonal antibody. At 14 DPI, serologic responses were detected in both infected groups, which maintained high titers through to 21 DPI. Lawsonia intracellularis DNA was detected in the feces of Group 2 on 7 DPI and in both infected groups on 14 DPI. Gross lesions were apparent in Group 1 and Group 2 on 14 DPI. Immunohistochemistry confirmed L. intracellularis antigen within cells of rabbits in Group 1 and Group 2 on 7, 14, and 21 DPI. No lesions, serologic response, shedding, or IHC labeling were found in Group 3 rabbits. This study describes an EPE rabbit model that simulates natural infection, as typical lesions, immune response, and fecal shedding were present.

Cette étude visait à démontrer la susceptibilité des lapins à Lawsonia intracellularis obtenu d'un cas clinique d'entéropathie proliférative équine (EPE). Ceci est une étape préliminaire dans le développement d'un modèle d'infection chez le lapin pour étudier la pathogénie et le traitement de l'EPE chez les chevaux. Neuf lapines ont été assignées également à 3 groupes. Les animaux dans deux groupes (Groupe 1 et Groupe 2) ont été inoculés oralement avec différentes doses de L. intracellularis cultivés sur cellules. Les témoins (Groupe 3) étaient faussement inoculés. Des fèces et du sang ont été prélevés avant que les lapins soient infectés et aux jours 7, 14 et 21 post-infection (DPI). Les titres sériques d'immunoglobulines G (IgG) ont été mesurés par une épreuve d'immunoperoxydase en monocouche (IPMA) et les échantillons de fèces ont été analysés par réaction quantitative d'amplification en chaîne par la polymérase (qPCR). Une lapine de chaque groupe a été euthanasiée 7, 14 et 21 DPI pour prélèvement et évaluation d'échantillons intestinaux. Les tissus étaient colorés à l'aide d'hématoxyline et éosine (H&E) et en immunohistochime (IHC) avec un anticorps monoclonal de souris spécifique à L. intracellularis. Au jour 14 post-infection, une réponse sérologique a été détectée chez les animaux des deux groupes infectés, et des titres élevés ont été maintenus jusqu'à 21 DPI. De l'ADN de L. intracellularis fut détecté dans les fèces du Groupe 2 au jour 7 PI et dans les 2 groupes infectés au jour 14 PI. Des lésions macroscopiques étaient apparentes dans le Groupe 1 et le Groupe 2 au jour 14 PI. L'immunohistochime a confirmé la présence d'antigène de L. intracellularis à l'intérieur des cellules de lapins dans les Groupes 1 et 2 aux jours 7, 14 et 21 PI. Aucune lésion, réponse sérologique, excrétion, ou marquage en IHC n'ont été trouvés chez les lapins du Groupe 3. La présente étude décrit un modèle lapin d'EPE qui imite l'infection naturelle, étant donné la présence de lésions typiques, de réponse immunitaire et d'excrétion fécale.(Traduit par Docteur Serge Messier).

Exogenous carbon monoxide attenuates inflammatory responses in the small intestine of septic mice.

AIM: To determine whether the carbon monoxide (CO)-releasing molecules (CORM)-liberated CO suppress inflammatory responses in the small intestine of septic mice. METHODS: The C57BL/6 mice (male, n = 36; weight 20 ± 2 g) were assigned to four groups in three respective experiments. Sepsis in mice was induced by cecal ligation and puncture (CLP) (24 h). Tricarbonyldichlororuthenium (II) dimer (CORM-2) (8 mg/kg, i.v.) was administrated immediately after induction of CLP. The levels of inflammatory cytokines [interleukin-1ß (IL-1ß) and tumor necrosis factor-α (TNF-α)] in tissue homogenates were measured with enzyme-linked immunosorbent assay. The levels of malondialdehyde (MDA) in the tissues were determined. The levels of nitric oxide (NO) in tissue homogenate were measured and the expression levels of intercellular adhesion molecule 1 (ICAM-1) and inducible nitric oxide synthase (iNOS) in the small intestine were also assessed. NO and IL-8 levels in the supernatants were determined after the human adenocarcinoma cell line Caco-2 was stimulated by lipopolysaccharide (LPS) (10 g/mL) for 4 h in vitro. RESULTS: At 24 h after CLP, histological analysis showed that the ileum and jejunum from CLP mice induced severe edema and sloughing of the villous tips, as well as infiltration of inflammatory cells into the mucosa. Semi-quantitative analysis of histological samples of ileum and jejunum showed that granulocyte infiltration in the septic mice was significantly increased compared to that in the sham group. Administration of CORM-2 significantly decreased granulocyte infiltration. At 24 h after CLP, the tissue MDA levels in the mid-ileum and mid-jejunum significantly increased compared to the sham animals (103.68 ± 23.88 nmol/mL vs 39.66 ± 8.23 nmol/mL, 89.66 ± 9.98 nmol/mL vs 32.32 ± 7.43 nmol/mL, P < 0.01). In vitro administration of CORM-2, tissue MDA levels were significantly decreased (50.65 ± 11.46 nmol/mL, 59.32 ± 6.62 nmol/mL, P < 0.05). Meanwhile, the tissue IL-1ß and TNF-α levels in the mid-ileum significantly increased compared to the sham animals (6.66 ± 1.09 pg/mL vs 1.67 ± 0.45 pg/mL, 19.34 ± 3.99 pg/mL vs 3.98 ± 0.87 pg/mL, P < 0.01). In vitro administration of CORM-2, tissue IL-1ß and TNF-α levels were significantly decreased (3.87 ± 1.08 pg/mL, 10.45 ± 2.48 pg/mL, P < 0.05). The levels of NO in mid-ileum and mid-jejunum tissue homogenate were also decreased (14.69 ± 2.45 nmol/mL vs 24.36 ± 2.97 nmol/mL, 18.47 ± 2.47 nmol/mL vs 27.33 ± 3.87 nmol/mL, P < 0.05). The expression of iNOS and ICAM-1 in the mid-ileum of septic mice at 24 h after CLP induction significantly increased compared to the sham animals. In vitro administration of CORM-2, expression of iNOS and ICAM-1 were significantly decreased. In parallel, the levels of NO and IL-8 in the supernatants of Caco-2 stimulated by LPS was markedly decreased in CORM-2-treated Caco-2 cells (2.22 ± 0.12 nmol/mL vs 6.25 ± 1.69 nmol/mL, 24.97 ± 3.01 pg/mL vs 49.45 ± 5.11 pg/mL, P < 0.05). CONCLUSION: CORM-released CO attenuates the inflammatory cytokine production (IL-1ß and TNF-α), and suppress the oxidative stress in the small intestine during sepsis by interfering with protein expression of ICAM-1 and iNOS.

Laparoscopic resection of omental actinomycosis forming fistula with transverse colon and jejunum: a case report and review of literature.

Omental actinomycosis without any predisposing factors is rare, and there are few reports on it invading the contiguous bowels to form fistulae. We describe the case of a 55-year-old male patient with omental actinomycosis that presented as an inflammatory tumor that formed fistulae with the transverse colon and upper jejunum. On admission, he had complaints of a palpable, tender mass on the left mid-abdomen without gastrointestinal symptoms. After 7 days of conservative treatments (NPO and intravenous antibiotics), the size of the mass was decreased and tenderness was more improved. Laparoscopic resected omental mass revealed fistulae to the colon and jejunum. There was no evidence of Crohn disease. After 1-week use of antibiotics owing to the concern about actinomycosis, the mass was decreased and it was more amenable to dissect laparoscopically.

Mouldy feed, mycotoxins and Shiga toxin - producing Escherichia coli colonization associated with Jejunal Hemorrhage Syndrome in beef cattle.

BACKGROUND: Both O157 and non-O157 Shiga toxin - producing Escherichia coli (STECs) cause serious human disease outbreaks through the consumption of contaminated foods. Cattle are considered the main reservoir but it is unclear how STECs affect mature animals. Neonatal calves are the susceptible age class for STEC infections causing severe enteritis. In an earlier study, we determined that mycotoxins and STECs were part of the disease complex for dairy cattle with Jejunal Hemorrhage Syndrome (JHS). For STECs to play a role in the development of JHS, we hypothesized that STEC colonization should also be evident in beef cattle with JHS. Aggressive medical and surgical therapies are effective for JHS, but rely on early recognition of clinical signs for optimal outcomes suggesting that novel approaches must be developed for managing this disease. The main objective of this study was to confirm that mouldy feeds, mycotoxins and STEC colonization were associated with the development of JHS in beef cattle. RESULTS: Beef cattle developed JHS after consuming feed containing several types of mycotoxigenic fungi including Fusarium poae, F. verticillioides, F. sporotrichioides, Penicillium roqueforti and Aspergillus fumigatus. Mixtures of STECs colonized the mucosa in the hemorrhaged tissues of the cattle and no other pathogen was identified. The STECs expressed Stx1 and Stx2, but more significantly, Stxs were also present in the blood collected from the lumen of the hemorrhaged jejunum. Feed extracts containing mycotoxins were toxic to enterocytes and 0.1% of a prebiotic, Celmanax Trademark, removed the cytotoxicity in vitro. The inclusion of a prebiotic in the care program for symptomatic beef calves was associated with 69% recovery. CONCLUSIONS: The current study confirmed that STECs and mycotoxins are part of the disease complex for JHS in beef cattle. Mycotoxigenic fungi are only relevant in that they produce the mycotoxins deposited in the feed. A prebiotic, Celmanax Trademark, acted as a mycotoxin binder in vitro and interfered with the progression of disease.

Neonatal lingual and gastrointestinal mucormycosis in a case of low anorectal malformation-a rare presentation.

We report a 1.7 kg male infant with a low anorectal malformation treated at an outside facility and referred to us on postoperative day 11. At presentation, his upper abdomen was distended, and he had perianal mucoid discharge. The tongue had a blackish discoloration. An erect abdominal radiograph showed a few fluid-filled bowel loops in the upper abdomen with a gasless lower abdomen and pelvis, suggestive of upper small bowel obstruction. There were no specific radiological features of necrotizing enterocolitis. He underwent laparotomy and bowel resection for perforated jejunum. Histopathology of the tissue specimen was suggestive of mucormycosis. Postoperatively, he received intravenous amphotericin B (liposomal) and was started on liquid enteral nutrition after 2 weeks. However, the anterior two thirds of his tongue gradually sloughed off. He is awaiting reconstruction of the tongue. The purpose of this report is to emphasize that physicians should have a high index of suspicion for oral and gastrointestinal tract mucormycosis in neonates with metabolic disturbances who present with a discolored oral mucosa and an abdominal mass with intestinal obstruction. Early diagnosis and an aggressive approach of combined medical and surgical treatment may improve the outcome of patients with this potentially lethal invasive disease.

Multifocal granulomatous jejunitis associated with an argyrophilic gram-positive segmented filamentous bacterium in a Holstein cow.

Multifocal, raised, ulcerated firm nodules accompanied by an intussuscepted area were detected in the jejunum of an 8-year-old Holstein cow. The cut surfaces of the nodules were yellow-white. Microscopically, the lamina propria was expanded by an intense infiltration of epithelioid cells, multinucleate giant cells, macrophages, lymphocytes and neutrophils. Numerous bacteria were found within the granulomatous lesions. These were argyrophilic, gram-positive, periodic acid-Schiff-positive, segmented, rarely branched, elongate filamentous bacteria (2-28 µm in length, 0.2-0.35 µm in diameter). Ultrastructurally, a cell wall with an electron-transparent zone was detected. The present pathogen was clearly different from the argyrophilic, gram-negative, non-segmented, filamentous bacterium previously reported in a Holstein cow with jejunal granuloma. Comparative 16S rDNA gene sequencing analysis revealed that the organism was an unpublished species (GenBank accession number AB539875). This is the first report of bovine jejunal granuloma associated with an argyrophilic gram-positive segmented filamentous bacterium.

[Actinomycosis associated with perforation of jejunum in patient after cholecystectomy--a case report]. / Perforacja jelita cienkiego w przebiegu promienicy u chorego po cholecystektomii--opis przypadku.

Actinomyces is endogenic infection with rare abdominal manifestations. Diagnosis is very difficult and not always taken into account in differential diagnosis. Disease is recurrent and treatment is mostly pharmacologic and takes a long time. The aim of the paper was to present a case of patient operated on acute cholecystitis with intraabdominal actinomycosis. The 66 years old patient 28 days after cholecystectomy appeared to have jejunal perforation in the course of actinomycosis. Patient regarded two interventions due to intraabdominal abscesses. Since last discharge, a year ago, we do not observe recurrence. Intraabdominal actinomycosis is often recurrent and should be considered in patients with purulent complications after surgical procedures.

Jejunal granuloma associated with an argyrophilic gram-negative non-segmented filamentous bacterium in a Holstein cow.

A length of intussuscepted jejunum, associated with a granuloma, was removed surgically from a 35-month-old Holstein cow. Microscopically, the granuloma consisted of multifocal aggregates of macrophages, epithelioid cells and occasional multinucleated giant cells within the lamina propria. Numerous argyrophilic, gram-negative, periodic acid Schiff-negative, non-segmented, long filamentous bacteria (2-17 microm in length, 0.1-0.3 microm in diameter) were detected in the cytoplasm of the epithelioid cells. The bacteria were localized to the granulomatous lesions. Comparative 16S rDNA gene sequencing analysis revealed that the organism was an unpublished species (accession number AB472332). This argyrophilic non-segmented filamentous bacterium appears to have been the cause of multifocal granulomatous jejunitis accompanied by intestinal intussusception in this cow.

[Jejunal mucormycosis in a patient with Hodgkin's lymphoma]. / Mucormicosis yeyunal en paciente con linfoma de Hodgkin.

We report a case of intestinal mucormycosis in a 46-year-old male diagnosed with classical Hodgkin's disease, IV-B stage. During the first phase of chemotherapy he had a massive digestive bleeding event secondary to a jejunal ulcer, and zygomicosis mucor-type was diagnosed by endoscopic biopsy. The patient was treated with antifungal drugs and surgical resection of the intestine involved. At surgery a double covered perforation of the jejunum was seen. Pathological examination confirmed the previous diagnosis. After one year of follow-up the patient is doing well, and his lymphoma is on remission. To our best knowledge this is the second case of intestinal mucormycosis in a patient with Hodgkin's lymphoma reported in the medical literature.

Mucormicosis yeyunal en paciente con linfoma de Hodgkin / No disponible

Comunicamos un caso de mucormicosis intestinal en un hombrede 46 años de edad, diagnosticado de enfermedad de Hodgkinclásica, estadio IV-B. Durante la primera fase de la quimioterapia,sufrió una hemorragia digestiva masiva secundaria a unaúlcera yeyunal por zigomicosis tipo mucor, diagnosticada porbiopsia endoscópica. El paciente fue tratado con antifúngicos yresección quirúrgica del intestino afectado. En la cirugía, se aprecióuna doble perforación yeyunal cubierta. El estudio anatomopatológicode la pieza confirmó el diagnóstico previo. Tras un añode seguimiento, el paciente está recuperado y su linfoma deHodgkin en remisión completa. Tras una extensa revisión de la literatura,según nuestro conocimiento, este es el segundo caso publicadoen la literatura de mucormicosis intestinal en un pacientecon linfoma de Hodgkin

We report a case of intestinal mucormycosis in a 46-year-oldmale diagnosed with classical Hodgkin’s disease, IV-B stage. Duringthe first phase of chemotherapy he had a massive digestivebleeding event secondary to a jejunal ulcer, and zygomicosis mucor-type was diagnosed by endoscopic biopsy. The patient wastreated with antifungal drugs and surgical resection of the intestineinvolved. At surgery a double covered perforation of the jejunumwas seen. Pathological examination confirmed the previous diagnosis.After one year of follow-up the patient is doing well, andhis lymphoma is on remission. To our best knowledge this is thesecond case of intestinal mucormycosis in a patient with Hodgkin’slymphoma reported in the medical literature