Blood tests and histological correlates in children with eosinophilic oesophagitis.

AIM: To determine the relationship between blood tests and oesophageal histology in Eosinophilic oesophagitis (EoE). METHODS: All children diagnosed with EoE at one hospital from 2000 to 2009 were considered for inclusion in this study. Three blood test results were analysed, blood eosinophil count, serum total immunoglobulin E (IgE) and radioallergosorbent tests (RAST) to common food allergens. Oesophageal histology was prospectively re-reviewed, and mean eosinophil counts were enumerated. Blood test results were correlated with oesophageal eosinophil counts using Spearman's rank test. RESULTS: Forty children (70% boys) were included in this study, median age at diagnosis 6.5 years (range 0-15). At the time of diagnosis, 78% of children had a raised blood eosinophil count, 90% had a raised serum total IgE and 83% had one or more positive RAST tests. The mean oesophageal eosinophil count was significantly correlated with both blood eosinophil count (p=0.008) and serum total IgE level (p=0.008). CONCLUSION: This study shows that blood tests are often abnormal in children with EoE at the time of diagnosis. Our data demonstrate an association between histological abnormalities and blood test results in children with EoE.

An atypical cutaneous presentation of vasculitis with features of Churg-Strauss syndrome, associated with anti-neutrophil cytoplasmic antibodies and anti-glomerular basement membrane antibodies.

We report the case of a 59-year-old woman who presented with a persistent papular and nodular cutaneous eruption and new-onset asthma, with normal renal function but persistent haematuria and proteinuria. Investigations revealed eosinophilia, both antineutrophil cytoplasmic antibodies and antiglomerular basement membrane antibodies on serological testing (double-positive vasculitis), and a focal necrotizing glomerulonephritis on renal biopsy. Histological examination of a skin biopsy showed a dense neutrophilic infiltrate with focal fibrinoid necrosis and few eosinophils. The clinical and pathological features suggested a double-positive vasculitis/Churg-Strauss overlap syndrome presenting with a predominantly neutrophilic dermatosis. Specific cutaneous features in patients with double-positive vasculitis have not been documented previously. The patient has responded extremely well to immunosuppressive treatment and her disease is currently in remission.

Fatal toxic epidermal necrolysis due to lansoprazole.

Toxic epidermal necrolysis (TEN) is a serious cutaneous reaction and is most commonly drug induced. It is associated with significant morbidity and mortality. We describe a patient who developed fatal TEN after re-exposure to lansoprazole. Three years previously he presented with erythema multiforme due to the same drug. To our knowledge this is the first published report of TEN occurring with lansoprazole.

A comparison of endoscopic and capsule small intestinal biopsy techniques in children with upper gastrointestinal disorders.

OBJECTIVE: To compare the adequacy for histological diagnosis and morphometric analysis of small intestinal biopsies obtained by either endoscopic forceps or a capsule technique. METHODOLOGY: Small intestinal biopsies from 176 children were reviewed, 92 obtained by endoscopy and 84 by capsule. RESULTS: The adequacy for making a histological diagnosis was 96 and 81% for endoscopic and capsule biopsies, respectively, and for morphometric analysis it was 86 and 71%. There were more tissue specimens from children who had endoscopic compared with capsule biopsies (2.3 vs 1.8 specimens per patient). CONCLUSIONS: Endoscopic biopsies provide better specimens for histological diagnosis and endoscopy has the advantage of allowing macroscopic assessment of the upper gastrointestinal tract which can be of value in recognizing unexpected pathology and in identifying patchy mucosal changes.

Radiological and pathological features of AIDS-related polypoid cholangitis.

A review of the radiographs obtained at ERCP from 31 patients with AIDS-related sclerosing cholangitis (ARSC) demonstrated intraluminal polypoidal defects within the common bile duct and larger intrahepatic ducts in eight cases (26%). The radiological features from this subgroup are described and correlated with the microbiological and histological findings from biopsy specimens including two patients who underwent post-mortem examination. At microscopy the polypoid lesions were demonstrated to consist of granulation tissue. The presence of these polyps did not adversely affect the prognosis nor were they associated with any particular infective agent. We propose recognizing the existence of this entity by the term AIDS-related polypoid cholangitis (ARPC).

Cytomegalovirus gastritis with perforation and gastrocolic fistula formation.

A 76-year-old man with lymphoma involving cervical and mediastinal lymph nodes and abdomen was treated by radiotherapy and chemotherapy. He subsequently developed cytomegalovirus gastritis and gastric ulcers with a gastrocolic fistula and a jejuno-jejunal fistula, necessitating a partial gastrectomy. The pathogenesis of cytomegalovirus gastritis and its complications are discussed.

Epstein-Barr virus associated oesophageal ulcers in AIDS.

Epstein-Barr virus (EBV) associated ulceration has not previously been included in the differential diagnosis of oesophageal ulcers in AIDS. We report five cases of oesophageal ulceration in homosexual men with advanced human immunodeficiency virus infection in whom this was considered to be the most likely cause. DNA in situ hybridisation studies showed EBV in biopsy material from three of four patients with oesophageal ulcers and in none of three controls. Of other viruses studied, only human papillomavirus was present, and this was found in both patients and control subjects. These findings support the hypothesis that EBV is an aetiological factor in some cases of AIDS-associated oesophageal ulceration.

Campylobacter pylori in the upper gastrointestinal tract of patients with HIV-1 infection.

Fifty one patients with human immuno-deficiency virus (HIV-1) infection who had been consecutively endoscoped for upper gastrointestinal symptoms were biopsied (stomach or duodenum, or both) and compared with 59 age and sex matched controls for the presence of Campylobacter pylori. In 28 (47%) of the control group but in only seven (14%) of the HIV seropositive patients were C pylori seen on histological examination (p less than 0.001, odds ratio 5.6, 95% confidence interval 2.2-14.5). Sixteen patients who were HIV antibody positive had other index diseases for the diagnosis of AIDS in the biopsy material and, when these were excluded, comparison with the control group still showed a significant difference; p less than 0.01, odds ratio 3.6, 95%, confidence interval 1.4-9.6. In this series, therefore, C pylori were far less common in HIV antibody positive patients than in controls. Among the HIV positive patients, a higher proportion of C pylori negative cases had AIDS but this trend was not significant. The findings of this study indicate that whatever abnormalities of cell mediated mucosal immunoregulation are caused by HIV infection, they do not seem to be important in the response to infection by C pylori.

Cytomegalovirus infection in gastrointestinal tracts of patients infected with HIV-1 or AIDS.

All gastrointestinal tract biopsy specimens from 190 patients positive for HIV-1 or with AIDS were reviewed to assess the prevalence of cytomegalovirus (CMV) infection, morphology of infected cells, and the associated histopathological features. Eighteen patients (10 (7.7%) of 129 HIV antibody positive and eight (13.1%) of 61 with AIDS) had CMV identified in 35 biopsy specimens from the following sites: oesophagus (n = 3); stomach (n = 6); small intestine (n = 4); colorectum (n = 18) and perianal area (n = 4). Eleven patients had CMV alone as the potential cause of symptoms and in seven there were coexistent pathogens or Kaposi's sarcoma. The appearance and type of infected cells at different sites was highly variable. Immunocytochemical techniques and electron microscopic examination were performed to confirm the presence of CMV antigen and CMV virus particles and to exclude the possibility of an adenovirus producing similar cytopathic changes. It is important to recognise the different morphological forms of infected cells, and the use of immunocytochemical techniques is recommended in patients at risk for CMV or in whom CMV infection is suspected.

Colonic complications of severe acute pancreatitis.

Colonic complications are rare in acute pancreatitis. Over the last 9 years at St. Mary's Hospital, London, UK, we have managed severe acute pancreatitis by intensive supportive therapy followed by sub-total pancreatic resection and/or debridement in those who fail to improve. Of the 22 patients who have undergone this form of surgery, nine were found to have colonic involvement in the form of either necrosis or perforation. In addition, one patient presenting at West Middlesex University Hospital, Isleworth, UK, had severe acute pancreatitis and almost total colonic necrosis as an unexpected finding at emergency laparotomy. These ten patients comprised seven men and three women of median age 59 years and with a median of four Ranson criteria. In seven patients, colonic involvement was discovered at the time of pancreatic surgery or laparotomy for pancreatitis and in the remainder it presented between 1 and 3 weeks later as either a faecal fistula (n = 2) or persistent abdominal sepsis (n = 1). The ascending colon was involved in one patient, the splenic flexure and descending colon in one, the transverse colon in three, the splenic flexure alone in four, and one patient had almost total colonic involvement. All patients underwent resection of the involved colon and exteriorization with either a proximal colostomy (n = 7) or ileostomy (n = 3) and a distal mucous fistula. Pathological examination of the resected colons revealed a spectrum of changes from pericolitis through to ischaemic necrosis suggesting at least two possible mechanisms. Six patients died from overwhelming sepsis between 1 day and 4 weeks (median 11 days) after colonic resection. Severe acute pancreatitis must be recognized as a cause of colonic ischaemia and necrosis; this complication is associated with a very poor prognosis despite surgical intervention.