Histopathological features predictive of a clinical diagnosis of ophthalmic granulomatosis with polyangiitis (GPA)

Background

The limited form of Granulomatosis with Polyangiitis (GPA), formerly known as Wegener’s Granulomatosis (WG) primarily involves the head and neck region, including the orbit, but is often a diagnostic challenge, particularly as it commonly lacks positive anti-neutrophil cytoplasm antibody (ANCA) titres or classical features on diagnostic orbital biopsies. The purpose of this study was to relate biopsy findings with clinical outcome and to determine which histopathological features are predictive of a clinical diagnosis of GPA.

Methods

Retrospective case series of 234 patients identified from the database of the UCL Institute of Ophthalmology Department of Eye Pathology as having had orbital biopsies of orbital inflammatory disorders performed between 1988 and 2009. Clinical records were obtained for the patients and analysed to see whether patients had GPA or not, according to a standard set of diagnostic criteria (excluding any histopathological findings). Biopsy features were then correlated with the clinical diagnosis in univariate and multivariate analyses to determine factors predictive of GPA.

Results

Of the 234 patients, 36 were diagnosed with GPA and 198 with other orbital pathologies. The majority of biopsies were from orbital masses (47%). Histology showed a range of acute and chronic inflammatory pictures in all biopsies, but the presence of neutrophils (P<0.001), vasculitis (P<0.001), necrosis (P<0.001), eosinophils (P<0.02) and macrophages (P=0.05) were significantly associated with a later clinical diagnosis of GPA. In a multivariate analysis, only tissue neutrophils (OR=3.6, P=0.01) and vasculitis (OR=2.6, P=0.02) were independently associated with GPA, in contrast to previous reports associating eosinophils and necrosis with the diagnosis.

Conclusions

Neutrophil, eosinophil and macrophage infiltration of orbital tissues, together with vasculitis and necrosis, are all associated with a clinical diagnosis of GPA, but only neutrophil infiltration and vasculitis are independently associated with this diagnosis. These features may assist in the establishing the diagnosis of limited GPA among patients with early orbital disease, particularly in the absence of positive serum ANCA titres.     

Association between HLA and Japanese patients with rheumatoid arthritis

Japanese patients with rheumatoid arthritis (RA) were observed to have a statistical association with HLA-DR4, MT3. Strong association between the clinical severity of RA and HLA was also observed. Male patients had a stronger association with HLA than female patients. Males are more resistant to RA than females. This suggested that the threshold of liability for RA is higher in males than in females. Japanese patients with RA with systemic vasculitis were negative for HLA-Bw44 and had antilymphocytotoxic autoantibody, indicating that RA with systemic vasculitis is different in etiology from RA without systemic vasculitis.     

Neuromuscular biopsy and diagnosis of vasculitis

One characteristic histological lesion on biopsy specimens is mandatory to establish the diagnosis of vasculitis. Combined nerve and muscle biopsies, by the same cutaneous incision, improve significantly the percentage of positive results. Nerve fragments should be taken in every patient presenting sensory manifestations. Such vasculitic lesions are present in medium-sized arterioles and/or small vessels, and correspond mainly to 4 necrotizing vasculitis: panarteritis nodosa (PAN), microscopic polyangiitis (MPA), Churg and Strauss syndrome and Wegener granulomatosis. Microvasculitis should be added to these classical entities, because it corresponds to small vessel wall infiltration by inflammatory cells, as observed in PAN and MPA, but without any necrosis. Microvasculitis has to be differentiated from the inflammatory cell infiltrates surrounding small vessels. However, such perivascular inflammatory cell infiltrates enable the diagnosis of probable vasculitis when associated with clusters of neo-vessels, hemosiderin deposits, or a focal damage of nerve fibers. Grossly, one third of vasculitis diagnosis is confirmed on muscle fragments, a second third on nerve fragments, and the last third on both nerve and muscle fragments. Moreover, in the search for vasculitis, an unpredicted diagnosis of lymphoma or amyloidosis is occasionally established on the neuro-muscular biopsy.     

Role of calretinin immunohistochemical stain in evaluation of Hirschsprung disease: an institutional experience

Background: The use of calretinin immunostain (IHC) in the evaluation of rectal suction biopsies for Hirschsprung disease (HD) has been reported by Kapur et al. and others. The first goal of this article is to report our institutional experience with the use of calretinin in specimens for evaluation of HD. The second goal is to describe the pattern of expression of calretinin in the junction of ganglionic-to-aganglionic segment of pull through specimens of patients with a previous diagnosis of HD on suction rectal biopsy. Material and methods: Three pathologists at University of Texas at Houston evaluated 28 rectal biopsy specimens from 2010-2011. The patients’ age ranged from 15 days to 8 years. Twenty-three cases were suction biopsies, and five were rectal full thickness biopsies. Hematoxylin-eosin (H&E) stain was performed on at least 80 levels for the suction biopsy specimens. Calretinin immunohistochemical stain was performed on levels 40-42 in all cases, with adequate controls. The H&E slides of nine pull through specimens with a diagnosis of HD on a suction rectal biopsy that was evaluated in this study, were evaluated. Calretinin IHC was performed on the slide(s) showing the junction of aganglionic-to-normal rectum, along with adequate controls. Results: The presence of ganglion cells consistently correlated with calretinin-positive thin nerve fibrils in the lamina propria, muscularis mucosae and superficial submucosa. These nerve fibrils were absent in the aganglionic segments of bowel and in the areas without ganglion cells from the junction of normal with diseased rectum. Calretinin was strongly expressed in the submucosal and subserosal nerve trunks in the ganglionic segment. It had faint expression in the thick nerve trunks from the areas without ganglion cells 1.6-2.5 cm proximal to the normal rectum. No calretinin expression was seen in the nerve trunks in the rest of the aganglionic segment. Conclusion: The pattern of expression of calretinin in rectal suction biopsies in HD and normal rectum coincide with the ones previously described in the literature. Calretinin IHC offered additional diagnostic value in the specimens with inadequate amount of submucosa and rarely seen ganglion cells. The pattern of expression of calretinin in HD pull-through specimens correlates with the rectal biopsy ones. Faint positivity of the thick submucosal and subserosal nerves in the absence of ganglion cells and calretinin positive nerve fibrils, is characteristic of the junction of the aganglionic-to-normal rectum. We are the first ones to document this finding.     

A prospective study of dysplasia and carcinoma in the rectal biopsies and rectal stump of eight patients following ileorectal anastomosis in ulcerative colitis

The present study concerns eight patients with ulcerative colitis treated by total colectomy and ileorectal anastomosis and subjected to follow-up rectal biopsies who later developed precancer (two cases) or carcinoma in the retained rectum. We report the results of the biopsies and the detailed mapping of lesions in the resected rectal stump to highlight certain features which may lead to increased detection rate of early malignancy. Two groups of patients emerged. Group A: in all four cases the follow-up biopsies showed increasing severity of dysplasia; altered mucin secretion with predominance of sialomucins was seen in the biopsies even in the absence of inflammation or dysplasia; the biopsy findings (morphological and secretory) mirrored those observed in the rectal stump; in three, the lesions were villous polypoid growths, of which two were invasive carcinomas. Group B: in none of the cases was dysplasia seen in the biopsies and mucus secretion was normal; similar features were seen in the rectal stump; all had invasive carcinoma of which three were flat ulcerated lesions. The different behaviour of carcinoma in the two groups almost certainly reflects the different tumour phenotype characteristics and this is a matter for further study. From the practical point of view we emphasize the risk of relying on biopsy evidence of dysplasia alone as an indicator of malignancy and the need for additional immunological or histochemical tests to assess the individual risk of cancer in colitis.     

Bone marrow biopsy in Hodgkin's disease

Bone marrow biopsies of 58 untreated patients with Hodgkin's disease were evaluated. Marrow involvement was seen in 36.2 % cases. Positive marrow biopsies were seen mainly in patients with clinical stages III and IV. Bone marrow involvement was most common in patients with less than 15 years of age and in males. HD patients with mixed cellularity had highest incidence of marrow involvement while none of the patients with lymphocytic predominance showed BM involvement. Focal infiltration was found to be more common. Bone marrow aspiration smears were negative in majority of cases with positive marrow biopsies. Thus BM trephine biopsy is a simple tool for assessment of disease spread.     

Mucous membrane hyperplasia of the rectum--a clarification requiring biopsy

The frequency of mucosal hyperplasia adjacent to the tumor was determined in 177 rectal biopsies with a diagnosis of adenocarcinoma. Previous rectal biopsies in these patients were analyzed. In a further step associated clinical and morphological findings were determined in 75 patients with mucosal hypertrophy on rectal biopsy. Half of these patients could be followed prospectively. Pathogenetic aspects of hyperplastic rectal mucosa are discussed. The need for improved clarification of the importance of these mucosal lesions particularly in unclear clinical situations is emphasized.     

Antibodies to endothelial cells in systemic lupus erythematosus: a potential marker for nephritis and vasculitis

Using an ELISA, anti-endothelial cell antibodies (AECA) have been found in sera obtained at the time of renal biopsy in 46 out of 57 patients (81%) with systemic lupus erythematosus (SLE) and nephritis (mean binding index (BI) = 84% +/- 52.8) compared with 22 out of 50 SLE patients (44%) without nephritis (mean BI = 45% +/- 35.9). Seventy normal human sera had a mean BI of 10% +/- 9.8. The highest levels were seen in patients with diffuse proliferative glomerulonephritis (WHO grade IV) and in patients with proteinuria and nephrotic syndrome. When the biopsies were assessed for activity and chronicity scores, AECA were associated with active renal lesions (P less than 0.001). AECA levels correlated with low complement levels but not with anti-DNA antibodies to extractable nuclear antigens (ENA), anti-cardiolipin or anti-neutrophil cytoplasmic antibodies. The presence of AECA conferred a positive predictive value of 0.68 for the presence of nephritis. Twenty-five patients had active vasculitis at the time of assay and the highest AECA values were seen in patients with both nephritis and vasculitis. No correlation was seen with serum immunoglobulin levels and immune complexes did not bind significantly to the endothelial surface. The possible role of these antibodies as a marker in lupus nephritis is discussed.     

Diamond-shaped'' crypts and mucosal elastin: elpful diagnostic features in biopsies of rectal prolapse

The biopsy diagnosis of prolapsing rectal mucosa syndrome can be difficult. We present two newly described features--'diamond-shaped' crypts and mucosal elastin--which appear to be helpful in histological diagnosis. Of 32 biopsies of prolapsing rectal mucosa syndrome, all showed diamond-shaped crypts or mucosal elastin, and 28 contained both. Control biopsies comprised cases of normal or irritable bowel syndrome (46), irradiation colitis and ischaemic colitis (16), inflammatory bowel disease (26), and adenomas (30). Mucosal elastin and 'diamond-shaped' crypts with distinctive scalloped edges, which were never seen in prolapse, were observed in half the cases of irradiation and ischaemic colitis. Diamond-shaped crypts were seen in one case of inflammatory bowel disease. Diamond-shaped crypts and elastin were seen in the base of adenomas large enough to cause localized prolapse, and in four biopsies from patients with irritable bowel syndrome, all of whom had given a history of straining at stool.     

Use of electron microscopy in examination of faeces and rectal and jejunal biopsy specimens.

The stools and rectal biopsy specimens of 44 patients with AIDS and diarrhoea were examined by culture, light microscopy, and electron microscopy. In 13 patients examination of rectal biopsy material and faecal samples showed no pathogen, but in two of these, microsporidiosis was found by electron microscopical examination of jejunal biopsy specimens. This organism was also identified electron microscopically in one of the further five jejunal biopsy samples taken from patients with a known cause of diarrhoea. Blastocystis hominis infection was identified electron microscopically in six patients, all of whom had cryptosporidiosis additionally seen by light microscopy. Four of these six patients remained well for long periods, with only moderate diarrhoea, and follow up showed no evidence of blastocystis infection. In only four of 11 patients found to have cryptosporidium in their stools at light microscopy were organisms found at electron microscopy. Viral inclusions were only identified at electron microscopy in one of 10 patients with an opportunistic viral infection seen at light microscopy (cytomegalovirus n = 7, herpes simplex virus n = 3). No additional viral pathogens were detected in either stools or rectal biopsy material by electron microscopy. It is concluded that routine electron microscopic examination of stool samples or rectal biopsy material taken from patients with AIDS and diarrhoea is unnecessary and does not increase the yield of potential pathogens compared with standard microbiological techniques and histology.     

Nonsystemic vasculitic neuropathy

The clinical, electrophysiological and pathological features and prognosis of 9 patients with nonsystemic vasculitic neuropathy are described. Nonsystemic vasculitic neuropathy accounted for 3% of cases of biopsy proven cases of various neuropathies and formed 56% of vasculitic neuropathy. Both clinically and on electrophysiological testing, mononeuritis multiplex was the form of neuropathy in 5 patients and 3 had sensory neuropathy. All the patients had a necrotizing vasculitis on nerve biopsy. Axonal degeneration was seen in teased fibers in all the patients. Eight patients showed good functional recovery one was left with mild bilateral claw hands.     

Amebic colitis can mimic tuberculosis and inflammatory bowel disease on endoscopy and biopsy

Biopsies of 11 patients with histopathologically diagnosed amebic colitis was evaluated; endoscopically, they were suspected to have tuberculosis or inflammatory bowel disease. Amebiasis was suggested in the differential diagnosis in only 3 cases. Three patients had purely rectal or sigmoid involvement, whereas the others had ileocecal, cecal, ascending, or transverse colon disease. The biopsies showed cryptitis and depletion of mucin but no crypt branching. Crypt abscesses were seen in one biopsy. Trophozoites of Entamoeba histolytica were seen in the exudate in all cases. The trophozoites were round to oval, approximately 25 to 40 microm in diameter and had a single, round nucleus and periodic acid-Schiff-positive cytoplasm. Phagocytosed erythrocytes were present in the trophozoites. Some features of ulcerative colitis and infectious colitis, such as cryptitis and crypt abscesses, are also seen in amebic colitis. Amebic colitis must be included in the differential diagnosis of all patients with suspected inflammatory bowel disease and tuberculosis.     

Associations of killer cell immunoglobulin-like receptor genes with complications of rheumatoid arthritis

We investigated whether killer cell immunoglobulin-like receptor (KIR) genes are risk factor(s) for rheumatoid arthritis (RA) and its clinical manifestations. One hundred and seventy-seven RA patients and 243 healthy individuals were tested for the presence of 11 KIR genes using PCR-SSP method. The frequencies of KIRs in patients with RA were similar to the frequencies in controls. However, RA patients positive for KIR2DL3 and negative for KIR2DS3 had earlier disease diagnosis. Additionally, KIR2DL2 and KIR2DS2 were significantly more frequent among RA patients with extra-articular manifestations and in its subgroup with vasculitis than in controls and in patients without these complications. Furthermore, the frequencies of KIR2DS1 and KIR3DS1 were lower in patients without bone erosions compared with healthy individuals. Relationships between the presence or absence of autoantibodies (rheumatoid factor and anti-cyclic citrullinated peptide) and KIR frequencies were also evaluated, but no significant differences were observed. These results suggest that particular clinical manifestations of RA may have different genetic backgrounds with respect to KIR genotype.     

Preoperative radiotherapy modulates ezrin expression and its value as a predictive marker in patients with rectal cancer

The purpose of this study was to assess the value of ezrin expression as a predictor of disease outcome in rectal cancer treated by preoperative radio- or chemoradiotherapy. Operative samples from 176 rectal cancer patients and 76 diagnostic preoperative biopsies from the same cohort were analyzed for ezrin expression using immunohistochemistry. The patients had received short- (n = 76) or long-course radiotherapy with (n = 36) or without chemotherapy (n = 10) or no treatment preoperatively (n = 54). The direct effect of radiation on ezrin expression was studied in cultured cells by Western blot analysis. The biopsies and respective operative samples were significantly different (κ = -0.010 for 4-tier scoring and κ = 0.028 for dichotomized scoring) in their ezrin expression. Most preoperative biopsies (61/76, 80%) had negative/weak ezrin expression compared with 56% (43/76) of the corresponding operative samples. After preoperative treatment, negative expression in the biopsies of 18 (82%) of 22 patients turned positive, whereas positive expression in 6 (11%) of 54 biopsies turned negative in the operative samples. In univariate analysis, disease-free survival and disease-specific survival were significantly longer (P = .027 and P = .002) when ezrin expression in the preoperative biopsy was negative/weak compared with moderate/strong expression. Such prognostic association was lost in the radiated operative specimens. In multivariate regression model, ezrin was not a predictor of disease-free survival. No direct effect of radiation on ezrin expression was seen in vitro. In conclusion, radiotherapy increases ezrin expression in rectal cancer. In pretreatment biopsies, negative/weak ezrin expression correlates with favorable disease outcome, suggesting that ezrin expression modulates tumor aggressiveness and/or response to treatment.     

Pulmonary-renal syndrome: clinical similarity amidst etiologic diversity

The medical records and morphologic materials (59 biopsies, 7 autopsies) of 21 patients presenting with a pulmonary-renal syndrome (PRS) were reviewed. A variety of disorders (Goodpasture's syndrome, 3; vasculitis, 7; idiopathic crescentic glomerulonephritis, 7; spurious PRS, 4) may have PRS presentation. Seventeen patients had extrarenal vasculitis and/or crescentic glomerulonephritis and were treated with immunosuppression. Seven patients died, six from complications related to infections and cardiovascular disease but only one from his original disease. Four other patients ("spurious" PRS) who did not have crescents or extrarenal vasculitis did well with supportive therapy alone. We conclude that a pulmonary-renal syndrome is a common manifestation of diverse disorders which differ in their prognosis and therapy. Since clinical parameters alone are too insensitive to resolve the etiologic possibilities, multiple biopsies and serologies tests are required for a reliable diagnosis.     

Rectal ulcer and pseudomalignant epithelial changes after prostate seed brachytherapy: A rare complication with a diagnostic pitfall

BackgroundImplant brachytherapy (IBT) is a well-recognized treatment modality for early stage prostate cancer. Rectal ulcer and rectourethral fistula complicating IBT may cause an alteration of the normal anatomic landmarks. In this context, pseudomalignant radiation-induced changes within prostatic epithelium may be misinterpreted as a primary rectal malignancy. Such challenging and misleading findings have not been described, and may not be recognized as such.Materials and methodsWe present the clinical and pathologic aspects of two patients who underwent IBT for low stage prostate cancer that was complicated by deep rectal ulcer. Both patients underwent extensive palliative surgical resection for disease control.ResultsThe histologic changes in both cases were noteworthy for extensive necrosis and inflammation of the prostate, associated with loss of recto-prostatic anatomical landmarks. Prostatic glands showed striking radiation-induced atypia and pseudomalignant epithelial changes extending to the rectal ulcer bed, with no residual viable tumor. The first patient had undergone a biopsy of the rectal ulcer bed that was misinterpreted as a rectal adenocarcinoma prior to surgery. The similarity between atypical glands of the biopsy and the benign prostatic tissue with radiation-induced atypia in resection specimen confirmed their benign nature.ConclusionsDeep rectal ulcer complicating IBT may lead to distortion of the normal recto-prostatic anatomical landmarks, resulting in detection of pseudo-malignant prostatic glands at the ulcer base. Such findings may be mistaken for a primary rectal malignancy in limited biopsy material if not familiar to the pathologist.     

Immunopathological studies in patients with farmer's lung

Immunohistological study of lung biopsies from four palients with farmer's lung revealed histological evidence of vasculilis along with deposits of immunoglobulins and C3 in and around the affected vessels in the biopsies from two palients. Both these patients were exposed to mouldy hay antigens shortly before biopsy. Both these patients also had considerable numbers of eosinophils in their lung lesions. Immune-complex mediated vasculitis is probably an early event in the pathogenesis of farmer's lung and might not be detectable in the absence of recent exposure to relevant antigens. The presence of large numbers of eosinophits in these lesions suggests a type I reaction acting as the trigger for a type 3 reaction.     

HLA-DR in Brazilian Patients with Polyarteritis Nodosa (PAN) and Microscopic Polyangiitis (MPA)

The aim of this study was to evaluate the frequency and clinical associations of HLA-DR alleles in Brazilian Caucasian patients with polyarteritis nodosa (PAN) or microscopic polyangiitis (MPA). We evaluated 29 Caucasian patients with vasculitis classified as PAN or MPA according to the American College of Rheumatology (ACR) 1990 Criteria, Chapel Hill Consensus Conference (CHCC) nomenclature for vasculitis and EULAR recommendations for conducting clinical studies in systemic vasculitis. HLA-DR alleles were typed using polymerase chain reaction-amplified DNA, hybridized with sequence-specific low resolution primers. DNA obtained from 59 Caucasian healthy blood donors were used as control. In order to evaluate if a specific HLA may have influence on the clinical profile of those diseases, we also divided the patients according to Birmingham vasculitis score (BVAS) and Five-Factors Score (FFS) at the time of diagnosis. Increased frequency of HLA-DRB1*16 (p = 0.023) and DRB4*01 (p = 0.048) was found in patients with higher disease activity at the time of diagnosis (BVAS ≥ 22). Patients with less severe disease (FFS = 0) had a higher frequency of HLA-DRB1*03 (p = 0.011). Patients with gastrointestinal tract involvement had significantly increased frequency of HLA-DRB1*11 or B1*12 (p = 0.046), B1*13 (p = 0.021) and B3 (p = 0.008). In contrast, patients with renal disease, had higher frequency of DRB1*15 or DRB1*16 (p = 0.035) and B5 (p = 0.035). In the subgroup of patients with MPA, increased frequency of HLA-DRB1*15 was found in patients with BVAS ≥ 22 (p = 0.038) and FFS ≥ 1 (p = 0.039) suggesting that this allele is associated with more aggressive disease. Antineutrophil cytoplasmic antibodies (ANCA) negative MPA patients had significantly increased frequency of HLA-DRB1*11 or DRB1*12 when compared to ANCA positive patients (p = 0.023). Our results suggest that HLA-DR alleles may influence PAN and MPA clinical expression and outcome and that in MPA they participate in the mechanisms involved in the development to ANCA.     

Pseudomembranous colitis.

Three basic histopathological patterns which may be seen in rectal biopsies from patients with pseudomembranous colitis are described, based on a study of 29 cases. The spectrum of change is illustrated and the problems of differential diagnosis are discussed--from a non-diagnostic proctitis at one extreme to acute ischaemia at the other. In the differential diagnosis of the acute colitic, the importance of urgent rectal biopsy and a carefully taken drug history is stressed. The association of pseudomembranous colitis with pre-existing disease and antibiotic therapy is confirmed. It is suggested that these cause local mucosal damage and may trigger the first part of a local Shwartzman reaction. Capillary microthrombosis may then paly a part in producing the mucosal necrosis seen later in the disease.