New Helicobacter species in humans

During the last decade several new Helicobacter species have been isolated from human gastric mucosa, fecal samples, liver, and gallbladder. Gastric corkscrew-shaped Helicobacter species: H. heilmannii is usually seen in the gastric foveolae in 0.2-0.6% of histological sections from the gastric mucosa of patients with dyspepsia in Western Europe, but it has only been cultured once. It is genetically and morphologically closely related to H. bizzozeronii and H. salmonis which are common in dogs and cats. It causes constantly active chronic gastritis and is regularly associated with peptic ulcer. Intestinal Helicobacter species: H. cinaedi, H. fennelliae, H. pullorum, H. westmeadii, H. canadensis, and 'H. rappini' have been isolated from patients with enteritis and proctitis. H. fennelliae, H. cinaedi, H. westmeadii, and 'H. rappini' have been isolated also from patients with septicemia. Studies indicate that H. cinaedi is transmitted from hamsters and that H. pullorum is common in chickens. 'H. rappini' has been isolated from sheep, dogs, and mice, whereas no animal reservoir has been found for H. fennelliae. Except for the cases of septicemia, none of these Helicobacter species have yet been proven to cause human disease, but they are suspected to play a role in inflammatory bowel diseases. Hepatobiliary Helicobacter species include several Helicobacter species isolated from bile and liver of animals, but only H. bilis has been isolated from the human gallbladder and H. pylori from the human liver. H. bilis has been isolated from dogs, cats, mice, and rats. Nonpylori Helicobacter species are usually difficult to culture and may be more frequently causes of human disease than realized today.

Leptospirosis mimicking acute cholecystitis among athletes participating in a triathlon

Leptospirosis, a disease acquired by exposure to contaminated water, is characterized by fever accompanied by various symptoms, including abdominal pain. An acute febrile illness occurred in athletes who participated in an Illinois triathlon in which the swimming event took place in a freshwater lake. Of 876 athletes, 120 sought medical care and 22 were hospitalized. Two of the athletes had their gallbladders removed because of abdominal pain and clinical suspicion of acute cholecystitis. We applied an immunohistochemical test for leptospirosis to these gallbladders and demonstrated bacterial antigens staining (granular and filamentous patterns) around blood vessels of the serosa and muscle layer. Rare intact bacteria were seen in 1 case. These results show that leptospirosis can mimic the clinical symptoms of acute cholecystitis. If a cholecystectomy is performed in febrile patients with suspicious environmental or animal exposure, pathologic studies for leptospirosis on formalin-fixed, paraffin-embedded tissues may be of great value.

Infection after Laparoscopic Cholecystectomy: Effect of Infected Bile and Infected Gallbladder Wall

OBJECTIVE

To assess the incidence of infected bile and gallbladder wall infection at the time of laparoscopic cholecystectomy, and find out if they influenced the rate of postoperative infective complications.

DESIGN

Prospective study.

SETTING

District hospital, Kuwait.

SUBJECTS

All 279 patients who had their gallbladders removed laparoscopically for gallbladder disease between September 1995 and August 1998.

INTERVENTIONS

Samples of bile and gallbladder wall were taken from all patients and cultured separately for aerobic and anaerobic bacteria. Patients with complicated gallbladder disease (n = 80) were given preoperative therapeutic antibiotics for five days (cephalosporin plus metronidazole), and other high-risk patients (n = 138) were given prophylactic ceftriaxone either 1 g x 3 starting at induction of anaesthesia (n = 42), or a single dose at induction (n = 96).

MAIN OUTCOME MEASURES

Incidence of infected cultures, and infective morbidity.

RESULTS

26 specimens of bile (9%) and 56 specimens of gallbladder wall (20%) were infected. Two patients in whom neither specimen had shown any growth developed minor infections at the umbilical port. No patient in whom either specimen was infected developed an infective complication.

CONCLUSIONS

The overall rate of infective complications was negligible, and did not correlate with the presence of bacteria in the bile or gallbladder wall. This is probably a reflection of our aggressive antibiotic regimen in the management of high-risk patients.

The protean nature of Whipple's disease includes multiorgan arteriopathy

Knowledge about the arterial abnormalities in Whipple's disease can be useful for our better understanding of both Whipple's disease and the more general question of pathogenesis of atherosclerosis. There are several notable morphological features of Whipple's arteriopathy. First, it appears to involve primarily arteries one millimeter or less in diameter. Second, there is very little evidence of inflammation accompanying invasion of any or all three layers of the walls of affected arteries, and there is almost no evidence of local attraction of platelets to these sites of arterial injury. Third, the nature of arterial injury appears to be one of slow progression. The few sites of actual arteritis are most likely attributable to some other coinciding microbial organism not yet identified. Although the arteriopathy in Whipple's disease is seen mainly in small arteries (the aorta is a notable exception), their significance can be illustrated by consideration of this fact as it applies to the coronary circulation (and probably the arteries of all other organs). In the heart these small arteries comprise almost the entire collateral circulation, the principal blood supply to each component of the conduction system, and most pragmatically, these small arteries represent the terminal distribution of every larger epicardial artery. Small arteries are important. The "cardiomyopathy" so often a feature of Whipple's disease (very much including his original case) is most logically attributable to recurring bouts of focal ischemia and subsequent focal fibrosis ending in myocardial incompetence. However, direct bacillary invasion of cardiac myocytes (22) also occurs. In lamina propria of jejunum, there is also arteriopathy, as there is in brain, lung, kidney, spleen, liver, gall bladder, rectum, stomach, lymph nodes and testis. It is likely that no organ in the body is spared. There is growing evidence that a wide variety of chronic infections (occurring concomitantly or sequentially) may participate in the early pathogenesis of human arterial disease, including atherosclerosis. Given that the coronary plaque represents the cumulative end result of countless earlier injuries and responses, the plaque is not the site to seek evidence of initial pathogenesis although understanding the behavior of coronary plaques is eventually of considerable clinical importance. In the context of original events in pathogenesis, the Whipple bacillus now deserves inclusion in the "total pathogen burden" concept, as it relates not only to coronary disease but to all aspects of atherosclerosis and even other forms of arteriopathy.

A prospective, randomised trial of prophylactic antibiotics versus bag extraction in the prophylaxis of wound infection in laparoscopic cholecystectomy

Septic complications are rare following laparoscopic cholecystectomy if prophylactic antibiotics are given, as demonstrated in previous studies. Antibiotic treatment may be unnecessary and, therefore, undesirable, so we compared two forms of prophylaxis: a cephalosporin antibiotic and bag extraction of the dissected gallbladder. A total of 76 patients undergoing laparoscopic cholecystectomy were randomised to either receive an antibiotic or to have their gallbladder removed from the abdomen in a plastic bag. Complicated cases were excluded. There was a total of 6 wound infections (7.9%), 3 in each of the study groups. All these were associated with skin commensals. There were no other septic complications. Bacteriological studies grouped the organisms isolated from the bile and the wound as potential pathogens and likely commensals. A total of 10 potential pathogens were isolated, 9 of which were found in the group receiving antibiotics. We conclude that septic sequelae of uncomplicated laparoscopic cholecystectomy are uncommon, but clearly not entirely prevented by antibiotic or mechanical prophylaxis. Prophylactic antibiotics may not be required in uncomplicated laparoscopic cholecystectomy. Further study is warranted.

Dysgonomonas gen. nov. to accommodate Dysgonomonas gadei sp. nov., an organism isolated from a human gall bladder, and Dysgonomonas capnocytophagoides (formerly CDC group DF-3)

Results of a polyphasic taxonomic study on an unknown Gram-negative, facultatively anaerobic, coccobacillus-shaped organism isolated from an infected human gall bladder are presented. Phenotypic and molecular taxonomic studies revealed the organism to be close to, but distinct from, organisms designated CDC (Centers for Disease Control and Prevention) group DF-3. The unknown bacterium was readily distinguished from reference strains of Bacteroides, Prevotella, Porphyromonas and related taxa by 16S rRNA gene sequencing, biochemical tests, analysis of cellular long-chain fatty acids and electrophoretic analysis of whole-cell proteins. Based on the results of the present study, it is proposed that the unknown bacterium be classified in a new genus, Dysgonomonas, as Dysgonomonas gadei sp. nov. (type strain CCUG 42882T = CIP 106420T). In addition, a new species, Dysgonomonas capnocytophagoides sp. nov., is proposed to accommodate strains previously belonging to CDC group DF-3. The type species of the genus Dysgonomonas is Dysgonomonas gadei.

[Microbiological study of gallbladder bile in a high risk zone for gallbladder cancer]

BACKGROUND

Gallbladder cancer is frequent in Chile and there is sparse information about the association between this type of cancer and the presence of bacteria in the gallbladder bile.

AIM

To determine the presence of aerobic bacteria in gallbladder bile in patients with and without gallbladder cancer.

MATERIAL AND METHODS

A microbiological analysis of bile and pathological study was performed in 608 gallbladders, obtained during to cholecystectomies performed to 513 women and 95 men aged 44 years old as a mean.

RESULTS

Pathological study showed a chronic cholecystitis in 468 cases (77%), an acute cholecystitis in 140 (33%), cancer in 24 (3.9%) and dysplasia in 5 cases (0.8%). A positive culture was obtained in 22.5% of women and 28.5% of males. Twenty seven percent of women over 30 years old had positive cultures compared with 10% of younger women (p < 0.001). Thirty two percent of acute cholecystitis had positive cultures, compared with 24% of chronic cholecystitis (p = 0.03). E Coli was isolated in 51% of positive cases, Streptococci-Enterococci in 24%, Enterobacter sp in 9%, Klebsiella and Proteus in lower proportions. Salmonella sp was isolated in 4 cases, being all women with chronic cholecystitis. Thirteen of 29 cases with cancer or dysplasia had positive cultures (45%), compared with 25% of patients with inflammatory gallbladder diseases (p = 0.02). Streptococci-Enterococci were isolated in 7 cases and Enterobacter sp in three.

CONCLUSIONS

The presence of Salmonella sp in gallbladder bile was not frequent in the studied patients. Its role in the pathogenesis of gallbladder cancer must be reassessed.

[The histopathological and microbiological aspects in a model of acute acalculous cholecystitis: an experimental study]

The early stages of acute acalculous cholecystitis (ACC) have been difficult to investigate due to the animal models developed and utilized over the past years. A new model of animal AAC induced by intra-abdominal sepsis is presented. Under general anesthesia 35 guinea pigs underwent laparotomy. The designed model included ligation and prick of the caecum in 25 animals (group A), while 10 animals served as control group (group B). Seven days after these experimental procedures animals underwent relaparotomy and were submitted to cholecystectomy and sacrifice. Histological studies of the specimen revealed various degrees of cholecystitis in all the gallbladders of survived animals from group A. Gallbladders of animals from group B were histologically normal. Gallbladder bile of 15 survived animals from group A were cultured. Bile cultures were negative in 10, while culture of gallbladder bile were positive in 5; the pathogen cultured were Streptococcus Faecalis and Streptococcus Sp. The results of this study suggest that intra-abdominal sepsis induces gallbladder inflammation of various degrees. This directly supports the theoretical relationship indicating that sepsis and shock could produce AAC. Moreover this model proved that AAC, in early stages, is primarily induced by inflammatory processes, while infection of the bile do represent a late event.

Helicobacter colonization of the biliary tree: commensal, pathogen, or spurious finding?

The authors hypothesized that Helicobacter species may be present in the bile and gallbladder wall of patients with chronic cholecystitis who live in a region with a high prevalence of gallbladder cancer. They attempted to identify such species by obtaining both bile and resected gallbladder tissue from 46 patients who underwent cholecystectomy. Tissue specimens were stained with hematoxylin and eosin as well as other stains used specifically for the identification of Helicobacter species, and culture was attempted using specialized media on samples from tissue and bile. Unfortunately, the authors were unable to culture any Helicobacter species, and the yield from histopathology was also poor with silver stains identifying curved bacteria suggestive, but not diagnostic, of Helicobacter species in only two cases. Molecular techniques were more successful. DNA was extracted from both tissue and bile and amplified by polymerase chain reaction (PCR) using a specific primer. The amplicons they identified were then compared with known Helicobacter proteins using a Southern blot approach. PCR amplification was relatively successful with 9 of 23 gallbladder samples and 13 of the 23 bile samples coming up positive for Helicobacter species using two specific primers. These specimens were also positive by Southern blot hybridization. The cloning and sequencing of the 16S ribosomal RNA amplicons in eight cases verified true Helicobacter origin with a phylogenetic analysis showing greater than 99.3% similarity. Five of the amplicons clustered with H. bilis, two with Flexispira rappini, and one with H. pullorum. The authors concluded that despite their being unable to identify organisms directly, the stringent PCR technique with amplicon sequencing confirmed that Helicobacter species could be identified within the bile and gallbladder tissue of patients with chronic cholecystitis in a region with high incidence of gallbladder cancer. They indicated that further studies are needed to ascertain whether similar species have a causative role in the development of gallbladder cancer.

Isolation of Enterobacter intermedium from the gallbladder of a patient with cholecystitis

We describe the isolation and identification of Enterobacter intermedium from the gallbladder of a patient with cholecystitis. There have been only four documented isolations of this organism from humans; it normally occurs in surface water and unpolluted soils. The identification was initially made by a MicroScan Walk/Away system with a Neg Combo 18 conventional identification-susceptibility panel. The organism is susceptible to the aminoglycosides and imipenem but resistant to the cephalosporins and ciprofloxacin.

[Experimental study of mixed infection by Vibrio cholerae and Salmonella typhi]

Mixed infection caused by V.cholerae and S.typhi was studied on guinea pig gall-bladder, used as an experimental model. These microorganisms coexisted in association in animals and exhibited no pronounced antagonistic properties in vitro. The cultures isolated from the organs of infected guinea pigs did not differ from initial ones. The study revealed that in nutrient broth containing 50% of dried bile salmonellae were preserved, but not V.cholerae. The latter could co-exist with S.typhi in 1% biliary medium prepared on meat-peptone broth (MPB). The use of bile and MPB as the basis for media intended for the study of material obtained from cholera and typhoid fever patients is recommended.

Hepatic Helicobacter species identified in bile and gallbladder tissue from Chileans with chronic cholecystitis

BACKGROUND & AIMS

Cancer of the gallbladder is the number one cause of cancer mortality in Chilean women. Incidence rates for this tumor vary widely on a worldwide basis, being approximately 30 times higher in high-risk than in low-risk populations, suggesting that environmental factors such as infectious microorganisms, carcinogens, and nutrition play a role in its pathogenesis. Because several Helicobacter sp. colonize the livers of animals and induce hepatitis, the aim of this study was to determine whether Helicobacter infection was associated with cholecystitis in humans.

METHODS

Bile or resected gallbladder tissue from 46 Chileans with chronic cholecystitis undergoing cholecystectomy were cultured for Helicobacter sp. and subjected to polymerase chain reaction (PCR) analysis using Helicobacter-specific 16S ribosomal RNA primers.

RESULTS

Recovery of Helicobacter sp. from frozen specimens was unsuccessful. However, by PCR analysis, 13 of 23 bile samples and 9 of 23 gallbladder tissues were positive for Helicobacter. Eight of the Helicobacter-specific PCR amplicons were sequenced and subjected to phylogenetic analysis. Five sequences represented strains of H. bilis, two strains of "Flexispira rappini" (ATCC 49317), and one strain of H. pullorum.

CONCLUSIONS

These data support an association of bile-resistant Helicobacter sp. with gallbladder disease. Further studies are needed to ascertain whether similar Helicobacter sp. play a causative role in the development of gallbladder cancer.

Actinomycosis of the cholecystic duct: case report and review

Actinomycosis of the gall bladder, cholecystic duct or common bile duct is rare, with only 16 cases reported to our knowledge. We report a case of actinomycosis in the cholecystic duct remnant of an 80-year-old woman with a history of cholecystitis, choledocholithiasis and cholecystoduodenal fistula requiring cholecystectomy and fistula closure three years prior. Histologic sections of the cystic duct remnant showed several dense basophilic masses containing numerous, dark blue, Gram-positive branching bacilli compatible with actinomycotic granules. Fluorescent antibody staining was positive for Actinomyces naeslundii. Staining for acid-fast bacilli was negative. The pathogenesis, presentation, diagnosis and management of abdominal actinomycosis with specific reference to disease involving the gall bladder are discussed.

Detection of Campylobacter jejuni in food and poultry viscera using immunomagnetic separation and microtitre hybridization

Thermophillic Campylobacter and Camp. jejuni were detected from samples of chicken liver, gall bladder, muscle and contaminated milk and chicken meat after an enrichment step by using immunomagnetic capture of cells with monoclonal antibody against a specific outer membrane protein of thermophilic Campylobacter. The detection of captured cells was achieved using two different hybridization methods. In one of the methods, the captured cells were lysed by guanidine isothiocyanate and the 23S rRNA was reacted with a microtitre plate-immobilized rDNA probe specific for thermophilic Campylobacter. In the other method, the captured cells were subjected to lysis by ultrasonication and the genomic DNA reacted with a microtitre plate-immobilized RNA probe specific for Camp.jejuni. Detection of the RNA-DNA hybrids formed in the wells was carried out using a monoclonal anti-RNA-DNA hybrid antibody.

Haemophilus segnis cholecystitis: a case report and literature review

Haemophilus segnis is a normal commensal of the human oropharynx which is occasionally associated with appendicitis, endocarditis or pancreatic abscess. Haemophilus segnis in the gall-bladder from a 58-year-old white female was recently encountered. The patient recovered from surgery without incident. This case is reported because the gall-bladder is now another site which has become infected with this organism. In order to provide guidance to physicians when H. segnis organism is identified, microbiologists should be aware of its behaviour in different sites.

Isolation of a novel Helicobacter species, Helicobacter cholecystus sp. nov., from the gallbladders of Syrian hamsters with cholangiofibrosis and centrilobular pancreatitis

A filamentous, gram-negative, motile bacterium with a single polar sheathed flagellum was isolated from gallbladders of hamsters with cholangiofibrosis and centrilobular pancreatitis. Bacteria grew under microaerophilic conditions at 37 and 42 degrees C, were oxidase, catalase, arginine aminopeptidase, and L-arginine arylamidase positive, reduced nitrate to nitrite, were resistant to cephalothin, and exhibited intermediate susceptibility to nalidixic acid. Sequence analysis of the 16S rRNA gene indicated that the bacterium was a novel member of the Helicobacter genus, most closely related to Helicobacter pametensis. We propose to name this bacterium Helicobacter cholecystus. In epidemiologic studies, isolation of H. cholecystus correlated strongly with the presence of cholangiofibrosis and centrilobular pancreatitis; however, further studies are needed to define the role of this bacterium in pathogenesis.

Gallbladder and biliary tract candidiasis

BACKGROUND

The clinical significance of Candida spp isolated from the gallbladder on the biliary tract is relatively unknown.

METHODS

To provide this information, patients with Candida spp isolated from gallbladder and other biliary tract sources during a 10-year period were identified through the records of our clinical microbiology laboratory. Medical records were analyzed for biliary disease causes, culture data, treatment, and outcome.

RESULTS

Twenty-seven patients were identified. Five of seven patients with cholecystitis were critically ill intensive care unit (ICU) patients in whom the mortality rate was 100%. Gallstone pancreatitis was found in four patients and was fatal in one patient with a pancreatic abscess and ongoing retroperitoneal sepsis. An external biliary shunt/endoprosthesis was placed in 16 patients to relieve biliary obstruction. Cholangitis was present in 14 patients, and most bile cultures contained Candida as part of a mixed flora. Only 3 of 27 patients had candidemia, and 22 of 27 patients were colonized with Candida at other sites.

CONCLUSIONS

(1) The ICU patient with Candida cholecystitis has a grave prognosis. (2) Patients with Candida isolated from biliary stents placed for obstruction and cholangitis should be treated with both antifungal and broad spectrum antimicrobial agents. (3) Candidemia is not frequently seen in this setting.

Vibrio cholerae 01 isolated in the gallbladder of a patient presenting with cholecystitis

Cholera is a topical infection of the intestinal tract and rarely causes extraintestinal disease. The gallbladder has been proposed to be the reservoir of this organism. We present a patient from Bolivia who developed symptoms of acute cholecystitis and whose bile culture grew Vibrio cholerae 01 El tor.

Bacteria closely resembling Helicobacter pylori detected immunohistologically and genetically in resected gallbladder mucosa

A microorganism with close immunohistological and genetic resemblance to Helicobacter pylori was found in the resected gallbladder mucosa of a 41-year-old woman. The woman was admitted to hospital complaining of fever and right hypochondrial pain. Cholecystectomy was carried out under the diagnosis of gallstones and cholecystitis. A microorganism resembling H. pylori (stained with H&E, Giemsa, and Wartin-Starry) was detected incidentally on pathological examination. The microorganism was also positive for immunohistochemical staining. An amplification reaction was seen on genetic examination by the polymerase chain reaction (PCR) method (urease beta-genes). Our findings suggest that H. pylori may be present in tissues other than gastric mucosa.

Autoimmunity in chronic active Helicobacter hepatitis of mice. Serum antibodies and expression of heat shock protein 70 in liver

Male A/JCr mice with naturally occurring Helicobacter hepaticus infection develop a progressive chronic active hepatitis and liver tumors, despite the presence of serum antibodies to Helicobacter proteins. A rabbit antiserum prepared against the bacterial proteins immunoreacted with hepatocytes present in liver sections from infected mice with progressive lesions. We found that sera from these mice contained IgG antibodies that reacted in immunoblots with recombinant heat shock protein 70 (DmaK from Escherichia coli) but not with heat shock protein 60 (GroEL) or heat shock protein 10 (GroES). A rabbit antibody to heat shock protein 70 reacted with H. hepaticus in tissue sections and to a H. hepaticus protein (70 kd) in Western blots. Immunohistochemistry and in situ hybridization for heat shock protein 70 revealed that individual hepatocytes and other cells expressed the protein in livers with hepatitis but not usually in normal livers. Liver tumors and preneoplastic lesions in infected mice did not usually express heat shock protein 70 except focally in a few tumors. In situ hybridization for H. hepaticus 16S rRNA showed that the bacteria was found throughout the liver associated with hepatitis but not within tumors. CD3+ T lymphocytes were found in close association with hepatic lesions. These data suggest a role for autoimmunity in progressive hepatitis and carcinogenesis in livers infected with H. hepaticus.

Occurrence of Salmonella in cold-blooded animals in Gran Canaria, Canary Islands, Spain

The occurrence of Salmonella in endemic and subendemic species of lizard and frog of Gran Canaria, Gallotia stehlini and Rana perezi, as well as captive reptiles from other regions of the world was investigated. The occurrence of Salmonella was statistically higher in endemic and subendemic species than in captive animals (p < 0.001). Seventy strains of Salmonella were isolated. S. berta and S. gran canaria were the most frequently isolated serotypes. The study of Salmonella in gall-bladder contents showed a high parasitation (85%), being higher in Gallotia stehlini (100%) than in Rana perezi (60%). None of the isolated salmonellae were resistant to tested antibiotics.

Emphysematous pyelonephritis with resultant emphysematous cholecystitis secondary to hematogenous dissemination

Both emphysematous pyelonephritis and emphysematous cholecystitis are uncommon, but potentially fatal, clinical entities. The simultaneous diagnosis of these two entities in the same patient has not previously been reported. In this paper, we describe a 68-year-old diabetic male who presented acutely with emphysematous pyelonephritis and emphysematous cholecystitis. This case demonstrates several important diagnostic and treatment considerations. Additionally, the unique circumstances of this case offer support for the proposal that emphysematous cholecystitis may often be secondary to hematogenous seeding/embolic phenomena rather than obstruction of the cystic duct. Prompt diagnosis is essential, as prompt intervention can minimize mortality and morbidity.