Nodular lymphoid hyperplasia with hypogammaglobulinaemia

The Epidemiology and Clinical Manifestations of Autoimmunity in Selective IgA Deficiency

Selective immunoglobulin A deficiency (SIgAD) is the most common primary immunodeficiency, defined as an isolated deficiency of IgA (less than 0.07 g/L). Although the majority of people born with IgA deficiency lead normal lives without significant pathology, there is nonetheless a significant association of IgA deficiency with mucosal infection, increased risks of atopic disease, and a higher prevalence of autoimmune disease. To explain these phenomena, we have performed an extensive literature review to define the geoepidemiology of IgA deficiency and particularly the relative risks for developing systemic lupus erythematosus, hyperthyroidism, hypothyroidism, type 1 diabetes mellitus, Crohn's disease, ulcerative colitis, rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, and vitiligo; these diseases have strong data to support an association. We also note weaker associations with scleroderma, celiac disease, autoimmune hepatitis, immune thrombocytopenic purpura, and autoimmune hemolytic anemia. Minimal if any associations are noted with myasthenia gravis, lichen planus, and multiple sclerosis. Finally, more recent data provide clues on the possible immunologic mechanisms that lead to the association of IgA deficiency and autoimmunity; these lessons are important for understanding the etiology of autoimmune disease.

Clinicopathological and Ileocolonoscopic Characteristics in Patients with Nodular Lymphoid Hyperplasia in the Terminal Ileum

Nodular lymphoid hyperplasia (NLH) in the small intestine is a rare benign lesion, characterized by the presence of multiple small nodules on the surface of the intestine. To define the clinicopathological and colonoscopic characteristics in Chinese patients with ileal NLH, we collected 65 patients with NLH in the terminal ileum from the endoscopic database in our hospital and clinical data from medical records. Histology and immunohistochemical staining were performed in the biopsies. The results demonstrated that the main symptoms included diarrhea (70.8%), abdominal pain (60.0%), hematochezia (46.2%), anemia (40.0%), and hypoproteinemia (21.5%). Enteroscopy revealed multiple, sporadic, granular or round-shaped nodules with diameters between 2 and 5 mm in the terminal ileum. The histology revealed the nodules consisted of mass lymphoid follicles in the lamina propria and submucosa of the terminal ileum. The follicles contained mitotically active germinal centers surrounded by well-defined lymphocyte mantles and composed predominantly of CD20⁺ B cells. The diseases found in patients with NLH included chronic diarrhea, Crohn's disease, ischemic enterocolitis and allergic purpura. The level of hemoglobin in NLH patients who had diarrhea and hematochezia remarkably decreased as compared with those in patients with chronic diarrhea. In conclusion, ileocolonoscopic screening is an important step to find the NLH in terminal ileum patients with diarrhea, abdominal pain, hematochezia, and hypoproteinemia. Histological examination is necessary for the exclusion of malignancy and chronic inflammation.

Lymphoid Polyps of the Palatine Tonsil

Tonsillar lymphoid polyps are uncommon lesions that have rarely been studied. The authors describe the clinical, histopathologic, and immunohistochemical features of 6 tonsillar polyps in which lymphoid tissue represented more than 80% of the lesion. Presenting symptoms were tonsillar mass and/or dysphagia. No predisposing factor was detected. Microscopically, all polyps contained follicles with germinal centers, crypts lined by lymphoepithelium, and a small amount of fibrous tissue in the center of the lesion. B cells (CD20+), T cells (CD45RO+), plasma cells (κ+ and λ+) and vessels (lymphatic, D2-40+; blood, CD34+) presented distribution and architectural patterns as expected for lymphoid tissue of a palatine tonsil. Tonsillar lymphoid polyps are possibly hamartomas characterized by overgrowth of lymphoid elements, which maintain an architectural pattern and cellular composition similar to those of the palatine tonsil.

Diffuse duodenal nodular lymphoid hyperplasia: a large cohort of patients etiologically related to Helicobacter pylori infection

BACKGROUND

Nodular lymphoid hyperplasia of gastrointestinal tract is a rare disorder, often associated with immunodeficiency syndromes. There are no published reports of its association with Helicobacter pylori infection.

METHODS

From March 2005 till February 2010, we prospectively followed all patients with diffuse duodenal nodular lymphoid hyperplasia (DDNLH). Patients underwent esophagogastroduodenoscopy with targeted biopsies, colonoscopy, and small bowel video capsule endoscopy. Duodenal nodular lesions were graded from 0 to 4 based on their size and density. Patients were screened for celiac sprue (IgA endomysial antibody), immunoglobulin abnormalities (immunoglobulin levels & serum protein electrophoresis), small intestine bacterial overgrowth (lactulose hydrogen breath test), and Helicobacter pylori infection (rapid urease test, and histological examination of gastric biopsies). Patients infected with Helicobacter pylori received sequential antibiotic therapy and eradication of infection was evaluated by 14C urea breath test. Follow up duodenoscopies with biopsies were performed to ascertain resolution of nodular lesions.

RESULTS

Forty patients (Males 23, females 17; mean age ± 1SD 35.6 ± 14.6 years) with DDNLH were studied. Patients presented with epigastric pain, vomiting, and weight loss. Esophagogastroduodenoscopy showed diffuse nodular lesions (size varying from 2 to 5 mm or more) of varying grades (mean score ± 1SD 2.70 ± 0.84) involving postbulbar duodenum. Video capsule endoscopies revealed nodular disease exclusively limited to duodenum. None of the patients had immunoglobulin deficiency or small intestine bacterial overgrowth or positive IgA endomysial antibodies. All patients were infected with Helicobacter pylori infection. Sequential antibiotic therapy eradicated Helicobacter pylori infection in 26 patients. Follow up duodenoscopies in these patients showed significant reduction of duodenal nodular lesions score (2.69 ± 0.79 to 1.50 ± 1.10; p < 0.001). Nodular lesions showed complete resolution in 5 patients and significant resolution in remaining 21 patients. Patients with resistant Helicobacter pylori infection showed no significant reduction of nodular lesions score (2.71 ± 0.96 to 2.64 ± 1.15; p = 0.58). Nodules partially regressed in score in 2 patients, showed no interval change in 10 patients and progressed in 2 patients.

CONCLUSIONS

We report on a large cohort of patients with DDNLH, etiologically related to Helicobacter pylori infection.

Medical treatment of recurrent intussusception associated with intestinal lymphoid hyperplasia

Intestinal lymphoid hyperplasia (ILH) is an uncommon cause of recurrent intussusception in infants and young children. Surgical treatment has been suggested in the management of this disorder. We report 2 cases in which recurrent intussusception was associated with ILH. A short course of steroids resulted in resolution of both symptoms and hyperplasia. We conclude that when recurrent intussusception occurs in association with ILH, and no other lead point can be identified, it is important that treatment with steroids is considered before resorting to a more radical surgical approach.

Lipomatous polyposis of the colon with multiple lipomas of peritoneal folds and giant diverticulosis: report of a case

A case of multiple lipomatosis exclusively located in the colon is reported in a young male (33 years). It is characterized by a great number of lipomas with polyposis growth appearance, multiple lipomas of peritoneal folds, and giant diverticulosis probably caused by weakened areas of colonic wall induced by the lipomas.

Enterocolitis in children with developmental disorders

OBJECTIVE

Intestinal pathology, i.e., ileocolonic lymphoid nodular hyperplasia (LNH) and mucosal inflammation, has been described in children with developmental disorders. This study describes some of the endoscopic and pathological characteristics in a group of children with developmental disorders (affected children) that are associated with behavioral regression and bowel symptoms, and compares them with pediatric controls.

METHODS

Ileocolonoscopy and biopsy were performed on 60 affected children (median age 6 yr, range 3-16; 53 male). Developmental diagnoses were autism (50 patients), Asperger's syndrome (five), disintegrative disorder (two), attention deficit hyperactivity disorder (ADHD) (one), schizophrenia (one), and dyslexia (one). Severity of ileal LNH was graded (0-3) in both affected children and 37 developmentally normal controls (median age 11 yr, range 2-13 yr) who were investigated for possible inflammatory bowel disease (IBD). Tissue sections were reviewed by three pathologists and scored on a standard proforma. Data were compared with ileocolonic biopsies from 22 histologically normal children (controls) and 20 children with ulcerative colitis (UC), scored in an identical manner. Gut pathogens were sought routinely.

RESULTS

Ileal LNH was present in 54 of 58 (93%) affected children and in five of 35 (14.3%) controls (p < 0.001). Colonic LNH was present in 18 of 60 (30%) affected children and in two of 37 (5.4%) controls (p < 0.01). Histologically, reactive follicular hyperplasia was present in 46 of 52 (88.5%) ileal biopsies from affected children and in four of 14 (29%) with UC, but not in non-IBD controls (p < 0.01). Active ileitis was present in four of 51 (8%) affected children but not in controls. Chronic colitis was identified in 53 of 60 (88%) affected children compared with one of 22 (4.5%) controls and in 20 of 20 (100%) with UC. Scores of frequency and severity of inflammation were significantly greater in both affected children and those with UC, compared with controls (p < 0.001).

CONCLUSIONS

A new variant of inflammatory bowel disease is present in this group of children with developmental disorders.

Lymphoid hyperplasia of the large intestine: a case report with immunohistochemical and gene analysis

A case of lymphoid hyperplasia arising in the large intestine of a 54-year-old woman is described. Barium enema X-ray and colonoscopic examination revealed multiple small polyps in the right side of the colon. Pathological findings from forceps biopsy revealed similar features to a mucosa-associated lymphoid tissue (MALT) lymphoma. A right hemicolectomy with mesenteric lymph node dissection was carried out. Histological sectioning demonstrated hypertrophic lymphoid follicles with well-formed germinal centers. Occasionally, lymphocytes infiltrated the crypts, in a way similar to that found in lymphoepithelial lesions, which was suggestive of a MALT lymphoma diagnosis. Cryptitis was also observed in the lamina propria. Immunohistochemically, proliferating lymphocytes were positive for CD20 (L26) and negative for CD45RO (UCHL-1). Analyses of immunoglobulin gene (IgHJH) rearrangement could not detect any monoclonality in these cells. These findings suggested that the present case should be categorized as lymphoid hyperplasia rather than lymphoma.

Lymphocyte-filled villi: comparison with other lymphoid aggregations in the mucosa of the human small intestine

BACKGROUND & AIMS

Solitary lymphoid structures that may be sites of primary extrathymic T-cell differentiation have been described recently in murine (cryptopatches) and rat (lymphocyte-filled villi) small intestine. This study tests the hypothesis that similar structures occur in human small intestine.

METHODS

Normal small intestine was obtained during surgery. Fixed tissue was examined histologically, and frozen sections were examined by an indirect immunoperoxidase technique using a panel of mouse monoclonal antibodies.

RESULTS

A new isolated lymphoid structure, with epithelium resembling follicle-associated epithelium of Peyer's patches, is described as a lymphocyte-filled villus. These structures contain major histocompatibility complex (MHC) class II-positive dendritic cells, a majority of memory T cells, a variable B-cell component, and no evidence of immature lymphocytes that express either c-kit or CD1a. Two previously described lymphoid aggregations (isolated lymphoid follicles and submucosal lymphoid aggregations) are components of a single structure. The complete structure contains a B-cell follicle, T cells with mainly memory (CD45RO-positive) phenotype, high endothelial venules, and no detectable population of immature lymphocytes.

CONCLUSIONS

A new solitary lymphoid structure is described in the human small intestine. Neither these structures nor isolated lymphoid follicles appear to be similar to solitary primary lymphoid structures in rodent intestine.

Giardiasis

Despite rapid progress in understanding the biology of Giardia, several questions remain unanswered. First, there is no adequate explanation for the diverse clinical spectrum of giardiasis. Second, the mechanisms by which Giardia produces diarrhea and malabsorption are poorly understood, although some progress has been made. Finally, despite extensive studies in animal models and human infections, the key immunologic determinants for clearance of acute infection and development of protective immunity remain ill defined. This article discusses the epidemiology, pathology, diagnosis, treatment, and prevention of giardiasis.

Multiple lymphomatous polyposis of the gastrointestinal tract. An extensive histopathologic and immunohistochemical study of 12 cases

BACKGROUND

Multiple lymphomatous polyposis (LP) is a rare entity, characterized by multiple polypoid tumors involving several segments of the gastrointestinal tract.

METHODS

In this large retrospective series of 12 patients with LP, histologic and immunohistochemical features were investigated from patients with multiple biopsy samples from each site (500 gastrointestinal biopsies). Immunohistochemistry was performed on paraffin embedded biopsies from 12 patients and on frozen tissue biopsies from 8 patients, for each of whom at least two different anatomic sites were studied.

RESULTS

Histologic features always were characterized by nodules located in mucosa and submucosa composed of lymphomatous, small cleaved cells. B-cell phenotype of the neoplastic cells was the same phenotype as adult mantle-zone cells or fetal follicle cells (frequent coexpression of surface IgM and surface IgD, and weak expression of CD5, CD35+, CDw32+, and CD23-). Tested cases expressed bcl-2. Five to 20% of LP cells were positive for the monoclonal antibody Ki-67. Five patients died within 5-32 months after diagnosis. Frequent extradigestive sites were also identified. There were two unique findings: five cases with digestive tract lymphoepithelial lesions (LEL), and one secondary transformation to large B-cell malignant lymphoma.

CONCLUSIONS

To the authors' knowledge, this is the largest series so far of LP studied with immunohistochemistry on frozen sections. Mantle-cell B cell phenotype of the nodular monotonous, small cleaved cells is confirmed. This entity may be classified as mantle-cell lymphoma with a similar aggressive clinical course, and treated as a high grade B-cell lymphoma. The authors know of no such LEL that has been reported previously, and secondary transformation has been described only briefly in one case.

Gastrointestinal disease in the immunocompromised patient

Gastrointestinal (GI) disease is frequent in all types of immunocompromised patients but occurs with greatest frequency in patients with acquired immunodeficiency syndrome (AIDS). Thus, much of this review deals with human immunodeficiency virus (HIV)-related GI diseases. Gastrointestinal diseases in other immunocompromised patients are compared with those in patients with AIDS. Conditions unique to transplant recipients, such as graft-versus-host disease (GVHD) and posttransplant lymphoproliferative disorders (PTLDs), are discussed separately. We have divided these GI diseases into four main categories: (1) HIV-related inflammatory conditions other than opportunistic infections (HIV-related enteropathy, proctocolitis, and CD8 lymphocytosis); (2) inflammatory conditions unrelated to HIV or opportunistic infections (neutropenic enterocolitis, regional enteritislike enteropathy, and GVHD); (3) opportunistic infections (illnesses caused by herpesvirus, cytomegalovirus, and miscellaneous other viruses; Mycobacterium, Candida, Histoplasma, Cryptococcus, Cryptosporidium, Microsporida, Isospora, Leishmania, Toxoplasma and Strongyloides organisms as well as Pneumocystitis carinii; and (4) neoplasias (Kaposi's sarcoma [KS], AIDS-related non-Hodgkin's lymphoma [NHL], HIV-related Hodgkin's disease [HD], PTLDs, and miscellaneous neoplasms). The prevalence, pathogenesis, clinical manifestations, gross pathological findings, and microscopic features of each disease entity are discussed.

Intussusception, adenovirus, and children: a brief reaffirmation

Surgical specimens (n = 48) or autopsy case materials (n = 15) were studied from 63 pediatric patients (44 males and 19 females) with intussusceptions involving the ileocecal junction (38 patients [60.3%]), ileum (16 patients [25.4%]), jejunum (four patients [6.3%]), and other sites (five patients [8%]). Lymphoid hyperplasia formed the leading edge in 32 cases (51%); other lesions included Meckel diverticulum (six cases), lymphoma (four cases), adenomyomatous hamartoma (four cases), cecal duplication cyst (three cases), ectopic pancreas (two cases), congenital bowel malformation (two cases), and examples of Peutz-Jeghers polyp, lymphangioma, leiomyoma, and inflammatory fibroid polyp (one case each). In six cases there was no associated lesion. Immunohistochemical evaluation for adenovirus was performed in 16 of the 32 cases in which lymphoid hyperplasia was present, and five reactive cases were identified; characteristic intranuclear adenovirus inclusions were visible on hematoxylin-eosin-stained specimens from all five of these cases as well as in five additional cases (a total of 10 of 32 cases [31.2%]). The presence of Yersinia sp was confirmed by serology in one case having characteristic histologic findings. Fourteen deaths were attributable to consequences of intussusception; these patients were younger (median and mean ages, 5.5 and 8.6 months; age range, 1 month to 3.5 years) than the surviving patients (median and mean ages, 2.0 and 3.2 years; age range, 6 days to 14 years), but were not more likely to have evidence of adenovirus infection.

Diarrhoeal disease: current concepts and future challenges. Pathogenesis of giardiasis

Giardiasis is the most common small intestinal protozoal infection and is found worldwide. The mechanisms by which Giardia duodenalis (= G. lamblia) produces chronic diarrhoea and malabsorption have still not been clearly defined. Many infections are associated with mild to moderate mucosal damage which, in animal models of infection, have functional correlates. Possible mechanisms include direct physical injury, release of parasite products such as proteinases or lectin, and mucosal inflammation associated with T cell activation and cytokine release. Other possible mechanisms of malabsorption include associated bacterial overgrowth and bile salt deconjugation, bile salt uptake by the parasite with depletion of intraluminal bile salts, and inhibition of pancreatic hydrolytic enzymes. Thus, there is no single mechanism to explain the diarrhoea and malabsorption caused by Giardia, which currently should be regarded as a multifactorial process.

Diffuse follicular lymphoid hyperplasia of the small intestine without primary immunoglobulin deficiency

Three cases of follicular lymphoid hyperplasia extending to the whole length of small intestine are reported in three young adult patients of low economic status. The disease was revealed by chronic diarrhea with malabsorption and/or protein-losing enteropathy. In one patient, all transitional patterns were found between the hyperplastic follicles and a small intestinal multicentric centrocytic-centroblastic lymphoma. No abnormalities in humoral or cellular immunity were found in the three patients. In particular, serum immunoglobulins (except IgG in one case) and plasma cell populations of small intestinal lamina propria were normal. Diffuse follicular lymphoid hyperplasia of the small intestine in the absence of primary immunoglobulin deficiency appears to be a rare condition associated with (or leading to) intestinal malignant lymphoma in most cases. Patients usually belong to the same populations as those suffering from alpha-chain disease.

Impaired proliferative response to B-lymphocyte activators in common variable immunodeficiency

The cell-mediated immune responses of 39 patients with common variable immunodeficiency (CVI) were studied in vitro, using Staphylococcus aureus and Escherichia coli prepared as whole cells and Candida albicans extract. These microbial activators wee found to require intact B-lymphocyte function for normal proliferative response. The patient group was observed to have significantly depressed lymphocyte responses compared wit those of controls studied in parallel (P less than 0.01). Negative lymphocyte response to one activator and strongly positive response to another were found in individual patients. Examination of patients' lymphocyte response to S. aureus and E. coli in association with serum IgG levels demonstrated that a rough correlation could be drawn, showing that patients with serum IgG less than 125 mg/dl had markedly lower (P less than 0.01) lymphocyte responses than those with serum IgG greater than 300 mg/dl. No similar correlation with phytohaemagglutinin activation was observed. Since depressed lymphocyte responses did not correlate with reduced B-cell number in these patients, intrinsic B-lymphocyte deficiency was indicated. These preparations of microbial activators are potentially useful tools in exploring lymphocyte subpopulation functions in primary immunodeficiency diseases.

Spectrum of lymphoid hyperplasia: colonic manifestations of sarcoidosis, infectious mononucleosis, and Crohn's disease

The radiographic pattern of nodular lymphoid hyperplasia, perhaps better called the lymphoid follicular pattern, has variously been described as an indication of disease and as a normal variant in the adult, with current opinion favoring the latter. We report 3 cases wherein this pattern resulted from definite pathologic processes: sarcoidosis, infectious mononucleosis, and Crohn's disease. Although usually of no pathological significance, the benign follicular pattern may reflect a variety of diseases.

Jejunal lymphoma in a patient with primary adult-onset hypogammaglobulinemia and nodular lymphoid hyperplasia of the small intestine

A patient is presented with primary adult-onset hypogammaglobulinemia and nodular lymphoid hyperplasia of the small intestine complicated by a jejunal lymphoma. The tumor was resected and was classified as a malignant diffuse histiocytic lymphoma with involvement of mesenteric lymph nodes. Gastroenterological, immunological, histological, and immunopathological studies on this case are reported. The possibility that nodular lymphoid hyperplasia of the small intestine in hypogammaglobulinemia is a premalignant condition is discussed.

Nodular lymphoid hyperplasia of the bowel in primary hypogammaglobulinaemia: study of in vivo and in vitro lymphocyte function

In vitro and in vivo lymphocyte function was studied in six patients with primary hypogammaglobulinaemia and nodular lymphoid hyperplasia (NLH) of the bowel. Lymphocyte transformation, numbers of circulating T and B lymphocytes, and delayed hypersensitivity skin tests did not significantly differ when compared with hypogammaglobulinaemic patients without NLH. However, patients with NLH had higher jejunal juice IgM concentrations and a tendency to higher serum IgM concentrations than those without NLH. The morphological features of NLH are similar to the germinal centres of lymph nodes but more closely resemble the follicle zone of Peyer's patches. These findings suggest that NLH represents a local immune response to antigens originating in the gut lumen.

Intestinal lesions in immune deficiency

The descriptive studies of intestinal lesions in immune deficiency and the research that has been done in order to explain their pathogenesis are reviewed. Current knowledge in this field is inadequate, and some of the intriguing phenomena described defy reasonable explanation, including the special role of Giardia lamblia and the rarity of gastrointestinal lesions in isolated IgA deficiency. Several hypotheses have been proposed regarding these phenomena.