Eosinophilic esophagitis, gastroenteritis, and colitis in a patient with prior parasite exposure

Eosinophilic gastrointestinal disorders (EGID) comprise a spectrum of inflammatory diseases that can affect any segment of the gastrointestinal tract. The pathogenesis of these conditions is complex; differentiating between primary and secondary forms of these disorders can be clinically challenging. We report a case of primary EGID in a patient with remote parasite exposure, whose symptoms were initially attributed to irritable bowel syndrome. Endoscopy revealed the rare finding of EGID involving the entire gastrointestinal tract; symptoms improved with an elimination diet. This case raises the possibility of a link between prior parasite exposure and development of EGID, and underscores the necessity of exploring alternative diagnoses in patients with presumed IBS who present with severe symptoms.

Epidemiology of Sulcascaris sulcata (Nematoda: Anisakidae) ulcerous gastritis in the Mediterranean loggerhead sea turtle (Caretta caretta)

Sulcascaris sulcata Rudolphi 1819 is a gastric nematode parasite of sea turtles. Here, we report the occurrence and describe for the first time the pathological changes caused by S. sulcata in the Mediterranean loggerhead sea turtle (Caretta caretta) stranded along the Tyrrhenian coast and northern Adriatic coast of Italy. Prevalence of infection was significantly higher in loggerhead sea turtles from the Adriatic Sea. Both prevalence and abundance of infection showed an increasing trend along with host age classes from both geographical localities. Nevertheless, while many small loggerhead sea turtles were found infected from the Adriatic Sea, only bigger individuals were infected from the Tyrrhenian Sea. The most common gross pathological change was a mucous gastritis with focal to multifocal raised ulcerous lesions roundish to irregular in shape ranging from 1 to over 20 cm in length, and cream-yellowish to greenish in color. The severity grade of gastritis increased with higher number of S. sulcata individuals. Microscopic pathological changes ranged from atrophic gastritis with heterophilic infiltration in the lamina propria to the destruction of the mucosal and sub-mucosal surfaces and necrosis. Results here obtained demonstrate that S. sulcata may cause ulcerous gastritis in both samples of loggerhead sea turtles studied from the Mediterranean Sea. Observed differences in S. sulcata infection among the different host age classes and between the two studied basins are likely linked to the differences of regional habitat and intermediate prey host availability.

Hypereosinophilia and epigastralgia after visiting Tunisia: a rare differential diagnosis of helminthiases

Causes of hypereosinophilia among travelers returning from North Africa are dominated by helminth infections, especially when associated with gastrointestinal signs. Non-infectious causes must nonetheless be investigated after negative microbiological assessment and failure of a broad empiric antiparasite treatment. We report the case of a young man with epigastralgia and major weight loss since a stay in Tunisia. Empiric treatment with albendazole was not successful. Eosinophilic gastroenteritis was diagnosed and resolved under corticosteroid treatment.

Gastritis, Enteritis, and Colitis in Horses

The gastrointestinal system of horses is affected by a large variety of inflammatory infectious and noninfectious conditions. The most prevalent form of gastritis is associated with ulceration of the pars esophagea. Although the diagnostic techniques for alimentary diseases of horses have improved significantly over the past few years, difficulties still exist in establishing the causes of a significant number of enteric diseases in this species. This problem is compounded by several agents of enteric disease also being found in the intestine of clinically normal horses, which questions the validity of the mere detection of these agents in the intestine.

First ultrastructural observations on gastritis caused by Physaloptera clausa (Spirurida: Physalopteridae) in hedgehogs (Erinaceus europeaus)

Ultrastructural changes of gastritis due to infection with Physaloptera clausa in 12 fresh carcasses of euthanized European hedgehogs (Erinaceus europaeus) collected from different part of Urmia, Iran, in which they were highly populated with this animal, six females and six males were subjected to detail necropsy with special reference to the stomach. Macroscopic changes of stomach were recorded and some of the worms collected. Based on number of parasites present in the stomach, they were divided into light infection, mild infection, and severe infection. Parasites were collected, and worms identification of the species was confirmed on the basis of light microscope examination with reference to keys. Tissues fixed in 3% glutaraldehyde, post-fixed in 1% osmium tetroxide and processed and plastic embedded; ultrathin sections of 60-70 nm were cut and stained with uranyl acetate and lead citrate; electron microscopic observations showed that, in light infection some changes were observed in gastric cells such as dilatation and vesiculation of the endoplasmic reticulum, large numbers of lipid granules, mitochondrial swelling, nuclear chromatin margination, and some nucleus showed washed out appearance. Other cells showed some alterations in mitochondria, dilatation of smooth endoplasmic reticulum, loss of both free and bound ribosomes, vesiculation in cytoplasm, and increase Golgi apparatus and secretory vesicles. The inflammatory cells including lymphocytes, macrophages, mast cells, and predominantly eosinophils were identified. In moderate infection, the cellular pattern of gastric mucosa replaced with inflammatory cells. The marked increase of macrophages and other inflammatory cell was observed. A particular finding in our study was the presence of globule leukocyte in the moderate stage. Moreover, scant formation and distribution of collagen fibers as well as fibroblasts were also noted. In severe infection, the most obvious observation was marked distribution of collagen fibers around the mucosal cells. The fibroblastic cells with elongated nucleus and extensive indentation were noticed. In conclusion, the result of our study revealed P. clausa could be a cause of gastritis and according to cellular pattern of inflammatory reaction, with the increase of worm burden and development of infection, chronic gastritis was stabilized. Present investigation documented the ultrastructural changes during verminous gastritis in hedgehogs.

Gastric infection by Strongyloides stercoralis: a case report

Strongyloides stercoralis is an intestinal nematode with a complex life cycle that involves colonizing and reproducing in the upper small intestinal mucosa. In a healthy host, the parasite usually does not cause any symptoms. We report a gastric infection case of S. stercoralis. A 72-year-old Turkish man was admitted to the Department of General Surgery with complaints of epigastric pain, nausea and vomiting for five days. Upper gastrointestinal endoscopy evidenced a diffuse infiltrate in the stomach, causing decreased distensibility. Microscopically, superficial chronic inflammation with hyperplastic reactive changes and damaged surface was observed. Histopathological examination of the gastric mucosa showed numerous cross-sections of adult worms, eggs and rhabditiform larvae of S. stercoralis developing in the gastric crypts.

Anisakis simplex: from obscure infectious worm to inducer of immune hypersensitivity

Infection of humans with the nematode worm parasite Anisakis simplex was first described in the 1960s in association with the consumption of raw or undercooked fish. During the 1990s it was realized that even the ingestion of dead worms in food fish can cause severe hypersensitivity reactions, that these may be more prevalent than infection itself, and that this outcome could be associated with food preparations previously considered safe. Not only may allergic symptoms arise from infection by the parasites ("gastroallergic anisakiasis"), but true anaphylactic reactions can also occur following exposure to allergens from dead worms by food-borne, airborne, or skin contact routes. This review discusses A. simplex pathogenesis in humans, covering immune hypersensitivity reactions both in the context of a living infection and in terms of exposure to its allergens by other routes. Over the last 20 years, several studies have concentrated on A. simplex antigen characterization and innate as well as adaptive immune response to this parasite. Molecular characterization of Anisakis allergens and isolation of their encoding cDNAs is now an active field of research that should provide improved diagnostic tools in addition to tools with which to enhance our understanding of pathogenesis and controversial aspects of A. simplex allergy. We also discuss the potential relevance of parasite products such as allergens, proteinases, and proteinase inhibitors and the activation of basophils, eosinophils, and mast cells in the induction of A. simplex-related immune hypersensitivity states induced by exposure to the parasite, dead or alive.

[Gastric cryptosporidiosis revealing a small cell lung carcinoma (Tunisia)]

Cryptosporidium, agent of cryptosporidiosis, is an ubiquitous protozoan organism causing diarrhoea especially in severe immunosuppressed patients. Cryptosporidium has been detected with increasing frequency in the gastrointestinal tract, but involvement of the stomach is rarely reported and discloses an underlying immunodeficiency state. We report the case of 67-year-old man, a heavy smoker, who presented with a history of epigastric pain with an altered general condition. Upper gastrointestinal endoscopy showed no significant mucosal abnormalities. The biopsy revealed a chronic active gastritis with Cryptosporidium parasites lining cryptic epithelium. Systematic chest X ray showed a right suspect parenchymatous opacity. Bronchoscopy with multiple biopsies concluded to a small cell lung carcinoma. Through this rare initial manifestation of immunocompromised state related to cancer we will discuss the role of gastrointestinal endoscopy with biopsies in the diagnosis of cryptosporidiosis.

Anisakis simplex: sensitization and clinical allergy

PURPOSE OF REVIEW

Whereas gastric anisakiasis has been known for several decades, the implications of Anisakis simplex-related allergic disorders had not been thoroughly studied until the late 1990s. This article reviews recent knowledge of allergic disorders ascribed to A. simplex contact or parasitism.

RECENT FINDINGS

Gastroallergic anisakiasis describes an acute hypersensitivity reaction emerging in the context of an acute parasitism by the nematode A. simplex. But other frequent allergic disorders like chronic urticaria are now being studied for a possible relationship with A. simplex parasitism. In recent investigations, non-IgE mediated mechanisms, such as the involvement of other immunoglobulin isotypes (IgG4), or non-immunological events are discussed.

SUMMARY

The experience of the last several years shows that allergic hypersensitivity symptoms in gastroallergic anisakiasis are clinical events accompanying a wide range of immunologic reactions as a host response against a ubiquitous parasite. The discussed and reviewed studies should motivate allergists around the world to search for this entity. Further studies in the field of allergy could benefit from the experience of this peculiar food-related disorder.

Gastric Toxoplasmosis as the Presentation of Acquired Immunodeficiency Syndrome

We report a case of a 39-year-old West African man with unknown human immunodeficiency virus status diagnosed with gastric toxoplasmosis as the presenting manifestation of acquired immunodeficiency syndrome. Toxoplasma gondii is common in severely immunosuppressed patients and most frequently involves the central nervous system, followed by the eye, myocardium and skeletal muscle, lungs, bone marrow, and peripheral blood. For unclear reasons, gastrointestinal involvement is exceedingly rare and occurs in the context of severe immunosuppression and disseminated disease. To our knowledge, this is the first report in the English literature of a patient with isolated, manifest gastric toxoplasmosis without evidence of concomitant cerebral or extracerebral involvement. It is important for both the clinician and the pathologist to maintain a high index of suspicion for toxoplasmosis in immunosuppressed patients presenting with nonspecific symptoms of gastritis and radiologic and endoscopic presence of thickened gastric folds with or without ulceration.

Dilated cardiomyopathy and amebic gastritis in a giant anteater (Myrmecophaga tridactyla)

An approximately 11-mo-old female giant anteater (Myrmecophaga tridactyla) exhibited anorexia, lethargy, hypothermia, depression, and minimal response to external stimuli. Radiography and ultrasonography revealed an enlarged heart, with free gas and fluid in the abdomen. Abdominocentesis produced a clear brown fluid with an acute to subacute septic suppurative exudate. Cardiac ultrasonography revealed a dilated, thin-walled left ventricle with a comparatively low fractional shortening. Despite intensive supportive care, the anteater died. Postmortem findings included gastric ulceration with perforation near the pylorus. Entameba spp. and Acanthamoeba spp. were both identified in large numbers at the site of the gastric ulceration and perforation.

Cryptosporidium sp.-associated enteritis without gastritis in rough green snakes (Opheodrys aestivus) and a common garter snake (Thamnophis sirtalis)

An epizootic of severe Cryptosporidium sp.-associated enteritis occurred in a group of 15 wild-caught juvenile rough green snakes (Opheodrys aestivus) at the Baltimore Zoo quarantine facility. All of the animals died with no premonitory signs. Histopathologic examination of the small and proximal large intestine of eight of the green snakes showed moderate to severe Cryptosporidium sp. infection and enteritis characterized by dense heterophilic and lymphocytic inflammatory infiltrates throughout the lamina propria with epithelial necrosis. Cryptosporidium sp. was also found in feces of an adult common garter snake (Thamnophis sirtalis) that was wild caught on zoo grounds and held in quarantine during the epizootic. After euthanasia, histologic examination of the garter snake showed a severe small intestinal Cryptosporidium sp. infection with only mild enteritis consisting of sparse heterophilic and lymphocytic infiltrates. There was no gross or histologic evidence of Cryptosporidium sp. gastritis in the nine snakes evaluated, and this is the first report of Cryptosporidium sp.-associated enteritis in snakes without gastric lesions.

[Giardia lamblia gastritis. A case report]

A 56 year-old male patient had a gastric resection (Billroth II) at age 33. In 1993 he had vague upper digestive complaints. During investigations for a moderate anaemia biopsies performed during an oesogastroduodenoscopy revealed a jejunitis with Giardia lamblia (G.l.) trophozoites which were also found on the gastric mucosa associated with Helicobacter pylori related chronic active gastritis. The few publications dealing with the presence of Giardia lamblia in the stomach either assert or cast some doubts on the pathogenicity of this protozoa for the gastric mucosa. Gastric involvement by G.l. is usually associated with duodeno-jejunal disease responsible for diarrhoea which may occur as epidemics of varying extension. Since Giardia lamblia infection is not submitted to reporting in Switzerland, the epidemiology in our country is scarcely known and investigated. In our opinion, however, health authorities in Switzerland should consider the need of reporting this infectious disease.

Gastroallergic anisakiasis: findings in 22 patients

BACKGROUND AND AIMS

Ingestion of Anisakidae larvae in raw seafood may cause anisakiasis. However, despite the high level of consumption of seafood in Spain, only a few cases of anisakiasis have been reported until now. Anisakis simplex can cause allergic reactions in sensitized patients as a result of its parasitism in the gastrointestinal tract. The purpose of this study was to analyse the clinical findings in 22 patients with gastroallergic anisakiasis.

METHODS

Patients with allergic and/or gastric symptoms after seafood ingestion were evaluated in the emergency room of the La Paz General University Hospital. Skin testing for Anisakis simplex and tests on the implicated seafood were performed and amounts of serum-specific immunoglobulin E were assessed. A gastroscopy was performed in those patients with severe allergic or/and persistent gastric symptoms after ingestion of raw or undercooked seafood.

RESULTS

Twenty-two patients were diagnosed with gastroallergic anisakiasis in 1 year. Most patients presented to the emergency room of our hospital with allergic symptoms. Gastric symptoms were usually moderate. Gastroscopy revealed local mucosal oedema and gastric erosion at the point of fixation. Two or more worms were detected in three patients. The mean time of latency of allergic symptoms was 5 h, while the mean time for gastric symptoms was 3 h.

CONCLUSION

Anisakis simplex parasitism was the causative agent of allergic and gastric symptoms. Gastroallergic anisakiasis appears to be a relatively common disease, that may have been underdiagnosed.

Concurrent enteric helminth infection modulates inflammation and gastric immune responses and reduces helicobacter-induced gastric atrophy

Helicobacter pylori is causally associated with gastritis and gastric cancer. Some developing countries with a high prevalence of infection have high gastric cancer rates, whereas in others, these rates are low. The progression of helicobacter-induced gastritis and gastric atrophy mediated by type 1 T-helper cells may be modulated by concurrent parasitic infection. Here, in mice with concurrent helminth infection, helicobacter-associated gastric atrophy was reduced considerably despite chronic inflammation and high helicobacter colonization. This correlated with a substantial reduction in mRNA for cytokines and chemokines associated with a gastric inflammatory response of type 1 T-helper cells. Thus, concurrent enteric helminth infection can attenuate gastric atrophy, a premalignant lesion.

Granulomatous gastritis due to taeniasis

Taeniasis is very common all over the world and invades the upper small bowel in humans. It is very unusual to see this parasite in the stomach. We report a case of gastric taeniasis that led to granulomatous gastritis. The elimination of the parasite resulted in complete disappearance of the granulomas in the corpus and antrum and in complete recovery of the patient.

A study on the relation between proton pump inhibitor and gastric giardiasis

Thirty patients treated with proton pump inhibitor and still having symptoms related to gastritis or peptic ulcers were subjected to upper gastrointestinal endoscopy and gastric biopsy for detection of giardiasis in these cases. Results showed presence of 3 (10%) cases of gastric giardiasis, intestinal metaplasia and presence of H. pylori in these cases. It is concluded that there may be a relation between the presence of gastric giardiasis and the intake of proton pump inhibitor. The endoscopists have to search for gastric giardiasis especially in the presence of H. pylori and/or intestinal metaplasia.

Gastric invasion by Trypanosoma cruzi and induction of protective mucosal immune responses

Trypanosoma cruzi is an intracellular parasite transmitted from a reduviid insect vector to humans by exposure of mucosal surfaces to infected insect excreta. We have used an oral challenge murine model that mimics vector-borne transmission to study T. cruzi mucosal infection. Although gastric secretions have microbicidal activity against most infectious pathogens, we demonstrate that T. cruzi can invade and replicate in the gastric mucosal epithelium. In addition, gastric mucosal invasion appears to be the unique portal of entry for systemic T. cruzi infection after oral challenge. The mucosal immune responses stimulated by T. cruzi gastric infection are protective against a secondary mucosal parasite challenge. This protective mucosal immunity is associated with increased numbers of lymphocytes that secrete parasite-specific immunoglobulin A. Our results document the first example of systemic microbial invasion through gastric mucosa and suggest the feasibility of a mucosal vaccine designed to prevent infection with this important human pathogen.

AIDS-associated cryptosporidiosis with gastric stricture and a therapeutic response to paromomycin

AIDS-associated cryptosporidiosis has been associated with severe, watery diarrhea and with multifocal biliary stricture. Gastric involvement has not been reported prominently. We report here the case of a 28-yr-old AIDS patient who developed typical watery diarrhea, followed by subtotal gastric obstruction secondary to antral stricturing. Biopsy of the stricture revealed severe inflammation and marked cryptosporidial infestation. Extensive workup excluded causes of stricture. He was empirically treated with paromomycin, with a surprisingly positive therapeutic response and clinical resolution of obstruction. Antral stricture may be another manifestation of cryptosporidial infection in AIDS. Paromomycin deserves further evaluation as an agent for treatment of this infection.

Gastritis caused by Aonchotheca putorii in a domestic cat

Aonchotheca putorii is a parasitic nematode of the stomach and small intestines of many wild mammals. Although A putorii has been found in domestic cats in Iowa, it has not been reported to be pathogenic. The parasite caused severe gastric and was associated with a gastric ulcer and secondary anemia in a 10-year-old domestic shorthair cat from Ohio. The source of infection was not determined. Surgical resection of the affected tissue resolved clinical signs. The importance of postoperative administration of an anthelmintic in the resolution of any remaining A putorii is unknown. Ivermectin was given empirically to this cat. It is not known whether, or at what dosage, ivermectin or any other anthelmintic is effective against A putorii.

Host tissue reaction to Gnathostoma malaysiae (Nematoda: Gnathostomidae) in Rattus surifer Miller

The occurrence of adult Gnathostoma malaysiae in Rattus surifer and R. tiomanicus in Malaysia has been reported but there are no known reports on the host tissue reactions. This paper reports on the gross pathology caused by G. malaysiae in a red spiny forest rat, R. surifer and the tissue reactions caused. A tumor-like growth was located on the mid-stomach wall in a female rat captured in Gunung Bachock, Kelantan, Malaysia. This growth consisted of four tunnel-like structures containing sanguinopurulent fluid and leukocytes and this structure led into a central canal. The tissue surrounding the tumor was greatly inflamed and there was localized gastritis. The tunnel-like structure was surrounded by dense fibrotic tissue. The stomach wall was devoid of superficial epithelium and smooth muscle but mucinous glands were present. The midregion of the fibrotic scar contained eggs of G. malaysiae which had evoked a strong tissue reaction and were surrounded by pus. Blood vessels were empty, dilated and had undergone vasculitis and thrombosis.

[Chronic gastritis caused by Ollulanus tricuspis (Leuckart, 1865) in a tiger]

A chronic gastritis caused by an infestation with O. tricuspis is described. The differential-diagnostic importance of this parasitosis in chronic maldigestive diseases is emphasized. Conventional coproscopic diagnostic procedures fail as the life cycle of the parasite is confined to the gastrum of the host.

Parasitic gastritis in a llama (Lama glama) associated with inhibited larval Teladorsagia spp. (Nematoda: Trichostrongyloidea)

A 7-year-old female llama was experimentally infected with 500 Fasciola hepatica metacercariae then turned out onto pasture also grazed by domestic sheep. The llama was necropsied approximately 22 weeks post infection. Routine examination of the gastrointestinal tract revealed diffusely coalescing, umbilicated nodules covering the caudal one-fifth of the third stomach compartment. Microscopically, the mucosa was irregularly thickened. Numerous nematode larvae were present in glandular lumens, often extending to the base of the glands. Where nematodes were most numerous, decreased numbers of parietal cells, attenuation of glandular epithelium and increased collagen within the lamina propria were evident. Of a total of 6510 adult nematodes in the third stomach compartment, 51% were Teladorsagia spp., 47% were Trichostrongylus axei, and 2% were Camelostrongylus mentulatus. Except for C. mentulatus, three sheep that had grazed with the llama and were necropsied at approximately the same time, harbored the same nematode species. The total number of larvae in the llama was 56,710, with more than 97% being ostertagiine early fourth-stage larvae. Ostertagiine larvae were also present in the sheep. Based on the composition of the adult populations in the llama and sheep, the larvae were considered to be species of Teladorsagia. Additionally, the larger numbers of early fourth-stage larvae indicated that the development of Teladorsagia spp. in the llama is inhibited.

Dyspepsia in acute falciparum malaria: a clinico-pathological correlation

Gastrointestinal symptoms are common in acute falciparum malaria. Dyspepsia often occurs in such patients and sometimes it is exceptionally severe. However, the pathogenesis of the dyspeptic symptoms in malaria has not been clearly defined. Upper gastrointestinal endoscopy was performed in 40 patients with acute falciparum malaria in order to correlate the dyspeptic symptoms with the macroscopic (endoscopic) and microscopic (histologic) pathology of stomach and duodenum. The patients were divided into a dyspeptic group (n = 20, male/female ratio = 17/3, age range 18-50 years, mean age = 28.85 + 9.14 years), and a non-dyspeptic group (n = 20, male/female ratio = 16/4, age range 15-47, mean age 26.05 + 9.98 years). The findings revealed that dyspepsia correlated with topographic endoscopic pangastritis (p = 0.0014), the category of endoscopic antral gastritis (p = 0.013), and the histologic severity of antral gastritis (p = 0.0434). The results suggested that gastritis should be considered in acute falciparum malaria patients presenting with dyspepsia.

[Experimental studies on the course and consequences of infection with Graphidium strigosum (Nematoda, Trichostrongylidae) in Oryctolagus cuniculus (domestic rabbit)]

After oral infection of domesticated rabbits with 1,500 Graphidium strigosum-larvae III third-stage larvae were discovered in the stomach during the next 6 d, fourth-stage larvae from the 8th d and mature nematodes from the 34th d onwards. In 26 rabbits infected with 75...2,000 larvae III the prepatent period of Graphidium strigosum-infestation varied from 40 to 60, in most cases from 40 to 50 d. After one oral infection with 500...1,000 Graphidium strigosum-larvae III 3-month old domesticated rabbits showed no clinical symptoms, their performance was impaired but only insignificant and a population of 154 to 765 mature nematodes parasitizing in the stomach caused a gastritis catarrhalis chronica, partly a fibrosing gastritis.

Radiographic study of acute gastric anisakiasis

The radiographic findings from 226 patients with acute gastric anisakiasis are reviewed. Suggestive but indeterminate findings such as coarse and broad gastric folds caused by mucosal edema were demonstrated in 224 patients (98%). In 179 patients (88%) mucosal edema was so extensive that it occupied more than half of the entire gastric wall. The most diagnostic radiographic finding, present in 139 patients, was the appearance of a threadlike filling defect about 3 cm in length, showing an anisakis larva itself. Careful demonstration of these radiographic findings is useful for the diagnosis of acute gastric anisakiasis.

Cryptosporidium in snakes with hypertrophic gastritis

Fourteen captive snakes of three genera and four species had severe chronic hypertrophic gastritis. Persistent postprandial regurgitation and firm midbody swelling were the most common clinical signs. Fecal smears had many roughly spherical organisms confirmed by ultrastructural study to be oocysts of Cryptosporidium. Pathologic changes included hypertrophy of gastric mucosa and atrophy of granular cells. There were cystic changes in gastric glands and focal mucosal necrosis. Many Cryptosporidium lined microvillar surfaces. All developmental forms were identified by ultrastructure. Characteristic oocysts were found in abundance.